Intro Lecture Flashcards
1
Q
What needs to be done for every pt?
A
Nutrition screening within 24 hrs of admission
2
Q
Definition of screening
A
A process to identify an individual who is malnourished or who is at risk for malnutrition to determine if a detailed nutrition assessment is needed
3
Q
Screening outcomes
A
Not at risk- rescreen at specified individuals
At risk- plan carried out according to ordinary ward routines
At risk but metabolic or functional problems prevent a standard plan being carried out
4
Q
Nutrition screening criteria
A
Height Weight Change in weight Food allergies Diet Lab data Change in appetite Nausea or vomiting Bowel habits Chewing/swallowing ability Dx
5
Q
NRS-2002
A
Medical-surgical and acute hospitalized
6
Q
MNA-SF
A
Ambulatory and sub-acute
7
Q
MST
A
Acute hospitalized and oncology outpatients
8
Q
MUST
A
Medical and surgical hospitalized
9
Q
NST/BAPEN
A
Acute, hospitalized
10
Q
Simple, two-part screen
A
Acute, hospitalized
11
Q
NRS
A
Acute care, medical and surgical
12
Q
Screen-II/AB
A
Seniors in the community/geriatric clinics
13
Q
Rapid screen
A
Sub-acute care (rehab center)
14
Q
Tool #1
A
Elderly in acute care and long-term care
15
Q
SNAQ
A
Not evaluated against a reliable standard
16
Q
What is assessed in the NRS?
A
Weight loss, BMI, food intake
Dx and severity of dz
Best predictor of postsurgical complications
Predicted length of stay (LOS), morbidity and mortality in acute care
In GI surgery, predicted morbidity, complications, LOS
17
Q
What is assessed in mini-nutritional assessment (MNA)
A
Weight and height data Food intake hx and appetite Dz Self-perception of health status -Mobility -Psychological stress/problems Predicted post-operative outcomes in elderly
18
Q
What are the advantages of the MST?
A
Accurately predicts malnutrition
Promotes early nutritional therapy with most appropriate pts
Simple, quick and easy to implement
19
Q
What is screened in the MUST?
A
BMI, weight change, illness severity
Predicted mortality in the elderly
Identified oncology pts at risk for longer length of stay (LOS)
20
Q
Screening vs assessment
A
Screening: Brief Assessment: Comprehensive Screening: Non-invasive Assessment: Can include invasive testing Screening: Inexpensive Assessment: More expensive Screening: Goal is to identify need for assessment Assessment: Goal is to identify need for intervention
21
Q
Definition of nutrition assessment
A
Food/nutrition hx Client hx PE findings Anthropometric measurements Biochemical data, medical tests, and procedures
22
Q
What does pt hx include in an assessment?
A
Diet
Medical
Surgical
Social
23
Q
What does a diet hx include
A
24-hr recall
Usual dietary intake or hx
Food frequency questionnaire
Food diary or record
24
Q
Components of diet hx
A
Current diet order Days of inadequate intake Dietary restrictions Recent dietary change Food consistency Appetite assessment Alcohol consumption Food intolerances, aversions, allergies Fad diets Vitamin, mineral or herbal supplements Commercial dietary supplements
25
Components of medical/surgical hx
```
CC
Current health status
Chronic dz states
Psychiatric hx
Diagnostic procedures
Medical therapies
Past hx of operations
Family health hx
Oral health hx
Medications with potential drug-nutrient interactions
```
26
Components of pt social hx
Degree of physical activity
Extent of family support
Housing situation
Socioeconomic issues
27
Anthropometric data
```
Height
Weight
BMI
Arm circumference and triceps skinfold measurements
Waist: hip ratio
```
28
BMI greater than or equal to 40
Grade III obesity (morbid)
29
BMI 35-39.9
Grade II obesity
30
BMI 30-34.9
Grade I obesity
31
BMI 25-29.9
Overweight
32
BMI 18.5-25
Nl
33
BMI 17-18.4
Grade I protein energy malnutrition
34
BMI 16-16.9
Grade II protein energy malnutrition
35
BMI <16
Grade III protein energy malnutrition
36
General components of a nutrition-focused physical exam
Overall appearance
Muscle mass and tone
Adipose stores/tissue (skinfold thickness)
37
Oral components of a nutrition-focused PE
Tongue
Gums
Lips
Mucous membranes
38
Skin components of a nutrition-focused PE
```
Color
Scars
Edema
Turgor
Temp
```
39
Nail components of a nutrition-focused PE
Color
Shape
Texture
40
Nose components of a nutrition-focused PE
Feeding devices
| Symmetry
41
Chest components of a nutrition-focused PE
Muscle wasting
Barrel chest
IV devices
42
Abdomen components of a nutrition-focused PE
Wounds
Scars
Distention or tenderness
Bowel sounds
43
Neurological components of a nutrition-focused PE
```
Motor skills
Weakness
Coordination
Paralysis
Acuity
```
44
SGA
Weight and diet hx
Diagnosis and level of stress
Physical sx
Functional capacity
Predicted
-Length of stay in acute care (medical) and GI dz
-Morbidity and mortality in critically ill
-Outcomes in elective surgery and stroke (elderly)
45
Nl albumin levels
3.5-5.0 mg/dL
46
Nl prealbumin levels
16-40 mg/dL
47
What electrolytes are measured in lab?
```
Na
K
Phos
Mg
Ca
Cl
```
48
Nl glucose level
70-110 mg/dL
49
What micronutrient levels are measured in lab?
Fe
B12
Folate
Zn
50
What other things are measured in lab?
Hemoglobin/hematocrit
Lipid panel
Acid-base disorders
51
Acute-phase response
Increased temp
Increased WBC count
Increased CRP
-Measures presence, intensity, and recovery from an inflammatory process
-Other nutrition related proteins WILL NOT return to nl until the APR resolves
52
Acute phase proteins-ceruloplamin
Pos
| Binds copper- antioxidant
53
Acute phase proteins- albumin
Neg
| Binds Ca and other molecules; antioxidant; plasma oncotic pressure
54
Acute phase proteins- prealbumin
Neg
| Thyroxine transport; forms complex with RBP
55
Acute phase proteins- transferrin
Neg
| Iron absorption and transport
56
Acute phase proteins: CRP
Pos
| Scavenger of cell membrane debris; complements DNA activation
57
Acute phase proteins- IGF
Neg
| Promotes protein synthesis in liver and muscle; inhibits lipolysis
58
When does hepatic status change?
Trauma
Infections
Cancer
Surgery
Low serum hepatic concentrations are not necessarily caused by nutrient deficit
Low concentrations associated with illness will not normalize just with nutritional intervention
59
Negative acute phase proteins
Excellent indicators of the severity of illness NOT nutritional status
-Correlate with morbidity and mortality
Decrease may predict those at risk of malnutrition
Indicates the need for a more comprehensive nutritional assessment by RD
60
When is the malnutrition risk increased?
Older adults
Critically ill pts
Pts with comorbid chronic dzs
-CA, COPD, CKD
61
Physiologic impact of malnutrition
```
Increased morbidity and mortality
Declining function and mobility
Decreased quality of life
Increased frequency and length of stay
Higher health care costs
```
62
Protein-calorie malnutrition criteria in the 20th century
Albumin less than or equal to 3.0 g/dL OR
Prealbumin less than or equal to 12 mg/dL
Wt loss >10% usual body weight and hx of poor intake
Current wt <90% of IBW OR BMI <18 kg/m squared
Pressure older greater than or equal to stage 2 OR
a non-healing wound
RD clinical judgment of PCM
63
Severe protein calorie malnutrition
Required presence of 3 criteria
64
Moderate protein calorie malnutrition
Required presence of 2 criteria
65
Inflammation and malnutrition
Consider when conducting nutrition assessment, intervention, and monitoring
Nutrition support alone is ineffective in prevention of muscle protein loss in the inflammatory state
Indicators of inflammation:
-Biomarkers
-Obesity
-Hyperglycemia
-Organ failure syndromes
66
Starvation-related malnutrition
Chronic starvation without inflammation (anorexia nervosa)
67
Chronic disease-related malnutrition
Inflammation is chronic and of a mild to moderate degree (RA, organ failure, pancreatic CA)
68
Acute dz-or injury-related malnutrition
Inflammation is acute and of a severe degree (major infection, burns, trauma, or closed head injury)
69
Clinical characteristics that the clinician can obtain and document to support a dx of malnutrition
```
Energy intake
Interpretation of weight loss
Physical findings
Body fat
Muscle mass
Fluid accumulation
Reduced grip strength
```
70
What is required for a malnutrition dx?
```
A minimum of 2 out of the 6 clinical characteristics
Severe or moderate malnutrition
Identify the setting:
-Acute illness or injury
-Chronic illness (>3 mos)
-Social/environmental circumstances
```
71
REE (resting energy expenditure)
Energy expended for nl body functions
72
BEE (basal energy expenditure)
Minimal energy expended required for life
73
BMR (basal metabolic rate)
Measured in morning before eating and activity
74
RMR (resting metabolic rate)
May include energy for digestion and oxygen consumption of tissues
75
Indirect calorimetry
```
Considered the gold standard
When used in the appropriate pt population, <4% error rate
Limitations:
-Increased cost of care
-Trained personnel needed
```
76
Conditions for accurate testing
Body position
| Restrictions for critically ill pts
77
Respiratory quotient (RQ)
```
Physiological range: 0.67-1.3
-If <0.7
--Prolonged fast >16 hrs
--Underfeeding
--Ethanol metabolism
-If >1.0
--Recent, excessive caloric intake
--Overfeeding
RQ is a good marker of test validity
```
78
Interpretation of respiratory quotient (RQ)
Substrate utilization assumes the subject is burning one substrate at a time
-Carbohydrate = 1.0
-Protein = 0.8
-Fat = 0.7
-Mixed fuel = 0.8-0.85
RQ should NOT be used to determine a specific nutrition regimen
79
Harris-Benedict
Commonly used
Higher error rate, esp with obese pts
Subjective use of stress factors
BEE x 1.1 may be more accurate
80
Ireton-Jones
Tailored to pts that are ventilator dependent and to pts that are spontaneously breathing
Considers factors such as trauma, burns and the presence of obesity
81
Frankenfeld and Swinamer
Equations that use dynamic parameters associated with greater correlation to measured REE
Parameters: Temp, min ventilation, presence of sepsis, hemoglobin, RR
Less accurate in obese pts
82
MIfflin-St. Jeor Equation
Accurate estimate of actual resting metabolic rate in obese and non-obese populations with a low rate of overestimation
Not reliable in the critically ill pt population
83
American College of Chest Physicians (ACCP) targets
Critically ill pts
-25 kcal/kg
Systemic inflammatory response syndrome (SIRS)
-27.5 kcal/kg
84
Hypocaloric feedings in pts with acute illness, stress of injury, or sepsis- nutrien(t requirements
20-25 kcal/kg body weight
85
Obesity nutrient requirements
>120% of ideal weight for height
| 20 kcal/kg body weight
86
Morbid obesity nutrient requirements
8-14 kcal/kg body weight
87
Stable pt with marasmus nutrient requirements
37 kcal/kg body weight
88
What tools are recommended for estimating the nutritional needs of critically ill pts?
Ireton-Jones equation
Penn State equation
20-25 kcal/kg recommendation by the ACCP
89
Adult Maint protein requirements
0.8-1.0 g/kg
90
Critical illness protein requirements
1.5-2.0 g/kg
91
Renal dz protein requirements
0.6-2.0 g/kg
92
Liver dz protein requirements
0.5-1.5 g/kg
93
CA protein requirements
1.0-1.5 g/kg
94
GI dz protein requirements
1.0-2.0 g/kg
95
Obesity, stressed protein requirements
1.5-2.0 g/kg ideal
96
Other protein requirements
0.8 g/kg/day for healthy individuals
If stressed and <120% ideal weight for height: 1.5 g/kg/day actual weight
If stressed and >120% ideal weight for height: 1.5 g/kg/day ideal weight
Head injury/CVA/bleeds: 1.8 g/kg/day actual weight
Renal failure: 1.5-2.0 g/kg/day dry weight with dialysis
97
Fluid requirements
30-35 mL/kg for maintenance
100 cc for the 1st 10 kg of body weight. 50 cc fort he 2nd 10 kg of body weight. Any weight >20 kg: Add 20 cc/kg/day if under 50 yoa and 15 cc/kg/day if > 50 yoa
Monitor adequacy of provision when IVF and meds reduced or discontinued
98
RDA method of estimating fluid needs
1 cc fluid per 1 kcal of estimated needs
99
Holliday-Segar method of estimating fluid needs
<10 kg: 100 mL/kg
11-20 kg: 1,000 mL + 50 mL/kg for each kg >10
>20 kg: 1500 mL + 20 mL/kg for each kg >20
