ASPEN Self-Assessment: Nutrition Assessment Flashcards
(T/F)
Catabolism of endogenous substrate including fat stored in adipose tissue (lipolysis) is common in both forms of malnutrition.
TRUE.
Hypoglycemia and ketosis are characteristic of starvation.
Hypermetabolism and hyperglycemia are characteristic of stress-related malnutrition.
Explain albumin.
A negative acute-phase protein.
Levels decrease in response to stress and hypoalbuminemia is more a reflection of the degrees of stress resulting from disease, injury, and inflammation than nutritional status.
Hypoalbuminemia has been associated with increased short-term mortality, length of hospital stay, and complications and correlates strongly with 30-day mortality.
Explain hyperhomocysteinemia.
Has been linked to an increased risk for coronary atherosclerosis.
Studies have shown that folic acid, vitamin B6, and vitamin B12 supplementation can reduce plasma homocysteine concentrations.
It is not known whether hyperhomocysteinemia is a causative factor of atherosclerosis or simply a marker of vascular disease.
What are the appropriate fluid requirements for each below?
- Healthy adults, aged 18-55
- Healthy adults, aged 55-75
- Healthy adults, older than 75
- Fluid restriction
- Healthy, aged 18-55: 35 ml/kg
- Healthy, aged 55-75: 30 ml/kg
- Healthy, older than 75: 25 ml/kg
- FR: Less than 25 ml/kg
Which amino acid is a key fuel for the small intestine?
Glutamine
It is essential for small intestinal structure and function.
Could be useful to supplement glutamine to patients who are suffering trauma or receiving PN.
What are two conditionally essential amino acids?
Glutamine & Arginine
- Other conditionally essential AAs are: Cysteine, glycine, proline, and tyrosine
- Conditionally essential AAs are synthesized from other AAs under normal conditions but require a dietary source in order to meet increased needs caused by metabolic stress.
(a) Example: Arginine becomes conditionally essential for wound healing.
Explain the recommendations for vitamin A deficiency with and without concurrent corticosteroid therapy.
For deficiency: 2,000 to 200,000 IU/day (606 - 60,600 RAE/day)
To counteract the inhibitory effects that steroids have on collagen synthesis and connective tissue repair: 3,000 to 15,000 RAE/day x 7 days orally
To enhance wound healing with concurrent corticosteroid use: 3,000 to 4,500 RAE/day orally
Zinc deficiency is most commonly associated with?
Diarrhea
The overall biochemical functions of zinc can be categorized as catalytic, structural, and/or regulatory in nature. Additional zinc is recommended in patients with additional losses from thermal injury, excessive GI losses such as diarrhea, decubitus ulcers, and high output fistulas
Copper toxicity is associated with what disease?
Liver Disease
- Copper toxicity can cause severe N/D/V. More serious manifestations with acute or more chronic toxic ingestion or Wilson’s disease include: coma, hepatic necrosis, liver failure, renal failure, vascular collapse, and death.
- Since about 80% of copper is excreted in the bile, patients who have liver disease should be monitored and supplementation reduced or eliminated.
- HD increases copper losses
- Enteral zinc supplementation can complete with copper for absorption.
What can result in an invalid IC measurement?
Chest tube leak
- IC is a respiratory measurement that under proper conditions is equivalent to metabolism, any factor that violates these conditions is a contraindication to IC.
- Examples: air leaks; extracorporeal membrane oxygenation(ECMO); HD; FiO2 > 60 in mech. vented patients; and for spontaneously breathing patients - reliance on supplemental oxygen; inability to cooperate with measurement, and claustrophobia or anxiety
-If RMR is the desired value to be measured (it usually is), then any factor that prevents that patient from being at rest or cooperating with the device operator is also a contraindication.
Explain REE.
Resting Energy Expenditure
- REE measured under steady stable conditions closely approximates true 24-hour energy expenditure.
- The addition of a stress or activity factor may not be necessary and could result in overfeeding.
- If a patient is measured while fasting or if feedings are intermittently provided, it is reasonable to allow an additional 5% factor to account for thermogenesis.
- Therefore, a critically ill patient’s energy delivery in response to REE does not need to be modified when measured by IC. AKA No stress/activity factors are needed.
Explain respiratory quotient (RQ).
RQ = CO2 produced/O2 consumed
Defined as the volume of CO2 released over the volume of O2 absorbed during respiration.
RQ <0.7 or >1.0 means?
Hypoventilation or hyperventilation
RQ of 0.71 means?
Primarily fat oxidation
RQ of 0.82 means?
Primarily protein oxidation
RQ of 0.85 means?
Suggests mixed substrate utilization
RQ of 1.0 means?
Carbohydrate oxidation
Facts about Crohn’s disease.
Malnutrition is the most common in this form of inflammatory bowel disease because Crohn’s usually involves the small intestine
- Can impact any area of the GI tract (mouth to anus)
- Depending on severity of illness, weight loss has been reported in 20% to 85% of those with Crohn’s
- 65-75% of inpatients and more than 50% of outpatients experience significant weight loss
- Possible mechanism for malnutrition in this disease: Malabsorption from diseased small bowel mucosa; increased nutrient requirements from active inflammation; and reduced oral food intake due to abdominal discomfort and diarrhea
Explain appropriate treatment for ascites.
- Fluid
- Sodium
- Protein
Includes fluids and sodium restriction.
- Protein intake: 1.0 - 1.5 g/kg/day for patients with cirrhosis.
- While optimum nutrition support may not be possible, use of maximally concentrated solutions provides the best opportunity to avoid further salt and fluid overload while providing necessary substrate for anabolism
Where is dietary fat primarily absorbed?
Duodenum and proximal jejunum
- Dietary fat is absorbed in the proximal small bowel
- Lingual lipase released in the mouth and gastric lipase produced in the stomach have a limited role in fat digestion in healthy adults.
- Bile acids secreted by the liver as well as lipase and colipase produced by the pancreas aid in the micellar solubilization and absorption of dietary fat.
Resections and nutrient absorption.
Resections of the proximal bowel, including the duodenum and proximal jejunum, are generally better tolerated because of ileal compensation and adaption.
- In general, ileal resection is poorly tolerated because of adaptive hyperplasia in the remaining jejunum is limited.
- The ileocecal valve slows intestinal transit allowing for greater absorption of nutrients.
- Colon has critical roles in fluid and nutrient absorption.
- Therefore, patients lacking a colon are at greater risk of dehydration.
- The colon is capable of salvaging calories through anaerobic bacterial fermentation of undigested carbohydrates into SCFAs.
Explain methotrexate.
Methotrexate acts by interfering with the normal intracellular metabolism of FOLATE.
- Drug used to treat cancer
- It is a folate analogue that became available in the 1950s
- Structurally similar to FOLATE
- It competitively inhibits dihydrofolate reductase (an enzyme that catalyses the conversion of dihydrofolate to tetrahydrofolate, a cofactor in the synthesis of purine nucleotides and thymidylate.
- Therefore, methotrexate impairs malignant growth by interfering with the DNA synthesis, repair and cellular replication.
Copper deficiency is associated with?
Microcytic hypochromic anemia
- Patients on long-term PN have developed anemia, leukopenia, neutropenia, and skeletal abnormalities.
- Other symptoms of copper deficiency are: sensory ataxia, lower extremity spasticity, parathesis in extremities, leukopenia, neutropenia, and hypercholesterolemia
Deficiencies of B12 or folate result in what?
Macrocytic anemia (large red blood cells)
Does a prominent iliac crest pertain to muscle or fat loss?
SubQ fat loss
Explain SGA
Subjective Global Assessment (SGA)
- Uses 5 historical components (weight history, dietary intakes, GI symptoms, functional status, and metabolic demand)
- 3 physical components (Fat depletion, muscle wasting, and nutrition-related edema)
(TRUE/FALSE) SGA is appropriate for use in critically ill patients?
FALSE
ASPEN and SCCM recommend the use of NRS-2002 or NUTRIC tool to determine risk in this patient population.
Explain NRS-2002 tool.
Appropriate for critically ill patients (5 Factors):
- Unintentional weight loss
- BMI
- Disease severity
- Impaired general condition
- Age >70
Explain the NUTRIC tool.
Appropriate for critically ill patients (5 Factors)
“Nutrition Risk in Critically Ill”
**Focuses on the severity of illness
- Age
- APACHE II score (ICU mortality prediction score)
- SOFA (Sequential Organ Failure Assessment)
- # of comorbidities
- Days from hospital to ICU admission
Explain NRI tool.
“Nutritional Risk Index (NRI)”
Uses serum albumin and the ratio of current weight to the usual weight
What does an elevated C-reactive protein indicate?
Inflammatory status, which may be the reason for hypoalbuminemia.
-Positive acute-phase proteins such as CRP increase during inflammation, whereas negative acute-phase proteins concentrations such as albumin and pre-albumin decrease during inflammation.
Where is iron primarily absorbed?
Jejunum
Cheilosis is a physical symptom associated with a deficiency of?
Riboflavin
-Cheilosis = cracking of the corners of the mouth
What compromises the reliability of urinary urea nitrogen to calculate nitrogen balance
creatinine clearance <50mL/min
What micronutrient has been shown to decrease plasma homocysteine concentrations
folic acid
hyperhomocysteinemia concentrations has been associated with an increased risk of
atherosclerosis
which three micronutrients can be supplemented to decrease homocysteine levels in plasma to decrease the risk of atherosclerosis
folic acid, vitamin B12 and vitamin B6
what is the most appropriate fluid requirement for a healthy 78 year old adults
25mL/kg/day
what is the recommended fluid requirement for healthy adults between the ages of 18-55
35mL/kg/day
what is the recommended fluid requirement for adults between the ages of 55 and 75 years old
30mL/kg/day
what is the recommended fluid requirement for adults with fluid restriction such as CHF
25mL/kg/day
What enzyme initiates the digestive process of carbohydrates in the mouth
salivary amylase
Lipase is an enzyme released by the pancreas that helps the digestion of
fat
Lactase and Maltase are enzymes located in the ______ of the small intestine to aid in intraluminal carbohydrate digestion
brush border
Iron is primarily absorbed in the __________ and ________ in the _______ state. Gastric ____ is very important in maintaining dietary iron in the _____ state
duodenum and jejunum
ferrous
acid
ferrous
What amino acid is most crucial in small intestine structure and function
glutamine
In persons with phenylketonuria (PKU), tyrosine becomes an essential amino acid due to a deficiency of
the phenylalanine hydroxylase enzyme
Phenylalanine Hydroxylase catalyzes the hydroxylation of phenylalanine to _______, so phenylalanine levels become _____ and _____ levels are decreased
tyrosine
elevated
tyrosine
Conditionally essential amino acids are synthesized from other amino acids under normal conditions but require increased needs from dietary sources during ________. For example, arginine becomes conditionally essential for _______ and _____ during trauma
stress
wound healing
glutamine
glutamine becomes conditionally essential during
trauma
arginine becomes conditionally essential during
wound healing
What are the conditionally essential amino acids
arginine, cysteine, glutamine, glycerin, proline, tyrosine
An NPO post operative patient has been on 2 in 1 PN for 3 weeks. He develops hair loss, diffuse scaly dermatitis, anemia and thrombocytopenia. What is the probable cause
he has not been getting ILE for 3 weeks
Provision of fat free PN for ____ weeks has resulted in essential fatty acid deficiency
3 weeks
Essential Fatty Acid deficiency usually results after ___ weeks of fat free PN, although signs and symptoms of deficiency can be as early as ___ to ____ days
10-20 days
what are the signs and symptoms of EFAD
alopecia, scaly dermatitis, impaired wound healing, anemia, thrombocytopenia
Provide __ to ___% total calories from ____ or ____ ILE to prevent EFAD
4-10% total calories
soy of safflower oil ILE
Which IV fluid most closely resembles jejunal and ileal electrolyte content
lactated ringers
Fluids and electrolytes of the jejunum contains ____ mEq of sodium, ___ mEq of potassium, ___ mEq of chloride and ____ mEq of bicarb
95-120 mEq of sodium
5-15 mEq of potassium
80-130 mEq of chloride
10-20 mEq of bicarb
Fluids and electrolytes of the ileum contains ____ mEq of sodium, ___mEq of potassium, ___ mEq of chloride and ___ mEq of bicarb
110-130 mEq of sodium
10-20 mEq of potassium
90-110 mEq of chloride
20-30 mEq of bicarb
Lactated Ringers IV solution contains ___ mEq/L of sodium, ___ mEq/L of potassium ____ mEq/L of chloride, ____ mEq/L of lactate and ___ mEq/L of calcium
130 mEq/L of sodium 4 mEq/L of potassium 109 mEq of chloride 28 mEq/L of lactate 2.7 mEq/L of calcium
Normal saline contains ___ mEq/L of sodium, ____mEq/L of chloride
154 mEq/L sodium
154 mEq/L chloride
Half Normal saline contains ___ mEq/L of sodium and ____ mEq/L of chloride
77 mEq/L sodium
77 mEq/L chloride
Dextrose and half normal saline contains ____ g/L of glucose, ___ mEq/L of sodium and ____ mEq/L of chloride
50 g/L dextrose
77 mEq/L sodium
77 mEq/L chloride
What are the clinical symptoms of inappropriate diuretic hormone (SIADH)
increased urinary sodium
hyponatremia
increased urinary osmolality
a disorder of sodium and water balance caused by inappropriate release of anti-diuretic hormone which causes increased total body water which causes dilution hyponatremia
SIADH
In SIADH, increased sodium and osmolality of the urine is due to
excessive water retention/re-absorption
In SIADH to compensate for the expansion of the extracellular fluid, aldosterone secretion is inhibited to maintain
euvolemia
A 45 year old patient with chronic corticosteroid use has suspected vitamin A deficiency. Supplementation of vitamin A (3,000 to 5,000 IU) should be given at a max of ____ days
7 days
what are the main functions of vitamin A
wound healing, cell differentiation, and collagen synthesis
what is the typical dose for vitamin A supplementation
3,000 to 5,000 IU for 7 days
when should vitamin A be supplemented
to enhance wound healing with corticoid steroid therapy
Corticosteroid therapy has been shown to decrease vitamin ______
vitamin A
A patient with alcoholism is admitted with a small bowel obstruction and is started on PN. The PN provides 400 grams of dextrose, If after 3 days, the patient develops mental status changes, it is most likely due to a deficiency of
thiamine
alcohol related thiamine deficiency presents as
Wernicke’s Encephalopathy
Symptoms of Wernicke’s Encephalopathy are
mental status changes, confusion, nystagmus, gait ataxia
The glucose load in PN is associated with PN increases metabolic demand for ____ which is essential for glucose metabolism
thiamine
Lactic acidosis can be a result of which vitamin deficiency
thiamine
Thiamine is required for ____ metabolism. When Pyruvate is converted to acetyl CoA. If thiamine is not present, pyruvate will convert to production of _____ fermentation
glucose
lactic acid fermentation
In addition to aggressive refeeding, what else places patients at high risk for hypophosphatemia
DKA
Which patients are at the highest risk for hypophosphatemia
malnourished, DKA, chronic alcoholism, respiratory and metabolic acidosis, critical illness
Insulin is an anabolic hormone that drives potassium and phosphorous into the cells causing serum _____ of these electrolytes
depletion
in DKA, large amounts of ____ is lost in urine from the osmotic diuresis resulted from hyperglycemia
phosphorous
The risk of metastatic calcification in soft tissues begins to increase when the product of serum calcium and phosphorous exceeds
55 mEq
Hyperphoshpatemia can cause which issues
soft tissue and vascular calcification
hyperparathyroidism
renal osteodystorphy
Zinc deficiency is most commonly associated with
diarrhea
what are the functions of zinc
catalytic reactions
structural function
regulatory functions
When is additional zinc provision recommended
thermal injury (burns)
excessive GI loss from diarrhea
decubitus ulcers
high output fistulas
Copper toxicity is associated with ___ disease
liver
what are the signs of copper toxicity
severe nausea, diarrhea
Copper toxicity can cause
Wilson's disease Coma Hepatic Necrosis Liver Failure Renal Failure Death
80% of copper is excreted via
bile
a patient with liver disease should be monitored and supplemented or be
decreased or eliminated
Hemolysis increases copper
loss
Enteral zinc supplementation can compete with ____ for absorption
copper
Hepatic encephalopathy is most likely to be improved by which trace element
zinc
Liver disease can cause altered ____ metabolism leading to decreased serum ____ levels. ____ supplementation has been shown to help in hepatic encephalopathy
zinc
zinc
zinc
In hepatic encephalopathy zinc should be supplemented in doses of ____ mg/day for 3 months
150 mg per day
What is the function of aluminum in PN solutions
Aluminum has NO KNOWN BIOLOGICAL function
Aluminum is only present in PN as
a contaminant
What can result in an invalid indirect calorimetry measurement
air leak chest tube leak extracorperoal membrane oxygenation hemodialysis FiO2 >60% in mechanically ventilated patients/spontaneously breathing patients reliance on supplementation oxygen unable to cooperate claustrophobia anxiety
How should a critically ill patient’s energy delivery be modified in response to resting energy expenditure measured by indirect calorimetry
use the caloric target WITHOUT adding a stress or activity factor
in calculating energy delivery, should a stress or activity factor be added
no, it can result in overfeeding
A respiratory quotient of 0.87 most likely suggests
mixed substrate utilization
RQ measures CO2 _____ divided by O2 _____
CO2 produced
O2 consumed
An RQ 0.7 or less likely indicates and >1 likely indicates
hyperventilation , hypoventilation
An RQ of 0.71 indicates primarily ____ oxidation
fat
An RQ of 0.82 indicates primarily ____ oxidation
protein
An RQ of 0.85 indicates _____ oxidation
mixed substrate
An RQ of 1.0 indicates primarily ____ oxidation
carbohydrate
which predictive equation has demonstrated the greatest accuracy in estimating actual resting metabolic rate in healthy obese and non-obese adults
Mifflin St. Jeor
Cheilosis is a physical symptom associated with a deficiency of _____, which can include hyperemia, edema of the oral mucosa, angular stomatitis, or glossitis
riboflavin
Malnutrition is most common in which form of IBD due to its involvement in the small intestine where micronutrients are absorbed
Chron’s Disease
A patient with end stage liver disease with refractory ascites awaiting liver transplantation is on PN due to intolerance to tube feeding. Sodium is 123 mEq/L. In addition to fluid restriction, what changes to his PN prescription is most appropriate?
restrict sodium
give 1.5 g/kg/day of protein
What is the dietary recommendations for patients on ascites
fluid and sodium restriction 1-1.5 g/kg/day of protein with cirrhosis
_______ nutrition formula should be used with patients who have ascites from ESLF to avoid further sodium and fluid overload
concentrated
Arginine supplementation should be used most cautiously in patients with
septic shock
arginine increases the production of ______ which causes vasodilation. Providing arginine during septic shock would further exacerbate ______
nitrous oxide
hemodynamic instability
the normal length of the small intestine in adults is about
300-600 cm long
when the small bowel is less than _____ cm, to an end jejunostomy/ileostomy, PN and hydration will likely be needed
120 cm
The presence of an ileocecal valve and colon significantly improves _____ , ______ and _____ absorption. If the ileocecal valve is left intact, a patient may NOT need PN with as little as 60 cm left of the small bowel
fluid, electrolytes, and short chain fatty acids
What is the primary fuel of colonocytes
short chain fatty acids
the three primary short chain fatty acids are
butyrate, acetate and propionate
short chain fatty acids can provide up to ______ kcals in short bowel syndrome
1,000 kcals
Dietary fat is predominantly absorbed in what part of the GI tract
duodenum and proximal jejunum
Gastrectomy patients are at risk for a deficiency of which vitamin
B12
___ is the total or partial removal of the stomach
gastrectomy
the _____ cells of the stomach produce intrinsic factor
parietal cells
Intrinsic factor aids in the absorption of ___ in the small bowel
vitamin B12
When the stomach is resected, there is no longer adequate intrinsic factor to bind is B12 and may result in
deficiency
what areas of the GI tract has the the LEAST impact on nutrient absorption and intestinal adaptation following significant intestinal resection?
jejunum
resecting the proximal bowel (duodenum & upper jejunum) is usually _____ tolerated than ilelal resection
BETTER tolerated because the ileum is good at adaptation of absorption of nutrients
the jejunum _____ adapt well when the ileum is resected
doesn’t
preservation of the ____ is important as it slows intestinal transit allowing for better absorption of nutrients
ileocecal valve
The colon is critical for ___ and ____ absorption. patients without a colon are at increased risk for _____ but can salvage calories through _____________
water & nutrient absorption
dehydration
anaerobic bacterial fermentation of undigested carbohydrates into short chain fatty acids
During fasting, fuel oxidation shifts from carbs to mainly ____ oxidation
lipid
During fasting lipolysis will _____, glycogenesis will ____, gluconeogenesis and glucose oxidation will ______
Increase
decrease
decrease. The body increases lipid oxidation to provide the body with fatty acids for energy
how much fluid per day is required to maintain fluid balance in an average healthy adult
25-35mL/kg/day
Valproic acid has been shown to induce a deficiency of ______
carnitine
Valproic acid is a ____ drug and can cause a deficiency in carnitine
anti epileptic drug
Carnitine plays a role in fatty acid metabolism and is an essential cofactor in the elimination of ___ and ___ from the body
valproic acid and ammonia
carnitine supplementation should be considered for patients
in a coma, with elevated ammonia, have liver disease or with valproic acid medications >450mg/day
methotrexate acts by interfering with the normal intracellular metabolism of which of the following nutrients
folate
Methotrexate is a ____ drug and ______ analogue, so that it’s binding sites are commentative
chemotherapeutic drug
folate
Methotrexate competes with folate for absorption to catalyze the function of the enzyme dihydrofolate reductase, which converts dihydrofolate to tetrahydrofolate, a cofactor for the production of purine synthesis making up ______
DNA
what vitamin absorption is most likely to be impaired with chronic use of proton pump inhibitors
B12
the process to identify someone who may be malnourished or at risk for malnutrition, to determine if a comprehensive nutrition assessment is indicated
screening
a positive screening result should result in
a nutrition consult
This screening tool is used mostly in the elderly. Describes food intake, appetite, chewing/swallowing, weight loss in 3 months, mobility issues, recent psych distress, neuropsych and BMI. The higher the points, the higher the risk
Mini Nutrition Assessment
what is the validated tool for the diagnosis of malnutrition
Subjective Global Assessment
this tool assesses weight changes, dietary intake changes, GI symptoms, functional capacity, edema, and disease related nutrition requirements. Scoring is based on well nourished, moderately malnourished or severely malnourished
Subjective Global Assessment
Social/Environmental malnutrition has ______ level of inflammation
no
pure, chronic starvation, anorexia nervosa, ETOH abuse, homelessness and psychological issues are ____ types of malnutrition
social/environmental
a chronic condition is considered how long per CMS standards
1 month or greater
organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenia obesity, COPD, CHF, CA, and IBD are examples of ____ malnutrition
mild/moderate; chronic disease
acute malnutrition has a _____degree of inflammation
high
major infection, burns, trauma, closed head injuries are examples of _____ malnutrition
acute malnutrition
criteria for severe acute malnutrition
<50% po > 5 days >2% weight loss x 1 week >5% weight loss x 1 month >7.5% weight loss x 3 months moderate fat loss moderate muscle loss moderate to severe edema
criteria for severe chronic malnutrition
=75% po intake >/= 1 month >5% weight loss x 1 month >7.5% weight loss x 3 months >10% weight loss x 6 months >20% weight loss x 1 year severe fat wasting severe muscle wasting severe edema below standards handgrip strength
criteria for severe social/environmental nutrition
<= 50% po intake x >/= 1 month >5% weight loss x 1 month >7.5% weight loss x 3 months > 10% weight loss x 6 months >20% weight loss x 1 year severe fat loss severe muscle loss below standards handgrip strength severe edema
Tools to assess dietary intake
direct from patient or family, from RN, 24 hour recall, 3 day recall, % meal eaten from EMR, indirect calorimetery
unintended weight loss is a ______ indicator of malnutrition
well validated
the most readily available tool inpatient to assess loss of subcutaneous fat/muscle
NFPE
a tool to evaluate decreased function in identification of malnutrition
hand grip strength (average of 3 tests)
hand grip strength is a _____ predictor of nutrition status
independent
is handgrip strength a validated tool
yes
positive acute phase proteins
CRP, fibrinogen, antibodies
positive acute phase proteins ____ during inflammation
INCREASE
negative acute phase proteins
albumin, pre albumin, transferrin
negative acute phase proteins _____ during inflammation
DECREASE
albumin will be decreased during inflammation regardless of
nutrition status/malnutrition
clinical indicators of inflammation
fever, UTI, wound infection, hypothermia, PNA, BSI, abscess
chronic disease states have ______ level of inflammation
mild to moderate
hematological malignancy, IBD, CVD, celiac disease, COPD, CHF, obesity, pressure wounds, chronic pancreatitis CF, dementia, RA, organ transplants and solid tumors are examples of ____ malnutrition
chronic (mild-moderate inflammation)
ARDS, closed head injury, critical illness, SIRS, acute severe malnutrition, major abdominal surgery, major infection/sepsis multi level trauma and severe burns are examples of ____ malnutrition
severe / acute
an approach to identify malnutrition globally with other global nutrition societies
Global Leadership Initiative on Malnutrition (GLIM)
GLIM has 2 criteria ___ and ___
phenotypic and etiologic
GLIM can be used in _____ settings/environments
all
copper deficiency is associated with _____ anemia
microcytic hypochromic anemia
because of copper deficiency, patients on long term PN have developed
anemia, leukopenia, neutropenia
_____ deficiency also causes microcytic hypochromic anemia other than copper
iron
B12 and Folate deficiencies cause ____ anemia
macrocytic
A patient getting PN has high ileostomy output, what changes to PN is recommended
increase fluid
increase sodium
When ileostomy output is over 1,000mL a day, a patient can lose up to ____ mEq/L of sodium, and if not replaced can lead to significant hyponatremia
120mEq/L
Clinical characteristics of acute disease or injury related severe malnutrition are _____ fat depletion, weight loss > _____% in _____ week(s), ______ weight loss in ____ month, > ___%weight loss in ____ months, decreased energy intake _____ days, _____ muscle depletion, ____ fluid accumulation
moderate fat depletion 2% in 1 week 5% in 1 month 7.5% in 3 months <50% > 5 days moderate muscle depletion moderate to severe fluid accumulation
which condition(s) are most likely to result in malnutrition of mild to moderate inflammatory response
cancer
involuntary weight loss of 10% of usual body weight over 6 months is suggestive of
malnutrition
Tricep skin fold thickness below the ____percentile indicates malnutrition
<5 percentile
Tricep skin fold thickness to assess for malnutrition may be falsely elevated with ____ and may not be reliable in _____
edema
obesity
Recent, involuntary weight loss >10% in 6 months detect risk of malnutrition in both
obese and non obese patients
When conducting an NFPE, hollowing/scooping depression of the temporalis muscle indicates ____ muscle loss
severe
in severe muscle depletion, the clavicle and acromion process / deltoid muscle will appear
square with very prominent bones
in severe muscle loss, the interosseous muscle on the dorsal hand will appear
depressed between the thumb and fore finger
in severe fat loss, the iliac crest will appear
prominent
Which is common in both acute illness or injury related malnutrition and social or environmental related malnutrition
lipoysis
in acute illness/injury related and social/environmental malnutrition both how catabolism of endogenous substrate, including fat stored in adipose tissue, is common in
both types of malnutrition
Which nutrition tool includes evaluating subsequent fat and muscle wasting at multiple body sites to determine nutrition status
Subjective Global Assessment (SGA)
hypermetabolism/hyperglycemia are characteristic of ___ related malnutrition
stress
The SGA is a nutrition assessment tool using 5 historical measures including weigh history, dietary intake, GI symptoms, functional status and metabolic demand plus 3 components of the physical exam (fat depletion, muscle wasting,, nutrition related edema). With this information patients are classified as
well nourished
moderately malnourished
or
severely malnourished
ASPEN and the SCCM recommend to use these screening tools for malnutrition in the ICU
NUTRIC/NRS 2002
This nutrition assessment tool monitors for unintentional weight loss, BMI, disease severity, impaired general condition and age over 70
NRS
This nutrition assessment tool uses the APACHE III score, SOFA score, number of comorbidities and days from hospital to ICU admit to identify malnutrition risk
The NUTRIC Tool
This nutrition assessment too uses serum albumin and the ratio of current weight to usual weight to asses malnutrition risk
The NRI (Nutritional Risk Index) Tool
what has been reported to be a significant independent predictor of morbidity and mortality in critically ill patients
albumin
______ is a negative acute phase protein
alubmin
levels of albumin decrease during stress. Hypoalbuminemia is more of a reflection of the degree of_____ , ___ and ___ rather than malnutrition
stress from disease, injury and inflammation
A previously well-nourished patient with persistent fever is admitted to the hospital. Lab tests reveal an albumin of 2.1 g/dL, C-RP of 30 mg/dL, and serum calcium of 7.2 mg/dL. What is the most likely cause of hypoalbuminemia ?
inflammatory response
