Chapter 12 NUTRITION ASSESSMENT Copyright © 2020 by Elsevier Inc. All rights reserved. Defining Nutritional Status The degree of balance between nutrient intake and nutrient requirements. Optimal nutritional status Achieved when sufficient nutrients are consumed to support day-today body needs and any increased metabolic demands due to growth, pregnancy, or illness Under nutritional status Affected by many factors, including physiologic, psychosocial, developmental, cultural, and economic factors Occurs when nutritional reserves are depleted or when nutrient intake is inadequate to meet day-to-day needs or added metabolic demands Over nutritional status Caused by consumption of nutrients, especially calories, sodium, and fat, in excess of body needs Copyright © 2020 by Elsevier Inc. All rights reserved. Obesity Statistics Estimated 17% of children and adolescents, ages 2 to 19 66% of adults in United States are either overweight or obese. For children, overweight defined as body mass index (BMI) equal to or greater than 95th percentile based on age- and gender-specific BMI charts For adults Overweight defined as BMI of 25 or greater Obesity defined as BMI of 30 Being overweight during childhood and adolescence associated with increased risk for becoming overweight during adulthood Copyright © 2020 by Elsevier Inc. All rights reserved. Adulthood During adulthood, growth and nutrient needs stabilize. Most adults are in relatively good health but influence of lifestyle factors can lead to development of disease. Lifestyle factors such as cigarette smoking, stress, lack of exercise, excessive alcohol intake, and diets high in saturated fat, cholesterol, salt, and sugar and low in fiber Adult years, therefore, are an important time for education to preserve health and to prevent or delay onset of chronic disease. Adult emergence of Metabolic syndrome is a concern leading to increased cardiac risk. Copyright © 2020 by Elsevier Inc. All rights reserved. The Aging Adult Increased risk for undernutrition or over-nutrition. Major risk factors for malnutrition in older adults: Poor physical or mental health, social isolation, alcoholism, limited functional ability, poverty, and polypharmacy Normal physiologic changes in aging adults that directly affect nutritional status include Poor dentition, decreased visual acuity, decreased saliva production, slowed gastrointestinal motility, decreased gastrointestinal absorption, and diminished olfactory and taste sensitivity. Decrease in energy requirements due to loss of lean body mass and increase in fat mass Sarcopenia: Age-related loss of muscle mass Sarcopenic obesity: low muscle mass with excess fat attributed to poor diet and low levels of physical activity Copyright © 2020 by Elsevier Inc. All rights reserved. Cultural Competence Foods and eating customs are culturally distinct, and each person has unique cultural heritage that may affect nutritional status. Immigrants commonly maintain traditional eating customs long after language and manner of dress of adopted country become routine. Newly arriving immigrants may be at nutritional risk Come from countries with limited food supplies due to poverty, poor sanitation, war, or political strife Unfamiliar foods, food storage, food preparation, and foodbuying habits in the U.S. contribute to nutritional problems. Period of adjustment required that is impacted by socioeconomic and cultural factors. Copyright © 2020 by Elsevier Inc. All rights reserved. Dietary Practices Cultural factors that must be considered: Cultural definition of food Frequency and number of meals eaten away from home Form and content of ceremonial meals Amounts and types of foods eaten and regularity of food consumption Knowing person’s religious practices r/t food Enables you to suggest improvements or modifications that do not conflict with dietary laws. Other issues are fasting and other religious observations that may limit a person’s food or liquid intake during specified times. Copyright © 2020 by Elsevier Inc. All rights reserved. Nutrition Screening Quick first step method to obtain data and identify individuals at nutrition risk Parameters include weight and weight history, conditions associated with increased nutritional risk, diet information, and routine laboratory data. A variety of valid tools are available for screening different populations. Malnutrition Screening Tool validated for use in adult acute-care patients; Mini Nutritional Assessment for use in older adults in long-term care and community settings. Individuals identified at nutritional risk during screening should undergo a comprehensive nutritional assessment, which includes the following: Dietary history and clinical information; Physical examination for clinical signs and anthropometric measures; Laboratory tests Copyright © 2020 by Elsevier Inc. All rights reserved. Nutrition Screening Methods Various methods for collecting current dietary intake information are available. 24-hour recall Food frequency questionnaire Food diaries or records: 3 days typically used Direct observation of feeding with documentation Use of standardized dietary guidelines can help to determine adequacy of diet: ChooseMyPlate Dietary Guidelines Dietary Reference Intakes (DRIs) Copyright © 2020 by Elsevier Inc. All rights reserved. Subjective Data Eating patterns Usual weight Changes in appetite, taste, smell, chewing, swallowing Recent surgery, trauma, burns, infection Chronic illnesses Nausea, vomiting, diarrhea, constipation Food allergies or intolerances Medications and/or nutritional supplements Patient-centered care Alcohol or illegal drug use Exercise and activity patterns Family history Copyright © 2020 by Elsevier Inc. All rights reserved. Additional Nutritional History For the aging adult, obtain information about Prior dietary history in ages 40’s and 50’s. Factors affecting present dietary intake. Vitamin D and calcium intake. Copyright © 2020 by Elsevier Inc. All rights reserved. Objective Data: Clinical Signs Observation of general appearance: obese, cachectic (fat and muscle wasting), or edematous; can provide clues to overall nutritional status More specific clinical signs and symptoms of nutritional deficiencies can be detected through physical examination and laboratory testing. Observe for clinical signs which are late manifestations of malnutrition, only in areas in which rapid turnover of epithelial tissue (skin, hair, mouth, lips, and eyes) are nutritional deficiencies readily detectable. Signs may also be non-nutritional in origin. Laboratory testing is necessary to make clinical diagnosis. Copyright © 2020 by Elsevier Inc. All rights reserved. Anthropomorphic Measures Derived weight measure Percent usual body weight: formula calculation Body mass index: practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition Waist-to-hip ratio Assesses body fat distribution as an indicator of health risk Waist circumference (WC) alone predicts health risk. Arm span or total arm length Useful in situations where height is difficult to measure Serial assessment Made at routine intervals weekly, biweekly, or monthly dependent on patient population. Copyright © 2020 by Elsevier Inc. All rights reserved. Cardinal Features of LongTerm Weight Loss Individualized and based on realistic patient goals Culturally sensitive Regular physical exercise Eating a low-calorie, low-fat diet 4 to 5 times a week for 30 minutes Caloric intake 1400 to 1500 kcal/day Fat intake 20% to 25% of total calories Monitoring daily food intake Food diary Portion size Weight Copyright © 2020 by Elsevier Inc. All rights reserved. Classification of Malnutrition Obesity Marasmus (protein-calorie malnutrition): caused by inadequate intake of protein and calories or prolonged starvation Anorexia, bowel obstruction, cancer cachexia, and chronic illness cause this Weight loss and subcutaneous fat and muscle wasting Kwashiorkor (protein malnutrition): caused by diets high in calories but little or no protein May appear well-nourished or obese; may appear edematous Marasmus/Kwashiorkor mix: caused by prolonged inadequate intake of protein and calories such as severe starvation and severe catabolic states Muscle, fat, and visceral protein wasting Major surgery, trauma, or burns in combination with prolonged starvation: AIDS wasting Highest risk for morbidity and mortality Emaciated appearance Copyright © 2020 by Elsevier Inc. All rights reserved. Abnormalities Caused by Nutritional Deficiencies Pellagra Scorbutic gums Vitamin A deficiency Rickets Vitamin A and/or linoleic acid deficiency Bitot’s spots Vitamin C deficiency Follicular hyperkeratosis Niacin deficiency Vitamin D and calcium deficiency Magenta tongue Riboflavin deficiency Copyright © 2020 by Elsevier Inc. All rights reserved. Metabolic Syndrome (MetS) Diagnosed in the presence of 3 out of 5 biomarkers Waist circumference Glucose level Above 100 mg/dL or being treated for hyperglycemia High-density lipoprotein (HDL-C) Being treated for hyperlipidemia <40 in men; <50 in women Triglyceride (TG) level >40 inches in men; >35 inches in women Above 150 mg/dL or being treated for elevated TG Hypertension (HTN) Systolic >130 or diastolic >85 or being treated for HTN Copyright © 2020 by Elsevier Inc. All rights reserved. Nutritional Consequences of Bariatric Surgery Potential nutritional consequences and related dietary change as a result of surgical intervention. Malabsorption of protein and calories Malabsorption of vitamins and minerals Taking supplements Weight regain Eat small nutrient dense meals. Avoid excess intake of calorically dense/liquid foods. Obstruction of bypassed sections or pouch Avoid chunks of food that could cause blockage. Copyright © 2020 by Elsevier Inc. All rights reserved. Summary Checklist: Nutritional Assessment Obtain a health history relevant to nutritional status. Elicit dietary history, if indicated. Inspect relevant systems (integument, musculoskeletal, and neurologic) for clinical signs and symptoms suggestive of nutritional deficiencies. Measure anthropometric parameters as indicated. Review relevant laboratory tests. Offer health promotion teaching. Copyright © 2020 by Elsevier Inc. All rights reserved. Case Study A: Question What methods would the nurse use to assess a patient’s nutritional status in a community setting? Copyright © 2020 by Elsevier Inc. All rights reserved. Answer to Case Study A: Question 1 24-hour recall: The individual or family member completes a questionnaire or is interviewed and asked to recall everything eaten within the past 24 hours. Food frequency questionnaire: With this tool information is collected on how many times per day, week, or month the individual eats particular foods, providing an estimate of usual intake. Food diaries or records: ask the individual or family member to write down everything consumed for a certain period of time. Three days (i.e., two weekdays and one weekend day) are customarily used. Direct observation of the feeding and eating process can detect problems not readily identified through standard nutrition interviews. Copyright © 2020 by Elsevier Inc. All rights reserved.
