Nutrition Assessment Overview

Nutrition Assessment

• Diet and health history is important
• Factors influencing nutrition should be taken into account
• Drug-nutrient Interactions must be considered
• Patient Preference is impotant
• Cultural and Religious Restrictions should be considered.
• Alternative Food Diets should be assessed.
• Screening must be performed
• Physical Assessment is necessary
• Check for Signs of Nutritional Status
• Check for Dysphagia
• Assess the patient's nutrition knowledge
• Take a diet history, a food diary spanning 3-7 days is useful
• Look out for Cultural & Religious backgrounds
• Ask about Food preferences
• Note Socioeconomic status
• Examine Social history
• Ask about Alcohol and Tobacco use
• Ask about Illegal substances
• Understand Psychological factors
• Note all Medications
• Look out for Prescription and OTC drugs
• Note Vitamins & Herbal supplements

Assessment Questions

• When assessing the patient, ask about dietary intake and food preferences.
• Consider what type of food a patient likes
• Consider how many meals a patient eats per day
• Note any dietary religious or cultural preferences
• Consider any unpleasant symptoms
• Note which foods cause indigestion, gas, or heartburn
• Note any Allergies, what kind of reaction the patient has and how the allergies are treated
• Consider the patient's sense of Taste, Chewing ability, and Swallowing ability
• Ask the patient if they wear dentures
• Ask the patient if they have difficulty swallowing
• Ask about Appetite and Weight
• Ask the patient if they have had a change in appetite

Factors Influencing Nutrition

• Environmental factors include: Access to full-service grocery stores, the high cost of healthy food, widespread availability of fast food and less healthy options, and a lack of access to safe places to exercise and play
• Socioeconomic factors include: Lack of transportation and fixed incomes

Developmental Factors

• Infants and school age children consume Formula and breast milk and/or Solid foods
• Adolescents have Increased metabolic demands for growth
• Adolescents need Essential Vitamins, Calcium, Iron, lodine, B complex
• Adolescents may develop Eating Disorders like Anorexia Nervosa and Bulimia
• For Young & Middle Adulthood, there is a reduction of nutrient demands
• Pregnancy increases the need for Folic acid and calcium
• Lactation increases the need for protein, calcium, vitamin A&C
• Older Adults experience Age Related Changes
• Older adults experince Loss of teeth
• Older adults experince Reduced saliva production
• Older adults have Atrophy of epithelial cells
• Older adults experience Decreased sense of thirst putting them at risk for dehydration
• Older adults experince Reduced gag reflex
• Older adults experince Reduce esophageal and colonic peristalsis

Drug-Nutrient Interactions

• Analgesics like Tylenol can decrease the absorption of food
• Antidepressants like SSRIs may cause taste alteration and anorexia
• Antihypertensives like Labetalol can cause taste alterations and weight gain
• Bronchodilators like Albuterol can act as appetite stimulants
• Anticoagulants like Warfarin are antagonists to vitamin K
• Diuretics like Lasix decrease drug absorption if taken with food
• Laxatives like Mineral oil decrease absorption of fat soluble vitamins
• Potassium Replacement decreases Vitamin B12 levels
• Antiarrhythmics like Amiodarone can cause taste alterations
• Antibiotics like Bactrim decrease folic acid levels

Cultural Restrictions

• Cultural factors Can influence the meaning of food not related to nutrition
• Cultures may have "Good" and "Bad" associations for certain food
• Some Cultures have foods and special dishes to be eaten when ill
• Culture Can enhance interpersonal relationships
• There are Racial and Ethnic differences regarding diet
• Lactose Intolerance is an example among Asian Pacific, African, Native American, Mexican American, and Middle Eastern ethnic groups

Religious Restrictions

• Muslim dietary restrictions include No pork, alcohol, or caffeine, participation in Ramadan fasting from sunrise to sunset, and following Ritualized methods for animal slaughtering
• Christian dietary restrictions include that Baptists have minimal or no alcohol consumption, and Catholics observe Lent and meatless days
• Hinduism involves No meats and alcohol
• Judaism dietary restrictions: No pork, mixing with milk or dairy products with meat dishes
• Church of Christ of Latter-Day Saints prohibits alcohol, tobacco, and caffeine

Alternative Diets

• Vegetarians include Vegans who eat No meats, dairy or eggs
• Ovo-Lacto vegetarians eat No meats but eat dairy and eggs
• Lacto vegetarians eat No meats or eggs but eat milk
• Semi-Vegetarians include Pescatarians, who eat No meat but eat fish and shellfish
• Medical Diets can be Casein and Gluten free
• Ketogenic diets are recommended for epilepsy

Nutritional Screening

• Nutritional Screening is Used to identify malnutrition or patients at risk
• Malnutrition Risk Factors include unintentional weight loss, modified diets, and altered nutritional symptoms such as N/V, diarrhea and constipation and IV fluids for more than 4-7 days
• Standardized tools include a Mini Nutritional Assessment
• Anthropometric Measurements include Body mass index (BMI) and Ideal body weight (IBW)
• Laboratory Tests include assessing Nutritional Status by checking Protein Plasma, Prealbumin, Albumin, and Retinol-Binding; checking for markers Related to specific diseases, and checking Liver enzymes (LFTs) and Kidney function (GFR)

Acute Care

• Acute care requires Therapeutic diets
• Acute care requires Medical nutrition therapy
• You must focus on Promoting Appetite
• You must focus on Assisting with Oral Feedings
• You must consider Dysphagia
• You must consider Enteral Tube Feedings
• You must focus on Patient Teachings
• You must focus on Health Promotion

Types of Therapeutic Diets

• Clear Liquid diets include Clear, fat free broth, bouillon, coffee, tea, carbonated drinks, and clear fruit gelatin
• Full Liquid diets include Any liquids with smooth-textured dairy products (ice cream) or blended creamed soups, custards, and refined cooked cereal, pudding
• Pureed/Thickened Liquids include Clear + Full liquid with addition of scrambled eggs, pureed meats and vegetables, and mashed potatoes
• Mechanical Soft diets include ground or finely diced meats, flaked fish, cottage cheese, rice, and potatoes
• Soft/Low Residue diets have Addition of low-fiber, easily digested foods, Pasta, casseroles, moist tender meats, canned cooked fruits and vegetables
• High Fiber diets have Addition of fresh uncooked fruits, steamed vegetables, bran oatmeal and dried fruits
• Low Sodium diets have Restrictions: 4 g (no added salt), 2 g, 1 g, or 500 mg
• Low Cholesterol diets have 300 mg/day
• Diabetic diets follow ADA recommendations: Balanced intake of CHO, fats, and proteins
• Gluten-free diets Eliminates wheat, oats, rye, barley and their derivatives
• Regular diets feature No restrictions unless specified

Promoting Appetite

• The Environment should be odor free, have oral hygiene to remove unpleasant tastes, and maintain patient comfort
• Smaller, more frequent meals are key
• Medications affect appetite such as insulin, glucocorticoid, and thyroid hormones which affect metabolism, antifungals and psychotropics which affect taste, and psychotropics and antibiotics which cause nausea
• Make meal times a Create a social activity
• Consult a dietician

Oral Feedings

• When providing oral feedings, Maintain independence and dignity allowing patients to select their own foods and direct what items to eat first and how fast
• Assess for aspiration risk
• Look out for patients at High risk with Decreased alertness, Poor gag reflex, Difficulty managing saliva
• Keep Oral suction at bedside
• Verbal coaching while feeding: and Provide positive reinforcements
• Consult a SLP if needed
  • Provide 30 minute rest periods before eating.
  • Have the patient in an Upright seated position or 90 degrees upright in bed
  • Tell the patient to keep their Head flexed slightly, chin down to prevent aspiration
  • Feed the patient on the stronger side of mouth (unilateral weakness)
  • Only feed the patient 1/2 to 1 teaspoon at a time
  • Have the patient Remain upright position for at least 30-60 minutes after meal
  • have the Patient swallow twice to clear pharynx
  • Inspect mouth for pocket of food

Dysphagia

• Dysphagia is Defined as difficulty swallowing
• Dysphagia Causes neurological, muscular, and obstruction type of disorders
• Warning Signs of dysphagia include: Cough during eating, a Change in voice tone or quality after swallowing, Abnormal movements of mouth/tongue/lips, Slow/weak/imprecise/uncoordinated speech, Abnormal gag reflex, and Delayed swallowing
• Dysphagia Leads to malnutrition and aspiration pneumonia
• Be aware of silent aspiration
• Liquid diets must be Thin (low viscosity), Nectar-like (medium viscosity), Honey-like, or Spoon-thick (viscosity of pudding)
• Remember to Feed slowly, and offer smaller size bites
• Match the speeding of feeding to patient's readiness and, allow thorough chewing and swallowing before taking another bite
• Remove food immediately if coughing or choking begins and suction

Oral Feedings with Visual Deficits

• Give Considerations for patients with Blind or impaired vision
• Maintain independence for patient
• Identify food location on meal plate and use a clock format with meat at 9 o’clock
• Ensure that the plate set up is the same with every meal
• Implement adaptive equipment and larger handled utensils with easy grip

Types of GI Intubation

• Temporary tubes:
  • Nasogastric (NG)**
  • Small bore: Dobhoff (weighted)
  • Nasojejunostomy (NJ)
  • Nasoduodenal (ND)
• Permanent tubes:
  • Gastronomy
  • Jejunostomy

GI Intubation Purposes

• Enteral feeding/Medication: Nutritional supplements into stomach or small intestine; use Duo, Dobhoff, Levin tubes
• Decompression: Removal of secretions and gaseous substances from GI tract; prevention or relief of abdominal distention; use Salem Sump, Levin, Miller-Abbott tubes
• Compression: Application of internal pressure via inflated balloon to prevent internal esophageal or GI hemorrhage; use Sengstaken-Blakemore tube
• Lavage: Irrigation of stomach for bleeding, poisoning, or gastric dilation; use Levin, Ewald, Salem Sump tubes
• Place the patient in high Fowler’s position (90 degrees)
• Determine the length by measuring the distance from the tip of the nose to earlobe to xiphoid process of sternum and mark with tape
• Upon insertion, have the patient take small sips of water
• Flex the patient’s head toward the chest after the tube has passed through the nasopharynx and instruct the patient to mouth breathe
• If the patient starts to cough or shows signs of distress, stop the procedure and remove the tube

GI Intubation-Management

• Checking for placement: Use pH strips and/or use Xray (KUB)
• Minimizing discomfort through oral care
• Replace tube when there is a blockage, flushing tubes regularly with normal saline or warm water, and determining the frequency of replacements dependent on type of tube

Oral Medication through an Enteral tube

• Verify the location of the tube (stomach or jejunum) using X-ray and pH strips for NGT and NJT
• Check for compatibility of medication with location
• Example: Fe dissolves in the stomach and absorbed in the duodenum
• Flush tube with at least 15-30 ml of sterile water in between medications
• Clamp enteral tube for at least for 30-60 minutes after giving medicine
• If liquid preparation is NOT available:
• Crush tablets or simple open gelatin capsules an dilute in sterile water
• DO NOT use tap water

Enteral Feedings Indication

• Indication: Patients who are unable to swallow and; has functional GI tract but are unable to eat
• Enteral tubes:
  • Short term: (<4 weeks):
    • Nasogastric (NGT), and Jejunal as Preferred for gastric reflux risk
  • Long term: (>4 weeks):
    • Gastronomy, and Jejunostomy
• Formula:
  • Continuous: Rate: mL/hr
  • Intermittent or Bolus: Rate: amount Qh

Enteral Feeding

• Warm tube feedings to room temperature
• Patient position:
• High fowler’s or HOB elevated at least 45 degrees
• Reversed Trendelenburg (pt who must be flat)
• Verify placement of NGT prior to feeding
• Start with full strength at slow rates
• Increase every 8-12 hours as tolerated per order
• Signs of Feeding intolerance: high GRV, n/v/d, GI cramping

Gastric Residual Volume

• Indicates Delayed gastric emptying, which can be caused by medications or disease
• Check Q4h or Before each feeding
  • Draw up 10-30 mL of air into the syringe and flush the tube
  • Pull back to aspirate the total gastric content and measure
  • Return contents unless >250 mL
• Large volumes pose a RISK FOR ASPIRATION
  • 500 mL or two consecutive measurements exceeding 250 mL (taken 1 hour apart)
    • Stop feeding!
• Medications can be added to increase emptying, such as Metoclopramide (Reglan) or erythromycin