Nutritional Assessment: Adults Flashcards
Nutritional assessment definition
Systemic process of obtaining, verifying, & interpreting data to make a decision about the nature & cause of nutrition-related problems
Value of nutritional assessment
- diagnose malnutrition
- association between malnutrition & poor outcome
Why be concerned about malnutrition?
- increased complications
- increased risk of infection
- increased length of stay
- increased human suffering
- increased reimbursement with malnutrition as a comorbidity
ABCD’s of nutritional assessment (A-F)
A = anthropometrics B = biochemical data C = clinical findings D = dietary data E = edema (fluid status) F = functional status
Anthropometrics definition
- physical measurements of body size & composition (fat, muscle)
- provides information on muscle mass & fat reserves
Anthropometrics measurements
- height
- weight
- BMI
- tricep skin fold (fat mass)
- Midarm muscle circumference (muscle mass)
Height use
Body SA
BMI
How do you measure weight
- primary parameter
- standard tables (Hamwi method)
- look at trends
What is the Hamwi Method?
- ideal weight
- Male 5’ = 106lbs, 6lbs for every inch after 5’
- Female 5’ = 100lbs, 5lbs for every inch after 5’
Problems with height
- men over state
- women under state
- as you age start to lose height
Alternative methods for measuring height
- arm span
- knee height
Guidelines for weight trends
- > 10% involuntary weight loss over 6 months or ~10lbs in 6 months
- trigger for action
BMI measurement
Weight/height^2
Underweight BMI
<18.5 kg/m^2
Desirable BMI
18.5 - 24.9 kg/m^2
Overweight BMI
25 - 29.0 kg/m^2
Obesity BMI
> 30 kg/m^2
Normal albumin level
3.6-5gm/dL
Biochemical data measurements
Albumin
Prealbumin
Non-nutritional causes of hypoalbuminemia
- infection/inflammation (APR)
- post surgical state (APR)
- fluid state (dehydrated = more)
- liver or renal dysfunction
Nutritional causes of hypoalbuminemia
Inadequate protein intake
Albumin
- commonly used indicator (historically)
- misinterpreted as nutritional marker
- predictor of mortality/morbidity
- half live 2-3 days
What are you looking for in clinical findings?
Physical evidence of malnutrition
- hair, skin, nails, tongue, gums, eyes, muscle wasting
Muscle wasting
- temporal wasting
- prominent clavicle
- deltoid muscle
- thorax
- biceps
- hand-interosseous wasting
- quads
Hair in malnutrition
- dry, thin, pluckable
Skin in malnutrition
- texture, turgor, pigment
Nails in malnutrition
- brittle, spoon shaped
Tongue in malnutrition
Swollen, magenta
Gums in malnutrition
Bleeding, soft
Eyes in malnutrition
Pale conjunctiva
What do you look at for dietary data?
- appetite
- dietary intake data
- food record, calorie count (3-7 days)
- evaluation
Dietary intake data
- % meals/snacks eaten
Evaluation of dietary data
- compare intake to standard or estimated needs
- DRIs, RDAs
- food guide pyramid, My plate
What does edema tell you?
Physical evidence of generalized or localized fluid accumulation
Edema as nutritional assessment
- extremities
- vulvar/scrotal edema
- ascites
- unexplained weight gain; weight loss often masked by edema
Inpatient measures of functional status
Hand grip strength
Outpatient measures of functional status
- ADLs
- distance walked
- rising out of seated position
T/F there is a single parameter that is sufficient in all patients in nutritional assessment
FALSE
- there is no single parameter
- conclusions should be confirmed using multiple parameters
Subjective Global Assessment
SGA
- method based on a focused history & physical examination
- practical, reliable tool
SGA ratings
- well-nourished
- mildly-moderately malnourished
- severely malnourished
Components of SGA
- history of weight & dietary change
- GI symptoms
- functional impairment
- physical exam
What are you looking for in physical examination in SGA?
- loss of subcu fat
- muscle wasting
- edema
Malnutrition in adults definition
- inadequate intake of protein and/or energy (calories) over prolonged periods of time resulting in loss of fat stores and/or muscle wasting
3 types of adult malnutrition
- starvation related
- chronic disease or injury related (>3 months)
- acute disease or injury related (<3 months)
ABC’s of malnutrition (6)
A = weight loss (%/time), loss of muscle mass C = loss of subcu fat D = insufficient energy intake E = edema- fluid status F = diminished functional status (hand grip)
Starvation related malnutrition
- no inflammation present
- pure chronic starvation (anorexia)
Chronic disease related malnutrition
- mild -moderate inflammation
- organ failure, pancreatic cancer, RA)
Acute disease or injury related malnutrition
- marked inflammatory response
- major infection, burns, trauma, closed head injury
Adult diagnosis of malnurtition
- minimum of 2 characteristics
- intervene early
T/F when inflammation is present, parameters may stabilize but no significantly improve with nutrition support
TRUE!
What needs do you look at once adult diagnosed with malnutrition?
- calorie needs
- protein needs
- fluid needs
- mode of treatment
Nutritional needs rule of thumb in malnourished adults
Calories: 25 - 35 Kcal/kg
Protein: 1-2 gm/kg
Fluid: 30-40 ml/kg (1ml/Kcal)
Progression of nutrition treatment
- balance oral diet
- oral diet + oral supplements
- tube feeding
- parenteral nutrition
- combinations
Ways to measure nutrition progress
- indirect calorimetry (measure energy expenditure)
- nitrogen balance (measures protein needs)
Pharmacist role in malnutrition
- BE ALERT (be aware of hospital practices that can contribute to malnutrition
- diagnose, intervene early monitor treatment
- consult dietitian
Levels of CRP and albumin/prealbumin in inflammation
Increased CRP
Decreased prealbumin/albumin
Levels of CRP and albumin/prealbumin in malnutrition
Decreased CRP
Increased albumin/prealbumin
+ acute phase protein
CRP protein
Increase with stress
(-) acute phase protein
Albumin/prealbumin
Decrease with stress
Acute phase response
- systemic response to inflammation
- associated with infection, trauma, surgery, cancer
- releases cytokines
- liver reprioritizes protein synthesis to maximize host defense
What does acute phase response indicate?
Level of stress OR response to illness
T/F inflammation is present in starvation related malnutrition
False!
Only in chronic and acute disease related malnutrition
Importance of anthropometric measurements in adults
Provide information of patient’s muscle mass and fat reserve
What is the primary parameter for anthropometric measurements in adults?
Weight
Dysfunction of which 2 organs cause low levels of albumin & prealbumin?
Livers & kidneys
Normal CRP level
<0.7 mg/dL
Why are albumin and prealbumin unreliable indicators of malnutrition?
Both levels decrease in presence of stress due to acute illness as well as malnutrition
Must look at whole picture rather than rely on these 2 values alone
What does hand interosseous wasting look like?
Decreased padding in fat pad between thumb and pointer finger on hands
Edema is often caused by low intake of which macronutrient?
Proteins
What test is used to determine protein needs?
N balance via urine collection or equation
Do NOT confuse this method with BUN (blood urea nitrogen lab)
What are the 3 modes of nutritional treatment in adults?
Oral
Enteral
Parenteral
What is the first step in treatment of malnutrition in adults?
Diagnosis
