09.03 Nutrition Assessments

Hey guys? Today I'm going to talk to you about nutrition assessment. Nutrition plays such an important role in overall health. The nurse has the first nutrition touchpoint with the patient when they conduct a nutrition screen. And then a lot of cases, the initial screen by the nurse will determine if a patient is ever seen by the dietician. In addition, the nurse will often be there to help carry out any nutrition interventions. So, this lesson is about the most common signs that you will see when nutrition status has been compromised.

First, we will go over what to look out for in a physical assessment. Second, we will discuss the ABCDs of a nutrition assessment. I'll leave you on your toes with that for now and start with the physical assessment. So, here we go. If you have already watched our health assessment video, you may recognize this slide. I pulled it in here and highlighted in blue specific areas that I want to focus on for nutrition. Nutrients like protein, fats, vitamins, minerals, they're required for essential reactions in literally every part of the body. From the hair on your head to the nails on your toes. So, I'm going to walk you through the most common nutrition signs and symptoms and risk factors.

Signs and symptoms indicate a current problem. For example, a patient with muscle wasting that indicates malnutrition. Risk factors are things to look out for that might cause a problem. An example of this would be a patient that has dementia who starts forgetting to make meals and eat. So, first we will start with the skin or integumentary. There are a few things that you might notice when looking at the skin that will have a nutritional significance.

First, I will start with some signs and symptoms of deficiencies. You may know the pallor of a patient that has anemia. They may be very pale looking. You may also see skin changes with certain vitamin deficiencies, vitamin C, niacin, riboflavin. With vitamin C, you see a rash of little dots. Niacin causes darkening and hardening of the skin. Wound healing may be compromised because of inadequate protein, inadequate zinc, vitamin A, vitamin C and B2 which is riboflavin.

Now onto some risk factors. A yellow coloring of the skin caused by jaundice is associated with liver disease which is often associated with malnutrition due to decreased appetite, early satiety which means that you're getting full quickly and poor absorption. Acanthosis nigricans is a darkening of the skin around the neck, sometimes under the arms and it's associated with high insulin in patients with diabetes.

Next I'd like to talk about neurologic status. Deficiency of almost all the B vitamins can lead to altered neurologic status or altered mental status. And the acronym we'll use for that is AMS, altered mental status. B12 in particular is actually involved in the myelin sheath production. And if you remember, myelin sheath protects nerve cells. It's like that plastic wrapping around a wire, helping to make sure the electric charge continues down the wire.

Some neurologic risk factors include chewing or swallowing problems. Patients may start pocketing food, which means that they're actually getting little pieces of food trapped in their cheek. All because they've forgotten to chew and swallow. Patients may be at risk for aspiration where some of the food is going into the trachea or airway instead of into their esophagus. That can be caused from dysphasia, which is the name for a swallowing disorder. So, patients may also forget to eat or have difficulty preparing food.

Head and neck. I'll start with the signs and symptoms. So, for hair you may see hair loss related to protein or iron deficiency. A goiter, which is an enlargement of the thyroid gland is related to iodine deficiency. You may see impaired vision due to inadequate vitamin A intake, bleeding gums and glossitis. Glossitis is an inflammation of the tongue. They're associated with vitamin C deficiency. A red swollen tongue and cracked lips are related to riboflavin or B2. And then lastly, the smooth tongue can be seen in B12 deficiency.

Now some risk factors impaired swallowing can have profound impacts on nutrition. And I mentioned swallowing in the last slide as well. Sometimes it's more physical thing. Sometimes it's more neurologic thing. One difficulty with swallow is you don't always know how long the issue will last. Sometimes it can go on indefinitely and other times it can just be a short term issue. Altered dentition can cause patients to start avoiding difficult eat foods like perhaps meats. Which are difficult to cut into small enough pieces to swallow.

Now let's talk about the abdomen or gastrointestinal tract. For the abdomen I will leave the signs and symptoms blank. Diarrhea can be associated with some deficiencies. However, diarrhea is such a nonspecific symptom. What I mean by that is that there are so many things that can cause diarrhea that would be impossible to know for sure if it was related to a deficiency versus one of the dozens of other causes. There are a lot of GI risk factors. The first one is too many or too few bowel sounds. The second one I want to talk about is bloating. The third is ascites, which I have a picture here to the right. Which is fluid in the abdomen.

And then, I’m gonna use an acronym here that you may see nausea, vomiting, constipation or diarrhea. All of those are risk factors as well. Blood in the stool which can lead to decreased iron. And the last one here is steatorrhea, which actually means fat in the stool and that's related to issues with absorption. Basically if it's staying in the small intestines and then passing through the colon, it's not being absorbed into the body and used for energy.

For musculoskeletal, the signs and symptoms you might see are muscle wasting which could indicate a protein calorie malnutrition. And it's particularly prominent in the temporal area in the shoulders and clavicle. So, even in patients that are overweight, you can still look in these places for signs that there's some muscle wasting. You may also note bone shape or density associated with calcium problems, vitamin C or Vitamin D deficiencies. Here we see a curvature of the spine related to osteoporosis. And we don't have any risk factors here.

Genitourinary, we'll leave the signs and symptoms blank here and focus on the risk factors. Which include frequent urination in patients with diabetes and we'll also have here decreased urine output or UOP in patients for example with renal or kidney disease. They may be needing to watch their sodium intake and their fluid intake.

Now onto the ABCDs. In addition to the physical assessment, it is important to be able to identify other factors that might either be signs of deficiency or might be factors that increase risk. An easy acronym for each of the important factors to consider is ABCD, which stands for anthropometrics, biochemical, clinical and dietary. Anthro actually means human and metric means measures. So, we're literally measuring the human. So, we have height, weight, percent weight change, body mass index, percent ideal body weight and head circumference, which is used in infants.

Weight change can be a significant indicator of malnutrition. However, fluid losses must be ruled out. A dialysis patient losing 20 pounds due to dialysis treatment is not necessarily malnourished. However, patient who's lost 20 pounds in a few weeks due to poor intake is likely malnourished.

Percent weight change takes into account weight loss in relation to the original size of the patient. The timeframe is then looked at to determine the level of risk based on the amount of time. As long as you can relapse fluid as the cause is a very good indicator. It's also relevant here if the weight loss is intentional versus unintentional. Unintentional weight loss may indicate underlying issue. For example, loss of appetite related to medication or to liver disease. It could also be due to increased nutrition needs. For example, in a patient with cancer.

MI is a ratio of height to weight. It's measured in kilograms per meter squared. I'll write that on here. Kilograms per meter squared. And then percent ideal body weight is calculated using height but amputations can be adjusted for. Whereas a tool like BMI doesn't allow for that.

Anthropometrics can be very helpful, but don't ever assume that a patient has to be emaciated or severely underweight to be malnourished. Biochemical is a patient's lab data. There are lab tests that can be done to identify nutrition deficiencies. But they are not incredibly common in an acute hospital setting. The tests are expensive. They're only run if there's a reason to suspect a specific deficiency. And I've seen a few like vitamin D and iron, but most are pretty uncommon.

So, typically the labs I will look for, they'll fall into the following categories and they tend to center around specific diseases. So, for gastrointestinal, we'll a lot of times look at LFTs or liver function tests. And those include alanine transaminase, which is abbreviated ALT and aspartate aminotransferase, which is abbreviated AST.

For diabetes we'll look at blood sugars, which will sometimes be fasting. In the hospital setting will almost always look at fasting and then hemoglobin A1c as well. For the renal profile, we'll look at glomerular filtration rate, GFR. We will look at blood urea nitrogen or BUN. We'll look at creatinine, potassium, phosphorus and sodium. All those will be evaluated.

Lipid profile, we're going to be looking at total cholesterol and we'll also be looking at triglycerides as well as low-density lipoproteins, LDL. Anemia, the most common we see is iron, but we might also see anemia related to B12 or thiamine deficiency.

Protein, albumin and prealbumin can indicate ... I'll go ahead and show you the abbreviations here as well, can indicate a protein malnutrition. Albumin gets a pretty delayed response. And liver and kidney issues will impact albumin, which can make it a poor nutrition indicator for patients with those issues. Prealbumin is a better indicator, but it's more expensive and not as routinely ordered, although some hospitals have started using it more often.

Clinical, when referring to clinical, I'm looking at medical conditions, treatments, medications, and vital signs that can also be risk factors for nutrition deficiencies. Medical conditions that impact nutrition include DM or diabetes, include kidney issues and also gastrointestinal diseases. Those are some of the most common. For treatments, the most common treatments that can cause issues sometimes patients on dialysis. Now it's common to waste protein during a dialysis treatment. And so, patients taking dialysis regularly may need to increase their protein intake to replace that.

Surgery requires extra nutrients for wound healing for example, protein, vitamin C, zinc. There are also some common treatments and procedures that make unsafe for to feed. Now onto medications. A lot of medications have nutritionally relevant side effects. Chemotherapy can cause altered taste. It can cause nausea, vomiting, mouth sores and constipation. ABX stands for antibiotics and that can cause diarrhea. And then there's medication called Propofol. It's used in the ICU to sedate patients. It's a lipid emulsion, which means you are delivering fat right into the vein of these patients. So, you want to adjust nutrition support so as not to overfeed them.

Lastly here we have vital signs. A common one is blood pressure. If someone has elevated blood pressure, they might need to look at decreasing their salt intake. Dietary, basically here we want to get a sense of possible risk factors based on the type of diet a patient has. Before I discuss how we collect that information, I want to mention that religious cultural ethnic influences may impact a patient's food choice. For example, an Orthodox Jew may reduce or may request kosher food preparation. Make sure to ask the patient if they have any diet modifications for those reasons.

Now, under the methods of collecting data. The three day food diary is where a patient writes down all their intake for three straight days as they go along. It doesn't really work in a hospital setting, but it's great for an outpatient to kind of send them home with homework and they can bring it back. The 24 hour recall, basically we ask what did you eat in the last 24 hours? And then the diet history, in this case will prompt with questions like, what is a typical breakfast? What's a typical lunch? What time of day do you usually eat? And you start looking for trends.

People tend to be more honest with the 24 hour recall since it's specific. However, the 24 hour recalls are not helpful for patients that have been NPO or nothing by mouth and haven’t been able to eat in the last 24 hours. Now that I have dug in there with you and provide a lot of very specific examples, I want to back up again and empathize ... I'd love to empathize with you too, but I want to emphasize the importance of knowing the basic signs and the basic risk factors that are going to impact the nutrition of your patient.

Patients in the hospital will only see the dietician maybe once a day at the very most. Likely they will only be seen every few days. So, the communication between the nurse and the dietitian makes all the difference in getting the bigger picture of the patient. I want to leave you with a few final takeaways. First, a reminder that the first touchpoint for nutrition is the nurse. You are so critical in this role. Second, make sure to know when something is abnormal and how to describe it. And lastly, remember your ABCDs, the most common risk factors and signs and symptoms for nutrition deficiencies.

Thank you so much for hanging in there with me and smile at your dietician the next time you see them. Now go out and be your best self today. And as always, happy nursing.