SCREENING and ASSESSMENT of THE NUTRITIONAL STATUS

▄ Nutritional Health – result of consistently meeting the body’s nutrient requirements

- determine average nutritional requirements by published standards such as RDA or food guide
pyramid
- adequacy of a client’s diet = use a food diary and compare the nutritional intake with RDA
- RDA
- Food Guide Pyramid

▄ Malnutrition – a condition resulting from excessive or inadequate nutrient availability over an extended
period.
*starvation – inadequate delivery of nutrients to the body.
Types:
1. Primary malnutrition – adequate nutrition is not delivered to the upper GIT over an extended period
2. Secondary malnutrition – occurs when GIT fails to absorb, metabolize or use nutrients
3. Mixed type malnutrition – inadequate calorie/protein intake with increased nutritional requirements

Protein and Calorie Deficiency Malnutrition

1. Kwashiorkor – inadequate protein intake but with adequate calorie intake
- moon-like flabby face, edema, body weight at above ideal range, visceral CHONs below
normal
2. Marasmus – inadequate calorie and protein intake
- BW and anthropometric appearance below normal, old man facie, cachectic appearance,
visceral CHONs within normal

* Micronutrient malnutrition – occurs when vitamins, minerals, trace elements are not absorbed, delivered
or used by GIT
- vitamins, minerals, trace elements deficits occur in combination. It is difficult to identify deficit of single
micronutrient

*Obesity – may result from nutrient delivery that exceeds the client’s nutritional requirement
I. History taking
▄ Biographical and Demographic Data
- analyze client’s demographic data within the context of nutritional status and upper GI function- -
women are at risk for problems r/t calcium deficiency
- culture, religion and ethnic origin may also affect the type, amount and frequency of dietary
consumption
▄ Chief complaints (n/v, indigestion, abdo pain, diarrhea, changes in weight or appetite)
-clinical manifestations that are related to nutritional status and upper GI function
-do symptom analysis

▄ Symptom analysis

a. nausea and vomiting – onset, duration, aggravating factors

- characteristic of vomitus = amount, color
= does the vomitus contains bile or undigested food?
- pain with n/v
b. indigestion – RT food intake, which food worsen or relieve the manifestations?
-medications- (antacids)
- description- burning or burping
c. abdominal pain – PQRST
-associated manifestations- fever – increased or relieved with movement? Does food exacerbate
pain?
Sources and Characteristics of Abdominal Pain
a. Intestinal obstruction – distended abdomen, no bowel movements or flatus
- intermittent or colicky pain
- RUQ pain radiating to shoulder (associated with gall bladder)
- pain near umbilicus (associated with small bowel)
- lumbar pain ((associated with colon)
b. Peritoneal inflammation – (perforated ulcer, ruptured spleen, ruptured appendix)
- steady aching pain over area of inflammation
- pain increasing with motion
- intensity of pain varying with source of inflammation (gastric acid may produce more pain than
alkaline content of small bowel)
- sometimes associated with manifestation of shock
c. Vascular obstruction – may be preceeded by 2-3 days of mild-moderate pain and hyperperistalsis,
folwed by severe abdominal pain and manifestations of shock.

d. weight and appetite changes – determine usual appetite and weight

- amt of weight loss or weight gain-
- diet- -causes
e. diarrhea –color
amount - how many stools expelled per day?how much?
Consistency- liquid or solid?
Color- back, tarry or bloody?
-associated manifestations = pain, abdominal cramping or bloating, time, fecal incontinence
*steatorrhea – fatty, foul-smelling stool
- non specific GI problems such as N/V and diarrhea can result from food-borne poisoning-
duration-
- provoking factors
- relationship of stool and dietary intake
- assess fluid and electrolyte balance
*vomiting – metabolic alkalosis (hcl)
*diarrhea – metabolic acidosis (HCO3)
* Lactose intolerance

▄ Past Health History

a. Major Illnesses and Hospitalization
- can provide clues about nutritional status and function of upper GIT
hospitalization due to GI s/sx-PUD, hematemesis, anemia, jaundice, gallbladder disease
- diagnostic tests of upper GI = clues about current health problem and serve as baseline data
- past surgical procedures
-> ask about surgery of the mouth, throat, stomach, liver, pancreas, gallbladder, abdomen

b. Medications – OTC, prescribed, herbal medications

- aspirin, aspirin compounds, NSAIDs = gastritis
- antacids, laxatives, stool softeners – frequency of use?
- vitamins and minerals = iron – may cause gastric irritation and can change stool color and
consistency

c. Nutritional supplements – vitamins, minerals, herbs, amino acids, meal supplements or

replacements
- can be harmful if taken in excess or in combination with other drugs
- in excessive doses, vitamins can cause toxic side effects
d. Allergies – hives, dyspnea, GI manifestations (cramping, flatulence, diarrhea) after food intake
*Lactose intolerance- common condition for many adults because of inadequate amount of lactase
(enzyme in the bowel)
->cannot break down lactose molecules->abdo cramping and drh

e. Family Health History- history of cancer, ulcer, UC, crohn’s disease

▄ Psychosocial History

a. occupation – toxic substances in the workplace (arsenic, lead, Hg)

- recent travels to foreign countries – increases risk of contracting GI dse.,caused by pathogenic
bacteria, protozoa, helminthes & other parasites
b. nutrition – type and amount of food intake are influenced by psychosocial factors
- describe a typical meal
- alcohol intake
- appetite
- food intake record= two weekdays and one weekend day
= to determine dietary intake
- average healthy person: 30 to 35 cal/kg and 0.8 to 1.2 g of protein/ kg

▄ ROS
- condition of the mouth- dental caries, number and condition of teeth
- oral lesions, halitosis, increased or decreased salivation
- brushing of teeth, visit to the dentist
- trouble chewing or swallowing
- dysphagia, odynophagia
- change in bowel habits or stool characteristics
- changes in appetite
- problems of hepatic or biliary systems (jaundice, pruritus, ascites, dark-colored urine, acholic stools,
bleeding problems

II. Physical Examination

▄ Anthropometric measures – provide an assessment of body mass or body compartments
1. Height or weight
- Weight = balance scale, calibrated sling, wheel chair scale
- Height = telescoping ruler; arm span measurement
- determine weight changes (current weight/ usual weight x 100)
- weight changes of less than 90% or more than 110% of the client’s usual weight is significant

2. Body Mass Index- acceptable method of standardizing height for weight measurement
 BMI= weight in kg/ height in meters2
= weight in lbs/ height in inches2 x 703

18.5 or less Underweight

18.5 – 24.9 Normal
25.0 – 29.9 Overweight
30.0 – 39.9 Obese
40 or greater Extremely Obese

▄ Mouth

Inspection
- lips = symmetry, color, hydration, lesions, nodules
- teeth = number and position; dental caries, missing or broken teeth,
= erythroplakia (red lesions); leukoplakia (white lesions)
- pharynx = tonsillitis
- tongue = symmetry, color, moisture
= Palpation
- lips, gingivae, buccal mucosa = loose teeth, masses, swelling, areas of tenderness
- tongue = lesions, masses, color changes
- dysphagia –
- tonsils –
▄ Abdomen-
Inspection
- skin, abdominal contour = smooth, intact, with varying amounts of hair, flat, concave or rounded-
= areas of distention or irregular contour
= rashes, discoloration, scars, petechiae, striae
- umbilicus = concave, located at the midline, no drainage and same color of the abdo skin
- peristaltic movement or abdominal pulsation

Auscultation-
- RLQ, RUQ, LUQ, LLQ- clockwise fashion
- Normal bowel sounds: every 5 to 15 sec; occur irregularly at a rate of 5 to 35 per minute
- borborygmi = loud, high-pitch bowel sounds
= hyperactive GIT
- hypoactive bowel sounds = bowel sound of 1 or fewer every minute
- use the bell of the steth to auscultate for vascular sounds = bruit, venous hum, friction rub
• bruit- vascular turbulence - aneurysm or partial obstruction of the vessel
• venous hum- heard in the periumbilical area indicates engorged liver circulation
• friction rub- two pieces rubbing together; suggest hepatic tumor when heard loudest over the
lower right rib cage or splenic inflammation when hear loudest over the lower rib cage in the
anterior axillary line

Percussion
- size and location of abdominal organs and to determine fluid, air or masses
- high-pitch, loud, musical sounds over gas-filled organs- tympanic
- dull sounds over fluid or solid organs- thud like
- determine size and position of liver and spleen

Palpation- systematic quadrant to quadrant or region to region

- begin with non-tender areas and progressing to painful ones
- light palpation = 1 to 2 cm depression
- deep palpation = size and shape of abdominal organs and masses
- * rebound tenderness

DIAGNOSTIC PROCEDURES

A. ACID PERFUSION TEST

AKA: Bernstein Test
Description: In this test, normal saline and acidic solutions are perfused separately into the esophagus
through a nasogastric tube.
Purpose: To distinguish heartburn-like pains caused by esophagitis from those caused by cardiac d/o.
Nursing Responsibilities
Pre-Test
• Explain the procedure and purpose of the test

• Instruct the patient to observe the following pretest restrictions:

 No antacids for 24 hrs. as ordered

 No food for 12 hrs.

  No fluids and smoking for 8 hrs.

• Inform pt. that some discomfort, coughing or gagging may be experienced during tube passage

• Inform pt. to report pain or burning sensation during perfusion

• Immediately before the test, check pt.’s PR & BP

During the Test

• Insert NGT that has been marked 12” from the tip into pt.’s stomach, aspirate stomach content,
then withdraw the tube into the esophagus.

• Hang labeled containers of NSS and 0.1 N HCL Solution on an IV pole then connect NGT to IV
tubing.

• Open the line from NSS @ 60-120gtts/min for 5-10 mins. then note pt.’s response.

• Close the line from NSS then open the line from HCL solution, same rate with NSS but to run for 30
mins., then note pt.’s response

• Stop the solution and withdraw NGT if the pt. experiences no discomfort after perfusion of HCL for
30 mins.

Post-Test
• Administer antacid as ordered

• Provide soothing lozenges or ice collar as ordered

• Patient may resume normal diet and medications as ordered

Nursing Alert!!!
• Observe the pt. closely for arrhythmias

• Withdraw the tube immediately if the pt. develops cyanosis or paroxysmal coughing

Normal Finding:
• Absence of pain

Abnormal Finding:
• Acidic solution causes pain or burning sensation (esophagitis)

B. BARIUM SWALLOW
AKA: Upper GI Series
Description: Is a fluoroscopic and x-ray examination of the esophagus, stomach and small intestine
Purpose:
• To detect ulcer, polyps, tumor, hernia, varices, strictures and foreign bodies

Nursing Responsibilities
Pre-Test
• Explain the procedure and purpose to the client

• Record V/S

• The client should be NPO and refrain from smoking for 8-12 hrs

• Withhold medications for 8 hrs unless indicated

• Inform the pt. That the test does not cause significant discomfort

Post-Test
• Check with the radiology department that the Upper GI Series and/or small bowel series are
completed before giving meal

• Administered the ordered laxatives

• Instruct client to increase fluid intake

• Inform the client that the stools should be light in color for the next several days

• Instruct the client to notify HCP if he/she does not have bowel movement in 2-3 days

Normal Findings:
 The bolus evenly fills and distends the lumen and the mucosa appears smooth and regular, normal
peristalsis

Abnormal Findings:
 ulcer, polyps, tumor, hernia, varices, strictures and foreign bodies
C. BARIUM ENEMA
AKA: Lower GI Series
Description: Radiographic examination of the large intestine after rectal instillation of barium sulfate
2 Types
a. Single Contrast (only barium sulphate)- provides a profile view of the large intestine

b. Double Contrast (Barium sulphate and air)- provides profile nad frontal view. It is better
for detecting small intraluminal tumors (esp. Polyps)

Purpose:
• To aid diagnosis of colorectal cancer and inflammatory diseases

• To detect polyps, diverticula, and structural changes in the colon

NURSING RESPONSIBILITIES
Pre-Test
• Explain the procedure and purpose of the test

• Oral medications should not be given for 24 hrs unless indicated

• Instruct the pt. to restrict dairy products and to follow a liquid diet for 24 hrs

• Instruct pt. to drink 8-oz of water or clear liquid for 12 to 24 hrs

• Inform patient that he/she will assume several position during instillation of barium.

• Prescribe laxatives to be taken the day before the test

• Administer a bowel preparation

Post-Test
• The client should expel the barium in the bathroom or bedpan immediately after the test

• Instruct pt. to increase fluid intake

• Encourage rest

• Administer laxative such as milk of magnesia or magnesium citrate or give cleansing enema as
ordered

• Inform pt. That the stool will be light colored for 24-72 hrs

• Absence of stool should be reported

Nursing Alert!!!
• Barium enema is contraindicated in pt. With tachycardia, severe ulcerative colitis, active GI
bleeding, suspected perforation

• The test is contraindicated to pregnant patient

Normal Findings:
Single Contrast: The intestine is uniformly filled with barium and mucosa has a regular and feathery
appearance
Double Contrast: The intestine is uniformly distended with air, with a thin layer of barium providing
excellent detail of the mucosal pattern
Abnormal Findings:
• Carcinoma, IBD, diverticula, fistulas, polyps, intussusception

D. FECAL OCCULT BLOOD TEST

Description: A microscopic analysis or chemical test for hemoglobin that determines hidden or invisible
blood (occult) in the stool.

Purpose:
• To detect GI bleeding

• To aid early diagnosis of colorectal cancer

NURSING RESPONSIBILITIES
• Explain the procedure and purpose to the client

• Obtain hx of recent or past bleeding episodes

• Instruct the client to maintain high-fiber diet and to refrain from eating red meat, poultry, fish,
green leafy vegetables for 48-72 hrs

• Instruct the client to withhold ascorbic acid, iron preparations, salicylates, and steroids for 48 hrs
 • Instruct client to report epigastric pain and abnormal-colored stool

• Be sure the stool is not contaminated with menstrual discharge

Normal Finding:
• Negative (Green Rxn)- less than 2.5 ml of blood in the stool

Abnormal Finding:
• Positive (Blue Rxn)- more than 2.5 ml of blood in the stool

E. PERCUTANEOUS LIVER BIOPSY

Description:
• Insertion of needle through the skin which involves needle aspiration of a core tissue for histologic
analysis

Purpose:
• To diagnose hepatic parenchymal disease, malignant tumors and granulomatous infections

NURSING RESPONSIBILITIES
Pre-Test
• Explain the procedure and purpose of the test

• Instruct the pt. to restrict food and fluids for 4-8 hrs

• Secure an informed consent

• Check pt. hx for hypersensitivity to local anesthesia

• Make sure PT, PTT, and platelet count are performed and recorded

• Instruct pt. to void before biopsy

• Record V/S

During the Test

• Instruct pt. to assume supine position with his right hand under his head

• Drape and clean the area of injection

• Instruct pt. to hold his breath while needle biopsy is inserted in the liver

• Apply pressure to the biopsy site to stop bleeding

Post-Test
• Position pt. On his right side for 2 hours, with small pillow or sandbag under the costal margin

• Check pt. V/S q 15 mins. For the 1 hr., then q 30 mins. for 4 hrs, and q 4 hrs for 24 hrs

• Observe carefully for signs of bleeding and shock

• Administer analgesic as ordered

• Provide rest and pt. may resume normal diet

• Send the specimen to the laboratory immediately

Nursing Alert!!!
• Watch for bleeding, signs of shock, bile peritonitis and pneumothorax

-S/SX of bile peritonitis: tenderness and rigidity around the biopsy site
-S/SX of pneumothorax: risisng RR, depressed breath sounds, dyspnea, persistent
shoulder pain, and pleuritic chest pain

Normal Findings:
• Normal liver cells

Abnormal Findings:
• Presence of malignancies and hepatic diseases

F. CT Scan
AKA: CAT Scan, CTT Scan, CATT Scan
- Computed Axial Tomography (CAT), Computed Transaxial Tomography (CTT),
Computed-assisted Transaxial Tomography

Description: It produces a narrow x-ray beam that examines body sections from many different angles.
Purpose:
To produce tissue analysis and images not readily seen on standard radiographs
Pre-Test:
• Explain the procedure and purpose of the test

• A consent form should be signed

• NPO for 4 hrs if contrast dye is used

• Assess pt. allergy to iodine products

• Remove all metal objects and jewelry

• Instruct pt. to wear loose and comfortable clothing

• Administer sedative as ordered

• Enema may be ordered

During the Test

• Instruct client to remain still during the procedure

• Instruct pt. That holding breath may be requested

• Instruct pt. To report unusual sensation especially if contrast dye is used

• Observe for S/Sx of severe allergic rxn to the contrast dye

Post-Test:
• Observe for delayed allergic reaction to the contrast dye

• Instruct pt. To increase fluid intake to enhace the excretion of contrast dye

• Instruct the client to resume his/her usual activity and diet as indicated

Nursing Alert!!!
• Watch for dyspnea, palpitations, tachycardia, itching and urtucaria

G. ULTRASONOGRAPHY
AKA: Ultrasound, Sonogram
Description: A procedure used to visualize body tissue structure or wave-form analysis of Doppler studies
Purpose:
• To detect tissue abnormalities

NURSING RESPONSIBILITIES
Pre-Test:
• Explain the procedure and the purpose of the test

• Obtain a signed consent form

• Restrict food and fluids for 4-8 hrs

• Advise pt. To eat fat-free meal night prior to the test

• Instruct client not to smoke or chew gum prior to the test

• Inform pt. that this is a painless procedure

• Enema may be performed as ordered

During the Test:

• Ask the client to breathe slowly and to hold breath after deep inspiration

• Instruct client to remain still during the test

Post-Test:
• Instruct the client to resume his/her usual activity and diet as indicated

H. X-RAY
AKA: Radiography, Roentgenography
Description: A procedure that emits x-radiation that is used to identify structure, size, and shape of bone
and body tissues
Purpose:
• For Screening purposes
NURSING RESPONSIBILITIES
• Explain the procedure and the purpose of the test

• Ask female client if she is pregnant

• Foods and fluids are not usually restricted

• X-ray should be taken before GI series

• Clothes are removed and cloth gown is worn

• Instruct pt. to lie in supine position with his arms away from the body