Nutritional assessment- a vital component

Malnutrition and undernourishment pose a major healthcare problem in the care of hospitalized patients in different care units in developed countries. There are numerous studies in health care literature reporting frequent malnutrition of patients in acute hospitals on admission and deterioration of nutritional status during hospitalization, particularly older people (Inge.K, 1999). Malnutrition can be defined in older people as faulty or inadequate nutritional status; undernourishment characterized by insufficient dietary intake, poor appetite, muscle wasting and weight loss (Carole S. Mackey, 2004).
The cause of malnutrition is commonly contributed to medical, social and environmental as well as individual factors, such as poor appetite and disinterest in food, unpalatable or inadequate food, and lack of assistance with eating, poor skills in recognizing malnourished patients or those at risk of malnutrition and the low priority given to patients’ nutrition by doctors and nurses. Undetected and untreated, malnutrition is found to be detrimental to the quality of life and can lead to severe consequences such as prolonged hospital stays, high risk of infection, pressure ulcers, reduced wound healing, increased morbidity and mortality as well as increased costs for care, therefore, it is vital that hospital wards for older people have a nutritional care policy to prevent and/or treat malnutrition (Carole S. Mackey, 2004).

Case scenario
In 2010 August, Mr. Wong complained dizzy and fell in the morning and initially presented to orthopedic ward for collapse of L1 after fall. On admission, Mr. Wong’s ear temperature was 36.8, blood pressure was 100/ 50 mmHg, pulse was 75 /min, oxygen saturation was 93% on 2 L/min oxygen. During the acute state, he was developed hospital acquired pneumonia and put on Augmentin for one week course. In same year of November, Mr. Wong was transferred to rehabilitation ward for recovery and physiotherapy.
Mr. Wong was retired. He has a 30-yr smoking history with one pack per day. He tries to quit smoking several times, but does not succeed. He lives in a 4-bedroom house with his wife and two sons and one daughter. He attended a Tai-Chi course with his wife in nearby park every day and had balanced diets prepared by Mrs. Wong. Mr. Wong had past history of Parkinson’s disease, hyperlipidaemia and gout followed up by Princess Margaret Hospital medical. On 2008 he had old lacunar infarct on computer tomography scan.
In the rehabilitation ward, Mr. Wong had some exercise or limbs training with physiotherapists on the bed, as he could not have enough energy to stand up or walk with or without any support. Therefore, Mr. Wong always lied on the bed and then subsequently suffered from bed sore at his sacral. Firstly, he just suffered from stage one pressure sore, which was redness at the site without any discharge, and protected from duoderm. The health care workers provided daily normal saline dressing, frequent turning and pillows to relieve the pressure at the sacral. However, the pressure sore still became worse.
At first, when the health care workers assessed Mr. Wong had high risk of worsening pressure sore; there are six risk factors including mobility, continence, nutritional, skin integrity, physical condition and medication common leading to developing pressure ulcers (Sharp CA, 2006). All possible preventions such as maintenance of well personal hygiene, frequent turning, and use of ripple bed had been provided. Also, wound nurse had assessed Mr. Wong’s situation and recommended the nurses for continuously providing dressing care and frequent skin observation. However, all recommendations and protections were given under strict supervision, but there is one criteria area missing in dealing pressure sore, this is nutrition. Poor nutritional status has been reported by several studies to be contributing factor to pressure ulcer development and malnutrition is positively correlated with pressure ulcer incidence and severity (Sharp. CA, 2006). Inadequate nutrition can increase the risk of developing pressure ulcers and infection as well as impede the healing process of all wounds. Also, adequate dietary protein is absolutely essential for proper wound healing, and tissue levels of the amino acids may influence wound repair and immune function. As a result, a nutritional support should be given to patients with identified nutritional deficiency and any support be based on nutritional assessment using a recognized tool, general health status, patient preference or expert dietician (Ulrika Soderhamn, 2008).
Moreover, nursing staff play an important role in the detection of the patient at risk and the implementation of sufficient preventive strategies. However, a comprehensive nutritional assessment is seldom performed on geriatric patients as routine and very few at-risk patients have a nutritional care plan. And some studies pointed that nurses in geriatric care feel they have a great responsibility for nutritional assessment and care but lack of sufficient knowledge for the tasks as well as of support from physicians (Ulrika Soderhamn, 2008). It is recommended that the health care workers should take the responsibility for informing, ordering, serving food and observing food intake and securing sufficient intake. These require the health care workers have sufficient knowledge and appropriate tools for screening and assessment of the older patients (Sharp. CA, 2006).
Nutritional assessment
A nutritional assessment is an in-depth evaluation of both objective and subjective data to define a person’s nutrition status. Specific data are obtained to create a metabolic and nutritional profile of the patient. The goals of the nutritional assessment are identification of patients who have, or at risk of developing malnutrition; to quantify a patient’s degree of malnutrition and to monitor the adequacy of nutrition therapy. It includes gathering information from the patient’s careful medical history, dietary history, a physical examination and laboratory tests (Weber, J, 2009).
Medical history collection approaches
Foremost in nutritional assessment is the patient interview for determining clinical history. Health care workers have recognized the way in which various diseases and conditions affect a person’s nutritional status. Attention should be focused on the disease state, duration of illness, intake of nutrients and presence of such gastrointestinal systems as nausea, vomiting and diarrhea.
Also, the natural aging process can lead to increased nutritional problems among the elderly. Nearly 65% of elderly patients are calorie-protein undernourished or nutritional deficits developed while in the hospital (Vanderwee K, 2010). There some risks that are related with poor nutrition on the elderly such as normal aging changes in the senses of smell and taste, the effects of chronic diseases on food intake, psychological factors, social isolation, side effects from multiple medications or diminished function that subsequently limits their ability to shop or prepare meals.
Choosing a dietary approach to nutritional status assessment
The most valid or accurate dietary methods are prospective methods. These involve keeping records of foods consumed over the period of time of interest. This can be done by individuals themselves, or by health care workers observing them. Sometimes the foods are weighed before eating and then plate waste is weighed and subtracted. A similar method is to prepare two duplicate meals; one is consumed by the subject and the other is analyzed for nutrient content. Another method is the dietary record, in which the subject records estimated amounts of foods consumed. In any case, these methods are highly reactive because individuals may alter usual behavior to make their diet more socially desirable or to simplify the process of record keeping. Recall methods are the most widely used type of dietary data collection method. They are less reactive, but also less accurate than record methods. Twenty-four hour recalls, in which the previous day’s intake is queried in detail, for instance, foods, amounts, preparation techniques, condiments, are easiest for health care workers to complete (Sharp. CA, 2006). The data reported are converted from foods to nutrients with the use of food composition tables. Because a single day is not representative of usual intake, multiple twenty-four hour recalls are frequently used. Besides, the twenty-four hour recall of food intake record are used, the health care workers should observe the patients’ food preference, history of eating pattern and eating ability such as mood changes or swallow problem that might affect their eating.
Physical examination
Evaluation of the patient’s overall appearance and thorough physical examination of the skin, eyes, mouth, hair, and nails provide a clue the presence of malnutrition. Weight is one of the most useful elements of the physical examination for the assessment of nutritional status (Inge.K, 1999). Body weight is expressed as a relative to established norms in the general population. For adults, body weight and height are used to evaluate overall nutritional status and to classify individuals as at healthy or non-healthy weights. The most recent classification is to use body mass index (BMI, in kg/?). BMI, regardless of age or population, is normal at 18.5-25.0 kg/?, overweight at 25.0 to 19.9 kg/?, and obese at over 30.0 kg/?. In general BMI greater than 30 is assumed to be due to excessive adiposity (World Heart Federation, 2005). Weight loss is often the first clue to an underlying cause of malnutrition. The loss of more than 10% of the patient’s usual weight necessitates a thorough nutritional assessment. Recent unintentional loss of 10% to 20% of the patient’s usual weight indicates moderate protein-calorie malnutrition, and loss of more than 20% indicates severe protein-calorie malnutrition (Ulrika Soderhamn, 2008).
In addition to weight and height, anthropometric approaches are for most part relatively noninvasive methods that assess the size of body composition of an individual. Anthropometric measures, such as mid-arm muscle circumference and triceps skin-fold thickness, estimate fat and lean tissue mass respectively (Carole S. Mackey, 2004). Anthropometric measures of nutritional status can be compromised by other health conditions. For example, edema characteristic of some forms of malnutrition and other disease states can conceal wasting by increasing body weight. Anthropometric data are used in nutritional assessment to compare measured values with standardized controls and to compare serial measurements over time in the same patient. These are useful in identifying the most severely malnourished patients, especially those with fluid retention as a result of disease (Inge.K, 1999).
Biochemical data
Laboratory tests based on blood urine can be important indicators of nutritional status, but they are influenced by non-nutritional factors as well. Measurements of serum protein levels are used in conjunction with other assessment parameters to determine the patients’ overall nutritional status. Serum proteins used in nutritional assessment include albumin and transferrin and preablumin. Albumin is a complex, high-molecular-weight protein produced by the liver and decreased albumin levels have been shown to correlate with increased morbidity and mortality in hospitalized patients; therefore it is often used as a prognostic indicator. If the patient’s serum albumin concentration lower then 3.5g/dL and the total lymphocyte count lower than 1500 cells/mm3, it should be take more concern with them (Carole S. Mackey, 2004). Also lab results can be altered by medications, hydration status, and disease states or other metabolic processes, such as stress. As with the other areas of nutrition assessment, biochemical data need to be viewed as a part of the whole.
Before utilization of the nutritional assessment, the health care workers might only concern how the pressure sore can be healed and provided further treatment or protection. The nutritional issue related to wound healing might be ignored. The health care workers should have knowledge and be conscious of nutritional issues and know the importance and relevance of these issues for the particular patient promoted the nutritional nursing assessment. Identifying, assessing and treating older patients’ nutritional problems is a challenge for all staff groups involved in the patients’ care, therefore, it need to collaboration between other caregivers and professionals and sufficient knowledge about nutrition among the staff groups (C. E. Weekes, 2009). For example, the nurse can organize one person into performing specific tasks like serving food to Mr. Wong to highlight his eating ability and facilitate the assessment process. There is also collaboration between the nurse and physician, speech therapist or dietician who can help with the estimation of the nutritional requirements and get suggestions of food supplements.
The first priority for the nurses is to let Mr. Wong know their nutritional needs and current problems, as he might think that he ate enough every day, but the situation perhaps was adverse. They should have an individual holistic patient view and discuss with Mr. Wong about his situation and then find out how and why the identified nutritional problem influenced the pressure sore. And the four assessment techniques in a nutritional assessment can perform at the same time. The health care workers always perform the twenty-four hours intake and output record with Mr. Wong for calculating the fluid balance and energy intake in the daily nursing routine. Also, it can be recognized Mr. Wong’s nutritional status from physical examination like Body mass index reading and mid-arm circumference to determine the specific needs and problems. And then collaboration with physicians to taking his blood for further laboratory assessment. The laboratory results like protein level and albumin level provide information for the nursing diagnosis. Using the clinical, biochemical and dietary data, influences on the nutritional status can be determined. A nutritional intervention which includes dietary guidance and exercise recommendations is then formulated and discussed with the individual. Further dialogues with and observations of Mr. Wong are used promoting for a continuous assessment process, because it can supply the nurse with information about the effects of the interventions and how the nutritional status of Mr. Wong changed, The nurse then feels a responsibility for him having a continuous and proper nutritional intake (C. E. Weekes e, 2009). If all the possible preventions and nutritional problem can be treated, the rate of getting infection should be minimized and the wound healing should be better.
Malnutrition becomes a considerable problem among hospitalized patients. The use of nutritional care practices and nutrition assessment of elderly patients is necessary and optimal in hospitals. Nutrition assessment involves a combination of examinations and patient history, and as such, no single laboratory test or finding should be used to indicate poor nutrition. An increased consciousness of the importance of nutritional care and assessment among health care professionals will contribute to further improvement of the quality of nutritional care.
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