04. Pain Assessment Nutritional Assessment

Pain Assessment


1.     Provide a definition of pain.

2.     Identify the physiology of pain.

3.     Describe the different types of pain.

4.     Discuss factors that influence pain.

5.     Describe techniques used for assessment of a client having pain.

Key Concepts


  • Pain assessment is the fifth vital sign.

  • Pain is a highly unpleasant and personal sensation.

  • Pain must be assessed accurately for treatment to be successful.


  • Pain comes from the Greek word meaning penalty.

  • Pain is whatever the person says it is.

  • Pain can be the primary problem or associated with a specific diagnosis, treatment, or procedure.

  • No two people experience pain in the same way.

  • Pain is subjective; however, it can produce objective changes in the individual.

Physiology of pain

  • Pain is a subjective, complex, multidimensional phenomenon that is not clearly understood.

  • Specificity theory demonstrates that pain neurons are special.

  • Pattern theory indicates clients will respond in a different manner to the same stimulus.

  • Gate control theory says peripheral nerve fibers carrying pain to the spinal cord can have their input modified at the spinal cord level before transmission to the brain.

  • Nociception is composed of four processes: transduction, transmission, perception, and modulation.

  • Three types of pain stimuli are mechanical, thermal, and chemical.

Nature of pain

  • Pain, a subjective and personal experience, can be described many ways.

  • Acute pain, mild to severe, lasts through the expected recovery period and is considered to be of short duration.

  • Chronic pain is prolonged, recurring or persisting over a 6-month or longer time frame.

  • Cutaneous pain originates in the skin or subcutaneous tissue.

  • Somatic pain arises from ligaments, tendons, bones, or blood vessels.

  • Visceral pain results from stimulation of structures in the abdomen, cranium, or thorax.

  • Radiating pain is perceived at the site of origin and surrounding structures.

  • Referred pain is felt in a body part distant from the source of origin.

Factors influencing the pain experience

  • Age and developmental stage must be considered when assessing a client’s pain.

  • Family, culture, and gender will influence a client’s ability to express pain and seek treatment.

  • External environmental factors such as heat and cold will influence pain.


  • Pain is considered the fifth vital sign.

  • Accurate and timely assessment is mandatory for effective pain management.

  • Taking a detailed history using many of the focused interview questions provides a detailed subjective database.

  • Unidimensional and multidimensional tools are available for pain assessment.


acute pain   Pain that lasts only through the expected recovery period from illness, injury, or surgery, whether it has a sudden or slow onset and regardless of the intensity.

chronic pain   Pain that is prolonged, usually recurring or persisting over 6 months or longer, and interferes with functioning.

cutaneous pain   Pain that originates in the skin or subcutaneous tissue.

deep somatic pain   Diffuse pain that arises from ligaments, tendons, bones, blood vessels, and nerves, tends to last longer than cutaneous pain.

fifth vital sign   Pain assessment.

intractable pain   Pain that is highly resistant to relief.

nociceptors   The receptors that transmit pain sensation.

pain   A highly unpleasant sensation that affects a person’s physical health, emotional health, and well-being.

pain threshold   The amount of pain stimulation the person requires to feel pain.

pain tolerance   The maximum amount and duration of pain that an individual is willing to endure.

radiating pain   Pain perceived at the source of the pain and extends to nearby tissues.

referred pain   Pain felt in a part of the body that is considerably removed from the tissues causing the pain.

visceral pain   Pain results from stimulation of pain receptors in the abdominal cavity, cranium, and thorax, appears diffuse and often has feeling of pressure, burning, or aching.

Caring for someone with a life threatening illness requires careful and thorough evaluation, or assessment, of their pain and other symptoms. You are the eyes and ears for the doctor and nurses caring for your loved one. You will be relaying important information about the patients pain and symptoms back to the health care team. Assessing pain and communicating it to the health care team will be one of the most important things you can do while caring for a loved one.

What is Pain?

It is important when assessing pain to understand what it is. The important thing to remember here is that pain is always what the person experiencing says it is, occurring when and where they describe it.

If a person can communicate their pain, it will be easy to record it and relay it back to their doctor. If they cannot communicate what they are feeling, it is can be more difficult to assess their pain but it is still possible. To do so, you must aware of physical signs and symptoms that convey what they are feeling, which we discuss more in detail below.

Assessing pain is something your healthcare provider will be doing at every visit or appointment but it will be up to you to assess their pain between professional visits. The following information will be helpful to you as you assess the pain yourself.

Severity of Pain

The first step in assessing pain is to find out how bad it is at the present moment. There are tools that can help someone who is able to communicate describe the severity of their pain. For adults, this is usually done with a numeric scale of 0-10. Zero would describe the absence of pain and ten would symbolize the worst pain imaginable. Ask the patient to rate their pain somewhere on that scale.

When asking young children or non-verbal adults to describe their pain, the tool most often used by healthcare providers is the Wong-Baker FACES Pain Rating Scale. It is recommended for persons age 3 years and older. With this scale, you would point to each face using the words to describe the pain intensity. Ask the child to choose the face that best describes their pain.

Acceptable Level of Pain

Everyone will have their own acceptable level of pain. For some it may be no pain and others will tolerate a pain level of 3 on a scale of 0-10. It is important to find out what the acceptable level is for the individual you are caring for. If your loved one is happy at a pain level of 3, you wouldn’t want to medicate them to the point of sedation to get them at a zero level of pain.

Location of Pain

The location of pain may be the same every time you ask. Someone with end stage liver disease may always have pain in the upper right side of their abdomen. It is important to ask, however, because new pain may develop. If the location differs or new pain emerges, be sure to record that information and pass it on to the patients healthcare provider.

Palliation and Provocation

Ask the patient what makes their pain better, or palliates it. This may only be pain medications. It may be changing positions or lying only on their left side. Finding this out will not only help you do things that aide in their comfort but may provide some clues to the physician on the cause of the pain if it isn’t already known.

Also ask what makes the pain worse, or provokes it. Again, it could be movement or lying on a particular side. It could also be eating or touch. This again will help you avoid things that cause discomfort and provide important clues to the physician.

Assessing Non-Verbal Signs of Pain

It was mentioned early that it can be difficult to assess someone’s pain if they are unable to verbalize it and/or unable to point to the FACES scale. There are some signs and symptoms that a patient may exhibit if they are in pain that can clue you in:

·         Facial grimacing

·         Writhing or constant shifting in bed

·         Moaning or groaning

·         Restlessness and agitation

·         Guarding the area of pain or withdrawing from touch to that area

The more symptoms a patient has and the more intense they are will give you a clue as to how much pain they may be in. You can then record their pain as "mild", "moderate", or "severe".

Keep a Record

One of the most important things you can do for the person you are caring for is to keep an accurate record of their pain and their pain treatments. Once you assess their pain, record the severity and location and any medications or treatments that you gave them. Take note whether the medications or treatments worked effectively. Also write down anything new they may have told you about what makes it feel better or worse. This is a great way to team up with your healthcare professionals to provide the best palliative care possible.

Example of a Pain Log

Pain Log


Level of Pain

Location of Pain

Medication/Treatment Given

11/26 9:00a


upper abdomen

Morphine 10mg

11/26 1:00p


upper abdomen

warm compress to abdomen

11/26 5:00p


headache and upper abdomen

Morhpine 10mg


Introduction to Assessing Pain

Although pain is referred to as the fifth vital sign,pain is a symptom. Subjective in nature, pain is “whatever the person says it is, whenever she or he says it does” (McCaffery, 1999). Pain has also been defined as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage” (International Association for the Study of Pain, 2006). It is the most common reason patients seek healthcare.

Far too often, not only the public but also healthcare providers undertreat pain owing to misconceptions surrounding it and its effective management. This is a serious issue,as undertreated pain can have serious physical, psychological, and financial consequences that affect the patient’s quality of life.

Accurate assessment of your patient’s pain is the first step in developing an effective treatment plan to deal with pain. Because pain is subjective, no two patients experience pain the same way. Since pain has physiological, psychological, sociocultural, behavioral, and affective components, assessment must address each component as it relates to your patient.


Structure and Function of Pain

Understanding the process of pain will help you to accurately assess and develop a plan of care to manage your patient’s pain.The process by which a painful stimulus is transmitted to the central nervous system (CNS) and perceived as pain is referred to as nociception.


The process of pain includes transduction, transmission, perception, and modulation. However, the exact mechanism of pain is unknown, and this process does not explain all types of pain, such as phantom limb. Also, not all nociception results in the perception of pain.

Transduction. Transduction begins with a response to a noxious (painful) stimulus that results in tissue injury. The noxious stimuli can be mechanical, thermal,or chemical. The noxious stimuli are then converted into a nerve impulse by sensory receptors called nociceptors.

Nociceptors are receptors found in the skin, subcutaneous tissue, joints,walls of arteries, and most internal organs (with the highest concentration found in the skin and the least in internal organs) that respond to painful stimuli. In response to tissue injury, cells break down and release byproducts and inflammation mediators (bradykinin, prostaglandins, substance P, histamine, serotonin,and cytokines).These substances activate or sensitize the nociceptors.Bradykinin also acts as a potent vasodilator, triggering the inflammatory response of redness, swelling, and pain. The inflammatory response is the greatest cause of pain.However,all pain that originates from the periphery is not nociceptive pain. Damaged peripheral nerves can result in peripheral neuropathic pain.

Transmission. Once the nociceptors are activated, the nerve impulse is transmitted to the spinal cord and brain. The sensory nerve impulses travel via afferent neurons to the dorsal horn of the spinal cord. Primary afferent nerve fibers travel along C-fibers,unmyelinated, slow-conducting fibers that transmit dull,aching pain,or A-delta fibers,myelinated, fast-conducting fibers that transmit sharp, localized pain. C-fibers transmit slow, constant pain from mechanical, thermal,and chemical stimuli.A-delta fibers transmit fast, intermittent pain from mainly mechanical stimuli. Excitatory amino acids (e.g., glutamine, aspartate) and  neuropeptides (e.g., substance P) facilitate transmission of impulse to the dorsal horn at the synapses from the primary afferent neuron to a second-order neuron in the dorsal horn. Inhibitory aminoacids (e.g., γ-aminobutyric acid [GABA]) and  neuropeptides (e.g., endogenous opioids) inhibit transmission of impulse.Once in the dorsal horn, the impulse can be transmitted to the brain or inhibited.Neuroregulators, neurotransmitters, or neuromodulators either inhibit or facilitate nociception.

From the dorsal horn, the impulses are then transmitted from (1) the spinothalamic tract to the thalamus, (2) the spinoreticular tract to the reticular formation, (3) the spinomesencephalic tract to the mesencephalon, and (4) the spinohypothalamic tract to the hypothalamus. Most impulses are transmitted to the thalamus from which they are directed to three areas: the somatosensory cortex, which perceives and interprets physical sensation; the  limbic system, which allows for emotional response to stimuli; and the frontal cortex, which involves thought and reason and perception of pain.

Perception. Perception is an awareness of pain and involves both the cortical and the limbic system structures.Realize that pain threshold, the point at which a painful stimulus is perceived as painful, is consistent from one person to the next; however, pain tolerance, the amount of pain one is able to endure, varies greatly.Psychosocial and cultural factors and past experiences influence pain perception, thereby accounting for such individual differences in pain perception even with similar painful stimuli.

Modulation. Nerve transmission from the dorsal horn is modulated by descending inhibitory input. Inhibition can also occur at the peripheral, spinal, and supraspinal levels. Inhibition occurs by analgesia or the gate-control theory of pain modulation. Inhibitory substances (e.g., GABA and neuropeptides [endogenous opioids, serotonin, norepinephrine]) bind to primary afferent receptors and dorsal horn neurons to inhibit transmission of impulse. Endogenous opioids include enkephalins, dynorphins, and beta endorphins.

Endogenous opioids can also be produced through exercise, meditation, visualization, and music therapy. The brain also sends descending inhibitory input that modulates the transmission of nociceptive transmission in the dorsal horn.

The gate-control theory of pain modulation (Fig. 4.2) proposes that impulses can be blocked by non-painful somatic stimuli. Impulses compete for transmission. Since two impulses cannot be transmitted at the same time, one goes through while the other is blocked.

For example, if you stub your toe, you automatically rub your toe.The rubbing sensation is transmitted by the fast, A-delta fibers, while the impulse from stubbing the toe travels along the slow C-fiber and is blocked.


Sensitization. Sensitization to pain can be peripheral or central. Peripheral sensitization occurs with prolonged exposure to noxious stimuli.The result is a lower threshold of pain, leading to hyperalgesia (increased response to painful stimuli) and allodynia (painful response to nonpainful stimuli). Central sensitization also occurs with prolonged exposure to noxious stimuli with spinal neuron hyperexcitability and results in hyperalgesia and allodynia as well as persistent pain and referred pain. Sensitization can act as a protective mechanism during healing,but when it persists, chronic pain can develop.


Classification of Pain

Pain can be categorized by duration, site of pain, cause,or other qualities.


Acute Pain. Pain is defined as acute when it lasts the expected recovery time. Acute pain serves as a protective mechanism in response to an actual or potential threat to injury, such as when you withdraw your hand from a hot surface. Injury also activates the “stress hormone response,” which, if left untreated, can produce negative physiological and psychological effects resulting in chronic pain. Acute pain is seen with injury and surgery and may last up to 6 months.

Chronic Pain. Chronic pain is defined as pain enduring for 6 months or longer.More specifically, chronic pain endures beyond expected recovery time. Chronic pain may be in response to a progressive illness or result from no apparent injury, as with neuropathic pain. Chronic pain often serves no adaptive purpose, and frequently results in depression. Chronic pain can be further classified as cancer/malignant pain or chronic noncancer pain.

Cancer/Malignant Pain. Pain associated with cancer may be categorized separately. Cancer or malignant pain may be acute pain or chronic pain that is associated with an underlying malignancy, diagnostic procedure, or disease treatment. The level of pain strongly correlates with the degree of pathology. Intractable pain, pain resistant to treatment, is often seen with advanced metastatic disease.

Chronic Noncancer Pain. Persistent pain not associated with malignancy may be categorized as chronic noncancer pain, a subtype of chronic pain. Pain levels and pathology have a weak link and may have no discernable cause.The pain becomes the disease. Any body system or region can be affected, with intensity ranging from mild to severe. Chronic noncancer pain has a major effect on every aspect of the patient’s daily life and is referred to as chronic pain syndrome. In this syndrome, the patient can no longer function and her or his entire life is centered on finding pain relief.


Nociceptive/Neuropathic Pain

Pain can also be classified by underlying pathology.

Nociceptive Pain. Nociceptive pain results from exposure to noxious (painful) stimuli. The painful stimuli can occur in the viscera, resulting in  visceral pain, or tissue, resulting in somatic pain.

Visceral pain results from overdistension, spasms, ischemia, inflammation, or traction of organs such as colic, appendicitis, peptic ulcer disease, and bladder distension. The pain can be localized or diffuse or referred. Referred pain is felt at a site other than at the site of origin. Referred pain occurs when internal organs and structures share nerve pathways within the CNS (Fig. 4.3). Pain can also radiate. Radiating pain begins in one area and extends to others, such as chest pain associated with myocardial infarction may be in the chest and radiate to the jaw or arm. The quality of visceral pain is deep aching or sharp stabbing. Visceral pain is often accompanied by nausea, vomiting, malaise, sweating, tenderness, and muscle spasm.


Somatic pain can be superficial or deep. Superficial somatic pain originates in the skin or mucous membranes from external stimuli such as sunburn; chemical and thermal burns; or injury to the skin, such as lacerations or contusions.The pain is very localized and described as sharp, pricking, or burning. Cutaneous tenderness, hyperalgesia (increased sensitivity to pain), hyperesthesia (increased sensitivity to sensory stimuli), and allodynia (painful response to nonpainful stimulus) may be associated with superficial somatic pain.

Deep somatic pain originates in muscles, bones, and joints from overuse, injury ischemia, cramping, or inflammation such as arthritis, tendinitis, and sprains. The pain can be localized or diffuse and radiating and described as dull, achy, or cramping. Tenderness and muscle spasm with an autonomic response (increase pulse,blood pressure, and respiratory rate; sweating; pallor; dilated pupils; nausea; vomiting; dry mouth; and increased muscle tension) are often associated with deep somatic pain.

Neuropathic Pain. Neuropathic pain results from injury to the peripheral or central nervous system. Neuropathic pain serves no adaptive purpose and therefore is “pathological” pain.

Neuropathic pain can be classified as mono/polyneuropathies, deafferentation, sympathetically maintained pain, and central pain (Clark, 2004).

Mono/Polyneuropathies. Mono/polyneuropathies involve pain along one or more damaged peripheral nerves. Neuropathies may be caused by metabolic disorders (diabetic neuropathy), toxins (alcoholic neuropathy or chemotherapy), infections (human immunodeficiency virus [HIV], postherpetic neuralgia), trauma, compression (compartment syndrome, carpal tunnel syndrome), and autoimmune and hereditary diseases. The pain associated with neuropathies may be described as continuous,deep,burning, aching or bruised, paroxsymal shocklike,or abnormal skin sensitivity.

Deafferentation. Deafferentation pain occurs with loss of afferent input from damage to a peripheral nerve, ganglion, or plexus, or the CNS. Phantom limb and postmastectomy pain are examples of deafferentation pain. The pain is often described as burning, cramping, crushing, aching, stabbing, or shooting. The patient may experience hyperalgesia (excessive sensitivity to pain),hyperpathia (hypersensitivity to sensory stimuli), dysesthesia (abnormal sensations of the skin such as numbness, tingling, burning, or cutting), or other abnormal sensations. Phantom limb pain, pain that is experienced in a missing limb or body part, is the result of sensory representations of the missing limb that are still present in the brain.

Sympathetically Maintained Pain. Sympathetically maintained pain is a pain mechanism that results from sympathetic nervous stimulation. Peripheral nerve damage, sympathetic efferent innervation, or circulating catecholamines can result in sympathetically maintained pain. Chronic pain syndrome, phantom limb pain, postherpetic neuralgia, and some metabolic neuropathies can trigger sympathetically maintained pain.

Central Pain. Central pain results from a primary lesion or dysfunction of the CNS. Ischemia (stroke), tumors, trauma, syrinx (a pathological cavity in the spinal cord or brain), or demyelination (multiple sclerosis) can cause central pain. The quality of the pain varies from a burning, numbing, tingling to a shooting sensation.Onset may be spontaneous, steady, or reactive with positive or negative sensory loss, allodynia, and hyperalgesia (Clark, 2004).


Developmental, Cultural, and Ethnic Variations

A common misconception is that infants, young children, and older adults or cognitively impaired adults do not experience pain. Just because the patient cannot verbally describe pain, that does not negate its presence. Although self-report is the most reliable indicator of pain, if this is not possible, physiological and behavioral indicators are used to assess pain.The challenge then is to accurately assess for pain in all patients at any age and to develop an effective treatment plan.

Infants. At one time, it was believed that infants did not experience pain, but research has refuted that idea. The process of pain is intact even though the emotional response is unclear. Since the infant cannot verbalize pain, physiological and behavioral indicators are used to assess for pain in the infant.

Infant physiological changes associated with pain include (Wong & Hockenberry-Eaton, 2001):

■ Integumentary system: Pallor or flushing,diaphoresis, palmar sweating.

■ Cardiovascular: Increased heart rate, increased blood pressure.

■ Respiratory: Rapid, shallow respirations, decreased arterial oxygen saturation, and transcutaneous oxygen saturation.

■ Musculoskeletal: Increased muscle tone.

■ Neurological: Increased intracranial pressure, dilated pupils, decreased vagal nerve tone.

■ Endocrine (hormonal release): Increased catecholamines, growth hormones, glucagon, cortisol, corticosteroids, and aldosterone.

■ Metabolism: Increased plasma lactate, pyruvate, ketone bodies, and fatty acids.

■ Laboratory values: Increased blood glucose (hyperglycemia) and corticosteroid levels and decreased pH.

Infant behavioral changes associated with pain include:

■ Vocalization: Intense, sustained crying, whimpering, and groaning.

■ Facial expression: Eye squeeze, brow bulge, open mouth, taut tongue, chin quivering, and grimaces.

■ Body movements: Limb withdraw, thrashing, rigidity or flaccidity, and fist clenching.

■ Sleep/wake cycle: Increased wakefulness and irritability.

■ Feeding: Loss of appetite, vomiting, loss of interest and/or energy in sucking.

■ Activity level: Decreased activity level; fussiness, irritability, and listlessness.

Children. Depending on the age of the child, assessing pain in children can be a challenge. The mnemonic QUESTT is helpful in assessing pain in children (Wong & Hockenberry-Eaton, 2001).QUESTT stands for:

■ Question the child.

■ Use a pain rating scale.

■ Evaluate behavioral and physiological changes.

Secure parents’ involvement.

■ Take the cause of pain into account.

■ Take action and evaluate results.

Question the Child. Self-report is the most accurate means for assessing pain, so ask the child to describe the pain. Self-report is more accurate than the child’s behavior.


Use a Pain Rating Scale. Various pain rating scales are available for assessing pain in children. Be sure to select one that is age appropriate for your patient.These scales are discussed later in this chapter.

Evaluate Behavioral and Physiological Changes. If the child is nonverbal and unable to describe pain, detecting behavioral and/or physiological changes is essential. Physiological changes that may be seen with acute pain include increase in blood pressure, increased or decreased heart rate, increased respirations, flushing, sweating, dilated pupils. Behavioral changes can vary depending on the child’s developmental level. Behavioral changes for a young child include crying, screaming, vocalizing hurt, thrashing of arms and legs, pushing away, clinging to parents, and increasing restlessness and irritability. Behavioral changes for a school-age child include crying, muscle rigidity, clenched fists, white knuckles, clenched teeth, closed eyes, and stalling techniques when anticipating a painful procedure. Behavioral changes for an adolescent include verbalization of pain and muscle tension.

Secure Parents’ Involvement. Parents know their child, so rely on their assessment. Parents are more attuned to subtle changes in their child’s behavior. Parents also usually know what will best comfort their child.Ask the parent:

What is the child’s past experience with pain?

What is the child’s response to pain?

How do you know your child is having pain?

What relieves the child’s pain?

Take the Cause of Pain Into Account. Consider the pathophysiology of the underlying problem when you evaluate the child’s pain.

Take Action and Evaluate Results. After assessing the pain, develop a plan to treat the pain. After treating pain, you need to assess the child to evaluate the effectiveness of the treatment and revise the plan as needed.

Older Adults. Assessing pain in the older patient can be challenging because of the misconceptions both patients and healthcare providers have surrounding pain and the elderly.

It is important to realize that the elderly do experience pain both acute and chronic. Untreated pain increases the risk for complications such as pneumonia, constipation, deep vein thrombosis, impaired immune function, sleep disturbances, weight loss, social isolation, and depression. Often, the older patient experiences chronic pain and does not exhibit the typical signs of pain.Answers to questions about the patient’s functional level and quality of life are good indicators of the effects of pain.

If the patient is cognitively impaired, assessing for pain becomes a greater challenge.The degree of impairment will determine the use of pain scales. Keep questions simple, specific, and in the here and now. If the patient is unable to verbally communicate, rely on physiological signs associated with pain, such as increased blood pressure, heart rate, and respirations; diaphoresis; and behavioral changes, such as agitation, restlessness, facial expression of pain, and vocal sounds (moaning and groaning) of pain.

Family members or caregivers should be included in the assessment process.They can provide invaluable data of the patient’s pain-related behavior and effective methods for relieving pain.


People of Different Cultures and Ethnic Groups. Although the physiological response to pain is consistent across cultures, your patient’s cultural or ethnic background influences his or her psychological and behavioral responses to pain. (See Cultural and Ethnic Variations in Response to Pain.)


Performing the Pain Assessment

Pain assessment includes a history and physical examination. As with any assessment,always begin with a history. Since pain is subjective in nature, the history component of the pain assessment is the most important.

Health History. Self-report is the most accurate indicator of pain. Because pain is subjective, the patient’s health history provides the best assessment of pain. The history also allows you to assess past experiences with pain,effective pain treatments, and the effects pain has on every aspect of the patient’s life.

Biographical Data. Review your patient’s biographical data. As described previously, your patient’s age,ethnicity,and religion may affect her or his perception and behavioral response to pain. Even the patient’s gender may influence her or his perception of pain. Also, your patient’s occupation may be a direct cause of the pain, such as back pain related to heavy lifting; the presence of pain may prohibit a return to work.

Current Health Status. When your patient presents with pain, perform a symptom analysis. The mnemonic PQRST provides a thorough description of pain. Ask:

■ Precipitating/Palliative/Provocative Factors

What were you doing when the pain started?

■ Does anything make it better, such as medication ora certain position?

■ Does anything make it worse, such as movement or breathing?

■ Quality/Quantity

What does it feel like?

■ Superficial somatic pain is sharp, pricking, or burning.

Deep somatic pain is dull or aching.

Visceral pain is dull, aching, or cramping.

■ Neuropathic pain is burning, shocklike, lancing, jabbing, squeezing, or aching.

How often are you experiencing it?

To what degree is the pain affecting your ability to perform your usual daily activities?

■ Region/Radiation/Related Symptoms

■ Can you point to where it hurts?

■ Does the pain occur or spread anywhere else?

■ Localized pain  is confined to the site of origin, such as cutaneous pain.

■ Referred pain is referred to a distant structure, such as shoulder pain with acute cholecystitis or jaw pain associated with angina.

■ Projected (transmitted) pain is transmitted along a nerve, such as with herpes zoster or trigeminal neuralgia.

■ Dermatomal pattern as with peripheral neuropathic pain.

■ Nondermatomal pattern as with central neuropathic pain, fibromyalgia.

■ No recognizable pattern as with complex regional pain syndrome.

■ Do you have any other symptoms? (e.g., nausea, dizziness, shortness of breath)

■ Visceral pain–related symptoms  include sickening feeling, nausea, vomiting, and autonomic symptoms.

■ Neuropathic pain–related symptoms  include hyperalgesia and allodynia.

■ Complex regional pain syndrome–related symptoms  include hyperalgesia, hyperesthesia, allodynia, autonomic changes, and shin, hair, and nail changes.

■ Severity

■ Use appropriate pain scale. (See Pain Scales, below.)

■ Timing

■ When did the pain begin?

How long did it last?

■ Brief flash: Quick pain as with needle stick.

■ Rhythmic pulsation: Pulsating pain as with migraine or toothache.

■ Long-duration rhythmic: As with intestinal colic.

■ Plateau pain: Pain that rises then plateaus such as angina.

■ Paroxysmal: Such as neuropathic pain.

How often does it occur?

■ Continuous fluctuating pain: As with musculoskeletal pain.

■ Do you have times when you are pain free?


When taking a patient’s current health status, pay attention to the words that the patient uses to describe her or his current pain level. They can provide important clues to her or his status.


Pain Scales. Various instruments are available to assess pain. Consider the patient’s age and developmental status along with his or her cultural background when selecting a pain scale. Select the one that will best meet your patient’s needs.

Pain Scales for Adults. Unidimensional and multidimensional pain scales are available.The unidimensional scale assesses one dimension, usually intensity of pain, and is often used to assess acute pain. Multidimensional scales provide additional information about pain, such as the pain’s characteristics and the effects on the patient’s daily life.A multidimensional scale is useful in assessing chronic pain.

Unidimensional Scales. These scales generally use numeric, verbal, or visual descriptors to quantify pain. Examples include the Numeric Rating Scale, Visual Analogue Scale, and categorical scales.

Numeric Rating Scale. The Numeric Rating Scale rates pain on a scale of 0 (no pain) to either 5 or 10 (worst pain) by asking the patient to rate her or his current pain level.

Visual Analogue Scale. The Visual Analogue Scale utilizes a vertical or horizontal 10-cm line with anchors. One end of the line is labeled “No pain” and the opposite end of the line is labeled “Worst pain.”The patient marks his or her current pain level on the line.


Categorical Scales. Categorical scales use verbal or visual descriptors to identify pain intensity. The patient selects the descriptor that she or he feels best represents the current pain level. Verbal descriptors include:

■ Mild, discomforting, distressing, horrible, excruciating.

■ No pain, mild pain, moderate pain, severe pain, very severe pain,worst possible pain.

Visual descriptors include the Faces Pain Scale for Adults and Children (FPS), which utilizes illustrated faces with facial expressions ranging from happy (no pain) to sad and crying (worst pain). The FPS has eight faces to select current pain level.The patient is asked to select the face that best represents his or her current pain level.

Multidimensional Pain Scales. These scales assess pain characteristics and its effects on patient’s activities of daily living and include such scales as the Initial Pain Assessment Inventory (IPAI), Brief Pain Inventory (BPI), McGill Pain Questionnaire (MPQ), and the Neuropathic Pain Scale.

Initial Pain Assessment Inventory. The IPAI is used for initial assessment of pain. It assesses characteristics of pain; effects of pain on the patient’s life, such as daily activities, sleep, appetite, relationships, and emotions; and the patient’s expression of pain. This assessment tool includes a diagram to note pain location, a scale to rate pain intensity,and space to document additional comments and the treatment plan.

Brief Pain Inventory. The BPI is used to quantify pain intensity and associated disability. It assesses pain intensity, location, effects on life, type, and effectiveness of treatment over the last 24 hours. Benefits of the BPI include that it is quick and easy to use and available in multiple languages.

McGill Pain Questionnaire. The MPQ uses descriptive words to assess pain on three levels: sensory, affective, and evaluative. It can be used with other tools and is available in short and long forms.

Neuropathic Pain Scale. The Neuropathic Pain Scale assesses the type and degree of sensations associated with neuropathic pain. The patient rates eight common qualities of neuropathic pain (sharp, dull, hot, cold, sensitive, itchy, deep, or surface pain) on a scale of 0 (no pain) to 10 (worst pain). This scale is still in the developmental stages,but early testing holds diagnostic and therapeutic promise.

Pain Scales for Children. Many pain scales are available to assess a child’s pain. Many of the pain scales are age specific. Instruments may also be specified by your institution since pain assessment forms are common use.

FACES Pain Rating Scale. The FACES Pain Rating Scale assesses pain for children ages 3 years and up.The Wong-Baker has five faces from which the child can select her or his current pain level (Fig. 4.4).


Oucher. The Oucher scale assesses pain for children ages 3 to 13 years with photos or a numeric scale.The photographic scale uses six photographs of children ranging from a child with “no hurt” to a child with “a lot of hurt.”The photographs are arranged vertically from 0 to 5, with 0 (no hurt) on the bottom and 5 (lot of hurt) on the top. This scale also has photographs of black and Hispanic children available.

Numeric Scale. The numeric scale ranges vertically from 0 to 100,with 0 being “no hurt” and 100 being “biggest hurt” (Beyer, Denyes,& Villaruel, 1992):

■ 0 = no hurt.

■ 1–29 = little hurt.

■ 30–69 = middle hurt.

■ 70–99 = big hurt.

■ 100 = biggest hurt.

Poker Chip Tool. The Poker Chip Tool assesses pain in children 4 years of age and up. The nurse places red poker chips horizontally in front of the child, with the poker chips denoting “pieces of hurt.” She then asks the child to select how many pieces of hurt he or she has (Hester et al., 1998).

Word-Graphic Rating Scale. The Word-Graphic Rating Scale assess pain in children ages 4 to 17 years. It uses words on a horizontal linear scale to assess pain. The child is asked to identify her or his current pain level on the scale (Tesler et al., 1991).

Numeric Scale. The Numeric Scale assesses pain for children ages 5 years and older. It uses a horizontal linear scale with numbers from 0 to 5 or 10, with 0 being “no pain” and 5 or 10 being “worst pain.”The child is asked to identify his or her current pain level on the scale. Although similar to a scale used for adults, this provides the child with a visual to help assess his or her pain.


Visual Analogue Scale. The Visual Analogue Scale, which assesses pain in children ages 41⁄2 and older, is similar to that used for adults. The child is asked to identify her or his pain level by marking the line in the area that represents her or his level of pain (Cline et al., 1992).

Color Tool. The Color Tool assesses pain for children as young as 4 years by having the child create a body outline using colored markers or crayons. The child selects four colors. The first color represents “most hurt,” the second represents “little hurt,” the third represents “least hurt,”and the last represents “no hurt.” Using all four colors, the child identifies areas and degree of hurt on the body outline (Eland & Banner,1999).

Past Health History. The past health history can identify factors that may affect the patient’s pain, response to pain, and treatment plan. When conducting the past health history, make sure to identify:

■ Cause of pain.

■ Past and present medical problems that may influence pain and its management.

Past psychiatric illnesses and chemical dependence.

■ Past and present pain management strategies.

■ Past experiences with pain.

■ Chronic vs. acute pain.


Family History. The family history may identify genetically linked causes of pain, such as sickle cell anemia and cancer. The family history also identifies familial history of chronic pain or illness. Ask the patient about hereditary or familial health problems.

Review of Systems. If there is a problem in one system, eventually other systems will be affected.The underlying cause of the pain determines the effect the pain will have on other systems.

Psychosocial Profile. Assessing the psychosocial history identifies the effects that pain has on every aspect of the patient’s life and evaluates quality of life.


Physical Assessment. The initial purpose of the physical examination is to identify the underlying cause of pain. As you perform the examination, assess the effects of physical movements (e.g., deep breathing, position changes) on the patient’s pain level.The physical examination may also reveal complications associated with untreated pain. The history findings should direct the physical exam.Be alert for physical, behavioral, and psychological responses to pain.

The autonomic response of the sympathetic nervous system to painful stimuli accounts for many of the physiological changes that are seen. This response is acute and cannot be sustained for prolonged periods of time, as the body adapts and physical indicators are no longer apparent in patients with prolonged pain or chronic pain. Again, physical signs are not as reliable of an indicator as self-report, the most reliable indicator of pain. However, when patients are unable to verbally communicate or who are cognitively impaired, you must rely on physical and behavioral indicators obtained by a head-to-toe assessment to evaluate your patient’s pain. (See Performing a Head-to-Toe Physical Assessment.)


Behavioral Pain Assessment Scales. Although the patient’s self-report of pain is the most accurate means to assess pain, there are times when the patient’s age or condition does not permit self-report, such as when the patient is confused or very young. Pain scales have been developed to objectively assess pain by scoring behavioral and physiological responses to pain. A variety of objective pain scales are available. The scales are mainly geared for the infant and young child. You need to consider the age of your patient in selecting a scale that will best assess your patient’s pain.

Behavioral Pain Assessment Scales for Infants. Since an infant cannot verbalize feelings of pain, physiological and behavioral changes need to be used to assess pain. Many scales are available to help you assess your patient’s pain. Identify the scale that is most appropriate in assessing your patient.

CRIES. CRIES (crying, requiring increased oxygen, increased vital signs, expression, sleeplessness) assesses postoperative pain from 32 weeks’ gestation to 20 weeks’ post-term. Each of the five categories is scored from 0 to 2. A score of 10 equates to the worst pain, and any score greater than 4 identifies significant pain (Krechel & Blidner, 1995). (See CRIES.)


Postoperative Pain Score. The Postoperative Pain Scale (POPS) assesses postoperative pain in infants ages 1 to 7 months. It scores each of its 10 categories (sleep, facial expression, quality of cry, spontaneous motor activity, spontaneous excitability, flexion of fingers and toes, tone, consolability, and sociability) on a scale of 0 to 2. A total score of 0 indicates worst pain, a score of 20, no pain (Attia, 1987).

Neonatal Infant Pain Scale. The Neonatal Infant Pain Scale (NIPS) is used to assess infants at an average gestational age of 33.5 weeks. It grades six categories: facial expression (0 to 1), cry (0 to 2), breathing pattern (0 to 1), arms (0 to 1), legs (0 to 1), and state of arousal (0 to 1).A final score of 0 identifies no pain while a score of 7 identifies worst pain (Lawrence et al., 1993).

Pain Assessment Tool. The Pain Assessment Tool (PAT) assesses pain from a gestational age of 27 weeks to full term. It grades 10 different categories:posture/tone (1 to 2), sleep pattern (0 to 2), expression (1 to 2), color (0 to 2), cry (0 to 2), respirations (1 to 2),heart rate (1 to 2), saturations (0 to 2), blood pressure (0 to 2), and nurse’s perception (0 to 2). A final score of 4 identifies no pain,while a score of 20 identifies worst pain (Hodgkinson et al., 1994).

Pain Rating Scale. The Pain Rating Scale (PRS) assesses pain for infants ages 1 to 36 months.The infant is given a grade of 0 (no pain) through 5 (worst pain) based on the following guidelines. For a score of 0, the infant exhibits smiling, sleeping, and no change when moved or touched. Behaviors associated with a score of 1 include taking small amounts orally, restlessness, moving, and crying. A score of 2 includes behaviors of not eating or drinking and short periods of crying but distracted with rocking or use of pacifier. With a score of 3, a definite change in behavior is noted. The baby is irritable with facial grimacing and arms and/or legs shake or have jerking movements. With a score of 4, the baby is inconsolable, flailing with a high-pitched wailing cry.A score of 5 is characterized by prolonged sleep periods interrupted by jerking movements, continuous crying, and shallow respirations ( Joyce et al., 1994).

Premature Infant Pain Profile (PIPP). The Premature Infant Pain Profile (PIPP) assesses pain for gestational ages 28 to 40 weeks. It grades seven categories on a scale of 0 (no pain) to 3 (worst pain).The categories are gestational age, behavioral stage, heart rate, oxygen saturation, brow bulge, eye squeeze, and nasolabial furrow. A final score of 0 identifies no pain, while a score of 21 identifies worst pain (Stevens, 1996).

Modified Behavioral Pain Scale. The Modified Behavioral Pain Scale (MBPS) assesses pain for children ages 4 to 6 months. It assesses three categories: facial expression (0 to 3), cry (0 to 4), and movements (0 to 3). A final score of 0 identifies no pain, while a score of 10 identifies worst pain (Taddio et al., 1995).

Behavioral Pain Assessment Scales for Children. Several behavioral pain assessment scales have been developed to assist in assessing pain not only for the infant but also for the older child. Brief descriptions are provided below.Again, you need to select the instrument most appropriate to meet your patient’s needs.

Objective Pain Score. The Objective Pain Scale (OPS) assesses pain for infants and children from ages 4 months to 18 years. It assesses five categories, each on a scale of 0 (no pain) to 2 (worst pain). The categories are blood pressure, crying, moving, agitation, and verbal evaluation/body language. A final score of 0 identifies no pain, and a score of 10 identifies worst pain (Hannallah et al., 1987).

Children’s Hospital of Eastern Ontario Pain Scale. The Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) assesses pain for children ages 1 to 5 years. It assesses six categories: crying (1 to 3), facial (0 to 2), child verbal (0 to 2), torso (1 to 2), touch (1 to 2), and legs (1 to 2).A final score of 4 identifies no pain,while a score of 13 identifies worst pain (McGrath et al., 1985).

Nurses Assessment of Pain Inventory. The Nurses Assessment of Pain Inventory (NAPI) assesses pain for infants and children from birth to age 16 years. It assesses three categories: body movement (0 to 2), facial (0 to 3),and touching (0 to 2). A final score of 0 identifies no pain,while the higher score identifies the worst pain (Stevens, 1990).

Behavioral Pain Score. The Behavioral Pain Score (BPS) assesses pain for children ages 3 to 36 months. It assesses three categories: facial expression (0 to 2), cry (0 to 3), and movements (0 to 3). A final score of 0 identifies no pain, while a score of 8 identifies worst pain (Robieux et al., 1991).

Riley Infant Pain Scale. The Riley Infant Pain Scale (RIPS) assesses pain in children younger than 36 months and children with cerebral palsy. It assesses five categories on a scale of 0 (no pain) to 3 (worst pain).


FLACC Postoperative Pain Tool. The FLACC Postoperative Pain Tool assesses pain for children ages 2 months to 7 years. It assesses five categories using a scale of 0 (no pain) to 2 (worst pain).A final score of 0 indicates no pain,while a score of 10 indicates worst pain.


Behavioral Pain Assessment Scales for Older Adults. Since a confused patient may not be able to verbalize feelings of pain, physiological and behavioral changes need to be used to assess pan.

Pain Assessment in Advanced Dementia Scale. The Pain Assessment in Advanced Dementia Scale (PAINAD) can be used to assess pain levels in patients with advanced dementia. It assesses five categories on a scale of 0 to 2.The higher the score, the greater the pain.


Reassessment of pain

Reassessment of pain is imperative to determine the effectiveness of treatment. Self-report and physical findings will help you evaluate the effectiveness of treatment. Compare the patient’s responses to the expected outcomes.Have the patient grade his or her current pain level and compare the grade with the previous rating. If relief has not been obtained, revise your plan and implement alternative interventions. Current recommendations for pain reassessment include:

■ Within 30 minutes after parenteral administration of pain medication.

Within 1 hour after oral administration of pain medication.

After each and every report of new or changes in pain.

The frequency of reassessment depends on the patient, type of pain, and setting. In acute care settings, reassessment of pain frequently occurs when vital signs are obtained. Outpatients or long-term healthcare residents should be instructed to report any changes in pain or ineffective pain control. Patients with chronic pain should have periodic pain reassessments to ensure effective pain control.


Pain Management

Pain and the control of pain are very big problems. There are over one million new cancer cases each year in the United States alone. Add that to the chronic diseases that cause intractable pain and you can see the magnitude of the problem. Unfortunately much of this pain is not being adequately controlled.

I had the opportunity to discuss this issue with Linda Schickedanz R.N. a Clinical Nurse Specialist who has extensive experience in the field of pain control. We discussed the inadequacies in pain control in this country and how it is affecting the lives of those in pain. The information she gave me should be of prime importance to seniors who at high risk for inadequate pain control.

The Problem

Pain is a major symptom for 70% of cancer patients, but 50 - 80% of cancer patients receive inadequate pain control. Advances in pharmacology have made many new drugs and technologies available that makes more than 90% of cancer pain controllable. The problem then is under treatment. Undertreatment of pain can lead to depression, non-compliance, anger, fear, and loss of control and suicide.

Risk Factors for Undertreatment

Who is more likely to be under treated for pain?

·         Minorities are three times as likely to be under treated.

·         Patients receiving a poor pain assessment from an inexperienced health care provider.

·         People with non-cancer pain.

·         People with "Good" performance status, such as someone who appears to be coping well and performing activities adequately.

·         People over the age of 70.

·         Females.

There Is Failure To Treat Pain Adequately In The Elderly
Seniors are among the biggest group that suffers from inadequate pain control. The elderly tend to minimize the expression of pain. They may also have underlying depression or dementia, which may affect their ability to communicate pain effectively. They may have impaired kidney or liver function that affect the absorption and metabolism of pain medications. Because of physical limitations such as poor eyesight the elderly may have difficulty managing high-tech pumps and infusion devises. One study found a lower pain medication use among non-communicative patients in nursing home than for patients who were able to communicate their needs. Did they really have less pain or were they just less able to communicate the pain.

Other Factors in Undertreatment

·         There is inadequate education for medical professionals on pain assessment and pain management.

·         Healthcare providers fear regulatory scrutiny, and legal consequences.

·         Patients and family fear addiction to pain medications.

·         Pain management is poorly reimbursed by payers.

·         Government regulations can be confusing and cumbersome. Regulations vary widely state by state.

When is Pain Controlled Adequately?

Pain evokes numerous physical and emotional responses such as a racing pulse, a rise in blood pressure, rapid respiration, sweating and dilation of the pupils. You might become frightened, anxious, or annoyed. Chronic pain can take over your life and dominates your every thought. It will interfere with sleep, work and relationships. Pain is controlled when the pulse and blood pressure are in normal ranges for the person affected, breathing is calm and eyes normal. It is controlled when functioning and sleep patterns become more normal and pain does not dominate thought.

Current Pain Treatment

·         Non-Steroidal Anti-inflammatory

·         These drugs which include ibuprofen and aspirin, have been very effective in treating pain that is caused by inflammation such as rheumatoid arthritis. The main side effects are stomach irritation and interference with the clotting mechanisms of the blood. The risk of problems with these medications increases with age.

·         Acetaminophen (Tylenol®)

·         This drug, which is gentle on the stomach but does little or nothing for inflammation. It is recommended for osteoarthritis. It can cause liver and kidney damage with high doses or long term use.

·         Narcotics
These are the most effective pain relievers, and work by blocking the pain signal that travels to the brain. Side effects can include drowsiness, constipation, slowed breathing, and mood changes. While used cautiously due to fears about addiction and abuse, research has found those fears unfounded in patients with chronic pain and no history of addiction.

·         Antidepressant and Antianxiety Drugs

·         These drugs can be used along with analgesics and often enhance the effects of those drugs. They are used cautiously as they can be addictive.

·         Disease Specific Drugs

·         Several new drugs have been introduced in the last few years that were designed to treat one specific disorder. These drugs include Imitrex® for migraines, Synvisc® for osteoarthritis of the knee, DMARDS such as methotrexate or Enbrel® for rheumatoid arthritis, oral or injected steroids for arthritis and lupus and the topical (skin cream) capsaicin used for arthritis or shingles pain.

·         Non - Drug Treatments

·         There are numerous other treatments that have all proven effective for some people. These include acupuncture, massage, meditation, and relaxation therapy.

Steps for Ensuring Adequate Pain Treatment

·         Establish open and honest communication with your physician. Describe your pain and ask for treatment. If your physician brushes you off or dismisses your pain it may be time to find a new physician.

·         Discuss any medications prescribed with your physician and pharmacist. Understand the side effects and signs of problems.

·         Set aside your fears of addiction or dependence. Most people once they have achieved pain control will actually be able to cut back some on their medications due to greater peace of mind.

·         Look at the legislation on pain control drugs that have been enacted in your state. If it restricts physicians in adequately treating their patients you can contact your representative and ask for a change in the law.


Importance of Controlling Pain

Inadequately managed pain can lead to adverse physical and psychological patient outcomes for individual patients and their families. Continuous, unrelieved pain activates the pituitary-adrenal axis, which can suppress the immune system and result in postsurgical infection and poor wound healing. Sympathetic activation can have negative effects on the cardiovascular, gastrointestinal, and renal systems, predisposing patients to adverse events such as cardiac ischemia and ileus. Of particular importance to nursing care, unrelieved pain reduces patient mobility, resulting in complications such as deep vein thrombosis, pulmonary embolus, and pneumonia. Postsurgical complications related to inadequate pain management negatively affect the patient’s welfare and the hospital performance because of extended lengths of stay and readmissions, both of which increase the cost of care.

Continuous, unrelieved pain also affects the psychological state of the patient and family members. Common psychological responses to pain include anxiety and depression. The inability to escape from pain may create a sense of helplessness and even hopelessness, which may predispose the patient to a more chronic depression. Patients who have experienced inadequate pain management may be reluctant to seek medical care for other health problems. (For more detail, go to the section, “Harmful Effects of Unrelieved Pain,” below.)

Poorly managing pain may put clinicians at risk for legal action. Current standards for pain management, such as the national standards outlined by the Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations, JCAHO), require that pain is promptly addressed and managed. Having standards of care in place increases the risk of legal action against clinicians and institutions for poor pain management, and there are instances of law suits filed for poor pain management by physicians. Nurses, as part of the collaborative team responsible for managing pain during hospitalization, also may be liable for legal action.

Hospitals stand to lose reputation as well as profit if pain is poorly managed. Patient satisfaction with care is strongly tied to their experiences with pain during hospitalization. Evidence indicates that higher levels of pain and depression are linked to poor satisfaction with care in ambulatory settings. With the advent of transparent health care, report cards for hospitals are becoming more prevalent, and performance on pain management is likely to be one of the indicators reported.

Undertreatment of Pain

The undertreatment of pain was first documented in a landmark study by Marks and Sachar in 1973. These researchers found that 73 percent of hospitalized medical patients had moderate to severe pain. The undertreatment of pain continues. Thirty years later in 2003, Apfelbaum and others found that 80 percent of surgical patients experienced acute pain after surgery, and 86 percent of those had moderate to extreme pain. Of 1,308 outpatients with metastatic cancer from 54 cancer treatment centers, 67 percent reported pain. Of those who had pain, 62 percent had pain severe enough to impair their ability to function, and 42 percent were not given adequate analgesic therapy. It is estimated that 45 percent to 80 percent of elderly patients in nursing homes have substantial pain that is undertreated. These studies and others suggested that when patients had moderate to severe pain, they had only about a 50 percent chance of obtaining adequate pain relief.

Harmful Effects of Unrelieved Pain

Patients suffer from pain in many ways. Pain robs patients of their lives. Patients may become depressed or anxious and want to end their lives. Patients are sometimes unable to do many of the things they did without pain, and this state of living in pain affects their relationships with others and sometimes their ability to maintain employment.

What is often overlooked is that pain has physically harmful effects. It is often actually physiologically unsafe to have pain. The effects of pain on the endocrine and metabolic system, cardiovascular system, gastrointestinal system, and immune system—and the potential for future pain—are but a few of examples of how unsafe unrelieved pain may be.

Pain causes stress. The endocrine system reacts by releasing an excessive amount of hormones, ultimately resulting in carbohydrate, protein, and fat catabolism (destruction); poor glucose use; and other harmful effects. This reaction combined with inflammatory processes can produce weight loss, tachycardia, increased respiratory rate, fever, shock, and death. Unrelieved pain prolongs the stress response, adversely affecting the patient’s recovery.

The cardiovascular system responds to stress of pain by activating the sympathetic nervous system, which produces a variety of unwanted effects. In the postoperative period, these include hypercoagulation and increased heart rate, blood pressure, cardiac work load, and oxygen demand. Aggressive pain control is required to reduce these effects and prevent thromboembolic complications. Cardiac morbidity is the primary cause of death after anesthesia and surgery.

Since the stress response causes an increase in sympathetic nervous system activity, intestinal secretions and smooth muscle sphincter tone increase, and gastric emptying and intestinal motility decrease. This response can cause temporary impairment of gastrointestinal function and increase the risk of ileus.

Unrelieved pain may be especially harmful for patients with metastatic cancers. Stress and pain can suppress immune functions, including the natural killer (NK) cells that play a role in preventing tumor growth and controlling metastasis. Further, management of perioperative pain is probably a critical factor in preventing surgery-induced decrease in resistance against metastasis.

Unrelieved acute pain can result in chronic pain at a later date. Thus, pain now can cause pain later. If acute shingles pain is not treated aggressively, it is believed to increase the risk of postherpetic neuralgia. A survey of patients having undergone surgery found a high prevalence of chronic postsurgical pain in patients whose acute postsurgical pain was inadequately managed.

Assessment of Pain

Assessment of pain is a critical step to providing good pain management. In a sample of physicians and nurses, Anderson and colleagues found lack of pain assessment was one of the most problematic barriers to achieving good pain control. There are many recommendations and guidelines for what constitutes an adequate pain assessment; however, many recommendations seem impractical in acute care practice. Nurses working with hospitalized patients with acute pain must select the appropriate elements of assessment for the current clinical situation. The most critical aspect of pain assessment is that it is done on a regular basis (e.g., once a shift, every 2 hours) using a standard format.5 The assessment parameters should be explicitly directed by hospital or unit policies and procedures. To meet the patients’ needs, pain should be reassessed after each intervention to evaluate the effect and determine whether modification is needed. The time frame for reassessment also should be directed by hospital or unit policies and procedures.5

An early Clinical Practice Guideline on Acute Pain Management released by the Agency for Health Care Policy and Research addressed assessment and management of acute pain. This guideline outlines a comprehensive pain evaluation that would be most useful when obtained prior to the surgical procedure. In the pain history, the nurse identifies the patient’s attitudes, beliefs, level of knowledge, and previous experiences with pain. Expectations of patient and family members for pain control postsurgically will uncover unrealistic expectations that can be addressed before surgery. This comprehensive pain history lays the foundation for the plan for pain management following surgery, which is completed collaboratively by the clinicians (physician and nurse), the patient, and his or her family.

Pain History

The pain history should include the following:

  • Significant previous and/or ongoing instances of pain and its effect on the patient

  • Previously used methods for pain control that the patient has found either helpful or unhelpful

  • The patient's attitude toward and use of opioids, anxiolytics, or other medications, including any history of substance abuse

  • The patient's typical coping response for stress or pain, including the presence or absence of psychiatric disorders such as depression, anxiety, or psychosis

  • Family expectations and beliefs concerning pain, stress, and postoperative course

  • Ways the patient describes or shows pain

  • The patient's knowledge of, expectations about, and preferences for pain management methods and for receiving information about pain management (p. 7–8)

Pain Assessment Tools

During the postsurgical period, pain assessment must be brief and simple to complete. Because choice of intervention, including type of analgesic and dosing, is made based upon intensity, every pain assessment should include this type of measure. Numerous pain intensity measures have been developed and validated. Several tools provide a numeric rating of pain intensity (e.g., visual analogue scale, numeric rating scale (NRS)). Simpler tools such as the verbal rating scale, which classifies pain as mild, moderate or severe, also are commonly used. For patients with limited cognitive ability, scales with drawings or pictures are available (e.g., the Wong-Baker FACES scale). Patients with advanced dementia require behavioral observation to determine the presence of pain; tools such as the PAIN-AD are available for this patient population. (For more detail, go to section “Tools to Assess Pain Intensity in Cognitively Intact and Impaired Adults,” below.)

The Joint Commission developed pain standards for assessment and treatment based upon the recommendations in the Acute Pain Clinical Practice Guideline. The Joint Commission requires that hospitals select and use the same pain assessment tools across all departments. This standard suggests providing options among scales such as the NRS, the Wong-Baker FACES scale, and a verbal descriptor scale.

Selecting the pain assessment tool should be a collaborative decision between patient and health care provider. When this is done during the preoperative period, it ensures the patient is familiar with the scale. If the nurse selects the tool, he or she should consider the age of the patient; his or her physical, emotional, and cognitive status; and preference. We tend to think of these intensity scales as verbal, but patients who are alert but unable to talk (e.g., intubated, aphasic) may be able to point to a number or a face to report their pain. The pain tool selected should be used on a regular basis to assess pain and the effect of interventions. It should not, however, be used as the sole measure of pain perception.

Location and quality of pain are additional assessment elements useful in selecting interventions to manage pain. Since patients may experience pain in areas other than the surgical site, location of pain using a body drawing or verbal report provides useful information. The pain experienced may be chronic (e.g., headache, low-back pain) or it may be related to the positioning and padding used during the procedure. The quality of pain varies depending upon the underlying etiology. Instruments such as the McGill Pain Questionnaire contain a variety of verbal descriptors that help to distinguish between musculoskeletal and nerve-related pain. Typically, patients describe deep tissue pain as dull, aching, and cramping, while nerve-related pain tends to be more sporadic, shooting, or burning.

Pain interferes with many daily activities, and one of the goals of acute pain management is to reduce the affect of pain on patient function and quality of life. The ability to resume activity, maintain a positive affect or mood, and sleep are relevant functions for patients following surgery. The Brief Pain Inventory includes four items that may be useful in assessing this aspect of the pain experience. Using an NRS format, assessment of interference with ability to walk, general activity, mood, and sleep during the recovery period will assist in selecting interventions to enhance function and quality of life.

The final elements of pain perceptions involve determining current aggravating and alleviating factors. Aggravating factors may be as simple as patient position, a full bladder, or temperature of the room. Alleviating factors include the interventions used (e.g., analgesics) and cognitive strategies used to control pain. Examples of such strategies are distraction, positive self-talk, and pleasant imagery. The pain history will provide insight into the coping strategies previously used by the patient and their effectiveness with previous painful episodes.

In addition to self-reported pain perceptions, a comprehensive assessment of pain following surgery includes both physiological responses and behavioral responses to pain (p. 11). Physiological responses of sympathetic activation (tachycardia, increased respiratory rate, and hypertension) may indicate pain is present. Behaviors that may indicate pain include splinting, grimacing, moaning or grunting, distorted posture, and reluctance to move. While these nonverbal methods of assessment provide useful information, self-report of pain is the most accurate. A lack of physiological responses or an absence of behaviors indicating pain may not mean the patient is not experiencing pain. (Go to section “Tools to Assess Pain Intensity in the Cognitively Impaired,” below, for more detail.)

Adequate pain management requires an interdisciplinary approach. Documentation of pain assessment and the effect of interventions are essential to allow communication among clinicians about the current status of the patient’s pain and responses to the plan of care. The Joint Commission requires documentation of pain to facilitate reassessment and followup. The American Pain Society suggests that pain be the fifth vital sign as a means of prompting nurses to reassess and document pain whenever vital signs are obtained. Documentation also is important as a means of monitoring the quality of pain management within the institution.

Monitoring the Quality of Pain Management

Establishing and maintaining an institutional pain performance improvement plan is a Joint Commission requirement. Institutions should develop interdisciplinary approaches to acute pain management with clear lines of responsibility for achieving good acute pain control. This interdisciplinary approach includes an individualized plan of care for pain control, developed in collaboration with the patient and family. Systems should be in place to monitor pain management that alerts the clinician when pain is poorly managed. For example, in an institution with a computerized documentation system, an alert may pop up when a patient’s pain exceeds a threshold. The threshold may be set individually by patient and clinician or institutionally. A reasonable threshold might be moderate to severe pain, which means a pain score of greater than 4 on a 0–10 scale. The plan of care provides the basis for monitoring the quality of acute pain management provided.

American Pain Society Current Guidelines

One of the first quality improvement programs was developed by the American Pain Society. The quality improvement guideline was refined and expanded in 2005 (p. 1576) based upon a systematic review of pain quality improvement studies conducted over the past 10 years. The emphasis has shifted from processes to outcomes.

  • Recognize and treat pain promptly.

  • Involve patients and families in pain management plan.

  • Improve treatment patterns.

  • Reassess and adjust pain management plan as needed.

  • Monitor processes and outcomes of pain management.

The goal of pain management after surgery is to prevent and control pain. Postsurgical pain, like cancer pain, is expected to be present continuously with spikes of increased pain with movement, deep breathing and coughing, and ambulation during the fist 24–48 hours after surgery. Around-the-clock dosing is recommended during this early postsurgical period to prevent severe pain and control continuous pain.

Quality Indicators (p. 1578)

Quality indicators for pain management focus on appropriate use of analgesics and outcomes.

  • Intensity of pain is documented using a numeric (0–10) or descriptive (mild, moderate, severe) rating scale.

  • Pain intensity is documented at frequent intervals.

  • Pain is treated by route other than intramuscular.

  • Pain is treated with regularly administered analgesics, and, when possible, multimodal approach is used. (Multimodal approach includes a combination of pain control strategies, such as opioids, nonsteroidal anti-inflammatory drugs, nonpharmacological interventions.)

  • Pain is prevented and controlled to a degree that facilitates function and quality of life.

  • Patients are adequately informed and knowledgeable about pain management.

To efficiently monitor quality indicators, patient records should contain documentation of

  • Pain intensity (0–10 or mild, moderate, severe)

  • Analgesics prescribed and administered, including drug, route, and dosing

  • Impact of pain on function and quality of life (e.g., ability to walk, general activity, mood, sleep)

  • Pain education for patient and family member(s)

Patient Satisfaction

Although satisfaction with pain management currently is used as a measure of institutional quality, satisfaction with pain management is no longer recommended as a quality indicator for pain control. This is because patient satisfaction findings are difficult to interpret. In their review of 20 quality improvement studies conducted between 1992 and 2001, Gordon and colleagues noted 15 studies reported high satisfaction with pain management despite many patients experiencing moderate to severe pain during hospitalization. Thus, patient satisfaction data should be cautiously interpreted and, if used, used in conjunction with other quality indicators. Because of the current focus on report cards for health care organizations, patient satisfaction data are routinely collected and easily obtained for review.

Many institutions use commercial patient satisfaction surveys to monitor satisfaction with care. Most of these surveys have at least one item on satisfaction with pain management. Institutions also may use generic health status or quality of life surveys, such as the Medical Outcomes Study Short From-36, to monitor patient outcomes; most of these surveys include one or more questions on pain experienced. Regular review of these patient satisfaction data can be used as a quick measure of quality of pain care. If satisfaction scores on pain management dip, a more thorough investigation of pain management processes is warranted.

Use of an interdisciplinary team to monitor current pain practice, identify areas for improvement, and oversee quality improvement plans is consistently recommended in the guidelines. To effectively monitor pain practice within a hospital, electronic systems are needed to capture and collate data on the indicators in a readily available form. One method of changing clinician behavior is through the use of feedback on performance; thus the reports generated for interdisciplinary committee review also may be used to assist clinicians to review and adjust their performance.



■ Pain is referred to as the fifth vital sign. Subjective in nature, self-report is the most accurate assessment indicator of pain.

■ Pain assessment includes a detailed history and symptom analysis and physical examination. The history is the most important piece of the assessment.

■ Realize that pain threshold, the point at which a painful stimulus is perceived as painful, is consistent from one person to the next; however, pain tolerance, the amount of pain one is able to endure, varies greatly.

■ Developmental, psychosocial, and cultural factors and past experiences influence pain perception, thereby accounting for such individual differences in pain perception even with similar painful stimuli.

The initial purpose of the physical examination is to identify the underlying cause of pain. The physical examination also identifies physical, behavioral, and psychological nonverbal responses to pain.

Although self-report is the most accurate assessment tool of pain, the age and mental status of the patient may prevent self-report. Assessment then becomes dependent on assessing physical, behavioral, and psychological nonverbal responses to pain.

Various pain scales are available to assess pain. Select the one best suited to meet your patient’s needs.

■ Be sure to document your findings,evaluate the effects of treatment, and revise the plan of care as needed to ensure pain relief for your patient.

Nutritional Assessment


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

1.     Define nutritional health.

2.     Outline risk factors that affect nutritional health status.

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

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

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

6.     Describe existing validated nutritional assessment tools.

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

8.     Differentiate between normal and abnormal findings in a nutritional assessment.

9.     Determine specific nutritional assessment techniques and tools appropriate for unique stages in the life span.

10.                       Discuss strategies for integrating a complete nutritional assessment into the nursing care process.


  • 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 Health

  • 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 between nutrient 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 when 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 assessment 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 Glossary

Click on the glossary term to listen to the audio.

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

angular stomatitis   A clinical finding of poor nutrition, cracks at the corner of the mouth.

anthropometrics   Any scientific measurement of the body.

atrophic papillae   A clinical finding of poor nutritional health.

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

cheilosis   Inflamation of mouth.

diet recall   24-hour recall, patient verbally recalls all food, beverages, and nutritional supplements or products consumed in a set 24-hour period".

flag sign   Dyspigmentation of mouth.

food frequency questionnaire    A questionnaire that assesses intake of a variety of food groups on a daily, weekly, or longer basis.

food security   A parameter used in nutritional assessment, free access to adequate and safe food.

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

immunocompetence    A biochemical assessment laboratory measurement used in nutritional assessment.

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

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

overnutrition   Excesses in nutrient intake or stores.

protein-calorie malnutrition   A nutrient deficiency resulting from undernutrition.

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

somatic protein   Muscle mass /skeletal muscle.

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

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

xerophthalmia   A clinical finding of poor nutrition, dry mucosa.


Nutrition is the relative state of balance between nutrient intake and physiological requirements for growth and physical activity. Optimal nutrition helps protect against disease, facilitates recovery, and decreases complications during illness. Good nutrition helps people stay healthy.

Malnutrition has traditionally been defined as a deficit of appropriate nutrients. However, it literally means bad nutrition and can encompass any situation that contributes to an imbalance in nutrient intake relative to actual needs. Therefore, malnutrition can mean a nutrient deficit or excess. Although nutritional deficits remain a significant health problem in Third World countries, the major problem in the United States is nutritional excess, as is shown by the rising rates of obesity in all age groups.

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

Assessing nutritional status achieves the following:

■ Identifies actual nutritional deficiencies.

Illuminates dietary patterns that may contribute to health problems.

Provides a basis for planning for more optimal nutrition.

■ Establishes baseline data for evaluation.


Review of Nutrients

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

Primary Nutrients. Nutrients are substances contained in food that are essential for optimal body functioning. The  primary nutrients are carbohydrates, proteins, fats, vitamins, minerals, and water. Carbohydrates, protein, and fat are the body’s major energy sources. Carbohydrates and protein each supply 4 calories per gram, and fat provides 9 calories per gram. Vitamins are essential to specific functions in the body. Minerals are inorganic elements that are essential to cell structure and physiological functions in the body.Water makes up 50 to 60 percent of the adult weight. It is required for many functions, and humans cannot survive for more than a few days without it.

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

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

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


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

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

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

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

Lipoproteins. Serum cholesterol and lipids attach to proteins and are transported throughout the body as  lipoproteins. The relative ratio of lipid to protein determines the density of the molecule.A low lipid-to-protein ratio results in a high-density lipoprotein (HDL).HDLs are produced during cellular metabolism. They lower serum cholesterol by transporting it from the cell to the liver for metabolism and excretion. Conversely, a high lipid-to-protein ratio produces a larger and low-density lipoprotein (LDL). LDLs are produced in the gastrointestinal wall after eating and transport dietary cholesterol and triglycerides to the cells.

Thus, HDLs guard against heart disease by lowering cholesterol, and LDLs contribute to heart disease by raising cholesterol.The risk for heart disease is particularly high when total serum cholesterol exceeds 200 mg/dL. The risk also increases as the HDL level decreases. An HDL less than 35 mg/dL is considered a major risk factor for heart disease, and an HDL above or equal to 60 mg/dL is a negative risk factor.

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

Minerals are inorganic compounds found in nature. They play a wide variety of roles in human nutrition. Minerals are required in varying amounts and are divided into major and trace elements. Major minerals are required in excess of 100 mg per day and include calcium, chloride, magnesium, phosphorus, potassium, sodium, and sulfur. The remaining minerals are known as trace elements (e.g. aluminum, bromine, chromium, cobalt, copper, fluorine, iron, iodine, magnesium, nickel, silicon, zinc, and other rare minerals).

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

Adults consume about 6 cups of water per day through beverages; another 4 cups are obtained through food; and about 1 cup is produced as a byproduct of metabolism. Sensible water loss occurs through excessive perspiration, urine, and gastrointestinal secretions. Evaporative or insensible water loss occurs via the lungs and skin. More than half of the body’s weight is composed of water, and therefore rapid weight changes are usually a reflection of fluid balance. This is especially true for infants who have a greater proportion of water weight and proportionately more extracellular fluid. Thirst is not an accurate indicator of hydration status because it does not occur until about 10 percent of the intravascular volume is lost, or 1 to 2 percent of the intracellular volume is depleted. Assessment of hydration and signs and symptoms of dehydration are discussed later in this chapter.

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

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


How a Nutritional Deficiency Develops

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

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

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

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

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

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

Infants, Children, and Adolescents. The growth and development that occur in infancy, childhood, and adolescence determine nutritional needs. For example, brain development is at its peak from birth through the second year of life, but after this, improved nutrition will not enhance brain growth. Growth charts are the standard against which infant and child growth is evaluated (see Appendix B).The following tables list indications of good nutrition in school-age children and summarize pertinent growth and developmental factors and corresponding nutritional needs of infants, children, and adolescents.



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

Pregnant women need an additional 300 calories a day, and lactating women an additional 500 calories a day. Development of the placenta, amniotic fluid, and fetal tissues, and increases in maternal blood volume during pregnancy require 10 g of protein a day. This requirement can be met simply by adding one additional serving each of milk and meat to the daily diet. Prenatal vitamins and mineral supplements during pregnancy and lactation are also critically important. The following table summarizes the vitamin and mineral needs of pregnant and lactating women.

Older Adults. Older adulthood begins at age 65. The senses become less acute, and diminished taste of sweet and salty foods may cause people to compensate by increasing sugar and salt. Decreased gastric acidity can impede vitamin B12 absorption. Antacid use impedes it further. Skin changes associated with aging impair vitamin D synthesis; so does spending less time outdoors. Diminished physical strength and decreased activity predispose older adults to bone demineralization and loss. This problem is especially common in women who do not consume adequate calcium and in postmenopausal women who have lost the protective advantage of estrogen. In addition, loss of urinary sphincter muscle tone in women and urination difficulty associated with prostate changes in men may discourage fluid intake. Confusion, a common consequence of dehydration, may impair mental status. Decreased income, loss of the social context for eating (e.g., death of spouse), and lack of accessibility to food markets are social and economic aspects of aging that may adversely affect nutrition.

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

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



Performing the Nutritional Assessment

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

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

■ History of unintentional weight loss (>10 lb or 10 percent of usual weight).

■ Serum albumin concentration lower than 3.5 g/dL.

■ Total lymphocyte count lower than 1500 cells/mm3.

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

■ Symptoms associated with nutritional deficiency or depletion.

■ Factors associated with inadequate nutritional intake or absorption.


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

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

Current Health Status. Inadequate nutrition is often discovered indirectly during a routine health history and physical examination. For instance, diminished growth and delayed development related to inadequate nutrition may be identified during a routine well-child checkup. Patient concerns that result from malnutrition usually present as a specific symptom or functional problem rather than a focused nutritional problem.For example,a person with iron deficiency anemia may complain of a lack of energy and an inability to concentrate.

Ask your patient if his or her health status has changed. If so, consider the potential influence of the health change on nutrition.Acute and chronic illnesses, debilitating conditions, medications, surgery, and trauma all affect nutrition. Illness and trauma stimulate the stress response and increase nutritional requirements. Vomiting and diarrhea can cause fluid and electrolyte loss. Febrile illnesses accelerate metabolic processes and insensible fluid loss. Energy and fluid requirements are also greater during infections and febrile illnesses. Certain diseases, such as DM, cystic fibrosis, and celiac disease, are linked to specific nutritional deficits.

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

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


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

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


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


Comprehensive Nutritional History. If the person has one or more known nutritional risks, perform a comprehensive nutritional history. If there is no time to perform a comprehensive history, perform a focused history. Although nutritional patterns are learned early in life and are hard to break,weight and nutrition are major health issues in Western cultures. Information on dieting, exercise, and nutrition pervades the news media, along with the message that people should take responsibility for making healthy changes. Consequently, many people worry that they will be scolded for poor nutritional practices, so they withhold or embellish information. So remember to convey an attitude of acceptance and caring, and never be authoritarian or paternalistic. Two dietary analysis techniques are discussed—24-hour recall and food intake records. You can use either technique as part of your comprehensive history.


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

The 24-hour recall is a valuable screening and assessment tool only if it represents the person’s typical daily intake. If a person is ill or has a change in routine, her or his intake will vary from normal. So be sure to ask if what she or he recorded represents a typical day. If she or he says no, ask her or him to substitute foods typically eaten.

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

Food Intake Records. Food intake records are typically done on people who are debilitated, have severe burns, or are on chemotherapy. A food intake record is a quantitative listing of all food and fluid consumed within a designated time frame—usually 3 to 5 days.Because food intake patterns often change on weekends and holidays, records kept during outpatient or home-care situations should reflect one atypical day for a 3-day period and one weekend for a 5-day period. Again, be sure to clarify serving sizes.

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

A less specific but more practical approach involves analyzing the patient’s food intake record using food labels on packages. Once you have determined the total number of calories consumed, calculate the total grams of carbohydrate, protein, and fat and the percentage of caloric intake contributed by each of these.

Protein should compose 10 percent of the diet; fat, 20 to 30 percent, and carbohydrates, the remaining calories.

Physical Assessment. Now proceed to the objective part of the assessment. Findings from the health history will determine the depth and scope of your physical examination. As you perform the examination, be alert to findings in various body systems that might signal malnutrition. Remember, determination of malnutrition cannot be made on physical findings alone.Many diseases and disorders mimic nutritional deficiencies. Always corroborate your physical findings with the health history and the results of laboratory assessments.The assessment includes performing a head-to-toe scan and taking various anthropometric measurements.

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

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


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


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

Growth Charts

Children. Growth charts for height, weight, and head circumference are excellent indicators of nutrition in children because they allow you to visualize the child’s growth progress. Two sets of charts are commonly used: one for birth to 36 months (includes head circumference) and one for age 2 to 18 (does not include head circumference because cerebral growth is complete by age 2).New charts have also been developed to track the unique growth patterns of premature infants.

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

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

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


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


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

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


Midarm circumference (MAC) provides a crude estimate of muscle mass and is most useful when combined with TSF. Measure the circumference of the patient’s dominant arm at the same site where you obtained the TSF. Wrap the measuring tape firmly around the patient’s arm without compressing the skin. Take two or three more measurements to ensure reliability. They should not vary by more than 1 cm. Compare midarm measurements with equivalent age- and gender-specific percentiles. Figure 8.5 illustrates MAC measurement.


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

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

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

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

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

3. Knowledge, deficient, related to nutrition

Identify any additional nursing diagnoses and any collaborative nursing diagnoses.















Understanding measures of nutritional status is critical for the interpretation of nutrition-related development outcomes.

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

Nutritional assessment is often viewed 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 reflected in the indicators used to assess progress towards MDG 1:

-         the prevalence of underweight children under-five years of age

the proportion of population below minimum level of dietary energy consumption


Nutrition is a key issue for healthcare professionals, yet the management of nutritional problems is often poor. Malnutrition is a significant risk for patients in hospital (NHS Quality Improvement Scotland, 2003). A failure to address the issue of malnutrition is a failure of the duty of nurses to protect the health of patients. In a study of 500 admissions to a large teaching hospital, McWhirter and Pennington (1994) found that 40% were malnourished on admission and two-thirds lost weight in hospital.



Malnutrition is a term used frequently in healthcare to refer to undernourished individuals who have inadequate intake of energy in their diet. But the term actually refers to any deviation from the normal adequate nutritional requirements for good health. Undernutrition can occur as a result of inadequate intake as well as disorders of digestion or absorption of protein and calories. The term can also be used to refer to deficiencies in the intake of a particular vitamin or mineral. However, with the exception of iron deficiency anaemia, vitamin or mineral deficiencies are more likely to occur in clusters or alongside inadequate intake of protein or calories

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

Nutritional assessment is used to evaluate nutritional status, identify disorders of nutrition and determine which individuals need instruction and/or support. An assessment should include screening for malnutrition using a validated tool. It is essential that screening is carried out initially on all patients to identify those in need of further investigation and subsequent nutritional support.

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

- Height and weight;

- Eating and drinking likes and dislikes;

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

- Cultural/ethnic/religious requirements (halal for Muslims or kosher for Jews);

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

- Physical difficulties with eating and drinking (such as tremor);

- Need for equipment to help with eating and drinking.

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

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

The individual’s recent medical and dietary history should also be noted. Dietary history can be used to devise a nutritional treatment plan and recent medical history combined with a dietary history may point to illnesses or conditions that can increase the risk of malnutrition. For example, a patient may report loss of appetite, nausea and vomiting, change in bowel habit, weight loss or tiredness, all of which could be indications of an underlying condition such as cancer. 

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

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

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

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

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

Ideal body weight
The 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 plus 2.3kg (5lb) for every additional inch.

Men: 48kg (106lb) for the first 1.52m (5ft) of height plus 2.5kg (6lb) for every additional inch.

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

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

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



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

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

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

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

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

Learning objectives
- Define malnutrition and the factors that influence it

- Outline what information should be recorded as part of a nutritional assessment

- Explain how you would calculate unintentional weight loss

- Identify how BMI can be used to assess problems with nutrition

Below 18.5 / Underweight

18.5-24.9 / Normal

25-29.9 / Overweight 

30-39.9 / Obese

Above 40 / Very obese

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

- Describe the last time you encountered a malnourished patient

- Identify information in this article that could have helped you in the care of that patient 

- Explain how you intend to disseminate what you have learnt among your colleagues

 A nutrition assessment is an in-depth evaluation of both objective and subjective data related to an individual's food and nutrient intake, lifestyle, and medical history.

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

Elements of the Assessment

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


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

As early as 1836, tables had been developed to compare weight and height in order to provide a reference for an individual's health status. The Metropolitan Life Insurance Company revised height and weight tables in 1942, using data from policyholders, to relate weight to disease and mortality. There has been much discussion about the relevance (and appropriateness) of using the individuals who buy life insurance as a basis for "ideal" height and weight. There are also a number of problems with using a table to determine whether an individual is at the right weight—or even what the "ideal



weight" means. Tables should therefore be used only as a guide, and other measurements should be included in the data collection and evaluation.

In 1959, research indicated that the lowest mortality rates were associated with below-average weight, and the phrase "desirable weight" replaced "ideal weight" in the title of the height and weight table.

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

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

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

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

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

Biochemical data.

Laboratory tests based on blood and urine can be important indicators of nutritional status, but they are influenced by nonnutritional 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 of nutrition assessment, biochemical data need to be viewed as a part of the whole.

Clinical data.

Clinical data provides information about the individual's medical history, including acute and chronic illness and diagnostic procedures, therapies, or treatments that may increase nutrient needs or inducemalabsorption. Current medications need to be documented, and both prescription drugs and over-the-counter drugs, such as laxatives or analgesics, must be included in the analysis. Vitamins, minerals, andherbal preparations also need to be reviewed. Physical signs ofmalnutrition can be documented during the nutrition interview and are an important part of the assessment process.

Dietary data.

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

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

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


After data are collected, the practitioner uses past experience as well as reference standards to assimilate the information into an assessment that provides an understanding of the individual's nutritional status. The practitioner uses the anthropometric data to assess ideal and desirable weight, as well as skinfold measurements to determine body fat. Height, weight, and age are plugged into the Harris-Benedict equation to determine calorie and protein needs. Using the clinical, biochemical, and dietary data, influences on the nutritional status can be determined. A nutritional intervention, which usually includes dietary guidance and exercise recommendations, is then formulated and discussed with the individual.

Under-nutrition is usually described as protein-energy malnutrition or PEM. In children, PEM is often perceived as a problem particular to the developing world, with a reported incidence of about 39% of the world's pre-school children and associated mortality in up to 20 % of these children.

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

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

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

The five pillars of paediatric nutrition

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

Maintenance of body function

A child's metabolic rate is higher per kilogram of bodyweight than that of an adult and, therefore, energy requirements are also proportionately greater. These requirements are further increased by physiological stresses, such as trauma and infection, and psychological stresses, such as separation and anxiety.

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


Play and activity are essential to a child's social and physical development. It is important that nutrition provides sufficient energy to allow for this. Even a short period of immobility or inactivity can prove detrimental.


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


Normal growth occurs only when more nutrition is provided than that required for body function, healing, metabolic stress and energy expenditure. A child's rate of growth is not linear, but occurs in stages with periods of accelerated growth, such as infancy or puberty, driven by a combination of nutrition and endocrine function. Any nutritional defect during a critical growth period could prevent the child from achieving his or her growth potential.

Catch-up growth

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

Nutritional assessment

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

Anthropometry, the measurement of the human body, can give useful information about growth and current nutritional status when compared with established norms. However, an assessment of nutritional status or growth should not rely on these measurements alone. Consideration must also be given to other factors, such as feeding history.

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


Equipment scales should be available for different age groups of children - for instance, baby scales, chair or standing scales. They should be calibrated regularly, centrally purchased and designed for clinical use.

Children should be weighed on admission to hospital and subsequently at least once a week. Frequency of weighing requires adjustment according to clinical condition on discussion with the multidisciplinary team. Repeat weights should be recorded under similar conditions and at the same time of day as the original measurement.

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

Additional factors that impact on the accuracy of weight measurements are presence of intravenous splints/lines, stoma devices, dressings/drains, timing of bolus/continuous feeds and intravenous therapy. Weights should be recorded on a weight chart, observation chart and on the centile chart in the medical notes and in parent-held records.

A single weight is of limited value in assessing a child's nutritional status. Similarly, daily weights may reflect hydration rather than nutrition. A measurement of weight is of nutritional value only when reviewed in the light of previous weights and clinical history.

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


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

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

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

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

Measurement of height/length is inappropriate for children who are unable to stand or bear weight or with conditions that impede correct positioning - for instance, curvature of the spine.

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

Length/height can provide a useful indication of growth in children. Impaired growth may indicate inadequate feeding, diet or malabsorbtion, where poor weight gain is also evident. In the presence of adequate weight gain, impaired height may be indicative of metabolic or endocrine disease. Measurements of parental height constitute a useful guide to target height in a child. However, it should be remembered that the parents themselves may not have achieved their full growth potential due to socio-economic factors or illness.

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

Head circumference

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

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

If a child's clinical condition is such that standard anthropometric measurements are inappropriate or misleading - for instance, if there is oedema, ascites or solid tumours - other techniques are available for measuring growth (Box 2).

The performance of anthropometric measurements provides the nurse with an ideal opportunity to observe the child's general appearance. With experience a paediatric nurse will be able detect specific signs of poor nutritional status/growth, such as the following:

- Short stature;

- Thin arms and legs;

- Poor skin condition/skin lesions;

- Poor hair condition;

- Ascites;

- Clearly visible spinal processes or rib cage;

- Wasted buttocks;

- Oedema, wasted facial appearance, lethargy.


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

Dietary record

In order to assess the adequacy of a child's nutritional intake, dietitians require detailed information about all food and drink consumed. As all children admitted to hospital are at risk of nutritional deficit, a dietary record should be started on all in-patients, although this may subsequently be discontinued when deemed appropriate. The dietary record should include details of food and fluids offered and consumed, with quantities expressed in terms of teaspoons, tablespoons and so on. Owing to the difficulties of providing for the likes and dislikes of individual children any record of dietary intake completed during admission is unlikely to provide an ideal reflection of a child's customary intake.

Psychosocial factors

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

Nutritional risk factors

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

- Predisposing medical condition;

- Static weight;

- Documented weight loss;

- Perceived weight loss;

- Poor intake;

- Poor feeding;

- Short stature;

- Pubertal delay;

- Developmental delay.

The short-term implications of failure to address PEM can lead to multiple complications. The long-term implications can be devastating and include stunting, developmental delay 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.___________________












Throughout the health assessment process, the nurse should be attuned to data related to nutrition.

■ Nutrition is influenced by a myriad of factors. Basic information in the health history can identify the need to more thoroughly investigate nutritional status.

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

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


Oddsei - What are the odds of anything.