Nurses key role in assessment

• assessing the nutritional needs of clients
• monitor and intervene with clients requiring acute and chronic nutritional
  care.
• consider and incorporate the family’s nutritional habits into a client’s individual plan of care.
• take an active role in assessing and teaching community groups regarding nutrition.

Cultural, social, and physical norms must be part of a client’s assessment

Diet History

• is an assessment of usual foods, fluids, and supplements
• Components include the following:
  • ● Time, type, and amount of food eaten for breakfast, lunch, dinner, and snacks
    ● Time, type, and amount of fluids consumed throughout the day, including water, health drinks, coffee/tea, carbonated beverages, and beverages with caffeine
    ● Type, amount, and frequency of “special foods” (celebration foods, movie foods)
    ● Typical preparation of foods and fluids (coffee with sugar, fried foods)
    ● Number of meals eaten away from home (at work or school)
    ● Type of preferred or prescribed diet (ovo-lacto vegetarian, 2 g sodium/low-fat diet)
    ● Foods avoided due to allergy or preference
    ● Frequency and dose/amount of medications or nutritional supplements taken daily
    ● Satisfaction with diet over a specified time frame (last 3 months, 1 year)

physical assessment

• is performed by the provider or nurse to identify indicators of inadequate nutrition.
• However, other diseases, or conditions can cause these
  clinical findings.

Manifestations - Inadequate Nutrition

● Hair that is dry or brittle, or skin that has dry patches
● Poor wound healing or sores
● Lack of subcutaneous fat or muscle wasting
● Irregular cardiovascular measurements (heart rate and rhythm, blood pressure)
● Enlarged spleen or liver
● General weakness or impaired coordination

Weight

• Weigh at the same time of day wearing similar clothingto ensure accurate weight readings.
• Daily fluctuations generally are indicative of water weight changes.
• Percentage weight change calculation (weight change over a specified time):
  • % weight change = (Usual weight - present weight / usual weight) x 100
  • Greater than 2% in 1 week indicates a significant weight loss.
  • Greater than 7.5% in 3 months indicates a significant weight loss

“Ideal” body weight based on height (plus or minus 10% depending on frame size).

◯ MALES: 48 kg (106 lb) for the first 152 cm (5 ft) of height, and 2.7 kg (6 lb) for each additional 2.5 cm (1 in).

◯ FEMALES: 45 kg (100 lb) for the first 152 cm (5 ft) of height, and 2.3 kg (5 lb) for each additional 2.5 cm (1 in)

Height

● Measure on a vertical, flat surface. Ask the client to remove shoes and head coverings and stand straight with heels together looking straight ahead.
● Obtain a recumbent measurement (lying on a firm, flat surface) for infants and young children.

Body mass index (BMI)

• Healthy weight is indicated by a BMI of 18.5 to 24.9.
• Overweight is defined as an increased body weight in relation to height. It is indicated by a BMI of 25 to 29.9.
• Obesity is an excess amount of body fat. It indicated by a BMI greater than or equal to 30.
• BMI = weight (kg) ÷ height (m2)

Fluid intake and output (I&O)

● Adults: 2,000 to 3,000 mL (2 to 3 L) per day
● Total average output: 1,750 to 3,000 mL/day

Protein levels

are measured by serum albumin levels. Many non-nutritional factors (injury or kidney disease), interfere with this measure for protein malnutrition.

Prealbumin (thyroxine-binding protein)

is a sensitive measure used to assess critically ill clients who are at risk
for malnutrition. This test reflects acute changes rather than gradual changes. However, it is more expensive and often unavailable. This is not part of routine assessment.
● Prealbumin levels can decrease with an inflammatory process resulting in an inaccurate measurement.
● Prealbumin levels are used to measure effectiveness of total parenteral nutrition.

Nitrogen balance

refers to the relationship between protein breakdown (catabolism) and protein
synthesis (anabolism).

How to measure Nitrogen Balance

• Record protein intake (g) over 24 hr and divide by 6.25.
• Record nitrogen excretion in urine over 24 hr and add 4 g.
• Subtract nitrogen output from nitrogen intake.
• 24 hr protein intake ÷ 6.25 = nitrogen intake (g)
• 24 hr urinary urea nitrogen + 4 g = total nitrogen output
• Nitrogen intake ‑ total nitrogen
  output = nitrogen balance
  • A neutral nitrogen balance indicates adequate
    nutritional intake
  • A positive nitrogen balance indicates protein synthesis is greater than protein breakdown as during growth, pregnancy, or during recovery.
  • A negative nitrogen balance indicates protein is used at a greater rate than it is synthesized as in starvation or a catabolic state following injury or disease.

BIOPHYSICAL FACTORS FOR INADEQUATE NUTRITION

● Medical disease/conditions/treatment (hypertension, HIV/AIDS, surgery)
● Genetic predisposition (lactose intolerance, osteoporosis)
● Age

PSYCHOLOGICAL FACTORS FOR INADEQUATE NUTRITION

● Mental illness (clinical depression)
● Excessive stress
● Negative self-concept
● Use of comfort foods

SOCIOECONOMIC FACTORS FOR INADEQUATE NUTRITION

● Poverty
● Alcohol and other substance use disorders
● Fad or “special” diets
● Food preferences: cultural, ethnic, or religious