Description
Choose one of the Course Learning Outcomes found in the syllabus THE ONE THAT THIS WILL BE BASED ON IS BELOW:Describe the roles of key nutrients in the prevention of diseases.and address all the points below:List the outcome.How have you met the outcome this term?How will you implement the information from this course into your clinical practice and personal life?Provide an evidence-based intervention that nurses can implement to meet the nutritional needs of their patients?Use evidence from one scholarly source other than your textbook orbook to support your answer. Use APA Style to cite your source. I WILL ATTACH THE CLASS TEXT BELOW ALSO AS A REFRENCE
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Nutrition
Essentials
for Nursing
Practice
Susan G. Dudek, RD, CDN, BS
Nutrition Instructor, Dietetic Technology Program
Erie Community College
Williamsville, New York
Consultant Dietitian for Employee Assistance
Program of Child and Family Services
Williamsville, New York
S E V E N T H
Dudek_FM.indd i
E D I T I O N
3/29/13 1:13 AM
Acquisitions Editor: David Troy
Product Manager: Maria McAvey
Production Project Manager: Marian Bellus
Editorial Assistant: Latisha Ogelsby
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Seventh Edition
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Copyright © 2010, 2007, 2006, 2001 by Lippincott Williams and Wilkins. Copyright © 1997 by Lippincott-Raven Publishers. Copyright © 1993, 1987 by J. B. Lippincott Company. All rights reserved. This book is protected by copyright. No part
of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other
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request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia,
PA 19103, via email at [email protected], or via our website at lww.com (products and services).
9 8 7 6 5 4 3 2 1
Printed in China
Library of Congress Cataloging-in-Publication Data
Dudek, Susan G.
Nutrition essentials for nursing practice / Susan G. Dudek. — 7th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4511-8612-3 (alk. paper)
I. Title.
[DNLM: 1. Diet Therapy—Handbooks. 2. Diet Therapy—Nurses’ Instruction. 3. Nutritional Physiological Phenomena —
Handbooks. 4. Nutritional Physiological Phenomena—Nurses’ Instruction. WB 39]
RM216
615.8’54—dc23
2013007075
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the author, editors, and publisher are not responsible for errors or omissions or for any consequences from application
of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or
accuracy of the contents of the publication. Application of this information in a particular situation remains the professional
responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and
universal recommendations.
The author, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text
are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing
research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions,
the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings
and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for
limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each
drug or device planned for use in his or her clinical practice.
LWW.com
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In loving memory of my mother, Annie M. Maedl—
everyone should be so lucky to have a mom like her.
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Reviewers
Zita Allen, RN, MSN
Professor of Nursing
Alverno College
Milwaukee, Wisconsin
Marina Martinez-Kratz, RN, BSN, MS
Carmen Bruni, MSN, RN, CAN
Assistant Professor
Texas A&M International University
Laredo, Texas
Janet Tompkins McMahon, RN, MSN
Ann Cleary, DNS, RN, NP-C
Associate Professor of Nursing
Long Island University, Brooklyn Campus
Brooklyn, New York
Patricia J. Neafsey, RD, PhD
Professor
University of Connecticut School of Nursing
Storrs, Connecticut
Tammie Cohen, RN, BS
Nursing Instructor, Faculty Advisory Committee
Chairperson
Western Suffolk BOCES
Northport, New York
Cheryl L. Neudauer, PhD, MEd
Biology Faculty
Center for Teaching and Learning Campus Leader
Minneapolis Community and Technical College
Minneapolis, Minnesota
Janet Goeldner, MSN
Professor
University of Cincinnati—Raymond Walters College
Cincinnati, Ohio
Christine M. Prince, RN, BSN, CCM
Nursing Faculty
Brown Mackie College Indianapolis
Indianapolis, Indiana
Coleen Kumar, RN, MSN
Associate Professor Nursing
Department Deputy Chairperson
Kingsborough Community College
Brooklyn, New York
Rhonda Savain, RN, MSN
Nursing Instructor
Ready to Pass Inc.
West Hempstead, New York
Professor of Nursing
Jackson Community College
Jackson, Michigan
Clinical Associate Professor of Nursing
Towson University
Towson, Maryland
Nancy West, RN, MN
Karen Lincoln, RNC, MSN
Nursing Faculty
Montcalm Community College
Sidney, Michigan
Professor of Nursing
Johnson County Community College
Overland Park, Kansas
Carol Isaac MacKusick, PhDc, MSN, RN, CNN
Adjunct Faculty
Clayton State University
Morrow, Georgia
iv
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Preface
L
ike air and sleep, nutrition is a basic human need essential for survival. Nutrition provides
energy and vitality, helps reduce the risk of chronic disease, and can aid in recovery. It is a
dynamic blend of science and art, evolving over time and in response to technological advances
and cultural shifts. Nutrition at its most basic level is food—for the mind, body, and soul.
Although considered the realm of the dietitian, nutrition is a vital and integral component of nursing care. Today’s nurses need to know, understand, apply, analyze, synthesize,
and evaluate nutrition throughout the life cycle and along the wellness/illness continuum.
They incorporate nutrition into all aspects of nursing care plans, from assessment and
nursing diagnoses to implementation and evaluation. By virtue of their close contact with
patients and families, nurses are often on the front line in facilitating nutrition. This text
seeks to give student nurses a practical and valuable nutrition foundation to better serve
themselves and their clients.
NEW TO THIS EDITION
This seventh edition continues the approach of providing the essential information nurses
need to know for practice. Building upon this framework, content has been thoroughly
updated to reflect the latest evidence-based practice. Examples of content updates that are
new to this edition are as follows:
■
■
■
■
■
■
■
MyPlate, which replaces MyPyramid as the graphic to illustrate the Dietary Guidelines for
Americans
Recommended Dietary Allowances (RDAs) for calcium and vitamin D
Inclusion of a validated stand-alone nutrition screening tool for older adults that is appropriate for community settings and in clinical practice
Expanded coverage of bariatric surgery and obesity in general, particularly with regard
to the importance of behavioral strategies for navigating our increasingly obesogenic
environment
The low-FODMAP (fermental oligo-, di-, and monosaccharides and polyols) diet for
irritable bowel syndrome and possibly other gastrointestinal disorders
A shift in focus from single nutrients (e.g., saturated fat) to a food pattern approach (e.g.,
the DASH diet) for communicating and implementing a heart healthy diet
Updated 2011 nutrition therapy guidelines for patients with chronic kidney disease who
are not on dialysis
ORGANIZATION OF THE TEXT
Unit One is devoted to Principles of Nutrition. It begins with Chapter 1, Nutrition in
Nursing, which focuses on why and how nutrition is important to nurses in all settings.
Chapters devoted to carbohydrates, protein, lipids, vitamins, water and minerals, and energy
balance provide a foundation for wellness. The second part of each chapter highlights health
promotion topics and demonstrates practical application of essential information, such as
how to increase fiber intake, criteria to consider when buying a vitamin supplement, and the
risks and benefits of a vegetarian diet.
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vi
PREFACE
Unit Two, Nutrition in Health Promotion, begins with Chapter 8, Guidelines for
Healthy Eating. This chapter features the Dietary Reference Intakes, the Dietary Guidelines for Americans, and MyPlate. Other chapters in this unit examine consumer issues and
cultural and religious influences on food and nutrition. The nutritional needs associated
with the life cycle are presented in chapters devoted to pregnant and lactating women, children and adolescents, and older adults.
Unit Three, Nutrition in Clinical Practice, includes nutrition therapy for obesity and
eating disorders, enteral and parenteral nutrition, metabolic and respiratory stress, gastrointestinal disorders, diabetes, cardiovascular disorders, renal disorders, cancer, and HIV/
AIDS. Pathophysiology is tightly focused as it pertains to nutrition.
RECURRING FEATURES
This edition retains popular features of the previous edition to facilitate learning and engage
students.
■
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■
Check Your Knowledge presents true/false questions at the beginning of each chapter
to assess the students’ baseline knowledge. Questions relate to chapter Learning
Objectives.
Key Terms are defined in the margin for convenient reference.
Quick Bites—fewer and more condensed to improve layout and readability in the new
edition—provide quick nutrition facts, valuable information, and current research.
Nursing Process tables clearly present sample application of nutrition concepts in context of the nursing process.
How Do You Respond? helps students identify potential questions they may encounter
in the clinical setting and prepares them to think on their feet.
A Case Study and Study Questions at the end of each chapter challenge students to
apply what they have learned.
Key Concepts summarize important information from each chapter.
TEACHING AND LEARNING RESOURCES
Instructors and students will find valuable resources to accompany the book on
at http://thePoint.lww.com/Dudek7e.
Resources for Instructors
Comprehensive teaching resources are available to instructors upon adoption of this text
and include the following materials.
■
■
■
■
■
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A free E-book on thePoint provides access to the book’s full text and images online.
A Test Generator lets instructors put together exclusive new tests from a bank containing NCLEX-style questions.
PowerPoint Presentations provide an easy way to integrate the textbook with the classroom. Multiple-choice and true/false questions are included to promote class participation.
An Image Bank provides the photographs and illustrations from this text for use in
course materials.
Access to all student resources is also provided.
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PREFACE
vii
Resources for Students
Students can activate the code in the front of this book at http://thePoint.lww.com/
activate to access the following free resources.
■
■
■
A free E-book on thePoint provides access to the book’s full text and images online.
NEW! Practice & Learn Interactive Case Studies provide realistic case examples and
offer students the opportunity to apply nutrition essentials to nursing care.
Journal Articles provided for each chapter offer access to current research available in
Lippincott Williams & Wilkins journals.
I hope this text and teaching/learning resource package provide the impetus to embrace
nutrition on both a personal and professional level.
Susan G. Dudek, RD, CDN, BS
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Acknowledgments
I am humbled and grateful to be still writing this book after six editions. It is a project that
has been professionally rewarding, personally challenging, and rich with opportunities to
grow. In large part, the success of this book rests with the dedicated and creative professionals at Lippincott Williams & Wilkins. Because of their support and talents, I am able to
do what I love—write, create, teach, and learn. I especially thank
■
■
■
David Troy, Senior Acquisitions Editor, who provided the spark to ignite the project.
Maria McAvey, Editorial Product Manager, for her meticulous attention to detail and
gentle guidance.
Marian Bellus, Production Project Manager; Holly Reid McLaughlin, Design Coordinator;
John Johnson, Education Marketing Manager, Nursing; and Latisha Ogelsby, Editorial
Assistant, the behind-the-scene professionals whose efforts help transform an ugly duckling into a beautiful swan.
■
The reviewers of the sixth edition, whose insightful comments and suggestions helped
shape a new and improved edition.
■
My friends and family—my sideline cheerleaders—who so patiently gave me the time and
space to work on “my story.”
■
I am especially thankful to my husband Joe . . . always there through thick and thin.
viii
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Contents
U N I T
O N E
CHAPTER 1
CHAPTER 2
CHAPTER 3
CHAPTER 4
CHAPTER 5
CHAPTER 6
CHAPTER 7
U N I T
Nutrition in Nursing 2
Carbohydrates 18
Protein 46
Lipids 66
Vitamins 92
Water and Minerals 124
Energy Balance 156
T W O
CHAPTER 8
CHAPTER 9
CHAPTER 10
CHAPTER 11
CHAPTER 12
CHAPTER 13
U N I T
Nutrition in Health Promotion 177
Guidelines for Healthy Eating 178
Consumer Issues 200
Cultural and Religious Influences on Food and Nutrition 230
Healthy Eating for Healthy Babies 257
Nutrition for Infants, Children, and Adolescents 286
Nutrition for Older Adults 320
T H R E E
CHAPTER 14
CHAPTER 15
CHAPTER 16
CHAPTER 17
CHAPTER 18
CHAPTER 19
CHAPTER 20
CHAPTER 21
CHAPTER 22
Principles of Nutrition 1
Nutrition in Clinical Practice 353
Obesity and Eating Disorders 354
Feeding Patients: Oral Diets and Enteral and Parenteral Nutrition 393
Nutrition for Patients with Metabolic or Respiratory Stress 423
Nutrition for Patients with Upper Gastrointestinal Disorders 443
Nutrition for Patients with Disorders of the Lower GI Tract and
Accessory Organs 461
Nutrition for Patients with Diabetes Mellitus 497
Nutrition for Patients with Cardiovascular Disorders 535
Nutrition for Patients with Kidney Disorders 567
Nutrition for Patients with Cancer or HIV/AIDS 593
A P P E N D I C E S
APPENDIX 1
APPENDIX 2
APPENDIX 3
APPENDIX 4
Dietary Reference Intakes (DRIs): Recommended Dietary Allowances
and Adequate Intakes, Total Water and Macronutrients 624
Dietary Reference Intakes (DRIs): Recommended Dietary Allowances
and Adequate Intakes, Vitamins 625
Dietary Reference Intakes (DRIs): Recommended Dietary Allowances
and Adequate Intakes, Elements 628
Answers to Study Questions 630
INDEX 633
ix
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U N I T
O N E
Principles of
Nutrition
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1
Nutrition in Nursing
CHECK YOUR KNOWLEDGE
TRUE
FALSE
1 The nurse’s role in nutrition is to call the dietitian.
2 Nutrition screening is used to identify clients at risk for malnutrition.
3 The Joint Commission stipulates the criteria to be included on a nutritional screen for
hospitalized patients.
4 Changes in weight reflect acute changes in nutritional status.
5 A person can be malnourished without being underweight.
6 The only cause of a low serum albumin concentration is protein malnutrition.
7 “Significant” weight loss is 5% of body weight in 1 month.
8 People who take five or more prescription or over-the-counter medications or dietary
supplements are at risk for nutritional problems.
9 Obtaining reliable and accurate information on what the client usually eats can help
identify intake as a source of nutrition problems.
10 Physical signs and symptoms of malnutrition develop only after other signs of malnutrition are apparent (e.g., abnormal lab values, weight change).
LEARNING OBJECTIVES
U p o n c o m p l e t i o n o f t h i s c h a p t e r, y o u w i l l b e a b l e t o
1 Compare nutrition screening to nutrition assessment.
2 Evaluate weight loss for its significance over a 1-month or 6-month interval.
3 Discuss the validity and reliability of using physical signs to support a nutritional diagnosis
of malnutrition.
4 Give examples of nursing diagnoses that may use nutrition therapy as an intervention.
5 Demonstrate how nurses can facilitate client and family teaching of nutrition therapy.
6 Explain why an alternative term to “diet” is useful.
2
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CHAPTER
1
Nutrition in Nursing
3
B
ased on Maslow’s hierarchy of needs, food and nutrition rank on the same level as air in
the basic necessities of life. Obviously, death eventually occurs without food. But unlike
air, food does so much more than simply sustain life. Food is loaded with personal, social,
and cultural meanings that define our food values, beliefs, and customs. That food nourishes the mind as well as the body broadens nutrition to an art as well as a science. Nutrition
is not simply a matter of food or no food but rather a question of what kind, how much,
how often, and why. Merging want with need and pleasure with health are keys to feeding
the body, mind, and soul.
Although the dietitian is the nutrition and food expert, nurses play a vital role in nutrition care. Nurses may be responsible for screening hospitalized patients to identify patients
at nutritional risk. They often serve as the liaison between the dietitian and physician as
well as with other members of the health-care team. Nurses have far more contact with the
patient and family and are often available as a nutrition resource when dietitians are not,
such as during the evening, on weekends, and during discharge instructions. In home care
and wellness settings, dietitians may be available only on a consultative basis. Nurses may
reinforce nutrition counseling provided by the dietitian and may be responsible for basic
nutrition education in hospitalized clients with low to mild nutritional risk. Nurses are intimately involved in all aspects of nutritional care.
This chapter discusses nutrition within the context of nursing, including nutrition
screening and how nutrition can be integrated into the nursing care process.
NUTRITION SCREENING
Nutritional Screen:
a quick look at a few
variables to judge a
client’s relative risk for
nutritional problems.
Can be custom designed for a particular
population (e.g., pregnant women) or for
a specific disorder
(e.g., cardiac disease).
Malnutrition: literally
“bad nutrition” or any
nutritional imbalance
including overnutrition.
In practice, malnutrition
usually means undernutrition or an inadequate
intake of protein and/or
calories that causes
loss of fat stores and/or
muscle wasting.
Dudek_CH01.indd 3
Nutrition screening is a quick look at a few variables to identify individuals who are malnourished or who are at risk for malnutrition so that an in-depth nutrition assessment
can follow. Screening tools should be simple, reliable, valid, applicable to most patients
or clients in the group, and use data that is readily available (Academy of Nutrition and
Dietetics, 2012). For instance, a community-based senior center may use a nutrition
screen that focuses mostly on intake risks common to that population, such as whether
the client eats alone most of the time and/or has physical limitations that impair the ability to buy or cook food (Fig. 1.1). In contrast, common screening parameters in acute
care settings include unintentional weight loss, appetite, body mass index (BMI), and
disease severity. Advanced age, dementia, and other factors may be considered. There is
no universally agreed upon tool that is valid and reliable at identifying risk of malnutrition
in all populations at all times.
The Joint Commission, a nonprofit organization that sets health-care standards and
accredits health-care facilities that meet those standards, specifies that nutrition screening be
conducted within 24 hours after admission to a hospital or other health-care facility—even
on weekends and holidays. The Joint Commission allows facilities to determine screening
criteria and how risk is defined. For instance, a hospital may use serum creatinine level as a
screening criterion, with a level greater than 2.5 mg/dL defined as “high risk” because the
majority of their patients are elderly and the prevalence of chronic renal problems is high.
The Joint Commission also leaves the decision of who performs the screening up to individual facilities. Because the standard applies 24 hours a day, 7 days a week, staff nurses are
often responsible for completing the screen as part of the admission process. Clients who
“pass” the initial screen are rescreened after a specified amount of time to determine if their
status has changed.
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4
UNIT
1
Principles of Nutrition
DETERMINE YOUR NUTRITIONAL HEALTH
The warning signs of poor nutritional health are often overlooked. Use this checklist to find out if
you or someone you know is at nutritional risk.
Read the statements below. Circle the number in the “yes” column for those that apply to you or
someone you know. For each “yes” answer, score the number in the box. Total your nutritional
score.
YES
I have an illness or condition that made me change the kind and/or amount of food I eat.
2
I eat fewer than two meals per day.
3
I eat few fruits or vegetables, or milk products.
2
I have three or more drinks of beer, liquor or wine almost every day.
2
I have tooth or mouth problems that make it hard for me to eat.
2
I don’t always have enough money to buy the food I need.
4
I eat alone most of the time.
1
I take three or more different prescribed or over-the-counter drugs a day.
1
Without wanting to, I have lost or gained 10 pounds in the last six months.
2
I am not always physically able to shop, cook and/or feed myself.
2
TOTAL
Total your nutritional score. If it’s –
Nutritional
Assessment: an
in-depth analysis of a
person’s nutritional
status. In the clinical
setting, nutritional
assessments focus on
moderate- to high-risk
patients with suspected
or confirmed protein–
energy malnutrition.
0-2
Good! Recheck your nutritional score in six months.
3-5
You are at moderate nutritional risk. See what can be done to improve your eating
habits and lifestyle. Your office on aging, senior nutrition program, senior citizens
center or health department can help. Recheck your nutritional score in three
months.
6 or more You are at high nutritional risk. Bring this checklist the next time you see your doctor,
dietitian or other qualified health or social service professional. Talk with them about
any problems you may have. Ask for help to improve your nutritional health.
Remember that warning signs suggest risk, but do not represent diagnosis of any condition.
■ F I G U R E 1 . 1 Determine your nutritional health. American Academy of Family
Physicians, the American Dietetic Association, the National Council on the Aging, Inc.
The Nutrition Screening Initiative.
NUTRITION CARE PROCESS
Clients considered to be at moderate or high risk for malnutrition through screening are
usually referred to a dietitian for a comprehensive nutritional assessment to identify specific risks or confirm the existence of malnutrition. Nutritional assessment is more accurately called the nutrition care process, which includes four steps (Fig. 1.2). While nurses
use the same problem-solving model to develop nursing or multidisciplinary care plans that
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CHAPTER
1
Nutrition in Nursing
5
Screening
Nutrition
assessment
Nutrition monitoring
and evaluation
■ F I G U R E 1 . 2 The nutrition care process.
Like the nursing process, the nutrition care
process is a problem-solving method used to
evaluate and treat nutrition-related problems.
Nutrition
diagnosis
Nutrition
intervention
may also integrate nutrition, the nutritional plan of care devised by dietitians is specific for
nutrition problems. Some obvious differences in focus are described below:
■
■
■
■
■
■
Dudek_CH01.indd 5
Dietitians may obtain much of their preliminary information about the patient from the
nursing history and physical examination, such as height and weight; skin integrity;
usual diet prior to admission; difficulty chewing, swallowing, or self-feeding; chief complaint; medications, supplements, and over-the-counter drugs used prior to admission;
and living situation. Dietitians may request laboratory tests to assess vitamin levels when
micronutrient deficiencies are suspected.
Dietitians interview patients and/or families to obtain a nutrition history, which may include
information on current dietary habits; recent changes in intake or appetite; intake of snacks;
alcohol consumption; food allergies and intolerances; ethnic, cultural, or religious diet influences; nutrition knowledge and beliefs; and use of supplements. A nutrition history can help
differentiate nutrition problems caused by inadequate intake from those caused by disease.
Dietitians usually calculate estimated calorie and protein requirements based on the
assessment data and determine whether the diet ordered is adequate and appropriate for
the individual.
Dietitians determine nutrition diagnoses that define the nutritional problem, etiology,
and signs and symptoms. While a nursing diagnosis statement may begin with “Altered
nutrition: eating less than the body needs,” a nutrition diagnosis would be more specific,
such as “Inadequate protein–energy intake.”
Dietitians may also determine the appropriate malnutrition diagnosis code for the patient
for hospital reimbursement purposes.
Nutrition interventions may include requesting a diet order change, requesting additional
laboratory tests to monitor nutritional repletion, and performing nutrition counseling or
education.
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6
UNIT
1
Principles of Nutrition
NUTRITION IN THE NURSING PROCESS
In nursing care plans, nutrition may be part of the assessment data, diagnosis, plan,
implementation, or evaluation. The remainder of this chapter is intended to help nurses
provide quality nursing care that includes basic nutrition, not to help nurses become
dietitians.
Assessment
Subjective Global
Assessment (SGA):
a clinical method of
assessing nutritional
status based on findings
in a health history and
physical examination.
It is well recognized that malnutrition is a major contributor to morbidity, mortality, impaired quality of life, and prolonged hospital stays (White et al., 2012). However, there is
currently no single, universally agreed upon method to assess or diagnose malnutrition.
Approaches vary widely and may lack sensitivity (the ability to diagnose all people who
are malnourished) and specificity (misdiagnosing a well-nourished person). For instance,
albumin and prealbumin have been used as diagnostic markers of malnutrition. These proteins are now known to be negative acute phase proteins, which means their levels decrease in response to inflammation and physiologic stress. Because they are not specific
for nutritional status, failure of these levels to increase with nutrition repletion does not
mean that nutrition therapy is inadequate (Fessler, 2008). Although their usefulness in
diagnosing malnutrition is limited, these proteins may help identify patients at high risk for
morbidity, mortality, and malnutrition (Banh, 2006). BMI and some or all of the components of a subjective global assessment (Box 1.1) are commonly used to assess nutrition
(Fessler, 2008).
Medical History and Diagnosis
The chief complaint and medical history may reveal disease-related risks for malnutrition
and whether inflammation is present (Fig. 1.3). Patients with gastrointestinal symptoms or
disorders are among those who are most prone to malnutrition, particularly when symptoms
such as nausea, vomiting, diarrhea, and anorexia last for more than 2 weeks. Box 1.2 lists
psychosocial factors that may impact intake or requirements and help identify nutrition
counseling needs.
Box 1.1
CRITERIA INCLUDED IN SUBJECTIVE GLOBAL ASSESSMENT
Weight Change
■ Unintentional weight loss and the time
period of loss
Functional Capacity
■ Normal or suboptimal; ambulatory or
bedridden
Dietary Intake
■ Change from normal, duration, type of
diet consumed
Disease and Its Relation to Nutritional
Requirements
■ Primary diagnosis; severity of metabolic
stress
Gastrointestinal Symptoms Lasting
Longer than 2 Weeks
■ Nausea, vomiting, diarrhea, anorexia
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Physical Signs and Severity of Findings
■ Loss of subcutaneous fat (triceps, chest),
muscle wasting (quadriceps, deltoids),
ankle edema, sacral edema, ascites
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CHAPTER
1
Nutrition in Nursing
7
Chronic illness
(e.g., cancer, AIDS, COPD)
Inadequate intake/
nutrient availability
(anorexia, malabsorption)
Acute illness
(e.g., infection,
trauma, pancreatitis)
■ FIGURE 1.3
Malnutrition
Inflammation/
catabolism
Frequent infection,
altered GI function
Factors that may be involved in the etiology of illness-related malnutrition.
Body Mass Index
Body Mass Index:
an index of weight in
relation to height that
is calculated mathematically by dividing weight
in kilograms by the
square of height in
meters.
Q U I C K
B I T E
Interpreting BMI
⬍18.5
18.5–24.9
25–29.9
30–34.9
35–39.9
ⱖ40
Box 1.2
underweight
healthy weight
overweight
obesity class 1
obesity class 2
obesity class 3
PSYCHOSOCIAL FACTORS THAT MAY INFLUENCE INTAKE,
NUTRITIONAL REQUIREMENTS, OR NUTRITION COUNSELING
Psychological Factors
■ Depression
■ Eating disorders
■ Psychosis
Social Factors
Illiteracy
■ Language barriers
■ Limited knowledge of nutrition and food
safety
■ Altered or impaired intake related to
culture
■ Altered or impaired intake related to
religion
■
Dudek_CH01.indd 7
Body mass index (BMI) is an index of a
person’s weight in relation to height used
to estimate relative risk of health problems
related to weight. Because it is relatively
quick and easy to measure height and weight
and requires little skill, actual measures, not
estimates, should be used whenever possible
to ensure accuracy and reliability. A patient’s
stated height and weight should be used only
when there are no other options.
Lack of caregiver or social support
system
■ Social isolation
■ Lack of or inadequate cooking
arrangements
■ Limited or low income
■ Limited access to transportation to
obtain food
■ Advanced age (older than 80 years)
■ Lack of or extreme physical activity
■ Use of tobacco or recreational drugs
■ Limited use or knowledge of community
resources
■
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8
UNIT
1
Principles of Nutrition
“Healthy” or “normal” BMI is defined numerically as 18.5 to 24.9. Values above and
below this range are associated with increased health risks. Although BMI can be calculated with a mathematical formula, tables and nomograms are available for convenience
(see Chapter 14). One drawback of using BMI is that a person can have a high BMI and
still be undernourished in one or more nutrients if intake is unbalanced or if nutritional
needs are high and intake is inadequate.
Weight Change
Unintentional weight loss is a well-validated indicator of malnutrition (White et al., 2012).
The significance of weight change is evaluated after the percentage of usual body weight
lost in a given period of time is calculated (Box 1.3). Usually, weight changes are more
reflective of chronic, not acute, changes in nutritional status. The patient’s weight can be
unreliable or invalid due to hydration status. Edema, anasarca, fluid resuscitation, heart
failure, and chronic liver or renal disease can falsely inflate weight.
Dietary Intake
A decrease in intake compared to the patient’s normal intake may indicate nutritional
risk. However, like other data, validity and reliability may be an issue. Although the nurse
may only be required to fill in a blank space next to the word “appetite,” simply asking the client “How is your appetite?” will probably not provide sufficient information.
A better question may be “Has the type or amount of food you eat recently changed?
If so, please explain.” Consuming only liquids and severely limiting the type or amount
of food are risks.
Another question to avoid while obtaining a nursing history is “Are you on a diet?” To
many people, diet is synonymous with weight loss diet; they may fail to mention they use
nutrition therapy to avoid sodium, modify fat, or count carbohydrates. A better question
would be, “Do you avoid any particular foods?” or “Do you watch what you eat in any
way?” Even the term “meal” may elicit a stereotypical mental picture. Questions
