Journal of Gerontological Nursing

Nutritional Assessment of the Elderly

Reatha Collinsworth, RN, MS; Kathleen Boyle, RN, EdD

Abstract

Early identification of nutritional deficiencies is an important nursing function. Perhaps nowhere is this assessment more crucial than in the elderly, who occupy up to 50% of the acute care hospital beds for adults.1 The elderly often have a declining ability to absorb and utilize nutrients and may take medications that interfere with the body's use of nutrients. Nutritional state has a significant impact on an individual's ability to resist infection,2 recuperate, and/or avoid accidents and illnesses.3

Assessment is an ongoing, systematic method of gathering data mat includes history taking (medical, social, and psychological) and physical examination with physical measurements and analysis of laboratory data. A knowledge of normal values of common lab tests, risk factors, and Stressors that can interfere with health is important to assessment. An experienced nurse who uses all of these can detect current and evolving problems in highrisk elderly patients.

PURPOSE OF THE STUDY

Nurses are involved in many types of assessment and must make good use of their time and skills. Nutritional assessment may not be a major concern when patients are acutely ill, but good nutrition is so vital to the healing process that time spent on it may be of major benefit to the elderly. Therefore , a study was conducted to determine which indicators of nutritional state are available to nurses, which are used by them, and if use of nutritional indicators relates to the educational level of nurses or their experience in nursing of the elderly. An additional purpose was to determine if the patients who are identified by staff nurses to be at nutritional risk or nutritionally depleted are the same as those identified by a researcher using predetermined criteria.

RELATED LITERATURE

Recognition of malnutrition as a health problem in the United States has been relatively recent. In 1973, the National Center for Health Statistics conducted the Health and Nutrition Examination Survey. A major finding was that malnutrition was associated with diseases and debilitation of the elderly. In the next year, a flurry of concern was stimulated by Butterworth, who was able to document cases of protein-calorie malnutrition and scurvy in hospitalized patients.4 He concluded that health-care professionals often disregard signs of malnutrition and mismanage the condition, thereby prolonging hospital stays and increasing mortality rates.

In a more recent investigation at a veterans hospital, 61% of a geriatric group were found to be malnourished, compared with 28% of a younger group. In addition, not only the death rate, but also the incidence of infection was found to be higher in the geriatric group.5

Laboratory values of such things as hemoglobin, hematocrit, albumin, total iron binding capacity, and leukocyte count as a measure of nutritional state are standard laboratory tests, and results are usually available to nurses for assessment. Decrease in these values from normal levels may be wrongly attributed to the aging process. (For more information on this topic, see "Check the Reasons Before Giving Supplements" on page 19.) Lipschitz and Mitchell demonstrated that low values of albumin and total iron binding capacity could be improved by nutritional therapy.6 This improvement suggests that malnutrition, rather than the aging process, is responsible for the lower laboratory values.

Assessment of nutritional state by nurses is an apparently neglected area. Moore, Gunter, and Bender reviewed nutrition- related research by nurses from 1970 to 1984 and found 104 studies , most of which dealt with parenteral nutrition or tube feedings . 7 A total of 20 studies dealt with assessment, but only Five were conducted exclusively by nurses, and tended to be assessmentspecific to some condition such as cancer or pregnancy.

METHOD

The…

Early identification of nutritional deficiencies is an important nursing function. Perhaps nowhere is this assessment more crucial than in the elderly, who occupy up to 50% of the acute care hospital beds for adults.1 The elderly often have a declining ability to absorb and utilize nutrients and may take medications that interfere with the body's use of nutrients. Nutritional state has a significant impact on an individual's ability to resist infection,2 recuperate, and/or avoid accidents and illnesses.3

Assessment is an ongoing, systematic method of gathering data mat includes history taking (medical, social, and psychological) and physical examination with physical measurements and analysis of laboratory data. A knowledge of normal values of common lab tests, risk factors, and Stressors that can interfere with health is important to assessment. An experienced nurse who uses all of these can detect current and evolving problems in highrisk elderly patients.

PURPOSE OF THE STUDY

Nurses are involved in many types of assessment and must make good use of their time and skills. Nutritional assessment may not be a major concern when patients are acutely ill, but good nutrition is so vital to the healing process that time spent on it may be of major benefit to the elderly. Therefore , a study was conducted to determine which indicators of nutritional state are available to nurses, which are used by them, and if use of nutritional indicators relates to the educational level of nurses or their experience in nursing of the elderly. An additional purpose was to determine if the patients who are identified by staff nurses to be at nutritional risk or nutritionally depleted are the same as those identified by a researcher using predetermined criteria.

RELATED LITERATURE

Recognition of malnutrition as a health problem in the United States has been relatively recent. In 1973, the National Center for Health Statistics conducted the Health and Nutrition Examination Survey. A major finding was that malnutrition was associated with diseases and debilitation of the elderly. In the next year, a flurry of concern was stimulated by Butterworth, who was able to document cases of protein-calorie malnutrition and scurvy in hospitalized patients.4 He concluded that health-care professionals often disregard signs of malnutrition and mismanage the condition, thereby prolonging hospital stays and increasing mortality rates.

In a more recent investigation at a veterans hospital, 61% of a geriatric group were found to be malnourished, compared with 28% of a younger group. In addition, not only the death rate, but also the incidence of infection was found to be higher in the geriatric group.5

Laboratory values of such things as hemoglobin, hematocrit, albumin, total iron binding capacity, and leukocyte count as a measure of nutritional state are standard laboratory tests, and results are usually available to nurses for assessment. Decrease in these values from normal levels may be wrongly attributed to the aging process. (For more information on this topic, see "Check the Reasons Before Giving Supplements" on page 19.) Lipschitz and Mitchell demonstrated that low values of albumin and total iron binding capacity could be improved by nutritional therapy.6 This improvement suggests that malnutrition, rather than the aging process, is responsible for the lower laboratory values.

Assessment of nutritional state by nurses is an apparently neglected area. Moore, Gunter, and Bender reviewed nutrition- related research by nurses from 1970 to 1984 and found 104 studies , most of which dealt with parenteral nutrition or tube feedings . 7 A total of 20 studies dealt with assessment, but only Five were conducted exclusively by nurses, and tended to be assessmentspecific to some condition such as cancer or pregnancy.

METHOD

The present study was conducted on multiple medical and surgical units of a midwestern veterans medical center and a nearby private hospital. These hospitals were chosen because their population included a large number of patients over 65 years old and registered nurses provided direct care to patients.

Table

TABLE 1A COMPARISON OF USE AND AVAILABILITY OF NUTRITIONAL INDICATORS

TABLE 1

A COMPARISON OF USE AND AVAILABILITY OF NUTRITIONAL INDICATORS

Questionnaires were given to all 116 staff nurses who were caring for the elderly in a total of 10 nursing units. Sixty-four were returned, of which 60 were useable. The questionnaires asked the nurses to identify the patients in their care who were nutritionally depleted or at risk. It also asked them to identify which indicators of nutritional state they used. At the same time, the nurse researcher did a chart audit to see which indicators of nutrition were available to the nurses and which patients fit specific predetermined criteria of nutritional depletion.

Criteria used by the researcher were those determined by two experts in the fields of nursing and nutrition. The expert in nursing was a nutritional support nurse in one of the hospitals, prepared with a master's degree in nursing, and with several years of experience working with the malnourished. The expert in nutrition was a professor, prepared at the doctoral level, who teaches nutrition and is also experienced in problems of malnutrition. Considering the qualifications of these two consultants, the judgments made by the researcher on the basis of their criteria can be considered a valid standard against which the judgment of the staff nurses can be compared.

Many nurses who work with the elderly may consider that some laboratory values change with age; however, there is no generally accepted norm for this group. Therefore, laboratory norms for adults were used.8 Height and weight values used are from the 1983 Metropolitan Life Insurance Company Tables.9

The questionnaires used for nurses and chart audits were both pretested to establish reliability. The investigator and anotiier nurse achieved a 97% interrater reliability using the chart audit tool. A test-retest using the nurses' questionnaire of nurses not in the study achieved the same results.

RESULTS

Nurses identified 20 items they use for nutritional assessment. Weight was the most common (100%), with observation of eating activity almost as common (95%). Appearance of the patient was also a frequently-used indicator (90%). Of the laboratory tests used, sodium and potassium were the most used, with 20% of the nurses using both. Thirteen nurses (21.7%) reported using electrolytes, but did not specify which ones.

The second research question involved which indicators of nutritional state are available to nurses. The list of available indicators is included in Table 1 for comparison with those used by nurses . The list of available indicators is limited to those recommended by the experts, and is less than those identified by the staff nurses.

A total of 78 patient charts were audited for 18 different indicators of nutritional state. Those found most frequently were hemoglobin and hematocrit, both available on 96.2% of the charts. White cell count was the next most frequent, being available on 91% of the charts. Skinfold thickness and upper arm circumference were listed as used by 36.7% and 8.3% of nurses respectively, but were not found on any chart that was audited. The nurses may have believed that skinfold thickness and upper arm circumference were from their own observations rather than objective measurements. Additional indicators stated by the nurses but not recommended by the experts are found in Table 2. Figure 1 presents the indicators used by nurses in declining order of use.

The six indicators of nutritional state most commonly available were used to compare the frequency of use by nurses with differing educational backgrounds and experience. Those six indicators were weight, height, hemoglobin, hematocrit, protein, and albumin, and were found on 73 of the 78 charts audited.

Few differences were noticed among the group of 28 associate degree graduates, 13 diploma graduates, and 18 baccalaureate graduates in use of indicators for considering a patient malnourished. Six associate degree nurses reported using hemoglobin and four reported using hematocrit as an indicator, compared with one each from the other groups. Likewise, the amount of experience in nursing of the elderly made little difference except for the use of hemoglobin, which was more frequent in the nurses with more than 10 years experience.

Table

TABLE 2ADDITIONAL INDICATORS REPORTED USED BY NURSES

TABLE 2

ADDITIONAL INDICATORS REPORTED USED BY NURSES

Table

FIGURE 1PERCENT OF NURSES STATING USE OF INDICATOR IN DECLINING ORDER OF USE

FIGURE 1

PERCENT OF NURSES STATING USE OF INDICATOR IN DECLINING ORDER OF USE

Staff nurses assessed a total of 78 patients and identified 34 of them as being nutritionally depleted. The investigator audited the charts of the same patients, deleting five due to insufficient data, and found 56 patients nutritionally depleted. Of this number, there was agreement between staff nurses and the investigator on 30 patients, 41.1% of the total. Figure 2 shows this comparison.

As shown in Figure 2, the staff nurses and researcher agreed that 30 patients were malnourished and that 13 were not. They therefore agreed on 43 cases (roughly 60%) and disagreed on 30 cases (roughly 40%). Most of the disagreement arose because the investigator, who used criteria established by experts, found more patients malnourished than did the staff nurses (76% versus 46%; z- -4.02; P = .002). Using a chi square formulation suggested by McNemar to focus on the differences found by the two assessments, it was found that there were more patients identified as malnourished solely by the researcher (n = 26) than solely by the staff (n = 4) (?2 = 16.13; P < .001). 10 Tins indicates that the investigator, using specific criteria, was able to identify a significantly larger number of the patients who were actually malnourished than were the staff nurses without such criteria.

FIGURE 2A COMPARISON BY STAFF AND RESEARCHER OF PATIENTS FOUND DEPLETED WITH THOSE FOUND NOT DEPLETED

FIGURE 2

A COMPARISON BY STAFF AND RESEARCHER OF PATIENTS FOUND DEPLETED WITH THOSE FOUND NOT DEPLETED

DISCUSSION

It is interesting to note that the most frequently used indicators of nutritional risk or depletion are those obtained by nurses in direct contact with patients. The indicators may be obtained visually, such as height, weight, appearance, and observation of eating activity. Other indicators may also be obtained verbally, such as health and diet history. Indicator usage drops drastically with laboratory values. Reasons for this may include lack of time to evaluate laboratory data thoroughly and to synthesize it with other patient data available to the nurse. Lack of knowledge of laboratory values or delay in obtaining results may also affect use of these data.

Nurses may have a tendency to rely on assessment skill or tools over which they have control, and rely less on laboratory data over which they have no direct control. Lack of use of laboratory values may also support the premise that nurses continue to rely on intuitive rather than scientific data in assessing nutritional risk or depletion.

Lack of use of upper arm circumference and skinfold thickness can be explained by lack of knowledge of their value or how to obtain them. The few who did claim their use may have confused the measurement with skin turgor, which is a measure of hydration.

Total lymphocyte count was not used by any nurse and was available on only four charts. This is a very sensitive indicator of nutritional state, according to the panel of experts, and can be calculated using the following formula: total lymphocyte count = % lymphocytes x white blood ceil count/100." White cell count was available on 91% of the charts, and lymphocyte counts are usually done with the white cell count.

The need for increased education of staff nurses on nutritional assessment of the elderly is a major finding of this study. Lack of use of available indicators or failure to obtain those that are the responsibility of the nurse (eg, height and weight) suggests a need to relearn nutritional assessment. The significantly higher number of depleted patients found by the researcher than by staff nurses suggests that methods employed in assessment by staff may be inaccurate or inappropriate. Inservice education directed toward appropriate and accurate methods of nutritional assessment, as well as follow-up by quality assurance audits, could do much to improve the nutritional assessment by staff nurses.

The steady increase of the number of elderly persons in our population makes the assessment of their health status more important than ever. Nutrition is a vital part of life at any age; it often gets overlooked in the elderly. Doing a thorough nutritional assessment is the first step in treating problems of malnutrition, which are common in the elderly. It need not take a great deal of time; however, the time spent will be reflected in better care for the elderly, improving the quality of their care and their lives.

REFERENCES

  • 1. Sloan R. Practical Geriatric Therapeutics. Oradell, NJ: Medical Economic Books; 1986.
  • 2. Chandra R, Puri S. Nutritional support improves antibody response to influenza virus vaccine in the elderly. BrMedJ. 1985; 291:705-706.
  • 3. Berlinger N. Wound healing. Otology Clinics of North America. 1982; 15:29.
  • 4. Butterworth CE. The skeleton in the hospital closet. Nutrition Today. 1974; 9(March/ April):4-8.
  • 5. BieniaR, RatcliffS, Barbour G, et al. Malnutrition in the hospitalized geriatric patient. J Am Geriatr Soc. 1982; 30:433-436.
  • 6. Lipschitz D, Mitchell C. The correctability of the nutritional, immune, and hematopoietic manifestations of protein-calorie malnutrition in the elderly. J Am Coll Nutr. 1982; 1:17-25.
  • 7. Moore M, Gunter P, Bender J. Nutrition related research. Image: Journal of Nursing Scholarship. 1986; 18:18-21.
  • 8. Pagana D, Pagana J. Diagnostic Testing and Nursing Implications: Case Study Approach. St. Louis: C.V. Mosby Company; 1986.
  • 9. Williams S. Essentials of Nutrition and Diet Therapy. St. Louis: Times Mirror/Mosby College Publishing Company; 1986.
  • 10. Hinkle DE, Wiersma W, JUTS SG. Applied Statistics for the Behavioral Sciences. Boston: Houghton Mifflin; 1988.
  • 11. Blackburn G, Bistrian B, Maini B, et al. Nutritional and metabolic assessment of the hospitalized patient. JPEN J Parenter Enterai Nutr. 1977; 1(1):11-22.

TABLE 1

A COMPARISON OF USE AND AVAILABILITY OF NUTRITIONAL INDICATORS

TABLE 2

ADDITIONAL INDICATORS REPORTED USED BY NURSES

FIGURE 1

PERCENT OF NURSES STATING USE OF INDICATOR IN DECLINING ORDER OF USE

10.3928/0098-9134-19891201-06

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