NUTRITION

CARE
PROCESS
Maria Sheila A. Clanor RN,MAN
 NUTRITIONAL ASSESMENT

• Objectives
At the end of the chapter, the student
should be able to:
1.Discuss the methods of assembling
nutritional status
2.Explain the significance and purpose of
nutritional assessment
 RECOMMENDED DIETARY
ALLOWANCES AND ADEQUATE
DIET
ADEQUATE DIET
•Composed of various nutrients which
the body needs for maintenance, repair,
living processes and growth and
development
•The purpose of daily meals is to supply
the essential elements
 Factors to consider for
planning nutritious meal
• Regional availability of foods
• socio-economic conditions,
• taste preferences,
• food habits,
• age of family members,
• storage and preparation facilities,
• cooking skills
Purpose and Applicability of RDA
1. RDAs are levels of intake of essential
nutrients on the basis of available
scientific knowledge, adequate to
meet the known nutritional needs of
practically healthy person.
2. RDAs should not be confused with
requirements.
3. RDAs meet the needs of healthy
people and do not take into account
special needs.
• RDA – Recommended Dietary Allowance
• RENI – Recommended Energy and
Nutrient Intakes
• AR – average physiologic requirement
 RENI
• Are levels of intakes of energy and
nutrients which on the basis of current
scientific knowledge are considered
adequate for the maintenance of
health and well being of nearly all
healthy persons in the population
 Evaluation of nutritional
status
• Involves physical condition, growth
and development, behavior, blood and
tissue levels of nutrients, and the
quality and the quantity of the
nutrient intake.
 ESSENTIAL OF ADEQUATE
INTAKE
• Milk group – provide most of the
calcium requirements
• Meat group – provides generous
amount of high quality protein
• Bread and cereal group – furnishes
thiamine, protein, iron, niacin,
carbohydrate and cellulose at a
relatively low cost
• Vegetable-fruit group – important
supplier of fiber, minerals and vit A ,C
ASSESSMENT OF NUTRITIONAL
STATUS
Nutritional status or nutriture
•is the degree to which the individual’s
psychological need for nutrients is being
met by the food the person eats.
ASSESSMENT OF NUTRITIONAL STATUS

All of the following aspects are considered:

1.Dietary history and intake data

2.Biochemical data
3.Clinical examination
4.Anthropometric data
5.Psychosocial data
METHODS OF ASSESSING DIETARY INTAKE

24-hour Recall
The individual completes a questionnaire or
is interviewed by a dietitian/nutritionist or a
nurse experienced in dietary interviewing and is
asked to recall everything that he/she ate
within the last 24 hours or the previous day:
24 hour Recall Form and Food Group
Evaluation
The following question pattern may
be used for conducting the 24-hour
recall. The information should then be
recorded in the chart at the end.
1. What time did you go to bed the night before last?____________________________
Was this the usual time? ___________________________________________________
2. What time did you get up yesterday?________________________________________
Was this the usual time?___________________________________________________
3. When was the first time you had anything to eat or drink?______________________
What did you have and how much?__________________________________________
4. When did you eat again?___________________________________________________
Where?__________________________________________________________________
What and how much?______________________________________________________
5. When did you eat next?____________________________________________________
What did you eat and how much?____________________________________________
6. Did you eat or drink anything else?
a. Anything from 1st and 2nd meal?
b. Anything from 2nd and 3rd meal?
c. Anything from 3rd meal to bed time?
7. Was this day’s food intake different from usual?_______________________________
If so, why?______________________________________________________________
8. Is weekend eating different?
________________________________________________
If so, why?_______________________________________________________________
 Table 44
Food and Fluid Intake from Time of Awakening until the Next Morning 24-hour Recall

Food and
Time Drink Number of Servings in the Food Groups
Consumed

Bread & Butter

Name & Amoun Milk Meat Vit. A Vit. C Vegetable-
  Cereal , Fat, Misc.
Type t Group Group Group Group Fruit Group
Group & Oil

                     
                     
                     
                     
                     
TOTA
L                    
 SAMPLE 24-HOUR RECALL FORM

Name __________________________________________________________
Date _______ / _______ / _______
Day of Week (encircle) : Sun Mon Tue Wed Thu Fri Sat
Time of Meal Food or Beverage Type of Preparation Amount

Was this intake unusual? Yes_____ No_____

If so, how? ______________________________________________________
________________________________________________________________
Do you take any vitamin or mineral supplement?
Yes_____ No_____
If yes, describe:
Name or Type Dose (if known) How often
_________________ _________________ _________________
_________________ _________________ _________________
_________________ _________________ _________________
Recommended Bread & Butter,
Milk Meat Vit. A Vit. C Vegetable-
Number of Amount Cereal Fat, & Misc.
Group Group Group Group Fruit Group
Servings Daily Group Oil
Children 6 yrs
  2-3 c 2 3/wk 1 2 4 2 tbsp  
or <
Adolescent   4c 2 3/wk 1 2 4 2 tbsp  
Adult   2c 2 3/wk 1 2 4 2 tbsp  
Pregnant or
4c 2 3/wk 1 2 4 2 tbsp  
Lactating
Evaluation: L = Low
A = Adequate
E = Excessive
2. Food Frequency Questionnaire
Questions, however, should be modified based on
the information from the 24-hour recall.
Answers should be recorded as 1/day, 1/wk, 3/mo,
for example, or as accurately as possible. If may just
have to be noted as “occasionally” or “rarely.”
1. Do you drink milk? If so, how much?__________
What kind? Whole _________ Skim ______
2. Do you use fat? If so, what kind?________________ How much? ___________
How much?____________
3. How many time do you eat meat?______________
Eggs________ Cheese________ Beans_______
4. Do you eat snack foods? If so, which ones?_________________
How often?___________ How much?________________
5. What vegetables do you eat? (in each group)
a.Broccoli______ Green pepper_____
Cooked greens_______ Carrot _____________
Sweet potato____________
b.Tomato ______ Raw cabbage______
Asparagus______ Beets _________
Cauliflower _________ Cooked cabbage__________
Celery________ Peas___________
Lettuce______________
6. What fruits do you eat and how often?
a. Apple or apple sauce _______ Apricots _______
Banana _________ Berries ______
Cherries_________ Grape or grape juice ______
Peaches_________ Pears________
Pineapple________ Plums_________
Raisins__________
b. Oranges___________ Orange juice______
Grape fruit_______ Grape fruit juice _________
7. Do you use fat? If so, what kind?________________ How much? ___________
How much?____________
a. How much bread do you usually eat with each
Meal?________ Between meal?__________
b. Do you eat cereal? (daily, weekly)
Cooked _________________ Dry ___________________
c. How often do you eat foods such as macaroni, spaghetti, noodles, and the
like?__________________________
8. Do you use salt?__________
Do you “crave” salts or salty foods? ______
9. How may tsp of sugar do you use/day?
(1 packet – 1 tsp) ____________
10. Do you drink water?______________
How often during the day?______________
How much each time? ________________
How much would you say you drink each day? ____________
11. Do you drink alcohol?_______ How often? __________
How much?________
Beer, wine, others? ___________
 Selective Food Frequency Questionnaire for Inquiring
about Cholesterol, Fat, Sodium, Iron, or Sugar Intake

Frequency of Food Used:

Record as times/week or day or N = never or R = rare

High or Moderately High in: Use of

CHOLESTEROL Eggs ________
Liver ________
Shellfish ________
Pork ________
Beef ________
SUGAR Beef ________
Pork ________
Butter ________
Whole Milk ________
Cream ________
Pastries ________
Gravies ________
Ice Cream ________
Frequency of Food Used:
Record as times/week or day or N = never or R = rare
High or Moderately High in: Use of
UNSATURATED FAT Soft Margarine ________
Vegetable Oils ________
SODIUM Prepared Frozen Foods ________
Sausages or Franks ________
Snack Foods ________
Pretzel, Potato Chips ________
Salted Peanuts ________
Softened Water ________
Olives, Pickles ________
Smoked Fish, Canned Fish ________
Ham & other Canned Meat ________
IRON Iron Supplements ________
Dark Green Leafy Vegetables ________
Enriched Cereals ________
Dried Beans ________
Meat, Fish, Poultry ________
Eggs ________
3.Dietary History
The dietary history is more complete than
either the 24-hour recall or food frequency
questionnaire, although it usually includes both of
these sources. The dietary history contains
additional information about the following:
1.Economics
a. Income
b. Amount of money for food each week or
month and individual perception of its
adequacy for meeting food needs
2. Physical Activity
a. Occupation
b. Exercise
c. Sleep-hours/day
3.Ethnic and Cultural Background
a. Influence on eating habits
b. Religion
c. Education
4.Home Life and Meal Patterns
a. Number of household members
b. Person who does shopping
c. Person who does cooking and
relationship with this person
d. Food storage and cooking facilities
e. Type of housing
f. Ability to shop and prepare food
5. Appetite
a. Good, poor, any changes
b. Factors that affect appetite
c. Taste and smell perception
6. Allergies, Intolerances, and Food Avoidances
a. Foods avoided and reason
b. Length of time of avoidance
7. Dental and Oral Health
a. Problems with eating
b. Foods that cannot be eaten
c. Problems with swallowing, salivation, and food
sticking
8. Gastrointestinal Concerns
a. Problems with heartburn, bloating, gas,
diarrhea, constipation, distention
b. Frequency of problems
c. Home remedies
d. Antacid, laxative, and other drugs used
9. Chronic Diseases
a. Treatment
b. Length of time of treatment
c. Dietary modification
10.Medication
a. Vitamin and/ or mineral supplement
b. Medications
4. Food Diary or Record
This method involves time, understanding,
and motivation on the part of the patient or client.
The subject is asked to write down everything
he/she eats or drinks for a certain time period.
 Day _____________________
Date_____________________
Prepared by_______________

AMOUNT OF NAME
MEAL
TIME PLACE PATIENT/CLIENT FOOD AND TYPE
TIME
SERVED OF FOOD
. Observation of Food Intake
Observation of food intake is the most
accurate method of dietary intake
assessment but also the most time-
consuming, expensive, and difficult.
It requires knowing the amount and kind of
food presented to the person and the record
of the amount actually eaten.
 NUTRITION SURVEY
• Is an epidemiological investigation of
the nutritional status of the population
by various methods together with an
evaluation of the ecologic factors in
the community
 Significance of Nutritional
Assessment
• It is the first essential in nutritional
planning
• It provides data and information for
planning and evaluation
• It helps define priorities and
responsibilities of public health system
at the national, regionals, provincial,
city, municipal and barangay levels
 Methods of Nutritional
Assessment
A. Methods that provide direct
information
1. clinical examination
2. biochemical examination
3. anthropometric examination
4. biophysical technique
B. Methods that provide indirect
information
` 1. studies on food consumption
2. studies on health conditions and
vital statistics
3. studies on food supply situation
4. studies on socio-economic conditions
5.studies on cultural and
anthropological influences
 FACTORS CONSIDERED IN THE
SELETION IN NUTRITION
SURVEYMETHOD
• Units to be surveyed
• Types of information required
• Degree of reliability and accuracy
required
• Facilities and equipment available
• Human resources
• Time reference
• Funding or financial support
 CLINICAL ASSESSMENT
• It deals with the examination of
changes that can be seen or felt in
superficial tissues such as skin, hair
and eyes
 CLINICAL ASSESSMENT
Advantages
•More coverage in a short time
•Inexpensive, no need for sophisticated
equipment
 CLINICAL ASSESSMENT
Disadvantages
•Non specificity of signs
•Overlapping of deficiency states
•Bias of the observer
 CLINICAL ASSESSMENT
Clinical signs on table 45
 CLINICAL ASSESSMENT
Clinical Symptoms of common
nutritional problems
1.PEM
•mild to moderate
•Severe
marasmus(dry form)
kwashiorkor(edematous form)
marasmic kwashiorkor
 CLINICAL ASSESSMENT
Clinical Symptoms of common
nutritional problems
2. Xerophthalmia – it affects the eyes,
gradually beginning with an impairment
of night vision
Symptoms
•Impaired night vision
•Smokey conjunctiva
•Dry eyes
•Cornea softening and ulcers
 CLINICAL ASSESSMENT
Clinical Symptoms of common
nutritional problems
3. Anemia
Symptoms
•Tiredness
•Paleness under the eyelid
•Breathlessness
•Heart palpitations
•Paleness under the nail
•edema
 CLINICAL ASSESSMENT
Clinical Symptoms of common nutritional
problems
4. Goiter – the enlargement of the thyroid
is due to its need for iodine
Goitrogenic agents – prevent the
absorption of iodine
Symptoms
•Swelling of the neck
•Difficulty in swallowing
•Difficulty in breathing
•Tight feeling in throat
• Classification of Goiter by palpation
• Grade 0
– no palpable or visible goiter
• Grade 1
palpable but not visible
• Grade 2
swelling in the neck is clearly visible,
enlarged thyroid gland when
palpated
 CLINICAL ASSESSMENT
Clinical Symptoms of common
nutritional problems
5. Vit B2 or Riboflavin deficiency
Symptoms
•Magenta red tongue
•Sores at the angle of the mouth and
folds of the nose
•Itching and scaling of skin around nose,
mouth , scrotum, forehead, ears and
scalp
 Biochemical Assessment
• Estimation of time desaturation,
enzyme activity or blood composition
• Tests are confined to two fairly easily
obtainable fluids: blood and urine
• Results are generally compared to
standards ( normal levels for age and
sex
 Biochemical Assessment
• Advantages
1.objectivity, independent of the
emotional and subjective factors that
usually affect the investigator
2. Can detect early subclinical states of
nutritional deficiency
 Biochemical Assessment
• Disadvantages
1.Costly
2.Time consuming
Factors affecting accuracy of result
1.Standards of collection
2.Methods of transport and storage
samples
3.Techniques employed
 Biochemical Assessment
• Common Biochemical Parameters
• Table 48
 Biochemical Assessment
• Tests Applicable and Interpretation
Protein
• Urea N/creatinine N ratio – index of
dietary adequacy
• 2-24hr urine sample
• Index of 30 or lower in a random sample
Indicative of malnutrition
 Biochemical Assessment
• Tests Applicable and Interpretation
Protein
Amino Acid ImbalanceTest – ratio of four
Indispensable amino acid in serumby paper
chromatography
High (5-10) in kwashiorkor and low (less
than 2) in well-fed children
Hydroxyproline excretion
Low (0.5-1.5) in clinically malnourished
children, normal (2.0-5.0)
 Biochemical Assessment
• Tests Applicable and Interpretation
Protein
Serum Albumin
Lowered in severe protein depletion
High 4.25
Acceptable 3.52-4.24
Low 2.80-3.51
Deficient less than 2.80
 Biochemical Assessment
• Tests Applicable and Interpretation
Iron
Hgb Determination
Cyanmethemoglobin method-
spectrophotometry
A.O. hemoglobinometer – simple
technique, handy equipment
Others: Sahli’s method; Tallquist method;
copper sulfate specific gravity method
 Biochemical Assessment
• Tests Applicable and Interpretation
Iron
Hematocrit –obtained from a finger prick
measure of red cell volume
6mos-6y.o 11gm
6y.o-14y.o 12
Adult male 13
Adult female 12(non pregnant)
Adult female 11(pregnant)
 Biochemical Assessment
• Tests Applicable and Interpretation
Vitamin A
Serum Vit A and serum carotene level –
spectrophotometry
Low serum Vit A reflects prolonged severe,
dietary deficiency probably up to
1 year in adult and 4 months in young
children
Serum carotene reflects recent ingestion
of carotene containing food
 ANTHROPOMETRIC
MEASUREMENTS
• Anthropometry- is the measurement
of variations of the physical dimensions
and gross composition of the human
body
At different age levels and degrees of
nutrition
 ANTHROPOMETRIC
MEASUREMENTS
Common Anthropometric Measurement
1.Weight – uses weighing scale
-assess body mass
-sensitive indicator of current
nutritional status
-uses reference values for age or
height or both of population
- key anthropometric measurement
 ANTHROPOMETRIC
MEASUREMENTS
Common Anthropometric Measurement
1.Weight
Advantages
-Simple and commonly used
-Weight can be determined fairly
accurately by personnel with minimum
training
 ANTHROPOMETRIC
MEASUREMENTS
Common Anthropometric Measurement
1.Weight
Disadvantages
-It depends on accurate age
determination
-Interpretation on individual basismay be
complicated by edema
-Does not distinguish between acute and
chronic malnutrition
 ANTHROPOMETRIC
MEASUREMENTS
Common Anthropometric Measurement
2. Height – assess linear dimensions of
legs, pelvis, spine, and the skull
-Less sensitive and generally an indicator
of past nutritional status
-Uses statiometer, anthropometric steel
rods fixed accurately and vertically to
the wall, infantometer is used(below 2
years old
 ANTHROPOMETRIC
MEASUREMENTS
Common Anthropometric Measurement
2. Height
Advantages
•Inexpensive tools may be used
•It is simple to do in the field
Disadvantages
•Less sensitive to changes in growth rate
•Errors in measurement are easily made
•Other factors
 ANTHROPOMETRIC
MEASUREMENTS
Common Anthropometric Measurement
3. Weight for heightllength
-Most accurate indicator of present or
current state of nutrition
-An expression of leanness or wasting
Advantage
1.It is nearly independent of age from 1-
10 years
2.it is probably independent of ethnic
group especially in ages of 1-5 years
 ANTHROPOMETRIC
MEASUREMENTS
Common Anthropometric Measurement
4. Skinfold Thickness
-Assesses body composition , fat
distribution, and reserve calories
-Must be compared against standards for
age and sex at all ages
-Uses a reliable caliper
 ANTHROPOMETRIC
MEASUREMENTS
Common Anthropometric Measurement
5. Body Circumference – the head/
chest circumference ratio is of value in
detecting PEM
- The mid upper arm circumference
(MUAC)has been mainly used on children
from 1-6 years old
 ANTHROPOMETRIC
MEASUREMENTS
Common Anthropometric Measurement
6. Birth weight
-it is related to maternal nutrition and
socio-economic status
-2500gm for low birth weight babies
Disadvantage
-births are often unattended by health
personnel
- Other factors(gestational age, infectious
and toxemic episode during pregnancy
 ANTHROPOMETRIC
MEASUREMENTS
Reference/ Standards Used
1. Weight for Age
-Depending on how far a child’s weight
compares with his/her standard weight
Normal
-the child’s weight is between 91% and
110% of his/her ideal weight
First degree
-76%-90%
 ANTHROPOMETRIC
MEASUREMENTS
Reference/ Standards Used
1.Weight for Age
Second degree
-61%-75%

Third Degree or Severely underweight

-60% or less
 ANTHROPOMETRIC
MEASUREMENTS
Reference/ Standards Used
2. Weight for height-nutritional status
by McLauren and Read
Overweight 110% of standard weight
Normal 90-109%
Mild underwt 85-89%
Moderate 75-84% undernourished
Severe 75%
 ANTHROPOMETRIC
MEASUREMENTS
Reference/ Standards Used
3. weight-for-height and height-for-
age – permits further distinction
between acute malnutrition and chronic
malnutrition as well as simple stunting
 Malnutrition Universal
Screening Tool
 is a five-step screening tool to identify
adults, who are malnourished, at risk
of malnutrition (undernutrition), or
obese.
 It also includes management guidelines
which can be used to develop a care
plan.
 Malnutrition Universal
Screening Tool
 This guide contains: A flow chart
showing the 5 steps to use for
screening and management BMI chart
Weight loss tables Alternative
measurements when BMI cannot be
obtained by measuring weight and
height.
 Subjective Global
Assessment
is a simple bedside method of assessing
the risk of malnutrition and identifying
those who would benefit from
nutritional support. Its validity for this
purpose has been demonstrated in a
variety of conditions including surgical
patients, those with cancer, on renal
dialysis and in the ICU.”
Dr. Khursheed Jeejeebhoy
Subjective global Assessment
• SGA fulfills the requirements of a desirable
system of nutritional assessment by:
• Identifying malnutrition
• Distinguishing malnutrition from a disease
state
• Predicting outcome
• Identifying patients in whom nutritional
therapy can alter outcome
 Mini nutritional assessment
• MNA has recently been designed and
validated to provide a single, rapid
assessment of nutritional status in
elderly patients in out patients clinics,
hospitals, and nursing homes. 
• The most recent version of the MNA®-
SF was developed in 2009 (Kaiser et
al., 2009) and consists of 6 questions
on food intake, weightloss, mobility,
psychological stress or acute disease,
presence of dementia or depression,
and body mass index (BMI). 
 Geriatric Nutritional Risk
Index
• The GNRI can be used as an objective
tool for assessment of nutritional
status and muscle strength.