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
2
Q
What is the normal range for sodium?
A
135-145 mEq/L
3
Q
How is hypernatremia corrected?
A
Correct volume status by pushing fluids (IV)
-The RD will be less involved until hemodynamically stable
4
Q
What are the clinical manifestations of HyperN?
A
- Lethargy
- Weakness
- Irritability
- Edema
- Higher levels >158 can cause seizures and coma
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
6
Q
Hyponatremia with edema, nutritional intervention?
A
Fluid and sodium restriction
7
Q
Hyponatremia, with no edema, nutritional intervention?
A
Fluid restriction
8
Q
What is hyponatremia with no edema sometimes associated with?
A
SIADH
9
Q
What could high lipid levels cause?
A
- Pseudohyponatremia
- Due to mix-up with measurement tools available
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
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
12
Q
Equation to calculate fluid deficit?
A
[(0.6 x wt, kg0 x (ECF Na mEq/L - 140)] / (ECF Na mEq/L)
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
14
Q
How can we assess hydration status?
A
- Sodium levels
- Fluid deficit
- Osmolality
15
Q
How to calculate serum osmolality?
A
= ( 2 x Serum Na) + BUN/2.8 + Glucose/18
if in SI units, do not divide
16
Q
When is serum osmolality for determining hydration status contraindicated?
A
When there is renal dysfunction
17
Q
Normal osmolality in adults?
A
275-295 mOsm/kg
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
19
Q
High osmolality is likely indicative of ____ fluid status
A
Low
More solutes in blood than water, dehydration
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)
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
22
Q
Normal anion gap?
A
- ranges by instituiotn
- 8-18 mmol/L
23
Q
Anion gap calculation (mmol/L) =
A
(Na+K) - (Cl + HCO3-)
24
Q
When can the anion gap be falsely low?
A
When albumin is low
25
If there is alkalosis, how can we intervene nutritionally?
-Select Cl- solution in PN
26
If there is acidosis, how can we intervene nutritionally?
-Select acetate solutions for PN, such as potassium acetate
27
What is HEENT
Head, eyes, ears, nose and throat
| Part of physical exam which may help us interpret nutritional status
28
What should be considered in the physical examination?
- That complications may not be due to solely nutrition or metabolism
- But complication may lead to compromised nutritional status
29
What are some physical limitations which will have an impact on nutrition?
- Ora cavity lesions can liimit intakes
- Drooling and dysphagia
- Ulcers, mouth sores upon eating
- Diarrhea, dumping syndrome
- Cognition, comprehension and education
30
What may impact saliva production?
- Cancer tx
| - Esophageal and mouth cancers
31
What are limitations of the physical exam?
-Many physical signs can be non-specific, such as angular stomatitis
32
IS eczema and hyperpigmentation of the skin caused by nutritional factors?
No, often unknown causes
33
Clinical manifestations of nutritional deficiencies are common in ____ but do not necessarily appear in the hospitalized patient
chronic states
34
Pale skin?
-Iron, folate, copper, B12
35
pale tongue?
-Biotin, B12, niacin, riboflavin, rion
36
Papillar atrophy?
Folate, B12, niacin, riboflavin, iron
37
What could cause pernicious anemia?
```
-Gastric ulceration/cancers
Gastric surgery
-Malabsorption, lack of intake
-med interaction
-recall that need functional stomach wall for intrinsic factor
```
38
Clinical signs of scurvy?
-Corkscrew hars and Periungual Hemorrhage (under fingernails)
39
What is the hall mark feature of vit k deficiency? When may it be observed Why?
-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
40
Clinical sign of niacin deficiency?
-Red, brown scaly dermatitis which may manifest as pellagra
41
Potential causes of niacin deficiency?
- Alcoholism
| - PEM
42
Which tests overlap due to similar functions/ enzymes?
Niacin and B6
43
Clinical sign of zinc deficiency?
- Ski scaling, due to fat malabsorption
| - Can occur in babies and in the elderly
44
What is Xerosis (Erythema Carquele; Asteatosis) caused by?
- Deficiencies of vitamin A, EFA and zinc
| - Often due to IBD, celiac disease, pancreatic insufficiency which eleicts fat malabsorption
45
What is mild vitamin A deficiencies characterized by?
- Follicular hyperkeratosis (rough, keratinized skin resembling goosebumps, but doesn't go down), anemia
- Increased susceptibility to infection
46
Discuss the storage of vitamin A
Vitamin A is stored in the liver, thus deficiencies of this vitamin can develop only over prolonged periods of inadequate intake
47
What vitamin deficiency is a cause of concern with prolonged TPN?
Biotin, as some TPN formulas do not include it
48
What was the finding of those on prolonged TPN without biotin?
-Alopecia manifested (hair loss)
49
What can cause a biotin deficiency?
- TPN without biotin
- Hemodialysis, anticonvulsant meds
- PEM
50
Besides biotin, what else can cause alopecia?
- PEM
- Zinc deficiency
- Chemotherapy
51
When is thiamine deficiency often observed? (2)
- Alcoholics
| - Those with absorption issues
52
What is a clinical sign of thiamine deficiency?
- Opthalmoplegia (bulging of eyes)
| - Not always the most reliable indice
53
What are people with thiamine deficiency at risk of?
Re-feeding syndrome, not enough thiamine to metabolism the influx of CHO
54
Nutritional intervention in thiamine deficiency to avoid re-feeding syndrome?
- Thiamine supplement right away
| - Potentially supplement with potassium, magnesium and phosphate to pre-empt the re-feeding syndrome
55
What is a severe vitamin A deficiency characterized by?
- Keratinization of the cornea of the eye, known as:
1) Bigot's spots (mild)
2) Xerosis conjunctivae (moderate)
3) Xerophthalmia (severe)
56
What will the final stage of xerophtalmia result in?
Infection sets in, resulting in haemorrhaging of the eye and permanent loss of vision
57
What is the conjunctival of the eyes?
A thin, transparent membrane which covere the sclera (when you pull the bottom of your lashline downwards_.
58
When the conjunctival is red and inflames, what is this indicative of?
Conjunctivitis
59
When the conjunctival sis very pale, what is this indicative of?
Severe anemia
60
Where is the pancreas located?
Upper right quadrant
61
What are some suspects of pitting edema at the ankle?
- Hypoalbuminemia
- Renal disease
- Liver disease
- Hormone deficiencies
62
Grade 0+ not pitting edema =
No depression of the skin
63
Grade 1+ mild pitting edema =
2 mm depression that disappears rapidly
64
Grade 2+ moderately pitting edema =
4 mm depression that disappears in 10-15 s
65
Grade 3+ moderately severe pitting edema =
6 mm depression that may last more than one minute
66
Grade 4+ severe pitting edema =
8 mm depression that can last more than 2 mins
67
What is Icteric sclera?
The yellowing of the eyes, which often occurs within the context of unconjugated bilirubin
68
Why is there less binding of bilirubin to albumin in TPN?
- 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
What is the impact of long-term TPN on the liver?
- May cause cholestasis
| - Cannot clear bilirubin through the biliary tree, causing a build-up
70
In hypoalbuminemia there is less _____ bound
bilirubin
71
In liver diseases, there is less ____ of bilirubin
conjugation
72
In trauma, there is an increased amount of bilirubin that _____
needs to be removed
73
When may spider agioma arise? What is it indicative of?
- Liver disease
- Preganancy
- HT and aging
- Chronic, sometimes indicate of malnutrition
74
Define malnutrition/undernutrition
The inadequacy of nutrients to maintain a persons healtht hat is caues by one of 3 factors
75
What are the 3 factors which could cause malnutrition/undernutrition ?
1) Insufficient intake
2) Impaired absorption
3) Altered nutrient transport and utilization
76
What is a major cause of malnutrition?
- 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
When there is inflammation, do we ignore the lab values?
No, we must state that it is consistent with inflammation
78
Biochemical parameters consistent with inflammation?
- Low albumin
- Elevated CRP and ferritin
- Hyperglucemia
79
Clinical manifestations of inflammation?
- Fever, hypothermia, chills, night sweats
- Tachycardia, low BP
- Rashed, discharge, etc
80
____ of hospitalized patients are malnourished
30-50%
81
What are the consequences of malnutrition within the context of the hospitalized patient?
- Increased complications, delayed wound healing, longer hospital stays
- Increased mortality and morbidity
- Increased health care costs
82
What is the purpose of nutritional screening?
- 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
What is the nutrition care process?
1) Assessment and Assessment
2) Nutritional Diagnosis
3) Nutritional Intervention
4) Nutritional Monitoring and Evaluation
84
For nutrition support, which nutrition screening tools are appropriate?
- SGA and PG-SGA (but not in ICU)
- Malnutrition Screening Tool (MST)
- NRS-2002
- Nutric Tool
85
Grade A in SGA is well-nourised, what is their dietary intake, weight change?
No change
86
Grade B in SGA is mild-moderate malnourished, what is their dietary intake and weight change?
- Decreased dietary intake
| - Ongoing weight loss, with significant 5-10% weight loss in past 6 months
87
Grade C is SGA is severe malnourished, what is their dietary intake and weight change? What other factors may the possess?
- 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
What is a feature of the MST?
Patients fill it out, and weight is listed in lbs as most people know their weight in lbs
89
What is a patient us unsure of their weight while filling out an MST?
- Will still give "2" points
| - Can still screen for malnutrition if unsure of weight
90
MST = 0 r 1
Not at risk
91
MST = 2 or more
At risk
92
What is the key nutrition screening tool, and appropriate for ICU patients?
NRS-2002
| **Memorize**
93
What are the 4 key questions of part 1 of the NRS-2002?
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
What happens if the answer is "yes" to any of the first 4 key questions of the NRS-2002?
Move onto the final screening stage
95
What happens if the answer is "no" to ALL of the first 4 key questions of the NRS-2002?
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
What are the two catagories needing to be scored in the final screening of NRS-2002?
1) impaired nutritional status
| 2) Severity of disease (which will affect increase in energy req.)
97
Weight loss >5% in 3 months OR Food intake below 50-75% of normal req. in the last week?
NRS-2002 Mild Score of 1
98
-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
NRS 2002 Moderate Score of 2
99
-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
NRS 2002 Severe Score of 3
100
Normal nutritional status?
NRS-2002 Score of 0
101
Normal nutritional requirements?
NRSE-2002 score of 0
102
Hip fracture, chronic patients with acute conditions, cirrhosis, COPD, chronic hemodialysis, diabetes, oncology?
NRS-2002 Mild score of 1
103
Major abdominal surgery, stroke, severe pneumonia, hematologic malignancy ?
NRS-2002 moderate score of 2
104
Head injury, bone marrow transplant, IC patients with APACHE >10
NRS-2002 Severe score of 3
105
How is the NRS-2002 scored? In <70 years old?
- Add scores from final screeing
| - Add 1 point to total score
106
NRS-2002 score is >/= to 3?
- Patient is nutritionally at risk
| - Nutrition care plan is initiated
107
NTS-2002 score is <3?
- Weekly re-screening of patient
| - If patient is scheduled for major operation, consider a preventative nutrition care plan
108
NRS-2002 >5?
- High risk
| - Identifies patients most likely to benefit from early EN therapy, which typically starts on day one or two
109
What does the NUTRIC score consider?
- Age
- APACHE II
- SOFA
- Co-morbidities
- Days from hospital to ICU admission
- IL-6
110
NUTRIC scoring can be used with or without ___
IL-7, scoring for malnutrition will be a lower threshold
111
What is SOFA?
-Sequential Organ Failure Score
112
What is IL-6?
Inflammatory marker, which will increase within the context of infections
113
What is the APACHE II scale?
- Stands for "Acute Physiology and Chronic Health Evaluation"
- Used in ICU
- APACHE >10 is considered critical
114
What does the APACHE II scale consider?
- Age
- Rectal temp
- Mean arterial pressure
- Heart rate
- PaO2
- Arterial pH
- Serum K, Na, Cr, Hct, WBC
- Glasgow score
- Chronic health stays
115
What does rectal temperature indicate?
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
What is included in the SOFA score?
1) Mean arterial pressure
2) PaO2
3) Glasgow comma score
