NUTRITION FOCUSED NURSING CARE PLANNUTRITIONAL ASSESSMENT

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Wt. Gain

1 lb/ wk (1/2 kg) = add 500 kcal./ daylose- less 500 cal2 lbs/ wk ( 1 kg ) = add 1000 kcal./ daylose- less 1000 cal.

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Consume 10 kcal/ lb of BW for wt. maintenanceMost adults 12 kcal/ lbActive adults 15 kcal/ lb

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A. NUTRITIONAL ASSESSMENTTOOLS: interview; medical chartssimple assessment determining if the person is overweight or underweight or has had a change in wt. that may be indicative of a change in health status.lab. Values hemoglobin; Albumin protein statusCholesterol & other blood fats such as triglycerides, BGphysical signs of nutritional status psychological issues contributing to physical health concerns comprehensive nutritional assessment conducted to det. goals & determine inteventions to correct actual or potential imbalances

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1. HISTORYDietary history used in conjunction w/ physical parameters of healthcurrent & past health history- EX: Chewing & swallowing problems 2 ill-fitting dentures or missing teeth or from mechanical problems ( obstruction, inflammation, edema )- neurological problem (dysphagia, parkinsons disease, stroke, traumatic brain injury )- anorexia or loss of appetite- cognitive impairments- paralysis or physical disabilities that may impair the ability to feed oneself- excessive nutrient intake bulimia nervosa/ obesity- GI disorders lactose intolerance; cystic fibrosis; pancreatic disorders; inflammatory bowel disease; liver disorders- altered metabolism pregnancy; fever; sepsis; thermal injury

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a. DIET EVALUATIONa.1. DIET HISTORY- through interview- food preferences & intolerances- taste, appetite, recent wt. changes- desired wt. & usual wt.- estimation of typical kilocalorie & nutrient intake

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TOOLS:DIETARY GUIDES- are tools devised to aid in planning, procuring, preparing, serving & consuming meals for both normal & therapeutic diets of individuals or groups.

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TOOLS COMMONLY USED:

1. Three food groups or your guide to good nutrition (YGGN)a. Energy-giving foods GOb. Body-building foods GROWc. body-regulating foods GLOW- based on the bodys physiologic functions

2. Plate model- illustrates the types of food needed for a healthy diet & the proportions that should be eaten every day.- is simple & designed so that appropriate food selection can be made visually without having to weigh or measure foods

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- helps one to eat more fruits & vegetables, less fat & cholesterol, and helps to control the amount of carbohydrate ingested at each meal- uses a 9-inch diameter plate which is divided into 3 portions.1st quarter lunch & dinner- filled w/ 1/2 inch deep starchy foods ( corn, pasta, & rice )2nd quarter filled w/ serving of meat or meat alternative.- best choices are lean meats, fish, poultry or legumes, prepared w/o oils or fatsRemaining half filled w/ non-starchy vegetables tomatoes, green leafy veg., carrots, etc.Side dishes serving fruit ( 1 cup fresh or 1 cup canned or 4 ounces juice )1 cup serving of low fat milk or yogurt

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4. Food pyramidis the hierarchy of food groups in a persons diet that helps to put the dietary guidelines into action.- requires consumption of a variety of foods w/ the right amount of servings to get the nutrients needed by the body, & to maintain or improve weight.- it specifies the recommended amounts needed by the body

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5. The recommended energy & nutrient Intakes ( RENI )- defined as levels of intakes of energy & nutrients which, on the basis of current scientific knowledge, are considered adequate for the maintenance of health & well-being of nearly all healthy persons in the population- it emphasizes that the standards are in terms of nutrients, & not foods or diets.

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6. New nutritional guides for Filipinos-are general but simple statements intended to provide the general public w/ recommendations about proper diet & wholesome dietary practice to promote good health for themselves & their families.- they do not provide quantitative recommendations; instead they provide qualitative recommendations considered essential for nutritional health.

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7. NUTRITIONAL GUIDELINES FOR FILIPINOS (2000)1. Eat a variety of foods every dayNo single food provides all the nutrients the body needs.

2. Breastfeed infants exclusively from birth to 4 6 months, and give appropriate foods while continuing breastfeeding.3. Maintain childrens normal growth through proper diet & monitor their growth regularly.

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4. Consume fish, lean meat, poultry, or dried beans.Provide good quality protein & dietary energy, as well as iron & zinc.5.Eat more vegetables, fruits, and root crops.6. Eat foods cooked in edible/ cooking oil in daily meals.7. Consume milk, milk products & other calcium-rich foods, such as small fish & dark green, leafy vegetables every day.

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8. Use iodized salt, but avoid excessive intake of salty foods.9. Eat clean & safe foods.

10. For a healthy lifestyle and good nutrition, exercise regularly, do not smoke, and avoid drinking alcoholic beverages.

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8. The food composition tables ( FCT )- a dietary tool which contains a list of foods w/ numerical values corresponding to the amount of energy, nutrients, fibers & ash per 100grams of any particular food in the list.

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9. The food exchange list ( FEL )- a list of common foods grouped in terms of equivalent amounts of CHO, CHON, FATS & CALORIEs.- consists of 8 groupings namely vegetable exchanges, fruit exchanges, milk exchanges, rice exchanges,meat & fish exchanges, fat exchanges, alcoholic beverages, and sugar exchages.a food in any group may be exchanged with another food in the same list or subgroup

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a.2. 24-HOUR food RECALL

- quick & easy of evaluationg intake- person must be able to recount all the types & amounts of foods & beverages consumed during a 24-hour period

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a.3. FOOD FREQUENCY checklists

- a checklist of particular foods that helps determine whats consumed & how often- may list the foods in one column, & the person marks off how often they are eaten - how often the food is consumed (per day/ per week, or per m0nthe)- if the food is eaten frequently, seldom, never- typically does not include the serving size, & it may only include specific foods or nutrients suspected of being deficient or excessive in the diet.

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a.4. CALORIE COUNTThe ENERGY (CALORIE) value of food is the amount of energy produced in the body as a result of food metabolism.Calorie the most common term to express energy a unit measure of heat

a.5. FOOD DIARY

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2. PHYSICAL EXAMINATION/ findings clinical assessment

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The physical examination (PE) of an individual for signs and symptoms suggestive of nutritional health and/or clinical pathologyconducted by the physician or trained clinical staff on anatomic changes

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a. ANTHROPOMETRYthe science that deals with body measurements, such as size, weight, & proportions

- useful in screening individuals who may have varying degrees of protein-energy ,malnutrition (Kwashiorkor & Marasmus)

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a.1. WEIGHT-this measurement needs to be undertaken at the very 1st encounter w/ a patient & must be regularly monitored- usual BW should be noted- taken on the same scale at the same time of day ( typically before breakfast & after voiding ), in the same amount of clothing, w/o shoes- wt loss is best expressed in term of percentage of wt. change

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Cut off point for Low Birth Weight (LBW) = 2500 g (2.5 kg)

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INFANTS:

1. 1st 6 MONTHS:DBW (gram) = Birthwt (g) + (Age in mos x 600)2. 7 12 MONTHS:DBW(g) = Birthwt (g) + (Age in mos x 500)

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Infants weight doubles at 5-6 monthsTriples at 12 monthsQuadruples at 24 months

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CHILDREN:

DBW = (Age in yrs x 2) + 8

Note: At least +2 kg every year

ADULT ( dietary calculations)

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Indicates wasting

if < 85% of standardMcLaren & Read Body Mass Index (BMI)

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% = Actual weight x 100Ideal weight

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Interpretations:Overweight 110%Normal90 109%Mildly UW85 89%Moderately UW75 84%Severely UW< 75%

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a.2. HEIGHT- Indicates stunting- Compare actual height with standard height for various ages- Using WHO tables- Stunted if < 90% of standard height

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- should be measured w/ the individual standing as straight as possible, w/o shoes, against the wall using a fixed measuring stick

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For infants:

- Height at birth is about 50 cm (48 to 52 cm)- + 24 cm at age 1 year- + 12 cm at age 2 years- + 8 cm at age 3 years- + 6 cm/year from 4-8 years

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1. HEAD-CHEST RATIOMeasures head & chest circumference0 5 or 6 mos => 16 months= 17 12 months=

2. MID-ARM CIRCUMFERENCE (MAC)- indicates the level of the bodys protein stores which are found mainly in the muscles- Non-dominant arm is flexed at a 90-degree angle and the circumference is measured w/ a nonstretchable measuring tape after the midpoint of the upper arm is determined.

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4. WAIST CIRCUMFERENCEValues above standards indicate central body fat adiposity5. WAIST HIP RATIO = Waist(in/cm) Hips (in/cm)

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Getting waist measurement: the narrowestGetting hip measurement: the broadest

Females:

Determines fatness or leannessCompare with standardsTriceps, biceps, subscapular, abdomen, upper thigh

a.4. SKIN FOLDS

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1. TRICEPS SKIN FOLD (TSF)- an index of the bodys fat or energy storesLow skin fold measurement --- may indicate malnutritionUsed for both men & womenMeasure the skinfold thickness --- in the posterior side of the nondominant upper arm at the midpoint

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b. CLINICAL FEATURES OF b.1. MALNUTRITION

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- or poor nutritional status a state in which a prolonged lack of one or more nutrients retards physical development orv causes the appearance of specific clinical conditions (anemia, goiter, rickets, etc. micronutrient deficiencies)- this may occur because the diet is poor or because of a digestion & metabolism problem.

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Protein Energy Malnutrition (PEM)lead to acute thinness (wasting) or a long term reduction in child growth(stunting).Kwashiorkor Protein deficiency

occurs after weaning, when milk high in protein is replaced by a starchy staple food that provide insufficient protein

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Kwashiorkor

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- swollen and discolored skin on the arms and legs - thin and pale hair,

- diarrhea,

- profound apathy, and loss of appetite.

- tissues and organs waste away, except for the liver.

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Marasmus Protein calorie deficiencyAs overall deficiency in food

Small size for chronological ageMental apathyDry flaky skinFrequent infectionsAnorexia & diarrheaRed swollen lips

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MARASMUS & KWASHIORKOR

b.2. OBESITY

OVERWEIGHT refers to an excess of body weight 10% greater than the standardOBESITY excess of body wt. 20% or more than the standard

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Overweight

Excess of body weight 10% greater than the standard

Obesity Excess in 20% or more of the standard.

Extreme obesity = 30%

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global epidemic

Increased intake of kilocalorie

High intake of sugar-based beverages

Decreased consumption of fiber based food

Fast pace of eating

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What are the known causes and theories of OBESITY?

- it occurs when caloric intake exceeds expenditure over an extended period- reduced physical activity

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b.3. CERTAIN VITAMIN DEFICIENCIES

Refer to your handouts on vitamins & assignment.

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3. DIETARY CALCULATIONS

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a.1. ACTUAL & IDEAL BODY WEIGHT & HEIGHT- wt. is the measure people use to judge their fitness

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IBW range can be 10% higher or lower depending on body size

% of IBW obtained Formula = pts true wt X 100 IBW110% - 120% - Overweight90 110% - Normal80 90% - mildly underweight70 79% - moderately underweightLess than 70% - severely underweight

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ADULTS

HAMWI METHODMales: For the 1st 5 ft, allow 106 lbs; 6 lbs every inch above or below 5 ftFemales: For the 1st 5 ft, allow 100 lbs; 5 lbs every inch above or below 5 ft

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NDAP FORMULA Males: For the 1st 5 ft, allow 112 lbs; 4 lbs every inch above or below 5 ftFemales: For the 1st 5 ft, allow 106 lbs; 4 lbs every inch above or below 5 ft

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3. TANHAUSSERS METHOD OR BROCCA INDEXDBW (kg) = Height (cm) 100* For Filipinos, deduct 10% of the difference

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4. DERIVED FORMULA BASED ON BMIDesirable BMI for Men: 22Desirable BMI for Women: 20.8 or 21DBW (kg) = Desirable BMI x height (m2)

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HEALTHY WEIGHT - defined by 3 criteria:

1. A weight that is within the suggested range for height

2. A fat distribution pattern that is associated w/ a low risk of illness & premature death.

3. A medical history that reflects an absence of risk factors associated w/ obesity, such as elevated blood cholesterol, blood glucose, or blood pressure.

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% IBW = current/actual weight x 100

ideal weightNormal:90 109%Overweight:110 119%Obese:120% or more

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% Usual body wt = current weight x100 Usual body wt

Interpretations:% usual body weightNutrition status85 95Mildly UW75 84 Moderately UW< 75Severely UW

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a.2. BODY MASS INDEX

- measures weight in relation to height- measure of adiposity or overfat, not simply overweight- should not be applied to children, adolescents, adults over 65 y/o, pregnant & lactating women, & highly muscular individuals.

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- formula:BMI = weight (kg)

Height(m)

>18.5 underwt.18.5 24.9 normal25.0 29.9 overwt.30.0 34.0 obese class 135 39.9 class 240 or greater morbid obesity

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Infant 6 y/o

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1 month = 30 days1 year = 12 mosWrite the date of weighing this wayEx. Date of weighing is Dec 6,2008YearMonth Day20081206

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b. Write the birth date of the child in the same wayEx. Birthdate is March 2, 2006YearMonthDay20060302

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c. Subtract the birthdate from the date of weighing2008-12-06minus2006-03-02 2-09-04*The child is 2 years, 9 months and 4 days

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d. Multiply years by 12. Add this to number of months. Disregard the days column 2-9-4 : 2 years x 12 = 24 months + 9 months= 33 months

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% = Actual weight x 100Ideal weightInterpretations:Normal 91 110%Mildly UW76 90%Moderate UW61 75%Severely UW60% or less

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4. LABORATORY EXAMINATIONS biochemical

- Routine blood and urine laboratory tests- composition of blood to compare w/ normal ranges for hemoglobin, albumin, transferrin, total plasma protein, nitrogen content in 24-hour urinary output

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ADVANTAGES:

It can detect early sub-clinical status of nutrient deficiency.It identify specific nutrient deficiency.It is independent of the emotional & subjective factors

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DISADVANTAGES:

It is expensive & time-consumingStandard could vary with wide range.There may be problem in interpreting results.

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5. NUTRITIONAL ASSESSMENT OF SPECIFIC DISEASES

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B. NURSING DIAGNOSISC. PLANNING

- this stage of the nursing process brings together all the findings of the assessment phase

Identifying priority health concerns, long- term health goals, & STO

Specified health outcomes is important for facilitating behavioral change

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D. IMPLEMENTATION/ intervention

- putting plan into actionbased on the information gathered in the comprehensive nutritional assessment may require restrictions in diet, such as --- reduction in calories; fat; saturated fat; cholesterol, sodium, or other nutrients

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1. DIETARY CALCULATIONS OF CALORIE/ DAY INTAKE

- GRAMS EACH FOODESTIMATING ENERGY/ CALORIE NEEDS- to create a tailored nutrition prescription, one must determine the patients energy/ calorie requirements

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2. FEEDING GUIDELINESE. EVALUATION- the final step- must be documented based on skills & information gained & by the outcomes of laboratory blood tests or other measures- EX: achieving 5% wt. loss- helps the health care professional if further intervention is needed- monitoring the growth in children- wt. changes in adults

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A- AIM FOR FITNESS- Aim for healthy weight.- Be physically active for each day.B- BUILD A HEALTHY BASE- Let the pyramid guide your food choices.- Choose a variety of fruits and vegetables daily- Keep food safe to eat.

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C- CHOOSE SENSIBLY- Choose a diet that is low in saturated fat & cholesterol and moderate in total fat.- Choose beverages and foods that limit your intake of sugars.- If you drink alcoholic beverages, do so in moderation.

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A nthropometricB iochemicalC linicalD ietary measurements

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Promotion of Health

provides the pathway or process to achieve this balance. The NCHF emphasizes a sharp distinction between disease prevention and health promotion. Disease prevention focuses on protecting as many people as possible from the harmful consequences of a threat to health (e.g., through immunizations). Health promotion consists of the development of lifestyle habits which healthy individuals and communities can adopt to maintain and enhance the state of well-being. The ultimate goal is the optimization of health. Health promotion addresses individual responsibility while preventive services can be fulfilled by health providers

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Examples of Promotion of HealthPhysical fitness Smoking control Mind-body health Spiritual health Medical self-care Environmental health Nutrition Stress management Social health Weight management Work safety Prenatal care

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THE THREE FUNCTIONS OF NUTRIENTS

Provide Energy Promote growth and development Regulate body functions Carbohydrates Proteins Proteins Proteins Lipids Lipids Lipids (fats and oils) Vitamins Vitamins Minerals Minerals Water Water

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SPECIAL DIET - are used in the treatment of persons with certain mental disorders to:- identify and correct disordered eating patterns - prevent or correct nutritional deficiencies or excesses - prevent interactions between foods or nutrients and medications

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SPECIAL DIET are designed to help individuals make changes in their usual eating habits or food selection. Some special diets involve changes in the overall diet, such as diets for people needing to gain or lose weight or eat more healthfully. Other special diets are designed to help a person limit or avoid certain foods or dietary components that could interfere with the activity of a medication. Still other special diets are designed to counter nutritional effects of certain medications.

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