Chapter 1 Nutrition in Nursing 2

Nutrition in Nursing
Chapter 1
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 1: Nutrition in Nursing
Learning Outcomes:
Upon completion of this chapter, you will be able to:
1. Compare nutrition screening to nutrition assessment.
2. Describe the components of nutrition care process.
3. Describe different food guides.
4. Conduct nutritional assessment given a certain client.
5. Integrate nutrition concepts to nursing interventions.
6. Utilize guidelines on provision of nutrition advice.
7. Describe the steps on how client teaching, monitoring and
evaluation of care is done.

What is Nutrition? ‫تعريف الغداء‬
“the science of food, the nutrients and the substances therein, their
action, interaction, and balance in relation to health and disease, and
the process by which the organism ingests, absorbs, transport, utilizes,
and excretes food substances”
The Council on Food and Nutrition of the American Medical Association
• In hospitals, nutrition may refer to the food requirements of patients,

including nutritional solutions delivered via an IV (intravenous) or IG
(intragastric) tube.
• an integral part of nursing care; like air, food is a basic
human need. ‫ يتجزأ من الرعاية التمريضية; مثل‬- ‫• جزء‬
.‫ الطعام أساسي حاجة بشرية‬,‫الهواء‬
Roles of Nurses in Nutrition Care
• screen hospitalized patients to identify those who are at
nutritional risk as part of admission process during
history and physical examination
• serve as the liaison between the dietitian and physician
as well as with other members of the health-care team
• may act as nutrition resource
• reinforce nutrition counseling provided by the dietitian
• may be responsible for basic nutrition education in
hospitalized clients with low to mild nutritional risk

Nutrition Care Process
• A problem-solving method that
dietetics professionals use to
evaluate and treat nutrition-
related problems
• It includes 4 steps:
– Screening nutrition
assessment
– Nutrition diagnosis
– Nutrition intervention
– Nutrition monitoring and
evaluation
‫الفحص الغذائي‬
Nutritional Screening
• Nutritional screen
– Quick look at a few variables to judge a

client’s relative risk for nutritional problems
– No accepted universal tool
– JCAHO mandates that screen must be done

within 24 hours of admission to the hospital.

Sample Tool
Note: Moderate to
high risk at
screening referred
to dietitian for
assessment

Nutritional Screening—(cont.)
• Comprehensive nutritional assessment ‫تقييم غذائي شامل‬
– Different from nursing care plan
‫اخصائي التغذية‬
o Dietitians can get most of information from
nursing admission assessment.
o Dietitians interview patients and/or families to
obtain a nutrition history.
– Helps to differentiate
o Nutrition problems caused by inadequate intake
from those caused by disease

Nutritional Screening—(cont.)
• Comprehensive nutritional assessment—(cont.)
– Dietitians
o Calculate estimated calorie and protein
requirements based on the assessment data
o Determine nutrition diagnoses that define the
nutritional problem, etiology, and signs and
symptoms
o May also determine the appropriate
malnutrition diagnosis
o Formulate nutrition interventions
Question
• Nutritional screening helps to differentiate

problems caused by inadequate intake from
those that are caused by
a. Malnutrition
b. Disease
c. Accident or injury
d. Chronic diseases

Integrating Nutrition
• Assessment
• collection and analysis of health-related information for
identifying specific problems and their underlying causes
– Data classified as ABCD
o Anthropometric ‫أنثروبومتري‬
o Biochemical ‫يوية‬.‫الكيمياء ا‬
o Clinical ‫السريري‬
o Dietary data ‫البيانات الغذائية‬
– Client’s medical–psychosocial history is also evaluated for
its impact on nutritional status.

Integrating Nutrition—(cont.)
• Anthropometric data
– Physical measurements of the body
– Body mass index
o ―Healthy‖ or ―normal‖ BMI is defined as 18.5
to 24.9.
o Above or below related to health risks
– ―Ideal‖ body weight
– Edema or dehydration skews accurate weight
measurements.
– Recent weight change
Anthropometric data: Ideal Body Weight
• Hamwi Method- universally used in clinical practice
• 1. ―Ideal‖ body weight (IBW) based on height:
– Men: 106 pounds for the first 5 feet of height and 6
pounds for each additional inch
– Women: 100 pounds for the first 5 feet of height and
5 pounds for each additional inch
Note: This method does not measure body fatness or

evaluates distribution of body fat, both of which
impact health risk.
Anthropometric data: Ideal Body Weight
• 2. Use current weight and ―ideal‖
weight to determine percent ideal
body weight:
>200% -morbid obesity
120–199% -obese
• %IBW = current weight × 100 110–119% -overweight
90–110% -within normal
ideal weight range
89–90% -mild malnutrition
70–79% -moderate
malnutrition
<69% -severe malnutrition

Anthropometric data: Body Mass Index
– an index of weight in relation to height

– BMI = weight (kg) ÷ height (m2)
– Actual measures should be used to
ensure accuracy and reliability
– a person can have a high BMI and still be
undernourished in one or more nutrients
if intake is unbalanced or if nutritional
needs are high and intake is inadequate.
Anthropometric data: Body Mass Index
BMI Interpretation
± 18.5 May health risk
18.5–24.9 healthy weight
25–29.9 overweight
30–34.9 obesity class 1
35–39.9 obesity class 2
≥ 40 obesity class 3

Anthropometric data: Waist Circumference
• Waist Circumference
– Recent evidence indicates that waist circumference
may be an acceptable alternative to BMI
measurement in some subpopulations
– location of excess body fat may be a more important
and reliable indicator of disease risk than the degree
of total body fatness
– men and postmenopausal women - store excess fat
in the upper body (abdominal area)
– premenopausal women tend to store excess fat in
the lower body (hips and thighs)
Anthropometric data: Waist Circumference
• People with a high distribution of abdominal

fat (i.e., ―apples‖) have a greater relative
health risk than people with excess fat in the
hips and thighs (i.e., ―pears‖)
• Abdominal Obesity
– Men- >40 in
– Women- > 35 in

Weight change
– a well-validated indicator of malnutrition (White et
al., 2012)
– reflective of chronic, not acute, changes in nutritional
status
– patient’s weight can be unreliable or invalid due to
hydration status (e.g. edema can falsely increase
weight)
– Significant unintentional weight loss is defined
according to the length of time over which the loss
occurred

Let’s practice!
A female client stands 5 feet 3 inches and weighs 63 kg.
Her waist circumference is 38 inches.
1. Calculate her ideal body weight in kilogram (kg) using
Hamwi method.
2. Calculate her BMI and interpret the finding.
3. Interpret the client’s waist circumference.

Let’s practice!
• A patient has been suffering from diarrhea for almost 2
months. His body weight last month is 88 kg. His
current weight is 82 kg.
1. Calculate for his % weight change.
2. Is the weight change significant? Explain.

• Biochemical data
– No single test is both sensitive and

specific for protein–calorie malnutrition.
– Biochemical data may help support the

diagnosis of a nutritional problem.

• Albumin
– Often used to assess protein status
– Serum levels may be maintained until malnutrition is
in a chronic stage.
– Low albumin may indirectly identify patients who may
benefit from nutrition assessment and intervention.
• Prealbumin ‫بروتي ملزم لهرمون‬-
– Thyroxin-binding protein ‫الغدة الدرقية‬
– More sensitive indicator of protein status ‫ مؤشر أكثر حساسية‬-
– More expensive to measure
‫@الة البروتي‬
‫ أكثر تكلفة للقياس‬-
‫سدية‬%‫مات وا*عراض ا‬/‫الع‬
• Clinical data
‫لسوء التغذية لوحظ ف العميل‬
– Physical signs and symptoms of malnutrition
observed in the client
– Most signs cannot be considered diagnostic.
– Physical signs and symptoms of malnutrition
can vary in intensity among population groups
because of genetic and environmental
differences.
– Physical findings occur only with overt
malnutrition.
Physical Signs and Symptoms of
Malnutrition
• Hair is dull, brittle, dry, • Muscle wasting

or falls out easily • Edema of lower
• Swollen glands of neck extremities
and cheeks • Weakened hand grasp
• Dry, rough, or spotty • Depressed mood
skin • Abnormal heart
• Poor or delayed wound rate/rhythm and BP
healing or sores • Enlarged liver or spleen
• Thin appearance with • Loss of balance and
lack of subcutaneous fat coordination
Question
• Is the following statement true or false?
Thyroid-binding protein is also called prealbumin.

Question
• Mrs. Kirk, age 75 years, was admitted to the long-
term care facility because she was found by her
children too weak to care for herself. What
assessment data would influence the nurse to
suspect possible malnutrition?
a. Brittle, dry hair and loss of reflexes
b. Weakened hand grasp and lack of subcutaneous
fat
c. Depressed mood and loss of sensation in
extremities
d. Abnormal BP and thin, wrinkled skin
• Dietary data
– Nurse should ask, ―Do you avoid any particular
foods?‖
– Nurse should not ask, ―Are you on a diet?‖
• Medical–psychosocial history
– May shed light on factors that influence intake,
nutritional requirements, or nutrition counseling

Factors that may be involved in the etiology of
illness-related malnutrition.

• Medication
– Both prescription and over-the-counter drugs have
the potential to affect and be affected by nutritional
status.
– At greatest risk for development of drug-induced
nutrient deficiencies include those who
o Habitually consume fewer calories and nutrients
than they need
o Have increased nutrient requirements including
infants, adolescents, and pregnant and lactating
women
o Are elderly
o Have chronic illnesses
• Medication—(cont.)
– At greatest risk for development of drug-induced
nutrient deficiencies include those who—(cont.)
o Take large numbers of drugs (five or more),
whether prescription drugs, over-the-counter
medications, or dietary supplements
o Are receiving long-term drug therapy
o Self-medicate
o Are substance abusers

• Nursing diagnosis
– Provide written documentation of the client’s status
– Serve as a framework for the plan of care that
follows
• Planning: client outcomes
– Outcomes, or goals, should be measurable,
attainable, specific, and client centered.
– Focus on the client, not the health-care provider.
– Keep in mind that the goal for all clients is to
consume adequate calories, protein, and nutrients
using foods they like and tolerate as appropriate.

Nursing Diagnoses with
Nutritional Significance
• Altered nutrition: more than body requirements
• Altered nutrition: less than body requirements
• Altered nutrition: risk for more than body
requirements
• Constipation
• Diarrhea
• Fluid volume excess
• Fluid volume deficit
Nursing Diagnoses with
Nutritional Significance—(cont.)
• Risk for aspiration
• Altered oral mucous membrane
• Altered dentition
• Impaired skin integrity
• Noncompliance
• Impaired swallowing
• Knowledge deficit
• Pain
• Nausea
• Nutrition concepts that could be

integrated to nursing interventions:
1. nutrition therapy
2. calculating estimated needs
3. estimating total energy expenditure
4. healthy eating guidelines
5. MyPlate
6. The Healthy Food Palm (Saudi)
7. client teaching
• Nursing interventions
– 1. Nutrition therapy
o Diet is a four-letter word with negative
connotations.
o Usually general suggestions to increase/
decrease, limit/avoid, reduce/encourage, or
modify/maintain aspects of the diet because
exact nutrient requirements are determined
on an individual basis.
o Nutrition theory does not always apply to
practice.
• 2. Calculating estimated needs
– A ―rule-of-thumb‖ method of estimating calorie
requirements:
– Multiply weight in kg by
• 30 cal/kg for most healthy adults
• 25 cal/kg for elderly adults
• 20–25 cal/kg for obese adults

Calculating estimated caloric needs

• Example: For an adult weighing 154 pounds:
– 154 pounds ÷ 2.2 kg/pound = 70 kg
– 70 kg x 30 cal/kg = 2100 cal/day

– A ―rule-of-thumb‖ method of estimating protein
requirements:
– Healthy adults need 0.8 g protein/kg
– Example: For an adult weighing 154 pounds:
• 154 pounds ÷ 2.2 kg/pound = 70 kg
• 70 kg x 0.8 g/kg = 56 g protein/day

Let’s practice!
• A healthy male adult weighs 60 kg.
1. Calculate the following:
 Calorie requirement
 Protein requirement

• 3. Calculating energy expenditure
– The body uses energy for involuntary activities and
purposeful PA.
– total of expenditures represents the number of
calories a person uses in a day.

Total Energy Expenditure: Terminologies
– Basal metabolism refers to the calories used to
conduct the involuntary activities of the body, such
as beating the heart and inflating the lungs.
– Total calorie expenditure = calories spent on basal
metabolism + physical activity (PA).
– Physical activity- voluntary muscular activity
– The thermic effect of food is the cost of digesting,
absorbing, and metabolizing food. At about 10% of
total calories consumed, it is a small part of total
energy requirements.
• 3. Calculating energy expenditure cont.
• Step 1. Estimate basal metabolic rate (BMR)

• Multiply your healthy weight (in pounds) by 10 for
women or 11 for men.
• If you are overweight, multiply by the average weight
within your healthy weight range
• _____ (weight in pounds) x __ = __calories for BMR
• Step 2. Estimate total calories according to usual

activity level
• Choose the category that describes your usual activities
and then multiply BMR by the appropriate percentage.

Activity Level Calories

Sedentary: mostly sitting, driving, sleeping, 20
standing, reading, typing, and other low-
intensity activities
Light activity: light exercise such as walking not 30
more than 2 hours/day
Moderate activity: moderate exercise such as 40
heavy housework, gardening, and very little
sitting
High activity: active in physical sports or a labor 50
intensive occupation such as construction work

• Step 3. Add BMR calories and physical activity

calories
• _______ calories for BMR +________ calories spent on
activity = ________ calories spent on involuntary and
physical activity

• Step 4. Add estimate of thermic effect of food

• _______ calories spent on involuntary and voluntary
activity + 10% for processing food = ________ total
calories expended daily

Let’s practice!
• Calculate the total energy expenditure of a female client
with healthy weight of 114 lbs and does moderate
activity.

• The state of energy balance is the relationship between the
amount of calories consumed and the amount of calories
expended.
• Note: Poor food choices and physical inactivity contribute to

the current state of energy imbalance

• 4. Dietary guidelines
• 1. Choose Nutrient-Dense, Not Calorie-Dense Items: food
and beverages that provide vitamins, minerals, and other
beneficial substances with relatively few calories.
Foods strongly associated with Foods inversely associated

weight gain (empty calorie foods) with weight gain
Potato chips Vegetables
Potatoes Whole grains
Sugar-sweetened beverages Fruits
Unprocessed red meats Nuts
Processed meats Yogurt

• 4. Dietary guidelines cont.
2. Eat only to relieve hunger
– Eating should not be used as a diversion from
boredom, loneliness, anxiety, or stress,
– eating only to the point of satisfaction, and not until
feeling ―stuffed‖
– eating slowly and not doing other things while eating,
such as watching television

3. Maintain a Consistent Eating Pattern
– Avoiding periods of hunger may help avoid bingeing
– Eat breakfast; there is inverse relationship between
the frequency of eating breakfast and the risk for
obesity and other chronic diseases such as type 2
diabetes.

4. Activity Choices: Move More, Sit Less
– Recommended exercises
• minimum of 2 hours and 30 minutes per week of
moderate-intensity aerobic activity
– Tips for increasing physical activity
• Find something enjoyable
• Start slowly and gradually increase activity
• Spread activity over the entire day if desired
• Move more
5. Right Portion Sizes
– telling people to remind themselves not to overeat is
not the answer; changing the environment that led
to large portion sizes is easier (e.g. switching to
smaller plates, bowls, and glasses, buying
smaller packages of food at the grocery store)

• 5. MyPlate
– replaced MyPyramid (in 2011) as the new graphic by
which the Dietary Guidelines are translated into food
choices
– Illustrates the 5 food groups that are the building
blocks for a healthy diet


6. Saudi
Palm Food
Guide

• Nursing interventions—(cont.)
– 7. Client teaching
– Provision of nutrition advice
– Patients in a clinical setting may be more
receptive to nutritional advice compared with
―well‖ clients especially if they feel better by
doing so or are fearful of a relapse or
complications.
– The patient’s ability to assimilate new
information may be compromised by pain,
medication, anxiety, or a distracting setting.

• Nursing interventions—(cont.)
– 7. Client teaching
– Ways to facilitate client and family teaching:
• Listen to the client’s concerns and ideas.
• Encourage family involvement if appropriate.
• Reinforce the importance of obtaining adequate
nutrition.
• Help the client to select appropriate foods.
• Counsel the client about drug–nutrient interactions.
• Advise the client to avoid foods that are not tolerated.

• Monitoring and evaluation
– Monitoring precedes evaluation as a way to stay on top of
progress or difficulties the client is experiencing.
– Monitoring suggestions:
• Observe intake whenever possible to judge the
adequacy
• Document appetite and take action when the client does
not eat.
• Assess tolerance (i.e., absence of side effects).
• Monitor weight.
– Evaluation assesses whether client outcomes were
achieved.
Next Topic
• Chapter 2. Carbohydrates
• Homework: Read Chapter 2: Carbohydrates

in your textbook.

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Nutrition in Nursing

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• In hospitals, nutrition may refer to the food requirements of patients,

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

– Quick look at a few variables to judge a

– No accepted universal tool

– JCAHO mandates that screen must be done

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Nutritional screening helps to differentiate

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Note: This method does not measure body fatness or

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

– an index of weight in relation to height

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• People with a high distribution of abdominal

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

– No single test is both sensitive and

– Biochemical data may help support the

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Hair is dull, brittle, dry, • Muscle wasting

• Is the following statement true or false?

Thyroid-binding protein is also called prealbumin.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Nutrition concepts that could be

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Calculating estimated caloric needs

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Step 1. Estimate basal metabolic rate (BMR)

• Step 2. Estimate total calories according to usual

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Activity Level Calories

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Step 3. Add BMR calories and physical activity

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Step 4. Add estimate of thermic effect of food

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Note: Poor food choices and physical inactivity contribute to

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Foods strongly associated with Foods inversely associated

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins