Nutrition Care Process
Mindset: “Ways to be Healthy.”
Module 4
Criteria for Identifying Malnutrition Risk
Category Specific Examples
Admission data Age, medical diagnosis, severity of illness or injury
Anthropometic data Height and weight, body mass index (BMI), unintentional weight
changes, loss of muscle or subcutaneous fat
Functional assessment Low hand grip strength, general weakness, impaired mobility
data
Historical information History of diabetes, renal disease, or other chronic illness; use of
medications that can impair nutrition status; extensive dietary
restrictions; food allergies or intolerances; requirement for nutrition
support; depression, social isolation or dementia
Laboratory test results Blood test results that suggest presence of inflammation or anemia
Signs and symptoms Reduced appetite or food intake, problems that interfere with food
intake (such as chewing or swallowing difficulty or nausea and
vomiting), localized or general edema, presence of pressure sores
Nursing Diagnoses with Nutritional Implications
Chronic confusion
Chronic pain
Constipation
Diarrhea
Disturbed body image
Feeding self-care deficit
Imbalanced nutrition: less than body requirements
Imbalanced nutrition: more than body requirements
Impaired dentition
Impaired oral mucous membrane
Impaired physical mobility
Impaired swallowing
Insufficient breast milk
Nausea
Readiness for enhanced nutrition
Risk for aspiration
Risk for deficient fluid volume
Risk for unstable glucose level
NUTRITION CARE PROCESS
NURSING PROCESS
Nutrition
Screening
[Link]
[Link] diagnosis
[Link] identification/
Nutrition
planning assessment
[Link] Nutrition
monitoring Nutrition
[Link] and diagnosis
evaluation
Nutrition
intervention
NUTRITION CARE PROCESS
1. Nutrition Assessment
2. Nutrition Diagnosis
Each nutrition problem = separate diagnosis
format: specific nutrition problem + + signs/symptoms
Ex. “Unintentional weight loss related to
as evidenced by a 10-pound weight loss in the past few
months ”
=can change during the course of an illness
NUTRITION CARE PROCESS
3. Nutrition Intervention
Ex. overweight person with diabetes- improve blood glucose & weight
- change dietary behavior
4. Nutrition Monitoring and Evaluation
-patient progress
-effectiveness of plan of care
NUTRITION ASSESSMENT
Historical Information
=Medical History
=Medication and Supplement History
=Personal and Social History
=Food and Nutrition History
Dietary Assessment
=24-hour Dietary Recall- interview-food/beverage consumed in 24 hours
=Food frequency questionnaire- written survey food consumption in 1 year
=Food record- food consumed in several consecutive days, to include
weights and measures of food
=Direct observation-Observation of meal trays before and after eating
FOOD FREQUENCY QUESTIONNAIRE
NUTRITION ASSESSMENT
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Anthropometric Data
A. Height
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NUTRITION ASSESSMENT
B. Body Weight
Weight loss could be PEM
BMI
TABLE 7-3 H ow to E v alu ate Your We ig ht (A du l ts )
• Weigh yourself and have your height measured. I
• Find your BMI category in the [Link] higher yourBMI category, the greater the risk for health problems.
• Me a sure around your wa ist, just abov e your hip bone s, whi le sta ndi ng . Hea l th risks increa se as wai st mea surem e
pa rti cul arly if wa ist is grea ter tha n 35 inche s for wom en or 40 inches for men . Ex cess abdom i na l fa t ma y pla ce you at g
health problems, even if your BMI is about right.
The hig her your BMI and wa i st mea surem en t, and the more ri sk factors you ha v e, the more you are likel y to bene fi t from w
NOTE: Weight loss is usually not advisable for pregnant woman.
Body Mass Index (BMI) Table
BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Height Weig ht (in pounds)
4'10" (58") 91 96 100 105 110 115 119 124129 134 138 143 148 153 158 162
4'11" (59") 94 99 104 109 114 119 124 128133 138 143 148 153 158 163 168
5' (60") 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174
5'1" (61") 100 106 111 116 122 127 132 137143 148 153 158 164 169 174180
5'2"(62") 104 109 115 120 126 131 136 142147 153 158 164 169 175 180 186
5'3"(63") 107 113 118 124 130 135 141 146152 158 163 169 175 180 186 191
5'4"(64") 110 116 122 128 134 140 145 151157 163 169 174 180 186 192197
5'5"(65") 114 120 126 132 138 144 150 156162 168 174 180 186 192 198 204
NUTRITION ASSESSMENT
C. Head Circumference
infants- assess brain growth and malnutrition in children up to 3 years
old
[Link] of waist and limbs
evaluate body fat - intra-abdominal
evaluate muscle mass- mid-upper arm
mid-thigh
mid-calf
NUTRITION ASSESSMENT(body composition)
Skin-fold measurement - determine fat stores. The most common site
for measurement is the triceps skinfold (TSF).
Mid-arm circumference (MAC) measure of fat, muscle and skeleton
Mid-arm muscle circumference (MAMC) calculated by using the
reference tables or by using a formula that incorporates the TSF and
the MAC. The MAMC is an estimate of lean body mass, or skeletal
muscle reserves.
MAMC = MAC(cm)-3.143 TSF (mm)
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STANDARD VALUES FOR ANTHROPOMETRIC MEASUREMENTS FOR
ADULTS
MEASUREMENT MALE FEMALE
Triceps skinfold (mm)- 12 20
TSF
Mid-arm circumference 32 28
(cm) -MAC
Mid-arm muscle 54 30
circumference (cm2)-
MAMC
MUAC TAPE
NUTRITION ASSESSMENT
Anthropometric assessment in infants and children
Height, weight, head circumference = growth chart
BMI to age
Anthropometric assessment in adults
CALCULATING AND INTERPRETING THE PERCENT OF DEVIATION FROM USUAL BODY WEIGHT AND THE
PERCENT OF WEIGHT LOSS
CALCULATING PERCENT OF USUAL BODY WEIGHT CALCULATING PERCENT OF WEIGHT LOSS
% USUAL BODY WEIGHT= Current weight % WEIGHT LOSS= Usual weight-current weight
Usual body weight Usual Weight
Mild Malnutrition- 85-90%
Moderate malnutrition -75-84% Significant Weight Loss Severe Weight Loss
Severe malnutrition- less than 74% 5% over 1 month >5% over 1 month
7.5% over 3 months >7.5% over 3 months
10% over 6 months >10% over 6 months
ESTIMATE AND EVALUATE %UBW AND %IBW
%UBW=current weight (pounds) x100
usual weight (pounds)
To estimate %IBW, compare an individual's current weight with a
reasonable (ideal) weight from a BMI table or other reference
%IBW=current weight (pounds) x 100
ideal weight (pounds)
BODY WEIGHT AND NUTRITIONAL RISK
% UBW %IBW Nutritional risk
85-95 80-90 Risk of mild malnutrition
75-84 70-79 Risk of moderate malnutrition
˂75 ˂70 Risk of severe malnutrition
NUTRITIONAL ASSESSMENT
BIOCHEMICAL ANALYSES
-protein energy nutrition, vitamin and mineral status, fluid and electrolyte
balances, and organ function
Serum proteins-protein energy status
Albumin-most abundant
-gauge severity of illness
-levels fall only when malnutrition is prolonged
Transferrin- rise as iron level decreases; can affect protein
evaluation
Pre-albumin and Retinol-binding protein- decrease rapidly during
PEM and respond quickly to improved protein intakes
Mean corpuscular volume- measures average size of RBC.
Hemoglobin is the protein in blood. Rbcs are smaller when they
don’t have enough hemoglobin
NUTRITION ASSESSMENT
Physical Examination
a. Clinical Signs of Malnutrition- hair, skin, eyes, lips, nails, mouth and
gums
b. Hydration Status- fluid imbalances- fluid retention/dehydration
c. Functional Assessment-hand-grip strength= wasting (loss of muscle
tissue)
Body composition
-more accurate indicator of ideal body weight than are weight and
height tables in determining the fatness or leanness of a person.
-adult body = 65% water.
=higher in lean persons because muscle tissue contains more
water than fat tissue.
=Minerals -6% of body weight - bones
=lean body mass can range from 40% to 70%, depending upon
size and activity
=Lean body mass decreases with age
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The Mini Nutritional
Assessment
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This tool can identify malnutrition in before changes in
biochemistry or weight are evident.
-rapid and simple evaluation of the elderly at risk for malnutrition in
order to facilitate early nutrition intervention.”
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Subjective Global Assessment
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-evaluates whether an individual is appropriately nourished i.e. whether
nutrient intake and absorption meet the nutrient requirements of an
individual.
-primary purpose: determine whether nutrition deficit plays a role in a
patient’s condition and therefore, whether nutritional treatment is
required.
- focused history and physical examination to classify individuals into
well nourished, mildly/moderately malnourished and severely
malnourished categories.
Factors to consider when completing the
Subjective Global Assessment:
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DIETARY INTAKE
WEIGHT LOSS
SYMPTOMS- nausea, vomiting
FUNCTIONAL CAPACITY- walking vs bedridden
METABOLIC REQUIREMENT- IBD
BODY COMPOSITION ASSESSMENT (fat and muscle wasting)
EDEMA AND ASCITES
Subjective Global Assessment
-evaluates a person’s risk of malnutrition by ranking key variables of the medical history and physical
examination. These variables are each given an A, B, or C rating
Medical History
Body weight changes
Dietary changes
Functional ability
Degree of disease-related metabolic stress
Physical Examination
Subcutaneous fat loss (triceps or chest)
Muscle loss (quadriceps or deltoid)
Ankle edema
Sacral (lower spine) edema
Ascites (abdominal edema)
Classification:
A: Well nourished: if no significant loss of weight, fat, or muscle tissue or dietary difficulties,
functional impairments, or GI symptoms; also applies to patients with recent weight gain and improved
appetite, functioning, or medical prognosis
B: Moderate malnutrition: if 5 to 10 percent weight loss, mild loss of muscle or fat tissue, decreased
food intake, and digestive or functional difficulties that impair food intake; The B classification usually
applies to patients with an even mix of A and B and C ratings
C: Severe malnutrition: if more than 10% weight loss, severe loss of muscle and fat tissue, edema,
multiple GI symptoms, and functional impairments
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GERIACTRIC NUTRITIONAL RISK INDEX
-simple method to assess nutritional condition, which utilizes only three
objective parameters of body weight, height and serum albumin.
-useful tool for the assessment of nutritional status, not only for elderly
patients but also for chronic haemodialysis patients.
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