Nutrition Assessment: Foundation of the Nutrition Care Process

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Nutrition Therapy and Pathophysiology | 3e
Nelms | Sucher | Lacey | Roth
Marcia Nelms, PhD, RD, LD
Diane Habash, PhD, RD, LD
The Ohio State University
Nutrition Assessment:
Foundation of the Nutrition Care
Process
Chapter 3

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Nutrition Assessment
• Foundation of the nutrition care process
• Systematic method for obtaining, verifying,
and interpreting data
• Identifies nutrition-related problems, their
causes, and significance

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Nutritional Status
• Reflects nutrient stores
– Excesses vs. deficiency
• Determination of nutritional risk
– Need to understand pathophysiology,
treatment, and clinical course of disease

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An Overview: Nutrition Assessment
and Screening
• AND
– “Process of identifying patients, clients, or
groups who process of gathering key pieces
of information correlated to nutrition risk”
– Standards of Practice include nutrition
assessment
• JCAHO
– Screening must be done within 48 hours of
admission

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Subjective Data Collection
• Obtained during interviews
– From patient, family members, significant
others, client’s perception
• Interviewer’s observations
• See Table 3.1

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Subjective Food- and Nutrition-
Related History Assessment

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Objective Data Collection
• Information from a verifiable source such
as medical record
• See Table 3.2

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Objective Nutrition Assessment
Information with Examples

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Client History
• Collected through patient interview
– Economic situation
– Support systems
– Food insecurity: See Figure 3.1

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Prevalence of Food Insecurity,
Average 2010–2012

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Information Regarding Education,
Learning & Motivation
• Ability to communicate
• Education level, attention span, and
readiness to learn
• History of previous nutrition interventions
and response to them

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Tools for Data Collection
• DETERMINE checklist
• Subjective Global Assessment
• Malnutrition Screening Tool (MST)
• Malnutrition Universal Screening Tool
(MUST)
– Sensitivity and specificity

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Food and Nutrition Related History
• General types
– Retrospective
– Prospective
• Key qualities
– Validity
– Reliability

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Nutrition Care Indicator:
Twenty-Four Hour Recall
• Recall of all food and drink for a 24 hr. period
• USDA multiple pass approach
• Advantages
– Short administration time, very little cost, and
negligible risk for the client
• Disadvantages
– May not reflect typical eating patterns

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A 24-Hour Recall Form

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Nutrition Care Indicator: Food
Record/Food Diary
• Client documents intake over specified
period of time
• Advantages
– Does not rest on client’s memory and may be
more representative of typical eating patterns
• Disadvantages
– Validity issues if client alters intake or
misrepresents intake; substantial burden on
client

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A Food Diary

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Nutrition Care Indicator:
Food Frequency
• Retrospective
– Foods organized into groups and client
identifies how often and in what quantities
specific foods are consumed
• Advantages
– Inexpensive and requires minimal time
• Disadvantages
– Self-administered, so has lower response
rates; may not include ethnic or child-
appropriate foods

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Example of a Food Frequency
Instrument: MEDFICTS

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Nutrition Care Indicator
• Observation of food intake/“calorie count”
– Food weighed before and after intake
– Measures “actual” intake

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Nutrition Care Criteria
• Evaluation and interpretation using:
– U.S. dietary guidelines
– USDA food patterns
– Diabetic exchanges/carbohydrate counting
– Individual nutrient analysis
• Computerized dietary analysis
– Daily Values/Dietary Reference Intakes

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Anthropometrics
• Nutrition care indicator: height/stature
– Age < 2 – length
– Age > 2 – standing height
• Using stadiometer
– Alternatives: arm span; knee height
• Nutrition care indicator: weight
– Balance beam & electronic scales
– Wheelchair & bed scales
– Amputation calculations

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Anthropometrics: Nutrition Care
Criteria – Infants/Children
• Evaluation and interpretation of height and
weight
– Growth charts: compare with reference
population
• Weight for height
• Percent weight for height
– Body mass index (BMI)
• Overweight 85- < 95% of BMI for age
• Obesity > 95% of BMI for age
• Underweight < 5th percentile

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Anthropometrics: Nutrition Care
Criteria – Adults
• Evaluation and interpretation of height and
weight
– Usual body weight
– Percent usual body weight and percent weight
change
– Reference weights
– Body mass index (BMI)
– Waist circumference

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Body Composition Measurements
• Body composition – distribution of body
compartments as part of total weight
– Fat mass vs. fat free mass
• Fat mass, body water, osseous mineral, protein
– Most concerned with metabolically active
tissue and fluid status

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Nutrition Care Indicator: Skinfold
Measurements
• Estimates energy reserves in
subcutaneous tissue
• Advantages
– Minimally invasive, requires minimal
equipment
• Disadvantages
– Requires practice for reliable performance
• See Figure 3.15

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Mid-Upper Arm Muscle Area in
Adults

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Nutrition Care Criteria: Skinfold
Measure
• Interpretation and evaluation of skinfold
measure
– At risk: < 5th or > 95th percentiles
– See Table 3.7

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Interpretation of Triceps Skinfold
Measurements

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Nutrition Care Indicator: Biolectrical
Impedance Analysis (BIA)
• Based on conduction of electric current
through fat and bone
• See Figure 3.17

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Bioelectrical Impedence Analysis
(BIA)

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Anthropometric/Body Composition
Measurements
• Nutrition care criteria: interpretation and
evaluation of BIA
– BIA not appropriate for patients who have
experienced major shift in water balance and
distrubution
• Phase angle should be used

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More Nutrition Care Indicators
• Hydrostatic (underwater) weighing
– Most accurate, less available
• Dual energy X ray absorptiometry (DXA)
– Considered precise (see Figure 3.18)
• Air displacement plethysmography
– Comparable to DXA and hydrostatic weighing

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DXA

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Biochemical Assessment and
Medical Tests and Procedures
• Measurement of nutritional markers and
indicators found in blood, urine, feces,
tissue
– Protein assessment
– Immunocompetence
– Hematological
– Vitamin/mineral levels
– Others

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Somatic Protein Assessment
• Nutrition care indicator: creatinine height
index
– Correlates daily urine output of creatinine with
height
• Nutrition care criteria: interpretation and
evaluation of creatinine height index
– Uses ratio of 24 hour output to expected
output
– See Table 3.8

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Expected 24-Hour Creatinine
Excretion

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Somatic Protein Assessment
(cont’d.)
• Nutrition care indicator: nitrogen balance
– In healthy individual, nitrogen excretion
should equal nitrogen intake
– Used in critical care, when nutritional support
is being provided, and in research
– Requires 24 hour urine collection
• Nutrition care criteria: interpretation and
evaluation of nitrogen balance
– Formula accounts for all sources of nitrogen
loss

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Protein Assessment
• Visceral protein assessment: non skeletal
proteins
– Albumin
– Transferrin
– Prealbumin/transthyretin
– Retinol binding protein (RBP)
– Fibronectin (FN)
– Insulin like growth hormone (IGF-1)
– C-reactive protein (CRP)

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Visceral Protein Assessment
Overview

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Other Biochemical Assessments
• Immunocompetence
– Total lymphocyte count (TLC)
• Hematological assessment
– See Table 3.10

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Routine Admission Laboratory
Measurements

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Nutrition Care Indicators for
Hematological Assessment
• Hemoglobin (Hgb)
• Hematocrit (Hct)
• MCV, MCH, and MCHC
• Ferritin, transferrin saturation,
protoporphyrin
• Serum folate, serum B12

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Other Labs with Clinical
Significance
• Lipid status
• Electrolytes
• BUN
• Creatinine (Cr)
• Serum glucose
• Vitamin/mineral assessment
– Not routinely done

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Nutrition-Focused Physical
Findings
• Assess for signs and symptoms consistent
with malnutrition or nutrient deficiencies
• Inspection, palpation, percussion, and
auscultation

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Functional Assessment
• Skeletal muscle function or strength
– Patient’s perception on Subjective Global
Assessment
• Perception of self-care abilities and environment
– ADL/ IADLs
• See Table 3.11
– Handgrip dynamometry
• Included in proposed criteria for malnutrition
diagnosis

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ADLs

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Nutrition Care Criteria: Energy and
Protein Requirements
• Indirect calorimetry
– BEE + PA + TEF = TEE
– Basal energy expenditure (BEE) or basal
metabolic rate (BMR)
• Approximately 60% of energy requirement
• May substitute Resting Energy Requirement (REE)
or Resting Metabolic Rate (RMR): approximately
10% higher than BEE

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Indirect Calorimetry
• Physical activity (PA)
– Most variable
– Approximately 15 to 20% of energy
requirements
• Thermic effect of food (TEF)
– Energy needed for absorption, transport, and
metabolism of nutrients
– Estimated at 10% of energy requirements
• See Figure 3.22

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Indirect Calorimetry: The Most
Accurate Method

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Estimation of Energy Requirements
• Choice of method based on patient
condition
– See Figure 3.23
• Several prediction equations available
– Choice of equation based on patient
characteristics
– See Table 3.12

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Applying Evidence-Based
Guidelines

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Estimation of Energy Requirements

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Energy Requirements of Common
Daily Activities

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Protein Requirements
• Measurement of protein requirements
– Nitrogen Balance
• Estimation of protein requirements
– RDA for protein
• .8 g/kg body weight
– Metabolic stress, trauma, and disease
• 1-1.5 g/kg
– Protein-kilocalorie ratio
• 1:200 healthy
• 1:150 to 1:100 if requirements higher

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Interpretation of Assessment Data:
Nutrition Diagnosis
• Determine specific nutrition related
problems as identified in nutrition
assessment
– See Figure 3.24
• International Classification of Disease
criteria
• Document using PES

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Etiology-Based Malnutrition
Definitions