Nutritional Assessment - 1 Flashcards
What is included in anthro?
- weight
- height
- BMI and interpretation
When use adj. weight?
If >125% IBW or >27 kg/m2
What 3 weight changes should be reported?
- % IBW and %UBW
- % Weight change and direction
- Significance of weight loss
What should anthro be interpreted alongside?
-Diet, disease state/management, biochemistry, clinical signs and symptoms
1-2% weight loss in 1 week =
Significant
> 2% weight loss in 1 week =
Severe
5% weight loss in one month =
Significant
> 5% weight loss in one month =
Severe
7.5% weight loss in three month =
Significant
> 7.5% weight loss in three months =
Severe
10% weight-loss in 6 months
Significant
> 10% weight-loss in 6 months
Severe
For adults with >65 years old ____ are critical in assessing the BMI
clinical
BMI<18.5
underweight
BMI 18.4-24.9 =
normal
BMI 25-29.9 =
Overweight
BMI 30-34.9 =
Obese Grade I
BMI 35-39.9 =
Obese Grade II
BMI >40 =
Extremely obese - Grade II
How can we calculate and ideal body weight range ?
-Use upper and lower end of health BMI (18.5 and 24.9
How can we calculated IBW?
- Use ideal body weight range
- Use BMI midpoint of 21.7
When is adjusted body weight used?
When >125% of IBW
How do we incorporate amputations into our weight assessment?
- Establish amount of amputations
- Subtract the proportion from IBW
- Continue with assessment
Amputation,hand?
0.7% of BW
Amputation, Lower arm and hand?
2.3% of BW
Amputation, entire arm?
5.0% of BW
Amputation, foot?
1.5% of BW
Amputation, lower leg and foot?
5.9% of BW
Amputation, entire leg?
16% of BW
A male weighs 72 kg, 180 cm tall and has a left leg amputation at the knee, what is his % IBW?
1) lower leg and foot = 5.9% of BW and use midpoint BMI
2) 100-5.9= 94.1%
3) 21.7 x 1.82 x 0.941 = IBW
Particularity about standing knee height?
Must be taken at 90 degree angle
Alternatives to standing height, adults?
Arm span, where measuring from tip of middle finger to middle finger OR measure from centre of sternum to tip of middle finger on RH x 2
Alternative to standing height, children?
- Arm span
- Sitting height, at crown length
What is the gold standard of estimating energy needs?
- Indirect calorimetry
- Measures O2 consumptions and C02 production to calculate energy expenditure over 24h
Harris-Benedict and MFSJ will measure weight in ___ and height in ____
kg
cm
HB, men?
13.75(w) + 5(ht) - 6.75 (age) + 66
HB, women?
9.56(w)+ 1.84 (ht) - 4.67 (age) + 655
MFSJ, men?
10(w) + 6.25 (ht) - 5 (age) + 5
MFSJ, women?
10 (wt) + 6.25 (ht) - 5(age) - 161
AF, confined to bed ?
1.0-1.2
AF, ambulatory with low activoty?
1.3
Average activity
1.5-1.75
Intense activity?
2.0
Which predictive equations are not recommended by AND for critically ill patient?
- Swinamer
- Ireton-Jones
Which predictive equations are recommended by AND?
-Penn state
What does the Penn state equation include?
- Mifflin SJ
- Temperature
- Ventilation support
- Constant from regression equation
What’s important to consider about AF?
MUST rationalize use of one over another
What do sedatives cause in the ICU?
Sometimes will decrease their REE
What’s important to consider about weight loss?
- Is it intentional?
- When was the period of the most rapid weight-loss?
- Interpret this
What may we do if we don’t know height?
May do volume feeds only, or use metabolic cart in ICU to assess peoples needs
Underweight rule of thumb?
35 kcal/kg of ABW
Normal weight rule of thumb?
30 kcal/kg of ABW
Overweight rule of thumb?
25 kcal/kg of ABW
Obese rule of thumb?
11-14 kcal/kg of ABW
22-25 kcal/kgof IBW
If the IBW is close to ABW, which weight do we use?
ABW
If underweight (<90% of IBW), what weight to we use?
1) Use ABW and add energy when ready to gain weight (ABW + 500 kcal/day)
2) Use IBW in equation to accommodate recovery
if overweight and >125% of IBW, what weight to use?
Adj. weight
Adj. weight =
[(ABW-IBW) x 0.25] + IBW
When is Adj. weight important for?
Proper fluid requirements, where LBM demands fluids
If overweight, and BMI <27-30, which weight to use?
ABW
If overweight, and BMI >30, which weight to use?
- IBW
- Adjusted
Which E equations should ABW be used?
-MFSJ and Ireton Jones
Which E equations should HB be used?
-Adjusted
Protein, basic?
0.8-1.0
Protein, Elderly, no stress
1..0-1.5
Protein, Metabolic stress, mild
1.2-1.5
Protein, metabolic stress, moderate
1.5-1.8
Protein, metabolic stress, severe
1.7-2.0
Protein, stroke
1.0-1.25
Protein, burns
1.7-2.5
Protein, abnormal protein losses (wounds, fistulas)
2.0-2.5
Weight <125% IBW, fluid. req for 18-55 y/o?
35 ml/kg
Weight <125% IBW, fluid re. for 56-75 y/o?
30 ml/kg
Weight <125% IBW, fluid req. for >75 y/o?
25 ml/kg
Weight <125% IBW, fluid req. for those with fluid restriction?
<25 ml/kg
Fluid requirements when weight is >125% IBW AND in people with obesity?
- Use Adj. body weight
- Avoid fluid overload, as fat is 25% metabolically demanding, and LBM demands water
ECF consists of what?
- Intravascular (plasma, serum)
- Lymph
- Interstitial
ECF consists of ___ of TBW
1/3
ICF consists of ___ of TBW
23
What is normal within the context of biochemistry?
Obtained from 95% of health population sample
4 example of what may impact labs
- Age, sex, ethnicity, genetics
- Adherence to diet
- Fasted/fed
- Exercise
What is prolonged fasting?
fasting >24 hours
Which lab values do exercise increase? (LAC)
- Lactate dehydrogenase
- AST/SGOT
- Creatine kinase
When someone is in shock, there is often an ____ of proteins
exacerbation
What is mean by “normal is not always good” within the context of lab values?
- Depends on the patient and diease context
- Diabetes, hypercholesterolemia
What is the concept of critical differences?
Each lab value has a certain % (the critical difference). When this certain % is reached, whether through increase/decrease signals an abnormality. For example, CRP has to double for it to be considered abnormal, whereas an increase of 8% in albumin is considered abnormal
Albumin is low at admission, and decreases after surgery in an elderly person, What is your impression?
- Lower albumin may be OK in the elderly, lower threshold for normal
- After sx, indicative of inflammation ad not nutritional status
What are other factors to consider when interpreting lab values?
- Med interaction
- Caffeine, alcohol and nicotine
- IV
Explain how IV could influence lab values
1) Contamination, or dilution of collection
2) Dextrose may inflate glucose levels
When someone is critically-ill, what is one of the first interventions?
Make hemodynamically stable by pushing IV fluids (isotonic), which will stabilize BP
In emergency medicine, there is often different ____
lab reference ranges
What is different about the lab reference range in critical medicine?
- Critical low and critical high
- More generous that the reference range
Sodium reference range
137-145
Sodium critical low
<125
Sodium critical high
> 155
Potassium reference
3.8-4.8
Potassium critical low
<2.5
Potassium critical high
> 6.0
Bicarbonate reference
22-32
Bicarbonate, critical low
<10.0
Bicarbonate, critical high
> 45
Glucose reference
3.8-5.5
Glucose, critical low
<2.0
Glucose, critical high
> 30
Calcium, reference
2.10-2.55
Calcium, critical low
<1.5
Calcium, critical high
2.55
Magnesium, reference
0.70-0.90
Magnesium, critical low
<0.3
Magnesium, critical high
> 2.5
In a health state, which electrolytes are not tightly regulated by hormones? Does nutritional intake have an impact on these paramenters?
- Na, glucose
- NO
What are important contributors to abnormal lab results? Does dietary intake have an effect?
- Medications and disease state
- Yes, but less effect
When should a dietitian intervene to assess lab value?
When the patient is hemodynamically stable
In emergency medicine, lab values are often inflated by pushing fluids, creating ___ which will in turn ___ lab value
- hypovolemia
- dilute
Stress and lab results within the context of hormones?
Stress will cause an increase in neurotransmitters, such as serotonin and cathecholamine which will elicit and increase in pulse BP, and blood glucose.
-Cortisol causes hyperglycaemic effect, and insulin resistance
Stress and lab results in the context of plasma volume increase?
Will dilute plasma proteins, causing them to appear lower than they actually are
Stress and lab results in the context of inflammation?
- Increase in cytokines and decrease in interleukins, albumin and transferring will cause the production of platelets and uptake of cholesterol
- Cholesterol is likely to decrease
- IL-6 increase thanks to cortisol, which will elicit an immune response
Discuss plasma cholesterol during a severe infection, surgery or after an MI
Can DECREASE up to 40%
recall the inflammation process, where cholesterol uptake increases
Mental stress an cholesterol?
Can cause HDL cholesterol to decrease by 15%
What does a CBC include?
- Number of RBC and WBC
- HMG
- Hematocrit
- MCV
- Platelet count
What is the fraction fo blood composed of RBCs?
Hematocrit
What is the size of red blood cells?
MCV
What does the platelet count usually indicate?
Stress, response to medical therapies
-often interpreted if a patient is on glucocorticoids
When is CBC calculations useful?
Sometimes in LTC
What can we derive from CBC calculations?
- Mean corpuscular hemoglobin (MCH)
- Mean corpuscular hemoglobin concentration (MCHC)
- Differential on WBC
How do we obtain our differential on WBC ?
Lymphocytes x 10^9 /L = (#WBC x % lymphocytes) / 100
What does differential mean?
Will allow us to calculate our % of each type of WBC in our blood
What does TLC allow us to interpret?
Malnutrition and weight loss
What is an issue with TLC?
Is non-specific and has low-sensitivity in early malnutrition
How can we calculate TLC?
TLC x 10^9/L
TLC, mild malnutrition?
1.200-1.800
TLC, moderate depletion?
0.800 - 1.199
TLC, Severe malnutrition?
<0.800
When are TLC values reduced?
- Viral infection
- Chemotherapy
- Radiation
- Steroids
- Penicillin
- Sulfonamides
- Some diuretics
When are TLC values elevated?
- Tissue necrosis
- Infections
What lab value is used to interpret aids?
CD4 cell count
> 800 CD4?
Normal (goal)
<500 CD4?
Initiate antiretroviral drug therapy
<200 CD4?
Prophylaxis for opportunistic pathogens
Basic mechnaism of HIB?
The HIV virus will use CD4 cells to propagate, thus as CD4 cells decline, the management of opportunistic infections and HIV-related malignancies will begin
What is particular about liver enzymes ?
Are also found in other organs, thus patterns of elevation may help us diagnose disease and injury processes
SGOT =
AST
SGPT =
ALT
Which liver enzymes will elevate in acute liver injury (1-2 days), but will not stay elevated if extensive liver damage?
ASt and ALT
What is the issue with interpreting liver enzymes?
- General enzymes which are impacted by so many things
- They change quick, hard to evaluate over long-term
In viral hepatitis, liver enzymes often ____ and don’t ____
go up
come down
Within the context of liver enzymes, what should be considered in nutritional management?
The stage of the liver disease
All types of ____ rise as liver function declines
-Bilirubin
What is bilirubin?
Bilirubin is part of the normal breakdown of the heme within the RBC, where is bound to albumin, then conjugated in the liver for excretion.
When albumin is low, why may it lead to jaundice?
Hard to get bilirubin out of tissues, cannot be transported with albumin to liver for conjugation, thus will cause build-up
What is unconjugated/indirect bilirubin more likely to be associated with
Liver dsyfunction, cannot conjugate glucuronic acid
- Albumin normal, but liver cannot conjugate
- Hemolysis
When is jaundice common?
In newborn iwth immature livers
What is conjugated/direct bilirubin more likely to be associated with?
- Hypoalbuminemia
- Excretion issue owing to disease
- Stress of injury/ state
Which meds may increase levels of unconjugated/indirect bilirubin?
Novobiocin or gentamicin
_____ bilirubin is more toxic
unconjugated
As the liver heals, what trends in bilirubin can we expect?
-Total bilirubin will fall very slowly
What sensitive marker of liver function will decrease with recover of function?
Conjugated/Direct Bilirubin
When will total/direct bilirubin rise?
-Prolonged TPN
-Biliary atresia
Both due to imapred excretion
Key concept with liver and visceral proteins?
The liver manufactures proteins, thus liver insufficiency will reduce levels
