13 Focus Assessment: Nutritional Assessment

I. Overview of Nutritional Assessment

Proper nutrition is important to maintain health and prevent illness. It is essential for the health care provider to routinely evaluate patient’s nutritional status and to identify any nutritional problems or potential problems, so that appropriate referrals and interventions can be provided.

Many physical conditions can cause disturbance of nutritional absorptions. For example, patients with gastrointestinal problems such as inflammatory bowel disease or liver cirrhosis may have malnutrition issues; patients with lung problems may not have enough oral intake due to difficulty breathing; diabetes patients will have inadequate glucose homeostasis; patients who have psychiatric disorders or depression may have functional impairments that cause poor nutritional intake; cancer patients may result cancer cachexia and malnutrition; patients who are in pain may decrease oral intake.

Effects and adverse effects of many medications can interfere nutritional absorptions. For example, diuretics may cause dehydration and electrolyte abnormalities; narcotics/opioids may have adverse effects of nausea and vomiting; anticholinergic drugs may cause dry mouth and affect food intake.

Malnutrition is defined as “deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients” (WHO, 2021). According to the World Health Organization (WHO), the following conditions can all be referred as malnutrition. These forms of malnutrition include,

• undernutrition: wasting (low weight-for-height), stunting (low height-for-age), and underweight (low weight-for-age);
• micronutrient-related malnutrition: vitamins or minerals deficiencies or excess;
• overweight, obesity, and diet-related noncommunicable diseases (NCDs):  body mass index (BMI) over 25 kg/m² is overweight;  BMI above 30 kg/m² is obesity. Diet-related NCDs include cardiovascular disease, diabetes, and certain cancers (such as liver cancer or oral cancer).

Body Mass Index (BMI) is using the person’s weight and height to estimate body fat. Through many research findings, BMI is highly correlated with many metabolic and cardiovascular diseases (CDC, nd.).

II. Anatomy and Physiology

Digestion begins in the mouth where chewing and mixing with saliva is the initial step in breaking down food. In stomach, foods mix with gastric juices and produce a mixture, chyme. Chyme passes to small intestine where most of the digestion takes place. In the small intestine, foods are dissolved, and nutrients are absorbed into the body. Unabsorbed wastes are passed down to the colon.

Nutrients are divided into macronutrients and micronutrients.

Macronutrients refer to carbohydrates, fats, and proteins that a person needs to consume daily to produce energy in order to function properly.

Watch the following short video clip to review digestion in small intestines.

Micronutrients refer to dietary minerals and vitamins that support metabolism of the body.

The following short video clip provides knowledge on nutrients that are essential for life: minerals and vitamins.

III. Medical Terminology

IV. Nutritional Assessment

Nutritional assessment is an ongoing component for daily assessment especial for patients with nutritional concerns and patients who are at risk for nutritional deficits.

Screening for Nutritional Status	Additional Information
1. Obtain health history Food allergies Medical dietary requirements (for example, Gluten-free diet for history of celiac disease) Dietary supplements (for example, vitamins or protein drinks) Cultural/ethnic/religious need Dietary intake history (for example, eating habits, like and dislike foods)	Dietary and nutritional differences can be found among racial and socioeconomic groups. Dietary selections can be affected by religious, spiritual, or philosophical beliefs.
2. Obtain chief complaints Pain? Changes in the taste of food? Feeling tiredness? Recent changes in appetite? Nausea? Vomiting? Change in bowel habit? Involuntary weight loss? Recent changes in weight?	Chief complaints should be considered because it may indicate the patient to be at risk for nutritional deficits. Problems with intake such as indigestion, heartburn, bloating, difficulty chewing or swallowing will affect nutritional status. If the patient has a specific concerns about hair, skin, or nails, a focused assessment regarding to the specific sign/symptom should be performed.
3. Check Height and weight Vital signs	Note the size of the patient and calculate BMI to determine normal, overweight, or obesity. Waist circumference can also be measured for adult patients to determine if the patient is at risk for cardiovascular disease. Normal waist for men should be less than 40 inches; for women, less than 35 inches (Hinkle & Cheever, 2018).
4. General inspection and examination General appearance Integumentary – hair and skin GI & GU – frequency of bowel movement and urination Neuro and Musculoskeletal – assessing for any physical problems for eating and drinking	During the meal time, observe the patient’s dietary intake and compare with recommended food groups for specific age groups and activity levels. Expected findings are alert & oriented, normal proportion of body structure, normal skin tone and skin color appropriate to ethnicity, no signs of malnutrition. Many diseases are directly or indirectly caused by a lack of essential nutrients in the diet. Changes in the skin and mucosal membranes can offer valuable clues to the presence of nutritional deficiencies. For example, gingivitis and bleeding gums may cause by vitamin C deficiency. For integumentary system, in malnutrition patients, hair is likely to be brittle and dry, and or hair loss; skin is likely to be pale, dry, and rough; wounds will tend to take longer time to heal. Physical difficulties, such as tremors, will affect dietary intake. Nurses should assess if equipment is needed to help with eating and drinking.
5. Review related laboratory results	Some laboratory values may reflect the patient’s nutritional status such as albumin, prealbumin, transferrin, electrolytes, and etc.
6. Report and document assessment findings and related health problems according to agency policy.	Accurate and timely documentation and reporting promote patient safety. Recommend additional nutritional evaluation referrals such as dietitian to determine the need for nutritional supplements.

Access additional information to educate patients on healthy dietary patterns. The guidelines were developed by the U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (HHS) to provide recommendations on healthy eating, and thus promote healthas well as prevent chronic illness. This guidelines include recommendations from birth through older adulthood, and also women who are pregnant or in breastfeeding.

• Dietary Guidelines for Americans, 2020-2025

V. Documentation of Assessment Findings

VI. Related Laboratory and Diagnostic Procedures/ Findings

Nutritional assessment is an ongoing process for hospitalized patients. Through the assessment findings, if the patient is suspected to have nutritional concerns such as inadequate oral intake or poor wound healing, further diagnostic and laboratory tests may be proceeded to uncover the underlining causes and provide nutritional support.

Some laboratory results can be reviewed to determine the patient’s nutritional status. Serum albumin and prealbumin levels can be used to decide the patient’s protein requirements. Electrolytes (such as serum calcium, magnesium, phosphorous), blood urea nitrogen (BUN), and creatinine can be evaluated to assess the patient’s overall fluid volume status and the need for parental nutrition. If diet-related non communicable diseases or metabolic diseases are suspected, glucose and lipid levels may be assessed. Transferrin is a protein that transports iron through the blood to different tissues and organs. Serum transferrin levels may indicate protein status. Low transferrin may indicate iron deficiency and cause anemia. In evaluation of anemia, Complete blood count (CBC), serum iron level, serum vitamin B12 and folate levels will also be checked. Blood tests for specific vitamin deficiencies may be necessary in patients who have gastrointestinal malabsorption (Hinkle & Cheever, 2018).

VII. Learning Exercises

VIII. Attribution and References

• Centers for Disease Control and Prevention. Healthy Weight, Nutrition, and Physical Activity: About adult BMI. Available at https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html#InterpretedAdults
• Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals by Chippewa Valley Technical College is licensed under CC BY 4.0.
• Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-surgical Nursing. (14th ed.). Philadelphia, PA: Wolters Kluwer.
• National Heart, Lung, and Blood Institute. Calculate Your Body Mass Index. Available at https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
• U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov
• World Health Organization. Malnutrition. 9th June 2021. Available at https://www.who.int/news-room/fact-sheets/detail/malnutrition.