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05. Nutritional Assessment

June 25, 2024

Nutritional Assessment

Objectives

Upon completion of this nchapter, you will be able to:

1. Define nutritional nhealth.

2. Outline risk factors that naffect nutritional health status.

3. Discuss the focus areas ndescribed in Healthy People 2010 in relation to nutrition.

4. Identify physical and nlaboratory parameters utilized in a nutrition assessment.

5. Identify components of a ndiet history and techniques for gathering diet history data.

6. Describe existing nvalidated nutritional assessment tools.

7. Develop questions to be nused when completing a focused interview.

8. Differentiate betweenormal and abnormal findings in a nutritional assessment.

9. Determine specific nnutritional assessment techniques and tools appropriate for unique stages ithe life span.

10. nDiscuss strategies for integrating a complete nutritional nassessment into the nursing care process.

Overview

Nutritional health is an influential component of overall health at all ages.
Nutritional status is determined through the gathering and evaluation of data for a nutritional assessment.

Defining nutritional nHealth

Nutritional assessment should be a routine component of health assessment.
Nutritional assessment serves as the foundation for making nutrition-related diagnoses and nutrition intervention planning.
Data gathered for a nutritional assessment can be used for a single assessment or for comparison over time, such as in monitoring children, pregnant females, or older adults.
Nutritional health is the physical result of the balance betweeutrient intake and nutritional requirements.
Undernutrition and overnutrition result from respectively inadequate or excessive intake of nutrients.
Risk factors for poor nutritional health include extreme age, hospitalization or institutionalization, low socioeconomic status, food insecurity, restrictive eating, chronic disease, multiple medications, alcohol abuse, and others.

Nutritional assessment

Nutritional assessment includes subjective and objective data.
Subjective data is gathered during the client interview and includes data about food habits and customs, meal patterns, food beliefs and skills, supplement use, and medical conditions affecting nutritional status.
Objective data includes the components of the physical examination, anthropometric measurements, and laboratory measurements.
Age, gender, and culture must be considered whe preparing for the physical examination portion of a nutritional assessment.
Equipment required for a physical examination includes a scale, fixed and flexible measures, a skin marker, and skinfold calipers.
Special populations may require additional equipment for anthropometric measurements, such as an infantometer or a knee-height caliper.
The physical examination includes both anthropometric measurements for height, weight, and body composition, and a head-to-toe clinical examination for physical findings.
Laboratory measurements vary in their sensitivity to nutritional changes.
A diet recall, food frequency questionnaire, food diary, and focused, comprehensive interview comprise the nutritional history parameters.
Life span issues and gender influence nutritional requirements and dictate areas of focus when conducting a nutritional history.

Nutritional screening and nassessment tools

General and life span–specific nutritional assessment tools exist to streamline the assessment process.
Some tools are for nutritional screening only and are for use in triaging nutritional assessment needs.
Nutritional assessment tools should include multiple parameters to improve accuracy of the assessment.

Audio nGlossary

Click othe glossary term to listen to the audio.

anabolism A condition that occurs nwhen the intake of protein and calories exceeds the nitrogen loss.

angular nstomatitis A nclinical finding of poor nutrition, cracks at the corner of the mouth.

anthropometrics Any scientific measurement nof the body.

atrophic npapillae A nclinical finding of poor nutritional health.

catabolism A condition that occurs nwhen there is a negative nitrogen balance.

cheilosis Inflamation of mouth.

diet nrecall 24-hour nrecall, patient verbally recalls all food, beverages, and nutritional supplements nor products consumed in a set 24-hour period”.

flag nsign Dyspigmentatioof mouth.

food nfrequency questionnaire nA questionnaire that assesses intake of a variety of food groups on a daily, nweekly, or longer basis.

food nsecurity A nparameter used iutritional assessment, free access to adequate and safe nfood.

glossitis A clinical finding of npoor nutrition, glands are smooth, beefy red or magenta.

immunocompetence A biochemical assessment nlaboratory measurement used iutritional assessment.

kilonychia A clinical finding of poor nnutrition, spoon-shaped ridges in the cardia.

malnutrition (Undernutrition) describes nhealth effects of insufficient nutrient intake or stores.

overnutrition Excesses iutrient nintake or stores.

protein-calorie nmalnutrition A nnutrient deficiency resulting from undernutrition.

rickets A clinical finding nassociated with poor nutritional health resulting in bowed legs.

somatic nprotein Muscle nmass /skeletal muscle.

undernutrition (Malnutrition) describes nhealth effects of insufficient nutrient intake or stores.

xanthalasma Clinical finding of poor nnutrition, yellow subdermal fat deposits around lids.

xerophthalmia A clinical finding of poor nnutrition, dry mucosa.

Nutritiois the relative state of balance betweeutrient intake and physiological nrequirements for growth and physical activity. Optimal nutrition helps protect nagainst disease, facilitates recovery, and decreases complications during nillness. Good nutrition helps people stay healthy.

Malnutritiohas traditionally been deﬁned as a deﬁcit of appropriate nnutrients. However, it literally means bad nutrition and can encompass any nsituation that contributes to an imbalance iutrient intake relative to nactual needs. Therefore, malnutrition can mean a nutrient deﬁcit or nexcess. Although nutritional deﬁcits remain a signiﬁcant health nproblem in Third World countries, the major problem in the United States is nnutritional excess, as is shown by the rising rates of obesity in all age ngroups.

As na nurse, you are in a unique position to assess people’s nutritional status and nprovide information on proper nutrition. You can reinforce positive nutritional npatterns, identify people at risk for malnutrition, and encourage more nhealthful eating habits.

Assessing nnutritional status achieves the following:

■ Identiﬁes actual nnutritional deﬁciencies.

■ Illuminates dietary npatterns that may contribute to health problems.

■ Provides a basis for nplanning for more optimal nutrition.

■ Establishes baseline data for nevaluation.

Review of Nutrients

The ngoal of eating is to supply body cells with necessary nutrients. Ingestion, ndigestion, absorption, and metabolism are the processes that normally naccomplish this goal. Interference with any of these functions can contribute nto nutritional problems.

Primary Nutrients. nNutrients are substances contained in food that are essential for optimal body nfunctioning. The nprimary nutrients are carbohydrates, proteins, fats, vitamins, nminerals, and water. Carbohydrates, protein, and fat are the body’s major energy nsources. Carbohydrates and protein each supply 4 calories per gram, and fat nprovides 9 calories per gram. Vitamins are essential to speciﬁc nfunctions in the body. Minerals are inorganic elements that are essential to ncell structure and physiological functions in the body.Water makes up 50 to 60 npercent of the adult weight. It is required for many functions, and humans ncannot survive for more than a few days without it.

Carbohydrates. Carbohydrates are the body’s major energy source. nFoods that contain the most carbohydrates are grains, legumes, potatoes, corn, nfruits, and vegetables. Adult carbohydrate intake should range from 50 to 100 g daily, depending olevel of activity. In a normal diet, this means that 50 to 60 percent of the ndaily caloric intake should be derived from carbohydrates.

Protein. Protein is nthe primary building block of all tissues and organs and serves an important nfunction in cell structure and tissue maintenance. Integrity of the skin, ninternal organs, and muscles depends on adequate protein intake and nmetabolism.The body can synthesize most of the necessary amino acids from nnonprotein dietary sources. However, there are nine essential amino acids that nthe body cannot synthesize and that must be obtained through dietary sources. For nthis reason, adults require 0.8 g/kg per day of protein (about 10 to 20 percent nof the daily caloric intake). Primary sources of protein include meat, milk and nmilk products (e.g., cheese and yogurt),nuts, and nlegumes.

More nprotein is needed during tissue building—for example, in pregnancy and nlactation, childhood, adolescence, postoperative recovery, tissue damage, and nlong-term illness. Athletes also require additional protein to build and nmaintain muscle. Animal products are the most common source of protein iindustrialized countries. However,well-planned nvegetarian diets can also provide ample dietary protein.

Fats. Lipids or nfats are insoluble in water and soluble in alcohol, ether, and chloroform. They ninclude true fats, lipids, and sterols, such as cholesterol. Fat supplies twice as much energy as carbohydrates or proteins. It nprovides essential fatty acids (linoleic and linolenic acids) and promotes the nabsorption of the fat-soluble vitamins A, D, E, and K. The typical Americadiet usually contains adequate fat, and recommended daily allowances in grams ndo not exist.

Triglycerides nand cholesterol are major contributors to heart disease,diabetes nmellitus (DM), and obesity. The U.S. Department of Agriculture (USDA) and the nAmerican Heart Association recommend that fat intake not exceed 20 to 30 npercent of a person’s total daily calories.

Highly nsaturated fat (solid at room temperature) signiﬁcantly contributes to nelevated serum triglyceride and cholesterol levels. So USDA/U.S. Department of nHealth and Human Services (USDHHS) guidelines recommend that no more than 10 npercent of daily calories be derived from saturated fats. Unsaturated and npolyunsaturated fats are recommended because of their inverse relationship with nheart disease.

Cholesterol noccurs naturally and exclusively in all animal food products.The body needs ncholesterol for cell structure, as a precursor for certain hormones and nvitamins, and to aid in the digestive process. But even if no cholesterol were nconsumed in the diet, the body would synthesize the needed supply.

Lipoproteins. nSerum cholesterol and lipids attach to proteins and are transported throughout nthe body as nlipoproteins. The relative ratio of lipid to protein determines nthe density of the molecule.A low lipid-to-protein ratio nresults in a high-density lipoprotein (HDL).HDLs are produced during ncellular metabolism. They lower serum cholesterol by transporting it from the ncell to the liver for metabolism and excretion. Conversely, a high nlipid-to-protein ratio produces a larger and low-density lipoprotein (LDL). nLDLs are produced in the gastrointestinal wall after eating and transport ndietary cholesterol and triglycerides to the cells.

Thus, nHDLs guard against heart disease by lowering cholesterol, and LDLs contribute nto heart disease by raising cholesterol.The risk for heart disease is nparticularly high when total serum cholesterol exceeds 200 mg/dL. The risk also nincreases as the HDL level decreases. An HDL less than 35 mg/dL is considered a nmajor risk factor for heart disease, and an HDL above nor equal to 60 mg/dL is a negative risk factor.

Vitamins and Minerals. Vitamins are organic compounds that play a major role nin enzyme reactions associated with the metabolism of carbohydrate, protein, nand fat. Although vitamins are required in small amounts, the body does not nsynthesize them, so they must be present in the diet. Vitamins are classiﬁed nas water soluble or fat soluble. The body does not store water-soluble vitamins n(B complex and C vitamins), so any surplus in daily intake is excreted in the nurine. Fat-soluble vitamins (A, D, E, and K) are obtained through dietary fat nand are stored in adipose tissue,where they caaccumulate and become toxic.Toxicity generally results from self-administered nlarge doses of a vitamin or excessive intake of foods that contain the vitamin.

Minerals are inorganic compounds found iature. nThey play a wide variety of roles in humautrition. Minerals are required ivarying amounts and are divided into major and trace elements. Major minerals are nrequired in excess of 100 mg per day and include calcium, chloride, magnesium, nphosphorus, potassium, sodium, and sulfur. The remaining minerals are known as ntrace elements (e.g. aluminum, bromine, chromium, cobalt, copper, ﬂuorine, niron, iodine, magnesium, nickel, silicon, zinc, and other rare minerals).

Water. We usually ndo not think of water as being related to nutria tion. But without it, humans ncannot survive more than a few days.Water helps regulate body temperature; nserves as a solvent for vitamins, minerals, and other nutrients; acts as a nmedium for chemical reactions; serves as a lubricant; and transports nutrients nto and wastes from the cells.

Adults nconsume about 6 cups of water per day through beverages; another 4 cups are nobtained through food; and about 1 cup is produced as a byproduct of nmetabolism. Sensible water loss occurs through excessive perspiration, urine, nand gastrointestinal secretions. Evaporative or insensible water loss occurs nvia the lungs and skin. More than half of the body’s weight is composed of nwater, and therefore rapid weight changes are usually a reﬂection of ﬂuid nbalance. This is especially true for infants who have a greater proportion of nwater weight and proportionately more extracellular ﬂuid. Thirst is not nan accurate indicator of hydration status because it does not occur until about n10 percent of the intravascular volume is lost, or 1 to 2 percent of the nintracellular volume is depleted. Assessment of hydration and signs and nsymptoms of dehydration are discussed later in this chapter.

Nutritional Guidelines and Standards. nEarly guidelines addressed the nutritional needs of the entire population, so nthey exceed the needs of most normal, healthy people. A diet that meets roughly ntwo-thirds of the Recommended Daily Allowances (RDAs) for each nutrient is nconsidered adequate.

Dietary nGuidelines and the Food Guide Pyramid The RDAs provide nguidelines for speciﬁc nutrient quantities for clinical applications. nThe six-group Food Guide Pyramid was developed to make these recommendations neasier for the public to understand and follow. The pyramid can be used to nevaluate individual nutritional status and to educate people about nutrition.

How a Nutritional Deﬁciency nDevelops

Nutritional ndeﬁciencies have characteristics that are relatively unique to the speciﬁc nnutrient that is lacking in the diet. For example, diminished night vision is a nclassic symptom of vitamin A deﬁciency, and fetal deformities are nassociated with folic acid deﬁciencies in pregnancy. A thorough nnutritional assessment can identify deﬁciencies long before actual nclinical symptoms occur. The following section describes the four stages of nnutritional deﬁciency.

Stage 1: Nutritional Deﬁciency Occurs. nMalnutrition occurs when the nutrient in question is not available for ndigestion, absorption, and metabolism. Primary malnutrition results when a nspeciﬁc nutrient is lacking in the diet. Iron-deﬁcient diets that nresult in anemia in infants and young children and calcium-deﬁcient ndiets that cause osteoporosis in postmenopausal women are examples. Secondary nmalnutrition results from impaired bioavailablity of nutrients to the body. nIntake of nutrients may be adequate, but physiological processes prevent them nfrom being digested, absorbed, or metabolized, such as with malabsorptiosyndrome. Primary and secondary malnutrition can occur together.

Stage 2: Tissue Reserves Decrease. When a nnutritional deﬁciency occurs, the body mobilizes tissue reserves to nsustain metabolic processes. Nutrient levels in the blood generally will remaiwithiormal limits as long as there are tissue reserves that the body can depend on.However, if the intake deﬁciency persists, ntissue reserves become depleted and blood levels of nutrients drop, causing nbiochemical abnormalities.

Stage 3: Biochemical Lesions Occur. Biochemical nlesions are changes in serum values that signal depletion of tissue reserves. nBiochemical testing is a valuable adjunct to nutritional assessment and may nreveal nutrient deﬁciencies well before clinical signs and symptoms noccur.

Stage 4: Clinical Lesions Occur. Clinical nlesions are physical changes that result from an inadequate supply of one or nmore nutrients necessary for tissue growth and maintenance.

Developmental, Cultural, and Ethnic Variations. As npeople grow and develop, their nutritional needs change. Developmental groups nespecially at risk for nutritional problems include pregnant and lactating nwomen, infants and children, adolescents, and older adults.

Infants, Children, and Adolescents. nThe growth and development that occur in infancy, childhood, and adolescence ndetermine nutritional needs. For example, brain development is at its peak from nbirth through the second year of life, but after this, improved nutrition will nnot enhance brain growth. Growth charts are the standard against which infant nand child growth is evaluated (see Appendix B).The following tables list nindications of good nutrition in school-age children and summarize pertinent ngrowth and developmental factors and corresponding nutritional needs of ninfants, children, and adolescents.

Pregnant Women. nGood nutrition is critical to the developing fetus. Women who fail to receive nadequate nutrition before and during pregnancy are at risk for premature birth, nlow-birth-weight (LBW) infants, or infants who are small for gestational age n(SGA).These infants are at higher risk for mental and physical disabilities and nother congenital anomalies. In addition, pregnant women who are poorly nnourished endanger their own health because maternal nutrients are sacriﬁced nto compensate for the increasing demands of the growing fetus.

Pregnant nwomeeed an additional 300 calories a day, and lactating women an additional n500 calories a day. Development of the placenta, amniotic ﬂuid, and nfetal tissues, and increases in maternal blood volume during pregnancy require 10 g of protein a day. This nrequirement can be met simply by adding one additional serving each of milk and nmeat to the daily diet. Prenatal vitamins and mineral supplements during npregnancy and lactation are also critically important. The following table nsummarizes the vitamin and mineral needs of pregnant and lactating women.

Older Adults. nOlder adulthood begins at age 65. The senses become less acute, and diminished ntaste of sweet and salty foods may cause people to compensate by increasing nsugar and salt. Decreased gastric acidity can impede vitamin B12 absorption. nAntacid use impedes it further. Skin changes associated with aging impair nvitamin D synthesis; so does spending less time outdoors. Diminished physical nstrength and decreased activity predispose older adults to bone ndemineralization and loss. This problem is especially common in women who do nnot consume adequate calcium and in postmenopausal women who have lost the nprotective advantage of estrogen. In addition, loss of urinary sphincter muscle ntone in women and urination difﬁculty associated with prostate changes nin men may discourage fluid intake. Confusion, a common consequence of ndehydration, may impair mental status. Decreased income, loss of the social ncontext for eating (e.g., death of spouse), and lack of accessibility to food nmarkets are social and economic aspects of aging that may adversely affect nnutrition.

The nRDA amounts beginning in early adulthood change only moderately through the nmiddle adult years. The most signiﬁcant changes beginning in midlife and nextending into older adulthood are related to the physical changes associated nwith aging. Energy requirements are thought to decrease by about 5 percent per ndecade after age 40. However, without dietary modiﬁcations, weight gaiwill occur, with the risk for obesity-related diseases. The nRDAs reﬂect a 200-mg increase in calcium and a twofold increase for nvitamin D to 10 µg after age 50. Unless ﬂuid intake is restricted nfor medical reasons, older adults still need to drink 6 to 8 glasses of water ndaily.

People of Different Cultural/Ethnic Groups. Sociocultural patterns of food intake also inﬂuence nnutritional status. Cultural patterns of eating are learned and nreinforced early in life and are difﬁcult to change without conscious nefforts and external support. Many cultures have healthy eating habits. For nexample, the traditional Asian diet provides adequate nourishment and is nassociated with lower rates of the chronic diseases that plague Westerpopulations. However, now that Asians are beginning to adopt Western food npreferences, chronic diseases are on the rise in these countries. In contrast, ndiets in Western industrialized cultures are high in meat, sugar, and fat.

Performing the Nutritional nAssessment

One nof the ﬁrst steps in assessing nutrition is screening the patient for npossible nutritional risks. At the very least, you should evaluate the health nhistory for symptoms and situations related to nutritional problems,perform a basic physical examination, and obtain laboratory ndata associated with malnutrition. A comprehensive nutritional assessment ninvolves a detailed dietary history, focused anthropometry, and evaluation of nlaboratory values. It is recommended for people with any of the following nnutritional risks:

■ Weight less than 80 percent or more than 120 npercent of ideal body weight (IBW).

■ History of unintentional nweight loss (>10 lb nor 10 percent of usual weight).

■ Serum albumin concentratiolower than 3.5 g/dL.

■ Total lymphocyte count lower than 1500 ncells/mm3.

■ History of illness, surgery, ntrauma, or stress.

■ Symptoms associated with nutritional deﬁciency nor depletion.

■ Factors associated with inadequate nutritional nintake or absorption.

Health History. Nutritional nhealth risks and problems are not always obvious to the patient or the nurse. nSo during the health history, stay alert for clues. The following sections nsummarize health history data that may signal nutritional problems warranting nfurther investigation.

Biographical Data. nScan the biographical data for clues that may affect the patient’s nutritional nstatus.Note age to determine normal dietary requirements.Nutritional needs also nvary according to gender. Religion and cultural background may inﬂuence ndietary preferences. Financial status may also affect the person’s ability to nmaintain a healthy diet.

Current Health Status. nInadequate nutrition is often discovered indirectly during a routine health nhistory and physical examination. For instance, diminished growth and delayed ndevelopment related to inadequate nutrition may be identiﬁed during a nroutine well-child checkup. Patient concerns that result from malnutritiousually present as a speciﬁc symptom or functional problem rather than a nfocused nutritional problem.For example,a person with niron deﬁciency anemia may complain of a lack of energy and an inability nto concentrate.

Ask nyour patient if his or her health status has changed. If so, consider the npotential inﬂuence of the health change outrition.Acute and chronic nillnesses, debilitating conditions, medications, surgery, and trauma all affect nnutrition. Illness and trauma stimulate the stress response and increase nnutritional requirements. Vomiting and diarrhea can cause ﬂuid and nelectrolyte loss. Febrile illnesses accelerate metabolic processes and ninsensible ﬂuid loss. Energy and ﬂuid requirements are also ngreater during infections and febrile illnesses. Certain diseases, such as DM, ncystic ﬁbrosis, and celiac disease, are linked to speciﬁc nnutritional deﬁcits.

Ask nabout changes in diet or weight. Diet changes may be a result of physical,economic,or other factors that could contribute to nmalnutrition.Weight gains can occur with certain endocrine problems, and weight nloss may accompany cancer, DM, and hyperthyroidism. Sudden weight changes are nmore likely to be related to ﬂuctuations in hydration status caused by nsuch conditions as congestive heart failure (CHF) or severe diarrhea.

Ask nabout prescription and over-the-counter (OTC) medications. Many of these drugs nadversely affect nutrition.Note the patient’s use of diuretics because they cacause non-nutritional weight changes.

Past Health History. Ask the person if she or he has experienced a major illness, nsurgery, or trauma. These are usually associated with increased nutritional nneeds, and depending on how recently they occurred and the person’s recovery nstatus, they may continue to pose a nutritional risk. Also ask if she or he has nany chronic conditions, such as cancer, that could affect utilization of nnutrients. In addition, inquire about dental or oral problems. Loss of teeth or pain and health problems, such as Crohn’s disease, nDM, or cystic ﬁbrosis; or anemias, such as thalassemia. Inquire nabout a family history of cardiovascular disease, atherosclerotic disease, or nobesity.

Review of Systems. nThe review of systems (ROS) provides a focused screening for past and present nproblems related to or affecting each of the physical systems. It may also identify nproblems or symptoms that indicate a nutritional risk.

Psychosocial Proﬁle. nBecause physical problems are frequently assumed to have a physical origin, nnurses may underestimate the relationship of everyday life to health. Taking a npsychosocial proﬁle can yield valuable clues about a person’s nnutritional status. Helping the person change unhealthy lifestyle behaviors may nalso be the most viable avenue of intervention.

Comprehensive Nutritional History. nIf the person has one or more knowutritional risks, perform a comprehensive nnutritional history. If there is no time to perform a comprehensive history, nperform a focused history. Although nutritional patterns are learned early ilife and are hard to break,weight and nutrition are nmajor health issues in Western cultures. Information on dieting, exercise, and nnutrition pervades the news media, along with the message that people should ntake responsibility for making healthy changes. Consequently, many people worry nthat they will be scolded for poor nutritional practices, so they withhold or nembellish information. So remember to convey an attitude of acceptance and ncaring, and never be authoritarian or paternalistic. Two dietary analysis ntechniques are discussed—24-hour recall and food intake records. You can use neither technique as part of your comprehensive history.

24-Hour nRecall. Ask the person to write down what he or she ate and ndrank during the previous 24 hours. Then use the Food Guide Pyramid to sort and ncategorize the foods and determine the general quality of his or her diet. nPeople often have trouble accurately recalling what they ate, so prompt them by nsaying, “Start with the ﬁrst thing you had when you got out of bed.” nAlso ask them to record between-meal drinks and snacks, desserts, bedtime nsnacks, condiments (e.g., mayonnaise, butter, sugar, or cream), and food npreparation items (e.g., cooking oil or lard).Water is critical to nutritional nmetabolic processes, so ask them to record water intake, too. Last, be sure to nhave them record the amount of each food or liquid they consumed, and translate nthese into standard servings according to the Food Pyramid. A person’s typical nserving may actually equal several servings.

The n24-hour recall is a valuable screening and assessment tool only if it nrepresents the person’s typical daily intake. If a person is ill or has a nchange in routine, her or his intake will vary from normal. So be sure to ask nif what she or he recorded represents a typical day. If she or he says no, ask nher or him to substitute foods typically eaten.

Use nthe Food Pyramid to categorize 24-hour-recall data. Then tabulate food items nalongside each corresponding Pyramid group, and document them in the person’s nhealth record.

Food nIntake Records. Food intake records are typically ndone on people who are debilitated, have severe burns, or are on chemotherapy. nA food intake record is a quantitative listing of all food and ﬂuid nconsumed within a designated time frame—usually 3 to 5 days.Because food intake npatterns often change on weekends and holidays, records kept during outpatient nor home-care situations should reﬂect one atypical day for a 3-day nperiod and one weekend for a 5-day period. Again, be sure to clarify serving nsizes.

To nanalyze the data, reduce the recorded food items into their constituent nnutrients, using USDA food composition tables. To get a daily average intake nfor each nutrient, add up the total nutrients and divide by the number of days nthe record was kept. Evaluate the averages against the RDAs. Two-thirds of the nRDAs is considered adequate for the general healthy npopulation. However, acceptable levels may vary in disease, risk, or deﬁciency nsituations and will be reﬂected in therapeutic treatment decisions.

A nless speciﬁc but more practical approach involves analyzing the npatient’s food intake record using food labels on packages. Once you have ndetermined the total number of calories consumed, calculate the total grams of ncarbohydrate, protein, and fat and the percentage of caloric intake contributed nby each of these.

Proteishould compose 10 percent of the diet; fat, 20 to 30 percent, and ncarbohydrates, the remaining calories.

Physical Assessment. nNow proceed to the objective part of the assessment. Findings from the health nhistory will determine the depth and scope of your physical examination. As you nperform the examination, be alert to ﬁndings in various body systems nthat might signal malnutrition. Remember, determination of malnutrition cannot nbe made on physical ﬁndings alone.Many diseases and disorders mimic nnutritional deﬁciencies. Always corroborate your physical ﬁndings nwith the health history and the results of laboratory nassessments.The assessment includes performing a head-to-toe scan and ntaking various anthropometric measurements.

Approach. You will nmainly use the techniques of inspection and palpation. Examining the skin and nmucous membranes is crucial, but additional data are derived from assessment of nother body systems.

Optimal nnutrition cannot occur without adequate hydration.Therefore, evaluate the nperson’s hydration status simultaneously. Red ﬂags include reports of nminimal ﬂuid intake, excessive thirst or excessive ﬂuid intake, nincreased urination, diarrhea, or diuretic use. Very young infants, very frail nolder adults, and chronically ill and debilitated people are less tolerant of ﬂuid nloss and are at particular risk for dehydration from vomiting and/or diarrhea.

Performing a Head-to-Toe Physical nAssessment. Look for changes in every system that might nsignal a nutritional problem.

Anthropometry. nAnthropometry literally means human measurement. It includes measuring overall nbody mass (particularly growth, fat reserves, and somatic protein stores) and nevaluation of related laboratory values. Growth charts that plot height, nweight, and head growth are used for children up to age 18. By adulthood, ngrowth has stabilized and ratio measurements of body mass are used. The nfollowing sections describe common anthropometric techniques for assessing nnutrition in children and adults.

Growth Charts

Children. nGrowth charts for height, weight, and head circumference are excellent nindicators of nutrition in children because they allow you to visualize the nchild’s growth progress. Two sets of charts are commonly used: one for birth to n36 months (includes head circumference) and one for age 2 to 18 (does not ninclude head circumference because cerebral growth is complete by age 2).New ncharts have also been developed to track the unique growth patterns of npremature infants.

Until nage 2, take growth measurements with the child nude or wearing only a diaper nand lying supine. For children age 2 to 18, take a standing height without nshoes, with the patient dressed in usual examination clothing. Record measurements on the corresponding axes of the chart at the npoint that intersects with the child’s current age. To visualize a ngrowth pattern, take serial measurements.The important factor is the relative nconsistency of the child’s growth within the norms of the curve.

As nlong as a child receives adequate nutrition,his or her ngrowth largely reflects genetic heritage. If a child shows a nconsistent decline into a lower percentile or falls below the ﬁfth npercentile, suspect undernutrition. Suspect overnutrition in childrewho begin to deviate into higher percentiles or who fall above the 95th npercentile. Growth chart abnormalities can also signify problems of a nnon-nutritional nature, such as endocrine disorders. If your history does not nsupport a nutritionally related growth problem, a medical referral is nwarranted.

Adults. nBy age 18, growth is largely complete and weight-for height tables replace ngrowth charts. The Metropolitan Life Insurance Company’s height and weight ntables, revised in 1983, are the standard, although they do not reﬂect ideal nweights. Instead, they represent the weights of people with the most longevity nin each height category and recommend weight ranges based on height and nskeletal frame size. Figures 8.2 and 8.3 illustrate height and weight nmeasurement.

Body Mass Index. nBody mass index (BMI) is an accurate indicator of fat in adults.The most ncommonly used BMI is Quetelet’s Index, which is obtained by dividing weight ikilograms by height in meters squared.BMIs between 20 and 25 kg/m² nare associated with the least mortality; BMIs under 16 kg/m² are nassociated with eating disorders. The relatively larger proportion of muscle iathletes and body builders and the greater blood and tissue volume in pregnant nand lactating women make BMI measurements inappropriate for these groups. It is nalso not recommend for growing children or frail and sedentary older adults.

Arm Measurements. Triceps skin fatfold (TSF) estimates nbody fat using a double fold of skin and subcutaneous adipose tissue from the npatient’s dominant arm. With the patient’s arm at his or her side and elbow ﬂexed nat 90 degrees, measure and mark the midpoint overlying the triceps muscle nbetween the elbow and the shoulder. Tell the patient to relax the arm.Then use nyour thumb and index ﬁnger to compress a symmetrical fold of skin and nadipose tissue 1⁄2 inch above the marked site. Use calipers to measure ithe middle of the skin fold at the marked site, about 1⁄2 inch below your nﬁngers. Release the calipers, and wait 4 seconds before reading the nmeasurement. To ensure reliability, take two to three additional measurements nat least 15 seconds apart. They should not vary by more than 1 cm.

Compare nfatfold measurements with equivalent age- and ngender-speciﬁc percentiles. Values below the 10th percentile or above nthe 90th percentile indicate diminished or extensive fat reserves, nrespectively. Figure 8.4 illustrates TSF measurement.

Midarm ncircumference (MAC) provides a crude estimate of muscle mass and is most useful nwhen combined with TSF. Measure the circumference of the patient’s dominant arm nat the same site where you obtained the TSF. Wrap the measuring tape ﬁrmly naround the patient’s arm without compressing the skin. Take two or three more nmeasurements to ensure reliability. They should not vary by more than 1 cm. Compare midarm nmeasurements with equivalent age- and gender-speciﬁc percentiles. Figure n8.5 illustrates MAC measurement.

Midarm nmuscle circumference (MAMC) is mathematically derived using TSF and MAC values. nAs an indirect measurement of muscle mass, it provides an index of proteistores. To calculate MAMC, multiply the TSF (in centimeters) by 3.143 and nsubtract the result from the MAC. Because MAMC estimates skeletal muscle nreserves, it should generally fall within 90 percent of standard. Values nfalling between 60 and 90 percent suggest moderate protein deﬁciency and nthose less than 60 percent indicate severe malnutrition. Compare MAMC nmeasurements with equivalent age- and gender-speciﬁc percentiles.

Waist-to-Hip Ratio. The waist-to-hip ratio n(WHR) estimates obesity by evaluating the amount of abdominal fat. People with na greater proportion of upper body fat are at greater risk for HTN, DM, nelevated triglycerides, and other atherosclerotic risk factors.WHR is ncalculated simply by dividing the waist circumference by the hip circumference. nA WHR of 1.0 or greater in men and 0.8 or greater in women indicates upper body nobesity.

Nursing Diagnoses. nConsider all of the data you have collected during your assessment of nMr.Thomas, and then use this information to develop a list of nursing ndiagnoses.Some possible ones are listed. Cluster the supporting data.

1. Nutrition: imbalanced, less than body requirements, nrelated to inadequate iron intake

2. Fluid Volume, deﬁcient, related to nmedications and poor intake

3. Knowledge, deﬁcient, related to nutrition

Identify nany additional nursing diagnoses and any collaborative nursing diagnoses.

Understanding measures of nutritional nstatus is critical for the interpretation of nutrition-related development noutcomes.

Standards, reference values and nindicators have been constructed for nutrition outcomes against which the nnutritional status of individuals and populations can be compared.

Nutritional assessment is ofteviewed according to the ABCD scheme:

–Anthropometry, i.e. physical growth and body size

–Biochemistry, used mostly for micronutrients

–Clinical evaluation

–Dietary intake assessment

Anthropometry and dietary intake are nreflected in the indicators used to assess progress towards MDG 1:

– nthe nprevalence of underweight children under-five years of age

the nproportion of population below minimum level of dietary energy consumption

Nutrition is a key issue for healthcare professionals, yet nthe management of nutritional problems is often poor. Malnutrition is a nsignificant risk for patients in hospital (NHS Quality Improvement Scotland, n2003). A failure to address the issue of malnutrition is a failure of the duty nof nurses to protect the health of patients. In a study of 500 admissions to a nlarge teaching hospital, McWhirter and Pennington (1994) found that 40% were nmalnourished on admission and two-thirds lost weight in hospital.

Definitions
nMalnutrition is a term used frequently in healthcare to refer to undernourished nindividuals who have inadequate intake of energy in their diet. But the term nactually refers to any deviation from the normal adequate nutritional nrequirements for good health. Undernutrition can occur as a result of ninadequate intake as well as disorders of digestion or absorption of proteiand calories. The term can also be used to refer to deficiencies in the intake nof a particular vitamin or mineral. However, with the exception of irodeficiency anaemia, vitamin or mineral deficiencies are more likely to occur iclusters or alongside inadequate intake of protein or calories.

Malnutrition resulting from the inadequate intake, ndigestion or absorption of protein or calories is often referred to as n‘protein-energy malnutrition’. PEM is common and can relate to poor eating nhabits, social circumstances, acute or chronic illness and disorders of the ndigestive tract. Acute illness compounded by PEM can lead to increased ninfection risk, reduced immune response, poor skin integrity, delayed wound nhealing, increased risk of complications and prolonged hospital stay.

Assessment
nNutritional assessment is used to evaluate nutritional status, identify ndisorders of nutrition and determine which individuals need instruction and/or nsupport. An assessment should include screening for malnutrition using a nvalidated tool. It is essential that screening is carried out initially on all npatients to identify those ieed of further investigation and subsequent nnutritional support.

All patients should have the following information recorded nas part of their nursing or medical assessment on admission to hospital n(NHSQIS, 2003):

– Height and weight;

– Eating and drinking likes and dislikes;

– Food allergies and medical dietary requirements (for nexample gluten-free diet for those with coeliac disease);

– Cultural/ethnic/religious requirements (halal for Muslims nor kosher for Jews);

– Social/environmental mealtime requirements (such as nminimising care-giving activities at mealtimes);

– Physical difficulties with eating and drinking (such as ntremor);

– Need for equipment to help with eating and drinking.

This basic information will help nurses to recognise and nrespond to some of the many issues (such as surroundings, portion size and nsuitable dietary availability) that can be a cause of PEM in some hospital npatients.

Those who are at risk of malnutrition will require more ndetailed questioning to assess the nature of their risk. The assessment of a npatient’s nutritional status should include a general observation of the nperson, looking for signs of malnutrition, such as the appearance of hair and nskin. In a malnourished person hair is likely to be dull, brittle and dry, and nthere may be signs of hair loss. The skin may be pale, dry and rough, and any nwounds will take longer to heal. Nurses should also look for signs of weight nloss such as thin appearance and a lack of subcutaneous fat.

The individual’s recent medical and dietary history should nalso be noted. Dietary history can be used to devise a nutritional treatment nplan and recent medical history combined with a dietary history may point to nillnesses or conditions that can increase the risk of malnutrition. For nexample, a patient may report loss of appetite, nausea and vomiting, change ibowel habit, weight loss or tiredness, all of which could be indications of aunderlying condition such as cancer.

Assessment tools
nThere is a range of assessment tools available. These include anthropometric nmeasurements, biochemical analyses and specific nurse-administered screening ntools, as well as physical assessment and dietary history (see part two of this nseries). Only a few of these tools have a place in routine nursing practice.

Anthropometric measurements
nThese are measurements of the human body, starting from simple estimates of nweight loss, through to ideal body weight, BMI and body composition.

Care must be taken when assessing weight loss using normal nweight-for-height assessments as they do not take into account factors such as nheight loss in old age (Barasi, 2003). In addition, there is a tendency to nassociate weight gain with fat gain. This may lead to false assumptions about nbody fat in an individual. For example, those engaging in weight training may ngain weight as a result of increased muscle mass.

Weight loss
nIt can be useful to estimate how much weight an individual has unintentionally nlost over a period of time because unintentional weight loss is often a feature nof serious illness and may be linked to malnutrition.

A weight loss of 5-10% over three to six months is an early nindication of risk of undernutrition, while a weight loss of more than 10% nindicates a clinically significant risk and the need for nutritional support. nWeight loss of more than 20% is considered severe and may require long-term nnutritional support

Ideal body weight
nThe ideal body weight is a measure of weight in relation to height and can be calculated using the formula:

Women: 45.5kg (100lb) for the first 1.52m (5ft) of height nplus 2.3kg (5lb) for every additional inch.

Men: 48kg (106lb) for the first 1.52m (5ft) of height plus n2.5kg (6lb) for every additional inch.

Body weight should be within 10% of the ideal body weight n(Moore, 2005). This method can be used to judge over- or undernutritio(Worthington, 2004) or to set targets for weight gain or loss.

BMI
nBMI is a useful reliable measure of the appropriateness of weight for height, nwhich is simple to carry out and is well-correlated with body-fat percentage n(Shetty, 2003). However, it is used differently in children and adults – iadults it is a height-weight ratio while in children age-related growth and nbody fat gain must be taken into consideration (Worthington, 2004). BMI should ndecline before the age of five and then increase through childhood into nadolescence until adulthood is reached. Its use is limited in older adults as nit does not account for loss of height and loss of muscle mass.

The World Health Organization (WHO) classifies npatients into several categories according to their BMI (see Box, below left).

BMI can also be used to assess possible nmalnutrition. A BMI of less than 16 indicates grade 3 malnutrition, 16-16.9 nindicates grade 2 malnutrition, while a BMI of 17-18.4 indicates grade 1 nmalnutrition (Barasi, 2003).

It should be remembered that while BMI will be high in aobese person, this may mask recent unintentional weight loss that may be nassociated with illness (Ward and Rollins, 1999). BMI is therefore not a ndiagnostic tool and other data and information must be considered wheassessing nutritional status.

Conclusion
nNutritional assessment is and will continue to be an essential part of the nnursing role and as nurses we have a professional duty to develop our knowledge nand skills in this area.

It is vital that patients who require additional nnutritional support be identified quickly in order that the appropriate nreferrals can be made and nutritional support provided. In the busy healthcare nenvironment the importance of nutritional assessment cannot be underestimated nand must not be forgotten.

The second article in this two-part series will look at nmore specific nutritional assessment tests.

Learning objectives
n- Define malnutrition and the factors that influence it

– Outline what information should be recorded as part of a nnutritional assessment

– Explain how you would calculate unintentional weight loss

– Identify how BMI can be used to assess problems with nnutrition

BMI / WEIGHT STATUS
nBelow 18.5 / Underweight

18.5-24.9 / Normal

25-29.9 / Overweight

30-39.9 / Obese

Above 40 / Very obese

Guided learning
n- Outline your place of work and why you were interested in this article

– Describe the last time you encountered a malnourished npatient

– Identify information in this article that could have nhelped you in the care of that patient

– Explain how you intend to disseminate what you have nlearnt among your colleagues

A nutrition assessment is an in-depth evaluatioof both objective and subjective data related to an individual’s food and nutrient intake, lifestyle, and medical nhistory.

Once the data on an individual is collected and norganized, the practitioner can assess and evaluate the nutritional status of nthat person. The assessment leads to a plan of care, or intervention, designed nto help the individual either maintain the assessed status or attain a nhealthier status.

Elements nof the Assessment

The data for a nutritional assessment falls into nfour categories:anthropometric, biochemical, nclinical, and dietary.

Anthropometrics.

Anthropometrics are the objective measurements of nbody muscle andfat. They are used to compare individuals, to compare ngrowth in the young, and to assess weight loss or gain in the mature nindividual. Weight and height are the most frequently used anthropometric nmeasurements, and skinfold measurements of several areas of the body are also ntaken.

As early as 1836, tables had been developed to ncompare weight and height in order to provide a reference for an individual’s nhealth status. The Metropolitan Life Insurance Company revised height and nweight tables in 1942, using data from policyholders, to relate weight to ndisease and mortality. There has been much discussion about the relevance (and nappropriateness) of using the individuals who buy life insurance as a basis for n”ideal” height and weight. There are also a number of problems with nusing a table to determine whether an individual is at the right weight—or evewhat the “ideal

1983 METROPOLITAN HEIGHT AND WEIGHT TABLES

weight” means. Tables should therefore be nused only as a guide, and other measurements should be included in the data ncollection and evaluation.

In 1959, research indicated that the lowest nmortality rates were associated with below-average weight, and the phrase n”desirable weight” replaced “ideal weight” in the title of nthe height and weight table.

To further characterize an individual’s height nand weight, tables also include body-frame size, which can be estimated in many nways. An easy way is to wrap the thumb and forefinger of the nondominant hand naround the wrist of the dominant hand. If the thumb and forefinger meet, the nframe is medium; if the fingers do not meet, the frame is large; and if they noverlap, the frame is small.

Determining frame size is an attempt at nattributing weight to specific body compartments. Frame size identifies aindividual relative to the bone size, but does not differentiate muscle mass nfrom body fat. Because it is the muscle mass that is metabolically active and nthe body fat that is associated with disease states, Body Mass Index (BMI) is used to estimate the body-fat nmass. BMI is derived from an equation using weight and height.

To estimate body fat, skinfold measurements cabe made using skin-fold calipers. Most frequently, tricep and subscapular n(shoulder blade) skin-folds are measured. Measurements can then be compared to nreference data—and to previous measurements of the individual, if available. nAccurate measuring takes practice, and comparison measurements are most nreliable if done by the same technician each time.

To estimate desirable body weight for amputees, nand for paraplegics and quadriplegics, equations have been developed from ncadaver studies, estimating desirable body weight, as well as calorie andprotein needs. Calorie needs are determined by nthe height, weight, and age of an individual, which determine an estimate of ndaily needs.

The Harris-Benedict nequation is frequently used, nbut there are quicker methods to estimate needs using just height and weight. nOpinions and methods vary on how to estimate calorie needs for the obese. As previously mentioned, nbody fat is less metabolically active and requires fewer calories for support nthan muscle mass. If an individual’s current body weight is more than 125 npercent of the desirable weight for the individual’s height and age, then using nbody weight to estimate calories needs usually leads to an over-estimation of nthose needs.

Biochemical ndata.

Laboratory tests based on blood and urine can be nimportant indicators of nutritional status, but they are influenced by nnonnutritional factors as well. Lab results can be altered by medications, hydration status, and disease states or other metabolic processes, such as stress. As with the other areas nof nutrition assessment, biochemical data need to be viewed as a part of the nwhole.

Clinical ndata.

Clinical data provides information about the nindividual’s medical history, including acute and chronic illness and diagnostic procedures, ntherapies, or treatments that may increase nutrient needs or inducemalabsorption. nCurrent medications need to be documented, and both prescription drugs and over-the-counter drugs, such as laxatives or analgesics, nmust be included in the analysis. Vitamins, minerals, andherbal preparations also need to be reviewed. nPhysical signs ofmalnutrition cabe documented during the nutrition interview and are an important part of the nassessment process.

Dietary ndata.

There are many ways to document dietary intake. nThe accuracy of the data is frequently challenged, however, since both nquestioning and observing can impact the actual intake. During a nutritiointerview the practitioner may ask what the individual ate during the previous ntwenty-four hours, beginning with the last item eaten prior to the interview. nPractitioners can train individuals on completing a food diary, and they carequest that the record be kept for either three days or one week. nDocumentation should include portion sizes and how the food was prepared. Brand nnames or the restaurant where the food was eaten can assist in assessing the ndetails of the intake. Estimating portion sizes is difficult, and requesting nthat every food be measured or weighed is time-consuming and can be nimpractical. Food models and photographs of foods are therefore used to assist nin recalling the portion size of the food. In a metabolic study, where accuracy nin the quantity of what was eaten is imperative, the researcher may ask the nindividual to prepare double portions of everything that is eaten—one portioto be eaten, one portion to be saved (under refrigeration, if needed) so the nresearcher can weigh or measure the quantity and document the method of npreparation.

Food frequency questionnaires are used to gather ninformation on how often a specific food, or category of food is eaten. The nFood Guide Pyramid suggests portion sizes and the number of servings from each nfood group to be consumed on a daily basis, and can also be used as a reference nto evaluate dietary intake.

During the nutrition interview, data collectiowill include questions about the individual’s lifestyle—including the number of nmeals eaten daily, where they are eaten, and who prepared the meals. nInformation about allergies, nfood intolerances, and food avoidances, as well as caffeine and alcohol use, nshould be collected. Exercise frequency and occupation help to identify the nneed for increased calories. Asking about the economics of the individual or nfamily, and about the use and type of kitchen equipment, can assist in the development of a plan of care. Dental and oral nhealth also impact the nutritional assessment, as well as information about gastrointestinal health, such as problems withconstipation, ngas or diarrhea, vomiting, or frequent heartburn.

Evaluation

After data are collected, the practitioner uses npast experience as well as reference standards to assimilate the informatiointo an assessment that provides an understanding of the individual’s nutritional nstatus. The practitioner uses the anthropometric data to assess ideal and ndesirable weight, as well as skinfold measurements to determine body fat. nHeight, weight, and age are plugged into the Harris-Benedict equation to ndetermine calorie and proteieeds. Using the clinical, biochemical, and ndietary data, influences on the nutritional status can be determined. A nnutritional intervention, which usually includes dietary guidance and exercise nrecommendations, is then formulated and discussed with the individual.

Under-nutrition is usually described as nprotein-energy malnutrition or PEM. In children, PEM is often perceived as a nproblem particular to the developing world, with a reported incidence of about n39% of the world’s pre-school children and associated mortality in up to 20 % nof these children.

While this may be true nof primary PEM (resulting from inadequate food supply), PEM related to nunderlying illness (secondary PEM) is a common problem in modern hospitals.

The short-terimplications of failure to address secondary PEM in children include increased nsusceptibility to infection, poor healing, perioperative complications and nreduced response to treatment. The long-term implications include stunting, ndevelopmental delay and an overall increase in morbidity and mortality.

The significance of PEM nin children becomes clearer when we consider the role of nutrition in the npaediatric patient and how it differs from the nutritional needs of the mature, nadult patient.

The five pillars of npaediatric nutrition

Adequate nutrition in the paediatric npatient must provide for all of the following factors:

Maintenance of body nfunction

A child’s metabolic nrate is higher per kilogram of bodyweight than that of an adult and, therefore, nenergy requirements are also proportionately greater. These requirements are nfurther increased by physiological stresses, such as trauma and infection, and npsychological stresses, such as separation and anxiety.

In addition, childre(particularly neonates) may have much smaller fat stores than adults, severely nreducing their ability to survive periods of starvation or under-nutrition.

Activity

Play and activity are nessential to a child’s social and physical development. It is important that nnutrition provides sufficient energy to allow for this. Even a short period of nimmobility or inactivity can prove detrimental.

Healing

As in adults, the nbody’s initial response to trauma is to deplete body stores – glycogen, proteiand fat – in order to preserve body function (Fuchs, 1990). The body’s reserves nof energy are more rapidly depleted in the younger/smaller child. Neonates, ntherefore, are at particular risk of nutritional problems and consequent growth ndelay (BAPEN, 2000). Trauma causes a loss of protein and fat from damaged ntissue. Healing requires increased provision of energy, nitrogen and certaimicronutrients, such as zinc (Golden and Golden, 1981). Estimation of nnutritional requirements following trauma must take these factors into account.

Growth

Normal growth occurs nonly when more nutrition is provided than that required for body function, nhealing, metabolic stress and energy expenditure. A child’s rate of growth is nnot linear, but occurs in stages with periods of accelerated growth, such as ninfancy or puberty, driven by a combination of nutrition and endocrine nfunction. Any nutritional defect during a critical growth period could prevent nthe child from achieving his or her growth potential.

Catch-up growth

When children have nexperienced an extended period of weight loss or failure to thrive, estimating ntheir nutritional requirements on the basis of current weight may not be nsufficient to allow them to achieve their growth potential. Extra calories and nprotein must be provided to allow for accelerated growth and weight gai(Lewinter-Suskind, 1990). The centile chart can be used to monitor the child’s ngrowth until he or she has regained acceptable levels in terms of weight and nheight.

Nutritional assessment

The nurse has a key role in identifying nchildren who might be at risk of PEM. The ability to assess a child’s nnutritional status using anthropometry, observation and history is vital, but nit is also as important for the nurse to have an understanding of the nimplications of information gained during an assessment.

Anthropometry, the nmeasurement of the human body, can give useful information about growth and ncurrent nutritional status when compared with established norms. However, aassessment of nutritional status or growth should not rely on these nmeasurements alone. Consideration must also be given to other factors, such as nfeeding history.

Although other nanthropometric measurements may be indicated, height/length, weight and head ncircumference constitute a minimum requirement in paediatrics.

Weight

Equipment scales should nbe available for different age groups of children – for instance, baby scales, nchair or standing scales. They should be calibrated regularly, centrally npurchased and designed for clinical use.

Children should be nweighed on admission to hospital and subsequently at least once a week. nFrequency of weighing requires adjustment according to clinical condition odiscussion with the multidisciplinary team. Repeat weights should be recorded nunder similar conditions and at the same time of day as the original nmeasurement.

Infants and toddlers n(up to three years) should always be weighed naked. Older children should be nweighed with a minimum of clothing. The choice of scales will be determined by nthe child’s age, size and general condition. Care should be taken whepositioning the child on the scales to ensure an accurate measurement – the nchild should be placed centrally and the measurement should not be recorded nuntil the child is still. All weights should be recorded in kilograms.

Additional factors that nimpact on the accuracy of weight measurements are presence of intravenous nsplints/lines, stoma devices, dressings/drains, timing of bolus/continuous nfeeds and intravenous therapy. Weights should be recorded on a weight chart, nobservation chart and on the centile chart in the medical notes and iparent-held records.

A single weight is of nlimited value in assessing a child’s nutritional status. Similarly, daily nweights may reflect hydration rather thautrition. A measurement of weight is nof nutritional value only when reviewed in the light of previous weights and nclinical history.

It should be noted that na measurement of weight should not be relied on as an accurate indication of nutritional nstatus in children with significant oedema or solid tumours. Weight should nalways be interpreted in conjunction with height/length and age, for which aunderstanding of the centile chart is vital. Although not definitive, comparing nweight, height and age can give useful clues to potential problems.

Height/length

Equipment should be navailable for measuring the height/length of different age groups of children – nfor instance, a measuring mat with head and foot boards for infants and a stadiometer nfor older children, It is not appropriate to use a tape measure.

Height/length should be nmeasured on admission and subsequently at least once a month.

Infants should be nmeasured naked and by two people, using an appropriate measuring mat with head nand footboard. The child should be placed supinely with the head held against nthe headboard and gentle downward pressure applied to the knees to ensure that nthe legs are straight and flat against the mat. Length is then measured by nbringing the footboard into contact with the child’s heels.

The standing height of nan older child should be measured using an appropriate stadiometer. Shoes nshould be removed and the child asked to stand with feet together and heels, nbuttocks and shoulder blades in contact with the vertical measure.

Measurement of nheight/length is inappropriate for children who are unable to stand or bear nweight or with conditions that impede correct positioning – for instance, ncurvature of the spine.

Measurements of nlength/height should be recorded in centimetres and documented as for weight.

Length/height caprovide a useful indication of growth in children. Impaired growth may indicate ninadequate feeding, diet or malabsorbtion, where poor weight gain is also nevident. In the presence of adequate weight gain, impaired height may be nindicative of metabolic or endocrine disease. Measurements of parental height nconstitute a useful guide to target height in a child. However, it should be nremembered that the parents themselves may not have achieved their full growth npotential due to socio-economic factors or illness.

Pubertal development is naccompanied by a period of rapid growth acceleration. Any assessment of growth nin adolescence should include evaluation of pubertal staging.

Head circumference

A thin metal or plastic ntape measure should be used to measure head circumference. It is not nappropriate to use paper or sewing tape for this purpose.

Head circumference is nmonitored in children under two and should be recorded on admission. The tape nis placed so that it lies midway between the eyebrows and hairline at the front nof the head and meets with the occipital prominence at the back. A second nperson is required to hold the child’s head still. Measurements of head ncircumference should be recorded in centimetres.

If a child’s clinical ncondition is such that standard anthropometric measurements are inappropriate nor misleading – for instance, if there is oedema, ascites or solid tumours – nother techniques are available for measuring growth (Box 2).

The performance of nanthropometric measurements provides the nurse with an ideal opportunity to nobserve the child’s general appearance. With experience a paediatric nurse will nbe able detect specific signs of poor nutritional status/growth, such as the nfollowing:

– Short stature;

– Thin arms and legs;

– Poor skicondition/skin lesions;

– Poor hair condition;

– Ascites;

– Clearly visible nspinal processes or rib cage;

– Wasted buttocks;

– Oedema, wasted facial nappearance, lethargy.

History

A nursing assessment ninterview conducted on admission should elicit useful information pertaining to nfeeding history and parental concerns regarding feeding and growth/weight gai(Box 3).

Dietary record

In order to assess the nadequacy of a child’s nutritional intake, dietitians require detailed ninformation about all food and drink consumed. As all children admitted to nhospital are at risk of nutritional deficit, a dietary record should be started non all in-patients, although this may subsequently be discontinued when deemed nappropriate. The dietary record should include details of food and fluids noffered and consumed, with quantities expressed in terms of teaspoons, ntablespoons and so on. Owing to the difficulties of providing for the likes and ndislikes of individual children any record of dietary intake completed during nadmission is unlikely to provide an ideal reflection of a child’s customary nintake.

Psychosocial factors

A number of npsychosocial factors may impact outritional status, such as family income, nfamily support systems, parenting skills and so on. As with any other aspect of nnutritional assessment, psychosocial factors should be interpreted only in the nlight of other findings.

Nutritional risk nfactors

If any of the following nproblems are identified during the assessment process the child may he nconsidered to be at increased risk of nutritional deficiency:

– Predisposing medical ncondition;

– Static weight;

– Documented weight nloss;

– Perceived weight nloss;

– Poor intake;

– Poor feeding;

– Short stature;

– Pubertal delay;

– Developmental delay.

The short-term nimplications of failure to address PEM can lead to multiple complications. The nlong-term implications can be devastating and include stunting, developmental ndelay and an overall increase in morbidity and mortality.

Nutrition Assessment Questionnaire

Name___________________________________ Date of Birth_________ Sex ________

Address__________________________________________ Phone________________

__________________________________________ email___________________

Physician____________________________________ Phone_____________________

List your medical conditions________________________________________________

________________________________________________________________________

Indicate the results of your last laboratory blood tests:

Total Cholesterol_________ LDL (bad) Cholesterol_________

HDL (good) Cholesterol__________ Triglycerides___________

Glucose (blood sugar) __________ Blood pressure______________

List the medications you take_______________________________________________

______________________________________________________________________

Vitamins or supplements __________________________________________________

Describe you usual activity level (example: sedentary – sitting all day) ______________

Do you have a regular exercise program? _______

If yes, what is the exercise, how often each week, how long per session? ______________

________________________________________________________________________

Present weight__________________________ Height__________________________

Has your weight changed in the past 5 years? __________________________________

How would you describe your weight as a child? _______________________________

Describe the weight of your family members (over weight, average, under weight)

________________________________________________________________________

At what weight would you feel your best? _________________________________

What is the number of people in your household? __________________________

Who does the shopping? _______________ How Often? _________________

Are you allergic to any foods or do you have any food intolerances? _______________

What foods? ________________________________________________________

Describe your current stress level ____________________________________________

List any special interests or hobbies that you enjoy. _____________________________

________________________________________________________________________

List your nutrition concerns or any other additional information.___________________

_______________________________________________________________________

________________________________________________________________________

SUMMARY

■ nThroughout the health assessment process, the nurse nshould be attuned to data related to nutrition.

■ nNutrition is inﬂuenced by a myriad of factors. Basic information in the nhealth history can identify the need to more thoroughly investigate nutritional nstatus.

■ nAssessment of nutritional status involves eliciting data that are both directly nand indirectly related to nutrition.

■ Comprehensive nnutritional assessment will provide speciﬁc data to enable the nurse to ndetermine potential or actual nutritional health problems, to devise aappropriate plan of intervention, and to determine criteria for evaluation