A nutritional assessment is the systematic process of collecting and interpreting data to determine an individual’s nutritional status, identify deficiencies or excesses, and guide appropriate interventions
Definition
It is the structured systematic process of collecting and interpreting subjective and objective data to determine an individual’s nutritional status.
Nutritional assessment includes anthropometry, biochemical, clinical, and dietary evaluation.
Purposes
- To obtain, verify, and interpret data needed to identify nutrition-related problems.
- To identify those who need nutritional interventions.
- To provide nutrients required for optimal well-being.
- To formulate person-centered approach.
- To revise the plan as per the change.
Articles
Preparation of Equipment
- Stadiometer to check height.
- Weighing scale.
- Content with nutritive values.
- Patient’s case sheet with lab reports.
Procedure
| Nursing actions | Rationale | |
| 1. | Explain the procedure to the patient. | To enhance cooperation. |
| 2. | Collect brief history focusing on present and past medical, personal family, and socioeconomic history. | To identify problems related to nutrition. |
| 3. | Gather dietary history Type of diet, meals taken per day with quantity, likes and dislikes, allergies, food restrictions, use of dietary supplements. Appetite, chewing, and digestive problems. | To identify problems related to nutrition. |
| 4. | Perform anthropometric measurement Height, Weight, BMI Weight (kg)/height (m²) | BMI <18.5: Underweight BMI 18.5-24.9: Normal BMI 24.9-29.9: Overweight BMI >30: Obesity |
| 5. | Biochemical data. Interpret whether they are in normal range or increased or decreased. | Changes indicate whether the patient is malnourished or overnourished. |
| Hemoglobin Males: 14 – 16g / dL Females: 12 – 14g / d L | Decreased value indicates anemia secondary to vitamin deficiency. Increased value may indicate dehydration, high altitude, intravascular hemolysis. | |
| Hematocrit Males: 40%-52% Females: 37%-47% | Same as for hemoglobin. | |
| Serum albumin: 3.5 – 5g / dL | Decreased value may indicate the need to improve nutritional intake or fluid intake. Increased value may indicate hemoconcentration or shock. | |
| Serum transferrin: 200 – 350mg / dL | Decreased value may indicate protein and calorie deficit. Increased value may indicate iron-deficiency anemia, acute hepatitis, or polycythemia. | |
| Blood urea nitrogen: 8 – 23mg / dL | Decreased value may indicate low protein intake. Increased value may indicate nephrotic syndrome, gouty arthritis, or obstructive uropathy. | |
| Serum creatinine: 0.6 – 1.2mg / dL | Decreased value may indicate severe malnutrition. Increased value may indicate nephritis or chronic kidney disease. | |
| 6. | Clinical data General appearance Normal: Alert/responsive. Abnormal: Listless, apathetic, cachectic, or easily fatigued. | |
| 7. | Hair Normal: Shiny, neither dry nor oily, thick and smooth. Abnormal: Dull, brittle, easily plucked, thin, and sparse. | |
| 8. | SkinNormal: Smooth, slightly moist, absence of edema or skin lesions. Abnormal: Rough, scaly, dry, pigmented, pale, yellow tinged, bruises, petechiae, swelling, rashes, or subcutaneous fat loss. | |
| 9. | Face and neck Normal: Healthy appearance with uniform color. Abnormal: Dark skin over cheeks and under eyes/flaky skin and mouth/edema. | |
| 10. | Eyes Normal: Bright, clear, moist healthy, pink conjunctiva. Abnormal: Pale, conjunctiva, dry eyes, Bitot’s spots, dull or soft appearance of cornea. | |
| 11. | Lips Normal: Smooth and moist. Abnormal: Swollen, puffy or chapped, and lesions at the corners. | |
| 12. | Tongue Normal; Pink in color, smooth, and moist. Abnormal: Presence of surface papillae, beefy red, swollen, hypertrophy or atrophy. | |
| 13. | Teeth Normal: Straight, not crowded or overlapped, well-shaped jaw. Abnormal: Caries, cavities, missing teeth, malocclusion, or mottled. | |
| 14. | Gums Normal: Firm and pink. Abnormal: Spongy, bleed easily, inflamed or recessed. | |
| 15. | Glands Normal: No enlargement of thyroid or lymph nodes. Abnormal: Enlargement of thyroid or lymph nodes. | |
| 16. | Nails Normal: Firm and pink; concave in shape, capillary refill of 2-5 seconds. Abnormal: Spoon shaped, brittle, pale with ridges and increased capillary refill time. | |
| 17. | Musculoskeletal Normal: Well-developed, firm and toned muscles; some fat under skin and erect posture. Abnormal: Flaccid or poor muscle tone, muscle wasting, poor posture, bowed legs, tender calf, tingling or weakness, prominent scapulae and ribs. | |
| 18. | Abdomen Normal: Flat.Abnormal: Swollen and fluid-filled. | |
| 19. | Nervous system Normal: Normal reflexes, alert, good attention, emotionally stable. Abnormal: Confusion, inattention, decreased reflexes, irritability, and emotionally labile. | |
| 20. | Cardiovascular system Normal: Normal heart rate and rhythm, normal blood pressure. Abnormal: Cardiac enlargement/ murmurs/tachycardia. | |
| 21. | Gastrointestinal system Normal: Good appetite; regular and normal elimination. Abnormal: Anorexia, enlarged liver or spleen, indigestion, diarrhea or constipation. | |
| 22. | Dietary data24-Hour recall of dietary intake. | |
| 23. | Document the findings. | Serves as a legal evidence, prevents duplication of care. |
24-Hour Dietary Recall
It is a structured interview intended to obtain detailed information regarding all the food and beverages consumed by the respondent in the past 24 hours, most commonly, from 06.00 am of the previous day to 06.00 am of the present day.
General Instructions
- Refer standard content for nutritive values of each food item.
- In the date column, specify the date of starting.
- In the time column, specify the time the person takes food or beverages.
- For example, 06.00 am, 08.30 am, 11.00 am.
- For food items, record the food or beverages taken.
- For example, idly 2 nos., sambar, chana dal.
- Ingredient column can be used or missed.
- It is used when the value is calculated for various ingredients in one food item.
- For example, 100 mL of sambar may have 25 g of dhal, 25 g of carrot, 10 g of beans, and 5 mL of oil.
- In this case, the value is calculated for each ingredient.
- In case of readymade values, the ingredient column can be deleted.
- For example, the value for two chapatis can be given directly instead of flour, salt, and oil.
- Likewise, the items consumed are calculated and a total value is written.
- Calculate the ideal and actual intake.
- Compare and interpret the differences.
- Formulate a menu plan based on the changes.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Stare FJ. The Pathology of Nutritional Disease. Am J Public Health Nations Health. 1948 Jun;38(6):880–1. PMCID: PMC1624455. https://pmc.ncbi.nlm.nih.gov/articles/PMC1624455/
Stories are the threads that bind us; through them, we understand each other, grow, and heal.
JOHN NOORD
Connect with “Nurses Lab Editorial Team”
I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.
