NATIONAL INSTITUTE OF

NURSING EDUCATION,
PGIMER

SEMINAR ON NUTRITIONAL
ASSESSMENMT AND RELATED
INVESTIGATIONS AND
DIAGNOSIS

SUBMITTED TO: Mrs Prabhjot

(Lecturer,NINE, PGIMER)
SUBMITTED BY: Pratibha Thakur
( M.Sc Nursing 1st year)
SUBMITTED ON: 09 August 2017
 NUTRITIONAL ASSESSMENT

INTRODUCTION
Nutrition is very important to maintain health and to prevent from disease and
death. When illness or injury occurs, optimal nutrition is an essential factor in
promoting healing and resisting infection and other complication. Assessment of
nutritional status of a person provides information about obesity, malnutrition,
weight loss, and deficiencies of specific nutrients and metabolic abnormalities.1

NUTRITION: Nutrition is the intake of food, considered in relation to the body’s

dietary needs. An adequate or well balanced diet combined with regular physical
activity is a feature of good health.1

Nutrients: These are substances obtained from food during digestion

Nutrition Status: is the current body status, of a person or a population group,

related to their state of nourishment

NUTRITIONAL ASSESSMENT:
A nutrition assessment is an in-depth evaluation of both objective and subjective
data related to an individual's food and nutrient intake, lifestyle, and medical
history. Once the data on an individual is collected and organized, the practitioner
can assess and evaluate the nutritional status of that person.

PURPOSES OF NUTRITIONAL ASSERSSMENT

The purpose of nutritional assessment is to:
• To determine nutritional health
• Look for warning signs
• Identify risks to medical treatment and recovery
 Identify individuals or population groups at risk of becoming malnourished
 Identify malnourished individuals or population groups.
 To develop health care programs that meet the community needs which are
defined by the assessment
 To measure the effectiveness of the nutritional programs & interventions. 6
ASSESMENT:
 past medical history
 family history
 social history

Past medical history: Past history is important to know about any past
hospitalizations, operations, major injuries, chronic illnesses, and significant acute
illnesses .Current or recent prescription medications, vitamins and minerals,
laxatives, topical medications, OTC medications, and nutritional supplements
.Potential drug-nutrient interactions, such as those caused by potassium-wasting
diuretics .Food allergies or lactose intolerance, all these factors may affect
nutritional status of individual.

Family history : family history include history of cancer, diabetes, heart disease,
hypertension, obesity, and osteoporosis .Parents, siblings, children, spouse: include
ages, current health status, and cause of death if deceased

Social history: It includeOccupation, daily exercise pattern, marital and family

status Economic status, educational level, residence, emotional response to illness
and coping skills Duration and frequency of use of substances, including tobacco,
alcohol, illegal drugs, and caffeine 6

METHODS OF NUTRITIONAL ASSESSMENT

Nutrition is assessed by two types of methods
1. Indirect methods use community health indices that reflect nutritional
influences.
2. Direct methods deal with the individual and measure objective criteria2

1. INDIRECT METHODS
These include three categories:
 Ecological variables including crop production
 Economic factors e.g. per capita income, population density & social habits
 Vital health statistics particularly infant & under 5 mortality & fertility index
 2. DIRECT METHODS OF NUTRITIONAL ASSESSMENT
These are summarized as ABCD
 Anthropometric methods
 Body mass index
 Clinical assessment
 Dietary evaluation methods
 Biochemical, laboratory methods
 Clinical methods

A. ANTHROPOMETRIC METHODS
Anthropometry is the measurement of body height, weight & proportions. It is
an essential component of clinical examination of infants, children & pregnant
women. It is used to evaluate both under & over nutrition. The measured values
reflects the current nutritional status & don’t differentiate between acute &
chronic changes.

Anthropometric Measurements
 Height
 Weight
 Mid-arm circumference
 Skin fold thickness
 Waist circumference

1. Height: Height is the measurement of someone or something from head to

foot or from base to top. Height is a standard component of most fitness
assessment.
Measurement of weight:
 The person is required to remove his/her shoes, stand erect, looking
 Straight in a horizontal plane with feet together and knees straight.
 The heels, buttocks, shoulder blades and the back of the head should touch
against the wall.

2. Weight: weight is the amount or quantity of heaviness or mass or amount

a thing weight
Measurement of weight:
 Make sure the scale pointer is at zero beforetaking a measurement.
  The person is required to dress in light clothes and take off shoes. Women
should remove scarf.
 He/she must stand straight and unassisted on the centre of the balance
platform. The weight should be recorded to the nearest0.1kg.

Average height and weight:

3. Mid- Upper arm circumference:

MUAC is defined as the circumference taken at the midpoint between

shoulder and elbow of arm using an insertion tape MUAC is a key indicator
of nutritional status mainly in children's .It is reduced substantially in
undernourished and in increased in children's who are over nourished .
Shakir's tape,are used to measure MUAC. The child's right arm.
Measurement of MUAC:

 Bend the left arm, find and mark with a pen the olecranon process and
acromium.
 Mark the mid-point between these two marks.
 With the arm hanging straight down, wrap a MUAC tape around the arm at
the midpoint mark.
 Measure to the nearest 1 mm.

4. Skin fold thickness:

Triceps skin fold is preferably used in conjunction with sub scapular, biceps
and suprailiac skin fold measurement to determine actual percentage of body
fat
Triceps skin fold:
o Male: 12.5 mm
o Female: 16.5mm

5. Waist circumference: Waist circumference is measured at the level of the

umbilicus to the nearest 0.5 cm. Subject have to stands erect with relaxed
abdominal muscles, arms at the side, and feet together. The measurement
should be taken at the end of a normal expiration. Two levels of risk have
been identified as:

MALES FEMALE
LEVEL 1 > 94cm > 80cm

LEVEL2 > 102cm > 88cm

Level 1: it is the maximum acceptable waist circumference and there should be no

further weight gain.

Level 2: It denotes obesity and requires weight management to reduce the risk of
type 2 diabetes & CVS complication
ADVANTAGES OF ANTHROPOMETRY

It provides with high specificity & sensitivity and measures many variables of
nutritional significance (Ht, Wt, MAC, HC, skin fold thickness, waist & hip ratio
& BMI).Readings are numerical & gradable on standard growth charts and also
readings are reproducible. It needs non-expensive & need minimal training

LIMITATIONS OF ANTHROPOMETRY: There can be Inter-observers errors

in measurement. There are Limited nutritional diagnosis and Problems with
reference standards, i.e. local versus international standards.1

B. BODY MASS INDEX

It mass index is the international standard for assessing body size in adults. BMI is
a ratio based on body weight and height .Evidence shows that high BMI (obesity
level) is associated with type 2 diabetes & high risk of cardiovascular morbidity &
mortality

BMI is calculated using the following formula:-

BMI = Weight (kg)/ Height (m²)

OR

BMI = weight in pounds × 703

Height in inches x height in inches

OR

BMI = weight in kilograms × 10,000

Height in centimeters x height in centimeters

BMI (WHO - Classification)

 BMI < 18.5 = Under Weight

 BMI 18.5-24.5 = Healthy weight range
 BMI 25-30 = Overweight (grade 1 obesity)
 BMI >30-40 = Obese (grade 2 obesity)
 BMI >40 =Very obese (morbid or grade 3 obesity)3
CLINICAL ASSESSMENT OF SIGNS OF NUTRITIONAL DEFICIENCY

It is an essential feature of all nutritional surveys. It is the simplest & most

practical method of ascertaining the nutritional status of a group of individuals. It
utilizes a number of physical signs, (specific & non specific), that are known to be
associated with malnutrition and deficiency of vitamins & micronutrients.
Good nutritional history should be obtained .General clinical examination, with
special attention to organs like hair, angles of the mouth, gums, nails, skin, eyes,
tongue, muscles, bones, & thyroid gland. Detection of relevant signs helps in
establishing the nutritional diagnosis

 ADVANTAGES
o It is fast & Easy to perform
o It is inexpensive
o Non-invasive
 LIMITATIONS
o It does not detect early cases

CLINICAL SIGNS OF NUTRITIONAL DEFICIENC

Good nutritional history should be obtained as soon as possible. General clinical

examination, with special attention to organs like hair, angles of the mouth, gums,
nails, skin, eyes, tongue, muscles, bones and thyroid gland must be given.
Detection of relevant signs helps in establishing the nutritional diagnosis

1. Hairs

Spare and thin Protein, zinc, biotin deficiency

Easy to pull out Protein deficiency
Corkscrew coiled hair Vitamin C and Deficiency

2. Mouth
Glossitis Riboflavin, niacin, folic acid, B12
Bleeding and spongy gums Vit. C,A,K,folic acid and niacin
Angular stomatitis, cheilosis and B2,6 and niacin
fissured tounge
Leukoplakia Vit. A, B12, B-complex, folic acid
and niacin
Sore mouth and tounge Vitamin B12,6, C, niacin, folic acid
and iron

3. Eyes
Night blindness and exophthalmia Vitamin A deficiency
Photophobia blurring, conjuctival Vitamin A and B2 deficiencies
inflammation

4. Nails
Spooning Iron deficiency
Transverse lines Protein deficiency

5. Skin
Pallor Folic acid, iron and B12
Follicular hyperkeratosis Vit B and C
Pigmentation, Desequmation Niacin and PEM
Bruising, Purpura Vit K, C and folic acid
Flaking dermatitis PEM, Vit B2, Vitamin A, Zinc and
niacin

6. Thyroid gland
In mountainous areas and far from sea places Goiter is a reliable sign of
iodine deficiency.

7. Joins and bones

It helps to detect signs of vitamin D deficiency (Rickets) & vitamin C
deficiency (Scurvy).

C. DIETARY EVALUATION METHODS: Nutritional intake of humans is

assessed by Following 5 methods:
 24 hours dietary recall
  Food frequency questionnaire
 Dietary history since early life
 Food dairy technique
 Observed food consumption

1. 24 hours dietary recall: A trained interviewer asks the person to recall all
food & drink taken in the previous 24 hours. It is quick, easy, & depends on
short-term memory, but may not be truly representative of the person’s usual
intake.

2. Food frequency questionnaire: In this method the interviewer gives a list

of around 100 food items to the person to indicate his or her intake
(frequency & quantity) per day, per week & per month.

Limitations:
 long Questionnaire
 Errors with estimating serving size.
 Needs updating with new commercial food products to keep pace with
changing dietary habits.

3. Dietary history: is an accurate method for assessing the nutritional status.

The information should be collected by a trained interviewer. Usual intake,
types, amount, frequency & timing details must be obtained. To verify data
is Cross-checking must be done.

4. Food dairy: Food intake (types & amounts) should be recorded by the
subject at the time of consumption. Collection period length range between
1-7 days. This method is reliable but difficult to maintain.

5. Observed food consumption: It is the most unused method in clinical

practice, but it is recommended for research purposes. The meal eaten by the
individual is weighed and contents are exactly calculated. The method is
characterized by having a high degree of accuracy but expensive & needs
time & efforts.
 EVALUATING THE DIEATRY INFORMATION

Quantitative method:

 After the dietary information has been obtained, the nurse evaluates the
patient’s dietary intake. If the goal is to determine if the person generally
eats a healthful diet, the food intake may be compared to the dietary
guidelines outlined in the USDA’s Food Guide Pyramid.

 The pyramid divides foods into five major groups and offers
recommendations for variety in the diet, proportion of food from each food
group, and moderation in eating fats, oils, and sweets. Determine the number
of serving from each group & compare it with minimum requirement.
Quantitative method:

 The amount of energy & specific nutrients in each food consumed can be
calculated using food composition tables & then compare it with the
recommended daily intake.
 Evaluation by this method is expensive & time consuming, unless
computing facilities are available.1

Biochemical, laboratory methods:

 Biochemical assessment reflects the tissue level of a given nutrient and any
abnormality of metabolism in the utilization of nutrients. These
determinations are made from studies of :

Serum: hemoglobin, serum protein, serum albumin and globulin, transferrin,

retinol binding protein, serum vitamin A, carotene, and vitaminC

Urine (creatinine, thiamine, riboflavin, niacin, and iodine)

 Low serum albumin and transferrin levels are often used as measures of
protein deficits in adults. Decreased albumin levels may be due to over
hydration, liver or renal disease, and excessive protein loss because of burns,
major surgery, infection, and cancer.

 Total lymphocyte count is reduced in people who become acutely

malnourished as a result of stress and low-calorie feeding are associated with
impaired cellular immunity.

 Serum electrolyte levels provide information about fluid and electrolyte

balance and kidney function. The creatinine/height index calculated over a
24-hour period assesses the metabolically active tissue and indicates the
degree of protein depletion.
 Advantages of Biochemical, laboratory methods:
 It is useful in detecting early changes in body metabolism & nutrition before
the appearance of overt clinical signs.
 It is precise, accurate and reproducible.
 Useful to validate data obtained from dietary methods e.g. comparing salt
intake with 24-hour urinary excretion

Disadvantages of Biochemical, laboratory methods:

 Time consuming
 Expensive
 They cannot be applied on large scale
 Needs trained personnel & facilities4

NUTRITIONAL DISORDERS

Nutritional disorders can be caused by an insufficient intake of food or of certain

nutrients, by an inability of the body to absorb and use nutrient, or by
overconsumption of certain foods.

Types of nutritional disorders:

Malnutrition has been defined as pathological state resulting from relative or

absolute deficiency or excess of one or more essential nutrient.

Protein Energy Malnutrition (PEM): PEM has been identified as a major health
problem in India. It occurs in children in first five year of life

Causes:
 Inadequate intake of food in both quantity and quality
 Poverty
 Poor environment conditions
 Failure of lactation
 Large families

PEM leads to two conditions:

  Kwashiorkor
 Marasmus

 Kwashiorkor: is an acute form of child protein energy malnutrition

characterized by edema, irritability, anorexia, ulcerating dermatomes and an
enlarged liver with fatty infiltrates. The presence of edema caused by poor
edema is known as kwashiorkor.

Characteristics of kwashiorkor:
o Wasting
o Fatty infiltration of the liver
o Mental Changes
o Hair
o Skin Changes
o Diarrhea
o Moon Face

Marasmus: The marasmus is generally known as the gradual wasting away

of the body due to severe malnutrition or inadequate absorption of food. It is a
severe form of malnutrition caused by inadequate intake of proteins and calories.

Characteristics of Marasmus:

o Ribs become prominent and limbs become prominent and limbs become
very thin as fat layer beneath the skin disappears
o Severe diarrhea and other digestive disorders.
o Retarded physical and mental growth.

Vitamin A Deficiency Disorders:

Vitamin A is necessary for good eyesight. Vitamin A deficiency results in

following diseases:

o Night blindness
o Xerophthalimia
o Keratomalacia
 Vitamin B deficiency:

o Vitamin B1 (Thiamin) : Beri Beri

o Vitamin B2 (Riboflavin): Glositis
o Vitamin B3 (Niacin) : Pellagra
o Vitamin B5 (Panthothene) : Parasthesia
o Vitamin B6 (Pyridoxine) : Peripheral neuropathy
o Vitamin B7 (Biotin) : Dermatitis, Enteritis
o Vitamin B9 (Folic acid) : Megaloblastic anemia, Neural tube defects
o Vitamin B12 (Cobalamin): Pernicious anemia

Vitamin C (Ascorbic acid):

o Scurvy

Vitamin D deficiency ( cholecalciferol):

o Rickets and osteomlacia

Vitamin E deficiency (Tocopherol): Sterility and Abortion

Vitamin k deficiency (Phylloquinone): Bleeding disorders 2

PROGRESSIVE HOSPITAL DIETS

The normal hospital diet which provides a patient with the energy and nutrients is
intended for the patient whose condition does not require a therapeutic diet. This
regular diet may be modified with regard to selection, methods of prepration and
consistency for patients who cannot tolerate a regular diet

1. Liquid diets: These diets are indicated in febrile states, Post-operative

or when the patients is unable to tolerate solid food, De[pending upon
the acuteness of a particular illness, the liquid diets are divied into :

a. Clear fluid died: Plain tea, coffee, fat free clear soups, lemon water, fat free
whey water, coconut water
b. Full fluid diet: Milk + Horlicks+ Complain, Milk +Proteinex,
 Fruit juices, vegetable soups.

2. Soft diet: This diet given to patients who have come out of acute illness
and to post-operative patients during early convalescence.
This diet is soft, easily digestible, bland low in fiber and non- irritating
Soups :
o Mashed cooked vegetables
o Grated processed cheese
o Butter and cornflour
o Dall
o Egg white and mased chicken
Cereals: Cereals are most commonly used in semi solid diets are sago,
suji, wheat, dalia, oats, sevian, rice, courn flour

Vegetables: light vegetables like carrot, pumpkin peas, spinach,

cauliflower etc

Egg/ paneer

TUBE FEEDING: Nutrition supplied through the tube may be:

 Natural liquid diet

 Blenderised to make liquid food
 Commercially supplied polymeric mixtures or elemental diet (Pre-digested)
 Natural liquid feeds like whole or skim milk, eggs and some form of
carbohydrate such as cooked cereals, sugar or molasses can be given.
Vegetable oil or cream and non fat dry milk are also important to increase
the calorie and protein levels respectively.

NUTRITION IN SURGICAL CONDITIONS:

HIGH PROTEIN FEED:

Milk 125ml, sugar 15gm+ Sk milk powder 15 gm, cournflour 5 gm

Indications for use: Pre and post operative period , fever, Burns, Injury, Under
radiotherapy
Provides: Energy 215kcal, protein 10 gm, fat 4.3 gm, CHO 39.8 gm

JEJUNOSTOMY FEED: Whey water 1tr, sk milk powder 150 gm, sugar 50 gm,
coconut oil 20 gm

Provides: energy 1115kcl, fat 20.1gm, CHO 146.2 gm, Protein 57 gm.

RENAL FEED: Custard powder 25 gm, sk milk powder 25gm, fat 125gm, sugar
150 gm, toned milk.

Provides: Energy 2062kcal, CHO 196 gm, Fat 134 gms, Protein 18.4 gm, Na 45.7
gm

DIALYSIS FEED; Lactose and gluten free

Provides: 1065 kcl, 71 gm protein, 340mg Na, 1665mg K+, 167 mg protein5

ROLE OF NURSE IN NUTRITIONAL ASSESSMENT

 To assess the nutritional status.

 To nurse’s role in nutrition is to educate patients about good nutrition to

promote health.

 To educate patients on how to improve eating habits to promote good health.

 To effectively manage and prevent malnutrition

 Documenting changes in weight loss, decreased appetite, oral health, and

physical activity.

 To plan a proper balanced diet according to patient condition 6

 REFRENCES
1. Brunner & Suddarth’s Textbook of Medical Surgical Nursing, 8th edition.
Lippincott Williams and Wilkins.Published by Philadelphia. 2003.pp
69,70,71,72,73,74

2. Burke .M Keren et al.Text Book of Medical Surgical Nursing in Critical

Thinking in Client Care, 4th edition.pp 1481,1482,1483.

3. Lewis’s, Medical Surgical Nursing “Assessment and Management of

Clinical Problems”.4th edition. Published by Elsevier. pp 900,920,921

4. Wilkins and Williams Lippincott’s “Review for Medical surgical

certification”. 5th edition, Published by J. Christopher Burghardt pp.83,84,85

5. Khurana S, Bose R, Wattas M, Malhotra S. Dietetics for you;PGIMER

Chandigarh.

6. www.ninindia.org/