SCREENING and ASSESSMENT of THE NUTRITIONAL STATUS

▄ Nutritional Health – result of consistently meeting the body’s nutrient requirements - determine average nutritional requirements by published standards such as RDA or food guide pyramid - adequacy of a client’s diet = use a food diary and compare the nutritional intake with RDA - RDA - Food Guide Pyramid ▄ Malnutrition – a condition resulting from excessive or inadequate nutrient availability over an extended period. *starvation – inadequate delivery of nutrients to the body. Types: 1. Primary malnutrition – adequate nutrition is not delivered to the upper GIT over an extended period 2. Secondary malnutrition – occurs when GIT fails to absorb, metabolize or use nutrients 3. Mixed type malnutrition – inadequate calorie/protein intake with increased nutritional requirements Protein and Calorie Deficiency Malnutrition 1. Kwashiorkor – inadequate protein intake but with adequate calorie intake - moon-like flabby face, edema, body weight at above ideal range, visceral CHONs below normal 2. Marasmus – inadequate calorie and protein intake - BW and anthropometric appearance below normal, old man facie, cachectic appearance, visceral CHONs within normal * Micronutrient malnutrition – occurs when vitamins, minerals, trace elements are not absorbed, delivered or used by GIT - vitamins, minerals, trace elements deficits occur in combination. It is difficult to identify deficit of single micronutrient *Obesity – may result from nutrient delivery that exceeds the client’s nutritional requirement I. History taking ▄ Biographical and Demographic Data - analyze client’s demographic data within the context of nutritional status and upper GI function- women are at risk for problems r/t calcium deficiency - culture, religion and ethnic origin may also affect the type, amount and frequency of dietary consumption ▄ Chief complaints (n/v, indigestion, abdo pain, diarrhea, changes in weight or appetite) -clinical manifestations that are related to nutritional status and upper GI function -do symptom analysis ▄ Symptom analysis a. nausea and vomiting – onset, duration, aggravating factors - characteristic of vomitus = amount, color = does the vomitus contains bile or undigested food? - pain with n/v b. indigestion – RT food intake, which food worsen or relieve the manifestations? -medications- (antacids) - description- burning or burping c. abdominal pain – PQRST -associated manifestations- fever – increased or relieved with movement? Does food exacerbate pain? Sources and Characteristics of Abdominal Pain a. Intestinal obstruction – distended abdomen, no bowel movements or flatus - intermittent or colicky pain - RUQ pain radiating to shoulder (associated with gall bladder) - pain near umbilicus (associated with small bowel) - lumbar pain ((associated with colon) b. Peritoneal inflammation – (perforated ulcer, ruptured spleen, ruptured appendix) - steady aching pain over area of inflammation - pain increasing with motion - intensity of pain varying with source of inflammation (gastric acid may produce more pain than alkaline content of small bowel) - sometimes associated with manifestation of shock c. Vascular obstruction – may be preceeded by 2-3 days of mild-moderate pain and hyperperistalsis, folwed by severe abdominal pain and manifestations of shock. d. weight and appetite changes – determine usual appetite and weight - amt of weight loss or weight gain- diet- -causes

e. diarrhea –color amount - how many stools expelled per day?how much? Consistency- liquid or solid? Color- back, tarry or bloody? -associated manifestations = pain, abdominal cramping or bloating, time, fecal incontinence *steatorrhea – fatty, foul-smelling stool - non specific GI problems such as N/V and diarrhea can result from food-borne poisoningduration- provoking factors - relationship of stool and dietary intake - assess fluid and electrolyte balance *vomiting – metabolic alkalosis (hcl) *diarrhea – metabolic acidosis (HCO3) * Lactose intolerance ▄ Past Health History a. Major Illnesses and Hospitalization - can provide clues about nutritional status and function of upper GIT hospitalization due to GI s/sx-PUD, hematemesis, anemia, jaundice, gallbladder disease - diagnostic tests of upper GI = clues about current health problem and serve as baseline data - past surgical procedures -> ask about surgery of the mouth, throat, stomach, liver, pancreas, gallbladder, abdomen b. Medications – OTC, prescribed, herbal medications - aspirin, aspirin compounds, NSAIDs = gastritis - antacids, laxatives, stool softeners – frequency of use? - vitamins and minerals = iron – may cause gastric irritation and can change stool color and consistency c. Nutritional supplements – vitamins, minerals, herbs, amino acids, meal supplements or replacements - can be harmful if taken in excess or in combination with other drugs - in excessive doses, vitamins can cause toxic side effects d. Allergies – hives, dyspnea, GI manifestations (cramping, flatulence, diarrhea) after food intake *Lactose intolerance- common condition for many adults because of inadequate amount of lactase (enzyme in the bowel) ->cannot break down lactose molecules->abdo cramping and drh

e. Family Health History- history of cancer, ulcer, UC, crohn’s disease
▄ Psychosocial History

a. occupation – toxic substances in the workplace (arsenic, lead, Hg)
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b.
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recent travels to foreign countries – increases risk of contracting GI dse.,caused by pathogenic bacteria, protozoa, helminthes & other parasites nutrition – type and amount of food intake are influenced by psychosocial factors describe a typical meal alcohol intake appetite food intake record= two weekdays and one weekend day = to determine dietary intake average healthy person: 30 to 35 cal/kg and 0.8 to 1.2 g of protein/ kg

▄ ROS - condition of the mouth- dental caries, number and condition of teeth - oral lesions, halitosis, increased or decreased salivation - brushing of teeth, visit to the dentist - trouble chewing or swallowing - dysphagia, odynophagia - change in bowel habits or stool characteristics - changes in appetite - problems of hepatic or biliary systems (jaundice, pruritus, ascites, dark-colored urine, acholic stools, bleeding problems II. Physical Examination ▄ Anthropometric measures – provide an assessment of body mass or body compartments 1. Height or weight - Weight = balance scale, calibrated sling, wheel chair scale - Height = telescoping ruler; arm span measurement - determine weight changes (current weight/ usual weight x 100) - weight changes of less than 90% or more than 110% of the client’s usual weight is significant

2. Body Mass Index- acceptable method of standardizing height for weight measurement

BMI= weight in kg/ height in meters2 = weight in lbs/ height in inches2 x 703 18.5 or less 18.5 – 24.9 25.0 – 29.9 30.0 – 39.9 40 or greater ▄ Mouth Inspection - lips = symmetry, color, hydration, lesions, nodules - teeth = number and position; dental caries, missing or broken teeth, = erythroplakia (red lesions); leukoplakia (white lesions) - pharynx = tonsillitis - tongue = symmetry, color, moisture = Palpation - lips, gingivae, buccal mucosa = loose teeth, masses, swelling, areas of tenderness - tongue = lesions, masses, color changes - dysphagia – - tonsils – ▄ AbdomenInspection - skin, abdominal contour = smooth, intact, with varying amounts of hair, flat, concave or rounded= areas of distention or irregular contour = rashes, discoloration, scars, petechiae, striae - umbilicus = concave, located at the midline, no drainage and same color of the abdo skin - peristaltic movement or abdominal pulsation Auscultation- RLQ, RUQ, LUQ, LLQ- clockwise fashion - Normal bowel sounds: every 5 to 15 sec; occur irregularly at a rate of 5 to 35 per minute - borborygmi = loud, high-pitch bowel sounds = hyperactive GIT - hypoactive bowel sounds = bowel sound of 1 or fewer every minute - use the bell of the steth to auscultate for vascular sounds = bruit, venous hum, friction rub • bruit- vascular turbulence - aneurysm or partial obstruction of the vessel • venous hum- heard in the periumbilical area indicates engorged liver circulation • friction rub- two pieces rubbing together; suggest hepatic tumor when heard loudest over the lower right rib cage or splenic inflammation when hear loudest over the lower rib cage in the anterior axillary line Percussion - size and location of abdominal organs and to determine fluid, air or masses - high-pitch, loud, musical sounds over gas-filled organs- tympanic - dull sounds over fluid or solid organs- thud like - determine size and position of liver and spleen Palpation- systematic quadrant to quadrant or region to region - begin with non-tender areas and progressing to painful ones - light palpation = 1 to 2 cm depression - deep palpation = size and shape of abdominal organs and masses - * rebound tenderness DIAGNOSTIC PROCEDURES A. ACID PERFUSION TEST AKA: Bernstein Test Description: In this test, normal saline and acidic solutions are perfused separately into the esophagus through a nasogastric tube. Purpose: To distinguish heartburn-like pains caused by esophagitis from those caused by cardiac d/o. Nursing Responsibilities Pre-Test • Explain the procedure and purpose of the test • Instruct the patient to observe the following pretest restrictions:  No antacids for 24 hrs. as ordered  No food for 12 hrs. Underweight Normal Overweight Obese Extremely Obese

 No fluids and smoking for 8 hrs. • • • Inform pt. that some discomfort, coughing or gagging may be experienced during tube passage Inform pt. to report pain or burning sensation during perfusion Immediately before the test, check pt.’s PR & BP

During the Test • Insert NGT that has been marked 12” from the tip into pt.’s stomach, aspirate stomach content, then withdraw the tube into the esophagus. • • • • Hang labeled containers of NSS and 0.1 N HCL Solution on an IV pole then connect NGT to IV tubing. Open the line from NSS @ 60-120gtts/min for 5-10 mins. then note pt.’s response. Close the line from NSS then open the line from HCL solution, same rate with NSS but to run for 30 mins., then note pt.’s response Stop the solution and withdraw NGT if the pt. experiences no discomfort after perfusion of HCL for 30 mins.

Post-Test • Administer antacid as ordered • • Provide soothing lozenges or ice collar as ordered Patient may resume normal diet and medications as ordered

Nursing Alert!!! • Observe the pt. closely for arrhythmias • Withdraw the tube immediately if the pt. develops cyanosis or paroxysmal coughing

Normal Finding: • Absence of pain Abnormal Finding: • Acidic solution causes pain or burning sensation (esophagitis) B. BARIUM SWALLOW AKA: Upper GI Series Description: Is a fluoroscopic and x-ray examination of the esophagus, stomach and small intestine Purpose: • To detect ulcer, polyps, tumor, hernia, varices, strictures and foreign bodies Nursing Responsibilities Pre-Test • Explain the procedure and purpose to the client • • • • Record V/S The client should be NPO and refrain from smoking for 8-12 hrs Withhold medications for 8 hrs unless indicated Inform the pt. That the test does not cause significant discomfort

Post-Test • Check with the radiology department that the Upper GI Series and/or small bowel series are completed before giving meal • • • • Administered the ordered laxatives Instruct client to increase fluid intake Inform the client that the stools should be light in color for the next several days Instruct the client to notify HCP if he/she does not have bowel movement in 2-3 days

Normal Findings:  The bolus evenly fills and distends the lumen and the mucosa appears smooth and regular, normal peristalsis Abnormal Findings:  ulcer, polyps, tumor, hernia, varices, strictures and foreign bodies

C. BARIUM ENEMA AKA: Lower GI Series Description: Radiographic examination of the large intestine after rectal instillation of barium sulfate 2 Types a. Single Contrast (only barium sulphate)- provides a profile view of the large intestine b. Double Contrast (Barium sulphate and air)- provides profile nad frontal view. It is better for detecting small intraluminal tumors (esp. Polyps) Purpose: • To aid diagnosis of colorectal cancer and inflammatory diseases • To detect polyps, diverticula, and structural changes in the colon

NURSING RESPONSIBILITIES Pre-Test • Explain the procedure and purpose of the test • • • • • • Oral medications should not be given for 24 hrs unless indicated Instruct the pt. to restrict dairy products and to follow a liquid diet for 24 hrs Instruct pt. to drink 8-oz of water or clear liquid for 12 to 24 hrs Inform patient that he/she will assume several position during instillation of barium. Prescribe laxatives to be taken the day before the test Administer a bowel preparation

Post-Test • The client should expel the barium in the bathroom or bedpan immediately after the test • • • • • Instruct pt. to increase fluid intake Encourage rest Administer laxative such as milk of magnesia or magnesium citrate or give cleansing enema as ordered Inform pt. That the stool will be light colored for 24-72 hrs Absence of stool should be reported

Nursing Alert!!! • Barium enema is contraindicated in pt. With tachycardia, severe ulcerative colitis, active GI bleeding, suspected perforation • The test is contraindicated to pregnant patient

Normal Findings: Single Contrast: The intestine is uniformly filled with barium and mucosa has a regular and feathery appearance Double Contrast: The intestine is uniformly distended with air, with a thin layer of barium providing excellent detail of the mucosal pattern Abnormal Findings: • Carcinoma, IBD, diverticula, fistulas, polyps, intussusception D. FECAL OCCULT BLOOD TEST Description: A microscopic analysis or chemical test for hemoglobin that determines hidden or invisible blood (occult) in the stool. Purpose: • To detect GI bleeding • To aid early diagnosis of colorectal cancer

NURSING RESPONSIBILITIES • Explain the procedure and purpose to the client • • • Obtain hx of recent or past bleeding episodes Instruct the client to maintain high-fiber diet and to refrain from eating red meat, poultry, fish, green leafy vegetables for 48-72 hrs Instruct the client to withhold ascorbic acid, iron preparations, salicylates, and steroids for 48 hrs

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Instruct client to report epigastric pain and abnormal-colored stool Be sure the stool is not contaminated with menstrual discharge

Normal Finding: • Negative (Green Rxn)- less than 2.5 ml of blood in the stool Abnormal Finding: • Positive (Blue Rxn)- more than 2.5 ml of blood in the stool E. PERCUTANEOUS LIVER BIOPSY Description: • Insertion of needle through the skin which involves needle aspiration of a core tissue for histologic analysis Purpose: • To diagnose hepatic parenchymal disease, malignant tumors and granulomatous infections NURSING RESPONSIBILITIES Pre-Test • Explain the procedure and purpose of the test • • • • • • Instruct the pt. to restrict food and fluids for 4-8 hrs Secure an informed consent Check pt. hx for hypersensitivity to local anesthesia Make sure PT, PTT, and platelet count are performed and recorded Instruct pt. to void before biopsy Record V/S

During the Test • Instruct pt. to assume supine position with his right hand under his head • • • Drape and clean the area of injection Instruct pt. to hold his breath while needle biopsy is inserted in the liver Apply pressure to the biopsy site to stop bleeding

Post-Test • Position pt. On his right side for 2 hours, with small pillow or sandbag under the costal margin


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Check pt. V/S q 15 mins. For the 1 hr., then q 30 mins. for 4 hrs, and q 4 hrs for 24 hrs Observe carefully for signs of bleeding and shock Administer analgesic as ordered Provide rest and pt. may resume normal diet Send the specimen to the laboratory immediately

Nursing Alert!!! • Watch for bleeding, signs of shock, bile peritonitis and pneumothorax -S/SX of bile peritonitis: tenderness and rigidity around the biopsy site -S/SX of pneumothorax: risisng RR, depressed breath sounds, dyspnea, persistent shoulder pain, and pleuritic chest pain Normal Findings: • Normal liver cells Abnormal Findings: • Presence of malignancies and hepatic diseases F. CT Scan AKA: CAT Scan, CTT Scan, CATT Scan - Computed Axial Tomography (CAT), Computed Transaxial Tomography (CTT), Computed-assisted Transaxial Tomography Description: It produces a narrow x-ray beam that examines body sections from many different angles.

Purpose: To produce tissue analysis and images not readily seen on standard radiographs Pre-Test: • Explain the procedure and purpose of the test • • • • • • • A consent form should be signed NPO for 4 hrs if contrast dye is used Assess pt. allergy to iodine products Remove all metal objects and jewelry Instruct pt. to wear loose and comfortable clothing Administer sedative as ordered Enema may be ordered

During the Test • Instruct client to remain still during the procedure • • • Instruct pt. That holding breath may be requested Instruct pt. To report unusual sensation especially if contrast dye is used Observe for S/Sx of severe allergic rxn to the contrast dye

Post-Test: • Observe for delayed allergic reaction to the contrast dye • • Instruct pt. To increase fluid intake to enhace the excretion of contrast dye Instruct the client to resume his/her usual activity and diet as indicated

Nursing Alert!!! • Watch for dyspnea, palpitations, tachycardia, itching and urtucaria G. ULTRASONOGRAPHY AKA: Ultrasound, Sonogram Description: A procedure used to visualize body tissue structure or wave-form analysis of Doppler studies Purpose: • To detect tissue abnormalities NURSING RESPONSIBILITIES Pre-Test: • Explain the procedure and the purpose of the test • • • • • • Obtain a signed consent form Restrict food and fluids for 4-8 hrs Advise pt. To eat fat-free meal night prior to the test Instruct client not to smoke or chew gum prior to the test Inform pt. that this is a painless procedure Enema may be performed as ordered

During the Test: • Ask the client to breathe slowly and to hold breath after deep inspiration • Instruct client to remain still during the test

Post-Test: • Instruct the client to resume his/her usual activity and diet as indicated H. X-RAY AKA: Radiography, Roentgenography Description: A procedure that emits x-radiation that is used to identify structure, size, and shape of bone and body tissues Purpose: • For Screening purposes

NURSING RESPONSIBILITIES • Explain the procedure and the purpose of the test • • • Ask female client if she is pregnant Foods and fluids are not usually restricted X-ray should be taken before GI series Clothes are removed and cloth gown is worn Instruct pt. to lie in supine position with his arms away from the body


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