Chapter 13 – Nutrition Care and Assessment

Chapter Outline Instructor Resources

I. Nutrition in Health Care Correcting nutritional problems may improve outcomes of medical treatment and

help prevent complications Malnutrition is common in patients hospitalized with acute illnesses

A. How Illness Affects Nutrition Status1. Reduced food intake/decreased appetite2. Nausea3. Inflammation of mouth4. Medications can cause GI upset and anorexia5. Interferes with digestion & absorption6. Alters metabolism & excretion7. Pressure sores8. Dietary restrictions for some surgeries or chronic illnesses9. Drain on financial resources10. Unable to prepare food11. Emotional upset

B. Responsibility for Nutrition Care - Plans of care = “critical pathways”1. Physicians - Prescribe diet orders2. Nurses

a. Screen patientsb. Participate in nutrition assessmentsc. Provide direct nutrition cared. Member of the nutrition support team

3. Registered Dietitians - Food and nutrition expertsa. Provide medical nutrition therapyb. Assess nutrition status, diagnose nutrition problems, develop, implement,

& evaluate nutrition care plansc. Plan & approve menusd. Provide dietary counseling and nutrition educatione. May also manage food and cafeteria services

4. Registered Dietetic Technicians - Assist the registered dietitians5. Other Health Care Professionals - Team members include: pharmacists;

physical, occupational, & speech therapists; nursing assistants; home health care aides; & social workers

C. Identifying Risk for Malnutrition1. Nutrition screening

a. Identifies persons at risk for nutrition problemsb. Joint Commission recommends that it be done 24 hours after admissionc. Should be completed in 10-15 minutes

2. Screening includes:a. Admitting diagnosisb. Physical measurementsc. Lab reportsd. Information about diet and health status

3. Screening tool: Subjective Global Assessment4. Nursing diagnosis may identify need for nutrition intervention

D. The Nutrition Care Process - Used by registered dietitians1. Nutrition Assessment

a. Medical recordb. Physical examc. Laboratory analyses

d. Medical procedurese. Interview with patient or caregiverf. Consultation with other health professionals

2. Nutrition Diagnosisa. Actual or potentialb. Problem, etiology, signs & symptoms

3. Nutrition Interventiona. Dietary & lifestyle changesb. Nutrition counseling or educationc. Medication changesd. Goal stated in measurable outcomes

4. Nutrition Monitoring and Evaluationa. May need to modify the planb. Must be flexiblec. May need to include motivational techniques or additional education

II. Nutrition AssessmentA. Historical Information

1. Medical History - including family medical history2. Medication & Supplement History

a. Prescription drugsb. OTC medicationsc. Dietary supplements

3. Personal & Social Historya. Cultural backgroundb. Religious beliefsc. Financial concernsd. Who prepares and shops for foode. Living situationf. Use of tobacco or illegal drugs

4. Food & Nutrition Historya. Lifestyle habitsb. Allergiesc. Nutrition & health beliefs

B. Dietary Assessment1. The 24-Hour Dietary Recall

a. All foods & beveragesb. Time of day eatenc. Amounts consumedd. Food preparatione. Food models and measuring utensilsf. Multiple-pass methodg. Typical day?h. Does not address fluctuation in food intake & season

2. Food Frequency Questionnairea. Surveys foods and beverages regularly consumedb. Qualitative or semi-quantitative

3. Food Recorda. Recorded over several daysb. Recorded as consumedc. Does not rely on memoryd. Time consuminge. Must be highly motivatedf. Recording may influence intake

4. Direct Observation

a. Calorie countingb. Time consuming

C. Anthropometric Data = measures of body size1. Height (or Length)

a. Height: Adultsb. Length: Infants < 24 months = recumbent measurec. How to Measure Length and Height

2. Body Weighta. BMIb. % usual body weightc. % ideal body weight d. How to Measure Weighte. How to Estimate and Evaluate %UBW and %IBW

3. Head Circumferencea. Assesses brain developmentb. < 3 years of age

4. Circumferences of Waist and Limbsa. Waist circumference correlates with intra-abdominal body fatb. Arm, thigh, or calf circumference can help evaluates muscle mass

5. Anthropometric Assessment in Infants and Children - Growth patterns tracked using height or length, weight, head circumference plotted on growth charts

6. Anthropometric Assessment in Adults - Changes in body weight over time; %UBW & %IBW

D. Biochemical Analyses1. Introduction

a. Provides information about1. Protein-energy nutrition2. Vitamin & mineral status3. Fluid & electrolyte balance4. Organ functioning

b. Analysis of blood & urine samples2. Serum Proteins3. Albumin

a. Most abundantb. Slow to reflect changes in status

4. Transferrina. Transports ironb. Indicates PEM & iron statusc. Slow to detect changes in status

5. Prealbumin and Retinol-Binding Proteina. Also called transthyretinb. Responds quickly to changes in protein statusc. Expensive test

E. Physical Examination1. Clinical Signs of Malnutrition - hair, skin, GI tract (mouth, tongue)2. Hydration Status

a. Edema1. Often accompanies disorders of heart, kidney, liver, and lungs2. Weight gain3. Facial puffiness4. Swelling limbs5. Abdominal distention6. Tight-fitting shoes

b. Dehydration

1. Can result from vomiting, diarrhea, fever, sweating, excessive urination, blood loss, skin injuries, or burns

2. Symptomsa. Thirstb. Dry skin or mouthc. Reduced skin tensiond. Dark yellow or amber urine with low volume

3. Functional Assessmenta. Skin responses to antigensb. Muscle weakness/wastingc. Exercise tolerance

III. Nutrition in Practice - Nutritional Genomics Nutritional genomics: Study of dietary effects on gene expression Genome: the complete set of genetic information in our cells Dietary factors may affect people who have particular gene variations Genes can determine susceptibility to disease

A. What is a genome? - It is where genetic information is encodedB. How did research in nutritional genomics begin?

1. The Human Genome Project, which was completed in April 20032. Genetic differences may cause inherited disorders

C. How do nutrients alter gene expression? - A combination of dietary factors and hormones influence the types of transcription factors.

D. How much genetic variation is there among people? - Except for identical twins, no two individuals are genetically identical, but variation is as little as 0.1%.

E. What are some examples of single-gene disorders?1. PKU2. Cystic fibrosis3. Hemochromatosis4. Most are readily managed with simple dietary changes

F. How are multigene disorders different from single-gene disorders?1. Are sensitive to a number of environmental influences2. Tend to develop over many years3. Heart disease4. Blood cholesterol

G. Can genomic research be used to explore the differences in nutrient needs among people? - Yes; it may provide a means for fine-tuning nutrient recommendations.

H. Will knowledge about the human genome substantially change the manner in which health care is provided? - Perhaps, but disease risk will still be more dependent on lifestyle choices.

I. What ethical concerns are raised by having extensive knowledge about an individual’s genome?1. Confidentiality 2. May not be in the best interest of children