1. calculate the BMI of the px 2. click appropriate bracket for the calculated BMI 3. CHoose what percentage of unplanned weight loss in the past 3-6 m0nths 4. answer "Yes" or "No" if px is acutely ill & there has been no nurtitial intake >5 days https://www.mdcalc.com/calc/4012/nutrition-risk-screening-2002-nrs-2002

Nutrition and Approach to Patients with Weight Abnormalities Flashcards by TRISHA JOY BASILLE RODRIGUEZ

What are the different adverse outcomes associated with malnutrition?

poor wound healing
compromised immune status
prolonged hospitalization
increased mortality

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what are the var used in assessment of px upon admission?

weight loss
compromised dietary intake
High risk medical/surgical diagnoses

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what is the normal and overweight BMI?

normal: 18.5-24.9
overweight: 25-29.9

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What is the tool used to predict risk of malnutrition in hospitalizd & ICU px?

NRS 2002: Nutrition risk screening 2002

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What is a better screening tool to validate risk predictor in ICU px?

NUTRIC score

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Which of the variables are used to assess and classify nutritional risk?
A. BMI
B. State of hydration
C. Actual body weight
D. Vital signs

A
BMI = weight in kg / (height in meters)
2
- BMI < 18.5 kg/m2 proposed screen for malnutrition.
- BMI ≤ 15 kg/m2 is associated with increased mortality.
- BMI > 25 usually indicates increased body fat
- BMI < 20 usually indicates decreased muscle mass and body fat
- BMI 11-13 is usually incompatible with life
- BMI 17 is consistent with protein energy malnutrition
- BMI > 17 does not rule out protein energy malnutrition
- Many patients with protein energy malnutrition have normal or above normal BMI due to residual obesity, expanded ECF volume or presence of edema.
- BMI < 16 carries a POOR prognosis

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Classify the underlying cause of unintentional weight loss with the type of inflammation: Hyperthyroidism
A. Chronic inflammation
B. Increased inflammation
C. Decreased inflammation

C
There is decreased inflammation in hyperthyroidism, and the weight
loss is d/t the hypermetabolic state from the increased thyroid
hormone.

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In assessing body weight, which of the following parameters is prognostic of clinical outcomes?(
A. 5 kg. weight loss over 12 months
B. > 10% weight loss from usual weight
C. ± 20% change from Ideal body weight
D. BMI < 18.5 kg/m2

B
Significant weight loss is prognostic of clinical outcomes: 4.5kg/10lb
weight loss over 6 months, weight loss of >10% of usual body weight. It is best to compare present weight with the usual weight rather than the ideal body weight and evidence has shown that >10% weight loss from usual body weight is of prognostic value.

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How do you use NRS 2002?

if all answers are “Yes” then proceed to final screening

If all 4 Qs aer “NO” then the px is low risk by NRS 2002

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What is the interpretation of results in NRS 2002? Low, at risk, &high risk?

Low risk: re-screen px weekly
At risk: initiate nutritional care plan
High risk: initiate early intervention nutritional care plan

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What nutritional screening tool is used for px >18 y/o and may be applied to euither hospital/community setting when px are at risk for malnutrition?

MUST: Malnutrition Universal Screening Tool

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What are the intervals of screening px? Inpatients, Patients in community care homes, & outpatients/community?

Inpatients: weekly
Px in community care homes: monthly
Outpx: Annual (low ris0

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How do you measure height if it is unrecalled/self-report cant be given?

(Pearls/Pitfalls)

Estimate either:
- ulna length
- knee height
- demispan

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What is ht & wt cant be obtained, what should be used?

MUAC = mid-upper arm circumference in place of BMI

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How to you use MUST?

calculate the BMI of the px
click appropriate bracket for the calculated BMI
CHoose what percentage of unplanned weight loss in the past 3-6 m0nths
answer “Yes” or “No” if px is acutely ill & there has been no nurtitial intake >5 days

https://www.mdcalc.com/calc/4012/nutrition-risk-screening-2002-nrs-2002

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The result of MUST has low risk, medium risk & high risk. What should be done in these conditions?

Low risk - subject px to routine clinical care
Medium risk - continue screening
High risk - treat & refer to dietitian to improve & INC overall intake, freq of monitoring accdg to local policy

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What are the historical data obtained in px with weight abnormalities?

Body weight
Medical and surgical conditions/chronic disease
Constitutional signs/symptoms
Eating difficulties/Gastrointestinal complaints
Medication hx
Dietary practice & supplement use
Influences on nutritional status, environment

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What are the physical exam data needed in px with weight abnormalities?

BMI
Weight loss
Weakness/loss of strength
peripheral edema
hair examination
skin examination
eye examination
perioral examination (mouth)
extremity examination
mental status/nervous system exmination
functional assessment

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What are the diff indications of health problem just by looking at the px’s hair?

hair loss = protein, B12, folate
brittle = biotin
color change = zinc
dry = vitamins A&E
easy pluckability = protein, biotin, zinc
coiled, corkscrew = vitamins A&C

Alopecia = excessive hair loss on pillow or when combing hair

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What are the diff indication sof health problem just by looking at the px’s skin?

Desquamation (peeling/flaking) = Riboflavin

Petechiae = Vit A & C

Perifocular hemorrhage = Vitamin C

Ecchymosis = Vitamins C & K

Xerosis, brain-like desquamation = Essential FA

Pigmentation, cracking, crusting = Niacin
Acneiform lesions, follicular keratosis

Xerosis = Vit A

Acro-orificial dermatitis, Erythematous, Vesiculobullous, & pustular = Zinc

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What are the diff indications of health problem in the eyes of px with wt abn?

Vitamin A = Bitot’s spots, Xerosis, Night vision/Night blindness

Riboflavin - Angular palpebritis

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What are the diff indications of health problem in the perioral of px with wt abn?

B complex, Iron, & Protein = Angular stomatitis & cheilosis

Niacin, Folate, & Vit B12 = Glossitis

Riboflavin = Magenta tongue

Vitamin C = Bleeding gums, gingivitis, tooth loss

Assoc w/ vitamin and mineral deficiencies = Angular stomatitis, Cheilosis, & Glossitis

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What are the diff indications of health problem in the perioral of px with wt abn?

B complex, Iron, & Protein = Angular stomatitis & cheilosis

Niacin, Folate, & Vit B12 = Glossitis

Riboflavin = Magenta tongue

Vitamin C = Bleeding gums, gingivitis, tooth loss

Assoc w/ vitamin and mineral deficiencies = Angular stomatitis, Cheilosis, & Glossitis

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What are the diff indications of health problem in the extremties of px with wt abn?

Arthralgia = vitamin C
Calf pain = Thiamine

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What are the diff indications of health problem in the mental status/NSE of px with wt abn?

Thiamine = Ophthalmoplegia & Foot drop Thiamine, Vit B12, Biotin = Paresthesia Vitamin B12 = Depressed vibratory & position sense, memory disturbance Thiamine & Vit B12 = Hyporeflexia, loss of lower extremity deep tendon reflexes

What are the diff body composition studies? Are these commonly done?

NO Anthropometrics Bioelectrical impedanec Water displacement Whole body counting & Isotope dilution technique Air plethysmography Dual energy x-ray absorptiometry Imaging with CT or MRI

What are laboratory tests done for px with wt abn?

Albumin Prealbumin Transferrin CRP Retinol-binding protein Cholesterol Carotene Cytokines Electrolytes, BUN, Creatinine & Glucose CBC w/ diff count Total lymphocyte count helper/suppressor T cell ratio Nitrogen balance - 24 hr urine (urine urea N) Urine 3-methylhistidine - muscle catabolism & protein sufficiency Creatinine height index - muscle depletion PTT/INR Specific micronutrients: Vit A, C, D, E, B12, zinc, folate, pyridixone Skin testing ECG Video fluoroscopy Endocopy and X-ray studies of GI Fat absorption Schilling test --> vit B12 absorption Indirect calorimetry --> resting energy expenditure Chest x-ray

what are the dietary assessment?

24 hr recall and modified det hx

what are the functional assessment?

hand grip strength - grip dynamometer TImed gait chair stands stair steps Advanced malnutrition => decline in overall functional status

What weight is termed as a clinically important weigth loss?

loss of 4.5kg or >5% of ne' body weight over 1 yr >65 yo

what are the likely cause of weight loss in older px?

falls & fractures pressure ulcers impaired immune function decreased functional status

what happens to weight regulation at age 20-80?

mean energy intake is reduced to 1,200kcal.d (men), 800kcal/d (women)

what happens to weight regulation at age 20-80?

mean energy intake is reduced to 1,200kcal.d (men), 800kcal/d (women)

What are the diff causes of unintentional weight loss?

malignant neoplasms chronic inflammatory/infectious diseaes metabolic disorders psychiatric disorders INC inflammation Chronic inflammation DEC inflammation

How do you assess measure px with unintentional weight loss?

- measure weight directly - change in clothing size - corroboration of weight loss by friend or relative - numeric estimate of weight loss provided by the px - comprehensive hx and PE - lab tests

What are the 4 major manifestations of unintentional weight loss?

- anorexia - sarcopenia - excess adipose tissue - Cachexia - weight loss; loss of muscle & adipose tissue; anorexia & weakness - dehydration

what is the 1st priority in managing weight loss?

identify and treat the underlying cause

what do you do for those px with unintentional weight loss?

- oral nutrition supplements (high-energy drink) - advise px to take supplements betw meals

what are the 4 pivotal points when evaluating a px with unintentional weight loss?

1. weight loss should be documented if possible to elicit specific amt of weight loss that can be compared to prev weight 2. identify px with nmalabsorption: changes in bowel movement, difficulty in defacation 3. Identify the "company it keeps" - comprehensive hx, detailed PE, lab evaluations, preventive health exams (MRI, etc.) 4. Differentiate weight loss: most common is DEC calirc intake

What are the steps in approaching UWL?

1. document weight loss 2. assesss for malabsorption 3. asses energy intake 4. take initial evluation hx and PE 5. test for lab evulation 6. if still no clues from above, consider upper endoscopy & abdominal ultrasound

How do you discern that a px's UWL is caused by cancer?

- CBC, HIV test, ESR, TSH, Biochem survey (Glu, Ca, BUn, Crea, Liver function tests), CROP, Urinalysis, Chest x-ray, abdominal ultrasound - Further testing: Upper & lower GI endoscopy, Hepatobiliary & Panceratic imaging

Where do you find clues to the px's condition if you think their UWL is caused by a malignancy?

history, PE, lab tests

What are the common metabolic disesaes causing UWL?

DM Hyperthyroidism

What are he clinical signs of hyperthyroidism?

Sinus tachycardia, systolic hypertension Frightened stare Enlarged goiter Fine, resting tremor Exophthalmos Others: hyperpigmentation, irregular menses, pruritus, thinning of hair

What are the specific findings that can help rule-in the dx of hyperthyroidism in px w/ UWL?

Lid lag Lid retraction both have high specificity

In what condition can TSH cause hyperthyroidism BUT with INC TSH, & Free T4?

Pituitary adenoma

In what condition can TSH cause hypothyroidism with decreased TSH & free T4?

Pituitary dysfunction/destruction

What is the most accurate test used to reflect thryoid activity

Free T4 (active)

In the absence of pituitary disease, what is the test of choice in detecting hyperthyroidism?

TSH

What metabolic cart can be used to determine resting energy expenditure (REE) for accurate estimation of energy needs? a. Bioimpedance Analysis b. Weighing Scale c. Air plethysmography d. Indirect calorimetry

A 45/F who is severely malnourished can have which 12 lead ECG finding that is not specific for malnutrition? a. ST elevation b. Prolonged QT interval c. Peak T waves d. Wide QRS complex

What laboratory test has a half-life of 2-3 days and is sensitive to short-term changes in inflammation and protein nutrition? a. Albumin b. Transferrin c. Retinol-binding protein d. Prealbumin

Unintentional weight loss is the earliest manifestation of which neurologic disease in the elderly? a. Multiple Sclerosis b. Alzheimer’s disease c. Parkinson’s disease d. Amyotrophic Lateral Sclerosis

Which of the following is the mechanism for weight loss in a patient with cardiopulmonary disease? a. Reduced caloric intake b. Presence of chronic inflammation c. Disruption of nutritional balance d. Increased inflammatory response

60/M diagnosed case of Colon Cancer being assessed for loss of force. What is the most practical routine clinical assessment of function? a. Skin-fold thickness b. Indirect calorimetry c. Muscle ultrasound d. Hand-grip strength

A 66/F brought for consult due to noted anxiety, depression and hallucinations. What is the vitamin deficiency? A. Riboflavin B. Folate C. Niacin D. Thiamine

C Niacin deficiency results in anxiety, depression, and hallucinations (also pigmentation, crusting, cracking skin; glossitis)

19/M, severely malnourished was noted to have white foamy areas in the conjunctiva. The doctor is suspecting a vitamin deficiency. What is this ocular finding? A. Pterygium B. Keratomalacia C. Xerosis D. Bitot's spot

D Bitot’s spots are white, foamy area of keratinizing squamous metaplasia of bulbar conjunctiva, seen in vitamin A deficiency

A 54/F recently diagnosed with Breast Cancer Stage IV consulted due to poor appetite. Current weight is 45 kgs. Last month the patient weight was 50 kgs. What is the percentage (%) weight loss? A. 20 B. 15 C. 5 D. 10

D To get the % loss 10% of 50kg is 5kg 50kg - 5kg = 45kg Soooo 10% weight loss

A 40/F vegetarian presented with loss of lower extremity deep tendon reflexes. What is the vitamin deficiency? A. Pyridoxine B. Thiamine C. Niacin D. Biotin

B Thiamine deficiency is associated with ophthalmoplegia and foot drop, paresthesia, hyporeflexia, loss of lower extremity DTR, and severe Wernicke-Korsakoff syndrome.

How can height be estimated in an 89/M who cannot safely stand? A. Doubling the arm span measurement B. Waist to hip ratio C. Height cannot be estimated D. Mid upper arm circumference

A Doubling the arm span measurement is the accurate way for bedridden patients.

75/M, hypertensive, with poor oral intake for 3 months, sought consult due to gingivitis, bleeding gums and tooth loss. What is the vitamin deficient? A. A B. C C. B12 D. D

B Vitamin C deficiency results in bleeding gums, gingivitis, and tooth loss (also, perifollicular hemorrhage, scurvy, impaired wound healing, thrombocytopenia)