NUTRITIONAL

ASSESSMENT
CHAPTER 9
• STRUCTURE AND FUNCTION

• HEALTH ASSESSMENT

• ANALYSIS OF DATA
• STRUCTURE AND FUNCTION

Nutritional Assessment

General Nutritional Status Interview

Anthropometric Measurements

Nutritional Problems
• HEALTH ASSESSMENT

Collecting Subjective Data: The Nursing Health History

Collecting Objective Data: Physical Examination

Validating Documenting Findings

• ANALYSIS OF DATA

Diagnostic Reasoning: Possible

Conclusions
• STRUCTURE AND FUNCTION

Information Nutritional
gathered assessment
Nutritional
during the can help to
assessment
nutritional identify
helps to
assessment nutritional
identify risk
provides deficits,
factors for
insight into which also
obesity and
the client’s greatly
to promote
overall impact the
health.
physical client’s
health. health.
• STRUCTURE AND FUNCTION
Nutritional Assessment

Composed of an interview and anthropometric

measurements, which are used to evaluate the
client’s physical growth, development, and
nutritional status.
• STRUCTURE AND FUNCTION
General Nutritional Status Interview

Questions should solicit

information about average
Begin with daily intake of food and
questions fluids, types and quantities
consumed, where and
regarding the
when food is eaten, and
client’s habits. any conditions or diseases
that affect intake or
absorption.
• STRUCTURE AND FUNCTION
General Nutritional Status Interview

A variety of tools for assessing food habits and

nutrition are available including:
• STRUCTURE AND FUNCTION
General Nutritional Status Interview

Checklist to use for nutritional screening.

• STRUCTURE AND FUNCTION
General Nutritional Status Interview

Estimated calorie Eating plan based

requirements on calorie level.
• STRUCTURE AND FUNCTION
General Nutritional Status Interview

Checklist to use for nutritional screening.

Estimated calorie requirements

Eating plan based on calorie level.

• STRUCTURE AND FUNCTION
General Nutritional Status Interview

USDA Food Guide

The new USDA food

pyramid and traditional
Asian diet and Latin
American diet pyramids
• STRUCTURE AND FUNCTION
Anthropometric Measurements

Help to evaluate the client’s physical growth, development,

and nutritional status.

Height and weight are obtained. By comparing these findings

to a standard table, the nurse can determine the client’s body
mass index (BMI).

BMI is calculated based on height and weight regardless of

gender.

BMI does not differentiate between fat or muscle tissue,

inaccurately high or low findings can result for individuals
who are particularly muscular or the elderly who tend to lose
muscle mass.
• STRUCTURE AND FUNCTION
Anthropometric Measurements

Body composition measurements are useful in determining

location of body fat.

According to a recent study, adding waist circumference to

body mass index (BMI) increases the predictive ability for
health risk more than using BMI alone.

Women with 35 inches or greater waist circumference or men

with 40 inches or greater waist circumference are at an
increased risk for such disorders as diabetes, hypertension,
hyperlipidemia, and cardiovascular disease.
• STRUCTURE AND FUNCTION
Anthropometric Measurements

Body composition measurements include mid-

arm circumference, triceps skin-fold
measurements, and mid-arm muscle
circumference calculations.

Mid-arm circumference helps to assess skeletal

mass.

The triceps skin-fold helps to evaluate

subcutaneous fat stores.

The mid-arm circumference and triceps skin fold

are used in a formula to calculate the mid-arm
muscle circumference to evaluate muscle
reserve stores.
• Nutritional Problems
Malnutrition and Biochemical Indicators

Certain diseases, disorders, or lifestyle behaviors

can place clients at risk for under nutrition or
malnutrition and can exacerbate or facilitate
diseases processes. The following is a selected list
of risk factors:

• Lower socioeconomic status whereby nutritious foods

are unaffordable.
• Lifestyle of long work hours and obtaining one or more
meals from a fast-food chain or vending machine
• Poor food choices by children, teens, and adults include
lots of fatty or fried meats, sugary foods, but few fruits
and vegetables
• Chronic dieting, particularly with fad diets, to meet
perceived societal norms for weight and appearance
• Nutritional Problems
Malnutrition and Biochemical Indicators

• Chronic dieting, particularly with fad diets, to meet

perceived societal norms for weight and appearance
• Chronic diseases (e.g., Crohn’s disease, cirrhosis, or
cancer) that may interfere with absorption or use of
nutrients
• Dental and other factors such as difficulty chewing, loss
of taste sensation, depression
• Limited access to sufficient food regardless of
socioeconomic status such as being physically unable
to shop, cook, or feed self
• Disorders whereby food is self limited or refused (e.g.,
anorexia, nervosa, bulimia, depression, dementia, or
other psychiatric disorders)
• Illness or trauma that increases client’s nutritional
needs dramatically but that interferes with his or her
ability to ingest adequate nourishment (e.g., extensive
burns)
• Nutritional Problems
Malnutrition and Biochemical Indicators

When people are malnourished, the body’s proteins

stores are affected. The proteins usually sacrificed
early are those that the body considers to be less
essential to survival: albumen and globulins, transport
proteins, and immunoglobulins.

Additional tests to evaluate general immunity

(immunocompetence) consist of all small-dose
intradermal injections of recall antigens such as those
used to test for tuberculosis, mumps, and Candida
(yeast).
• Nutritional Problems
Overnutrition

Increased caloric consumption. Especially food

high in fat and sugar, with decreased energy
expenditure has led to near-epidemic obesity.
Obesity is defined as excessive body fat in
relation to lean body mass.
The amount of body fat or adipose tissue
includes concern for both as well as the size of
the fat deposits.

The health risk of obesity include diabetes,

heart disease, stroke, and hypertension, some
forms of cancers, osteoarthritis, and sleep
apnea.
• Nutritional Problems
Overnutrition

Generally a person who is 10% over his or her ideal

body weight (IBW) is considered to be overweight,
whereas one who is 20% over IBW is considered obese.

Muscle, bone, fat, and body fluid can account for excess
body weight.
• Nutritional Problems
Hydration Assessment

Adequate hydration can be affected by various

situations in all age groups. Some examples in adults
include:

• Exposure to excessive high environmental

temperatures
• Inability to access adequate fluids, especially
water (e.g., clients who are unconscious,
confused, or physically or mentally disabled)
• Excessive intake of alcohol or other diuretic fluids
(coffee, sugar-rich and/or caffeine-rich soft drinks)
• People with impaired thirst mechanisms
• People taking diuretic medications
• Diabetic clients with severe hyperglycemia
• People with high feyers
• Nutritional Problems
Hydration Assessment

Dehydration can have a seriously damaging effect on

body cells and the execution of body functions.

Overhydration in a healthy person is usually not a

problem because the body is effective in maintaining a
correct fluid balance.
 HEALTH ASSESSMENT

• COLLECTING SUBJECTIVE DATA: THE

NURSING HEALTH HISTORY

• COLLECTINGOBJECTIVE DATA: PHYSICAL

EXAMINATION

• PHYSICAL ASSESSMENT

• VALIDATING AND DOCUMENTING

FINDINGS
 COLLECTING SUBJECTIVE DATA: THE NURSING
HEALTH HISTORY

• The clients interview provides invaluable information about the client’s nutritional
status.

 HISTORY OF PRESENT HEALTH CONCERN

QUESTION RATIONALE

Height and Weight Answer provides a baseline for

What are your height and usual comparing client’s perception
weight? with actual and current
measurements.

Diet Whether or not the client is

Are you now or have you been on
a diet recently? How did you
decide which diet you to follow?
following his or her own diet or
a medically prescribed diet,
helps to identify chronic dieters
and clients with eating
disorder.
  PAST HEALTH HISTORY

QUESTION RATIONALE

Chronic illnesses, such as

Do you have any chronic illnesses?
diabetes, may impact the client’s
nutritional status

Have you experienced any recent Each of these may increase the
trauma, surgery, or serious client’s nutritional needs but
illness? decreases the client’s ability to
meet these needs
  FAMILY HISTORY

QUESTION RATIONALE

Obesity often runs in families. In

Are any members of your family
addition, families may have unhealthy
obese?
eating patterns that contribute to
obesity.

Do any members have heart disease Heart disease and diabetes run in
or diabetes? families

 LIFESTYLE AND HEALTH PRACTICES

QUESTION RATIONALE

Does your religion or culture Some cultures and religion

have diet restrictions or dictate dict.
requirements?
What current Some medications may decrease
medications/vitamins/supplements are the client’s absorption of nutrients
you taking?

Do you prepare your own meals? What do A daily account of dietary and fluid
you eat on a typical day? What fluids and intake provides insight into the
how much do you drink? client’s nutrition and hydration.
 COLLECTING OBJECTIVE DATA: PHYSICAL
EXAMINATION
Physical examination includes observing body build, measuring weight and
height, taking anthropometric measurements, and assessing hydration.

 PREPARING THE CLIENT

After the interview, ask the client to put on an examination gown. The client
should be in a comfortable sitting position on the examintion table (or on
a bed in the home setting). Unless the clien is bed-bound in the hospital,
nursing home, or home care setting, explain that he will need to stand
and sit during the assessment particularly during anthropometric
assessments. Keep in mind that some clients may be embarrassed to be
measured like this, especially if they are overweight or underweight. To
reassure the client, explain that the examination is necessary for
evaluating overall health status. Proceed with the examination in a
straighforward, nonjudgemental manner.

EQUIPMENT
• Balance beam scale with height attachment • Marking pencil
• Metric measuring tape • Skin fold calipers
 PHYSICAL ASSESSMENT

During examination of the client, remember these key points:

 Identify the equipment needed to take anthropometric

measurements and the equipment’s proper use.
 Explain the importance of anhropometric measurements to
general health status.
 Educate the client regarding nutritional concerns and health
related risks.
  PHYSICAL ASSESSMENT

Assessment Procedure Normal Findings Abnormal Findings

BODY BUILD
Observe body build as well A wide variety of body A lack of subcutaneous
as muscle mass and fat types fall within a normal fat with prominent
distribution. range from small amounts bones is seen in the
of both fat and muscles to undemourished.
large amounts of muscle
or fat.
MEASUREMENTS

Measure height. Measure the Height is within range for age, Extreme shortness is
client’s height by sing the L- ethnic and genetic heritage. seen in achordro -
shaped measuring attachment Children are usually within plastic dwarfism and
on the balance scale. Instruct the range of parents’ height. Turner’s syndrome.
the client to stand shoeless on Heigh begins to wane in the Extreme tallness is
the balance scale platform fifth decade of life because seen in gigantism and
with heels together and back the intervertebral discs in Marfan’s
straight and to look straight become thinner and spinal syndromeeeee.
ahead. Raise the attachment kyphosis increases.
above the client’s head. Then
lower it to the top of the
client’s head. Record the
client’s height.
Clinical Tip:
Without a scale, have the client stand shoelesswith the back and
heels against the wall. Balance a straight, level object(ruler) atop
the clients head parallel to the floor and mark the object’s
position on the wall.
Measure weight. Level the Desirable weights for men Weight does not fall
balance beam scale at zero and women are listed in the within range of
before weighing the client. BMI table. Body weight may desirable weights for
Move the weights on the decrease with aging because women and men
scale zero and adjusting the of a loss of muscle or lean
knob by turning it until the body tissue.
balance beam is level. Adjust
the weights to the right and
left until the balance beam is
level again. Record weight
( 1 lb = 2.2 kg).

Determine Ideal Body Body weight is within A current weight that

Weight (IBW) and 10% of ideal range. is 80% to 90% of IBW
percentage of IBW. Use this
indicates a lean client
formula to calculate the
and possibly mild
client’s IBW:
malnutrition. 70% to
Female: 100 lb for 5 ft + 65 lb for each inch over 5 ft 80% indicates
10% for small or large frame. moderate malnut-
rition; less than 70%
Male: 106 lb for 5 ft + 6 lb for each inch over 5 ft 10% may indicate severe
for small or large frame. malnutrition possibly
Measure triceps skinfold Compare the client’s Measurements less
thickness ( TSF). Take the TSF current measurement to than 90% of the
measurement to evaluate the past measurements. standard reference
degree of fatstores. Instruct Standard reference is indicate a loss of fat
the client to stand and hang 12.5 mm for men and stores and place
the nondominant arm freely. 16.5 mm for women. client in the
Grasp the skinfold and moderately
subcutaneous fat between the malnourished
thumb and forefinger miday category.
between the acromion Clinical Tip:
process and the tip of the A more accurate
elbow. Pull the skin away from measurement can be
the muscle. ( ask client to flex obtained from the
arm: if you feel a contraction suprailiac region of the
with this manuever, you still abdomen or the
have the muscle). Repeat 3 subscapular area.
times and average the 3
measurements. Record the
measurements in millimeters.
Calculate mid-arm muscle
circumference (MAMC). To
determine skeletal muscle
reserves or the amount of lean
body mass and evaluate
malnourishment in client,
calculate the midarm muscle
circumference (MAMC). MAMC
is derived from MAC and TSF by
the following formula:
MAMC = MAC (cm) -
[0.314 x TSF(mm)]
Compare the clients’s
C
current MAMC to past
measurements.
Standard reference is
25.3 cm for men and
23.2 cm for women.
Malnutrition:
Mild - MAMC of 90% to
99%
Moderate - MAMC 60%
to 90%
Severe - MAMC <60%
as seen in protein-
calorie malnutrition.

Clinical Tip:
When evaluating anthropometric data base conclusions on a data cluster, not on
individual findings. Factor in any special considerations and general health status.
Although general standards are useful for making estimates, the client’s overall health
and well-being may be equal or more useful indicators of nutritional status
HYDRATION
Inpatient Setting: Intake and Output
Measure intake and output
( I&O) in patient settings:
Measure all fluids taken in by
oral and parenteral routes,
through irrigation tubes, as
medications in solution, and
through tube feedings.
All Settings: Fluid-Related Changes
Weight clients at risk for hydration
changes daily.
Intake and output are
closely balanced over 72
hours when insensible
loss is included.
Clinical Tip:
Fluid is normally retained
during acute stress, illness,
trauma, and surgery.
Expect diuresis to occur in
most clients in 48 to 72
hours
Weight is stable or changes
less than 2 to 3 lb over 1 to 5
days
Imbalance in either
direction suggest
impaired organ function
and fluid overload or
inability to compensate
for losses resulting in
dehydration.
Weight gains or
losses of 6 to 10 lb
in 1 week or less
indicate a major
fluid shift.
Check skin turgor. Pinch a small There is no tenting and This finding must be
fold of skin, observing elasticity, skin returns to original correlated with other
and watch how quickly the skin position. hydration findings.
returns to its original position.

Check for pitting edema. No edema is present Pitting edema is a

sign of fluid retention
especially in cardiac
and renal diseases.

Observe skin for moisture. Skin is not excessively Abnormally dry and
dry. flaky skin.

Assess venous filling. Lower Veins fill in 3 to 5 Filling or emptying

the client’s arm or leg and seconds. Veins empty that takes more
observe how long it takes to in 3 to 5 seconds. than 6 to 10
fill. Then raise the arm or leg seconds suggests
and watch how long it takes fluid volume deficit.
to empty.
Observe neck veins with Neck veins are softly visible
client in the supine in supine position. With
position then with the head elevated above 45
head elevated above 45 degrees, the neck veins
degrees. flatten or are slightly visible
but soft.
Inspect the tongue’s Tongue is moist, plump with
condition and furrows. central sulcus and no
additional furrows.
Gently palpate eyeball. Eyeball is moderately firm to
touch but not hard.
Flat veins in supine client
may indicate dehydration.
Visible firm neck veins
indicate distention
possible resulting from
fluid retention and heart
disease.
Tongue is dry with
visible papillae and
several longiudinal
furrows, suggesting
loss of normal third
space fluid
dehydration.
Eyeball is boggy and
lacks normal tension,
suggesting loss of
normal third space
fluid and
dehydration.
Observe eye position and
surrounding coloration.
Ausculate lung sounds.
Take blood pressure with
client in standing, sitting,
and lying positions. Also
palpate radial pulse.
Eyes are not sunken and no
dark circles appear under
them.
No crackles, friction rubs,
or harsh lung sounds are
auscultated.
There are no orthostatic
changes; blood pressure
and pulse rate remain
within normal range for
client’s activity level and
status.
Sunken eyes, especially
with deep dark circles,
point to dehydration.
Loud or harsh breath
sounds idicate
decreased pleural fluid.
Friction rubs may also
be heard. Crackling
idicates increased fluid.
as in interstitial fluid
sequestration.
Blood pressure
registers lower than
usual and/or drops
more than 20 mmHg
from lying to standing
position, thereby
indicating fluid
volume deficit,
especially if the pulse
is also elevated.
VALIDATING AND DOCUMENTING FINDINGS

 Validate the nutritional assessment data you have collected. This is necessary
to verify that the data are reliable and accurate. Following the health care
facility or agency policy, document the assessment data.

SAMPLE OF SUBJECTIVE DATA

Sarah Bostic is a Caucasian female, stated age 42 years. Reports she had a fever
for 2 days a week ago. Treated with Tylenol. No recurrences of fever. Lost 5
pounds over last 3 months with daily walking and low fat diet. Drinks 4 to 6
glasses of water daily. Avoids concentrated sugars, alcohol, and caffeinated
drinks. Has a bowl of cereal with skim milk and banana for breakfast, a sandwich
of low-fat meat, cheese, lettuce and low-fat chips for lunch. Eats moderate
amount of meat, rice, and vegetables for dinner. Reports one to two daily
snacks of fruit, vegetables, pretzels, or popcorns. Allergic to seafood.
 SAMPLE OF OBJECTIVE DATA

Well developed body build for age with even distribution of fat and firm muscle.
Height: 5 feet, 5 inches ( 165 cm) ; body frame: medium; weight: 128 lb (58 kg); BMI:
21.3; ideal body weight:125; waist circumference: 30 inches; MAC: 28 cm; TSF: 16.8
mm;MAMC : 22.7 cm.

ANALYSIS OF DATA

DIAGNOSTIC REASONING: POSSIBLE CONCLUSION

After collecting subjective and objective data pertaining to the nutritional
assessment, identify abnormal findings ad client strengths. Then cluster the data to
reveal any significant patterns or abnormalities. These data may then be used to
make clinical judgements about the status of the client’s nutritional health.
 SELECTED NURSING DIAGNOSES

Following is a listing of selected nursing diagnoses ( wellness, risk, or actual)

that you my observe when analyzing the cue clusters.

WELLNESS DIAGNOSES

• Health-Seeking Behaviors related to desire and request to learn more

about attaining ideal body weight.
• Readiness for Enhanced Fluid Balance related to a desire for
information pertaining to a need for increased fluids while shoveling
snow.
RISK DIAGNOSES

• Risk for Deficient Fluid Volume related to impending dehydration secondary

to nausea and vomiting
• Risk for Imbalanced Fluid Volume related to lack or adequate home cooling
system and high environmental temperatures forecasted.
 ACTUAL DIAGNOSES

• Disturbed Body Image related to recent increase in weight

• Hopelessness related to inability to ose weight and remain on prescribed diet

SELECTED COLLABORATIVE PROBLEMS

After grouping the data, certain collaborative problems may become apparent.
Remember that collaborative problems differ from nursing diagnoses in that they
cannot be prevented by nursing interventions. In addition, the nurse can use
physician- and nurse-prescribed intrventions to minimize the complications of these
problems. In such situations, the nurse may also have to refer the client for further
treatment of the problem. Following is a list of collaboratve problems that may be
identified when obtaining a nutritional assessment:

• PC: Type 2 diabetes mellitus

• PC: Hypertension
• PC: Hyperlipidemia
• PC: Stroke
 MEDICAL PROBLEMS

After you group the data, it may become apparent thus the client has signs and
symptoms that require medical diagnosis and treatment. Refer to a primary care
provider as necessary.

CASE STUDY

The case study demonstrates how to analyze nutritional assessment data for a specific
client.

Mrs. Helen Jones, 78 years old, has a history of insulin dependent diabetes mellitus
(IDDM), also known as type 1 diabetes. When you weigh heer during your weekly
home visit, you find that she weighs 98 lb, which is 12 lb less than weighed at your
last visit. You try to weigh her at the same time of day each week -- 9:30 AM. She
usually has breakfast at 6:30 AM and takes her morning NPH, 40 units at 7:30 AM.
Today she tells you that she has been urinating “a lot” and that she feels like she has
the flu for about 3 days with nausea and “ just a little vomiting”. She says she has not
been eating well but adds, “ I’m keeping my blood sugar up by drinking orange juice.”
On assessment you find that she has soft, sunken eyeballs and her tongue is dry and
furrowed. Her blood pressure is 104/86 ( usual is 150/88); herpulse is 92, and
resprations are 22. Her temperature is 99.4 °F . Her blood glucose level , tested by
fingerstick, is 468 mg/dL (usual is 250 to 300 mg/dL). Mrs Jones refuses to check her
blood glucose leve herself. When asked why she did not call the nurse or doctor when
she became ill, she stated, “I didn’t think it was that serious, I didn’t have a high
temperature.