This section will describe how a nurse uses the nursing process and the clinical judgment model to promote healthy diets. Stages of the National Council of State Board of Nursing (NCSBN) Clinical Judgment Model are indicated in parentheses.

Assessment

Subjective Assessment

A thorough assessment of a client’s dietary intake and preferences is the first step in developing a plan of care for clients. A nutritional assessment includes gathering information from the client through interviewing, review of lab and diagnostic results, and physical examination.

Subjective assessments include questions regarding normal eating patterns and risk factor identification. Subjective assessment data is obtained by interviewing the client as a primary source or a family member or caregiver as a secondary source. While a wealth of subjective information can be obtained through a chart review, it is important to verify this information with either the client or family member because details may be recorded inaccurately or may have changed over time. Subjective information to obtain when completing a nutritional assessment includes age, sex, history of illness or chronic disease, surgeries, dietary intake including a 24-hour diet recall or food diary, food preferences, cultural practices related to diet, normal snack and meal timings, food allergies, special diets, and food shopping or preparation activities.^[1]

A detailed nutritional assessment can also provide important clues for identification of risk factors for nutritional deficits or excesses. For example, a history of anorexia or bulimia will put the client at risk for vitamin, mineral, and electrolyte disturbances, as well as potential body image disturbances. Swallowing impairments place the client at risk for decreased intake that may be insufficient to meet metabolic demands. Use of recreational drugs or alcohol places the client at risk for insufficient nutrient intake and impaired nutrient absorption. Use of nutritional supplements places the client at risk for excess nutrient absorption and potential toxicity. Recognizing and identifying risks to nutritional status help the nurse anticipate problems that may arise and identify complications as they occur. Ideally, the nurse will recognize subtle cues of impending or actual dysfunction and prevent bigger problems from happening. Information from these subjective assessments can be used, in conjunction with review of lab and diagnostic results and physical examination, to develop a plan of care for the client.^[2]

Nutritional Assessment Tools

A variety of tools may be used to obtain information about a client’s food intake patterns. This section will provide an overview of common nutritional assessment tools.

24-hour Dietary Recall

A 24-hour dietary recall aims to provide detailed information about food and beverages consumed by a client in the past 24 hours. Clients are interviewed by trained individuals or complete an automated interviewing system that gathers information, including the types of foods or drinks consumed, time of consumption, preparation method, and portion size.

Food Record

A food record, also called a food diary, allows the client to record their intake in real-time over a specific period of time. Instructions are provided to the client as to how to use a designated form or record. The client should record all foods and beverages consumed, including type of food, brand names, preparation method, and portion size. Several food tracker apps are also available for download onto smart devices for clients who prefer to record their intake electronically. See Figure 3.10^[3] for an image of a sample weekly food record.

Diet History Questionnaire

A diet history questionnaire is used to track consumption of specific foods or beverages over a period of time, such as the last week, month, or year. Use the link in the following box to view the National Cancer Institute’s examples of free, online diet history questionnaires.

Mini Nutritional Assessment

The Nestle Nutritional Institute created a nutritional assessment for clients over the age of 65 called the mini nutritional assessment (MNA). The MNA uses information about food intake, weight loss, mobility, psychological stress, acute disease, neuropsychological problems, and body mass index to assess nutritional status. Based on scoring, clients are categorized as having normal nutritional status, at risk for malnutrition, or malnourished. Recommended interventions are outlined for providers based on the MNA score.

Objective Assessment

Objective assessment data is information derived from direct observation by the nurse and is obtained through inspection, auscultation, and palpation. The nurse should consider nutritional status while performing a physical examination.^[4]

The nurse begins the physical examination by making general observations about the client’s status. A well-nourished client has normal skin color and hair texture for their ethnicity, healthy nails, and appears energetic. The nurse also measures and documents the client’s height and weight.^[5]

Body Mass Index

Height and weight in adults are often compared to a body mass index (BMI) graph. BMI can also be calculated using the following formulas^[6]:

• BMI = weight (kilograms)/height(meters)²
• BMI = weight (pounds) x 703)/height(inches)²

To calculate BMI using a BMI table, the client’s height is plotted on the horizontal axis, and their weight is plotted on the perpendicular axis. The BMI is measured where the lines intersect. See Figure 3.11^[7] for a BMI table for interpreting adult weights. BMI is interpreted using the following ranges^[8]:

• Less than 18.5 kg/m2: Underweight
• 18.5-24.9 kg/m2: Desirable range
• 25-29.9 kg/m2: Overweight
• Equal or greater than 30 kg/m2: Obese

Pediatric Height, Weight, and Growth Charts

Growth charts can be used to monitor nutritional status in children. Height and weight for infants and children are plotted on a growth chart to give a percentile ranking across the United States population.^[9]

The Centers for Disease Control and Prevention (CDC) recommends growth charts be used in conjunction with other assessments rather than as a sole measurement of health of a child. Consideration should be given to parental stature, chronic illness, or other special health care needs. The World Health Organization (WHO) charts are recommended for children from birth to two years, and the CDC growth charts are recommended for children from 2-19 years of age.^[10] See Figure 3.12^[11] for an example of a growth chart for boys from birth to 36 months.

Growth chart training is provided by the Center for Disease Control and Prevention (CDC).^[12] Use the information provided in the following box to view these instructions from the CDC. If growth is not proceeding as expected based on the growth charts, the client is referred for additional evaluation by health care providers.

Accurate Pediatric Length and Weight Measurement

Accuracy is vital when measuring and documenting pediatric heights and weights used to identify potential growth and/or nutrition-related problems. Three critical components for accurate pediatric measuring and weighing for use with the growth charts are technique, equipment, and trained measurers.^[14]

When weighing an infant, the scales should be calibrated with precision of 0.01 kg or 1/2 ounce. Infants should be nude; wearing a clean, disposable diaper; and positioned in the center of the scale tray. The weight should be documented to the nearest 0.01 kg or 1/2 oz. The infant should be repositioned in the scale, the weight measurement repeated, and the second weight noted in writing. The two weights should agree within 0.1 kg or 1/4 pound; if they don’t meet this standard, the infant should be repositioned and reweighed a third time. An alternative measurement technique may be used if an electronic scale is available. Have the parent stand on the scale, reset the scale to zero, and then have the parent hold the infant and read the infant’s weight. However, many adult scales generally only weigh to the nearest 100 gm.^[15]

Length should be measured in the supine position for infants younger than 24 months of age or children aged 24 to 36 months who cannot stand unassisted. Accurate length measurement requires a calibrated length board with a fixed headpiece and a moveable, perpendicular foot piece. Shoes and hair ornaments should be removed. The child should be placed on their back in the center of the length board so that they are lying straight, and their shoulders and buttocks are flat against the measuring surface. The child’s eyes should be looking straight up. Both legs should be fully extended, and the toes should be pointing upward with feet flat against the foot piece. The infant’s chin should not be tucked in against their chest or stretched too far back. Both legs should be fully extended for an accurate and reproducible length measurement. Correctly positioning the infant for a length measurement generally cannot be accomplished without two measurers. The length should be documented to the nearest 0.1 cm or 1/8 inch, and then the infant should be repositioned, and the length measurement repeated and noted in writing. The length measurements should be compared and agree within 1 cm or 1/4 inch. If they don’t agree within this range, the infant should be repositioned and remeasured a third time.^[16]

Common Laboratory and Diagnostic Tests

Diagnostic and lab work may be ordered by health care providers to assess a client’s nutritional status. Common lab tests ordered to assess nutritional status include hemoglobin (Hgb), hematocrit (HCT), white blood cells (WBC), albumin, prealbumin, and transferrin.^[17]  See Table 3.5a for a summary of nursing considerations related to these lab results.

Table 3.5a Selected Laboratory Tests Related to Nutrition

See “Appendix A”  for reference ranges of other lab values. As always, refer to agency lab reference ranges when providing client care.

Analyzing Data: Expected and Unexpected Findings

After completing the subjective and objective assessment, the nurse analyzes the data for expected and unexpected findings. See Table 3.5b for a comparison of expected versus unexpected assessment findings related to nutritional status.

Table 3.5b. Expected Versus Unexpected Findings In Body Systems Related to Nutritional Status1

Diagnosis

After a comprehensive nutritional assessment is completed, relevant cues are recognized and analyzed, and nursing problems (diagnoses) are identified. See Table 3.5c for common nursing diagnoses related to nutrition.

Table 3.5c. NANDA Nursing Diagnoses Related to Nutrition^[18]

Outcome Identification

Goals for clients experiencing altered nutritional status depend on the selected nursing diagnosis and specific client situation. Typically, goals relate to resolution of the nutritional imbalance and are broad in nature, such as the client’s weight will be within normal range for their height and age. Outcome criteria are specific, measurable, achievable, realistic, and time oriented. Sample SMART goals related to nutritional status are as follows^[19]:

• •  The client will select three dietary modifications to meet their long-term nutritional goals using recommended guidelines by discharge.
  •  The client will achieve a BMI between 18.5 – 24.9 kg/m2 within six months.

Interventions

After SMART outcome criteria are customized to the client’s situation, nursing interventions are planned to help achieve identified outcomes. It is vital to consider the client’s cultural and religious beliefs and encourage clients to make healthy food selections based on their food preferences.

Nutrition Therapy

Interventions are specific to the alteration in nutritional status, current dietary guidelines, and history of existing chronic disease. The box below outlines selected interventions related to nutrition therapy.^[20]

Promoting Effective Weight Loss

Weight loss is a desired outcome for clients who are overweight or obese and have expressed readiness in doing so. Collaboration with a health care provider is important to ensure interventions are safe when developing a weight loss plan. Safe and effective weight-loss programs should focus on healthy lifestyle habits and not diet alone. Slow, steady weight loss, such as one to two pounds a week, is generally recommended.^[22]

Many people are tempted by the marketing of fad diets, which promise quick, easy weight loss. Research shows fad diets do not work, or if people do lose weight, it is often temporary. If a fad diet eliminates entire food groups such as wheat or dairy, important nutrients are missed. Clients should be taught to avoid diets that contain the following^[23]:

• A promise of quick, easy weight loss
• Something must be purchased
• Data that is vague or scientific sounding instead of research
• Endorsements from celebrities or influencers

Helping a Child Who is Overweight

Children who are overweight or obese are more likely to be obese as adults.^[24] Encouraging healthy lifestyle habits, such as a healthy diet, daily physical activity, limited screen time, and adequate sleep can help overweight children achieve a healthy weight. The health care provider may refer children to a registered dietician to assist in developing a weight-loss plan that is safe for the child. Obese children between the ages of 6 and 11 are generally recommended to lose no more than one pound per month, while older children and adolescents should limit weight loss to two pounds a month. Parents can support their children’s weight loss by modeling healthy behaviors, such as regular exercise and healthy food choices. Healthy eating includes prioritizing fruits and vegetables over processed foods, limiting sweetened beverages, avoiding fast food, serving smaller portion sizes, and eating as a family.^[25],[26]

Other Considerations at Mealtime to Promote Appetite

If a client has nutritional deficit, perform nursing interventions prior to mealtime to promote their appetite. For example, if the client has symptoms of pain or nausea, administer medications prior to mealtime to manage these symptoms. Do not perform procedures that may affect the client’s appetite, such as wound dressing changes, immediately prior to mealtime. Manage the environment prior to the food arriving and remove any unpleasant odors or sights. For example, empty the trash can of used dressings or incontinence products. If the client is out of the room when the meal tray arrives and the food becomes cold, reheat the food or order a new meal tray.^[27]

When assisting clients to eat, help them to wash their hands and use the restroom if needed. Assist them to sit in a chair or sit in high Fowler’s position in bed. Set the meal tray on an overbed table and open containers as needed. Encourage the client to feed themselves as much as possible to promote independence. If a client has vision impairments, explain the location of the food using the clock method. For example, “Your vegetables are at 9 o’clock, your potatoes are at 12 o’clock, and your meat is at 3 o’clock.” When feeding a client, ask them what food they would like to eat first. Allow them to eat at their own pace with time between bites for thorough chewing and swallowing. If any signs of difficulty swallowing occur, such as coughing or gagging, stop the meal and notify the provider of suspected swallowing difficulties.^[28]

Evaluation

Nurses evaluate the effectiveness of the nursing care plan to determine if the outcome criteria have been met, partially met, or not met. For example, sample criteria that may be used to evaluate a client diagnosed with Imbalanced Nutrition: Less than Body Requirements may include the following: stable or increasing weight; sufficient daily calories according to energy expenditure; well-balanced food intake; improved energy; and shiny hair, intact nails, and moist, intact skin.