Nutritional

Assesment
Group 3
1. Fefrina Helda
2. Rany Ika Fardila
3. Ridho Mahendra
4. Zahara Muthia Rusdy
 Defining Nutritional Status

Undernutrition is occurs when

nutritional reserves are depleted and/or
Nutritional status refers to the when nutrient intake is inadequate to
degree of balance between nutrient meet day-to-day needs or added
intake and nutrient requirements. metabolic demands.

Optimal
Nutritional status nutritional Undernutrition Overnutrition
status

Optimal nutritional status is Overnutrition is caused by the

achieved when sufficient nutrients consumption of nutrients
are consumed to support day-to-day especially calories, sodium,
body needs and fat-in excess of body
needs.
 Dietary Practices of Selected Cultural Groups

• It is necessary to avoid cultural stereotyping, the

tendency to view individuals of common cultural
background similarly and according to a preconceived
notion of how they “ought” to behave. For example,
despite widely held stereotype we know that some
Chinese do not like rice, some Italians dislike
spaghetti, some Irish dislike corned beef and cabbage,
and so forth. Aggregate dietary preferences among
people from certain cultural groups, however, can be
described (eg, characteristic ethnic dishes, methods of
food preparation). Cultural food preferences are often
interrelated with religious dietary beliefs and
practices. Many religions use foods as symbols in
celebrations and rituals. Knowing the person's
religious practices related to food enables you to
suggest improvements or modifications that do not
conflict with dietary laws. Table 11-1 summarizes
dietary practices for selected religious groups.
 Purposes and Components of Nutritional Assesment
The purposes of nutritional assessment are to;

1. Identify individuals who are malnourished or are at risk for developing malnutrition.

2. Provide data for designing a nutrition plan of care that will prevent or minimize the development of malnutrition, and

3. Establish baseline data for evaluating the efficacy of nutritional care.

• Nutrition screening, the first step in assesing nutritional

status, is required for all patients in all health care setting
within 24 hours of admission.

• Based on easily obtained data, nutrition screening is a quick

and easy way to identify individuals at nutrition risk, such as
those with weight loss, inadequate food intake, or recent
illness.

• Parameters used for nutrition screening typically include

weight and weight history, conditions associated with
increased nutritional risk, diet information, and routine
laboratory data. A variety of valid tools are available for
screening different populations.
 Features of Subjective Summary of 2010
Global Assessment (SGA) Dietary Guidelines
 Subjective Data
Examiner Asks
Eating patterns • Number of meals/ snacks per day?
• Kind and amount of food eaten?
• Fas, special, or alternative diets?
• Where is food eaten?
• Food preferences and dislikes?
• Religious or cultural restriction?
• Able to feed self?
Usual wight • 20% below or above desirable weight?
(what is your usual weight) • Recent weight change? How much lost or gained? Over what time period?
• Reason for loss or gain?
Changes in appetite, taste, smell, chewing, • Type of change?
swallowing • When did change occur?
Recent surgery, trauma, burns, infection • When? Type? How treated?
• Conditions that increase nutrition loss (e.g., draining wounds, effusions, blood
loss, dialysis?
Chronic illness • Type? When diagnosed? How treated?
• Dietary modification?
• Recent cancer chemotherapy or radiation therapy?
 Subjective Data
Examiner Asks
Nausea, vomiting, diarrhea, constipation Any problems? Due to? How long?

Food allergies or intolerances Any problematic foods? Type of reaction? How long?

Medications and/ or nutritional supplements • Prescription medications?

• Nonprescription?
• Use over a 24-hour period?
• Type of vitamin/ mineral supplement? Amount? Duration of use?
• Herbal and botanical products? Functional foods or foods enhanced with
nutrients? Specific type/ brand and where obtained? How often used? Who
recommended? How does it help you? Any problems?
Self-care behaviors • Meal preparation facilities?
• Transportation for travel to market?
• Adequat income for food purchase?
• Who prepares meals and does shopping?
• Environment during mealtimes?
 Subjective Data
Examiner Asks
Alcohol or illegal drug use • When was last drink of alcohol?
• Amount taken that episode?
• Amount alcohol each day? Each week?
• Duration of use?
(repeat questions for each drug used)
Exercise and activity patterns • Amount?
• Type?
Family history, heart disease, osteoporosis, • Effect of each on eating patterns?
cancer, gout, GI disorders, obesity, or • Effect on activity patterns?
diabetes
 Objective Data
Table 11-5 Clinical Signs of Malnutrition
Area of Normal Signs Associated With Malnutrition Nutrient Deficiency
Examination Appearance
Skin Smooth, no signs 1. Dry, flaking, scaly 1. Vitamin A, Vitamin B-complex, linoleic
of rashes, bruises, 2. Petechiae/ ecchymoses acid
flaking 3. Follicular hyperkeratosis (dry, bumpy 2. Vitamin C and K
skin) 3. Vitamin A, linoleic acid
4. Cracks in skin, lesions on the hands, legs, 4. Niacin, tryptophan
face, or neck 5. Niacin
5. Pellagrous dermatosis (hyperpigmentation 6. Riboflavin, vitamin B6
of skin exposed to sunlight) 7. Vitamin B6
6. Nasolabial seborrhea 8. Linoleic acid
7. Acneiform forehead rash 9. Excessive serum levels of LDLs or VLDLs
8. Eczema
9. Xanthomas (excessive deposits of
cholesterol)
Hair Shiny, firm, does 1. Dull, dry, sparse 1. Protein, zinc, linoleic acid
not fall out, easily, 2. Color changes 2. Copper or protein
healthy scalp 3. Corkscrew hair 3. copper
 Objective Data
Table 11-5 Clinical Signs of Malnutrition
Area of Normal Signs Associated With Malnutrition Nutrient Deficiency
Examination Appearance
Eyes Corneas are clear, 1. Foamy plaques (bitot’s spots) 1. Vitamin A
shiny; membranes 2. Dryness (xerophthalmia) 2. Vitamin A
are pink and 3. Softening (keratomalacia) 3. Vitamin A
moist; no sores at 4. Pale conjunctivae 4. Iron, Vitamins B6, B12
corners of 5. Red conjunctivae 5. Riboflavin
eyelieds 6. blepharitis 6. Vitamin B-complex, biotin
Lips Smooth, not 1. Cheilosis (vertical cracks in lips) 1. Riboplavin, niacin
chapped or 2. Angular stomatitis (red cracks at sides of 2. Riboplavin niacin, iron, vitamin B6
swollen mouth
Tongue Red in 1. Glossitis (beefy red) 1. Vitamin B-complex
appearance; not 2. Pale 2. Iron
swollen or 3. Papillary atrophy 3. Niacin
smooth, no lesions 4. Palillary hypertrophy 4. Multiple nutrients
5. Magenta/ purplish colored 5. riboflavin
Gums Reddish-pink, 1. Bleeding 1. Vitamin C
firm, no swelling
or bleeding
 Objective Data
Table 11-5 Clinical Signs of Malnutrition
Area of Normal Signs Associated With Malnutrition Nutrient Deficiency
Examination Appearance
Nails Smooth, pink 1. Brittle, ridged, or spoon shaped 1. Iron
(koilonychia) 2. Vitamin C
2. Splinter hemorrhages
Musculoskelet Erect posture, no 1. Pain in calves, thighs 1. Thiamine
al malformations, 2. Osteomalacia 2. Vitamin D, calcium
good muscle tone, 3. Rickets 3. Vitamin D, calcium
can walk or run 4. Joint pain 4. Vitamin C
without pain 5. Muscle wasting 5. Protein, carbohydrate, fat
Neurologic Normal reflexes, 1. Peripheral neuropathy 1. Thiamine, vitamin B6
appropriate affect 2. Hyporeflexia 2. Thiamine
3. Disorientation or irritability 3. Vitamin B12
 Anthropometric Measures

The measures evaluate growth,

development, and body composition. The most
commonly used anthropometric measures are
height, weight, triceps skinfold thickness, elbow
breadth and arm and head circumferences.
 Derived Weight Measures

Three derived weight measures are used to depict changes in body weight. Body weight as a percentage of ideal body weight is
calculated using the following formula:

Abnormal Findings: A current weight of 80% to 90% of Ideal weight suggests mild mainutrition; 70% to 80 %, moderate mainutrition, and < 70%, severe malnutrition

Ideal weight is based on the Metropolitan Life Insurance Tables, 1983. these
tables remain the recommended standard. The percet usual body weight is
calculated as follows
Abnormal findings:
• A current weight of 85% to 95% of usual
body weight indicates mild malnutrition;
75% to 84% moderate malnutrition; and
<75% severe malnutrition
Recent weight change is calculated using the following formula: • An unintentional loss of >5% of body
weight over 1 month, >7,5% of body
weight over 3 months, or >10% of body
wight over 6 months is clinically
significant
 Body Mass Index

Abnormal Findings:

BMI interpretation for adults:

Body Mass Index, Body mass index is a
1) <18.5 Underweight
practical marker of optimal weight for height
2) 18,5-24,9 Normal weight
and an indicator of obesity or undernutrition.
3) 25.0-29.9 Overweight
It is calculated by
4) 30.0-39.9 Obesity

5) >40 Extreme obesity

BMI interpretation for children ages 2-20 years:

1) <5th percentile Underweight

2) 5th-85th percentile Healthy weight

3) 85th-95th percentile Overweight

4) >95th percentile Obese

 Waist-to-Hip Ratio

The waist to hip ratio assesses body fat distribution as an indicator of health risk. Obese persons with
a greater proportion of fat in the upper body, especially in the abdomen, have android obesity, obese
persons with most of their fat in the hips and thighs have gynoid obesity. The equation is;

Abnormal findings: A waist-to-hip ratio of 1.0 or greater in men or 0.8 or greater in women indicative of android (upper
body) obesity and increasing risk for obesity-related diseases and early mortality
 Skinfold Thickness

Skinfold thickness measurements estimate the body fat stores or the extent of obesity or undernutrition. Although other
sites can be used (biceps, subcapsular. or suprailiac skinfolds), the triceps skinfold (TSF) is most easily accessible. and
standards and techniques are most developed for this site. To measure TSF thickness:
1) Have the ambulatory person stand with arms hanging
freely at the sides and back to the examiner. (Non-
ambulatory persons should lie on one side. The
uppermost arm should be fully extended, with the palm
of the hand resting on the thigh.)

2) Using the thumb and forefinger of your left hand,

gently grasp a fold of skin and fat on the back of the
person's left upper arm, midway between the acromion
process of the scapula and the olecranon process (the
tip of the elbow). Gently pull the skinfold away from
the underlying muscle (Fig. 11-4).
11-4
 Skinfold Thickness

3) While grasping the skinfold, pick up the calipers

with your right hand and depress the spring-loaded
lever. Apply caliper jaws horizontally to the fat
fold. Release the lever of the calipers while holding
the skinfold. Wait 3 seconds, and then take a
reading. Repeat three times, and average the three
skinfold measurements (Fig. 11-5).

4) Record measurement to the nearest 5 mm (0.5 cm)

on the nutritional assesment data form. Compare
the person's measurements with standards be age, 11-5

gender, and body frame size.

Abnormal Findings, TSF values 10% below or above

standard suggest undernutrition and overnutrition, respectively.
 Mid-Upper Arm Circumference

Mid-Upper Arm Circumference (MAC) estimates

skeletal muscle mass and fat stores.

1) Have the person stand or sit with arm hanging

fully extended and relaxed by the side of the
body

2) Loop the insertion tape at measuring tape

around the arm at the midpoint at the upper arm
(midway between the acromion and olecranon
processes)

3) Position the tape horizontally at the midpoint,

and then tighten it firmly around the arm but
not so tightly as to cause skin contour
indentation or pinching (Fig. 11-6).

4) Note and record the measurement (in

centimeters) on the appropriate form. Compare
with norms
11-6
 Mid-Upper Arm Circumference

For example, a normal MAC for a 20-year-old female ranges from 23 to 34.5 cm; for a 20-
year-old male, the normal range is 27/2 to 37.2 cm. Remember that accurate MAC and TSF
measurements are difficult to obtain and interpret in older adults because of sagging skin, ages
in fat distribution, and declining muscle mass

Abnormal findings: Measurements below the 10 th percentile or above the 95 th percentile warrant further medical and
nutritional evaluation, very high or very low readings may be due to examiner error
 Documentation and Critical Thinking

Sample Charting
Subjective
No history of diseases or surgery that would alter intake/ requirements; no recent weight changes; no
appetite changes. Socioeconomic history is noncontributory Does not smoke, drink alcohol, or use illegal,
prescription, or over-the-counter drugs. No food allergies. Sedentary lifestyle; plays golf once per week.
Objective
Dietary intake is adequate to meet protein and energy needs. No clinical signs of nutrient deficiencies.
Height, weight, and screening laboratory tests within normal ranges.
 Documentation and Critical Thinking

Focused Assessment: Clinical Case Study 1

Molly is a 14-year-old high school freshman who has been overweight most of her life
Subjective
Molly presents to the school clinic with a weight gain of 10 pounds since starting high school 6 months ago. Daily calorie Intake
averages 2500 to 3000 calories/day. Skips breakfast and eats lunch at a fast food restaurant across the street from the high
school-usually a cheeseburger, fries, and soft drink. Lives in a low-income neighborhood where the nearest grocery store with
fresh fruits and vegetables is a bus ride away, and there are few safe laces to exercise
Objective
Inspection: General appearance is overweight for age and height
Anthropometric: Height is 157.4 cm (62 in). Current weight is 63.6 kg (140 lb); BMI is 25.6 (91st percentile-at risk for
overweight).
Laboratory: Not available, but fasting plasma glucose should be checked for prediabetes.
Assessment
Imbalanced nutrition: more than body requirements R/T high fat and calorie intake, undesirable eating patterns, lack of exercise,
environmental influences, knowledge deficit.
Overweight with high risk for becoming an obese adult and for developing obesity related complications, such as type 2
diabetes mellitus, sleep apnea, arthritis, asthma, poor self-esteem and quality of life, and metabolic syndrome
 Documentation and Critical Thinking

Focused Assessment: Clinical Case Study 2

E.F. is an 87-year-old widow who lives alone in her own home. She has enjoyed good health all of her life
Subjective
During the past year, she has experienced declining memory and no longer cooks or drives. Relies on children to take her
grocery shopping and prepare occasional meals. Income adequate. Describes her appetite as excellent. Spends her days
watching television and reading. Experiences occasional constipation. Eats a well-balanced diet and enjoys high carbohydrate
foods such as cookies, candy, and doughnuts because they are easy to chew. Caloric intake is 1800 kcal/day
OBJECTIVE
Inspection: No clinical signs of nutrient deficiencies
Anthropometric: Height is 160 cm (63 in). Current weight is 56 8 kg (125 lb), usual weight is 56.8 kg (125 lb), and ideal weight
is 56.4 kg (124 lb)
Laboratory: Hemoglobin, hematocrit, and albumin values within normal limits
Assessment
Normal nutriture
Constipation related to inactivity and diet highs in refined carbohydrates
 Abnormal Findings
Table 11-6 Clasifications of Malnutrition

Type/ Etiology Clinical Features Anthropometric Laboratory Findings

Measures
Obesity Obese appearance • Weight > 120% standard • Serum cholesterol
due to caloric excess refers to weight for height 200 mg/dL
more than 20% above ideal body weight • BMI >30 • Serum triglycerides
or body mass index (BMI) of 30.0-39.9. • Triceps skinfold (TSF) >250 mg/dL
The cases are complex and multifaceted >10% standard
genetic social, cultural, pathologic, • Waist to hip ratio > 1.0
psychological, and physiologic factors (men) or 0.8 (women)
are implicated. Regardless of cause, the • BMI 240 is morbid or
underlying problem is usually an extreme obesity
imbalance of caloric intake and caloric
expenditure. In most cases, a small
caloric surplus over a long period results
in the extra pounds. Although visceral
protein levels are normal in the obese
individual. anthropometric measures are
above normal
 Abnormal Findings
Table 11-6 Clasifications of Malnutrition

Type/ Etiology Clinical Features Anthropometric Laboratory Findings

Measures
Marasmus Starved appearance • Weight < 80 % standard
(protein-calorie malnutrition) is due to for height
inadequate intake of protein and calories • TSF 90% standard
or prolonged starvation. Anorexia, bowel • Mid-upper arm muscle
obstruction, cancer cachexia, and chronic circumference (MAMC)
illness are among the clinical conditions <90% standand
leading to marasmus. Marasmus is
characterized by decreased
anthropometric measures weight loss and
subcutaneous fat and muscle wasting.
Visceral protein levels may remain within
normal ranges
 Abnormal Findings
Table 11-6 Clasifications of Malnutrition

Type/ Etiology Clinical Features Anthropometric Laboratory Findings

Measures
Kwashiorkor • Well nourished appearance • Weight >100 standard • Serum albumin
(protein malnutrition) is due to diets high • Edematous for height •  <3,5 g/dl.
in calories but contain little or no protein, • TSF >100% standard • Serum transferrin
e.g. low-protein liquid diets, fad dirts and <150 mg/dL
long-term use of dextrose containing IV
fluids. Individuals with kwashiorkor, in
contrast to those with marasmus, have
decreased visceral protein levels but
adequate anthropometric measures. They
may therefore appear well nourished or
even obese
 Abnormal Findings
Table 11-6 Clasifications of Malnutrition

Type/ Etiology Clinical Features Anthropometric Laboratory Findings

Measures
Marasmus/kwashiorkor mix Emaciated appearance • Weight <70% standard • Serum albumin
is due to prolonged inadequate intake of • TSF <80% standard < 2,8g/dL
protein and calories, such as severe • MAMC <60% standard Serum transferrin
starvation and severe catabolic states. <100 mg/dL
This mix combines elements of both
marasmus and kwashiorkor. Nutritional
assessment findings include mascle, fat,
and visceral protein wasting Individuals
have usually undergone acute catabolic
stress, such as major surgery, trauma, or
burns in combination with prolonged
starvation or have AIDS wasting Without
mutritional support, this type of
malnutrition is associated with the
highest risk for mirbidity and mortality
 Abnormalities Due to Nutritional Deficiencies

Pellagra

Pigmented Keratoric scaling lesions resulting from

a deficiency of niacin. These lesions are especially
prominent in areas exposed to the sun, such as
hands, forearms, neck, and legs.

Kwashiorkor

Occurs in children and adults whose diets contain

mostly carbohydrate and little or no protein and
are under stress (growth, parasitic or viral
infections, major surgery, trauma, or burns).
Accompanying signs include generalized edema,
scaling areas of decreased pigmentation, and
decreased hair pigmetation
 Abnormalities Due to Nutritional Deficiencies

Follicular Hyperkeratosis

Dry, bumpy skin associated with vitamin A

and/ or linoleic acid (essential fatty acid)
defiency. Linoleic acid deficiency may also
result in eczematous skin, expecially in infants

Scorbutic Gums

Deficiency of vitamin C. Gums are swollen,

ulcerated, and bleeding due to vitamin C-induced
defects in oral epithelial basement membrane and
periodontal collagen fiber synthesis
 Abnormalities Due to Nutritional Deficiencies

Rickets

Sign of vitamin D and calcium

deficiencies in children (disorders of
cartilage cell growth, enlargement of
epiphyseal growth plates) and adults
(osteomalacia)

HIV Infection Discordant Twins

An HIV-infected 4,5-year-old girl with her

uninfected twin brother. The girl has been
sickly since shortly after birth and suffers
from HIV- associated Malnutrions
 Abnormalities Due to Nutritional Deficiencies

Bitot’s spots

Foamy plaques of the cornea that are a sign of vitamin A

deficiency. Severe depletion may result in conjunctival
xerosis (drying) and progress to corneal ulceration and
finally, destruction of the eye (keratomalacia)

Magenta tongue

A sign of riboflavin deficiency. In contrast, a pale tongue

is probably attributable to iron deficiency; a beefy red-
colored tongue is caused by vitamin B-complex
deficiency