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NUTRITION

ASSESSMENT

NUTR 2050 Nutrition for Nursing Professionals

Mrs. Deborah A. Hutcheon, MS, RD, LD

Lesson Objectives At the end of the lesson, the student will be able to:

1. Define the 4 steps of the Nutrition Care Process.

2. Identify individuals most prone to nutrition risk.

3. Distinguish between a nutrition screen & nutrition assessment.

4. Identify factors that affect the accuracy of a patient’s wt measure.

5. Calculate BMI, %IBW, and % weight loss.

6. Identify tissues that may demonstrate nutrient deficiencies.

7. Differentiate between the 4 methods of assessing dietary quality.

8. Identify the nutrition composition of standard therapeutic diets.

Nutrition Care Process

NCP Steps

Problem Identification

1) Nutrition Assessment:

Gather Data/Analyze Data

2) Nutrition Diagnosis

Problem Solving

3) Nutrition Intervention:

Develop/Implement Plan

4) Monitoring & Evaluation

Referred to as A D I M E

Assessment

Diagnosis

Intervention

Monitoring

Evaluation

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Pre-Process: Nutrition Screening What does it do? Quick identification of those at nutrition risk.

What is its purpose? Promote health prevention to reverse, retard, or halt progress of disease by detecting it as soon as possible.

Answers the Questions:

• Does a problem exist?

• Does the person need further investigation & treatment of the problem?

Nutrition Screening Initiative

Disease

Eating poorly

Tooth loss/mouth pain

Economic hardship

Reduced social contact

Multiple medicines

Involuntary weight loss/gain

Needs assistance in self-care

Elder years above age 80 http://www.healthcare.uiowa.edu/igec/tools/nutrition/determineNutrition.pdf

http://www.mna-elderly.com/forms/mini/mna_mini_english.pdf

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NCP Step 1: Nutrition Assessment

• A comprehensive evaluation carried out by a RD for defining nutrition status using medical, social, nutritional, and medication histories, physical examination, anthropometric measurements, and laboratory data

• Purpose: gather adequate information in which to make a professional judgment about nutrition status (interpret information according to standards)

• First step of the Nutrition Care Process

• An ongoing process with reassessment as needed and as outcomes change.

NCP Step 1: Nutrition Assessment

• A major focus of nutritional assessment is to identify any potential nutritional problems.

• A nutritional problem is any situation or condition that may adversely impact nutritional status and impede recovery.

• A nutrition problem usually becomes a nutrition diagnosis.

Gathering Information: ABCD Model

Anthropometric: height, weight, history/changes

Biochemical: laboratory values

Clinical: physical exam, visual assessment

Dietary: diet, intake, appetite, allergies

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Anthropometrics: Physical Measurements

Height, Weight, Waist Circumference

Accurate measurements over period of time.

Don’t just ask, measure!!

Weight Measurements: scale calibration & time of day

Height Measurements: direct vs. indirect (arm span)

Classification of Weight Status

Body Mass Index (BMI)

Underweight <18.5

Healthy 18.5 – 24.9

Overweight 25 – 29.9

Obesity (Grade I) 30 – 34.9

Obesity (Grade II) 35 – 39.9

Extreme Obesity (Grade III) 40+

Calculating IBW (Hamwi Formula)

• Men: IBW = 106# + 6# for every inch >60 ins

• Women: IBW = 100# + 5# for every inch >60 ins

Adjust for frame size: +/-10%

%IBW = actual body weight x 100

IBW

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Calculating Weight Loss

% Weight Loss = UBW – Actual Weight x 100

UBW

% Weight Change Time Frame Nutrition Status

1-2% 1 week Moderate Wt Loss

>2% 1 week Severe Wt Loss

≥5% 1 month Severe Wt Loss

≥7.5% 3 months Severe Wt Loss

≥10% 6 months Severe Wt Loss

Let’s Practice: A Case Study

Mr. Carr is a 75 yr old male living alone. He is seeing the doctor due to a cold and bronchitis. He has been losing weight slowly since his wife died a year ago. At 5’8” he weighs 135 lb. His previous normal weight was 160 lb.

“My wife always did the cooking, now I just don’t feel like eating.” He skips breakfast, has soup and bread for

lunch and sometimes eats a cold-cut sandwich or frozen dinner for supper. He lives on a meager income.

1. Calculate his BMI, %IBW, and % weight loss.

2. How would you classify each of these?

Biochemical: Laboratory Values

• Comparison with known standard.

• Comparison with baseline.

• Comparison over time.

• Evaluate test results in light of patient’s current medical

condition.

• Factors Affecting Results: hydration status, age,

medication usage, current medical condition

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Inflammation & Protein

• Body’s natural stress response produces

inflammatory responses causing increased protein

synthesis in the liver and degradation of muscle

protein to meet the demand

• Acute phase proteins: proteins whose concentration

fluctuates in response to tissue injury (i.e. trauma, MI,

acute infections, malignancy, burns, and chronic

inflammation)

Inflammation & Protein

• Negative Acute-Phase Respondents: plasma

proteins whose concentrations DECREASE during

inflammatory conditions

• Albumin, Pre-albumin, Retinol-binding protein

• Positive Acute-Phase Respondents: plasma

proteins whose concentrations INCREASE during

inflammatory conditions

• C-reactive protein, fibrinogen, ferritin

Biochemical Assessment of Protein

Albumin Pre-Albumin

LT Marker (3 mo) ST Marker (1 wk)

Normal 3.5-5.0 g/dL 16-40 mg/dL

Mild Depletion 3.0-3.5 g/dL 10-15 mg/dL

Moderate Depletion 2.4-2.9 g/dL 5-9 mg/dL

Severe Depletion <2.4 g/dL <5 mg/dL

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• Observe the patient’s gait, movements, posture.

• Focus on rapidly proliferating tissues

• What tissues?

• Why?

• Side note: Consider chemotherapy’s affect.

• Observe overall appearance: muscle wasting,

edema (swelling), change in metal status

Clinical: Physical Examination

Oral Indications of Nutrient Deficiency

Red, Bleeding

Gums

Glossitis/Magenta

Tongue

Cheilosis

Hyperkeratosis

Petichial Hemorrhage

Dermatitis

Dermatological Indications of Nutrient Deficiency

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Dermatological Indications of Nutrient Deficiency

Edema--Protein

Rickets—Vitamin D Muscle

Wasting

Other Indications of Nutrient Deficiency

Clinical: Disease State

Moderate Nutrition Risk High Nutrition Risk

Age 65-75 YO 75 YO

Disease/Dx

Heart, Pain,

Orthopedics,

Short Stay

Cancer, Renal, Pancreas,

Liver, GI, Eating Disorder,

Transplant, PEM

Feeding Modified Oral Diet

Parenteral Nutrition (PN)

Enteral Nutrition (EN)

NPO

Clear Liquids >3 days

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1. Daily Food Record or Food Diary

2. Food Frequency Questionnaire

http://riskfactor.cancer.gov/diet/FF

Q.English.June0304.pdf

3. 24-Hour Recall

4. Nutrient Intake Analysis, or

Calorie Count (3 Days, or 72 hrs)

Diet: Diet History

• Nutrition diagnosis (ND) is the identification and labeling

of an existing nutrition problem that the nutrition

professional is responsible for “treating” independently.

• Nutrition diagnostic statement includes:

1. Problem (diagnostic label)

2. Etiology (cause/contributing factor)

3. Signs/Symptoms

NCP Step 2: Nutrition Diagnosis

Nutrition Problem:

Factors Affecting Food Intake

1. Economic situation

2. Emotional climate

3. Cultural influences

4. Effects of disease state on appetite

5. Ability to consume and absorb nutrients

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1. Physiologic stressors—infection, acute or chronic

disease, fever, trauma

2. Anabolic states—pregnancy or rehab

3. Body maintenance

4. Psychological stress

Nutrition Problem:

Factors Affecting Nutrient Requirements

1. Inadequate ingestion (poor intake)

2. Impaired ability to intake nutrients

3. Impaired digestion or absorption

4. Dysfunctional metabolic processing

5. Increased excretion

Nutrition Problem:

Factors Causing Nutrient Deficiency

1. Impaired growth and development

2. Overweight or underweight

3. Impaired immunity

4. Poor wound healing

5. Poor clinical outcome—morbidity and mortality

• Morbidity: incidence of disease

• Mortality: incidence of causing death

Nutrition Problem:

Factors Resulting in Nutrient Deficiency

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Let’s Practice: A Case Study

Mr. Carr is a 75 yr old male living alone. He is seeing the doctor due to a cold and bronchitis. He has been losing weight slowly since his wife died a year ago. At 5’8” he weighs 135 lb. His previous normal weight was 160 lb.

“My wife always did the cooking, now I just don’t feel like eating.” He skips breakfast, has soup and bread for

lunch and sometimes eats a cold-cut sandwich or frozen dinner for supper. He lives on a meager income.

1. Identify Mrs. Carr’s main nutrition problem.

2. What are some factors contributing to his nutrition problem?

Sarcopenia

Characteristics…as natural part of aging process

1. Gradual decline in skeletal muscle mas

2. Subsequent decline in strength &/or performance

Aging promotes ↓ LBM & ↑ in lipogenesis

1. Decline in protein synthesis & cell mass

2. Decline in physical activity

3. Increase in proteolysis (diminished sex hormones

& increase pro-inflammatory cytokines)

Cachexia

Characteristic…as part of metabolic stress

• Loss of muscle mass with or without fat loss

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Sarcopenia vs. Cachexia

Source: Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and

diagnosis. Age Aging. 2010:39:412-423.

Source: Evans WJ, Morley JE, Argiles J, et al. Cachexia: a new definition. Clin Nutr. 2008:27(6):793-799.

Malnutrition (AND/ASPEN Definition)

2 or More Present for Dx:

1. Insufficient Kcal Intake

2. Weight Loss

3. Loss Muscle Mass

4. Loss Subcutaneous Fat

5. Local or General Edema

6. Diminished Functional

Status Source: White JV, Guenter P, Jensen G, et al. Consensus statement

of the Academy of Nutrition and Dietetics/American Society for

Parenteral and Enteral Nutrition: characteristics recommended for the

identification and documentation of adult malnutrition (undernutrition).

J Acad Nutr Diet. 2012;112(5):730-738.

Nutrition Intervention Terminology

Food and/or

Nutrient Delivery

Nutrition

Education

Nutrition

Counseling

Coordination of

Nutrition Care

An individualized

approach for

food/nutrient

provision, including

meals and snacks,

enteral and

parenteral feeding, and supplements.

A formal process

to instruct or train

a patient/client in

a skill or to impart

knowledge to help

patients/clients

voluntarily manage or modify

food choices and

eating behavior to

maintain or

improve health.

A supportive

process,

characterized by a

collaborative

counselor-patient

relationship, to set

priorities, establish

goals and create

individualized

action plans that

acknowledge and

foster

responsibility for

self-care to treat

an existing

condition

And promote

health.

Consultation with,

referral to, or

coordination of

nutrition care with

other health care

providers,

institutions, or agencies that can

assist in treating

or managing

nutrition-related

problems.

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Therapeutic Diets

Diet Other Names Components

Regular House or Standard No dietary restriction.

Diabetic

Consistent Carbohydrate

No Concentrated Sweets

Controlled CHO servings.

Standard pattern = 3 to 4 CHO per meal & 1 to 2 CHO per snack.

Use sugar substitutes. No added sugar.

Cardiac Heart Healthy

Low Fat = 80 grams fat

Low Sodium = 2g Na (no salt packet)

Low Cholesterol = 300 mg cholesterol

Renal

Low sodium (2 g)

Low potassium (1.2 g)

Low phosphorus (800 mg)

Fluid restriction (1.5 L)

Therapeutic Diets

Diet Components

Clear Liquid

Permits: tea, broth, ginger ale, clear fruit juices, gelatin

Omits: milk & milk-based products & juices with pulp

Nutritionally Inadequate: 500 kcal, 5-10 g pro, 120g CHO

Full Liquid

Clear liquid diet items plus dairy products—milk, yogurt, cream soups, ice cream/sherbet

Transitional use—question of benefit?

Nutritionally Inadequate: 1000 to 1500 kcal, 45 g pro,

50 to 65 g fat, 150 to 170 g CHO

NPO

Nothing by Mouth—no food to be offered.

Dysphagia Diets

Diet Components

NDD1

(Puree)

Foods blended to smooth, pudding consistency.

No coarse or crunchy textures, raw F/V, nuts, etc.

NDD2

(Ground)

Food ground to no larger than ¼ inch. Gravy and sauce

added for moistness.

No mixed textures. No coarse or crunchy textures.

NDD3

(Chopped)

Regular texture for most foods.

Avoids foods that are very hard, sticky, or crunchy.

Meat cut into bite size pieces.

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Dysphagia Diets

Diet Components

Thin Liquid Normal liquid consistency. No restriction.

Thickened Liquid

**No Straws!

**Temperature!

Nectar: beverage coats & drips off spoon (unset gelatin)

Honey Thick: flows off spoon like a ribbon of honey

Spoon Thick/Pudding Thick: stays on spoon in soft mass

Other Therapeutic Diets

• Low-Residue (limits fiber, milk, caffeine, fermented items):

use for individuals with GI conditions

• Lactose-Free Diet: all milk & dairy products omitted in

addition to foods containing such products

• BRAT: banana, rice, applesauce, toast

• High Protein/High Calorie

• Allergen-Specific Diet

Vegan/Vegetarian Diets

• Individuals espouse vegetarianism for health benefits,

religious beliefs, &/or ethical convictions

• Vegan: strictest, do not consume any animal-based foods

• Lacto-ovo-vegetarian: will consume dairy and egg products

but refrains of meat and poultry products

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Kosher Diets (Jewish)

• No pork products (pork chops, bacon, sausage, ham,

animal shortenings, animal gelatin)

• No fish without scales or fins (eel, shellfish, octopus)

• No meat or poultry in combination with dairy products

• No dairy containing beverages until 6 hours after eating

• No food containing blood

Halal Diet (Islam/Muslim)

• Halal: specifications for slaughter & preparation of meat

(permitted foods)

• Haram: forbidden foods

• No pork products; No products with blood.

• No alcoholic beverages or other intoxicants

• Use of stimulants (caffeine) is discouraged

Other Religious Diets

Roman Catholicism—Fish on Friday (no meat)

Buddhism & Hinduism—Vegetarianism

7th Day Adventist—Recommend Vegetarianism

Avoid snacks, hot spices, alcohol, caffeine

Church of Jesus Christ of LDS (Mormons)

Discourages alcohol & caffeine

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Nutrition Supplements

Nutrition Supplements

Let’s Practice: A Case Study

Mr. Carr is a 75 yr old male living alone. He is seeing the doctor due to a cold and bronchitis. He has been losing weight slowly since his wife died a year ago. At 5’8” he weighs 135 lb. His previous normal weight was 160 lb.

“My wife always did the cooking, now I just don’t feel like eating.” He skips breakfast, has soup and bread for

lunch and sometimes eats a cold-cut sandwich or frozen dinner for supper. He lives on a meager income.

1. What might be some interventions to address promoting factors and correct his nutrition problem?