Exam 2: protein-energy malnutrition (PEM) Flashcards
Definition: malnutrition
- nutrition imbalance
- can also refer to obesity (nutrient poor, high cal foods)
- loss of LBM
in the past, PEM was diagnosed using
- serum albumin or prealbumin (may still see it diagnosed this way in the clinical setting)
- clinical setting slow to adopt other methods of diagnosing malnutrition bc of coding/billing still using albumin and prealbumin for diagnosis
- these levels are not good indicators of malnutrition in the presence of inflammation (patient is already going to be stressed and have inflammation, so albumin will be decreased)
Negative acute phase proteins
- decrease when inflammation is present in the body
- albumin and prealbumin tend to indicate severity of inflammation (not nutritional status)
- do not predict change w/ calorie restriction or weight loss or nitrogen balance
- likely that those w/ low albumin and prealbumin will have impaired nutritional status
Conditions that affect albumin levels due to inflammation
- dehydration
- liver failure
- cancer
- infection
- bed rest
- pregnancy
- trauma
3 types of malnutrition
- chronic starvation without inflammation (ex: anorexia)
- chronic diseases with sustained inflammation (ex: organ failure, pancreatic cancer, arthritis, sarcopenic obesity)
- acute injury/disease with inflammation (ex: infections, burns, trauma, closed head injury)
sarcopenia
- age related loss of muscle mass often accompanied by loss of strength and/or functionality
- direct relationship between sarcopenia and malnutrition
- increased risk of falls and fractures
- starts at age 30, increases at age 75
malnutrition-sarcopenia syndrome risk factors
Those at risk have 4/5 criteria:
- recent history of decreased appetite resulting in poor food intake
- unintentional weight loss of 3kg or more over the past 3 months
- low muscle mass
- decreased gait speed
- reduced hand grip strength
chronic starvation
can be alleviated by increased nutrient intake
malnutrition treatment
- cannot be alleviated with increased nutrient intake alone
- treatment includes vasopressors, resuscitation, ventilations and nutrition therapy
- must provide adequate energy and protein to support recovery
- arginine + glutamine (juven) supplements may be beneficial for healing
feeding route
- if inadequate intake, start w/ oral supplements, fortifying foods or altering consistencies of foods/drinks
- if pt still not consuming enough calories and protein, enteral nutrition may be next best option
- if gut does not work, PN may be appropriate
malnutrition assessment tools
- MNA (mini nutrition assessment) used for 65 and older
- SGA (subjective global assessment)
6 clinical characteristics used to identify malnutrition
- energy intake - meeting needs?
- interpretation of weight loss (make sure to take into account edema or dehydration that may mask weight loss - get UBW)
- body fat
- muscle mass
- fluid accumulation
- reduced grip strength
Pt must meet 2/6 of the criteria to be diagnosed
2 ways to diagnose malnutrition
- severe
2. moderate (non-severe)
Techniques used for physical assessment of fat/muscle loss
Inspection and palpation
Sites to check for fat loss
- orbital region
- upper arm/triceps (arms at 90 degrees)
- thoracic and lumbar region (lower back and mid axillary line)
- ribs visible?
- hips - padding?
- iliac crest is present = severe fat loss
- shoulder blades protruding = severe fat loss
Sites to check for muscle loss
- start at temples; have patient bite down. muscle should have firmness
- If facial bones are showing = severe muscle loss
- clavicles (may always see in females, but prominent and protruding clavicles = severe muscle loss)
- Deltoid area - squared shoulders = severe loss
- overweight patients can still have muscle loss in clavicle/neck area
- dorsal hand region - if prominent depression when making “ok” sign = severe muscle loss
- patellar region/anterior thigh –> prominent knee bones, no muscle to give definition around patella
- calf: have pt sit down with knees bent; thin calf w/ no definition/firmness = severe muscle loss
clinical signs of inflammation
- fever
- hypothermia
- signs of SIRS
When conducting a physical exam,
go into it thinking you’re going to view all sites (but this may not be possible due to patient’s condition)
start from head to toe
Lab data to think about when assessing malnutrition
- albumin and prealbumin (use w/ caution)
- c-reactive protein (CRP)
- white blood cell count
- blood glucose levels
- negative nitrogen balance
- elevated resting energy expenditure
functional assessment for malnutrition
hand grip strength test (using a dynamometer)
