Transcript Nutrition Screening and Assessment

Kerry Stone MS, RD,CNSC
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Identify clinical assessment measurements used to
determine nutritional status.
Identify the difference between a Nutrition Risk
Assessment and a Nutrition Assessment.
Identify how to calculate nutrition requirements.
State why nutrition assessment is important.
Malnutrition is a measurably poor nutritional
status resulting from:
 Nutrient deficiency
 Under or over nutrition
 Nutritional imbalance or altered utilization
 Impaired nutrient absorption
The reported incidence of malnutrition in the
hospital ranges from 30 to 50%.
No single measurement is of consistent value.
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Many disease states have a nutritional
component which can impact both clinical
and financial outcomes. Nutritional risk
assessment allows early identification of
malnutrition or risk for becoming
malnourished that can go unrecognized or
untreated.
The goals of nutrition therapy should
optimally be supportive of nutritional status,
performance status, body composition,
immune competence and quality of life.
Complications of malnutrition can be
prevented and treated through:
Nutrition screening for the level of risk
by providing Nutrition counseling
 Oral supplementation
 Enteral nutrition
 Parenteral nutrition
Adequate – no nutritional deficiencies
 Mild – at risk for developing
deficiencies
 Moderate – exacerbation of nutritional
deficiencies if nutrition therapy is not
initiated
 Severe – significant nutrition
intervention required to achieve a
positive outcome
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History
Clinical
Psychosocial
Appetite-% of usual
intake
Nausea, vomiting
Cognitive impairment
Open wounds/pressure
ulcers
Diarrhea, constipation
Depression
Difficulty chewing,
swallowing
Limited mobility to
cook, shop, prepare
food
Limited resources –
includes transportation
Changes in taste or
smell
Alcohol consumption,
smoking
Lives alone
Inability or
unwillingness to eatanorexia or early satiety
Medically restricted diet
(COPD, CHF, HTN,DM,
kidney/liver disease)
Limited social support
system
Dental problemsDecayed or missing
teeth/ill fitting dentures
Complimentary or
alternative medicine
(CAM)/Herbs/
Supplement use
Pain
Mouth sores- thrush,
stomatitis,
dryness
Involuntary weight loss
or gain of 10 lbs. in I
month
Takes 2-4 or more
medications daily
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Subjective Global Assessment (SGA) was first
described by Baker in 1982. It was introduced to
assess the patient for malnutrition at the bedside
and had 5 components w/o the need for precise
body composition analysis.
Today SGA has morphed to include disease
specific evaluations and has been deemed the
assessment method of choice for oncology,
transplant, liver disease and dialysis patients.
It is the fastest and least complicated tool with
high interobserver reproducibility and validity.
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Nutritional Assessment is a process in which
the status of nutritional health of an
individual is evaluated and specific nutrition
needs are estimated to determine the
preferred route of supportive nutritional care.
A complete nutrition assessment establishes
individual goals and develops a plan of care
to address the problems or needs identified
from the assessment.
Information
Gathering
Body
Nutrient
Composition Intake /
Data
Dietary
History
Laboratory
Evaluation
Psychosocial
/ Functional
Status
Patient Interview
Physical Exam for
Fluid Status
Cultural or
Religious
Preferences
Nutritional
Anemias i.e. Folate,
Iron & B-12
Ethical issues & the
pt’s right to
autonomy
Primary &
Secondary
Diagnosis. Look for
fever & infection.
Examination of
the skin
The quality &
quantity of meals –
24 –hour recall or
food diary
Pre-albumin. Short
½ life.
N= 20-50 mg/dL
Income, education
& other
socioeconomic
conditions such as
chemical
dependency
Past medical &
surgical history
Examine the oral
cavity
Food allergies,
intolerances or Fad
diets
Albumin.
Long half life.
N= 3.5-5.0 g/dL
Environment or
displacement
Medication Reviewinclude OTC
Muscle definition
Eating Out
Cholesterol/triglyc
erides/ glucose
Caregiver(s)
Drug/Nutrient
interaction
Wasting,
Sarcopenia
Inability to feed
self
Liver Function
Tests
Bedridden,
suboptimal activity
Congenital or
genetic conditions
Drainage, losses
Total Lymphocyte
Count N= 1500 3000 mm2
Full capacity
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Marasmus – ICD-9 code: 261 AKA – adapted starvation
Loss of body fat and skeletal muscle
Preservation of visceral protein stores
Cell mediated immunity and cardiac output are
spared
Kwashiorkor – ICD-9 code: 260 AKA protein
malnutrition
Caused by acute illness or stress
Edema may mask this condition. The patient can be
obese
Low or very low albumin
Poor wound healing and infection risk
Mixed Protein Energy Malnutrition can be a life
threatening condition that results from a combination
of chronic energy deficiency and severe protein
deficits. ICD-9 code: 263
Characteristics include:
Loss of fat stores, skeletal muscle and visceral
protein stores
Usually vitamin and mineral deficiency, immune
incompetence
Edema
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Height
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Height in inches X 2.54 = height in centimeters
5’9” = 69” X 2.54 = 175.26 = 175 centimeters
We need height to calculate energy requirements,
determine ideal body weight and interpret body
composition data.
According to Stewart*, The average difference between
self reported height and measured height was not
greater than +/- 0.9% and was not clinically significant.
Arm span is not influenced by age and may be used if
appropriate.
Amputations and paralysis have adapted equations.
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* Stewart AL. J Chronic Dis. 1982: 35: 205-309.
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Weight in pounds divided by 2.2 = weight in
kilograms (kg)
We need as accurate information as possible
because weight is used to determine daily energy
requirements.
Parameters for evaluating significance of weight
loss:
Interval
Significant Loss
Severe Loss
1 month
5%
>5%
3 months
7.5%
>7.5%
6 months
10%
>10%
Use the Metropolitan Life Height/ Weight
Tables (1983) – Not over age 59
 Hamwi Method: must know height
Males: 106 lbs for the first 5 feet of height
plus 6 lbs for each additional inch
Females: 100 lbs for the first 5 feet of height
plus 5 lbs for each additional inch
This method is easy and is relatively accurate
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Percent Weight Loss→
Take Actual weight divided by Usual body weight X 100
Example: 150 lbs divided by 180 lbs X 100 = 83% of usual
Percent of Ideal Body Weight →
Take Actual weight divided by Ideal body weight X 100
Example: 150 lbs divided by 160 lbs X 100 = 93% of ideal
Adjusted Body Weight → for obesity
Actual weight - Ideal body weight X 0.25* + Ideal body weight
220 lbs – 160 lbs X 0.25 + 160 lbs = 175 lbs
* Assumes that 25% of body fat tissue is metabolically active
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Can not be used effectively for elite athletes or certain
ethnic groups
BMI = weight in kg
height in (meters)₂
19-25 Appropriate weight for (19-34 years)
21-24.9 Appropriate weight for (>35 years)
25-29.9 Overweight
30-34.9 Obesity Grade I
35-39.9 Obesity Grade II
>40 Obesity Grade III (Morbid)
>50 Super Obesity
17-18.5 Mild malnutrition
16-17 Moderate malnutrition
<16 Severe malnutrition
Skeletal Muscle Measurement:
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Mid- Arm Circumference (MAC): measures fat stores
and muscle mass by measuring the circumference of the
mid arm. It can determine marasmus.
Triceps Skin Fold (TSF): measures body fat reserves. Not
as accurate in the obese patient and different value
tables must be used for the elderly, children and ethnic
groups. The “pinch” caliper test.
Mid-Arm Muscle Circumference (MAMC): measures
skeletal muscle reserves – MAC – (3.14 (Π) X TSF) =
MAMC
Must be done as serial measurements by the same
person on the same arm to increase accuracy. But as
good reference data.
Is conducted by placing 2 electrodes on the
body to measure current in tissues that are
rich in water such as muscle.
Advantages- Easy, portable, rapid & safe.
Disadvantages_ Accuracy is effected by
hydration, exercise, amputation, eating, fever
and obesity etc.
Comments: Measurement must be taken after
4-hours of fasting and sedentary activity.
Must lie down and be still for 10-minutes.
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Hydrodensity or underwater weighing – Most accurate
Is not suited to individuals who are unable to maximally
exhale, brush water bubbles away and those that are
unwilling or unable to be totally submerged in a water
tank.
 Air displacement PlethysmographyDisplacement of air is measured while the person sits
inside a small chamber (BodPod). The calculation is
similar to underwater weighing.
Advantages – Easy if the equipment is available. No
radiation.
Disadvantages- Must remain still. No information on fat
distribution.
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“ A picture is worth a 1000 Words”
Look at the patient and concentrate on the areas that reflect
what the patient expressed in the nutrition history. Focus on
high turn over rate areas.
Area
Hair
Appearance
Nutrient Deficiency
Sparse, dry, dull,
easily plucked
Protein, Zinc, EFA
Skin
Scaly, cracked
Rash, Lesions
B- vitamins,
Vitamin A
Lips
Cracks at the sides,
swollen
Vitamins B-2, B-3,
B-6
Eyes
Cornea, Conjunctiva Iron, B-complex,
Vitamin A
Tongue
Glossitis, Magenta
color
Vitamins B-12, B-2
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A Nutrition Focused Physical Exam can
yield important clues about micro and
macro nutrient status. Unfortunately,
clinical signs and symptoms of most
nutrient deficiencies do not appear until
an advanced state of deficiency exists.
In addition, the disease process,
treatment or medication my mask or be
confused with the symptoms of nutrient
deficiencies.
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Resting Energy Metabolism (REE) includes
energy required for the functioning of vital
organs, muscles, skin and maintenance of
body thermoregulation.
Indirect calorimetry provides an assessment
of REE through the measurement of inspired
oxygen to expired carbon dioxide. REE
accounts for 60-70% of the total daily energy
expenditure. With the multiplication of
additional stress and activity factors a daily
calorie need is established.
An accurate assessment of energy needs is necessary to
complete individual nutrition assessments and to determine the
effectiveness of planned nutrition interventions.
 Harris Benedict Equation calculates Resting Energy Expenditure
Males: 66.47 + {13.75 x wt (kg)} + [5.0 x ht (cm)] – {6.76 x
age(yrs)}
70 kg (154#)
66.47 + 962.5 + 876.3 – 270.4 = 1635 kcals
Females: 655.10 + {9.56 x wt(kg)} +[ 1.85 x ht(cm)] – {4.68 x
age(yr)}
55 kg (121#) 655.1 + 525.6+ 118.4 – 87.2 = 1112 kcals
This must be multiplied by an activity and/or stress factor:
Activity: Confined to bed = 1.0-1.2 Out of bed= 1.3
Injury or Stress – Surgery=1.0-1.2 Infection= 1.0-1.8
Trauma= 1.2-1.3 Moderate Stress (SBS, Cancer)=1.5
Burns/Transplant= up to 1.95
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Note: The thermogenic effect of food represents 5-10% of kcals used by the body each day.
Problems:
 Over predicts resting energy needs by 10%
 When choosing a stress factor be conservative
 Substantial limitations with age, certain ethnic
groups and obesity
 Don’t use adjusted body weight in this equation –
it really underestimates kcal needs
 Overall underestimates kcals by 35% and
overestimates kcals by 43% in various
populations when compared to measured REE.
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Is the best estimate at 10% off measured REE. Still has
limitations with certain ethnic groups and age.
Works well with obese men. Underestimation=20% &
overestimation =15% from measured in certain groups.
Calculates Resting Metabolic Rate or (RMR)
Males: {9.99 x wt(kg)} + [6.25 x ht(cm)] – {4.92 x age(yr)} +5
70 kg (154#) 699.3 = 1095.4 – 196.8 = 1603 kcals
Females: {9.99 x wt(kg)} + [6.25 x ht(cm)] – {4.92 x age(yr)} -161
55kg (121#) 549.45 + 1016- 196.8 – 161 = 1208 kcals ^
Stress / Injury factors follow the HB equation = 1.2-1.8
^ 100 kcals more than predicted with the HB equation
* Frankenfeld et al. JADA. 2005: (5) 105: 775-789.
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Status
Kcals/ Kg
Obese
15-20
Sedentary/ Hospitalized 25-30
Moderately active or ill
30-35
Very active or ill
40
45 kcals/kg is the maximum recommended
for an adult. This model is often referred to
as the Hamwi method because it mirrors fluid
recommendations.
Grams per kg
Protein provision for
0.6-0.8
Grade>2 hepatic encephalopathy,
pre-renal w/o dialysis
Zero to low stress
Moderate stress (minor surgery,
infection
Higher stress (major surgery,
wound healing, dialysis)
Higher stress (peritonitis, burns,
transplant, hypermetabolic states
such as head injury
0.8 – 1.0
1.0-1.2
1.3-1.5
>1.5
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Fluid requirements for adults can be
estimated using the following equations:
1500 ml/m2
1500 ml for the first 20 kg + 20 mL/kg over 20 kg
30-35 ml/kg (average adults)
30-35 ml/ kg (18-64 years of age)
30 ml/kg (55-65 years of age)
25 ml/kg (>65 years of age)
1 ml/ kcal
1ml/kcal + 100 ml/gm of nitrogen with losses
Nutrition Assessment is a vital part of the
overall medical plan of care
It allows us to recommend lab testing as
appropriate and monitor nutrition
effectiveness.
Provides nutrition to assist with poor wound
healing, shorter hospital stays, fewer readmissions to the hospital and reduce the use
of home health services.