nurtitional needs and nutritional assesment

the BMR calculation and the nutritional assessment for children

1. Nutritio
nal Needs

2. NUTRITIONAL NEEDS: Introduction
Health and nutrition are the most important contributory factors for
human resource development in the country.
Long-term malnutrition leads to stunting and wasting, non-
communicable chronic diet related disorders, increased morbidity
and mortality and reduced physical work output. It is a great
economic loss to the country and undermines development.

3. Contd….
Nutrients are essential for the normal growth and functioning of the
body.
According to WHO, nutrition is the intake of food, considered in
relation to the body's dietary needs. Good nutrition-an adequate, well-
balanced diet combined with regular physical activity is the
cornerstone of good health. Poor nutrition can lead to reduced
immunity, increased susceptibility to disease, impaired physical and
mental development, and reduced productivity.

4. DIETARY GOALS by National Institute of
Nutrition
1.Maintenance of a state of positive health and optimal performance in populations at
large by maintaining ideal body weight.
2.Ensuring adequate nutritional status for pregnant women and lactating mothers.
3.Improvement of birth weights and promotion of growth of infants, children and
adolescents to achieve their full genetic potential.
4.Achievement of adequacy in all nutrients and prevention of deficiency diseases.
5.Prevention of chronic diet-related disorders.
6.Maintenance of the health of the elderly and increasing the life expectancy.

5. DIETARY GUIDELINES

6. Eat variety of foods to ensure a balanced diet.

8. Dietary guidelines
Ensure moderate use of edible oils and animal foods and very less
use of ghee/ butter/ vanaspati.
Avoid overeating to prevent overweight and obesity.
Exercise regularly and be physically active to maintain ideal body weight.
Restrict salt intake to minimum.
Ensure the use of safe and clean foods.
Adopt right pre-cooking processes and appropriate cooking methods.
Drink plenty of water and take beverages in moderation.
Minimize the use of processed foods rich in salt, sugar and fats.
Include micronutrient-rich foods in the diets of elderly people to enable them
to be fit and active.

10. IMPORTANCE OF GOOD NUTRITION
Nutrients that we obtain through food have vital
effects on physical growth and development,
maintenance of normal body function, physical
activity and health. Nutritious food is, thus needed
to sustain life and activity.

11. Our diet must provide all essential nutrients in the required amounts.
Requirements of essential nutrients vary with age, gender, physiological status and
physical activity.
Dietary intakes lower or higher than the body requirements can lead to
undernutrition (deficiency diseases) or overnutrition (diseases of affluence)
respectively.
Eating too little food during certain significant periods of life such as infancy,
childhood, adolescence, pregnancy and lactation and eating too much at any age can
lead to harmful consequences.
An adequate diet, providing all nutrients, is needed throughout our lives. The
nutrients must be obtained through a judicious choice and combination of a
variety of foodstuffs from different food groups.

12. Nutrition is a basic prerequisite to sustain life.
Variety in food is not only the spice of life but also the essence of nutrition and health.
A diet consisting of foods from several food groups provides all the required nutrients
in proper amounts.
Cereals, millets and pulses are major sources of most nutrients.
Milk which provides good quality proteins and calcium must be an essential item of
the diet, particularly for infants, children and women.
Oils and nuts are calorie-rich foods, and are useful for increasing the energy density
and quality of food. Inclusion of eggs, flesh foods and fish enhances the
quality of diet. However, vegetarians can derive almost all the nutrients from diets
consisting of cereals, pulses, vegetables, fruits and milk-based diets. Vegetables and
fruits provide protective substances such as vitamins/ minerals/ phytonutrients.
Diversified diets with a judicious choice from a variety food groups provide the
necessary nutrients.

20. Food habits, customs and beliefs
Food habits are among the oldest and most deeply
entrenched aspects of any culture.
They have deep psychological roots and are associated
with love, affection, warmth, self image and social
prestige.
The family play as important role in shaping the food
habits and these habits are passed from generation to
generation.

28. Food fads
In the selection of food , personal likes and dislikes
play an important role. These are called food fads.
The food fads may stand in the way of correcting
nutritional deficiencies.

29. Health and sickness
Infectious diseases are an important conditioning
factors responsible for malnutrition, particularly in
small children.
Diarrhea , intestinal parasites, measles, whooping
cough, malaria tuberculosis, all contribute to
malnutrion.

30. Environmental factors
Environmental conditions also influence the nutrition
and health of the individual.
Where the environmental conditions are poor , small
children may suffer from some infections or the other
for almost half of their first three years of life.
The interrelationship between malnutrition and
infection has been well documented.

31. Cooking practices
Draining away the rice water at the end of the
cooking, prolonged boiling in open pans, peeling of
vegetables, all influences the nutritional status of
infants and children.

32. Child rearing practices
These vary widely from region to region and
influences the nutritional status of the infants and
children.
E.g. During first 6 months adoptions of bottle feeding
and commercially produced refined foods.

33. Miscellaneous
In some countries , men eat first and women eat last and
poorly.
Consequently , the health of women in these societies may be
adversely affected.
Chronic alcoholism is an another factor which may lead to
various diseases, e.g. Liver failure, malnutrion, behavioral
problems etc.

35. THERAPEUTIC DIET
Introduction :Therapeutic diet are planned to maintain or
restore good nutrition in patient.
In most cases the therapeutic diet are used to supplement the
medical or surgical treatment of the patient, while in some
instances like diabetes mellitus, a therapeutic diet is the most
aspect of the patient’s treatment rather the medical therapy.
Diet therapy is concerned with recovery from illness and
prevention of disease.

36. Diet therapy
 It is a branch of dietetics concerned with the use of food for
therapeutic purpose. Diet therapy is a broad term used for the
practical application of nutrition as a preventive or corrective
treatment of a disease. It concerns with recovery from illness by
giving good diet and prevention of disease.
It may involve the modification of the existing dietary lifestyle to
promote optimum health.

37. For example a dietitian or a nutrition counselor may prescribe
a diet therapy to an obese person to improve health. The
therapy may involve including foods that improve the health
condition while avoiding foods (such as fats, sugars etc.)
Basically the therapy promotes a balanced selection of foods
vital for good health.

38. Principles of diet therapy
 To maintain good nutritional status,
 To correct deficiencies or disease, if any,
 To provide rest to the body,
 To help metabolize the nutrients, and
 To make changes in body weight, when necessary.

39. Balanced diet
 It is defined as one which contains a variety of foods in such
quantities and proportions that the need for energy, proteins,
vitamins, minerals, fats and other nutrients is adequately met
for maintaining health and well being.

40. Therapeutic diet
A therapeutic diet is a meal plan that controls the intake of
certain foods or nutrients. It is part of the treatment of a
medical condition and are normally prescribed by a physician
and planned by a dietician. A therapeutic diet is usually a
modification of a regular diet. It is modified or tailored to fit the
nutrition needs of a particular person.

41. Some common examples of therapeutic diets 3 include clear liquid
diet, diabetic diet, renal diet, gluten free diet, low fat diet, high
fiber diet etc.
Therapeutic diets are usually prescribed by dietitians, nutritionists
or physicians.

42. Therapeutic diet
A therapeutic diet is a qualitative/quantitative modified
version of a normal regular diet which has been tailored to
suit the changing nutritional needs of patient/individual and
are used to improve specific health/disease condition. It is a
planned diet used to supplement the medical or surgical
treatment.

43. Therapeutic diets are modified for
(1) nutrients,
(2) texture, and/or
(3) food allergies or food intolerances.

45. Common reasons therapeutic diets
may be ordered
•To maintain nutritional status
•To restore nutritional status
•To correct nutritional status
•To decrease calories for weight control
•To provide extra calories for weight gain
•To balance amounts of carbohydrates, fat and protein for control of
diabetes
•To provide a greater amount of a nutrient such as protein

46. •To decrease the amount of a nutrient such as sodium
•To exclude foods due to allergies or food intolerance
•To provide texture modifications due to problems with
chewing and/or swallowing

47. Diet used in Hospital settings

48. Normal or general diet
Normal or general diet in a hospital setting is a balanced diet
which meets the nutritional needs of an individual/patient. It is
given when the individual's medical condition does not warrant
any specific modification. Most hospitals follow simple dietary
recommendations (given by ICMR for Indian population) while
planning the general diet.

49. Diets of Altered Consistency
Therapeutic diets are modified for consistency, texture to fit the
nutritional needs. Some individuals may require a clear liquid diet,
while others a fully liquid diet or soft diet based on their medical
condition.
E.g.
Liquid Diet
Soft Diet
Mechanically soft diet
Bland diet

50. Liquid Diet
Liquid Diet consists of foods that can be served in liquid or
strained form in room temperature. They are usually
prescribed in febrile states, postoperatively i.e. after surgery
when the patient is unable to tolerate solid foods.

51. i) Clear liquid diet
Provides foods and fluids that are clear and liquid at room
temperature. The purpose of the clear liquid diet is to provide
fluids and electrolytes to prevent dehydration. It provides some
amount of energy but very little amount of other nutrients. It is
also deficient in fibre. Hence it is nutritionally inadequate and
should be used only for short periods i.e. 1-2 days.

52. An average clear liquid diet contains 600 to 900Kcal, 120 to
200g carbohydrate, minimal fat 5 to 10g protein and small
amount of sodium and potassium (electrolytes). The clear liquid
diet is usually useful in situations when the gastrointestinal tract
has to be kept functionally at rest.

54. ii) Full liquid diet
Full liquid diet provides food and fluids that are liquid or semi liquid
at room temperature. It is used as a step between a clear liquid diet
and a regular diet. The purpose of the full liquid diet is to provide an
oral (by mouth) source of fluid for individuals who are incapable of
chewing, swallowing or digesting solid food.

55. It provides more calories than the clear liquid diet and gives
adequate nourishment, except that it is deficient in fibre. It is
indicated for post operative patients and for gastrointestinal illness.
An average full liquid diet can provide approximately 1000 to 1800
calories and 50 to 65g of protein and adequate minerals and
vitamins.

57. Soft diet
Soft diet as the name suggests provides soft whole food that is lightly
seasoned and are similar to the regular diet . The term 'soft' refers to the
fact that foods included in this type of diet are soft in consistency, easy
to chew and made of simple, easily digestible foods. It does not contain
harsh fibre or strong flavours. It is given during acute infections, certain
gastrointestinal disorders and at the post operative stage to individuals
who are in the early phase of recovery following a surgery

58. Soft diet can be nutritionally adequate (providing approximately
1800-2000 calories, 55-65g protein) provided the patient is able
to consume adequate amount of food.

60. Mechanical soft diet
Mechanical soft diet also known as the dental diet which is a normal diet
that is modified only in texture for ease of mastication i.e. chewing. When
an individual cannot chew or use facial muscles for a variety of dental,
medical or surgical conditions mechanical soft diet is recommended.
Elderly persons who have dental problems are prescribed mechanical soft
diets.

61. The food in mechanical soft diet is similar to the soft diet and may
be full liquid, chopped, pureed or regular food with soft
consistency. Simple salads, fruit salads and cottage cheese may be
included. No food is restricted unlike in the case of the customary
soft diet. Just removing the skin and seeds, cutting or chopping the
food into small fine pieces are processes usually employed.

62. Any foods that can be blended, mashed, pureed, or
chopped using a kitchen tool such as a knife, a grinder,
a blender, or a food processor.
 

63. Bland Diet
A bland diet is made of foods that are soft, not very spicy and low in
fiber. It consists of foods which are mechanically, chemically and
thermally non-irritating i.e. are least likely to irritate the
gastrointestinal tract. Individuals suffering from gastric or duodenal
ulcers, gastriris or ulcerative colitis are prescribed this diet.

64. Foods Included: Milk and milk products low in fat or
fat free; Bread, pasta made from refined cereals, rice;
cooked fruits and vegetables without peel and seeds;
Eggs and lean tender meat such as fish, poultry that
are steamed, baked or grilled; Cream, butter; Puddings
and custards, clear soups

66. Modification in Nutrients
The nutrient content of the diet is modified to treat deficiencies,
change body weight or control diseases such as hypertension or
diabetes.

67. Examples of Nutrient modifications:
•No concentrated sweets diet
•Diabetic diets
•No added salt diet
•Low sodium diet
•Low fat diet and/or low cholesterol diet
•High fiber diet
•Renal diet

68. Dysphagia
Dysphagia is derived from the Greek word “phagein” means “to
eat”.
Dysphagia is any disruption/Difficulty in the swallowing
process during bolus transport from the oral cavity to the
stomach.

69. Types of Dysphagia
Dysphagia is classified into the following major
types:
1. Oropharyngeal dysphagia
2.Esophageal dysphagia
3.Complex neuromuscular disorders
4.Functional dysphagia

71. Causes of dysphagia:
•Bad teeth
•Problems with the jaw
•Xerostomia - dry mouth
•Tumors - Oral cancer, pharyngeal or laryngeal cancer
•Masses outside the pharynx, such as osteophytosis on the
vertebrae that press on pharynx
•Complication of head or neck surgery

72. •Immune system diseases such as polymyositis
•Cricopharyngeal(Upper esophageal sphincter)
dysfunction- can result in material remaining in
posterior pharynx with risk of aspiration of material into the
airway after the swallow
•Age-related changes in swallow function

73. Infants who are born with an opening in the roof of the mouth (cleft
palate) are unable to suck properly
cancer of the head, neck, or esophagus may cause swallowing
problems
People with dementia, memory loss and cognitive decline may
make it difficult to chew and swallow.

74. Care of patient
Maintain the patient in high fowlers position with head
flexed slightly forward towards meals
Instruct patient not to talk while eating
Avoid milk or milk products
If patient had stroke, place food in the back of the
mouth, on the unaffected side,gently massage the
unaffected side of the throat

75. If any signs are present put on gloves, eliminate all food
from oral cavity and feeding and consult with speech
and language payhologist.
Encourage high calorie diet that involve all food groups
Discuss the importance of exercise to enhance the
muscular strength of the face and tongue to enhance
swallowing
Educate patient,family and all care givers about
rationales for food consistency and choices

76. Anorexia Nervosa
Anorexia nervosa is a serious and potentially life-threatening — but
treatable — eating disorder.
Definition; Anorexia nervosa is characterized by excessive food
restriction, irrational fear of gaining weight, and a distorted body self
perception which leads to excessive weight loss.

80. Care of patient
Monitor the weight of client
Correction of nutritional deficiency by providing
nutritious diet
Eating must be supervised by the nurse and provide
balanced diet of atleast 3000 clalories should be
provided in 24hrs
Monitor the serum electrolysis level
Control vomiting by making bathroom inaccessible for
atleast 2 hrs. after food

82. Nutritional Assessment
Nutritional assessment is the systematic process of collecting and
interpreting information in order to make decisions about the
nature and cause of nutrition related health issues that affect an
individual (British Dietetic Association (BDA), 2012).

83. Introduction contd….
Nutrition assessment, defined as a more detailed
evaluation of existing status and future nutrition risk, often
includes several additional components of clinical
assessment that can be synthesized to inform a plan for
intervention or future rescreening.

84. Introduction contd….
Nutritional assessment includes subjective and objective data.
Subjective data is gathered during the client interview and includes
data about food habits and customs, meal patterns, food beliefs and
skills, supplement use, and medical conditions affecting nutritional
status.
Objective data includes the components of the physical examination,
anthropometric measurements, and laboratory measurements.

85. OBJECTIVES OF NUTRITIONAL
ASSESSMENT
Identifies actual nutritional deficiencies.
Illuminates
 dietary patterns that may contribute to health
problems.
Provides
 a basis for planning for more optimal nutrition.
Establishes baseline data for evaluation.

86. ASSESSMENT
TECHNIQUES

87. ASSESSMENT METHODS
1.Anthropometric assessment
2.Biochemical evaluation
3.Clinical examination
4.Dietary intake assessment
5.Ecological assessment

88. CLINICAL EXAMINATION
It is a practical method to determine the nutritional status by
assessing various signs & symptoms.
WHO expert committee has classified signs into 3
categories:
1.Signs which are not related to nutrition(alopecia)
2.Signs which need further investigations (malar
pigmentation, corneal vascularisation)
3.Signs which are of value(calf tenderness, bitot spot,
absence of knee jerks, enlargement of thyroid gland

89. ANTHROPOMETRY
In this the parameters used are:
Weight
Height
Skin fold thickness
Mid upper arm circumference
Head & chest circumference

90. If anthropometric measurement recorded over a period of time ,
they reflect the pattern of growth and development and how
individuals deviate from the average at various ages in body
size, build and nutritional status.

93. Parameters to assess nutritional status
Weight:
It should be measured at interval till 5 years
of age as this age group is at risk from
growth deviation due to nutritional
inadequacy.
Jelliffe has given 80% of median weight
per age of reference as cut off point.

94. HEIGHT FOR AGE:
Height should
increase with age.
Low height for age is
known as stunting
which reflects the
past malnutrition.
The cut off point is
90% of height for age

95. HEAD & CHEST
CIRCUMFERENCE:
At birth head
circumference is 2 cm
more than chest
circumference.
With in 6 to 9 months it
becomes equal & then
afterwards chest
circumference is more
than head circumference.

96. HEAD CIRCUMFERENCE:
At birth -34 to 35 cm
6 months -42 to 43 cm
1 year -46 to 47 cm
2
nd
year -Increases by 2 cm
2-6 years -Increases by 2 cm

97. MID UPPER ARM CIRCUMFERENCE:
At birth - 10 cm
1 year - 16 cm
1 to 5 years - o.15 cm/year
5 years - 17 cm

98. SKINFOLD THICKNESS
The skinfold measurement test is one of the oldest and most
common methods of determining a person's
 
body composition 
and
body fat percentage. This test estimates the percentage of body fat
by measuring skinfold thickness at specific locations on the body.

99. Body sites to measure Skinfold
thickness
Abdomen: Next to the belly button
Midaxilla: Midline of the side of the torso
Pectoral: The mid-chest, just forward of the armpit
Quadriceps: Middle of the upper thigh
Subscapular: Beneath the edge of the shoulder blade
Suprailiac: Just above the iliac crest of the hip bone
Triceps: The back of the upper arm

101. BIOCHEMICAL and laboratory TESTS
Laboratory test:
Hemoglobin estimation
Stool and urine examination
Biochemical Test:
Required to assess the concentration of nutrients in body fluids. It
includes:
Serum retinol(Vit A)
Leucocyte ascorbic acid(Vit C)
Prothrombin time (Vit K)
Serum folate (Folate)

102. ASSESS DIETARY INTAKE
Nutritive value of food is calculated by which it can be assessed that how
many calories, proteins, vitamins, minerals, fats & carbohydrates are
consumed.
This assessment provides the information that whether the intake is adequate
or not.

103. MEETING
NUTRITIONAL
NEEDS

104. There are total 3 types by which we can provide the
nutrition to the patients.
1.Oral
2.Enteral
3.Parenteral

105. Oral Nutrition
Normal or regular Diets
Vegetarian diets
Modified consistency diet
Nothing by mouth

106. Enteral Nutrition
Nasogastric
 Orogastric feeding
Gastrostomy
Jejunostomy

107. Parenteral Nutrition
Total Parenteral Nutrition

108. Enteral Nutrition
An alternative feeding method to ensure adequate nutrition in cludes enteral
(through the gastrointestinal system) methods. Enteral nutrition (EN), also
referred to as total enteral nutrition (TEN), is provided when the client is
unable to ingest foods or the upper gastrointestinal tract is impaired and the
transport of food to the small intestine is interrupted. Enteral feedings are
administered through nasogastric and small bore feeding tubes, or through
gastrostomy or jejunostomy tubes.

109. Indications of Enteral Nutrition
•Malnutrition
•Prolonged fasting
•Severe trauma & burns – early EN proved beneficial
•Maintenance of gut mucosa, prevention of gut atrophy, hypertrophy
after small bowel resection
•Preparation for oral feeding

110. Contraindication of enteral feeding
•Absolute
•Generalized peritonitis
•Severe shock
•Nonfunctional gut: obstruction, ischemia, anatomic disruption

111. Contraindication of enteral feeding
•Relative
•Abdominal distension during EN
•Localized peritonitis
•Intra-abdominal abscess
•Severe pancreatitis
•Extremely short bowel (<30 cm)

112. Routes of Enteral Feeding
•Nasogastric
•Nasoduodenal
•Nasojejunal
•Gastrostomy
•Jejunostomy

113. Enteral feedIndications Advantages Disadvantages
Nasogastric •Intact gag reflex
•No esophageal reflux
•Normal gastric
emptying
•Stomach uninvolved
with primary disease
•Easytube
insertion
•Larger
reservoir capacity
in stomach
•Highestriskof pulmonary
aspiration
•Patientself- conscious due
to appearance of
nasogastric tube
Nasoduodenal
•Gastroparesis or
impaired gastric
emptying
•Esophageal reflux
•Reduced
aspiration risk
comparedto NG
•PotentialGI intolerance
(bloating, cramping, diarrhea).
•May require endoscopic
placementof nasoenteric
tube.
•Patient self- conscious
dueto appearanceof
nasoenteric tube.
•Tube displacement and
potential risk for aspiration

116. Enteral feedIndications Advantages Disadvantages
Nasojejunal
Gastroparesis or
impairedgastric
emptying
•Esophageal reflux
•Gastric dysfunction
due to trauma or
surgery.
TF may be initiated
immediately after
injury.
•Reduced aspiration
risk comparedto
NG.
Potential GI intolerance
•Endoscopic placement
•Patient self-
conscious due to
appearanceof nasoenteric
tube
•Tube displacement
& potential aspiration

117. Enteral feedIndications Advantages Disadvantages
Gastrostomy
•Long-term feeding; normal
gastric emptying
•Swallowing dysfunctionand
subsequent impairment of
ability to consume an oral
diet
•Nasoentericroute unavailable
•Intact gag reflex; no esophageal
reflux
•Stomachuninvolved with
primary disease
•Placed adjunct with
GI surgery.
•Nosurgery needed
for percutaneous
endoscopic
gastrostomy (PEG)
•PEGless
costlythan surgical
gastrostomy.
•↓ risk of tube
occlusion
•Larger resevoir
capacityin
stomach
•Potential risk of
aspiration
•Stoma care needed;
potential infection at
stoma site
•Potentialskin
excoriation from
leakages
of digestive
secretions at stoma
site
•Potential fistula
after tube removed
•Surgery needed for
surgical gastrostomies

119. Enteral feed Indications Advantages Disadvantages
Jejunostomy •Long-term feeding
•High risk of
aspiration
•Esophageal reflux
•Inability to access
upper GI tract
•Gastroparesis or
impairedgastric
emptying
•Gastric dysfunction
due to trauma or
surgery
•Reducedrisk of
aspiration
•Placed adjunctly
with GI surgery
•Nosurgery
needed
for percutaneous
endoscopic
jejunostomy
(PEJ)
•PEJ less costly
than surgical
jejunostomy
•TFmaybe
initiated
immediately after
injury
•Potential risk of
aspiration
•Stoma care needed;
potential infection at
stoma site
•Potentialskin
excoriation from
leakages of
digestive secretions at
stoma site
•Potential fistula after
tube removed
•Tube occlusion
•Surgery needed for
surgical jejunostomies

121. TOTAL PARENTERAL NUTRITION
Total parenteral nutrition is a way of supplying the
nutritional needs of the body by bypassing the digestive
system and dripping nutrients solution directly into a
vein.
The administration of a nutritionally adequate
hypertonic solution (consisting of
glucose,protein,hydrolysates,minerals and vitamin)
thrugh an indwelling catheter into the superior vena
cava or other main vein

122. Normally TPN is administered in a hospital but under
certain condition and with proper client and caregiver
education.
Ideally TPN provides all the nutrients in the correct
quantities to ensure the body functions normally