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Clinical Nutrition 2 > Nutritional Assessment - 3 > Flashcards

Nutritional Assessment - 3 Flashcards

1
Q

A 73 YOM with no relevant PMH was admitted for epigastric pain and 18% weight loss over 4 mo. Gastric endoscopy showed large cancer of the body of the stomach. No extragastric neoplasias.

  • Albumin = 30 g/L
  • Hb = 90 g/L
  • BMI = 18
A
  • Low albumin and Hb secondary to blood loss by large gastric tumor
  • Low Hb can also be interpreted with the severe unintentional weight loss of 18%, which suggests PEM, and edema may evolve.
  • Pre-op nutrition support to maintain or elevate albumin and N balance. Low albumin and N balance associated with poorer post-op prognosis. Limit NA and fluids
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2
Q

What is the normal range for sodium?

A

135-145 mEq/L

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3
Q

How is hypernatremia corrected?

A

Correct volume status by pushing fluids (IV)

-The RD will be less involved until hemodynamically stable

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4
Q

What are the clinical manifestations of HyperN?

A
  • Lethargy
  • Weakness
  • Irritability
  • Edema
  • Higher levels >158 can cause seizures and coma
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5
Q

What is a sodium level above 180 mEQ/L associated with?

A

Higher mortality rate, and often these high Na level are secondary to a medical issue

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6
Q

Hyponatremia with edema, nutritional intervention?

A

Fluid and sodium restriction

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7
Q

Hyponatremia, with no edema, nutritional intervention?

A

Fluid restriction

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8
Q

What is hyponatremia with no edema sometimes associated with?

A

SIADH

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9
Q

What could high lipid levels cause?

A
  • Pseudohyponatremia

- Due to mix-up with measurement tools available

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10
Q

Hyponatremia due to outside losses (GI , renal issues, meds), nutritional intervention?

A

Replacement therapy usually corrected medically, but could be asked to supply extra sodium

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11
Q

Calculating fluid deficit requires what two variables?

A
  • Body weight
  • Sodium status
  • Will provide us with the amount of missing fluid to correct fluid status
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12
Q

Equation to calculate fluid deficit?

A

[(0.6 x wt, kg0 x (ECF Na mEq/L - 140)] / (ECF Na mEq/L)

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13
Q

What values can you check if you suspect dehydration? they are likely to be high within the context of dehydration

A
  • HCT, Hbg, Albumin

- Na, k, Cl, creat, gluc, bun

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14
Q

How can we assess hydration status?

A
  • Sodium levels
  • Fluid deficit
  • Osmolality
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15
Q

How to calculate serum osmolality?

A

= ( 2 x Serum Na) + BUN/2.8 + Glucose/18

if in SI units, do not divide

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16
Q

When is serum osmolality for determining hydration status contraindicated?

A

When there is renal dysfunction

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17
Q

Normal osmolality in adults?

A

275-295 mOsm/kg

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18
Q

Why does osmolality help us determine fluid status? What is it’s impact in nutrition?

A
  • We want to be isotonic prior to delivering nutrition
  • Osmolality can impact absorption of nutrients
  • TPN considerations
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19
Q

High osmolality is likely indicative of ____ fluid status

A

Low

More solutes in blood than water, dehydration

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20
Q

Why is osmolality important in TPN?

A

We cannot administer TPN if osmolality is not a 300, as we need to ensure the fluid status is OK to avoid tissue burns (i.e. flux of water into veins to dilute nutrients, which will have a detrimental effect on tissues)

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21
Q

What does the anion gap allow us to determine?

A
  • Whether someone has too much acid or too much base

- We can choose the form of electrolytes that we can administer to improve the acid-base balacne

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22
Q

Normal anion gap?

A
  • ranges by instituiotn

- 8-18 mmol/L

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23
Q

Anion gap calculation (mmol/L) =

A

(Na+K) - (Cl + HCO3-)

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24
Q

When can the anion gap be falsely low?

A

When albumin is low

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25
Q

If there is alkalosis, how can we intervene nutritionally?

A

-Select Cl- solution in PN

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26
Q

If there is acidosis, how can we intervene nutritionally?

A

-Select acetate solutions for PN, such as potassium acetate

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27
Q

What is HEENT

A

Head, eyes, ears, nose and throat

Part of physical exam which may help us interpret nutritional status

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28
Q

What should be considered in the physical examination?

A
  • That complications may not be due to solely nutrition or metabolism
  • But complication may lead to compromised nutritional status
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29
Q

What are some physical limitations which will have an impact on nutrition?

A
  • Ora cavity lesions can liimit intakes
  • Drooling and dysphagia
  • Ulcers, mouth sores upon eating
  • Diarrhea, dumping syndrome
  • Cognition, comprehension and education
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30
Q

What may impact saliva production?

A
  • Cancer tx

- Esophageal and mouth cancers

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31
Q

What are limitations of the physical exam?

A

-Many physical signs can be non-specific, such as angular stomatitis

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32
Q

IS eczema and hyperpigmentation of the skin caused by nutritional factors?

A

No, often unknown causes

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33
Q

Clinical manifestations of nutritional deficiencies are common in ____ but do not necessarily appear in the hospitalized patient

A

chronic states

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34
Q

Pale skin?

A

-Iron, folate, copper, B12

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35
Q

pale tongue?

A

-Biotin, B12, niacin, riboflavin, rion

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36
Q

Papillar atrophy?

A

Folate, B12, niacin, riboflavin, iron

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37
Q

What could cause pernicious anemia?

A 
-Gastric ulceration/cancers
Gastric surgery
-Malabsorption, lack of intake
-med interaction
-recall that need functional stomach wall for intrinsic factor
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38
Q

Clinical signs of scurvy?

A

-Corkscrew hars and Periungual Hemorrhage (under fingernails)

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39
Q

What is the hall mark feature of vit k deficiency? When may it be observed Why?

A

-Easy brusing
-Colectomy
(Vit k synthesis)
-Recall that vit K is involved in the clotting cascade, thus platelets will not clot properly without vitamin K

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40
Q

Clinical sign of niacin deficiency?

A

-Red, brown scaly dermatitis which may manifest as pellagra

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41
Q

Potential causes of niacin deficiency?

A
  • Alcoholism

- PEM

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42
Q

Which tests overlap due to similar functions/ enzymes?

A

Niacin and B6

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43
Q

Clinical sign of zinc deficiency?

A
  • Ski scaling, due to fat malabsorption

- Can occur in babies and in the elderly

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44
Q

What is Xerosis (Erythema Carquele; Asteatosis) caused by?

A
  • Deficiencies of vitamin A, EFA and zinc

- Often due to IBD, celiac disease, pancreatic insufficiency which eleicts fat malabsorption

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45
Q

What is mild vitamin A deficiencies characterized by?

A
  • Follicular hyperkeratosis (rough, keratinized skin resembling goosebumps, but doesn’t go down), anemia
  • Increased susceptibility to infection
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46
Q

Discuss the storage of vitamin A

A

Vitamin A is stored in the liver, thus deficiencies of this vitamin can develop only over prolonged periods of inadequate intake

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47
Q

What vitamin deficiency is a cause of concern with prolonged TPN?

A

Biotin, as some TPN formulas do not include it

48
Q

What was the finding of those on prolonged TPN without biotin?

A

-Alopecia manifested (hair loss)

49
Q

What can cause a biotin deficiency?

A
  • TPN without biotin
  • Hemodialysis, anticonvulsant meds
  • PEM
50
Q

Besides biotin, what else can cause alopecia?

A
  • PEM
  • Zinc deficiency
  • Chemotherapy
51
Q

When is thiamine deficiency often observed? (2)

A
  • Alcoholics

- Those with absorption issues

52
Q

What is a clinical sign of thiamine deficiency?

A
  • Opthalmoplegia (bulging of eyes)

- Not always the most reliable indice

53
Q

What are people with thiamine deficiency at risk of?

A

Re-feeding syndrome, not enough thiamine to metabolism the influx of CHO

54
Q

Nutritional intervention in thiamine deficiency to avoid re-feeding syndrome?

A
  • Thiamine supplement right away

- Potentially supplement with potassium, magnesium and phosphate to pre-empt the re-feeding syndrome

55
Q

What is a severe vitamin A deficiency characterized by?

A
  • Keratinization of the cornea of the eye, known as:
    1) Bigot’s spots (mild)
    2) Xerosis conjunctivae (moderate)
    3) Xerophthalmia (severe)
56
Q

What will the final stage of xerophtalmia result in?

A

Infection sets in, resulting in haemorrhaging of the eye and permanent loss of vision

57
Q

What is the conjunctival of the eyes?

A

A thin, transparent membrane which covere the sclera (when you pull the bottom of your lashline downwards_.

58
Q

When the conjunctival is red and inflames, what is this indicative of?

A

Conjunctivitis

59
Q

When the conjunctival sis very pale, what is this indicative of?

A

Severe anemia

60
Q

Where is the pancreas located?

A

Upper right quadrant

61
Q

What are some suspects of pitting edema at the ankle?

A
  • Hypoalbuminemia
  • Renal disease
  • Liver disease
  • Hormone deficiencies
62
Q

Grade 0+ not pitting edema =

A

No depression of the skin

63
Q

Grade 1+ mild pitting edema =

A

2 mm depression that disappears rapidly

64
Q

Grade 2+ moderately pitting edema =

A

4 mm depression that disappears in 10-15 s

65
Q

Grade 3+ moderately severe pitting edema =

A

6 mm depression that may last more than one minute

66
Q

Grade 4+ severe pitting edema =

A

8 mm depression that can last more than 2 mins

67
Q

What is Icteric sclera?

A

The yellowing of the eyes, which often occurs within the context of unconjugated bilirubin

68
Q

Why is there less binding of bilirubin to albumin in TPN?

A
  • TPN delivers an influx of lipids, where the binding of lipids to albumin will displace bilirubin
  • Often ill patients will already have low-albumin due to inflammation or disease state
69
Q

What is the impact of long-term TPN on the liver?

A
  • May cause cholestasis

- Cannot clear bilirubin through the biliary tree, causing a build-up

70
Q

In hypoalbuminemia there is less _____ bound

A

bilirubin

71
Q

In liver diseases, there is less ____ of bilirubin

A

conjugation

72
Q

In trauma, there is an increased amount of bilirubin that _____

A

needs to be removed

73
Q

When may spider agioma arise? What is it indicative of?

A
  • Liver disease
  • Preganancy
  • HT and aging
  • Chronic, sometimes indicate of malnutrition
74
Q

Define malnutrition/undernutrition

A

The inadequacy of nutrients to maintain a persons healtht hat is caues by one of 3 factors

75
Q

What are the 3 factors which could cause malnutrition/undernutrition ?

A

1) Insufficient intake
2) Impaired absorption
3) Altered nutrient transport and utilization

76
Q

What is a major cause of malnutrition?

A
  • Inflammation
  • Associated with loss of LBM for use in inflammatory processes
  • However, we cannot truly interpret if the inflammation has impacted visceral protein status until the inflammation goes down
77
Q

When there is inflammation, do we ignore the lab values?

A

No, we must state that it is consistent with inflammation

78
Q

Biochemical parameters consistent with inflammation?

A
  • Low albumin
  • Elevated CRP and ferritin
  • Hyperglucemia
79
Q

Clinical manifestations of inflammation?

A
  • Fever, hypothermia, chills, night sweats
  • Tachycardia, low BP
  • Rashed, discharge, etc
80
Q

____ of hospitalized patients are malnourished

A

30-50%

81
Q

What are the consequences of malnutrition within the context of the hospitalized patient?

A
  • Increased complications, delayed wound healing, longer hospital stays
  • Increased mortality and morbidity
  • Increased health care costs
82
Q

What is the purpose of nutritional screening?

A
  • To identify patients who are malnourished or at risk of developing malnutrition
  • Done within 24-48 hours of admission, and can be done by any member of the health care team
83
Q

What is the nutrition care process?

A

1) Assessment and Assessment
2) Nutritional Diagnosis
3) Nutritional Intervention
4) Nutritional Monitoring and Evaluation

84
Q

For nutrition support, which nutrition screening tools are appropriate?

A
  • SGA and PG-SGA (but not in ICU)
  • Malnutrition Screening Tool (MST)
  • NRS-2002
  • Nutric Tool
85
Q

Grade A in SGA is well-nourised, what is their dietary intake, weight change?

A

No change

86
Q

Grade B in SGA is mild-moderate malnourished, what is their dietary intake and weight change?

A
  • Decreased dietary intake

- Ongoing weight loss, with significant 5-10% weight loss in past 6 months

87
Q

Grade C is SGA is severe malnourished, what is their dietary intake and weight change? What other factors may the possess?

A
  • Severe decrease in dietary intake
  • Ongoing weight-loss of >10% within last 6 months
  • Often have GI symptoms, bedridden and high metabolic stress & severe muscle wasting, fat loss and edema
88
Q

What is a feature of the MST?

A

Patients fill it out, and weight is listed in lbs as most people know their weight in lbs

89
Q

What is a patient us unsure of their weight while filling out an MST?

A
  • Will still give “2” points

- Can still screen for malnutrition if unsure of weight

90
Q

MST = 0 r 1

A

Not at risk

91
Q

MST = 2 or more

A

At risk

92
Q

What is the key nutrition screening tool, and appropriate for ICU patients?

A

NRS-2002

Memorize

93
Q

What are the 4 key questions of part 1 of the NRS-2002?

A

1) Is BMI <20.5?
2) Has the patient lost weight within the last 3-months?
3) Has the patient had a reduced dietary intake in the last week?
4) Is the patient severely ill

94
Q

What happens if the answer is “yes” to any of the first 4 key questions of the NRS-2002?

A

Move onto the final screening stage

95
Q

What happens if the answer is “no” to ALL of the first 4 key questions of the NRS-2002?

A

Re-screen patient at weekly intervals
-However, if that patient is scheduled for a major operation which may change nutritional status, consider preventative nutrition care plan

96
Q

What are the two catagories needing to be scored in the final screening of NRS-2002?

A

1) impaired nutritional status

2) Severity of disease (which will affect increase in energy req.)

97
Q

Weight loss >5% in 3 months OR Food intake below 50-75% of normal req. in the last week?

A

NRS-2002 Mild Score of 1

98
Q

-Weight loss >5% in 2 months
OR
-BMI 18.5-20.5 with impaired general condition
OR
-Food intake 25-60% of normal requirement in the last week

A

NRS 2002 Moderate Score of 2

99
Q

-Weight loss >5% in 1 month or >15% in 2 months
OR
-BMI <18.5 with impaired general condition
OR
-Food intake 0-25% of normal req. in the last week

A

NRS 2002 Severe Score of 3

100
Q

Normal nutritional status?

A

NRS-2002 Score of 0

101
Q

Normal nutritional requirements?

A

NRSE-2002 score of 0

102
Q

Hip fracture, chronic patients with acute conditions, cirrhosis, COPD, chronic hemodialysis, diabetes, oncology?

A

NRS-2002 Mild score of 1

103
Q

Major abdominal surgery, stroke, severe pneumonia, hematologic malignancy ?

A

NRS-2002 moderate score of 2

104
Q

Head injury, bone marrow transplant, IC patients with APACHE >10

A

NRS-2002 Severe score of 3

105
Q

How is the NRS-2002 scored? In <70 years old?

A
  • Add scores from final screeing

- Add 1 point to total score

106
Q

NRS-2002 score is >/= to 3?

A
  • Patient is nutritionally at risk

- Nutrition care plan is initiated

107
Q

NTS-2002 score is <3?

A
  • Weekly re-screening of patient

- If patient is scheduled for major operation, consider a preventative nutrition care plan

108
Q

NRS-2002 >5?

A
  • High risk

- Identifies patients most likely to benefit from early EN therapy, which typically starts on day one or two

109
Q

What does the NUTRIC score consider?

A
  • Age
  • APACHE II
  • SOFA
  • Co-morbidities
  • Days from hospital to ICU admission
  • IL-6
110
Q

NUTRIC scoring can be used with or without ___

A

IL-7, scoring for malnutrition will be a lower threshold

111
Q

What is SOFA?

A

-Sequential Organ Failure Score

112
Q

What is IL-6?

A

Inflammatory marker, which will increase within the context of infections

113
Q

What is the APACHE II scale?

A
  • Stands for “Acute Physiology and Chronic Health Evaluation”
  • Used in ICU
  • APACHE >10 is considered critical
114
Q

What does the APACHE II scale consider?

A
  • Age
  • Rectal temp
  • Mean arterial pressure
  • Heart rate
  • PaO2
  • Arterial pH
  • Serum K, Na, Cr, Hct, WBC
  • Glasgow score
  • Chronic health stays
115
Q

What does rectal temperature indicate?

A

A rising temp will indicate greater energy expenditure, higher inflammation and more leaky capillaries which can cause the exacerbation of albumin- may change direction of fluids causing changes in fluid volume

116
Q

What is included in the SOFA score?

A

1) Mean arterial pressure
2) PaO2
3) Glasgow comma score

Clinical Nutrition 2 (21 decks)

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