Nutrition Assessment and
Nutrition Care-What Nurses
Need to Know
Chapter 1
Obesity and Eating Disorders as
Examples of Malnutrition
Chapter 14
Nutritional Screening
• Nutritional screen
– Quick look at a few variables to judge a
client’s relative risk for nutritional problems
– No accepted universal tool
– Screen must be done within 24 hours of
admission to the hospital.
Nutritional Screening—(cont.)
• Comprehensive nutritional assessment
– Moderate to high risk at screening referred to
dietitian for assessment-dietitian may not
always be available so nurses/physicians may
very well have to do all four steps below
– Nutritional care process: four steps
o Assessment
o Nutritional diagnosis
o Implementation
o Monitoring and evaluation
Nutritional Screening—(cont.)
• Comprehensive nutritional assessment—(cont.)
– Different from nursing care plan
o Dietitians (if available) or otherwise
nurses/physicians can get most of information
from nursing admission assessment.
o Dietitians (if available) or otherwise
nurses/physicians interview patients and/or
families to obtain a nutrition history.
– Helps to differentiate
o Nutrition problems caused by inadequate intake
from those caused by disease
Nutritional Screening—(cont.)
• Comprehensive nutritional assessment—(cont.)
– Dietitians (if available) or otherwise
nurses/physicians
o Calculate estimated calorie and protein
requirements based on the assessment data
o Determine nutrition diagnoses that define the
nutritional problem, etiology, and signs and
symptoms
o May also determine the appropriate
malnutrition diagnosis
o
Formulate nutrition interventions
Integrating Nutrition
• Assessment
– Data classified as ABCD
o Anthropometric
o Biochemical
o Clinical
o Dietary data
– Client’s medical–psychosocial history is also
evaluated for its impact on nutritional
status.
Integrating Nutrition—(cont.)
• Anthropometric data
– Physical measurements of the body
– Body mass index
o “Healthy” or “normal” BMI is defined as 18.5
to 24.9.
o Above or below related to health risks
– Edema or dehydration skews accurate weight
measurements.
– Recent weight change
Integrating Nutrition—(cont.)
• Biochemical data
– No single test is both sensitive and
specific for protein–calorie malnutrition.
– Biochemical data may help support the
diagnosis of a nutritional problem.
Integrating Nutrition—(cont.)
• Albumin
– Often used to assess protein status
– Serum levels may be maintained until malnutrition is
in a chronic stage.
– Low albumin may indirectly identify patients who may
benefit from nutrition assessment and intervention.
• Prealbumin
– Thyroxin-binding protein
– More sensitive indicator of protein status
– More expensive to measure
Integrating Nutrition—(cont.)
• Clinical data
– Physical signs and symptoms of malnutrition
observed in the client
– Most signs cannot be considered diagnostic.
– Physical signs and symptoms of malnutrition
can vary in intensity among population groups
because of genetic and environmental
differences.
– Physical findings occur only with overt
malnutrition.
Integrating Nutrition—(cont.)
• Dietary data
– Nurse should ask, “Do you avoid any particular
foods?”
– Nurse should not ask, “Are you on a diet?”
• Medical–psychosocial history
– May shed light on factors that influence intake,
nutritional requirements, or nutrition counseling
Integrating Nutrition—(cont.)
• Medication
– Both prescription and over-the-counter drugs have
the potential to affect and be affected by nutritional
status.
– At greatest risk for development of drug-induced
nutrient deficiencies include those who:
o Habitually consume fewer calories and nutrients
than they need
o Have increased nutrient requirements including
infants, adolescents, and pregnant and lactating
women
o Are elderly
o Have chronic illnesses
Integrating Nutrition—(cont.)
• Medication—(cont.)
– At greatest risk for development of drug-induced
nutrient deficiencies include those who—(cont.)
o Take large numbers of drugs (five or more),
whether prescription drugs, over-the-counter
medications, or dietary supplements
o Are receiving long-term drug therapy
o Self-medicate
o Are substance abusers
Integrating Nutrition—(cont.)
• Nursing diagnosis
– Provide written documentation of the client’s status
– Serve as a framework for the plan of care that
follows
• Planning: client outcomes
– Outcomes, or goals, should be measurable,
attainable, specific, and client centered.
– Focus on the client, not the health-care provider.
– Keep in mind that the goal for all clients is to
consume adequate calories, protein, and nutrients
using foods they like and tolerate as appropriate.
Integrating Nutrition—(cont.)
• Nursing interventions
– Nutrition therapy
o Diet is a four-letter word with negative
connotations.
o Usually general suggestions to increase/
decrease, limit/avoid, reduce/encourage, or
modify/maintain aspects of the diet because
exact nutrient requirements are determined
on an individual basis.
o Nutrition theory does not always apply to
practice.
Integrating Nutrition—(cont.)
• Nursing interventions—(cont.)
– Client teaching
o Clients in clinical settings may be more
receptive to nutritional advice.
o Hospitalized patients are also prone to
confusion about nutrition messages.
• Monitoring and evaluation
– Monitoring precedes evaluation.
– Evaluation assesses whether client outcomes
were achieved.
Physical Signs and Symptoms of
Malnutrition
• Hair is dull, brittle, dry,
or falls out easily
• Swollen glands of neck
and cheeks
• Dry, rough, or spotty
skin
• Poor or delayed wound
healing or sores
• Thin appearance with
lack of subcutaneous fat
• Muscle wasting
• Edema of lower
extremities
• Weakened hand grasp
• Depressed mood
• Abnormal heart
rate/rhythm and BP
• Enlarged liver or spleen
• Loss of balance and
coordination
Nursing Diagnoses with
Nutritional Significance
• Altered nutrition: more than body requirements
• Altered nutrition: less than body requirements
• Altered nutrition: risk for more than body
requirements
• Constipation
• Diarrhea
• Fluid volume excess
• Fluid volume deficit
Nursing Diagnoses with
Nutritional Significance—(cont.)
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Risk for aspiration
Altered oral mucous membrane
Altered dentition
Impaired skin integrity
Noncompliance
Impaired swallowing
Knowledge deficit
Pain
Nausea
Obesity and Eating Disorders as
Examples of Malnutrition
Malnutrition
Chapter 14
Obesity and Eating Disorders
• Prevalence of obesity (BMI ≥30) increasing
• One of the most common causes of preventable
death
• A far less common weight issue is disordered eating
manifested as anorexia nervosa or bulimia.
• Historically, the study of obesity and eating
disorders has been separate.
• Commonalities between them
Obesity
• Overweight is defined as having a BMI ≥25.
• Obesity is defined as having a BMI ≥30.
• Waist circumference is a better measure
than BMI
Obesity—(cont.)
• Causes of obesity
– Occurs when people eat more calories than they
expend over time
– Why it occurs is not fully understood.
– Some people are able to burn hundreds of extra
calories in the activities of daily living to help control
weight.
– Likely that a combination of genetic and
environmental factors is involved.
Obesity—(cont.)
• Genetics
– Estimates on the heritability of body mass index
range from 40% to 70% (Herrera and Lindgren,
2010).
– Genetics are involved in:
o How likely a person is to gain or lose weight
o Where body fat is distributed
o Response to overeating
Obesity—(cont.)
• Environment
– Rise in obesity without change in gene poolepigenetics can play a role
– Root cause in most cases is lifestyle and
environment, not biology.
– Environmental influences include
o Abundance of palatable, low-cost, high–calorie
density foods that are readily available in
prepackaged forms and in fast-food restaurants
o Increasing consumption of soft drinks and snacks
o Great proportion of food expenditures spent on
food away from home
Obesity—(cont.)
• Environment—(cont.)
– Environmental influences include—(cont.)
o Growing portion size of restaurant meals
o Low levels of physical activity
o Increases in television watching
o Widespread use of electronic devices in
the home, such as computers and video
games
– All lead to sedentary lifestyle.
Obesity—(cont.)
• Environment—(cont.)
– Gene–environment interaction
o In people with a genetic predisposition to obesity,
the severity of the disease is largely determined
by lifestyle and environmental conditions.
• Complications of obesity
– Most common complications of obesity include
o Insulin resistance, type 2 diabetes, hypertension,
dyslipidemia, cardiovascular disease, stroke,
gallstones and cholecystitis, sleep apnea,
respiratory dysfunction, and increased incidence
of certain cancers (e.g. colon, breast,
prostate,endometrial)
Obesity—(cont.)
• Complications of obesity—(cont.)
– Increases the risk of complications during
and after surgery
– Obesity is considered to be a major
contributor to preventable deaths in Canada.
– Obesity presents psychological and social
disadvantages.
– Negative social consequences
Obesity—(cont.)
• Goals of treatment
– Ideally, treatment would “cure” overweight
and obesity.
– In reality, this ideal is seldom achieved.
– A modest weight loss of 5% to 10% of initial
body weight is associated with significant
improvements in blood pressure, cholesterol
and plasma lipid levels, and blood glucose
levels.
Obesity—(cont.)
• Goals of treatment—(cont.)
– Modest weight loss
1. Is more attainable
2. Is easier to maintain over the long term
3. Sets the stage for subsequent weight loss
Obesity—(cont.)
• Evaluating motivation to lose weight
– Objectively identifying who may benefit from
weight loss
– Assessing the client’s level of motivation is
crucial.
– Imposing treatment on an unmotivated or
unwilling client may preclude subsequent
attempts at weight loss.
Obesity—(cont.)
• Evaluating motivation to lose weight—(cont.)
– Treatment approaches
o A lifestyle approach is the basis of treatment for all
people whose BMI is ≥30.
 Includes diet modification
 Exercise
 Behavior modification
o Pharmacotherapy and surgery may be used in
conjunction with lifestyle interventions, based on
the individual’s BMI and the presence of
comorbidities.
Obesity—(cont.)
• Treatment approaches—(cont.)
– Diet modification
o Cornerstone of most weight loss programs
o Fewer calories
o Macronutrient composition
o Micronutrient composition
o Nutrition education
o Promoting dietary adherence
Obesity—(cont.)
• Treatment approaches—(cont.)
– Physical activity
o Benefits of exercise are numerous.
o Favorably impacts metabolic rate
Obesity—(cont.)
• Physical activity—(cont.)
– Sixty to 90 minutes of daily moderate-intensity
physical activity are recommended to sustain weight
loss.
– Promoting exercise adherence
o Seems to increase with less structure
o Strategies that may promote exercise adherence
 Exercise at home
 Exercise in multiple short bouts (10 minutes
each)
 Adopt a more active lifestyle
Obesity—(cont.)
• Behavior modification
– Focuses on changing the client’s eating and exercise
behaviors
– Key behavior modification strategies
o Self-monitoring
o Goal setting
o Stimulus control
o Problem solving
o Cognitive restructuring
o Relapse prevention
Obesity—(cont.)
• Pharmacotherapy
– Recommended for
o People with a BMI ≥30
o People with a BMI ≥27 with comorbid
conditions
o People with waist circumferences at or
above IDF cut offs are also candidates
for pharmacotherapy if comorbidities
are present.
Obesity—(cont.)
• Pharmacotherapy—(cont.)
– Drugs are central nervous system stimulants.
– Tolerance may develop after only a few weeks.
– Risk of abuse
– Common side effects
o Increased heart rate and blood pressure, dry
mouth, agitation, insomnia, nausea, diarrhea,
and constipation
Obesity—(cont.)
• Surgery
– Most effective treatment for severe obesity
– Appropriate for clients whose BMI is 35 to 39.9
who have major comorbidities
– Works by
1. Restricting the stomach’s capacity
2. Creating malabsorption of nutrients and
calories
3. A combination of both
Obesity—(cont.)
• Surgery—(cont.)
– Laparoscopic adjustable gastric banding (LAGB)
o An inflatable band encircles the uppermost
stomach and is buckled.
o Small pouch of approximately 15- to 30-mL
capacity is created with a limited outlet
between the pouch and the main section of
the stomach.
o Outlet diameter can be adjusted by inflating
or deflating a small bladder inside the “belt”
through a small subcutaneous reservoir.
Obesity—(cont.)
• Surgery—(cont.)
– Laparoscopic adjustable gastric banding
(LAGB)—(cont.)
o Size of the outlet can be repeatedly
changed as needed.
o Mortality rate for gastric banding is the
lowest of all bariatric procedures.
o Successful weight loss after LAGB requires
frequent follow-up and band adjustments.
Obesity—(cont.)
• Surgery—(cont.)
– Roux-en-Y gastric bypass (RYGB)
o Combines gastric restriction to limit food intake
with the construction of bypasses of the
duodenum and the first portion of the jejunum
o Creates malabsorption of nutrients
o “Dumping syndrome”
o Superior to gastric resection in both promoting
and maintaining significant weight loss
o Major complication with RYGB is anastomotic leak.
Obesity—(cont.)
• Postsurgical diet
– Progression begins with small quantities of
sugar-free clear liquids.
– Advances as tolerated to full liquids, followed
by pureed foods, and then a regular diet
within 5 to 6 weeks after surgery
– Nutrition therapy guidelines
Obesity—(cont.)
• Weight maintenance after loss
– Keeping weight off is even harder than losing
it.
– Diets that lead to weight loss are not
necessarily effective for maintaining weight
loss.
– Single best predictor of who will be
successful at maintaining weight loss is how
long someone has kept his or her weight off.
Obesity—(cont.)
• Obesity prevention
– Small changes in diet and exercise that total
a mere 100 cal/day may be enough to
prevent obesity in most of the population.
– One ounce of cheddar cheese a day for 1
year = 10-pound weight gain
Eating Disorders: Anorexia Nervosa (AN),
Bulimia Nervosa (BN), and Eating Disorders
Not Otherwise Specified (EDNOS)
• Defined psychiatric illnesses that can have a
profound impact on nutritional status and health
• Generally characterized by abnormal eating
patterns and distorted perceptions of food and
body weight
• Continuum of disordered eating
Eating Disorders: Anorexia Nervosa (AN),
Bulimia Nervosa (BN), and Eating Disorders
Not Otherwise Specified (EDNOS)—(cont’d)
• Etiology
– Considered to be multifactorial in origin
– Risk factors
o Dieting, early childhood eating and GI
problems, increased concern about weight
and size, negative self-evaluation, sexual
abuse, and other traumas
Eating Disorders: Anorexia Nervosa (AN),
Bulimia Nervosa (BN), and Eating Disorders
Not Otherwise Specified (EDNOS)—(cont.)
• Etiology—(cont.)
– Precipitating factors
o Onset of puberty, parents’ divorce, death of
a family member, and ridicule of being or
becoming fat
– People with eating disorders often suffer from
o Depression, anxiety, substance abuse, or
body dysmorphic disorder
Eating Disorders: Anorexia Nervosa (AN),
Bulimia Nervosa (BN), and Eating Disorders
Not Otherwise Specified (EDNOS)—(cont.)
• Etiology—(cont.)
– Treatment plans are highly individualized.
– Antidepressant drugs effectively reduce the frequency
of problematic eating behaviors.
– Most eating disorders are treated on an outpatient
basis.
– Nutritional intervention seeks to reestablish and
maintain normal eating behaviors.
Nutrition Therapy for Anorexia
• Step-by-step goals of nutrition therapy
1. To prevent further weight loss
2. To gradually reestablish normal eating
behaviors
3. To gradually increase weight
4. To maintain agreed-on weight goal
• Half of those who receive care are expected to
recover.
• Overall mortality rate is 5% to 16%.
Nutrition Therapy for Anorexia—(cont.)
• Involving the client in formulating individualized
goals and plans promotes compliance.
• Large amounts of food may not be well
tolerated.
Nutrition Therapy for Bulimia Nervosa
• People with BN tend to have fewer serious
medical complications than people with AN
because their undernutrition is less severe.
• Nutritional counseling focuses on identifying
and correcting food misinformation and fears.
• Structured and relatively inflexible to promote
the client’s sense of control
• Initial meal plan provides adequate calories for
weight maintenance.
Nutrition Therapy for Bulimia Nervosa—
(cont.)
• Adequate fat is provided to help delay gastric
emptying and contribute to satiety.
• Calories are gradually increased as needed.
Eating Disorders Not Otherwise Specified
• At least as common as AN and BN
• This group represents
– Subacute cases of AN or BN
– Binge eating disorder