Chapter 010

Nutritional Assessment
Chapter 10
Copyright © 2005, Mosby, Inc. all rights reserved.

Nutritional Assessment
• Food/fluid basic biologic needs requiring
assessment
– Nutritional status and identification of risk factors
– Dietary intake/perceived nutritional related problems
• Anthropometric measurements, biochemical
tests, nutrition-focused exam
• General approach to collection same throughout
life cycle

Anatomy and Physiology
• Nutrients provide calories, build/maintain
tissues, regulate body processes
• Base energy requirement = BMR (influenced
by multiple factors)
• Caloric intake
– Equal to energy needs, no weight change
– More than energy needs: weight gain
– Less than energy needs: weight loss
• Three groups– carbohydrates, protein, fats
(needed in large amounts)
Anatomy and Physiology:
Macronutrients
• Carbohydrate major source for energy/fiber
– 1 g carbohydrate = 4 kcal energy
– Fiber: bulk that stimulates peristalsis
– Major sources: plant foods/lactose
– Some stored in liver/muscle (glycogen)—
moderate amounts ingested for energy
– Surplus carbohydrates ingested stored as fat
– 130 g/day (55%-60% total calories)

Macronutrients
• Protein: essential for growth and repair of
body tissues; energy source
– Amino acid (20): simplest form of protein
– 10 essential: not synthesized in body
– Complete protein: contains all essential amino
acids (high biologic value proteins)
• Meat, fish, poultry, milk, eggs

Macronutrients
• Protein (cont.)
– Incomplete proteins: cereals, legumes,
vegetables
– Combining incomplete proteins to provide
essential amino acids
– Excess protein supplies energy or stored
(fat)
– 1 g = 4 kcal energy; 12% to 20% of caloric
intake (45-56 g/day)
Macronutrients
• Fat: main source of fatty acids essential for

normal growth and development
– Hormone synthesis/regulation, tissue structure,
impulse transmission, energy, insulation,
protection
– Linoleic/linolenic acids (metabolic processes)

Macronutrients
• Fat (cont.)
– Major form of stored energy
• Fat converted to glucose (gluconeogenesis)
• Increased intake stored as adipose tissue
– Less than 30% caloric intake (66 g/day);
American diet higher (37%)
– Nutritional deficiencies when less than 10%
of calories/day

Micronutrients
• Required in small amounts (vitamins/
minerals)
– Essential for growth/development and metabolic
processes
• Vitamins
– Water soluble not stored: ingested; daily intake
necessary
– Fat soluble: stored; toxic in large amounts
– Deficiencies/toxicities leads to diseases (when
observed—depletion)
Micronutrients
• Major minerals: large amounts in body;

daily intake greater than 100 mg/day
• Trace minerals: small amounts
– 10 essential (<100 mg/day); 8 others not
known

Water
• 60% to 70% total body weight
– Critical component: cellular function
– Constant loss requiring replacement
(survival needs)
– 2½ to 3 L metabolized daily (foods/fluids)
– Increased needs in certain conditions
(fever, infections, GI losses, respiratory
illness)
Health History: General Health
History
• Present health status: chronic illnesses,
medications, weight changes, intolerances/
allergies, typically eat, problems with
obtaining/ preparation/eating, street
drugs/alcohol?
• Past medical/family history: weight/eating
problems, family nutritional problems, eating
disorders?
Problem-Based History:
Weight Loss
• When started, normal weight, how
much in past 6 months?
• Cause: desired/undesired; what
measures
• Other symptoms: fatigue, headaches,
bruising, constipation, hair loss, cracks
in lip corners
Weight Gain
• When started, what’s normal weight,

weigh now, pounds gained in 6
months?
• Cause: intentional/unintentional?

Difficulty Chewing/Swallowing
• Describe; when started?

• Foods that cause/don’t cause?
• Weight changed?

Loss of Appetite/Nausea
• Describe; when started; constant/
intermittent?
• Cause?
• Offensive/intolerable foods; what
consume without difficulty?
• Weight change?

Health History:
Assessment of Dietary Intake
• Accuracy questionable: underreporting,
variable daily intake, portion variations
• Intake estimated with instruments/
techniques
• How describe appetite, typical daily
intake, food preferences, dislikes,
intolerances, restrictions, supplements
Health History:
Assessment of Dietary Intake
• Determining dietary adequacy
– Compare intake with food pyramid
– Compare intake with DRI
• Four nutrient-based reference values: EAR,
RDA, AI, UI
• Calculation time consuming: assessment option
– RDIs based on healthy individuals; not
used for ill individuals

Examination Techniques:
Overview
• Not all techniques with every exam;
used occasionally
• Use dependent on reason for exam,
type of exam, setting, condition/age of
client, nurse skill level

Anthropometric Measurements
• Height/weight replaced with BMI
– Weight:hight ratio correlated to body fat
• Weight compared with DBW
• Current body weight compared with UBW
• Triceps skinfold (AP): total body fat
• Waist-to-hip ratio (AP): apple/pear body
shape
– Females < 0.8; males < 1.0
Laboratory Tests
• Review laboratory tests

Focused Nutritional Exam
• General appearance/level of orientation

• Inspect skin: characteristics, hydration, lesions
• Inspect hair/nails: appearance/texture
• Inspect eyes: surface characteristics
• Inspect oral cavity: dentition/mucous membranes
• Inspect/palpate extremities: shape, size,
coordinated movement, sensation

Age-Related Variations:
Neonates and Infants
• Anatomy and physiology
– First year of life: rapid growth, nutrition
essential
– Breast milk promotes growth/immunity
– Weight doubled at 4 months, tripled by end of
year

• Health history
– How feeding
• Breast: how often/long; getting enough?
• Formula: type/preparation/how
much/problems?
• Water: how much/frequency
• Solid foods: what/age started/problems

• Examination
– Weight, height, head circumference record on
growth chart
– Biochemical tests if abnormality suspected
– Observe for rooting/suck/swallowing
• Normal/abnormal findings
– Strong root/suck, swallowing without difficulty
– Greater than 95th percentile: LGA
(hypoglycemia?/first 24 hours)
Children
– Rapid growth slows down; school-age child
gains 4½ to 8½ pounds per year
• Health history
– Same as for adult
– Vegetarian diet at risk for deficiencies
– Unhealthy dietary habits may contribute to
chronic disease
Children
• Examination
– Same as for adult, weight-for-height best
indicator
– BMI after first year
– Skinfold/biochemical tests: if malnourished/
obese

Children
• Normal and abnormal findings
– Height/weight between 5th and 95th
percentile
– Less than 5th/greater than 95th: further
evaluation (FTT)
– Teeth: present and without decay
• Baby bottle tooth decay

Adolescents
– Rapid growth; if outside parameters, monitor
frequently
• Health history
– Same as for adult (address obesity/eating
disorders)
– Poor eating due to school/athletic activities
– Females: menstruation (iron deficiency anemia);
pregnancy: intensive nutritional counseling

Adolescents
• Examination
– Same as for adult; weight for height
continued (growth charts)
– BMI if weight for height outside parameters
– Skinfold/biochemical measures: not if
healthy (indicated if obese)

Older Adults
– Fewer calories, decreased taste sensation/GI absorption
– Dehydration common
– Chewing/swallowing difficulties most prevalent
• Health history
– Same as for adult with additions; medications (food/drug
interactions)
– Functional ability/activities impacts nutritional/hydration
status
– Ability to obtain/prepare meals
– Social isolation/loneliness may lead to inadequate
nutritional intake
Older Adults
• Examination
– Similar as for adult
– BMI reliable indicator for obesity
– TSF not as accurate due to changes in fat
distribution,↓muscle mass, sagging skin
– Glucose/hemoglobin/hematocrit routine
– Cholesterol level decreased significance (if
increased in client older than 70 without other risk
factors, no increased risk)
– Observe eating: able to carry food to mouth, chew,
swallow
Health Promotion
Health Promotion/Health Protection
• Overweight/obesity: serious health care

problem in United States
– Found in all age groups; contributes to
many other diseases
– More than half of adults overweight
• Low socioeconomic groups; African
Americans/Latinos
• Children: increased incidence of type II DM

Health Promotion
• Goals/objectives: Healthy People 2010
• Goal: promote health, reduce chronic disease
associated with diet/weight
• Three objectives
– Increase proportion of adults with healthy weight
– Reduce proportion of adults who are obese
– Reduce the proportion of overweight/obese
children/adolescents

Health Promotion
• Diabetes mellitus: incidence increasing (type II)
• More than 800,000 new cases in United States
each year
– Individuals older than 60
– Latinos, Native American, African American
• Results in blindness, renal disease, amputations,
heart disease/stroke
• Seventh leading cause of death (cardiovascular
disease)
• May be prevented/delayed
Health Promotion
• Goals/objectives: Healthy People 2010

• Reduce the disease and economic
burden of disease and improve quality
of life through prevention

Health Promotion
• 17 objectives
– Prevention/reduction of new cases; decrease deaths
– Reduce gestational diabetes, reduce amputations
– Increase numbers who have annual urinary
microalbumin/glycosylated Hgb measurement
– Annual eye/foot/dental exam
– Increase numbers who take aspirin/perform self-
glucose monitoring

Common Problems and
Conditions: Obesity
• Greater energy intake than expenditure
• Fat cell development, genetics,
overeating, inactivity
• If energy intake more than used, stored
as fat
• Amount of fat reflects fat cell size
• Fat cells divide when at maximum size
Common Problems and
Conditions: Obesity
• Genetics: obese parents lead to obese
children
• Overeating: increased energy intake;
inactivity; decreased energy expenditure
• Contributes to four leading causes of death:
heart disease, cancer, stroke, diabetes
• Contributes to other conditions

Common Problems and
Conditions: Obesity
• Clinical findings
– Visual recognition
– Clinically defined with BMI greater than 30

Common Problems and
Conditions: Malnutrition
• Excess/deficiency of one or more nutrients
• Most typically deficiency/underweight
• Not enough nutrients for healing/immune
function
• Caused by wasting disease, poor intake,
malabsorption, hormone/endocrine imbalance,
poor living conditions
• Increased risk of infection/decreased stress
response
Common Problems and
• Older adults unable to care for self –
contributes to malnutrition from
inadequate intake
– Weight loss, poor appetite/decreased
intake
– Mental decline, difficulty chewing or
swallowing
– Decline in functional self-care or
ambulation problems
Common Problems and
– Underweight: thin, muscle wasting, loss of
subcutaneous fat
– BMI less than 20; more than 10% below
DBW
– Less than 10% American population

Common Problems and
Conditions: Eating Disorders
• Altered food consumption from emotional/

psychologic conflict
– Lowered intake results in malnutrition;
increased intake results in obesity
– Incidence greater in females (after puberty 5-
10 million females/1 million males affected)

Common Problems and
• Anorexia nervosa: body image disorder (fear
of becoming obese)
– Self-induced starvation: not eat, even if hungry;
emaciated
– Adolescence/young adulthood (females)
– Refusing to eat/extreme thinness
– Anemia, amenorrhea, irregular heart rate,
decreased GI motility, lowered immune function
– Decreased serum albumin, dry/thin skin,
abnormal nerve functioning, ↓ temp, ↓ BP

Common Problems and
• Bulimia nervosa: binge eating leads to
purging (vomiting, laxatives/diuretics,
exercise)
• 20% of college women engage in
• Initial feeling of can’t stop eating; loss of
control over eating leads to purging
(compensatory behavior)

Common Problems and
• Bulimia nervosa: clinical findings

– History of binge eating followed by purging
– Extreme concern with body shape/weight
– Electrolyte disorders, irritation/erosion of
pharynx/esophagus/teeth from HCl

Common Problems and
• Binge eating disorder: frequent binge eating

due to stress/anxiety/depression
• Eats rapidly/alone, consumes large amount of
food until uncomfortably full (out of control)
• After binge: lowered self-esteem, remorse,
depression
• Not followed by purging but weight gain

Common Problems and
• Binge eating: clinical findings
– History of binge eating behavior
– Excessive weight gain
– Often other addictive disorders

Common Problems and
Conditions: Hyperlipidemia
• High blood cholesterol: common nutritional
problem (half adult population higher than
200)
• High saturated fat intake
• Higher than 240 leads to increased risk for
heart disease/stroke
– No symptoms until significant cardiac event
– Routine screening, especially if family history

Common Problems and
Conditions: Anemia
• Fewer RBC, change in size, lowered Hgb/Hct
• Iron deficiency anemia: decreased iron for RBC
production
– GI malabsorption/lower intake
• Vitamin B12 deficiency anemia (pernicious)
– Vegetarian diet, lower intake, decreased absorption
• Folic acid anemia
– Chronic alcoholics, fewer fruits/vegetables
– All anemias: fatigue, weakness, pallor, cold sensitivity

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Nutritional Assessment

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

• Fat: main source of fatty acids essential for

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

• Major minerals: large amounts in body;

Copyright © 2005, Mosby, Inc. all rights reserved.

• When started, what’s normal weight,

Copyright © 2005, Mosby, Inc. all rights reserved.

• Describe; when started?

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

• Review laboratory tests

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• General appearance/level of orientation

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

• Overweight/obesity: serious health care

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

• Goals/objectives: Healthy People 2010

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

• Altered food consumption from emotional/

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

• Bulimia nervosa: clinical findings

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• Binge eating disorder: frequent binge eating

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Copyright © 2005, Mosby, Inc. all rights reserved.

Copyright © 2005, Mosby, Inc. all rights reserved.

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