Nutrition Assessment

DETERMINE

Disease

Eating poorly

Tooth loss/mouth pain

Economic hardship

Reduced social contact

Multiple medicines

Involuntary weight loss/gain

Needs assistance in self-care

Elder years above age 80

Diet assessment includes

24 hour recall

Food diaries/calorie counts

Food frequency record

Diet history

• Intake

• Allergy/intolerances

• Food prep

• Dietary practices

• Eating disorder patterns

Medical assessment includes

Current illness and any history

Drug history

Medications

Drug abuse

Ability to chew and swallow

Appetite

Bowel habits

Socioeconomical assessment includes

Age, family history, sex assigned at birth, lifestyle

Social determinants of health

Information about exercising sleep

Religious, cultural, and ethnic background

Cultural and traditional foods

Use of alcohol and tobacco

Biochemical data

Serum albumin

Pre albumin

Hemoglobin

Hematocrit

Blood glucose

BUN

Creatine

Urine specific gravity

General appearance, Indicators of malnutrition

easily fatigue, no energy, falls asleep easily, looks tired apathetic, cachetic

Posture, Indicators of malnutrition

Poor posture, sagging shoulders, sunken chest, humped back

Muscles, Indicators of malnutrition

Flaccid, weak, poor tone, tender, “wasted” appearance, impaired mobility

Neurological function, Indicators of malnutrition

Burning and tingling of hands and feet (paresthesia), loss of position and vibratory sense, Decrease or loss of ankle and knee reflexes

GI function, Indicators of malnutrition

Anorexia,

indigestion

constipation or diarrhea

symptoms of malabsorption

liver or spleen enlargement

abdominal distention

Cardiovascular function, Indicators of malnutrition

Tachycardia

abnormal rhythm

elevated blood pressure

Hair, Indicators of malnutrition

Stringy

Dull

Brittle

Dry

Thin and sparse

Depigmented

Skin, Indicators of malnutrition

Rough

Dry

Scaly

Pale

Pigmented

Irritated

Bruises

Petechiae

Face and neck, Indicators of malnutrition

Swollen

Skin dark over cheeks and under eyes

Lips, Indicators of malnutrition

Dry

Scaly

Swollen

Redness and swelling at the corners of the mouth (cheilosis)

Angular lesions at corners of mouth

Fissures or scars (stomatitis)

Mouth, oral mucous membranes, Indicators of malnutrition

Swollen

Deep red oral mucous membranes

Oral lesions

Gums, Indicators of malnutrition

Spongy

Bleed easily

Inflamed

Receding

Tongue, Indicators of malnutrition

Swelling

Scarlet and raw

Magenta color

Beefy (glossitis)

Teeth, Indicators of malnutrition

Missing teeth

Broken teeth

Eyes, Indicators of malnutrition

Eye membranes pale (pale conjunctivae)

Redness of membrane (conjunctival injection)

Dryness or infection

Nails, Indicators of malnutrition

Spoon shaped (koilonychia)

Brittle

Riged

Legs and feet, Indicators of malnutrition

Edema

Tender calf

Tingling

Weakness

Lesions

Skeleton, Indicators of malnutrition

Bowlegs

Knock-knees

Chest deformity at diaphragm

Beaded ribs

Prominent scapulas

Normal findings, mouth

Lips should be pink and smooth

Tongue and mucus membranes normally moist, pink, no swelling or lesions

Gums should be pink and smooth

Uvula center and movable

Tonsil, small pink symmetric

Teeth free of cavities or may have dental restoration

Normal findings, neck

Neck should be symmetric smooth, controlled ROM

No neck veins distended

Advanced practitioners may palpate the thyroid

Abdominal assessment, Subjective data

History of abdominal pain

Indigestion, nausea, vomiting, constipation, diarrhea

Food, allergies

Appetite

Bowel/bladder elimination patterns

Any GI disorders

Any abdominal surgery or trauma

Alcohol ingestion

Menstrual history

Abdominal assessment order

Inspection, auscultation, percussion, palpation

Hyperactive bowel sounds

Increased frequency of bowel sounds

Diarrhea

Early bowel obstruction

Active bowel sounds

Bowel sounds occur irregularly every 5 to 15 seconds

Hypoactive bowel sounds

Bowel sounds are quiet and infrequent

After abdominal surgery

Late bowel obstruction

Absent bowel sounds

No bowel sounds (listen over 3-5 mins all 4 quadrants)

Paralytic illeus