Chapter 13 Nutrition Care and Assessment

medical problems often associated with malnutrition

-AIDS -alcoholism -anorexia nervosa or bulimia nervosa -burns (extensive or severe) -cancer and cancer treatments -cardiovascular diseases -celiac disease -chewing or swallowing difficulties -chronic kidney disease -dementia or other mental illness -diabetes mellitus -feeding disabilities -infections -inflammatory bowel diseases -liver disease -malabsorption -pressure sores -surgery (major) -vomiting (prolonged or severe)

medical history in subjective global assessment

-body weight changes: percentage weight loss in past six months; weight loss or gain in past two weeks -dietary changes: suboptimal, low kcalorie, liquid diet, or starvation -GI symptoms: nausea, diarrhea, vomiting, or anorexia for more than two weeks -Functional ability: full capacity versus suboptimal, walking versus bedridden -Degree of disease-related metabolic stress: low, medium, or high

nursing diagnoses with nutritional implications

-chronic confusion -chronic pain -constipation -diarrhea -disturbed body image -feeding self-care deficit -imbalanced nutrition: less than body requirements -impaired dentition -impaired oral mucous membrane -impaired physical mobility -impaired swallowing -insufficient breast milk -nausea -obesity -readiness for enhanced nutrition -risk for aspiration -risk for deficient fluid volume -risk for overweight -risk for unstable blood glucose level

Role in nurses in nutrition care

-interact closely with patients and thus are in an ideal position to identify people who would benefit from nutrition services -often screen patients for nutrition problems and may participate in nutrition & dietary assessments -also provide direct nutrition care, such as encouraging patients to eat, finding practical solutions to food-related problems, recording patient's food intake, and answering questions about special diets -responsible for administering tube and IV feedings -in facilities that do not employ registered dietitians, nurses often assume responsibility for much of the nutrition care

roles of registered nutrition technicians in nutrition care

-often work in partnership with registered dietitians and assist in the implementation & monitoring of nutrition services -depending on their background and experience, they may screen patients for nutrition problems, develop menus and recipes, ensure appropriate meal delivery, monitor patient's food choices and intakes, and provide patient education & counseling -sometimes supervise food service operations and may have roles in purchasing, inventory, quality control, and sanitation, or safety.

roles of other health care professionals in nutrition care

-other healthcare professionals who may assist with nutrition care include pharmacists, physical therapists, occupational therapists, speech therapists, nursing assistants, home healthcare aides, and social workers -these individuals can be instrumental in alerting dietitians or nurses to nutrition problems or may share relevant information about a patient's health status or personal needs

advantages of direct observation

-process does not rely on memory -method does not influence food intake -method can be used to evaluate the acceptability of a prescribed diet

advantages of food record

-process does not rely on memory -recording foods as they are consumed may improve accuracy of food intake data -process is useful for controlling intake because keeping records increases awareness of food choices

advantages of food frequency questionnaire

-process examines long-term food intake, so day-to-day & seasonal variability should not affect results -questionnaire is completed after food is consumed, so method does not influence food choices -method is inexpensive to administer

disadvantages of direct observation

-process is possible only in residential situations -method is labor intensive

disadvantages of food frequency questionnaire

-process relies on memory -food lists often include common foods only -serving sizes are often difficult for respondents to evaluate without assistance -calculated nutrient intakes may not be accurate -food lists for the general population are of limited value in the special populations -method is not effective for monitoring short-term changes in the food intake

Role of Registered Dietitians In Nutrition Care

-qualified to provide medical nutrition therapy -may conduct nutrition and dietary assessments, diagnose nutrition problems; develop, implement, and evaluate nutrition care plans, order patient diets, plan and approve menus; and provide dietary counseling & nutrition education services -may also manage food and cafeteria services in health care institutions

disadvantages of food record

-recording process itself influences food intake -underreporting and portion size errors are common -process is time-consuming and burdensome for respondent; requires high degree of motivation -method requires literacy and the physical ability to write -seasonal changes in diet are not taken into account

disadvantages of 24-hour dietary recall

-relies on patient memory -underestimation and overestimation of food intakes are common -food items that cause embarrassment (alcohol, desserts) may be omitted -data from a single day cannot accurately represent the respondent's usual intake -seasonal variations may not be addressed -skill of interviewer affects outcome

Advantages of 24 hour dietary recall

-results are not dependent or literacy or educational level of respondent -interview occurs after food is consumed, so method does not influence dietary choices -results are obtained quickly; method is relatively easy to conduct -method does not require reading or writing ability

physical examination in subjective global assessment

-subcutaneous fat loss (triceps or chest) -muscle loss (quadriceps or deltoids) -ankle edema -sacral (lower spine) edema -ascites (abdominal edema)

classifications on subjective global assessment

-well nourished -moderate malnutrition -severe malnutrition

the nutrition care process steps

1. nutrition assessment 2. nutrition diagnosis 3. nutrition intervention 4. nutrition monitoring and evaluation

depending on the patient population, estimates of malnutrition in hospital patients range from what?

15 to 60 percent

how long is the multiple pass interview conducted for?

30 to 45 minutes

criteria for identifying malnutrition risk

Admission data, anthropometric data, functional assessment data, historical information, lab test results, signs and symptoms

food and nutrition history

Food and nutrient intake, nutrition and health knowledge, physical activity and exercise habits, food availability, recent weight changes, dietary restriction, food allergies or intolerances

complications of malnutrition often lengthen what?

Hospital stays and increase the overall cost of patient care

food frequency questionnaire

Written survey of food consumption during a specific period of time, often a one-year period -some are qualitative only: food lists contain common foods, organized by food group, with checkboxes to indicate the frequency of consumption -others can collect semiquantitative information by including portion size as well

Registered Dietitian OR Registered Dietitian Nutritionist

a food and nutrition expert who has completed the education and training specified by the academy of nutrition and dietetics including a bachelor's degree in nutrition or dietetics, a supervised internship, and a national registration examination

how do you identify patients who are malnourished or at risk for malnutrition?

a nutrition screening is conducted within 24 hours of a patient's admission to a hospital or other extended-care facility -a screening may also be included in certain types of outpatient services and community health programs

Illnesses and their treatments can lead to malnutrition by causing what?

a reduction in food intake, interfering with digestion and absorption, or altering nutrient metabolism and excretion

protein-energy malnutrition (PEM)

a state of malnutrition characterized by depletion of tissue proteins and energy stores, usually accompanied by micronutrient deficiencies

PES statement

a statement that describes a nutrition problem in a format that includes: -the problem (P) -the etiology or cause (E) -the signs and symptoms (S).

Nutrition Care Process

a systematic approach used by dietetics professionals to evaluate and treat nutrition-related problems

Nutrition Intervention

after nutrition problems are identified, the appropriate nutrition care can be planned and implemented -may include counseling or education about appropriate dietary and lifestyle practices, a change in medication or other treatment, or adjustments in the meals or services offered to a hospital patient -to be successful, the intervention should consider the individuals food habits, lifestyle, and other personal factors

medical history in historical information

age, current complaints, past medical problems, ongoing medical treatments, surgical history, family medical history, chronic disease risk, mental/emotional health status

malnutrition is frequently reported in patients hospitalized with what?

an acute illness

Nutrition Screening

an assessment procedure that helps to identify patients who are malnourished or at risk for malnutrition

reduced food intake symptoms and effects of illness

anorexia due to illness; nausea and vomiting; pain with eating; mouth ulcers or wounds; difficulty chewing or swallowing; depression or psychological stress; inability to feed oneself

dietary changes required during an acute illness

are usually temporary and can be tailored to accommodate an individuals preferences and lifestyle

altered nutrient metabolism and excretion treatment

chemotherapy; uses of diuretics (increased urination and nutrient excretion), side effects of medications (can affect nutrient function)

nursing diagnoses

clinical judgments about actual or potential health problems that provide the basis for selecting appropriate nursing interventions

Personal and Social History

cognitive abilities, cultural/ethnic identity, educational level, employment status, home/family situation, religious beliefs, socioeconomics status, use of tobacco, alcohol, or illegal drugs

a nutrition screening involves what?

collecting health-related data that can indicate the presence of protein-energy malnutrition (PEM) or other nutrition problems

what happens in the second pass?

conducted to help the respondent remember foods that are often forgotten, such as beverages, bread, additions of foods (such as butter on toast), savory snacks, and sweets

what happens in the final pass?

conducted to provide a final opportunity to recall foods and to probe for additional details

multiple pass method

considered the most effective approach for conducting a 24-hour dietary recall -the interview includes four or five separate passes through the 24-hour period of interest -in the first pass, the respondent provides a "quick list" of foods consumed without prompts by the interviewers

clinical pathways outline what?

coordinated plans of care for specific medical diagnoses, procedures, or treatments

clinical pathways

coordinated programs of treatment that merge the care plans of different health practitioners

the nutrition assessment data is used to what?

develop a plan of action to prevent or correct energy or nutrient imbalances, or to determine whether a care plan is working

the cost of health care can what?

drain financial resources and limit the ability to make the appropriate food choices

Nutrition Diagnosis

each nutrition problem identified by the nutrition assessment receives a separate diagnosis, which is formatted as a PES statement

altered nutrient metabolism and excretion symptoms and effects of illness

elevated metabolic rate: muscle wasting; changes in hydration; prolonged immobilization: nutrient losses due to excessive bleeding, diarrhea, or frequent urination

what happens in the third and fourth passes?

elicit additional details about the foods consumed, such as the amounts eaten, preparation methods, and places where foods were obtained or consumed

kcalorie counts

estimates of food energy (and often, protein) consumed by patients for one or more days

Subjective Global Assessment

evaluates a person's risk of malnutrition by ranking key variables of medical history and physical examination -A for well nourished -B for potential or mild malnutrition -C for severe malnutrition

24 hour dietary recall

guided interview in which the foods and beverages consumed in a 24-hour period are described in detail -interview includes questions about the times when meals or snacks were eaten, amounts consumed, and ways in which the foods were prepared

nutrition support teams

health care professionals responsible for the provision of nutrients by tube feeding or intravenous infusion

moderate malnutrition on subjective global assessment

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 -usually applies to patients with an even mix of A, B, and C ratings

severe malnutrition on subjective global assessment

if more than 10% weight loss, severe loss of muscle or fat tissue, edema, multiple GI symptoms, and functional impairments

well nourished on subjective global assessment

if no significant loss of weight, fat, or muscle tissue and no dietary difficulties, functional impairments, or GI symptoms; also applies to patients with recent weight gain and improved appetite, functioning, or medical prognosis

Poor nutritional status weakens what?

immune function and compromises a person's healing ability, influencing both the course of illness and the body's response to treatment

in some cases, the patient's nutrition care is what?

incorporated into the medical care plan developed by the entire health care term

an illness may have what?

indirect effects that influence nutrition status

Impaired digestion and absorption symptoms and effects of illness

inflammation associated with bowel conditions; insufficient secretion of digestive enzymes or bile salts; altered structure or function of intestinal mucosa

Nutrition Assessment

involves the collection and analysis of health-related data in order to identify specific nutrition problems and their underlying causes -information may be obtained from the medical record, physical examination, laboratory analyses, medical procedures, an interview with the patient or caregiver, and consultation with other healthcare professionals

chronic illnesses may require what?

long-term dietary adjustments

anorexia

loss of appetite

goals are stated in terms of what?

measurable outcomes -other goals may be positive changes in dietary behaviors and lifestyles

Historical Information used in nutrition assessment

medical history, medication and supplement history, personal and social history, food and nutrition history

physicians are responsible for what?

meeting all of a patient's medical needs, including nutrition -they prescribe diet orders and other instructions related to nutrition care, including referrals for nutrition assessment and dietary counseling

pressure sores can increase what?

metabolic stress and raise protein & energy needs

each nutrition care process step must what?

must be documented in the medical record, providing a record for future reference and facilitating communication among members of the health care team

physicians rely on who?

nurses, registered dietitians, and other health professionals to alert them to nutrition problems, suggest strategies for handling nutrition care, and provide nutrition services

nursing care plans often include what?

nursing diagnoses that suggest the needs for nutrition interventions

Medical Nutrition Therapy

nutrition care provided by a registered dietitian; includes assessing nutrition status, diagnosing nutrition problems, and providing nutrition care

direct observation

observation of meal trays or shelf inventories before and after eating; possible only in residential facilities -this method can also reveal a person's food preferences, changes in appetite, and any problems with a prescribed diet -nurses use this to conduct patient's kcalorie counts -requires regular and careful documentation & can be labor intensive and costly

emotional health may suffer as a result of what?

of chronic disease or terminal illness, causing lack of appetite and disinterest in food preparation

information collected in a nutrition screening

often included are the admitting diagnosis, physical measurements and laboratory test results obtained during admission process, relevant symptoms, and information about diet & health status provided by the patient or caregiver

recall interviews may be conducted for how long?

on several nonconsecutive days to get a better representation of a person's usual diet

the information collected in a nutrition screening varies according to what?

patient population, the type of care offered by the healthcare facility, and the patient's medical problem

medication and supplement history

prescription drugs, over the counter drugs, dietary and herbal supplements

Historical Information in nutrition assessment

provides valuable clues about the patients nutrition status and nutrient requirements -it also reveals personal preferences that should be considered when developing a nutrition care plan

Impaired digestion and absorption treatment

radiation therapy; gastrointestinal surgeries; side effects of medications on gastrointestinal tract structure or function

the nutrition care process steps are frequently revisited in order to what?

reassess and revise diagnoses and intervention strategies

pressure sores

regions of skin and tissue that are damaged due to prolonged pressure on the affected area by an external object, such as a bed, wheelchair, or cast; vulnerable areas of the body include buttocks, hips, and heels. Also called decubitus ulcers.

Anthropometric

related to physical measurements of the human body, such as height, weight, body circumferences, and percentage of body fat

reduced food intake treatments

restrictive diets; bowel rest; surgical resection of head, neck, mouth, or esophagus; preparation for surgery or diagnostic tests; surgical wounds; side effects of medications (which can cause anorexia or gastrointestinal distress)

how is obtaining accurate food intake data challenging?

results may vary depending on an individual's memory, honesty, and the assessor's skill & training

The screening should be what?

sensitive enough to identify patients who require nutrition care but simple enough to be completed within 10 to 15 minutes

diet orders

specific instructions regarding dietary management; also called nutrition prescriptions.

nutrition care plans

strategies for meeting an individual's nutritional needs

if progress is slow or a patient is unable or unwilling to make the suggested changes, what should happen?

the care plan should be redesigned and take into account the reasons why the earlier plan was not successful -the new plan may need to include motivational techniques or additional patient education -if the patient remains unwilling to modify behaviors despite the expected benefits, the health practitioner can try again at a later time when the patient may be more receptive

Nutrition Monitoring and Evaluation

the effectiveness of the nutrition care plan must be evaluated periodically: -the patient's progress should be monitored closely, and updated assessment data or diagnoses may require adjustments in goals or outcome measures

after the day's intake is recounted, what can the interviewer ask?

the interviewer can ask whether the intake that day was fairly typical and, if not, how it varied from the person's usual intake

how do you form a kcalorie count?

the nurse records the dietary items that a patient is given at meals and subtracts the amounts remaining after meals are completed -this procedure allows an estimate of the caloric content of foods and beverages that are actually consumed

what happens in the first pass?

the respondent provides a "quick list" of foods consumed without prompts by the interviewers

the challenge for nurses and other health professionals is to what?

to help their patients understand the potential benefits of nutrition therapy and accept the dietary changes that can improve their health

briefer screening tools may use just what?

two or three variables -for example, some tools screen for malnutrition risk by evaluating health status, unintentional weight changes, and reduced appetite or food intake

Example of a PES statement

unintended weight gain (the problem) related to long term use of corticosteroids (the etiology or cause) as evidenced by an involuntary weight gain of 10% of body weight over the past six months (the sign or symptom)

who performs and documents screenings?

usually a nurse, nursing assistant, registered dietitian, or dietetic technician

the role of health professionals may what?

vary among different institutions, and their responsibilities can sometimes overlap

members of the health care team do what?

work together to ensure that the nutritional needs of patients are met during illness

food record

written account of food consumed during a specified period, usually several consecutive days. Accuracy is improved by including weights or measures of foods -detailed food record includes the types and amounts of foods and beverages consumed, times of consumption, and the methods of preparation -may also include information about medication use, disease symptoms, and physical activity -provides valuable information about food intake as well as a person's response to and compliance with nutrition therapy