NUTRITIONAL ASSESSMENT

1. Nutritional
Requirements in
Different Age
Groups

2. These groups are to be affected to a much greater
extent than the general population with nutritional
deficiency due to their physiological status, include:
Feeding of infants
Feeding of children
Feeding of mothers [pregnant and lactating].
Feeding of adolescence
Feeding of the elderly.
Energy requirement =BMR+ physical activity +TEF

3. The total calorie content of food can be measured by a
device called (Bomb Calorimeter). It is design to burn food
& the amount of energy produced per gram of protein, fat
or CHO by Bomb calorimeter are;
1 gm of protein = 4 Kcal
1gm of fat = 9 Kcal.
1gm of CHO = 4 Kcal.
1 gm of alcohol =7 Kcal (not nutrient)
The percentage of various nutrients to the total calories
intake;
Protein10-20% , fat 20-30%, CHO 50-60% of total calories
(or according to the food guide pyramid). The intake more
than two third of the R.I. of nutrients are considered
adequate.

4. Pre& periconceptional
nutrition in women
The fetus is most vulnerable to nutritional deficiencies in
1st
trimester of pregnancy , often before pregnancy.
Poor maternal nutrition has both immediate (LBW)& long
term consequences (CVD &type II D.M.)
Dietary changes can the mother made to giving birth to
a healthy infant; take folic acids supplements to protect
against neural tube defects, 400µg during preconception
until 12th
week of pregnancy, to prevent recurrence of
NTD 5000µg during preconception until 12th
week of
pregnancy.

5. Choose foods rich in folic acid; >100µg kale , spinach,
50-100µg fortified bread, cereals, broccoli, cauliflower , Chickpeas , lettus .

6. Maintain ideal wt. at preconception (3m. Before conception), obesity (BMI≥30) can
inhibit ovulation (associated changes in insulin activity,& its effect on hormone
activity), underwt. (BMI<18.5) at preconception can increase the risk of pre term
delivery &LBW.
Avoid excessive intake of retinol (β-carotene is not toxic), avoid vit.A supplements
(drugs or oint.), liver, sausage (8000-10000µg).
Giving up smoking& drinking alcohol.

7. Nutritional Requirements During Pregnancy &
Lactation
:
The RDA suggest increase during
pregnancy of all nutrients except
Vit. A, D, Ph, florid, with separate dietary recommendations for pregnant adolescent.
CHO requirements:
not less than 50-200 gm / day, to prevent ketosis &excessive protein breakdown.

8. Fats & Essential fatty acids
requirements:
Maternal fat is accumulated primarily
during the 1st &2nd trimester & 3-5gm/ day of EFA required for lactation. Most of
the fat in fetal organs such as liver &brain contain a high proportion of
phospholipids that require long- chain Poly Unsaturated FA that are derived from
linolenic W6& linolenic acid W3 . 4.5% of caloric intake in form of EFA is
recommended during pregnancy.

9. Caffeine:
It can pass rapidly crosses the human placenta & enters the fetal circulation.
The fetus & neonate appear to lake the enzymes that necessary to
demethylate the caffeine. It is present in high concentration in coffee(45-
155mg/cup), in tea(9-50mg/cup), cola(30-65mg/cup). Soft beverages
not more than
300mg/day or 2 cups.

10. Vit. & mineral supplements:
Try to obtain nutrients from a balanced diet (Eatwell plate), &advice her
against taking high dose multivitamin & minerals supplements.
* folic acid 400µg/d.
*Iron supplementation.

11. FACTS:
Folic Acid supplementation is recommended even prior
to conception.
Adolescent pregnant more prevalent to an iron
deficiency
A woman who enters pregnancy malnourished, with
limited nutrient stores, is more likely to have a low-
birth-weight infant who may continue with retarded
growth during childhood.
Malnutrition during 1st
trimester this stage can cause
irreversible damage to brain and spinal cord, heart,
liver, kidneys, etc.

12. Sweet should consume in moderation to avoid excessive weight gain.
A woman who enters pregnancy weighing >20% of her ideal body weight for
her height is at a higher risk for gestational diabetes & hypertensive disorders.
Pregnancy is NOT the time to reduce extra wt.

13. Changes in the daily Food Guide pyramid during pregnancy & lactation:
Non pregnant pregnant or adolescent preg.
lactating & lactating
*Milk group 2-3 servings 3-4 servings 5 servings
*Meat group 2-3 servings 3-4 servings 4 =
*Fruits 2-4 servings 2-4 servings (1-2 citrus)
*vegetables 3-5 servings 3-5 servings (1-2 green leafy
vegetables)
*Bread group 6-11 servings 7-11 servings

14. RDA during pregnancy & lactation
:
Adult women Pregnant Lactating
Energy (kcal) 2200 2500 2700
Protein (gm) 50 60 65
Vit.A (IU) 800 800 800
Vit. D (IU) 5 5 5
Vit.E (mg) 8 10 12
Vit.C (mg) 60 70 95
Folate (µg) 180 600-800 600-800
Ca (mg) 800-1000 1200 1200
Ph (mg) 700 700 700
Fe (mg) 15 30 30
Zn (mg) 12 15 19
I (mg) 150 175 200
Se (mg) 55 65 65
Moderate fat intake.

15. Problems During Pregnancy
Hyperemesis Gravidarum:
Severe & unrelenting vomiting in the 2nd trimester &may
severely interferes with mother’s life.
A serious condition usually requires i.v. replacement of fluids
& nutrients.
*There are no specific foods to avoid, but there may be some
benefit to eat small ,frequent meals
*Drink fluids between rather than with the meals.
*Avoid fried & greasy foods.
*Reduce coffee intake.
*Dry toast or crackers eaten before getting out of bed may
reduce nausea.
*Prepare meals near the windows to avoid cooking odors.

16. Constipation &hemorrhoids:
–advice to eat whole bran bread & cereals, eat
high fiber foods.
– drink at least 8 glasses of water/day.
– exercise regularly.
Heartburn
– relax and eat slowly
– eat small, frequent meals
– drink liquids between meals (in order to avoid increasing stomach pouch size & pressu
on lower esophageal sphincter).

17. Preeclampsia= Pregnancy Induced Hypertension PIH:
Sudden rise in arterial B.P. accompanied by rapid
weight gain & marked edema during pregnancy,
after 28 weeks of gestation.
PIT may occur in 5-15% of all pregnancies & is one of
the leading causes of prematurity & maternal & fetal
death.
Nutrition support during PIH includes provision of
a well-balanced diet;
protein replacement
adequate vitamins &minerals
sufficient energy intake

18. moderate sodium intake <2000mg/day (1 tea spoon)
Ca supplements
Linolenic acid = omega-3 f.a. (fish oil) suggested as preventive.

19. Nutrition during lactation:
To produce sufficient milk the mother has to eat a well
balanced diet with special emphasis on critical nutrients;
Ca, Fe, water sol. Vit., with a very Little alteration in the
normal diet.
The milk volume produced /day 550-850ml/d
More water& fluids intake8-10cups/d(additional700ml).
Avoid caffeine leads to infant hyperactivity &sleeplessness.
Avoid spicy foods.

20. Impact of nutrition status of lactating mother on
composition of milk:
Adequately nourished mother: composition is more or
less unchanged[ hind milk, however, is of more fat and
protein content than fore milk]
Inadequate nutrition is mild/ moderate: quantity of milk
may be somewhat affected while composition is not,
due to physiological adaptation, with depletion of
mother.
Sever malnutrition: both quantity and quality of
secreted milk are affected.

21. Lactation Effects:
It may be a good time for over weight mother to lose weight. By moderate
dietary restriction &ensuring
the availability of adequate amounts
of essential nutrient. Lactation minimizes
postpartum blood loss &helps to restore the uterus to its pre pregnancy
state sooner..

22. II] Advantages to BF to mother:
•Post partum value: suckling stimulates secretion of oxytocin that causes
contraction of the uterus and enhances involution of uterus.
•Lower risk of breast cancer.
•Psychological/ emotional value.
•Fertility regulation: exclusive breast feeding suppresses ovarian activity and
post partum ovulation, and is thus associated with lactation amenorrhea.

23. Nutritional Requirements During infancy
:
For the 1st 6ms of life; exclusive breast feeding,
as often the child wants day &night, at least 8x/d.
Energy requirement: up to 120Kcal/kg/day,
(both breast milk & formula provide 67Kcal/100ml)
Protein requirement: 2-2.5gm/kg /day
(35% of total caloric intake).
CHO : 50% of total calories.
Amylase enzyme which digest starch is low during
1st
4-6m of life, (starchy foods should be avoided).
Major CHO source is lactose which incr. absorption of dietary
Ca &Mg (decr. PH of intestinal content).

24. Lipids: play a role in absorption of
fat sol. Vit.& as a source of E.F.A.,
milk provides E.F.A. &long chain
PUFA. Infant formula containing
Only 2% of total EFA. Growth monitoring is important.
Vitamins& minerals:
*Vitamin K is routinely administered 0.5-1mg i.m. or oral to
protect them against hemorrhagic diseases .
*Vit. D; in exclusive B.F. infant, & adequate exposure to
sunlight there is no need for vit D supplementation during 1st
6m. If no sunlight exposure 10µg/day vit.D
supplementation = 400IU.

25. *Iron store can last up to the age of 6m to start
complementary feeding.
Oral dose of 1mg/kg/d as prophylactic.
*V.A 50 000IU-100 000IU with measles vaccine.
*Fluoride for teeth growth (from diet or fortified water
=fluoridated).
Water: 1.5ml/ Kcal, under ordinary circumstances breast milk
supply sufficient water &
no need for extra water.
Can only give other foods if:
-The infant not gaining wt.
-Appear hungry after breast feeding.
Given 1-2x/d after B.F.( one or more of food listed under 6-
12m.)

26. Breast milk contains all of the vitamins and minerals
that an infant needs (but is low in vit D, so may need
to supplement).
– carbohydrates, proteins, fats are
already predigested for absorption.
– breast milk is very high in omega-3 fats.
– the iron, zinc, and magnesium in breast milk is
highly absorbable.
– breast milk is low in sodium.
– the Calcium to Phosphorus ratio is 2:1, so calcium
absorption is enhanced.

27. If breastfeeding is not possible, an iron fortified infant
formula should be used to prevent iron deficiency
anemia.
Cow’s milk is not recommended because:
– Protein is poorly digested in newborns and can
cause GI upset.
– Too high in sodium.
– Very low in iron and vit C.
– Can cause failure to thrive because
of the overall lack of nutrients
in cow’s milk.

29. Complementary feeding:
For the past few decades there has
been a trend towards earlier
introduction of solid foods, often after
4-6wks of life. While the current recommendation
is to delay until 6ms of age.
Addition of semisolid foods is desirable, which provide
iron & other nutrients esp. vit. C. Start with iron
fortified cereals. Each type should be given separately
for about week to avoid allergy or intolerance. Rice is
the best cereals to begin with (less likely cause allergy).
Fruits & vegetables are added next. No need to add
sugar or salt at the beginning.

30. 6-12m.:
•Breastfeed as the child wants.
•Give adequate servings of:
*Thick porridge made of rice, potato, milk with starch
can add sugar & oil or sesame oil after 8th month.
*Mixture of mashed foods; rice or potato with green
vegetables, beans, chicken, red meat, & finally fish.
•Give 3 meals /d if breastfed.
•Give 5 meals/d if not breastfed.
•Give nutritious snacks between meals like egg, banana or
bread after 8th
m.
•Allergy Foods: peanuts , seafood, cow milk, egg.

31. Regular monitoring of wt. &ht./1 m. during 1st
y. of life,
&/ 2m. During 2nd
y. of life.
Adverse reactions to food:
* Milk allergy: incidence of cow’s milk protein allergy1-
3% in bottle-fed babies. Breast milk is ideal, also soy
protein milk appear to be tolerated by most of infants.
* Wheat allergy = celiac disease: sensitivity to gluten (in
wheat , barley , rye & oats) asymptomatic until 6m. of
age.

32. *Lactose intolerance=Lactase enz. Def.
disaccharide lactose hydrolyzed to glucose & galactose
by lactase enz., either;
Genetic (inborn error) or acquired condition( following diarrhea of any
cause). It is temporary state & reversible, temporary elimination of all
lactose containing
foods.

33. 1-2y.:
*Breastfeed as often as the child wants.
*Give adequate servings of; Family foods,
mixture of mashed foods of rice,
potato, cereals, with meat----, beans,
+green vegetables, carrots+ add
sugar &oil mixed with milk.
*Give 3 meals/d +2 snacks.
*Encourage to eat.
2y. & older:
*Family foods 3 meals/d +2 nutritious snacks.
*Encourage to eat.

35. Nutrition during childhood:
The growth during 1st year (especially 1st
4m)
of life is very rapid( 3x BW &50% incr. B. Ht.),
but after 12m the speed growth is decrease.
Prior to adolescence there is little difference in yearly height
increment betw. both sexes, but boys wt. more than girls until
about 11-13y when girls wt. is more.
Energy & protein:
The needs vary according to the age, body size (Ht.& wt.) &
physiological activities (about 15-20% of school age children are
overweight).
Age total Cal. Cal/kg total protein protein/kg
1-3y 1300 102 16gm 1.2gm
4-6y 1800 90 24gm 1.1gm
7-10y 2000 70 28gm 1gm

36. Minerals & vitamins:
Preschool children are at risk for development of IDA. Attention to good sources of
iron foods.
Calcium should be adequate for bone mineralization & growth maintenance
(adequate milk & dairy products intake).
Child should learn good food pattern during this period.
Careful assessment of growth is important for early diagnosis of malnutrition.

37. Common Nutrition Related
Problems Among Children:
Obesity; 1 in 4 children and 1 in 4
adolescents are now classified as obese.
Prevalence has increased 50% in children in last 10years.
Deal with weight gain through growth, do not put child on a
weight loss diet; have child maintain current weight while he
grows taller.
Dental caries
Iron deficiency anemia
Hyperactivity due to lack of regular
meals & caffeinated beverages.

38. Nutrition During adolescence:
Adolescent is a period between the onset
of puberty & adulthood(10-20y).
Puberty is anabolic period with incr. in Ht.
&wt., a growth spurt is experienced by
every organ system in the body with the exception
of lymphoid system& CNS which remain stable.
Rapid growth for girls betw. 10-13y & for boys 12-
15y (last for 3y.).
Nutrient needs are greatest during the pubescent
growth spurt & gradually decrease as individual
achieve physical maturity.

39. The nutritional needs of males and females of the same age differ little in
childhood but diverge after the onset of the pubertal growth spurt.
After puberty, the differences in nutrient needs persist.

40. Energy & protein:
Age total Cal Cal/kg total protein
Boys 11-14y 2500 55 45gm
15-18y 3000 45 59gm
19-24y 2900 40 56gm
Girls 11-14y 2200 47 46gm
15-18y 2200 40 44gm
19-24y 2200 38 46gm

41. Vitamins & minerals:
All are needed in increased amount in proportion to
energy requirements.
Calcium, iron, zinc, are needed during growth spurt ;
Ca RDA 1200mg/d (from dairy foods =4 cups/d).
Fe RDA 12mg/d for male &15mg/d for female.
Zn RDA 15mg/d for male &12mg/d for female is
necessary for growth & sexual maturity (from meat, sea
foods, eggs,& milk).

42. Nutritional Needs During Adolescence:
Energy requirements begin to differ between males
and females beginning in adolescence, males have
higher kcal requirements due to increased muscle
mass.
• Body composition of females differ from males higher
body fat composition at onset of menstruation.
• Kcal needs are based on body composition (height
and weight), age, and physical activity.

43. Follow the Adult Food Guide Pyramid
• Snacks should be nutrient-dense
• Balance fast foods with fruits &vegetables high in fiber
• Do not skip breakfast
• Consume plenty of lean meats to increase iron and protein consumption
Consume at least 4 cups of low-fat milk to meet calcium requirements

44. • Encourage healthy eating habits and lifestyle,
to prevent adult onset of diseases related to nutrition e.g
.,cardiovascular diseases, diabetes, osteoporosis and
cancer.
Common Nutrition Related Problems During
Adolescence:
• Obesity 1 in 5.
• Eating Disorders.
• Dental Caries.
• Iron deficiency anemia seen
in adolescent girls.
• Calcium deficiency decrease in bone size.

45. Nutrition & Aging:
Aging is a complex biological process,
normal, progressive& irreversible
phenomenon throughout adult life & is
associated with incr. prevalence of chronic
diseases or degenerative conditions
eg. CVD, H.T., D.M., cancer, obesity, & osteoporosis. Elderly
form 10-12% of population.

46. The process of aging begins with the cessation of growth & development & the
changes that occur in body composition, organ function & physical
performance.
There is a general variability from person to person& even within individuals
when various organs may age at different rates.

47. Epidemiological & social aspects of
ageing
:
There are an estimated 605 million older persons, i.e.
age 60 and over, in the world today, nearly 400 million
of whom live in low-income countries.
Older persons currently represent around 20% of the
total population and the proportion is expected to
increase to 29% by 2025.
Women today have lower mortality than men do in
every age group& for most causes of death.

48. Older persons are vulnerable to protein-energy
malnutrition (PEM), which is one of the main public
health problems in most low-income tropical and
subtropical countries with predominantly rural
populations.

49. Factors affecting nutrition status:
Physiologic changes:
Decline in total body K & N as age advances which is
indicative of a decr. In total body cell mass & skeletal
muscle.
Decline in lean body mass with concomitant incr. in total
body fat with same body wt., & centralized shift of s.c.
fat from the limbs to the trunk.
Total body water is decr. Which is significant for
detoxified metabolites &thermal regulation.
Reduction of organs function& wt.; kidneys, lungs, liver,
bone 12% in male & 25% in women.

50. Mal absorption &GI disorders:
The efficiency of digestion &absorption of nutrients is
affected due to reduced level of some enzymes.
Metabolism:
Decr. In BMR about 20% between 30-90y. decr. of
vit. D precursor with decr. Ca. absorption. Also a
progressive impairment of CHO intolerance.
Diseases: CVD, DM, HT& Cancer all may modify nutrient
requirements.
Other factors: Disability, inadequate or
improperly fitted dentures, poverty, social
& personal problems all affect nutritional status.

51. Nutrient Requirements
:
Energy:
A progressive decline in lean body mass, along with
depressed physical activity, causes a reduction of
energy needs in aged compared to younger
individuals.
For ages 51-75y, energy allowances decrease to
about 90% of the amount for young
adult( reduction of 300Cal/d for men & 200Cal/d
for women.
For person over 75y, there is a further reduction to
about 75-80% of energy consumed by young adult (
progressive decrease of voluntary intake of
energy).

52. Protein:
It is necessary to maintain nitrogen balance in elderly because of possible
decrease in the efficiency of digestion, absorption, & utilization of dietary
protein

53. some feel that the need for protein is more in aged
population; however because of the decreased
skeletal muscle mass the loss of daily total body
protein is less so the need for protein may be less
than younger adult 12-14% of total energy intake.
Other macronutrients:
*Daily consumption of 15-25gm fat( to ensure a
source of EFA & carrier of fat sol. Vit.).
.

54. *There is no RDA for CHO but not < 50-100gm /d of total
caloric intake with the inclusion of more complex CHO
&less refined sugar.
*Dietary fiber serves an important function in
intestinal tract by promoting the elimination of waste
products moderate intake of dietary fiber (20-35g/d)
from fruits, veg., & whole grains, & not rely on laxatives

55. Micronutrients:
For most of nutrients, the needs for elderly are the same
except for thiamine& riboflavin which are expressed in term of
total caloric intake.
The need for vit. D higher because of the reduction capacity
of their skin to produce 7-dehydro cholesterol ( precursor to
convert inactive form to active one)+ their limited exposure to
sunlight.
Efficiency of calcium absorption is decr. With age
osteoporosis advisable to take 1200mg
cal./d +daily use of multivitamin
mineral supplements.

56. • Encourage to eat several (5–6) small non-fatty
meals. This pattern appears to be associated with
greater food variety and lower body fat & lower
blood glucose and lipid levels, especially if larger
meals are eaten early in the day.
• Be physically active on a regular basis and include
exercises that strengthen muscles and improve
balance.

57. • Avoid dehydration by regularly consuming, especially in warm climates, fluids
and foods with a high water content. 30 ml/kg of water/d
at least 1500 ml of fluid per day.

58. Nutritional Assessment
Nutritional Assessment

59. Outlines

60. Learning Outcomes
 Discuss essential components and purposes of nutritional
assessment and nutritional screening.
 Identify developmental nutritional considerations.
 Identify factors influencing nutrition.
 Identify anthropometric measures.
 Identify risk factors and clinical signs of malnutrition.
 Describe nursing interventions to promote optimal
nutrition.
 Plan, implement, and evaluate nursing care associated
with nursing diagnoses related to nutritional problems.
At the end of this lecture the students
should be able to:

61. Defining nutritional status:
Refers to the degree of balance between nutrient
intake and nutrient requirement.
This balance is affected by many factors , including
physiologic, psychical, developmental, cultural, and
economic.

62.  Optimal nutrition : sufficient nutrients are
consumed to support day to day body needs and any increased metabolic
demands . (growth , illness , pregnancy ).
 Undernutrition: Nutrient intake is inadequate to meet
day to day need or add metabolic demand .
 Vulnerable groups: infants, pregnant women, low incomes, hospitalized people,
aging adults.
 This group are at risk for impaired growth and development, lowered
resistance to infection and disease, delay wound healing, longer hospital stays,
and higher health care costs.
 Overnutrition: consumption of nutrient in excess
of body need .
 A major nutritional problem today: can lead to obesity and it’s risk for
heart disease, type 2 DM, HTN, stroke, GB disease, sleep apnea, and
osteoarthritis.

63. Developmental care
Infants and children:
(Birth-4month) most rapid period of growth in the life cycle.
The infant double birth weight by 4 month and triple by 1 year .
Breastfeeding is recommended for full-term infants for the 1st
year of life because breast milk is ideally formulated to promote
normal infant growth and development and natural immunity.
Infants increase their length by 50% during the first year of life
and double it by 4 years of age.

64.  Adolescence:
 characterized by rapid physical growth and endocrine and
hormonal change.
 Calorie and protein requirement increase to meet this demand ,
and because of bone growth and increasing muscle mass and in
the girls the onset of menarche calcium and iron requirement
increased.
 In general, boys grow taller and have less body fat than girls.

65. Adulthood:
 growth and nutrient needs stabilize, most adult are relatively good
health.
 This time is important for health education because life style
factor such as smoking ,alcohol ,stress, lack of exercise , diet high in
fat ,sugar ,and low in fiber result this factor the adult high risk
for HTN, DM, obesity, atherosclerosis, cancer, and osteoporosis .

66.  The aging adult:
 Older adults have increased risk for undernutrition or
overnutrition.
 Risk factor: poor physical or mental health, social isolation,
limited functional ability, poverty, and disease.
 Normal physiologic changes that directly affect nutritional
status: Poor dentition, Decreased visual acuity, Decreased saliva
production, Slowed gastrointestinal absorption, Diminished
olfactory and taste sensitivity

67. Nutritional Assessment:-
a comprehensive analysis of a person's nutrition status that uses
historical information , food intake data , anthropometric
measurements , physical examination & biochemical data.

68. Purposes and components of
nutritional assessment.
Purposes:
1.Identify individuals who are malnourished or are at
risk for developing malnutrition.
2.Provide data for designing a nutrition plan of care to
prevent or minimize development malnutrition.
3.Establish baseline data for evaluating the efficacy of
nutritional care.

69. Nutrition screening :
 The first step in assessing nutritional status , is required for all
patients in all health care setting within 24 hours of
admission.
 Parameters used for nutrition screening typically include weight
and height history, conditions associated with increased nutritional
risk, diet information and routine laboratory data.
 Varity of valid tools are available for screening different
populations e.g.:
 Malnutrition screening tool (MST): adult acute care patient.
 Mini nutritional assessment (MNA): older adult long-term care.

70. Score of 2 or more= patient at risk for malnutrition.

71. Individuals at nutritional risk during
screening should undergo
Comprehensive nutritional
assessment which includes :
dietary history and clinical
information.
physical examination for clinical sign .
anthropometric measures .
laboratory test .

73. Methods for collecting current
dietary intake information:
 24-hour recall: Is a guided interview in which an individual recounts all of
the food & beverages consumed in the past 24 hours or during the previous
day.
Food frequency questionnaire: A survey of food routinely consumed
Food diaries: A detailed log (record of events) of food eaten during a
specified time period , usually several days.
Direct observation: Just by observing
food intake of the individual directly
in a facility.

74. Process of Nutritional
assessment

75. Assessment
Subjective data:
Examiner asks:
1.Eating patterns :number of meal ,Kind, amount,
preference, where is eaten, religious and cultural restriction, able to
feed self.
2.Usual weight.
3.Changes in appetite, teste ,smell, chewing,
swallowing.
4.Recent surgery, trauma, burns, infection.
5.Family history and chronic illnesses: (e.g.
obesity, GI disorder, DM, HTN,CANCER.)

76. 6. nausea, vomiting, diarrhea, constipation.
7.Food allergies or intolerance.
8.Medication and/or supplements.
9.Self care behaviors :who meal preparation
Environment during meal time
10. Exercise and activity patterns.

77. Additional history

Infants and children: (obtain from caregiver)
 gestational nutrition : infant birth weight, any delayed in physical
or mental growth.
 infant breast fed or bottle fed .
 Child’s willingness to eat what you prepare.
 Overweight and obesity risk factor.

78. Adolescent:
Your present weight
(what would you like to Wt., feel about your
Wt.)
Use of anabolic steroid or other agent to
increase muscle size .
Overweight and obesity risk factor.
(amount, time, where, type, skipped meals..)
Age first started menstruating .
?

79. Pregnant women:
 Number of pregnancies.
(how many, problems, take vitamins or supplements)
 Food preferences when pregnant.
(preferred, avoid, crave any particular foods)

80. aging adult:
 Any diet differences from when you were in your 40s and 50s?
(why, what factor affect: note physiologic or psychological
changes or socioeconomic changes)
 Review the mini notional assessment tool.
 Food changes past 3months
 Weight lose past 3months
 Mobility
 Psychological stress or acute disease past 3months
 Neuropsychological problems
 BMI

81. General appearance: provide clues to overall nutritional status.
(obese, cachectic (fat and muscle wasting), or edematous)

Review physical assessment findings for
signs of poor nutrition.

Equipment needed:

Pen or pencil.

Nutritional assessment data form.

Anthropometer.

chair or bed scale, tape measure
Objectivedata

82. Physical examination
Physical examination
Physical examination can help the assessor detect signs of
nutrition deficiency and fluid imbalances.
Clinical signs of malnutrition: signs of malnutrition tends
to appear most often in parts of the body where cells
replacement occurs at rapid rate such as:
eyes hair skin tongue
nails
lips

83. EVALUATING NUTRITIONAL DISORDERS
Body system
or region
Sign or symptom Implications
General • Weakness and
fatigue
• Anemia or electrolyte imbalance
• Weight loss • Decreased calorie intake, increased
calorie use, or inadequate nutrient
intake or absorption
Skin, hair,
and nails
• Dry, flaky skin • Vitamin A, vitamin B-complex, or
linoleic acid deficiency
• Dry skin with poor
turgor
• Dehydration
• Rough, scaly skin
with bumps
• Vitamin A deficiency
• Petechiae or
ecchymoses
• Vitamin C or K deficiency
• Sore that won't heal • Protein, vitamin C, or zinc deficiency
• Thinning, dry hair • Protein deficiency
• Spoon-shaped,
brittle, or ridged
nails
• Iron deficiency

84. Eyes • Night blindness; corneal
swelling, softening, or
dryness; Bitot's spots (gray
triangular patches on the
conjunctiva)
• Vitamin A deficiency
• Red conjunctiva • Riboflavin deficiency
Throat and
mouth
• Cracks at the corner of the
mouth
• Riboflavin or niacin
deficiency
• Magenta tongue
• Beefy red tongue
• Riboflavin deficiency
• Vitamin B12 deficiency
• Soft, spongy, bleeding gums • Vitamin C deficiency
• Poor dentition • Overconsumption of refined
sugars or acidic carbonated
beverages; illicit drug use15
• Swollen neck (goiter) • Iodine deficiency
Cardiovascular • Edema
• Third and fourth heart sounds
• Shortness of breath
• Cough
• Protein deficiency, thiamine
deficiency
• Tachycardia, murmur,
hypotension
• Fluid volume deficit; anemia

85. GI • Ascites • Protein deficiency
Musculoskeletal • Bone pain and bow
leg
• Vitamin D or calcium deficiency
• Muscle wasting • Protein, carbohydrate, and fat
deficiency
Neurologic • Altered mental
status
• Ataxia
• Dehydration and thiamine or vitamin
B12 deficiency
• Paresthesia,
neuropathies
• Vitamin B12, pyridoxine, thiamine, or
niacin deficiency
Mueller, C., et al. (2011). A.S.P.E.N. clinical guidelines: Nutrition screening, assessment, and
intervention in adults. Journal of Parenteral and Enteral Nutrition, 35, 16–24.

86. Anthropometric measures
Measures evaluate growth, development, and body composition.
 most common anthropometric measures:
Height or length.
Weight.
Arm and head circumference.
Waist circumference.
Body mass index.
Triceps skin-fold thickness.
Elbow breadth.

87. A. Derived weight measures:
(used to depict change in body weight)
 Body weight as a Percent ideal body weight: is the
optimal weight recommended for optimal health
Percent ideal body weight =current wt./ideal wt.*100
(If the result 80% -90% mild malnutrition . 70%- 80% moderate
malnutrition . Less than 70% sever malnutrition) .
 percent usual body weight :
Percent usual body weight = current wt. /usual wt. *100 .
(If the result 85% -95% mild malnutrition , 75%-84% moderate mal
nutrition ,less than 75 % sever malnutrition)
 recent weight change is calculated by :
Usual wt. – current wt. /usual wt. *100 .
(An unintentional loss of >5% of body wt. over 1 month , or > 7.5 % over 3
month , or 10 % over 6 month is clinically significant)

89. B. Body mass index:
practical marker of optimal weight for height and indicator
of obesity or under nutrition.

90. C. waist-hip ratio:
To assess body fat distribution .
1.0 or more in men the person is obese .
If the women .8 or more the women is obese

91. D. Skin fold thickness:
measurements provide an estimate of body fat stores or the
extent of obesity or under nutrition.(biceps, subcapsular,
suprailiac skinfolds).

92. TSF values 10 % below or above standard suggest undernutrition or
overnutrition .

93. E. Mid-upper arm circumference (MAC):
estimates skeletal muscle mass and fat stores.
Example: the normal MAC for 20years old female range from 23-
34.5 cm, and male range from 27.2-37.2 cm.
 difficult to obtain and interpret in older adult because of
sagging skin ,changes in fat distribution ,and declining
muscle mass.

95. Arm span or total arm length :
measurement arm span is useful those situation in which height is
difficult to measure.(children with cerebral palsy, scoliosis or in aging
person)
Frame size
:
is calculated to determine appropriate range of
ideal body weight
.
Elbow breadth measure of skeletal breadth is
the most accurate method to determine frame
size
,

96. Developmental care:
infants, children, and adolescent:
Weight: during infancy, childhood, and adolescent, height and
weight should be measured at regular intervals ,because
longitudinal growth is one of the best indices of nutritional
status over time .
The pregnant women:
Weight: measure weight monthly up 30weeks gestation ,then
every 2weeks until the last month of pregnancy ,when weight
should be measured weekly .
The aging adult:
Height: with age declines in both men and women very slowly from
the early 30s. leading to an average2.9cm loss in men and 4.9cm loss
in women.

97. Laboratory studies
Important because it can detect preclinical nutritional deficiencies
and can be used to confirm subjective finding .
Glucose: plasma glucose level.
N(60-110 mg/dl), HBA1C
Hemoglobin. To detect iron deficiency anemia .(M:14-18) (F:12-16)
•Increase Dehydration.
•Decrease anemia.
Hematocrit : measure cell volume also an indicator of iron status (M:
37% -49% ) (F :36%to46% )
-low value indicate insufficient hemoglobin formation .
Cholesterol : To evaluate fat metabolism and to assess risk for CVD.
N(120-200) .200 -239 moderate risk , 240 or more high risk .

98.  Triglycerides: used to screen for hyperlipidemia and to determine the risk of CAD. N(<
150mg /dl).
 Serum proteins, Serum albumin : to measure of visceral protein status, Albumin is a better
indicator of long-term protein status. N(3.5-5.5 g/dl)
- low serum albumin level occur with protein calorie malnutrition, altered hydration status,
decrease liver function .
 Serum transferrin : Iron transport protein ,more sensitive indicator of visceral protein
status than albumen .
-Serum transferrin = (.8* total iron binding capacity ) -43
Normal result (170-250 mg/dl)
 Prealbumin: serve as a transport protein for thyroxine (T4) and retinol-binding
protein. N(15-25 mg/dl)
-elevated in renal dis., and reduce by surgery, trauma, burn, infection.

99.  C –Reactive protein :
a plasma protein marker of inflammatory status produced by the
liver is used to monitor metabolic stress .(trauma , surgery , burns)
and to determine when to begin nutritional support in critically ill
patients.
CRP is generally not detectable in the blood , when the CRP detectable are
associated with increased risk of atherosclerosis and may be seen in
other inflammatory condition .
NORMAL <0.1 mg/dl

100. • Related to nutritional problems:
– Imbalanced Nutrition: More Than Body Requirements RT high
fat and calorie intake , lack of exercise, knowledge deficit.
– Imbalanced Nutrition: Less Than Body Requirements
– Readiness for Enhanced Nutrition
– Risk for Imbalanced Nutrition: More Than Body Requirements
– Activity Intolerance
– Constipation RT inactivity and diet high in refined
carbohydrates.
– Low Self-Esteem
– Risk for Infection
Diagnosis

101. Desired Outcomes
• Maintain or restore optimal nutritional
status
• Promote healthy nutritional practices
• Prevent complications associated with
malnutrition
• Enhance activity tolerance.
• Decrease weight
• Regain specified weight
• Prevent infection.

102. Intervention and Evaluation
• Intervention selected to meet goals??
• Evaluation based upon criteria set in
outcomes??

103. Documentation
 Subjective:
no history of disease or surgery that would alter intake/ requirement, no
recent weight changes, no appetite change, socioeconomic history is
noncontributory, does not smoke or drink alcohol, not use illegal or
prescription drugs, no food allergies, sedentary life style, play football
twice per week.
objective:
• Inspection: no signs of nutrient deficiencies.
• Anthropometric: Ht. 165cm, current Wt. 60kg, usual Wt. 59.5, ideal
Wt. 59.2.
• Laboratory: HB, HCT, and albumin values.
 DX: Imbalanced Nutrition: More Than Body Requirements RT high
fat and calorie intake , lack of exercise, knowledge deficit.

104. ABNORMAL FINDINGS
malnutrition:
 Obesity.
 Marasmus (protein-calorie malnutrition).
 Kwashiorkor (protein malnutrition).
nutritional deficiencies:
 pellagra.
 Rickets.
 Follicular hyperkeratosis.
 Scorbutic gums.
Eating disorder
Anorexia nervosa.
bulimia nervosa.

105. Obesity:
Du to caloric excess, refers to weight more than 20% Ideal
body weight or BMI (30.0-30.9).
 The causes are complex and multifaceted:
 Genetic.
 Social.
 Cultural.
 Pathologic.
 Psychological.
 Physiologic.
 Is usually an imbalance of caloric intake
and Caloric expenditure.

106.  Clinical features: obese appearance.
 Anthropometric measures:
o Wt. > 120% standard for height.
o BMI > 30
o TRICEPS SKINFOLD > 10%
o Waist-to-hip ratio > 1.0 men , > 0.8 women
 Laboratory finding:
o Serum cholesterol 200mg/dl
o Serum triglycerides > 250mg/dl

107. Marasmus (protein-calorie malnutrition).
Is due to inadequate intake of protein and calories or Prolonged
starvation .
 condition Leading to Marasmus: Anorexia, bowel obstruction
,cancer cachexia ,and Choric illness .
 Marasmus is characterized by decreased anthropometric
measurers weight and subcutaneous fat and muscle wasting,
visceral protein level remain within normal range.
 Clinical feature : starved appearance .
 Anthropometric measures:
o Wt. ≤ 180% standard for height.
o TSF < 90% standard.
o Mid-upper arm muscle circumference ≤ 90% standard.

108. Kwashiorkor (protein malnutrition)
Is due to diets high in calories but that contain Little or no
protein, e.g.: low protein liquid diets ,fad diets ,and long term
use of dextrose-containing intravenous fluids.
 Individuals with kwashiorkor in contrast to those with
marasmus, have decreased visceral protein levels but generally
they have adequate anthropometric measures.
 These individuals may therefore
appear well nourished or even obese.

109.  Clinical features: well-nourished appearance edematous.
 Anthropometric measures : wt. >100%, TSF>100% standard.
 Lab test : albumen <3.5 g/dl , transferrin <150.

110. Abnormalities due to nutritional
deficiencies:
Pellagra
Pigmented keratotic scaling lesion resulting from a deficiency of niacin.
These lesion are especially prominent in areas exposed to the sun ,such as
hands ,forearms ,neck, and legs .

111. Follicular hyperkeratosis :
Dry, bumpy skin associated with vitamin A and or linoleic acid deficiency
(essential fatty acid ).

112. Scorbutic gums:
vitamin c deficiency. gums are swollen , ulcerated , and bleeding.

113. Rickets:
sign of vitamin d and calcium deficiencies in children and adult
(osteomalacia)

114. Eating disorder
Is a compulsion to eat, or avoid eating, that
negatively affects both one's physical and mental
health.
Anorexia nervosa and bulimia nervosa are the most
common.

115. Anorexia
People with anorexia have a real fear of weight gain and a
distorted view of their body size and shape. As a result, they
can't maintain a normal body weight. Many teens with anorexia
restrict their food intake by dieting, fasting, or excessive
exercise. They hardly eat at all — and the small amount of food
they do eat becomes an obsession.
Others with anorexia may start binge eating and purging —
eating a lot of food and then trying to get rid of the calories by
forcing themselves to vomit, using laxatives, or exercising
excessively, or some combination of these.

116. Bulimia
Bulimia is similar to anorexia. With bulimia, someone might
binge eat (eat to excess) and then try to compensate in
extreme ways, such as forced vomiting or excessive exercise,
to prevent weight gain. Over time, these steps can be
dangerous — both physically and emotionally. They can also
lead to compulsive behaviors.

117. Health promotion
Eat variety of food from all the basic food to ensure nutrient
adequacy .
Consume the recommended amounts of fruits /vegetables ,whole
grains, and fat-free or low-fat milk products or equivalent.
Limit intake of food high in saturated or trans fats, added sugar,
starch, cholesterol, salt, and alcohol.
Match calorie intake with calories expended.
Be physically active for at least 30minutes most every day of the
week or 45minutes every other day.
Follow food safety guidelines for handling , preparing and
storing foods.

118. Food Pyramids diagram representing the optimal
number of servings to be eaten each day from each of
the basic food groups
61

119. References
o JARVIS , C. (2008) Physical Examination & Health Assessment,
chapter11.
o FDA food safety: www.foodsaftey.com
o USDA food and nutrition information center: ww.nal.usda.gov
o American cancer society : www.cancer.org
o Center for disease control and prevention:
www.cdc.gov/nccdphp/dna/nutrition/index/htm
o http://www.primehealthchannel.com

120. Thank you for your patient listening and active
participation