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Jarvis: Physical Examination and Health Assessment, 5th edition Instructors Manual Chapter 11: Nutritional AssessmentANNOTATED LEARNING OBJECTIVES At the completion of this chapter, the student will: Define nutritional status. The degree of balance between nutrient intake and nutrient requirement is referred to as nutritional status. As with all aspects of assessment, several factors can affect the health status of a person. For nutrition assessment, the physiologic, psychosocial, developmental, cultural, and economic aspects of the individuals life must be considered. The health practitioner needs to determine whether the patient has optimal nutrition, undernutrition, or overnutrition. Describe the unique nutritional needs for various developmental periods throughout the life cycle. Although nutritional assessment should be included consistently in the provision of health care, recognition of nutritional needs for each stage of development will enable the health care provider to better meet those needs. Each of the following groups has special nutritional needs: infancy and childhood, adolescence, pregnancy and lactation, adulthood, and older adulthood. Describe the role cultural heritage and values may play in an individuals nutritional intake. Although each patient must be viewed as an individual within his or her environment, knowledge of the role of food in the cultural groups within the health care service area will increase the ability of the health care provider to meet individual needs. Some areas to be considered when completing an individual nutritional assessment include the role of cultural values and heritage, in addition to occupation, socioeconomic group, religion, health awareness, patterns of eating, and dietary practices. It is important, however, to avoid cultural stereotyping. State the purposes of a nutritional assessment. Three purposes for completing a nutritional assessment are (1) to identify persons who are malnourished, including overnutrition and undernutrition, or to identify persons who are at risk for developing malnutrition; (2) to obtain data for developing a nutrition plan that will prevent or decrease the development of malnutrition; and (3) to establish baseline data for the evaluation of the effectiveness of nutritional care. Describe the components of a nutritional assessment. A comprehensive nutritional assessment is used for persons identified as being at nutritional risk. Nutrition screening is the first step in the nutritional assessment. On the

Elsevier items and derived items 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Instructors Manual basis of the data obtained, patients can be identified for nutritional risk. Weight and weight history, conditions associated with increased nutritional risk, dietary history, direct observation, anthropometric measures, and routine laboratory data are used as parameters for screening. Discuss the strengths and limitations of the methods used for collecting current dietary intake.

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The 24-hour diet recall can be obtained during the nutritional assessment and is therefore easy to use. Sources of error with this method include the following: the historian may be unable to recall the type or amount of food eaten; the last 24 hours may be atypical of usual intake; the historian may alter the truth or underestimate serving size; and the historian may underreport snack items and gravies, sauces, and other additives. A food frequency questionnaire can also be completed during the nutritional assessment interview and is therefore easy to use. Limitations of this method include the absence of quantity or serving size of food eaten and the dependence on the historians memory. Food diaries have the potential to be a more accurate representation of dietary intake. However, potential problems also exist for this method. These include noncompliance, inaccurate recording, atypical intake on the recording days, and conscious alteration of diet during the recording period. Direct observation of the feeding and eating process can lead to detection of problems not readily identified by standard nutrition reviews. Use anthropometric measures and laboratory data to assess the nutritional status of patients. Various methods of determining nutritional status through body measure and laboratory data have been described in the text. Accurate identification of nutritional problems allows for earlier intervention. Use nutritional assessment in the provision of health care and for health promotion. As with all aspects of health assessment, the goal of nutritional assessment is to identify actual or potential health problems and provide individualized care toward resolution of the problem. Health promotion concepts regarding a healthy diet and approaches for weight loss for the overweight person are discussed. KEY TERMS 24-hour recall questionnaire anthropometry arm span body mass index cachectic cultural stereotyping food diary food frequency questionnaire frame sizeElsevier items and derived items 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Instructors Manual kwashiorkor marasmus mid arm muscle area mid upper arm circumference mid upper arm muscle circumference nutritional assessment nutritional screening nutritional status obesity overnutrition nitrogen balance percent ideal body weight percent usual body weight serum albumin serum transferrin skinfold thickness undernutrition waist-to-hip ratio TEACHING STRATEGIES Have the students search the Internet for dietary assessment instruments.

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Discuss the impact of economic factors and living situation on food choices. Without advanced notice (so that food intake wont be altered), have students relate the results of a personal 24-hour record of food intake to the Food Guide Pyramid. Using the suggested questions provided at the end of this section and the nutritional assessment forms provided in the text, have students complete a screening and comprehensive nutritional assessment of a peer. Using the suggested questions provided at the end of this section and the nutritional assessment forms provided in the text, have students complete a nutritional screening or assessment of a patient. Using the charting formats of the clinical agencies used by the school, have students document the results of the above screening or assessment and other relevant data (see Performance Checklist). Assign students to provide nutrition counseling to a patient on the basis of the above assessment. When possible, use a variety of clinical settings: acute care, long-term care, rehabilitation, community, and home. Have students discuss the similarities and


Instructors Manual differences of their findings.

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Assign students to examine frozen and prepackaged food for nutritional value. Assign students to examine the nutritional value of the foods available in local fast food establishments. Discuss the implications of the above examination for patients who are on various special diets such as low sodium, calorie restriction, low fat, and so forth. Discuss drug/food interactions that must be included in patient teaching. Assign students to conduct a nutritional assessment of a person from a different culture. Have them describe the nutritional implications of the cultural values of the person. Have nursing students visit a grammar school or high school and assess the school lunch program in relation to the Food Guide Pyramid. Is good nutrition provided? Do they have suggestions for change? Are food machines in the school? If so, evaluate choices. Have nursing students visit a soup kitchen or other public-assistance food distribution center and have them assess the food given in relation to the Food Guide Pyramid. Is good nutrition provided? Do they have suggestions for change? Ask students to share any cultural practices that may exist in their families regarding nutrition and meals.

CRITICAL THINKING EXERCISES Application to Clinical Practice For each person described in the situations below, have students discuss the developmental, age, socioeconomic, and cross-cultural considerations that should be considered during the gathering of subjective and objective data and the provision of health care. In addition, have students relate findings to the food pyramid for adequacy of diet or the identification of nutritional deficiencies. Calculate anthropometric measures with the data provided. Use the screening nutritional assessment form found in the text to determine whether additional information is needed to make a judgment and individualize the plan of care. When indicated, identify at least one relevant nursing diagnosis for any actual or potential problem identified and, in particular, address any health-teaching needs of the patient.

K. B., age 30 years, is 55 and weighs 350 pounds. She has two children, ages 3 and 5 years. K. B. is employed as a secretary, earning $20,000 a year. A 24-hour food record reveals the use of prepackaged food and snacks with high-fat, high-salt content. L. R., age 16 years, was in an auto accident 2 months ago in another state. He was hospitalized a total of 5 weeks, 4 of which were in an intensive care unit. He was on a ventilator for 3 weeks and did not receive tube feedings. Weight before accident was 195 pounds and height is 61. Current weight is 155 pounds. Appetite is good, and he


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is able to eat now at preaccident ability. He has been referred to the home health agency for care of a pressure ulcer on his heel that developed during hospitalization.

P. S. has been transferred to a cardiac step-down unit. She has been complaining of nausea and vomiting since her physician changed her medications. After reporting her symptoms to the physician, who adjusted her medications, the nurse begins a health interview. P. S. indicates that she and her husband each have two to three martinis each evening. Albumin is noted to be 3.3 g/dl. H. M. has come to the health clinic for a follow-up visit. Her primary health problem is asthma. Medications include aminophylline, begun at the last visit. Interview reveals anorexia, and the health practitioner notes a weight loss of 20 pounds since the last visit. K. K. has been admitted to a long-term care facility. He had a CVA 1 month ago, resulting in right-sided paralysis. Review of the record indicates that fluids were initially provided by IV. After swallowing studies, the patient was placed on a pureed diet. The patient is right handed. Comparison of weight before illness as reported by the patients wife and admitting weight reveals a weight loss of 30 pounds. The patient is 5 8 and weighed 180 pounds before onset of illness. Albumin is 3.1 g/dl, hemoglobin is 12, and hematocrit is 35. R. M. has brought her 5-month-old infant to the health clinic for a routine visit. Weight at birth was 9 pounds 1 ounce, and length was 21 inches. Current weight is 30 pounds and length is 24 inches. When asked, R. M. states that the child takes between 9 and 10 bottles of formula a day in addition to solid foods three times a day. T. G., age 75 years, has come to his health care provider complaining of insomnia and abdominal pain. Examination reveals a weight loss of 20 pounds since his last visit 6 months ago. The health care provider is aware that T. G.s wife, who did the shopping and cooking for both of them, died 5 months ago. Income is Social Security and a small pension. J. D., age 212 years, is brought to the clinic by his mother. He is in the 85th percentile for height and weight. His mother is upset because he refuses most of his food and demands PJ, his term for peanut butter and jelly sandwiches. E. S., age 16 years, has been on Accutane for acne for 3 months. At this visit, she indicates that she is very happy with her appearance and clear skin. However, her mother tells the nurse, privately, that E. S. has lost 15 pounds and has shown no interest in eating. R. T., age 48 years, is in the office for her annual gynecologic exam. She is surprised to see that her weight has increased 30 pounds since last year. The urine dipstick results show high levels of glucose and protein in her urine, and her blood pressure is 148/98. R. T. relates that her life has been so stressful since her husband went to work in another state 7 months ago and she is alone to deal with her two teenaged daughters.

WEB SITES OF INTEREST American Diabetes Association, http://www.diabetes.org


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American Dietetic Association, http://www.eatright.org American Heart Association, http://www.americanheart.org Centers for Disease Control and Prevention, http://www.cdc.gov National Institute of Diabetes and Digestive and Kidney Disease, http://www2.niddk.nih.gov Nutrition.gov, http://www.nutrition.gov MyPyramid.gov, http://www.mypyramid.gov Nutrition Explorations, http://www.nutritionexplorations.org MyPyramid Tracker, http://www.mypyramidtracker.gov

PERFORMANCE CHECKLIST Nutritional Assessment Subjective Data Yes Assess for general factors that may influence nutrition Socioeconomic factors Psychologic factors Culture/values Religion/religious practices Food preferences Drug and alcohol intake What is the general appearance of the patient? Request a description of typical eating patterns Does the patient have dentures? If yes, do they fit? Are they used? Is the patient on a special diet? If yes, are adequate nutrients provided by the diet? Does the patient use prepackaged and prepared foods? Does the patient eat fast foods often? Assess diet for adequacy of vitamin and mineral intake. Has there been a recent change in diet? If yes, was this intentional? No Comments


Instructors Manual Are there any food preferences and dislikes? Are there any religious or cultural restrictions? What is the patients usual weight? Has there been a recent weight change? If yes, how much, and over what time period? Reason for gain or loss? Has there been a recent increase or decrease of caloric intake? If yes, was this intentional? Has there been a recent change in bowel habits, mobility, physical exercise? Have the patient describe his or her life style as active, sedentary, etc. Does the patient have a regular exercise regimen? Has the patient experienced recent physical or emotional stress such as surgery, trauma, burns, infection, loss of spouse or job, retirement, or other changes that may affect nutrition? Does the patient take any over-the-counter medications, especially vitamin or mineral supplements or appetite suppressants? If yes, obtain reason, dose, and beginning date. Does the patient use any health foods? Describe Review the patients current medication regimen, including over-the-counter preparations. Have the patient describe his or her alcohol, tobacco, snuff, or caffeine intake. Does the patient have any eating disorder? Is there any family history of food allergy or intolerance? Does the patient have a history of cardiovascular disease, osteoporosis, Crohns disease, diabetes mellitus, gastrointestinal tract disorders, sickle-cell anemia, allergies, food intolerance, or obesity? Objective Data Yes No

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Comments


Instructors Manual Inspection for clinical signs and symptoms of nutritional deficiencies Skin, hair, eyes, oral cavity, nails, musculoskeletal and neurologic systems Anthropometric measures Weight Height Triceps skinfold thickness Elbow breadth Arm and head circumference Derived weight measures Percent ideal body weight Percent usual body weight Recent weight change Body mass index Waist-to-hip ratio Skinfold thickness Triceps skinfold thickness Mid upper arm circumference Derived anthropometric measures Mid upper arm muscle circumference Mid arm muscle area Arm span (total arm length) Frame size

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Instructors Manual Developmental care Laboratory studies Health promotion teaching Document findings OPEN-BOOK QUIZ

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Chapter 11: Nutritional Assessment Match each definition (left column) with its corresponding term (right column) NOTE: Not all terms will be used.

{LEFT COLUMN} ____ 1. A practical marker of optimal weight for height


Instructors Manual ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

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This measure assesses body fat distribution as an indicator of health risk. Protein malnutrition from high-calorie, low-protein diets Malnutrition from inadequate intake of protein and calories, or prolonged starvation A sign of vitamin D and calcium deficiency in children Niacin deficiency Deficiency of this vitamin causes swollen, ulcerated, and bleeding gums. Weights more than 20% above ideal body weight This religious group forbids the use of alcoholic beverages and stimulants such as caffeine. These measurements provide an estimate of body fat stores and are performed on the persons upper arm The food group at the base of the Food Guide Pyramid The easiest and most popular method for obtaining information about dietary intake Measurement and evaluation of growth, development, and body composition This test is used to detect iron deficiency anemia. This test is used to measure visceral protein status.

{RIGHT COLUMN} A. B. C. D. E. F. G. H. I. J. K. L. M. Anthropometry Triceps skinfold thickness Weight Hindus Mormons Waist-to-hip ratio Body mass index Transferrin Hemoglobin Rickets Marasmus Kwashiorkor Vitamin K


Instructors Manual N. O. P. Q. R. S. T. U. V. Vitamin C Riboflavin Pellagra Overweight Obesity Food diary 24-hour recall Bread, cereal, rice, and pasta Fruits and vegetables

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