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Dec.29.2020

Assessment: Nutrition Screening (Home Health Care) - CE

ALERT

Closely monitor electrolyte levels in patients who are being fed after a period of inadequate nutrition.

OVERVIEW

Initial screening and ongoing assessment of nutritional status are essential aspects of patient care. The screening is usually performed by a nurse but may also be performed by a dietetic technician, registered dietitian, physician, or other qualified health care professional. The purpose of screening is to detect nutritional problems and identify patients who are malnourished or at nutritional risk who may need a more detailed assessment (Table 1)Table 1. The components of nutritional screening may vary based on the patient population and the setting, but most cases include determining if a patient has a history of weight loss over a specific period or a recent history of poor appetite and inadequate nutritional intake.

Comprehensive assessment of nutritional status involves interpreting data from the initial screening and information obtained during a complete nutritional assessment, anthropometric measurements, and physical examination. Biochemical parameters may offer information on immune function and protein status.

Height and weight help determine nutritional status and are the typical anthropometric measurements used to calculate body mass index (BMI).

The direct measurement of height involves a measuring rod and the patient standing or lying flat. When the patient’s condition prevents such positioning, indirect methods, such as recumbent length, arm span, or knee height, may be used to estimate height.

Body weight is one of the most important measurements in assessing nutritional status and for predicting energy expenditure. Weight changes may indicate nutritional status and may help to estimate risk and make clinical management decisions (Table 2)Table 2. Weight and body mass information can be evaluated in several ways, including estimating usual body weight, calculating ideal body weight, measuring actual body weight, and calculating BMI. In most cases, obtaining repeated body weight measurements over time is highly recommended to monitor changing trends in weight.undefined#ref6">6 Serial assessment of body weight is easily obtained, inexpensive, and usually acceptable to the patient.6 The magnitude of weight loss is one of the best validated nutritional assessment parameters, and in many cases it is an indicator of underlying disease or an inflammatory condition.6 Percentage of weight change is a useful nutritional assessment parameter and also provides an indirect measure of body adiposity.2 Percentage of weight change is calculated using the following formula:

% weight change =
(usual weight - actual weight) × 100

 
usual weight

BMI provides an estimation of adiposity by calculating weight corrected for height. The easiest way to estimate BMI is to refer to a standard BMI chart (Figure 1)Figure 1. BMI may be listed by degree of adiposity (Box 1)Box 1. However, BMI alone is not a perfect indicator that a person is overweight or obese. Other factors must be considered when evaluating muscular patients (e.g., bodybuilders) and patients with large amounts of edema or ascites because these physiologic states lead to an overestimation of the degree of body fat. BMI may also underestimate fat in older adults.1

No single laboratory test is available for measuring nutritional status or evaluating short-term response to medical nutritional therapy. Along with other assessment data, various laboratory tests conducted over time give more accurate information than a single test. Measuring hepatic proteins (serum albumin, prealbumin, and transferrin) is useful for identifying patients who may become malnourished because of inflammatory processes, which may accelerate nutritional depletion. Although not a direct measure of nutritional status, hepatic proteins indicate the risk of morbidity and mortality.5 In addition, chemistry panels, lipid panels, and hematologic laboratory results may provide information about glucose tolerance, renal function, electrolyte abnormalities related to malnutrition and refeeding syndrome, cardiovascular disease risk, and nutritional anemias, which may indicate a need for nutritional intervention.5

Patients who are identified during the admission process as malnourished or at risk for becoming malnourished should be referred to a registered dietitian. The dietitian can further evaluate the patient and ensure appropriate nutritional intervention and follow-up assessments, including calculation of actual calories required and calories consumed.

The nurse should be aware that patients who have been without adequate nutritional intake for an extended period are at risk for acute electrolyte shifts when adequate diet or enteral or parenteral nutrition is resumed or IV dextrose is administered. This condition, called refeeding syndrome, may cause severe hypokalemia, hypomagnesemia, hypophosphatemia, fluid and sodium retention, and dysfunction of several organ systems. Electrolyte levels in patients who are being fed after a period of inadequate nutrition must be closely monitored.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Provide the patient, family, and caregivers with an explanation of the procedure and the equipment.
  • Explain the process and outcomes of laboratory testing.
  • Instruct the patient, family, and caregivers to collaborate with a registered dietitian to address nutritional concerns, as appropriate.
  • Determine whether the patient is prescribed medications that may contribute to weight gain or loss.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene.
  2. Introduce yourself to the patient, family, and caregivers.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient, family, and caregivers and ensure that the patient agrees to treatment.
  5. Verify the practitioner’s order and assess the patient for pain.
  6. Prepare an area in a clean, convenient location and assemble the necessary supplies.
  7. Assess the patient’s health history for factors influencing current nutritional status (e.g., appetite, dietary supplements, psychosocial factors affecting intake, economic status, cultural issues).
  8. Assess the patient’s medical history, including surgery, and coexisting medical conditions that may compromise nutrition.
  9. Assess the patient’s psychological history, including screening for depression, alcohol abuse, or abnormal psychiatric behavior leading to alterations in food intake.
  10. Assess the patient’s social history, focusing on economic status, avoidance of specific food groups, and food customs influencing nutritional education.
  11. Assess the patient’s dietary history, including current diet, food choices and preferences, appetite, explanations for any restrictions, food allergies, and food intolerances (Box 2)Box 2. Record eating habits that may indicate food practices that impair nutritional status.
  12. Assess for risk factors for nutritional problems, which may include liquid diets, nothing-by-mouth (NPO) status, ability to swallow, and other risk factors related to chronic or acute health status (Box 3)Box 3.
  13. Determine the medications and dietary and herbal supplements the patient is taking, both prescribed and over the counter.
  14. Determine the patient’s ability to manipulate eating utensils safely and self-feed.
  15. Review previous surveys or self-assessments performed by the patient.
  16. Ask the patient to report usual body weight and to recount changes in the last month. Emphasize the importance of an accurate estimate.
  17. Perform hand hygiene and don gloves. Perform a physical assessment, including the condition of skin, hair, nails, oral mucosa, and eyes (Table 1)Table 1. Remove gloves and perform hand hygiene.
  18. Obtain the patient’s actual weight in kilograms. Reweigh the patient if appropriate.3 Stated, estimated, or historical weight should not be used.3
    Rationale: An actual weight is important for nutritional assessment and medication dosing.
    1. Have the patient void.
    2. Ensure that the scale is zeroed and placed on a firm, hard surface. Adjust the scale as needed according to the manufacturer’s instructions.
    3. Help the patient to a standing position, if required.
    4. Have the patient stand on the scale or, if he or she is unable to use a standing scale independently, use a chair, bed, or sling-type scale, when available.
    5. Instruct the patient to remain still and record his or her weight.
    6. If possible, weigh the patient at the same time each day.
  19. Measure the patient’s height, as possible.
    1. Assist the patient to a standing position, if required. Have the patient stand erect with weight equally distributed on the feet with heels against a flat surface (e.g., wall, door frame).
    2. Instruct the patient to let the arms hang freely at the sides with palms facing the thighs.
    3. Have the patient look straight ahead and hold the position. Use a ruler, tongue blade, or other flat surface to measure a line from the top of the head to the wall surface. Measure the length from the floor to the marking on the wall or door frame with a tape measure.
    4. If the patient is unable to stand, use an indirect method of measurement.
  20. Calculate the patient’s ideal body weight using one of these formulas:4
    1. Male: 48.1 kg (106 lb) for the first 152.4 cm (5 ft), then add 2.7 kg (6 lb) per additional 2.5 cm (1 inch).
    2. Female: 45.4 kg (100 lb) for the first 152.4 cm (5 ft), then add 2.3 kg (5 lb) per additional 2.5 cm (1 inch).
  21. Compare the patient’s weight for height with his or her ideal weight.
    Rationale: Significant weight fluctuations or weight outside of normal range indicates nutritional risk. The acceptable range is within 10% above or 10% below ideal body weight.4
  22. Calculate the patient’s BMI (Box 1)Box 1. Compare the patient’s BMI with recommended BMI for height.
  23. Review the history and physical findings, noting any abnormal findings or areas of concern.
  24. Review the results of relevant laboratory tests. Compare the patient’s laboratory results with normal levels.
    Rationale: Abnormal values when considered with other nutritional parameters may indicate malnutrition or refeeding syndrome.
  25. Explain to the patient that the nutritional assessment is complete.
    Rationale: Completeness of data obtained from the history and physical findings allows prompt identification of the risk of malnutrition and the need for nutritional interventions.
  26. Report dietary restrictions and preferences to the practitioner.
  27. Monitor the patient’s nutritional intake, nutritional risks, and weight during each nursing visit.
  28. If the patient is malnourished or at risk for malnutrition, refer him or her to a registered dietitian.
  29. Assess pain, treat if necessary, and reassess.
  30. Discard or store supplies, remove gloves, and perform hand hygiene.
  31. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • Patient’s weight is maintained or changes according to the nutritional care plan.
  • Relevant laboratory test results are within normal limits.

UNEXPECTED OUTCOMES

  • Patient’s weight is below or above usual body weight or ideal body weight.
  • Relevant laboratory test results are not within normal limits.

DOCUMENTATION

  • Results of nutritional screening, including significant differences from normal
  • Serial weights
  • Nutritional intake
  • Device and method used to measure height
  • Patient’s height measurement
  • BMI
  • Laboratory test results
  • Referral to a registered dietitian
  • Education
  • Patient’s weight in kilograms per the organization’s practice
  • Unexpected outcomes and related interventions
  • Patient’s progress toward goals
  • Assessment of pain, treatment if necessary, and reassessment

OLDER ADULT CONSIDERATIONS

  • The normal anthropometric standards are based on a healthy, middle-aged population. However, there are methods of comparing anthropometric measurements over time for older adults.
  • Researchers lack consensus on normal ranges in BMI for older adults.
  • Chronic disease, polypharmacy, and chewing and swallowing difficulties are common in older adults and increase the risk of malnutrition.
  • Screening tools for older adults are helpful for assessment in various clinical settings, including acute care, long-term care, and home care (Figure 2)Figure 2.

REFERENCES

  1. Centers for Disease Control and Prevention (CDC). (2020). About adult BMI. Retrieved October 23, 2020, from https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html (Level VII)
  2. Creo, A.L., Kumar, S. (2020). Chapter 78: Obesity. In R.D. Kellerman, D.P. Rakel (Eds.), Conn’s current therapy 2020 (12th ed., pp. 354-360). Philadelphia: Elsevier.
  3. Institute for Safe Medication Practices (ISMP). (2020). 2020-2021 Targeted medication safety best practices for hospitals. Retrieved October 23, 2020, from https://www.ismp.org/sites/default/files/attachments/2017-12/TMSBP-for-Hospitalsv2.pdf (Level VII)
  4. Litchford, M.D. (2021). Chapter 5: Clinical: Biochemical, physical, and functional assessment. In L.K. Mahan, J.L. Raymond (Eds.), Krause’s food & the nutrition care process (15th ed., pp. 57-80). St. Louis: Elsevier.
  5. Mogensen, K.M., Robinson, M.K. (2020). Chapter 79: Parenteral nutrition in adults. In R.D. Kellerman, D.P. Rakel (Eds.), Conn’s current therapy 2020 (12th ed., pp. 361-370). Philadelphia: Elsevier.
  6. Ziegler, T.R. (2020). Chapter 204: Malnutrition: Assessment and support. In L. Goldman, A.I. Schafer (Eds.), Goldman-Cecil medicine (26th ed., pp. 1401-1405). Philadelphia: Elsevier.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports

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