Transcript Egan`s Fundamentals of Respiratory Care

Chapter 21
Nutrition Assessment
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
Learning Objectives
• Describe how a comprehensive nutrition
assessment is conducted.
• Describe how to calculate and interpret body
mass index.
• Describe how to distinguish two forms of proteinenergy malnutrition from each other.
• List the biochemical indicators of nutritional
status.
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
2
Learning Objectives (cont.)
• State what to observe clinically in the
malnourished patient.
• Describe how to obtain and evaluate a nutrition
history.
• Describe how to estimate daily resting energy
expenditure.
• List the indications, contraindications, hazards,
and limitations of indirect calorimetry.
• Describe how to properly prepare a patient for
indirect calorimetry.
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
3
Learning Objectives (cont.)
• Describe how to interpret the results of indirect
calorimetry.
• Describe how REE values are adjusted to reflect
a patient’s actual energy needs.
• State the effects of malnutrition and on the
respiratory system.
• Describe how to identify patients at high risk for
malnutrition.
• Identify the effect on a patient of too much
protein, carbohydrate, or fat.
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
4
Learning Objectives (cont.)
• State when enteral nutrition and parenteral
nutrition are needed.
• Describe how to identify and minimize the
common respiratory complications of enteral
feedings.
• State specific nutritional guidelines that apply to
patients with a specific pulmonary disease.
• Explain how common pulmonary medications
affect nutrition.
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
5
Nutrition Assessment
• Process of collecting & evaluating data to
determine nutritional status of patient
• Performed by registered dietician or physician
trained in clinical nutrition
• Compares social, pharmaceutical,
environmental, physical, & medical factors to
evaluate nutrient needs of patient
• Done to develop nutrition care plan
• Data is collected from anthropometrics,
biochemical tests, & clinical observations
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
6
The ABCDs of nutritional assessment include all of
the following:
A. Airway, breathing, circulation, and defibrillation
B. Assessment (physical), BMI calculation, caloric
count, and diet (intake/output)
C. Anthropometric, biochemical tests, clinical
observations, and dietary analyses
D. Albumin, Bilirubin, Creatinine, and Deoxycortisol
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
7
Anthropometrics
• Refers to measurements of body
 Height & weight
 Skinfold thickness
 Arm muscle measurements
 Waist & hip measurements
 Head circumference
 Wrist diameter
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
8
Anthropometrics (cont.)
• Height & weight
 Usually measured to determine weight status using
body mass index (BMI) & ideal body weight (IBW)
 BMI between 18.5 & 24.9 kg/m2 for adults is
considered healthy
 BMI of 25 to 29.9 kg/m2 = overweight
 BMI > 30 kg/m2 = obese
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
9
BMI Categories
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
10
BMI Categories
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
11
Anthropometrics (cont.)
• Ideal Body Weight:
 Ideal body weight may also be determined using
Hamwi formulas:
• Men: 106 pounds for first 5 feet, plus 6 pounds for each inch
over 5 feet
• Women: 100 pounds for first 5 feet, plus 5 pounds for each
inch over 5 feet
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
12
The IBW for a 25 year-old female patient whose
height is measured at 5'5" would be:
A. 155 lb.
B. 125 lb.
C. 100 lb.
D. 130 lb.
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
13
Anthropometrics (cont.)
• Kwashiorkor & marasmus
 Marasmus - typically seen in children ages 6 to18
months in deprived areas of world chronically
malnourished
 Kwashiorkor results from more sudden lack of protein &
calories in infant (seen as protruding belly & edematous
face)
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
14
Weight Classification According to BMI
• Healthy weight:
 BMI between 18.5 & 24.9 for adults or BMI-for-age
between 10th & 85th percentiles for children
• Overweight:
 BMI 25.0 to 29.9 in adult & BMI-for-age in children
between 85th & 95th percentiles
• Obesity:
 BMI greater than 30 in adults & greater than 95th
percentile in boys & girls ages 2 to 20 years
• Underweight:
 BMI of less than 18.5; underweight children score in
bottom 10th percentile for BMI-for-age
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
15
Biochemical Indicators
• Albumin measured for long-term trends in
nutrition because it has half-life of 21 days
• Transthyretin has half-life of 2 to 3 days &
therefore responds to nutritional changes much
quicker than albumin
• Total lymphocyte count may be reduced with
malnutrition due to lack of protein intake
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
16
Biochemical Indicators (cont.)
• Creatinine-height index measures amount of
creatinine excreted in urine over 24 hours
 60% to 80% of normal = mild deficit of muscle mass
 40% to 60% = moderate deficit
 <40% = severe depletion of muscle mass
• Nitrogen balance used to assess protein
balance because 16% of protein is nitrogen
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
17
Biochemical indicators are important element of
nutritional assessment because:
A. They are use to determine ideal body weight
B. Can predict nutritional outcomes
C. Indicate the level of protein synthesis in the
body
D. Help to calculate predicted body weight
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
18
Pulmonary Function
• Protein malnutrition has been linked to reduced
function of diaphragm & other muscles of
breathing
• Leading to reduced vital capacity & peak
inspiratory pressures
• Represents significant problem in ICU when
trying to wean patient from mechanical
ventilation
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
19
Clinical Indicators
• Examination of hair, eyes, lips, mouth & gums,
skin, & nails provides clinical indication of
nutritional status
• Chronically malnourished patient will appear
thin; appearance of protruding ribs; patient is
cachexic in such cases
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
20
Common Dietary Measures
•
•
•
•
•
24-hour recall
Usual intake recall
Food diary or food record
Food frequency questionnaire
Evaluation of nutrition history
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
21
All of the following are economic benefits of a
well-designed, multidisciplinary nutritional
intervention plan, except:
A. Decreased nosocomial infections
B. Reduced hospital stays
C. Reduced need for medication or medical care
D. Increased years of productivity
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
22
Macronutrients & Energy Requirements
• Macronutrients supply the body’s energy
requirements:
 Protein
 Carbohydrate
 Fat
• Classic measure of energy expenditure is basal
metabolic rate (BMR)
• Alternatively, predictive equations like HarrisBenedict Equation can be used to estimate daily
resting energy expenditure (REE)
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
23
Indirect Calorimetry
• Estimation of energy
expenditure (caloric
needs) by
measurement of O2
consumption & CO2
production
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
24
Indirect Calorimetry
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
25
Interpretation of Calorimetry (cont.)
• Results are used to assess metabolic status &
plan nutritional support
• First step is to compare results to predicted
normal using Harris-Benedict equations
• Resting energy expenditure (REE) >10% above
normal indicate hypermetabolic state
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
26
Interpretation of Calorimetry (cont.)
• REE results <90% of normal predicted indicate
hypometabolism
• Next, interpret RQ, which is ratio of CO2
produced to O2 consumed
• RQ of carbohydrates = 1.0; protein = 0.82; & fat
= 0.7.
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
27
Interpretation of Calorimetry (cont.)
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
28
During indirect calorimetry a steady-state condition
is reached when:
A. Patient remains still for 1 minute
B. REE results are within normal limits
C. No artifacts are detected during the test
D. Five consecutive 1-min averages have a
variability of 5% or less
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
29
Nutritional Support
• Malnutrition results from insufficient energy
(calorie) intake over time
• Protein-energy malnutrition (PEM) has adverse
effects on patient’s immune system & on
respiratory musculature
• PEM can be result of starvation or disease
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
30
Respiratory Impairment & Malnutrition
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
31
Respiratory Consequences of
Malnutrition
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
32
Providing Substrates
• Protein should provide about 20% of patient’s
caloric needs
• Carbohydrates should provide about 50% of
patient’s caloric needs
• Fat should provide about 20% to 30% of
patient’s caloric needs
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
33
Routes of Feeding
• Enteral (oral & tube feeding) feeding is route of
choice; safer, healthier, & easier than parenteral
route
• Potential complication of enteral feeding is
aspiration
• Parenteral (intravenous) feeding can be done
through peripheral or central vein
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
34
Pulmonary Patient
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
35
All of the following can help decrease the risk of
pulmonary aspiration for tube-fed patients, except:
A. Aspiration of subglottic secretions
B. Endotracheal intubation
C. Keep head of bed at 45 degree angle
D. Placement of feeding tube beyond the pylorus
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
36