Introduction, why choose this topic.
I’ve chosen gastrointestinal and nutritional assessment because I find it easier and more interesting to elaborate on the digestive tract and the diet offered to the service users. It is an interesting topic as; firstly the gastrointestinal system is broken down into so many different and specific parts or processes. Secondly the link between gastrointestinal and nutritional assessment is very much like a puzzle. When one gets used to it, it becomes so clear and simple that it induces one into more research but also more practice, as both require precise knowledge and experience. I will now start my essay by explaining the gastrointestinal system.
Paragraph 1- Describe what the gastrointestinal system is?
The gastrointestinal system in its simplest version is the study and illustration of the digestive system. It starts in the top part of the body, the mouth, and ends in the bottom part, the anus. Gastrointestinal tract activities include ingestion, mechanical digestion, chemical or enzymatic digestion, propulsion, absorption and defecation. Overall hence, these different stages are summarized in only two words, which are digestion and absorption. There are of course more aspects, which relate to parts outside of the digestion and absorption but I will explain those briefly further on during my essay. Starting with ingestion, it is the stage where food is voluntarily put into ones mouth. Then it is propulsion, this can easily be defined as the process where food is sent (propelled) from one organ to the other. This depends on a process called ‘peristalsis’. Peristalsis is the flow and movement of the muscles in the organs, which enables the food to move forward to the other stage, which is food breakdown. Food breakdown can be divided into two more processes, which are mechanical and chemical digestion. The former is the mixing of food in the mouth, the process of it going through the stomach and intestine where the food is broken down into smaller parts. Chemical digestion is the breaking down of food molecules to their smallest area. This is done by enzymes, protein molecules that reduce the food to its simplest state. It is of course a very complex study and I thought that the easiest way is to illustrate that via a table.
After food breakdown comes absorption. This can be described as the transport of the broken down molecules from the gastro intestinal tract to the blood or lymph. The major site for absorption is the small intestine. Finally the last step in the digestive system is the elimination process. It is scientifically termed as defecation. It is of course the getting rid of indigestible substances from the body via the anus in the form of faeces. There are some more complex terms and activities, which take place during the digestive phase. For instance in the mouth there are two actions taking place, these are mechanical and chemical digestion, which occur during chewing and saliva mixing. Just from the mouth to the throat, there are more phases to pass through. Again I will illustrate this through diagrams I obtained during my research work.
There are so many more examples of the different stages of digestion that I didn’t refer to. I find it interesting but it would be irrelevant for my essay. I hence offer a list of references at the end of my essay, which gives clear details and understanding of the gastrointestinal system.
Paragraph 2- Elaborate on nutritional assessment.
Nutritional assessment from what I have understood is the assessing of the food service provided in the care and medical field. It is both practical and theoretical work which gives information on who, how, when and what to provide for a straight nutritional providing system. The service users must be evaluated physically and psychologically so as to get proper data as how to feed him, what to feed him with and when to feed him. Hence, in one phase it is the research for the best diet that can be given to each service user.
One of my researches brought me to the statement below. It is more specific but more complex that what I have stated above.
A nutritional assessment has the following aims:
To evaluate baseline parameters of nutritional status at a set point in time and obtain information on the adequacy of recent nutrient intake.
To identify individuals who require nutritional support.
To evaluate, by serial measurements, the efficacy of nutritional support.
(Clinical skills series, Nutritional support: A team approach, Stephen Taylor and Susan Goodison- Mclaren, Wolfe publishing limited, 1992)
Nutritional assessment, apart from identifying what is essential as a good diet can also be used in calculating individual data. An example is, the amounts of specific nutrients required by an individual like for instance, the measurement of nitrogen balance. This is a very complex calculation, which is analysed during the construction of the food tables and the sorting out of the nutritional status of the service user. During this specific calculation and research, different aspects must be taken into consideration. There is first of all the range of foods covered by the tables. The food tables do not cover everything and involve some substitutes outside of its list. These alternatives have to be assessed and judged in order to evaluate whether it provides what is needed or not. An example is the kiwi fruit, which wasn’t listed before. It has only previously joined the list as it is common now. The second point to be considered is the recipe variations. What I mean is that a particular and precise recipe cannot be obtained every time. Someone can cook the same meal over and over again but the taste varies as sometimes there is less or more of some ingredients involved in the cooking. The range, the ratio, the consistency differs every time and there always is that persisting slight difference. My third point is the biological variation. AN example can be an apple. The amount of vitamin C varies according to the different varieties. Another example is meat; the amount of fat varies due to the region and manner the cattle are bred. Food tables in the end offer just an average and thus cannot be considered for all cases. My final point is the method and duration of storage. The nutrient content of foods changes during storage, some products gain vitamins or minerals while some lose those. A clear example is potatoes, the longer they are stored, the more vitamin C they lose. My next two paragraphs will deal a bit more with the research done during nutritional assessment but I will also explain the link between theory and practice.
Paragraph 3 and 4- Further research, link between theory and practice.
There are many scientific tests, which are performed in order to estimate the content of a particular product. The energy content of foods has to be measured. This is done by a bomb calorimeter. It is a scientific test, which measures the heat of the product after an electrical shock. There are different estimation tests as well, done to gain information on protein amount, fat, carbohydrate, vitamin and mineral contents. I will now elaborate a little more on how a service user is assessed. A service user has to be evaluated physically and psychologically. The first step is to know about the patient’s history. Information is thus collected about his dietary history. Then he will have to go through clinical examination. He will undergo screening, weighing, physical assessing, and many other tests relevant for data collection about the patients past and present condition. It is the main step as only then can the staff establish what is right or wrong for the client and what can be done to improve or maintain the service user’s condition. After this check, other aspects must be considered. These are related psychologically. The patient’s social and economic background must be considered. What were his or her eating habits and why were they like that? Religion must be considered because some products are not allowed for all. After an admission check the patient will fit into the system more easily. He will be classified in a specific group where the needed diet will be offered to him. But, still the assessment doesn’t end here as, the patient will not maintain a stable condition always. The service user will thus have to be assessed at very regular intervals, which are different depending on where he is. He will have regular physical check ups. His weight and any other condition will be verified for the client’s maintenance of good health. Usually for a very precise check, the skin fold thickness and skeletal muscle mass is measured. This will establish whether there is improvement or not. The average condition of a normal fit person will be compared to the service users. Finally, there will be an assessment of food intake. This provides more detailed information and it identifies whether there is nutrient deficiency. This step though is unfortunately not undergone everywhere. This assessment is done by weighing the intake or by referring to the usual diet and the instructions.
Essentially, there are four stages in both approaches:
Record and quantity of the foods eaten
Analyse the nutrient content using tables of food composition
Estimate the actual nutrients each day
Compare with recommended daily allowances
(Clinical skills series, Nutritional support: Stephen Taylor and Susan Goodison- Mclaren, Wolfe publishing limited, 1992).
I have been elaborating a lot over nutritional assessment and the gastrointestinal system. Having done the theoretical part, I will describe the practical part now. Nutritional assessment on the practical side involves,
Comparison between average people and clients
Physical check ups to verify any abnormality
The best diet for a particular individual.
Those three points can be put into one single term, which is, ‘clinical observations’. ‘Clinical observations can be among the most important aspects of a nutritional assessment’, (Potter and Perry, 2000, pg1350). These clinical observations are what a nurse put in practice.
A more precise term known for this is, objective assessment. This is based on evaluation and research of the clients or patients weight and height. The calculation done based on those research is called Body Mass Index (BMI). BMI does not guarantee that a patient is malnourished and it should be used with caution in those with oedema and ascites but it is so far the quickest and most reliable research and analysis process.
BMI = Weight (kg)
< 16 malnourished
31-40 moderately to severely obese
> 40 morbidly obese.
There is the percentage weight loss that is calculated as well during both long term and short term. This is the percentage weight loss, which is,
The percentage weight loss= (usual weight- current weight)* 100
< 9% monitor not clinically significant unless weight loss is rapid or the patient is already underweight
10-20% clinically significant, needs nutritional support
>20% severe must have nutritional support.
Lippincott (1990,pg 424) gives a general evaluation of the nutritional status of people by giving us the comparison between healthy and unhealthy nutrition. The hair will be very healthy, firm, lustrous, and shiny if the nutrition is appropriate. If not it is the opposite that is noticed. Same for the face, which is healthy in all aspect with a good nutrition but very dull and dark if without a good nutrition. Usually the eyes are the main source of any bad or good conditions to be noticed. They look bigger and about to fall off there sacks when in a bad condition.
‘Clinical observations can be among the most important aspects of a nutritional assessment’, (Potter and Perry 2000 pg 1350). Good sources for observations in a patient are, the cardiovascular function. This, in good nutrition is ‘normal heart rate and rhythm, lack of murmurs, normal blood pressure for age’, however in poor nutrition, ‘rapid heart beat enlarged abnormal rhythm, elevated blood pressure’.
Also, general vitality in an individual with good nutrition should be ‘endurance, energy, good step habits, vigorous appearance’ but in an individual with poor nutrition, it could be ‘easily fatigued, lack of energy, falling asleep easily, tired and a pathetic appearance’.
Paragraph 5- what I have learnt and experienced? How it is related to the topic?
Our first role as a nurse is to take care of the patient. For that, it is crucial for both us and the patient not to let the immune system be compromised in any manner. It is thus our role as a health care professional to try at all times to ensure that all clients/patients are eating sufficiently and if they are not, know what actions to take to change the situation. The best way to maintain an appropriate monitoring is via daily notes. This is known as the nutritional assessment sheets. This enables the staff to keep track with the individuals eating habits even when the care is not continuous by a particular nurse. Also taken into consideration are the nutritional intake, nutritional supplements or by enteral or parenteral nutrition. Enteral nutrition should be undertaken in the following circumstances (Potter and Perry 2000, pg 1359), cancer ‘head and neck, upper GI, critical illness, trauma’, ‘neurological and muscular disorders’, ‘brain neoplasm, cerebrovascular accident, dementia, myopathy, Parkinson’s disease’, ‘gastro intestinal disease, mild pancreatitis’ or for ‘respiratory failure with prolonged intubations and finally in the case of inadequate oral intake’. Parenteral nutrition should be undertaken in the following circumstances, non-functional GI tract, ‘GI surgery, paralytic ileus, intestinal obstruction, severe malabsorption, chemotherapy’, extended bowel rest, ‘severe diarrhoea, moderate to severe pancreatitis’, or for preoperative TPN, ‘pre operative bowel rest, treatment for co morbid severe malnutrition in patients with non-functional GI tracts, severely catabolic clients when the GI tract is non-usable for four to five days’. It can be understood therefore, that for us to use these enteral or parenteral nutritional methods, the situation must be fairly grave and the implications of them must be fully understood. To resume the whole explanation, it is imperative that as members of the health care profession we ensure that clients are at all times maintaining their nutritional status or that we are trying to rectify any nutritional problems, e.g., malnutrition, ‘a condition arising from deficiency in the diet or deficiency in the absorption or metabolism of food’, (Pears, 2001, pg394) and that we understand how, why and when we evaluate someone’s nutritional status.
Other matters in concern, which I got to learn about while on my training are, the factors that influence the ability to eat. I have explained technically previously how a client/patient is sometimes unable to eat. This time I will explain this topic based on my placement experience. First there is the physical ability that must be considered. The patient may need assistance or special cutlery to prepare and eat his food. Secondly, the mouth. A sore mouth, poor dentition or filling dentures reduce the ability to chew and swallow food. Thirdly, the gastrointestinal function. Diarrhoea, constipation, nausea and vomiting can reduce appetite and make it difficult to eat. Fourthly physical environment. A new environment like a hospital can affect appetite. Fifthly emotional and mental state. Bereavement, depression, loneliness or mental illness can reduce appetite. The two last factors are food itself and pain. Food because unfamiliar food and meal patterns can affect what is eaten by the patient and pain because uncontrolled pain can reduce appetite.
Paragraph 6 and 7- personal comment and conclusion.
Dieticians are the ones who assess usually the situation, hence nutritional assessment. But concerning the part where every research has to be put into practice, it is the nurse’s role. Nurses and dieticians therefore need to work together to identify patients who are at risk and to provide nutritional support to those who are in need.
Actions point thus includes,
Ensuring access to accurate scales
Recording recent food intake
Considering implementation of a nutritional screening tool in conjunction with a dietician or nutrition team
Knowing how and when to refer to a state registered dietician
Routinely measuring and documenting weight, and identifying any loss or gain.
Conclusively I think personally that nutrition is a vital component in nursing practice. Because of that, a programme in relation with nutritional education should be applied in all pre-qualifying educational training and programmes. If possible, even the past qualifying programme followers must be provided with this aspect. They might be professionals already but if further training is offered on a long-term basis, there knowledge and experience will only improve on nutritional assessment.
I learnt a lot on my placement concerning nutritional assessment and I learnt even more during my theory on nutritional assessment and the gastrointestinal system. This probably helped me with this essay. I managed to make some proper research work and I also managed to build up my concern on this and at the same time get a personal opinion on what could be offered as a further aid to nutritional assessment. I may not have offered the best performance in this field of nursing but now I’m confident and sure enough that I’ll be able to do a lot better in my future placement.
Diet related diseases, the modern epidemic, by Stephen Seely, David J.L.Freed, Gerald A.Silverstone and Vicky Rippere (1985)
Managing nutrition in hospital, a recipe for quality, by Alan Maryon Davis and Amanda Bristow. Foreword by John Wyn Owen (Nuffield Trust 1999)
Nutritional support: A team approach, by Stephen Taylor and Susan Goodinson-Mclaren (Clinical skill series 1992)
ABC of nutrition, by Stewart Trutwell (1986)
Artificial nutrition support in clinical practice, edited by Jason Payne James, George Grimble and David Silk (1995)
Food and nutrition customs and culture, by Paul Fieldhouse (1986)
Pears Pocket Medical Encyclopedia, by Brown J.A.C (2000)
Lippincott manual of medical-surgical nursing, by Brunner Lillian and Suddarth Doris (1990)
Nurses dictionary, by Churchill Livinstone
Essentials of human anatomy and physiology, 6th edition by Elaine N.Marieb (2000)
Medicine, a guide for study and practice, by Friedman Ellis and Moshy Roger (1992)
Anatomy and physiology in health and illness, by Kathleen Wilson and Anne Waugh (2000)
Nutrition handbook for nursing practice, by Susan G.Dudek, (Lippincott 3rd edition, 1997)
Krause’s Food and nutrition and diet therapy, by Kathleen Mahan and Marian Arlin (8th edition, 1992)