Assessing an individuals nutritional status

Nurses are in an ideal position to assess a client’s nutritional status, and thus identify if they are at risk from malnutrition. It should include taking a nutritional history, including consideration of the factors identified below that can interfere with nutritional status, along with physical measurements (see Figure 5.1). There are also local and national nutritional assessment tools; however, not all of them are research based. Most of them consist of a list of questions with the answers being scored (see Figure 5.2). The total score gives an indication of the client’s nutritional status and susceptibility to malnutrition. If a tool is not being used, the client on admission should at least be asked the following questions:

1 Have you been eating more or less than usual?
2 Have you unintentionally lost or gained weight?
3 How tall are you?
4 What is your normal weight?

The weight of a client on admission can act as a baseline and if there is cause for concern then weekly weight measurements should be taken. A greater than 10 per cent loss in body weight in less than three months indicates that the client is malnourished and needs to be referred to the

Figure 5.1 Are you the right weight for your height?

dietician. It is also important to remember that clients who are obese can equally be malnourished, as they may not be ingesting an adequate range of nutrients.

Figure 5.2 Example of nutrition risk assessment tool
Weight loss, unintentional in past three months • No weight loss • 0–3 kg weight loss • 3–6 kg weight loss • > 6 kg weight loss	Score 0 1 2 3
BMI • 20 or more • 18–19 • 15–17 • < 15	0 1 2 3
Appetite • Good, manages most of three meals/day • Poor, leaves percentage of meals provided • Nil, unable to eat	0 2 3
Ability to eat/retain food • No difficulties eating, independent. No diarrhoea/vomiting • Problems handling food. Occasional diarrhoea/vomiting • Difficulties swallowing. Needs modified consistency. Moderate diarrhoea/vomiting • Unable to take food orally. Unable to swallow. Severe diarrhoea/vomiting/ malabsorption	0 1 2 3
Total score

Score	Action
0–3 low risk 4–5 needs monitoring 6–12 high risk	No action required, weigh weekly Encourage eating and drinking. Possibly food record charts. Repeat score after one week Refer to dietician

Remember that assessment of the activity of eating and drinking is only part of a holistic nursing assessment and should not be undertaken in isolation without reference to or consideration of the client’s other activities of living.

Specific points to consider when assessing individuals’ nutritional and hydration status include:

• Physical
What is the condition of the mouth, teeth and gums? Poor oral hygiene, a
sore mouth or ill-fitting dentures can cause difficulty when eating.
Does the client have halitosis? This may indicate poor oral hygiene or
dehydration.
Appearance: dry, scaly skin may indicate that the client is malnourished or
dehydrated.
Does the client have sunken eye sockets? This may be suggestive of
dehydration.
Is their hair dull, lifeless or in bad condition? This can be an indication of
poor nutritional status.
Is their clothing loose or tight, or rings or dentures slack, indicating a
recent weight gain or loss?
Does the client have limited hand dexterity resulting in difficulty in
manipulating cutlery (for example rheumatoid arthritis)?
Does the client have any visual deficits, physical handicap or positional
difficulty? These may interfere with independence in eating and
drinking.
Are they nauseous or vomiting? Symptoms such as these will prevent
clients from eating, even if they feel hungry. Do they have any food
allergies?
Are they able to chew and swallow? Certain conditions, such as motor
neurone disease, stroke and cerebral palsy, can cause problems with
chewing and swallowing and leave the patient at risk of aspiration
and/or malnutrition.
Any diarrhoea or constipation? This can lead to malabsorption
syndrome.
Does the client require starving prior to surgery/investigations or because
of condition? For example, intestinal obstruction carries a high risk of
malnutrition.
Any pain, stress, fatigue or reduced physical activity? This often
accompanies illness and can result in a loss of appetite.
Is the client receiving any medications that can adversely affect their
appetite?
Is the physical effort of eating too great for the client? This can be true
for people with heart failure or emphysema, or children with congenital
heart disease.
Has the client any additional nutritional requirements due to wound or
bone healing or loss, for example dehydration following burn injury?
Does the client have any pressure sores? These are often associated with
poor nutrition.
Is there any deterioration in a client’s level of consciousness or mental
state (for example confusion) that may affect their ability and desire to
eat or drink?
Does the client require any special diet that may restrict their choice, for
example renal disease, diabetes mellitus, malabsorption syndromes,
obesity?
Does the client have a learning difficulty affecting their ability to select an
appropriate diet or prepare food?
Remember that children have higher metabolic rates than adults, and so
require more energy. They also need to eat the correct amount and
type of food to support growth in adulthood.

• Psychological
Is the client depressed or bereaved, thereby affecting appetite and
motivation to prepare food?
Is the client turning to food as a source of comfort, resulting in overeating
during periods of loneliness, insecurity or depression?
Is the client suffering from paranoia and not eating because of fear of
being poisoned?
Is the client suffering from stress or anxiety, which is suppressing their
appetite?
Does the client have any deviations in eating patterns, for example
anorexia nervosa or bulimia nervosa?
Does the individual neglect their diet as a result of a busy, stressful life?

• Sociocultural
Are there any cultural factors (that is, the collection of attitudes, taboos
and beliefs) influencing the individual’s diet and eating habits? For
example, some people may feel that without a daily hot meal their diet
is incomplete.
Any other food ideologies that might influence the individual’s motivation
to alter their food habits?
Are there any religious beliefs/customs influencing their diet and eating
habits? (See Table 5.2 for guidance.)
Is the client vegetarian or vegan?
Are they following any fad diets?
Do they have any spurious health beliefs resulting in them following a diet
that is too restricted to meet their nutritional needs?

• Environmental
Does the client have adequate food preparation and cooking equipment
(or access to it)?
Do they have shops or supermarkets in the vicinity?
Are these conducive? Local shops may not have as good a choice as
supermarkets and can be more expensive.
Is their appetite likely to be affected by the hospital environment, for
example unpleasant/unfamiliar smells and sounds.

• Politico-economic
Is the client unemployed or on a low income? Elderly people or those with
children may be living beneath the poverty line and low-income families
are less likely than higher-income families to eat vegetables and
fresh fruit.
Does the client rely on starchy ‘filler’ foods such as white bread, biscuits,
cakes, sweets and fatty foods?
Is their vitamin and mineral status compromised as a result?
Does shopping for food involve a bus journey costing time and money?
Does the client lack knowledge about the importance of good nutrition?
Are they unable to buy suitable food or to prepare it?
Lack of knowledge may also lead to errors in making up bottle feeds for
infants resulting in over-concentration that can cause harm, or conversely,
weak feeds, resulting in failure to gain weight.