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
Download The PPT/PDF document "Chapter 11 Nutritional Assessment" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Chapter 11
Nutritional Assessment
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
Slide2Nutritional 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
2
Slide3Defining 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
3
Slide4Undernutrition
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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
4
Slide5Overnutrition
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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
5
Slide6Overnutrition 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
6
Slide7Question
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
7
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
Slide8Developmental 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
8
Slide9Developmental 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
9
Slide10Developmental 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
10
Slide11Developmental 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
11
Slide12Developmental 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
12
Slide13Developmental 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
13
Slide14Developmental 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
14
Slide15Developmental 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
15
Slide16Cultural 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
16
Slide17Cultural 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
17
Slide18Cultural 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
18
Slide19Cultural 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
19
Slide20Cultural 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
20
Slide21Dietary 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
21
Slide22Nutritional 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
22
Slide23Nutrition 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
23
Slide24Nutrition 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
24
Slide25Nutrition 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
25
Slide2624-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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
26
Slide27Food 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
27
Slide28Food 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
28
Slide29Direct 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
29
Slide30Dietary 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
30
Slide31Subjective 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
31
Slide32Eating 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?
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
32
Slide33Usual 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?
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
33
Slide34Subjective 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
34
Slide35History 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
35
Slide36History 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
36
Slide37History 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?
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
37
Slide38History 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
38
Slide39History 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?
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
39
Slide40History 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
)
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
40
Slide41Objective 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
41
Slide42Anthropomorphic 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
42
Slide43Waist-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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
43
Slide44Skinfold 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
44
Slide45To 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
45
Slide46To 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
46
Slide47Techniques 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
47
Slide48Arm-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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
48
Slide49Frame 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
49
Slide50Developmental 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
50
Slide51Developmental 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
51
Slide52Developmental 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
52
Slide53Developmental 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
53
Slide54Laboratory 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
54
Slide55Laboratory 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
55
Slide56Laboratory 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
56
Slide57Laboratory 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
57
Slide58Laboratory 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
58
Slide59Laboratory 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
59
Slide60Serial 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
60
Slide61Approaches 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)
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
61
Slide62Classification of Malnutrition
ObesityMarasmus (protein-calorie malnutrition)Kwashiorkor (protein malnutrition)Marasmus/Kwashiorkor mix
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
62
Slide63Abnormalities Caused by Nutritional Deficiencies
PellagraScorbutic gumsFollicular hyperkeratosisBitot’s spots
Kwashiorkor
Rickets
Magenta tongue
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
63
Slide64Question
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
64
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
Slide65Summary 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
65
Slide66Case 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?
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
66
Slide67Case 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.
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
67
Slide68Case 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
68
Slide69Case 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?
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
69