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Clinical Nutrition > Nutrition Assessment > Flashcards

Nutrition Assessment Flashcards

0
Q

Nutrition Screening

A
  • comes before nutrition assessment
  • quickly IDs clients for risk for malnutrition, or who may require intervention
  • compare specific client characteristics to cut-off points or factors associated with nutritional risk
  • what is the reason for admission
  • involves interdisciplinary collaboration: ask
    1. what is the condition now
    2. is the condition stable
    3. will the condition get worse
    4. will the disease accelerate nutritional deterioration
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1
Q

Steps in Nutrition Care Process

A

Nutrition screening or referral –> nutrition assessment –> nutrition diagnosis –> nutrition intervention –> nutrition monitoring and evaluation

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2
Q

Subjective Global Assessment

A
  • detects established malnutrition rather than acute nutrition changes
  • efficient, cost-effective, well-validated
  • history (have a sense of what is important to ask)
    • weight change, diet, Gi symptoms, functional capacity, metabolic demands of underlying disease
  • physical exam
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3
Q

SGA Rating

A 
A = well nourished 
- recent dry weight gain
- mild fat and muscle loss
- improved historical 
B = moderately malnourished/at risk
- >5% dry weight loss without recent gain 
-decreased dietary intake
- mild fat and muscle loss
C = severly malnourished
- >10% dry weight loss
- severe fat and muscle wasting
- some edema
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4
Q

Malnutrition in Hospitalized Patients

- 3 kinds

A
  • starvation - related
  • chronic disease related
  • acute disease or injury related
  • can be with or without inflammation but leads to a change in body composition and diminished function
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5
Q

malnutrition in hospitalized patients leads too…

A
  • increased complications
  • increased nosocomial infections
  • increased hospital costs
  • increased mortality rates
  • increased LOS in hospital
  • effects surgery/ recovery success rate
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6
Q

Iatrogenic Malnutrition

A
  • physician induced malnutrition
  • treatment can have more of an effect of nutritional status than the disease condition itself
  • be aware of what we are doing that may compromise nutritional status
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7
Q

How does disease or condition affect nutrition requirements

A
  • metabolic rate
  • food intake (don’t feed hungry, eversions, nausea, physically cannot feed self, dysphagia)
  • losses - fluids, nutrients, electrolytes
  • malabsorption
  • fever
  • catabolism
  • food/nutrient intolerances
  • medication effects
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8
Q

Purpose of Nutrition Assessment

A
  • ID individuals at risk
  • provides justification for the nutrition care plan
  • forms the basis for evaluating the nutrition care plan
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9
Q

Nutrition Assessment

A

a) medical and social history
b) dietary history
c) physical examination
d) anthropometry and body composition
e) biochemical data
f) estimation of energy, protein and fluid requirements

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10
Q

Medical History

A
  • diagnosis if known
  • all diseases and conditions the pt has had over their lifetime (most recent)
  • all surgical procedures the pt has undergone over lifetime
  • all symptoms pt is experiencing related to diagnosis or not
  • should cover all systems in the body
  • thorough medical history obtained upon admission in hospital
  • verify info in chart with pt and family
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11
Q

Social History

A
  • all symptoms
  • living arrangements
  • cooking and shopping abilities
  • religion food restrictions
  • socioeconomic status and food security
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12
Q

Diet History

A
  • several methods can be used depending on capabilities of pt, time constraints, info from secondary source
    24 hour recall - quick, inexpensive, low client burden, likely not usual intake, memory dependent
    food records - considered actual intake, increased accuracy with increased time period, higher client burden, eating behavior may change
    food frequency questionnaire - retrospective better for research,can examine specific nutrients, better for groups
    direct observation - prospective, controlled setting, used in hospital setting, not usual intake, low client burden
  • diet history needs to include changes to diet; omitting foods, decreased intake, changes in pattern
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13
Q

Dietary Assessment Evaluation

- diet history

A
  • comparing intake to Canada’s Food Guide servings

- gives an approximation of quality of intake

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14
Q

Nutrient Analysis

- diet history

A
  • food composition tables
  • nutrient analysis software
  • compare to DRI values
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15
Q

RDIs

A

RDA - amount that is adequate for 97-98% of healthy population
Estimated Average Requirements (EAR) - estimated req. adequate in 50% of population
Adequate intake (AI) - used when no RDA or EAR exists due to lack of evidence
Tolerable Upper intake level - max nutrient intake NOT associated with adverse side effects

all are for healthy populations and are specific for age and gender

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16
Q

Physical Examination

A
  • examine for clinical signs and symptoms reflecting malnutrition
  • physical signs do not usually appear until deficiency level is severe (dark circles around eyes/sunken eyes mean dehydration, dry mucus membranes, dry lips, urine output and colour)
  • physical signs are often non specific
  • examine for protein deficiency; if of concern, patients may have a disease from alcoholism, liver failure, renal failure, high GI losses
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17
Q

Physical Assessment

- protein energy deficiency

A
  • dry dull hair, alopecia (hair loss)
  • drawn in face
  • delayed wound healing in skin, skin breakdown or ulcers
  • musculoskeletal wasting or decreased strength (hand grip test)
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18
Q

Physical assessment

- hand muscle wasting

A
  • as a result of protein deficiency

- sunken in muscle appearance (hands)

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19
Q

Physical assessment

- edema

A
  • as a result of protein deficiency
  • may also be a sign of very low activity level
  • may indicate poor renal function chronic or acute
  • can contribute to skin breakdown
  • liver will synthesis less proteins and albumin with less protein in diet
  • if albumin is not in the blood, fluid from the blood seeps out into tissue
  • kidneys may leak albumin from the blood to urine (not a sign of protein synth)
  • skin expands and becomes thin; healing is impaired and high breakdown
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20
Q

Physical Assessment

- ascites

A
  • fluid overload due to liver disease
  • decreased synthesis of albumin, fluid from blood seeps into peritoneal space *
  • BMI might appear normal however weight may be due to fluid * dry weight
  • drug doses need to be determined through dry weight
  • rapid increase in weight gain probably due to fluid
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21
Q

Anthropometry and body composition

A
  • used to determine body size and proportions
  • height
  • weight
  • circumference
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22
Q

Anthropometry

- height

A
  • used for energy requirement calculations
  • used in BMI
  • used for height/weight tables
  • measure if possible
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23
Q

Anthropometry

- body weight

A
  • the most important measurement
  • standing, chair, bed scales
  • take amputations into account
  • fluid status ~ edema can effect weight, get dry weight
  • measure ongoing
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24
Q

Body weight

- evaluatons

A
  • BMI
  • IBW
  • % of IBW
  • UBW
  • % UBW
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25
Q

BMI

A
  • weight kg / height m squared
  • evaluation of obesity, associated health risks, high blood pressure, CVD and T2D
    Pros: easy, not influenced by height, correlates with body fat measures, high correlation with specific diseases, permits comparisons
    Cons: not as useful for children, elderly, athletes, pregnancy and lactation, doesn’t take body comp into consideration, fat distribution or hydration status
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26
Q

Ideal Body Weight (IBW)

A

age 19-65: 20 - 25
age > 65: 22 - 27

20 x height squared = ideal body weight bottom end
25 x height squared = ideal body weight top end

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27
Q

% IBW

A

= current wt / IBW x 100

>200 = morbid obesity
130-199 = obese
121 - 129 = overweight
90 - 120 = healthy
80 - 89 = mild malnutrition
70 - 79 = moderate malnutrition
<69 = severe malnutrition
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28
Q

UBW

A
  • used to determine weight changes
  • rapid change may indicate nutritional risk, used for diff diagnosis, can indicate and increased requirement or decreased intake
  • does not necessarily indicate a healthy body weight
  • is loss or gain intentional, and is it too rapid?
  • rapid loss in children can be a sign of disease
29
Q

% UBW formula

A

= current wt / UBW x 100

% weight change = UBW - current weight / UBW x 100%

  • most important weight assessment
30
Q

%UBW interpretations

A

85-95% = may indicated mild malnutrition
75 - 85 = may indicate moderate malnutrition
< 74 = may indicate severe malnutrition

31
Q

Interpretations of weight change

A

1 week = 1-2% loss significant, >2% severe loss
1 month = 5% loss significant, >5% severe loss
3 months = 7.5% loss significant, >7.5 severe loss
6 month = 10 % loss significant, >10 severe loss
unlimited time = 10-20% loss significant, >20% severe loss

32
Q

Unplanned weight loss

A

> 5% UBW over one month
10% of UBW over 6 months

  • weight gain of more than 1 kg/week likely indicates change in fluid status
  • safe to lose about 1 kg/week
33
Q

Body Composition

A
  • body circumference and areas
  • skinfold measurements
  • bio-electrical impedance analysis
  • dual energy x-ray absorptiometry
  • hydrodensitometry
  • air displacement plethysmography
34
Q

Circumference

A
  • used to estimate skeletal muscle mass and body fat stores
35
Q

waist circumference

A
  • correlates with visceral fat stores
  • abdominal obesity and metabolic syndrome
  • increase risk of CVD and type2D
  • males >40” or 102 cm
  • females > 35” or 88 cm
  • measure from bottom of lower rib cage and the top of the pelvic bone with feet about 25-30 cm or 10-12 inches apart
36
Q

waist to hip ratio

A
  • estimates distribution of subcutaneous and intra-abdominal adipose and muscle tissue
  • possible increase risk for morbidity and mortality with ratios:
    > 1.00 in men
    > 0.8 in women
  • pear shaped body types has fat distributed away from the body
37
Q

Mid-upper arm circumferences

A
  • measures skeletal muscle within the arm
  • additional measure can monitor nutrition intervention
  • prevention of loss of lean tissue
  • gain in muscle mass
  • measure length from indent at top of shoulder to the elbow and take halfway length
  • both lean and fat compartments measured
  • NHANES I and II and Nutrition Canada reference tables
  • risk for altered nutrition status >95 percentile or <5
  • risk for depleted nutrition status 5-15th percentile
38
Q

skinfold thickness

A
  • measures subcutanous adipose tissue stores
  • calipers are used
  • adipose stores vary with age, race, and gender
  • tricepts skinfold TSF, subscapular, biceps, suprailiac skin folds
39
Q

BIA

A
  • estimates body comp; total body water, fat free mass and fat mass, body cell mass
  • low level electrical current passes through the body
  • fat free mass = electrical conductor
  • fat mass = insulator
  • not safe for pacemakers, or with fluid overload
40
Q

DEXA

A
  • gold standard
  • precise measurements of bone mineral density, lean tissue mass, total and regional body fat
  • low dose radiation
  • not for pregnant women
41
Q

Hydrodensitometry

A
  • underwater weighing ~ subject exhales upon submersion in tank
  • estimates % body fat from measured body volume
  • affected by recent food consumption, hyperhydration, dehydration, variability in residual lung volume
42
Q

Bod Pod

A
  • estimates % body fat from measured body volume
  • appropriate for infants, adults, elderly, obese and disabled
  • affected by body heat and moisture
43
Q

Biochemical Analysis

A
  • can detect before signs and symptoms appear
  • blood and urine samples
  • easily affected by acute changes
  • pt result compared to reference values
44
Q

Blood analysis

- serum proteins

A
  • affected by factors like protein intake, protein metabolism/synthesis, hydration, medications, medical condition, activity level, pregnancy
  • not always representative of protein status
  • low sensitivity and low specificity
45
Q

Serum Albumin

A
  • half life 20 days; shows longer term status, insensitive to acute nutritional status, better marker of chronic malnutrition
  • decreases significantly from overhydration, retaining fluid, or acute illness
  • most useful for pts being followed long term and pts with no acute illness
46
Q

Serum Albumin Levels

- without confounding factors

A

> 35 g/L - no visceral protein depletion
30-35 - mild
24-29.9 - moderate
<24 - severe

  • wrong conclusions if pt has liver or renal disease
47
Q

Thyroxin Binding Protein (Prealbumin)

A
  • half life 3-7 days
  • may show short term changes in protein status
  • gold standard - sensitive to acute nutritional changes
  • decreases significantly by acute illness (<0.5 g/L)
  • most useful when pts are being followed in the hospital or recovering
  • a drop within 24 hours of a trauma pt will indicate acute illness not protein status
48
Q

Nitrogen Balance

A
  • reflects total protein mass
  • requires 24 hour urine collection
  • urea excreted = measure of protein breakdown
  • comapre against intake
  • negative balance will result in delayed wound healing and infection
49
Q

Creatinine Excretion

A
  • reflects muscle mass
  • increases with muscle wasting
  • high levels can give info about recent protein breakdown from the muscle or poor kidney function
50
Q

Iron

- 3 types

A
  • Essential (Hgb) = RBC, myoglobin, enzymes
  • transport (transferrin)
  • Storage (ferritin) = liver, bone marrow, spleen
  • iron deficiency anemia = once all storage and transport iron is used up
  • low Bh levels does not necc mean protein deficiency (menstrual losses)
51
Q

Stages of iron status

A

with depleted stores - normal Hb and transferrin, low ferritin
with iron deficiency - normal Hb and low transferrin and ferritin
with iron deficiency anemia - low Hb, transferrin and very low ferritin
- with iron deficiency, TIBC increases *
- 60% saturation is okay, 10 or 20% is not

52
Q

Anemia

A
  • RBC synthesis requires B12, folate and iron
  • decrease in B12 and folate: chronic disorders (liver, kidney disease, alcoholism), malabsorption disease (celiac)
  • shrunken RBCs are evidence of iron deficiency
53
Q

C-Reactive Protein

A
  • marker of acute inflammation and infection
  • highly sensitive, non specific
  • cancer, CVD, TB, pneumonia
  • ICU patients
  • more useful in determining disease progress and effectiveness of treatments
  • indicates when it might be okay to increase feeding to normal
54
Q

BUN

A
  • concentration of N in the serum
  • high BUN may be related to acute chronic kidney disease, dehydration, excessive protein intake, meds, obstruction of bladder
  • low BUN may be related to malnutrition or profound liver disease
  • BUN may be indicative of high protein intake
55
Q

Creatinine

A
  • produced in muscle, creatinine is spontaneous decomp of creatine and creatine phosphate for ATP
  • high creatinine may be related to impaired renal function, rhabdomyolysis (the destruction or degeneration of skeletal muscle tissue) and meds
  • low levels may be due to decreased hepatic synthesis of creatine or decreased muscle mass (elderly, malnutrition, amputation, muscle wasting)
  • rapid depletion, level will be high at first and then become low
56
Q

Electrolytes

A

Na - dehydration with increased Na, fluid balance indicator, most abundant
Cl - follows Na and water
K - primary cation in extracellular space, if K goes inside cell levels will drop and this is dangerous (refeeding), also major regulatory of muscle and nerve excitability, fluid balance, protein synth, enzymatic reactions and carb metabolism
Co2 - helps to maintain a stable pH

57
Q

Lipid Panel / Lipid Profile

A
  • determines risk of coronary heart disease
  • total cholesterol
  • low density lipoprotein (LDL)
  • high density lipoprotein (HDL)
58
Q

Dyslipidemia

A
  • condition marked by abnormal concentrations of lipids or lipoproteins in the blood
59
Q

fat soluble vitamins

A
  • malabsorption seen in Crohn’s disease or cystic fibrosis

- gastric bypass surgery

60
Q

Factors to Consider about energy assessment

A
  • age, gender, height and weight, body comp, nutritional status, activity level, illness, ventilation, malabsoprtion, trauma, wounds, medications, infection and fever
61
Q

Activity Factors

A

below 0 at sleeping

  1. 0 - bed rest
  2. 2 - out of bed plus very light activity
  3. 3-1.5 - sedentary walking around
  4. 7 - normal activity speed walking (can be up to 2-2.5)
62
Q

Stress Factor

A
  • 1.0-1.2 for hospital, could be higher if infections

- 1.0 - 1.3 for cancer patients

63
Q

Ireton-Jones equation

A
  • critically ill and severe malnutrition
  • different for ventilated and spontaneously breathing pts
  • spontaneously breathing - includes increase for obesity
  • ventilated includes increase for burns and trauma
64
Q

25 - 35 kcal/kg for healthy people

21 kcal/kg for obese pts

A

.

65
Q

Indirect Calorimetry

A
  • measures O2 consumed and CO2 produced
  • assumes that 1L consumed oxygen = 3.9 kcal
    and 1L produced CO2 = 1.1 kcal
  1. BEE - awake, fasted
  2. REE - after 30 minutes, at least 4 hours after meal
    - respiratory quotient: CO2/O2
  3. 0 - carb
  4. 83 - protein
  5. 71 fat
66
Q

indirect calorimetry Pros and Cons

A

Pros

  • accurate
  • info on substrate utilization
  • can see acute changes
  • can be used in ventilated pts

Cons

  • expensive
  • trained personnel
  • precise criteria to follow
67
Q

Med Gem

A
  • handheld device that measures O2 consumption only and determines REE
    Pros
  • small, light, portable,
  • self calibrating, quick

Cons

  • cannot measure RQ
  • uncomfortable
  • assumes fasting RQ of 0.85
68
Q

protein requirements

A
  • healthy adults RDA = 0.8 g/kg
  • in hospital at least 1g/kg but could be around 1.2-1.9 for burns
  • based on ideal weight if body weight is outside the range
  • requirements may be changed with renal or liver disease
69
Q

Fluid Requirements

A
  • do not use IBW use actual body weight and best estimate of dry weight
  • 55-65% of body weight is water
  • 19-55 years - 35ml/kg
  • 55-75 years 30 ml/kg
    >75 years 25ml/kg

Clinical Nutrition (14 decks)

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