Chapter 11 Nutritional Assessment - PowerPoint Presentation

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Chapter 11 Nutritional Assessment - PPT Presentation

Copyright 2016 by Elsevier Inc All rights reserved Copyright 2012 2008 2004 2000 1996 1993 by Saunders an affiliate of Elsevier Inc Nutritional Status Nutritional status refers to the degree of balance between nutrient intake and nutrient requirements ID: 777173

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Slide1

Chapter 11

Nutritional Assessment

Slide2

Nutritional Status

Nutritional status refers to the degree of balance between nutrient intake and nutrient requirementsThis balance is affected by many factors, including physiologic, psychosocial, developmental, cultural, and economic factors

Slide3

Defining Nutritional Status

Optimal nutritional statusAchieved when sufficient nutrients are consumed to support day-to-day body needs and any increased metabolic demands due to growth, pregnancy, or illnessPersons having optimal nutritional status are more active, have fewer physical illnesses, and live longer than persons who are malnourished

Slide4

Undernutrition

Occurs when nutritional reserves are depleted or when nutrient intake is inadequate to meet day-to-day needs or added metabolic demandsVulnerable groups—infants, children, pregnant women, recent immigrants, persons with low incomes, hospitalized people, and aging adults—are at risk for the following:

Impaired growth and development

Lowered resistance to infection and disease

Delayed wound healing

Longer hospital stays

Higher health care costs

Slide5

Overnutrition

Caused by consumption of nutrients, especially calories, sodium, and fat, in excess of body needsMajor nutritional problem today, overnutrition can lead to obesity and is risk factor for the following:

Heart disease and hypertension

Type II diabetes

Stroke

Gallbladder disease

Sleep apnea

Certain cancers

Osteoarthritis

Slide6

Overnutrition Statistics

Estimated 17% of children and adolescents, ages 2 to 1966% of adults in United States are either overweight or obeseFor 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

Slide7

Question

The nurse is assessing a patient with a body mass index (BMI) of 33.5. How should the nurse document this finding?Patient’s BMI within normal range

Patient’s BMI under current recommendations, suggestive of being underweight

Patient’s BMI over current recommendations, suggestive of being overweight

Patient’s BMI over current recommendations, suggestive of obesity

Slide8

Developmental Competence: Infants and Children

Time from birth to 4 months of age is most rapid period of growth in life cycleAlthough infants lose weight during first few days of life, birth weight usually regained by 7th to 10th day

Thereafter, infants double their birth weight by 4 months and triple it by 1 year of age

Breastfeeding recommended for full-term infants for first year of life because breast milk ideally formulated to promote normal infant growth and development and natural immunity

Slide9

Developmental Competence: Infants and Children (Cont.)

Although relatively few, contraindications to breastfeeding existInfants increase their length by 50% during first year and double it by 4 years

By age 2 years, brain has reached 50% of its adult size, by age 4, 75%, and by age 8, 100%

For this reason, infants and children younger than 2 should not drink skim or low-fat milk or be placed on low-fat diets

Fat, calories, and essential fatty acids are required for proper growth and central nervous system development

Slide10

Developmental Competence: Adolescence

Adolescence characterized by rapid physical growth and endocrine and hormonal changesCaloric and protein requirements increase to meet this demand, and because of bone growth and increasing muscle mass (and, in girls, the onset of menarche), calcium and iron requirements also increase

Increased requirements cannot be met by three meals per day; therefore, nutritious snacks play an important role in achieving adequate nutrient intake

In general, boys grow taller and have less body fat than girls

Slide11

Developmental Competence: Adolescence (Cont.)

Percentage of body fat increases in females to about 25% and decreases in males (replaced by muscle mass) to about 12%Typically, girls double their body weight between the ages of 8 and 14Boys double their body weight between the ages of 10 and 17 years

Slide12

Developmental Competence: Pregnancy and Lactation

To support synthesis of maternal and fetal tissues Sufficient calories, protein, vitamins, and minerals must be consumedNational Academy of Sciences (NAS) recommends weight gain of 25 to 35 lb for women of normal weight

28 to 40 lb for underweight women

11 to 20 lb for overweight women

Slide13

Developmental Competence: Adulthood

During adulthood, growth and nutrient needs stabilizeMost adults in relatively good healthHowever, 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 can be factors in development of hypertension, obesity, atherosclerosis, cancer, osteoporosis, and diabetes mellitus

Adult years, therefore, are an important time for education to preserve health and to prevent or delay onset of chronic disease

Slide14

Developmental Competence: The Aging Adult

As people age, a number of changes occur that make them prone to undernutrition or overnutritionMajor risk factors for malnutrition in older adults include 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

Slide15

Developmental Competence: The Aging Adult (Cont.)

Important nutritional features of older yearsDecrease in energy requirements due to loss of lean body mass and increase in fat mass

Socioeconomic conditions frequently have a significant effect on nutritional status

Decline of extended families and increased mobility of families reduce available support systems

Facilities for meal preparation, transportation to grocery stores, physical limitations, income, and social isolation interfere with acquisition of balanced diet

Multiple medications that have a potential for interaction with nutrients and with one another

Slide16

Cultural Competence

Foods and eating customs are culturally diverse, and each person has unique cultural heritage that may affect nutritional statusImmigrants commonly maintain traditional eating customs long after language and manner of dress of adopted country become routine

Occupation, class, religion, gender, and health awareness also have a great bearing on eating customs

Not only do food habits change to accommodate their new cultures, but also their food habits have influence on their adoptive country

Slide17

Cultural Competence (Cont.)

Newly arriving immigrants may be at nutritional risk for a variety of reasonsFrequently come from countries with limited food supplies caused by poverty, poor sanitation, war, or political strifeGeneral undernutrition, hypertension, diarrhea, lactose intolerance, osteomalacia (soft bones), scurvy, and dental caries are among more common nutrition-related problems of new immigrants from developing countries

They are in a new country with a completely new language, culture, and society

Slide18

Cultural Competence (Cont.)

When immigrants arrive in the United States, other factors contribute to their nutritional problemsFaced with unfamiliar foods, food storage, food preparation, and food-buying habitsFamiliar foods are difficult or impossible to obtain

Low income may also limit their access to familiar foods

When traditional food habits are disrupted, borderline deficiencies or adverse nutritional consequences may result

As an example, Japanese immigrants to the United States have increased risk of colon and breast cancer as they adapt to diet higher in saturated fats and cholesterol

Slide19

Cultural Heritage and Nutrient Needs

Cultural values may conflict with optimum nutrition; for example, many cultures worldwide consider obesity an indication of beauty, affluence, and well-beingBest way to learn about the eating patterns of people is to talk with them, eat with them, and ask about their dietary customs

Recent immigrant groups, such as Southeast Asians, are often shorter and weigh less than Western counterparts, so standard tables of weight for age, height for age, and weight for height may not be appropriate to evaluate growth and development of immigrant children

Slide20

Cultural Factors and Nutrient Needs

Cultural factors that must be consideredCultural definition of foodFrequency 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

Slide21

Dietary Practices of Cultural Groups

Knowing person’s religious practices related to 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

Muslims fast from dawn to sunset during month of Ramadan in Islamic calendar and eat only twice a day, before dawn and after sunset

Jews observe a 24-hour fast on Yom Kippur

Slide22

Nutritional Assessment Purposes

Purposes of nutritional assessmentIdentify individuals who are malnourished or are at risk of developing malnutritionProvide data for designing a nutrition plan of care that will prevent or minimize development of malnutrition

Establish baseline data for evaluating efficacy of nutritional care

Slide23

Nutrition Screening

First step may be completed in any setting (e.g., clinic, home, hospital, long-term care)Based on easily obtained data, nutrition screening is quick and easy way to identify individuals at nutrition risk, such as those with weight loss, inadequate food intake, or recent illness

Parameters include weight and weight history, conditions associated with increased nutritional risk, diet information, and routine laboratory data

Slide24

Nutrition Screening (Cont.)

A variety of valid tools are available for screening different populationsAdmission Nutrition Screening Tool validated for use by nurses in hospital settingsNutrition Screening Initiative form designed and validated in outpatient, geriatric population

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

Anthropometric measures

Laboratory tests

Slide25

Nutrition Screening Methods

Various methods for collecting current dietary intake information are available24-hour recallFood frequency questionnaireFood diary

During hospitalization, documentation of nutritional intake can best be achieved through calorie counts of nutrients consumed or infused

Slide26

24-Hour Recall

Easiest and most popular method for obtaining information about dietary intakeIndividual or family member completes questionnaire or is interviewed and asked to recall everything eaten within past 24 hoursHowever, several significant sources of error may occur when this method is used due to inability to remember

Intake within past 24 hours may be atypical or unusual

Individual or family member may alter truth for variety of reasons

Snack items and use of gravies, sauces, and condiments may be underreported

Slide27

Food Frequency Questionnaire

May be used to counter some of difficulties inherent in 24-hour recall methodWith this tool, information collected on how many times per day, week, or month individual eats particular foodsDrawbacks to use of food frequency questionnaire

Does not quantify amount of intake

Relies on individual’s or family member’s memory for how often a food was eaten

Slide28

Food Diaries or Records

Require asking individual or family member to write down everything consumed for certain period of timeThree days, including two weekdays and one weekend day, are customarily usedFood diary is most complete and accurate if individual instructed to record information immediately after eating

Potential problems with food diary

Noncompliance

Inaccurate recording

Atypical intake on recording days

Conscious alteration of diet during recording period

Slide29

Direct Observation

Can lead to detection of problems not readily identified through standard nutrition interviewsObserving typical feeding techniques used by parent or caregiver and interaction between individual and caregiver can be of value in assessing failure to thrive in children or unintentional weight loss in older adults

ChooseMyPlate

, Dietary Guidelines, and Daily Reference Intakes (

DRIs

) are three guides commonly used to determine adequacy or inadequacy of a diet

Slide30

Dietary Reference Intakes (DRIs)

DRIs are recommended amounts of nutrients to prevent deficiencies and reduce risk of chronic diseasesIn addition to recommending adequate intakes, also specify upper limits of nutrients to avoid toxicity

With increased use of dietary supplements, risk for nutrient toxicities is on rise

Slide31

Subjective Data

Eating patternsUsual weightChanges in appetite, taste, smell, chewing, swallowingRecent surgery, trauma, burns, infection

Chronic illnesses

Vomiting, diarrhea, constipation

Food allergies or intolerances

Medications or nutritional supplements

Self-care behaviors

Alcohol or illegal drug use

Exercise and activity patterns

Slide32

Eating Pattern Questions

Number of meals/snacks per day?Kind and amount of food eaten?Fad, special, or alternative diets?Where is food eaten?Food preferences and dislikes?

Religious or cultural restrictions?

Able to feed self?

Slide33

Usual Weight Questions

What is your usual weight?20% below or above desirable weight?Recent weight change?How much lost or gained?Over what time period?

Reason for loss or gain?

Slide34

Subjective Data Related to Nutritional History

Changes in appetite, taste, smell, chewing, swallowingRecent surgery, trauma, burns, infectionChronic illnesses

Nausea, vomiting, diarrhea, constipation

Food allergies or intolerances

Medications and nutritional supplements

Self-care behaviors

Alcohol or drug use

Exercise and activity patterns

Family history

Slide35

History for Infants and Children

Dietary historiesFor infants and children generally obtained from child’s parents, guardian, babysitter, or daycare centerUsually, person responsible for food preparation is able to provide fairly accurate dietary history

Having caregivers keep thorough daily food diary and occasionally requesting 24-hour recalls during clinic visits are most commonly employed techniques for this population group

Slide36

History for Infants and Children (Cont.)

Gestational nutritionMaternal history of alcohol or illegal drug use?Any diet-related complications during gestation?

Infant’s birth weight?

Any evidence of delayed physical or mental growth?

Infant breastfed or bottle-fed?

Type, frequency, amount, and duration of feeding?

Any difficulties encountered?

Timing and method of weaning?

Child’s willingness to eat what is prepared

Slide37

History for Adolescents

Your present weightWhat would you like to weigh?How do you feel about your present weight?On any special diet to lose weight?

On other diets to lose weight? If so, were they successful?

Constantly think about “feeling fat”?

Intentionally vomit or use laxatives or diuretics after eating?

Slide38

History for Adolescents (Cont.)

Use of anabolic steroids or other agents to increase muscle size and physical performance?When? How much? Any problems?

Use of caffeinated, energy-boosting drinks? When? Type? Duration?

What

snacks or fast foods

do you like to eat?

Age first started menstruating

Slide39

History for Pregnant Women

How many times have you been pregnant?When?Any problems encountered during previous pregnancies?Problems this pregnancy?What foods do you prefer when pregnant?

What foods do you avoid?

Crave any particular foods?

Slide40

History for Aging Adults

How does your diet differ from when you were in your 40s and 50s?Adequate vitamin D Adequate calcium intakeReview the Mini Nutritional Assessment Tool (MNA

)

Slide41

Objective Data: Clinical Signs

Observation of general appearanceObese, cachectic (fat and muscle wasting), or edematous, can provide clues to overall nutritional statusMore specific clinical signs and symptoms of nutritional deficiencies can be detected through physical examination and laboratory testing

Because clinical signs are late manifestations of malnutrition, only in areas in which rapid turnover of epithelial tissue occurs, skin, hair, mouth, lips, and eyes, are nutritional deficiencies readily detectable

Slide42

Anthropomorphic Measures

Measurement and evaluation of growth, development, and body compositionMost commonly used anthropometric measuresHeight and weight, triceps skinfold thickness, elbow breadth, arm and head circumferences

Derived weight measure

Three derived weight measures are used to depict changes in body weight

Body weight as a percentage of ideal body weight

Percent usual body weight

Body mass index

Body mass index is practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition

Slide43

Waist-to-Hip-Ratio

Waist-to-hip ratio assesses body fat distribution as an indicator of health riskAndroid obesity: persons with greater proportion of fat in upper body, especially in abdomen

Gynecoid obesity:

persons with most of fat in hips and thighs

Waist circumference is measured in inches at smallest circumference below rib cage and above umbilicus

Hip circumference is measured in inches at largest circumference of buttocks

In addition, waist circumference alone can be used to predict greater health risk

Slide44

Skinfold Thickness

Measurements provide an estimate of body fat stores or extent of obesity or undernutritionAlthough other sites can be used (biceps, subcapsular, or suprailiac skinfolds), triceps skinfold (TSF) is most commonly selected because of its easy accessibility and because standards and techniques are most developed for this site

In preparation to measure TSF thickness

Have ambulatory person stand with arms hanging freely at the sides and back to examiner

Nonambulatory

persons should lie on one side with uppermost arm fully extended and palm of hand on thigh

Slide45

To Measure TSF Thickness

Using the thumb and forefinger of your left hand, gently grasp a fold of skin and fat on posterior aspect of person’s left upper arm, midway between acromion process of scapula and olecranon process, tip of elbow

Gently pull skinfold away from underlying muscle

While grasping skinfold, pick up calipers with your right hand and depress spring-loaded lever

Apply caliper jaws horizontally to fat fold

Release lever of calipers while holding skinfold

Wait 3 seconds, and then take a reading

Slide46

To Record and Interpret TSF Thickness

Repeat three times and average three skinfold measurementsRecord measurements to nearest 5 mm (0.5 cm) on nutritional assessment data formCompare person’s measurements with standards by age, sex, and body frame size

Slide47

Techniques to Measure Body Composition

Two newer techniques to measure body compositionBioelectrical impedance analysis (BIA)Dual-energy x-ray absorptiometry (DEXA) Both BIA and DEXA measure fat and lean body mass

In addition, DEXA measures bone mineral density

Slide48

Arm-Span Measurement

Arm span or total arm lengthUseful for situations in which height difficult to measure, such as children with cerebral palsy or scoliosis or in aging persons with spinal curvatureArm span, which is nearly equivalent to height, is sometimes used clinically instead of height

Ask person to hold arms straight out from sides of body

Measure distance from tip of middle finger on one hand to that on other hand

Slide49

Frame Size Measurement

Calculated to determine appropriate range of ideal body weightMost weight standards of ideal weight for height contain classifications of weight by frame sizeElbow breadth, a measure of skeletal breadth, is most accurate method to determine frame size

To measure it, you must be familiar with use of flat-blade sliding calipers or broad-blade anthropometer

Slide50

Developmental Competence

Infants, children, and adolescentsWeightDuring infancy, childhood, and adolescence, height and weight should be measured at regular intervals, because longitudinal growth is one of best indices of nutritional status over time

Skinfold thickness

Determination of skinfold thickness and/or body mass index may be useful in evaluating childhood and teenage overnutrition

Slide51

Developmental Competence (Cont.)

Pregnant womanWeightMeasure weight monthly up to 30 weeks’ gestation

Then every 2 weeks

During last month of pregnancy weight should be measured weekly

Slide52

Developmental Competence (Cont.)

Aging adultHeight age, height declines in both men and women very slowly from early 30s

Height measures may not be accurate in individuals confined to a bed or wheelchair or those over 60 years of age because of osteoporotic changes

Therefore, arm span, which is correlated with height, may be better measure for elderly

Slide53

Developmental Competence (Cont.)

Aging adult Other measurementsMAC and TSF measures

may not be accurate and are difficult to obtain in older adults because of sagging skin, changes in fat distribution, and declining muscle mass

Body mass index and waist-to-hip ratio

are better indicators of obesity in this age group

Slide54

Laboratory Studies

Laboratory studies are objective and can detect preclinical nutritional deficiencies and can be used to confirm subjective findingsUse caution when interpreting test results that may be outside normal ranges, because they do not always reflect nutritional problems and because standards for aging adults have not yet been firmly established

Slide55

Laboratory Studies (Cont.)

Best routinely performed laboratory indicators of nutritional statusHemoglobinHematocrit

Cholesterol

Triglycerides

Total lymphocyte count

Serum albuminGlucose, low- and high-density lipoproteins, prealbumin, transferrin, and total protein levels also provide meaningful information

Slide56

Laboratory Studies (Cont.)

Skin testingAdequate immunity can be demonstrated by a positive reaction to multiple skin test antigensIn these tests of immune function, at least six antigens injected intradermally in forearm area, and response (redness or induration) noted at 24 and 48 hours

5 mm or greater response to more than one antigen is generally considered to be positive reaction (i.e., indicative of adequate immunity)

Commonly used antigens include

Candida

, tetanus toxoid, diphtheria toxoid, streptococcus, old tuberculin, proteus, and

Trichophyton

Slide57

Laboratory Studies (Cont.)

Nitrogen balanceAlso used as an index of protein nutritional statusNitrogen is released with catabolism of amino acids and excreted in urine as urea

Indicates whether person is anabolic (positive nitrogen balance) or catabolic (negative nitrogen balance)

Creatinine-height index

Method of estimating skeletal muscle mass

Creatinine derived from breakdown of creatine, an energy-containing complex found in muscle

Excreted unchanged in urine at constant rate in proportion to amount of body muscle

Slide58

Laboratory Studies Life Cycle

Infancy and childhoodLaboratory tests performed only when undernutrition suspected or if child has acute or chronic illnesses that affect nutritional statusAdolescenceUnless overt disease suspected, laboratory evaluation of hemoglobin and hematocrit levels and urinalysis for glucose and protein levels are adequate

Slide59

Laboratory Studies Life Cycle (Cont.)

Pregnant womanHemoglobin and hematocrit values can be used to detect deficiencies of protein, folate, vitamin B12, and iron

Urine frequently tested for glucose and protein (albumin), which can signal diabetes, preeclampsia, and renal disease

Aging adults

All serum and urine data must be interpreted with understanding of declining renal efficiency and tendency for aging adults to be overhydrated or

underhydrated

Slide60

Serial Assessment

To monitor nutritional status in malnourished individuals or in individuals at risk for malnutritionSerial measurements of nutritional assessment parameters are made at routine intervalsAt a minimum, weight and dietary intake should be evaluated weekly

Because other nutritional assessment parameters change more slowly, data on these indicators may be collected biweekly or monthly

Slide61

Approaches to Weight Loss

Tailored to the individual and culturally sensitiveConsider the patient’s readiness to lose weight and health beliefsCardinal features of a long-term weight loss plan

Regular exercise plan (4 to 5 times a week for 30 minutes minimum)

Eating low-calorie low-fat diet (1400 to 1500 kcal/day and 20% to 25% of calories taken in as low fat)

Monitoring daily food intake and weight (food diary and portion size)

Slide62

Classification of Malnutrition

ObesityMarasmus (protein-calorie malnutrition)Kwashiorkor (protein malnutrition)Marasmus/Kwashiorkor mix

Slide63

Abnormalities Caused by Nutritional Deficiencies

PellagraScorbutic gumsFollicular hyperkeratosisBitot’s spots

Kwashiorkor

Rickets

Magenta tongue

Slide64

Question

Which of the following patients is at the highest risk for nutritional deficits?A 5-month-old infant who is only being breastfed

A 2-year-old toddler who is in the 50th percentile

An 13-year-old female who is 5’3” and weighs 110

lbs

and thinks she’s “fat”

A 65-year-old female who is on a fixed income and is taking five medications

Slide65

Summary Checklist: Nutritional Assessment

Obtain a health history relevant to nutritional statusElicit 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

Slide66

Case Study

A nurse is going to work in a community setting and is preparing for a health promotion class on educating the public regarding weight status. What information would the nurse include in the health promotion class relative to anthropometric measurements? How would you obtain derived body measurements?

Slide67

Case Study (Cont.)

What methods would the nurse use to assess a patient’s nutritional status in a community setting? Compare and contrast the various methods, looking at advantages and disadvantages.

Slide68

Case Study (Cont.)

The nurse working in the community setting has scheduled visits with the following patients:A 28-year-old Gravida 3 Para 2, who is 32 weeks pregnant and has gained a total of 20 pounds thus farA 54-year-old male patient who complains of frequent “reflux” following meals

A 5-year-old toddler whose mother is concerned about his not eating a varied diet, as he refuses to eat most vegetables

Slide69

Case Study (Cont.)

What interventions would the nurse implement relative to nutritional status? The nurse in the community is reviewing laboratory information of the patients seen at the health clinic. Which lab parameters will provide an accurate assessment of an individual’s nutritional status?

Chapter 11 Nutritional Assessment - PowerPoint Presentation

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