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1. Nutritional assessment
Assessment of nutritional status
Nutrition plays a great role in maintaining health
and preventing diseases.
Underfeeding, over feeding or feeding the wrong
food are all harmful nutritional habits.
In the assessment of nutritional status of an
individual, certain sign and symptoms are specific.
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2. Effective nutritional assessment includes the
following four areas abbreviated as ABCD:
Anthropometrical measurements,
Biochemical measurements,
Clinical examination of findings and
Dietary data.
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3. • Anthropometrical measurements
In the adult patient, useful Anthropometrical
measurements include:-
1.Height: decreased height may be considered as an
indication of osteoporosis, an important problem
related to nutrition, especially in old women.
A loss of 5-7.5 cm of height indicates osteoporosis.
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4. 2. Weight: weight loss is an extremely important
because it reflects inadequate caloric intake.
In some people who are semi-starved weight loss
indicates an increased loss of protein from the
body cell mass.
Weight should be interpreted in relation to age,
sex, and body frame.
Calculations of ideal body weight and body
frame are given below
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5. 1. Ideal body weight (IBW)
• To calculate the ideal body weight for
females:-
• Allow 100 Ibs for 5ft of height
• Add 5 Ibs for each additional inch over 5ft
• Subtract 10% for small frame and add 10% for
large frame
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6. To calculate the ideal body weight for male
• Allow 106 Ibs for 5ft of height
• Add 6 Ibs for each additional inch over 5ft
• Subtract 10% for small frame and add 10% for
large frame
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7. 1 pound(Ib)=0.453 kg
1 feet (ft)=12 inches=30.48 cm(1 inch=2.54 cm)
To estimate frame size, use the following guideline:-
• Measure height in cm.
• Measure wrist circumference in cm by placing a tape
measure around the wrist where it bends at the
styloid process.
• Calculate the ratio of height to wrist circumference to
estimate frame size.
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8. Use the following standard range to compare
and interpret.
Frame size female male
-Small frame-------------- >11 ------------>10.4
-Medium frame ----------- 10.1-11 ----- 9.6-10.4
-Large frame --------------- <10.1 --------- <9.6
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9. According to this estimation, body weight up to
10% above or below the ideal body weight for
the individual is considered to be normal
finding.
Body weight less than 10-20% of the ideal
weight calculated for the individual is under
nutrition and body weight greater than 10%
of the ideal weight is over weight.
If it is greater than 20%of the ideal body weight,
it is obesity.
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10. 2. Body mass index
It is a weight to height ratio composed of body
weight in kgs divided by the square of height in
meters.
The obtained values then compared with
established standard.
However, trends or changes in values over time are
considered more useful than isolated or one
time measurement.
The BMI is highly correlated with body fat.
But increased lean body mass of a large body
frame can also increase the BMI.
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11. BMI values 18-24 are considered normal
BMI values less than 18 are undernourished
BMI above 30 are obese
BMI 40 or above are considered to be
morbidly obese
Other indicators such as weight for age,
weight for height, weight for length are not
appropriate in adults because of many
limitations but in children.
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12. 3. Mid Upper Arm Circumference(MUAC)
 Helps to determine skeletal muscle mass. To assess it
follow the following procedure.
 Ask the pt to hang upper arm of his non dominant hand
in an independent position with the elbow at 90 degree
angle and palms up
 Find the mid point of the non-dominant arm half way
b/n the top of the acromoin process and the olecranon
process and mark (point).
 Measure mid arm circumference in cm while the patient
flex his arm
 Compare the value with the standard value and his prior
measurements.
 Mid arm circumference decreases among other reasons,
with malnutrition and increases with fat and muscle
hypertrophy.
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13. 4. Triceps skin fold (TSF)
• It helps to determine subcutaneous fat stores. The
procedure is as follows;
• Ask the pt to hang his non dominant arm freely
• Grasp skin fold and subcutaneous fat b/n your
thumb and for finger 1 cm above mid point mark
• Pull skin away from muscle and apply caliper
• Read after 2-3 seconds.
• For increased accuracy you can average three
measurements
• Compare the result measured in millimeters with
the reference data and the pt’s prior measurements
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14. 5. Mid arm muscle circumference (MAMC)
• It indicates the state of muscle protein.
Therefore, provides information about protein-
calori malnutrition. MAMC is calculated from
MUAC and TSF using the following formulae;
• MAMC(cm)=MUAC(cm)-(0.314xTSF (mm))
• As usual the calculated value is compared with
the standard value for the individual and prior
values.
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15. • Biochemical assessment
• Reflects the tissue level of a given nutrient and any
abnormality of metabolism in the nutrient.
• These determinations are made from serum (serum
protein, serum albumin and globulin, transferin
hemoglobin, serum vitamin A, carotene, and vitamin
C) studies.
• The test can detect recent intake of the nutrients
and identify below normal levels when there are no
clinical symptoms of deficiency.
• Reduced number of lymphocytes in people who
become acutely malnourished because of stress and
low calorie feeding are associated with impairment
of cellular immunity.
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16. Clinical examination of nutritional status
The state of nutrition is often reflected in the
person’s appearance. Although the most obvious
physical sign of good nutrition is a normal body
weight with respect to height, sex, age, body
frame, other tissues can serve as indicators
general nutritional status and adequate intake of
specific nutrients.
These include the hair, skin, teeth, gums mucous
membrane, mouth, tongue, skeletal muscles,
abdomen, lower extremities and thyroid gland.
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17. The dietary data
In this context you should consider the quality and
quantity of the patient’s diet. And also the
frequency in which certain food items is
consumed in order to determine current or
customary intake of nutrients.
Then calculate the patient’s daily calorie
requirements using the following formulae;
Calorie requirement=IBW(in Ibs)x ca/Ib of IBW
based on sex and activity level
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18. • The calculation of calorie requirement needs
your knowledge of the calorie content per unit
of the actual items eaten by the patient and
your talent in classifying the activity level of the
patient as sedentary, moderate and heavy. You
are strongly advised to study the nutritional
values of actual items consumed in your area.
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20. Examination of the Skin
• Examine the patient in good lighting
• Inspect and palpate skin for the following:
 Color Pigmentation
 Lesions Texture
 Hair distribution Turgor
 Warmth: use back of hand Moisture
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21. Abnormal Findings
• Color
• Pallor:
• Iron def. anemia
• Yellow:
• Jaundice
• Carotenemia/yellow skin/
• Hemolysis
• Red:
• Erythroderma
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22. • Pigmentation
– Hyper pigmentation
– Localized:
• Pregnancy
• BCP ingestion
– Generalized:
• Thyrotoxicosis
• Liver disease
• Renal disease
– De-pigmentation:
• Vitiligo
• Injury
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23. Abno…
• Texture
– Soft: (Thyrotoxicosis)
– Tight: (Scleroderma)
– Rough: (Hypothyroidism)
• Moisture
– Dry: (Vitamin A def,
Myxedema)
– Oily: (Acne
• Turgor
– Decreased: (Dehydration)
• Warmth:
– Generalized warmth:
(Fever, Hyperthyroidism)
– Localized warmth:
(Inflammation)
– Coolness:
(Hypothyroidism,
Frostbite, Hypothermia,
Shock, Low cardiac
output)
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24. MOLE WARNING SIGNS
The "ABCD" rule & Melanoma Danger Signs
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25. • Asymmetry
– Unequal or asymmetric moles are
suspicious.
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26. • Border
– If the border is irregular or indistinct, it
is more likely to be cancerous (or
precancerous)
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27. • Color
– Variation of color (e.g., more than one
color or shade) within a mole is a
suspicious finding
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28. • Erythema
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29. CYANOSIS
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30. Jaundice
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31. Pallor
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32. Vitiligo
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33. • Diameter
– Any mole that has a diameter larger
than a pencil's eraser in size (> 6 mm)
should be considered suspicious.
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34. • Elevation
– If a mole is elevated, or raised from of the skin,
it should be considered suspicious
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35. Inspect skin vascularity
• Ecchymosis
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36. Petechiae
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37. Inspect skin lesion
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38. Palpate skin temperature, texture,
moisture and turgor
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39. EDEMA
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40. PITTING EDEMA
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41. • Grades of pitting
edema
• Grade 0 : (none)
• Grade +1 :( trace , 2 mm)
• Disappear rapidly
• Grade +2 ( moderate , 4
mm)
• 10-15 sec
• Grade +3 (deep, 6 mm)
• ≥ 1min
• Grade +4 (very deep, 8
mm)
• 2-5min
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42. ASSESSING NAILS
• Shape; convex
• Angle : between nail and its base is 160
degrees
• Texture: smooth, nail base should be firm and
non tender
• Color: pinkish nail bed with translucent white
tips
• Capillary refill
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43. ABNORMALITIES OF NAIL
• Koilonychias (spoon nail)
• clubbing
• Paranychia
• indentations called (beau’s line)
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44. ASSESSING HAIR AND SCALP
• color,
• texture and distribution.
• Thickness and lubrication of hair
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45. INSPECT THE SCALP
• Cleanliness, color, dryness,
• Lump, lesions,
• Lice (pediculus humanus capitus)
• Dandruff etc
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46. HEAD
• ASSESSING THE SKULL
• for size, symmetry
• any nodules or masses
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47. INSPECT THE FACE
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48. ASSESS THE EYE
• Inspect external eye structure
• Position and alignment
• Exophthalmoses
• Strabismus/squint/
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49. ASSESS THE EYE
• Eye brows
• Eye lid :
• Ectropion( eversion, lid margin turn out)
• entropion(inversion, lid margin turns inwards)
• ptosis( abnormal drooping of lid over pupil
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50. ASSESS THE EYE
• Eye lashes : sty/ an inflamed swelling on the
edge of an eyelid.
• Eye balls
• Conjunctiva and sclera{ Paleness, redness or
purulent, jaundice}
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51. ASSESS THE EYE
• Cornea and iris :arcus senilis/ a narrow opaque
band encircling the cornea, common in old age/
• Pupil : PERRLA./pupils equal ,round, react to
light accommodation/
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52. ACCOMMODATION
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53. PUPILLARY REFLEX TO LIGHT
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54. INSPECT INTERNAL EYE STRUCTURES
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55. EXTRA OCULAR MOVEMENTS
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56. PERIPHERAL VISION
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57. EARS
• AURICLES
• EAR CANAL AND TYMPANIC MEMBRANE
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58. HEARING
• WEBER’S TEST:
• RINNE, S TEST:
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59. NOSE AND SINUSES
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60. INSPECT THE MOUTH PHARYNX
• LIPS: lesions ,pallor (anemia),
cyanosis(respiratory cardiovascular problems),
cherry colored
• BUCCAL MUCOSA , GUMS AND TEETH: teeth
look for alignment , dental caries.buccal mucosa
is a good site to visualize jaundice and
pallor.leukoplakia (thick white patches ) is a
precancerous lesion.
• TONGUE
• FLOOR OF MOUTH
• PHARYNX:
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61. ABNORMAL FINDINGS
• pallor, cyanosis or redness
• lesions, swollen lips red tonsils, swollen red
bleeding gums,
• white coating of tongue fissured tongue from
dehydration.
• bright red tongue seen in deficiency of iron
b12 or niacin,
• black tongue
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