Chapter 9: Malnutrition Screening & Assessment

Question 1

Nutrition Screening

Answer 1

“to identify an individual who may be malnourished or at risk for malnutrition and to determine if a comprehensive nutrition assessment is indicated”

Question 2

Nutrition Assessment

Answer 2

“a comprehensive approach to defining the nutrition state that uses a combination of the following:

• medical
• nutrition
• medication
• physical exam
• anthropometric measurements
• lab data”

Question 3

Malnutrition

Answer 3

“undernutrition”

all definitions include an inadequacy of nutrients to maintain a persons health, that is caused by one or more of the following factors:

• insufficient intake
• impaired absorption
• increased nutrient requirements
• altered nutrient transport and utilization

Question 4

How should critically ill patients be assessed?

Answer 4

SGA has limited use for critically ill patients

ASPEN recommends that the Nutrition Risk Score (NRS-2003) OR Nutrition Risk in Critically Ill (NUTRIC) tool be used to assess nutrition risk & plan interventions

Question 5

SGA

Answer 5

“Subjective Global Assessment”

• Validated, reliable assessment tool for diagnosing nutrition status, which relies on the patients medical hx and physical assessment
• patients are classified to: “well-nourished,” “moderately malnourished,” “severely malnourished”
• has 5 components that consider medical hx (wt. changes, dietary intake, GI symptoms, functional capacity, metabolic stress)
• has 3 components for physical exam (muscle wasting, fat depletion, nutrition-related edema)

Question 6

**ASPEN // AND Classification for Malnutrition

Answer 6

-Similar to SGA but includes how pro-inflammatory states affect malnutrition and seeks to identify the etiology on an individual basis

• 3 etiologies:
  
  1. Acute illness
  2. Chronic Illness
  3. Social/environment/behavioral circumstances
• 2 characteristics, out of 6, required to dx malnutrition:
  
  1. Weight Loss
  2. Fat Loss
  3. Decreased energy intake
  4. Muscle mass loss
  5. Decreased hand strength
  6. Fluid accumulation
• *Enter Image w/ specific wt. loss requirements
• most similar to PHSW guidelines

Question 7

IBW

Answer 7

Males: 50 kg + 2.3 kg for each inch over 5 feet.

Females: 45.5 kg + 2.3 kg for each inch over 5 feet.

Question 8

ABW

Answer 8

Estimated Adjusted Body Weight (kg)
If the actual body weight is greater than 30% of the calculated IBW, then use this:

ABW = IBW + 0.4 (actual weight - IBW)

Question 9

Lab Values for Assessing Nutritional Status

Answer 9

“…useful as supportive data for nutrition deficiencies, but they should be interpreted with caution because they lack specificity and sensitivity as direct indicators of nutrition status”

Question 10

DRIs

Answer 10

Dietary Reference Intakes; “intended to define amounts that support most healthy individuals. So, clinicians should exercise caution when using them to evaluate nutrient intakes with patients with diseases”

Question 11

NFPE

Answer 11

Nutrition-Focused Physical Exam; focuses on changes to muscle, fat stores, fluid retention and/or other sign that can result from micronutrient deficiencies or excesses

-should evaluate parts of the body with high cell turnover (hair, skin, mouth, tongue)

FOR ASPEN/AND MALNUTRITION CRITERIA:

• mild fat/muscle/fluid loss is required for Acute/Chronic/Social malnutrition
• moderate fat/muscle loss/fluid losses (can be moderate or severe) is required for Acute
• severe fat/muscle/fluid loss is required for Chronic/Social

Question 12

Overview of Starvation

Answer 12

Goal is: preserve LBM
Glycogen is primary energy source for short-time, then
Amino acids are used to make glucose, then
Fat becomes main energy source, as keytones

Question 13

Overview of Inflammation

Answer 13

Stress response is characterized by extreme catabolism and negative N balance, driven by hormones and cell mediators, initiating the immune defense and repairing of tissues
All of the above, accelerate muscle breakdown to generate energy (Gluconeogenesis)
Cytokines act to inhibit repair and creation of new muscle, promote muscle breakdown and affect muscle function

Question 14

Muscle Atrophy

Answer 14

“is a loss of bulk and tone that is detectable by palpation”

Upper body is more often used, as the lower body can be more affected by edema

Question 15

Sarcopenia

Answer 15

“age-related loss of muscle mass and has been associated with a decline in function”

From the ages of 20 years to 80 years, muscle mass declines by approx. 30%; as well as, the potential quality of the muscle

Question 16

Sarcopenic Obesity

Answer 16

“reduced muscle mass, and perhaps muscle quality, that is disproportionate to fat mass”

Question 17

Cachexia

Answer 17

“loss of muscle mass, irrespective of adipose tissues changes, which accompanies underlying illnesses and is often associated with inflammation, IR, decreased appetite and intake, and protein catabolism. Because of its multifaceted and profound inflammatory state, cachexia is not responsive to nutrition support; however, symptom management (psychological, oral, GI, pharmacological) is imperative.”

Cachectic = Sarcopenia
Sarcopenia does not always = Cachectic

Question 18

What area of the spine, when scanned (CT), is a precise and valid means to quantify and distinguish between lean and adipose tissue?

Answer 18

Third lumber vertebrae (L3) region

Question 19

WHAT body composition assessment instrument can be used to quantify muscle layer thickness? WHERE (what body part?) & What body part has been shown to be indicative of overall LBM?

Answer 19

WHAT = bedside ultrasound (not as accurate as CT scans, but shows promise to assess LBM in the ICU setting)
WHERE = Mid-upper arm
WHERE = Quad muscle

Question 20

Edema

Answer 20

“an excess of interstitial fluid accumulation, can be caused by a variety of diseases, conditions, and meds, but it is rarely the direct result of malnutrition”

In malnutrition cases, it can be caused by prolonged periods with frank deficiencies in protein intake, or response to refeeding syndrome

Clinical manifestations of fluid retention may not be noticeable until it accounts for at least 10% of body weight or when interstitial fluid volume increases by 2.5 - 3L

So, fluid retention can be present without a physical exam, such as: increased BP, ascites, declining [Na2+] levels and rapid weight increase

Question 21

Overview of Functional Status

Answer 21

“defined as a measurement of the capacity of an individual to perform usual activities”

Muscle function, assessed by handgrip (dynamometer is a validated tool), shows a DIRECT relationship with measures of functional status and physical components of quality of life

If not available, Obtaining a patient’s perspective regarding his/her functional status may be useful

**ASPEN/AND use functional status as an indicator for severe malnutrition in all 3 categories (acute, chronic, social) when measurable reduced functional status is noted.