Transcript NUTRION ASSESSMENT

NUTRITION SCREENING
& ASSESSMENT
Dr Yahya Pasdar
Kermanshah University of Medical Sciences
[email protected]
www.Drpasdar.com
Nutritional Screening & Assessment
Overall View
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Screening
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Assessment
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Available Tools
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Validity and Reliability
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Take Home Massage
Nutrition Care Process Model
Screening & Referral
System
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Identify risk factors
Use appropriate tools
and methods
 Involve
interdisciplinary
collaboration
Nutrition Assessment
 Obtain/collect timely and
appropriate data
 Analyze/interpret with
evidence- based standards
Document
Nutrition Diagnosis
 Identify and label problem
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Determine cause/contributing risk
factors
 Cluster signs and symptoms/
defining characteristics
 Document
Relationship
Between
Patient/Client/Group
& Dietetics
Professional
Nutrition Monitoring and
Evaluation
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Monitor progress
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Measure outcome indicators
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Evaluate outcomes
 Document
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Outcomes
Management System
Monitor the success of the Nutrition Care
Process implementation
Evaluate the impact with aggregate data
Identify and analyze causes of less than
optimal performance and outcomes
Refine the use of the Nutrition Care
Process
Nutrition Intervention
 Plan nutrition intervention
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Formulate goals and
determine a plan of action
Implement the nutrition intervention
 Care is delivered and actions
are carried out
 Document
Effects of under-nutrition on organ function
Ventilation - loss of
muscle & hypoxic
responses
Psychology –
depression & apathy
Immunity – Increased risk
of infection
liver fatty change,
functional decline
necrosis, fibrosis
Decreased cardiac output
Renal function - loss of
ability to excrete
Na & H2O
Impaired wound
healing
Hypothermia
Impaired gut
integrity and
immunity
Anorexia
Loss of strength
Malnutrition & cancer
Immune
functions
Survival
Malnutrition
(60~85%)
Response to
chemotherapy
Performance
status
Muscle
function
Quality of
life
6
Van Cutsem et al., 2005
Mariette et al., 2012
The Malnutrition Carousel
28-34% of patients
admitted to hospital are at
risk of malnutrition
Hospital
Home
More GP visits
Longer stay
More hospital
admissions
More support postdischarge
More likely to be
discharged to Care Homes
Up to 70% of patients
discharged from hospital
weigh less than on admission
Why do we need to identify
malnutrition?
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Malnutrition is associated with:
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 length of stay in hospital
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 complications
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 hospital costs
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 mortality rates
Screening vs Assessment
Screening
“Rapid, simple, general
procedure done at first
contact with subject to
detect risk of malnutrition,
done by nurses, doctors or
other care workers” (Elia/
MAG 2003)
Assessment
“Detailed, more specific
in depth evaluation of
subject’s nutritional
status, done by those
with nutritional
expertise” (Elia/ MAG
2003)
Cancer patients are not all created
equal…should we expect the impact of
nutrition therapy to be the same across all
patients?
Why screen for malnutrition?
Malnutrition is not always visible, is more common than you
think and costs health and social care ≥£13b/year
• At any one time, more than 3 million adults in UK are at risk
• 93% live in the community & 2% are in hospital where ~1 in 3
are at risk on admission
• Older people and those with chronic conditions are
particularly at risk
• Help people stay independent and well in their own home as
long as possible & reduce the need for admission into hospital
Why screen for malnutrition?
• Effective management of malnutrition reduces the
burden on health & care resources
• Regular screening is the only way that malnourished
individuals can be identified and appropriate action
taken
• Recommended / required by various bodies e.g NICE,
NHSQIS, Council of Europe, Care Quality Commission,
Nutrition Action Plan
What is clinical concern?
Unintentional weight loss, fragile skin, poor wound
healing, apathy, wasted muscles, poor appetite,
impaired swallowing, altered bowel habit, loose
fitting clothes or prolonged inter-current illness. (NICE
2006)
What is screening and how can we
do it?
Characteristics of Nutrition
Screening
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Simple and easy to complete
Routine data
Cost effective
Effective in identifying nutritional
problems
Reliable and valid
Screening: Nutrition Care Indicators
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Nutritional history
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Feeding modality
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>10 lbs in past 3 months
Serum Albumin
Diagnosis
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TPN/PPN
TF
Diet restrictions
Unintentional Weight Loss
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Appetite
Nausea/vomiting (>3 days)
Diarrhea
Dysphagia
Reduced food intake (<50% of normal for 5 days)
Cachexia, end-stage liver or kidney disease, coma, malnutrition, decubitis ulcers,
cancer of GI tract, Crohns, Cystic Fibrosis, new onset diabetes, eating disorder
Above used to determine nutritional risk and need for referral to RD
Nutrition Screening Tools
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Requirements
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quick and simple to administer
sensitive enough to identify individuals at risk
appropriate for client group being screened
capable of being used by non-dietitians
reproducible when used by different observers
able to guide non dietetic staff into taking appropriate action
for findings recorded
Nutritional Screening Tools
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No single / standard way of assessing nutritional status
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Various validated assessment tools developed
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some disease specific
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some age specific
2 examples
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Mini Nutritional Assessment (MNA)
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Subjective Global Assessment (SGA)
‘Malnutrition Universal Screening
Tool’ (‘MUST’)
A simple 5 step validated tool for use by all care
workers in all care settings:
Step 1-height and weight to obtain BMI
Step 2- recent unintentional weight loss
Step 3- effect of acute disease
Step 4- overall score / category of risk
Step 5- management guidelines
‘Malnutrition Universal Screening Tool’
(‘MUST’)
Malnutrition Screening Tool (MST)
Have you lost weight recently without trying?
If NO
If unsure
If YES, how much weight have you lost?
1 – 5 kg (2 – 11 lb)
6 – 10 kg (1 – 1½ st)
11 – 15 kg (1¾ - 2⅓ st)
> 15 kg (> 2⅓ st)
Unsure
Have you been eating poorly because of a
decreased appetite?
If NO
If YES
Total
If the score is 2 or more please refer to the dietitian.
(Ref: Ferguson M et al, Nutrition 15: 458-464, 1999)
0
2
1
2
3
4
2
0
1
‘MUST’ e-learning
Link to Hospital module:
https://secure.digitalroutes.co.uk/bapen
The Short Nutritional Assessment
Questionnaire (SNAQ)
Question
Score
Did you lose weight unintentionally?
>6kg in the past 6 month
3
>3kg in the past month
2
Did you experience a decreased appetite
over the past month?
1
Did you use supplemental drinks or tube
feeding over the past month?
1
Mini Nutritional Assessment (MNA)
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Screening and Assessment tool for the identification of
malnutrition in the elderly
Considers:
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Dietary Intake – foods, patterns
Weight change, BMI, Muscle circumferences
Functional impairment, Independence, Living arrangements
Psychological issues, Self assessment
Subjective Global Assessment
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Valid assessment tool
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Strong correlation with other subjective and objective
measures of nutrition
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Highly predictive of nutritional status in a number of
different patient groups
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Quick, simple and reliable
Subjective Global
Assessment…features
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Medical History
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Weight change
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Dietary intake
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GI symptoms
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Functional impairment
Physical Examination
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Loss of subcutaneous fat
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Muscle wasting
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Oedema and ascites
Subjective Global Assessment
…Classifications
A
B
C
Well nourished
Moderately malnourished or
of malnutrition
Severely malnourished
suspected
Adult Ambulatory Screen
Full Nutrition Assessment
Step 1…Data collection
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Systematic Approach
Assessment based on clinical/psychosocial/physical
information
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Dietary
Anthropometric
Biochemical
Physical
Including
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Subjective (eg. signs/symptoms of nutritional problem,
appetite)
Objective (eg. Lab results)
Data Collection…
An Example… A B C D E
A
B
C
D
E
Anthropometry
Biochemical Data
Clinical signs and symptoms,
Dietary Intake
Exercise (Energy balance –
Consider current level, history and changes
medical condition
expenditure)
Anthropometry
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Height
Weight
Weight history / pattern
(% weight change)
Weight for Height
BMI
Growth Pattern, head
circumference (paediatrics)
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MAMC
TSF
Waist circumference
Hip circumference
WHR
Be aware of fluid status,
presence of oedema.
Anthropometrics
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Ideal body weight
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Males: 106 lbs + 6 lbs per inch over 5 ft
Females: 100 lbs + 5 lbs per inch over 5 ft
Add 10% for large-framed and subtract 10% for smallframed
%IBW = (current wt/IBW) X 100
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80-90% mild malnutrition
70-79% moderate malnutrition
60-69% severe malnutrition
<60% non-survival
Anthropometrics
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%UBW: usual body weight
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= (current wt/UBW) X 100
85-95% mild malnutrition
75-84% moderate malnutrition
0-74% severe malnutrition
% weight change = usual weight – present weight/usual
weight X 100
Significant weight loss
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>5% in 1 month
>10% in 6 months
Body Mass Index = BMI
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Evaluation of body weight independent of height
BMI = weight (kg)/height2 (m)
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>40
30-40
25-30
18.5-25
17-18.4
16-16.9
<16
obesity III
obesity II
overweight
normal
PEM I
PEM II
PEM III
Bioelectrical Impedance Analysis (BIA)
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Measures electrical conductivity through water
in difference body compartments
Uses regression equations to determine fat and
LBM
Serial measures can track changes in body
composition
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Obesity treatments
DEXA: dual-energy X-ray absorptiometry
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Whole body scan with 2 x-rays of different
intensity
Computer programs estimate
Bone mineral density
 Lean body mass
 Fat mass
 “Best estimate” for body composition of clinically
available methods
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Anthropometrics: additional methods
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Research methods: precise, but cost prohibitive
Total body potassium
 Underwater weight (hydrodensitometry)
 Deuterated water dilution
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Muscle strength and endurance
Biochemistry & other Blood Tests
(See also disease/condition specific lectures)
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Objective measures
No single test is diagnostic
Consider “normal / recommended range” for various and
combination of conditions, eg. age, gender, physiological
state, disease type and stage
Consider clinical significance of test result
Test result may reflect immediate intake (eg glucose) or long
term status (HbA1c)
Other factors to Consider…
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Other factors can mask/influence test results eg.
Acute phase response due to stress / injury (
reduced albumin)
 GI bleed (higher urea)
 Blood transfusion (higher serum K and Hb)
 Surgery (lower Hb and albumin)
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Nutritional Indicators
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Ideal indicator or marker is sensitive and specific to
nutritional intake
Commonly Used “Nutritional Indicators”
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Albumin
Pre-albumin
Transferrin
Retinol-binding protein
Albumin
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Synthesised in the liver
May be useful indicator of nutritional status in
“healthy” person.
Not a good indicator of protein status during critical
illness (due to acute phase response)
Long half life (14-20 days) and large body pool  slow
to respond to improvements in clinical status
Factors Affecting Serum Albumin
Levels
Increased in:
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Dehydration, blood transfusions, exogenous
albumin
Decreased in:
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Overhydration, hepatic failure, inflammation,
infection, metabolic stress, post-op, bed rest,
pregnancy, nephrotic syndrome.
Pre-albumin
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Also known as Transthyretin, thyroxine binding protein.
Synthesised in the liver
Relatively short half life (2 days)
Negative acute phase reactant -  with inflammatory
response
May be useful in healthy population
Transferrin and RBP
Transferrin
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Half life 8-10 days
Poor correlation with nutrition status
Involved with iron transport, influenced by iron status
Retinol Binding Protein (RBP)
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Half life 12 hours
Affected by renal function, Vitamin A and Zn status
Unreliable measure of nutritional status
C-reactive protein
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Positive acute phase respondent
Increases early in acute stress as much as 1000fold
Decreased correlates with end of acute phase
and beginning of anabolic phase where
nutritional repletion is possible
Creatinine Height Index
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Estimates LBM
= actual creat excretion (24 hour urine collection)
expected creat excretion
Males: IBW X 23 mg/kg
Females: IBW X 18 mg/kg
>80% normal
60-80% moderately depleted
<60% severely depleted
Accurate 24-hr urine collection is difficult to obtain in acutecare setting
Biochemistry & other Blood Tests,
cont’d
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Interference – drugs, sampling
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Nutrient-nutrient interactions, drug-nutrient
interactions
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Be aware of hydration status
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Must interpret lab results with other nutritional
parameters
Clinical issues to consider:
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Medical history, treatment and medications
Significant factors affecting nutritional intake
Fluid balance – input and output, Bowel habits
Physical assessment of nutritional status
Clinical signs and symptoms
Clinical Signs and Symptoms
Signs
 Subjective, impression
 Descriptive, observation
 Appearance
 Visual examination
 Needs clinical judgement
 Eg muscle wasting,
malnutrition
Symptoms
 Recall, report by subjects
 Descriptive
 Eg nausea, itchiness,
diarrhoea, anorexia
Dietary Intake
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Is intake meeting requirement?
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Basic nutrition adequacy
Special requirement / disease / conditions
Consider factors affecting intake
Consider clinical, nutritional and psycho-social issues
Methods of collecting information/data
? Relevant and practical
Exercise – Energy Balance
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Nutrition and exercise closely linked – metabolic and physical
fitness
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Functional capacity and Nutritional status
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Correlation between muscle mass and physical strength, nutritional status
and physical function
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Energy Balance to attain optimal weight and body composition
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Bed Rest / Inactivity
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Negative effects on muscles, bone and CV system, eg. 8 g protein loss /
day of bed rest
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Exercise – affects on appetite, bowel function
Estimating Nutritional
requirements
Consider
 Energy
 Protein
 Fluid
 RDIs for micronutrients
Estimating Energy Requirements
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Indirect Calorimetry
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preferred method
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use of a metabolic monitor/cart
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measures respiratory gas exchanges
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Differences in oxygen and carbon dioxide content between air going
in and air coming out  respiratory exchange  energy expenditure
(Ref: Mann & Truswell(ed) Essentials of Human Nutrition, Chap. 5)
Harris Benedict Equation
Males (kJ/24hr)
BEE = 278 + (57.5 x W) + (20.9 x H) - (28.3 x A)
Females (kJ/24hr)
BEE = 2741 + (40.0 x W) + (7.7 x H) - (19.6 x A)
W = actual weight in kg, H = height in cm,
A = age in years.
Activity Factors
Resting sedated +/- ventilated
Resting conscious
Bedrest (moving self around bed)
Light (mobilizing around ward) 1.3
Moderate (regular, intense physio)
1.0
1.1
1.2
1.4
Injury Factors
Medical (IBD, liver/pancreatic d)
Surgical (transpl, fistula)
Cancer (tumour/leukaemia)
Trauma (or minor burns)
Sepsis (or other major infection)
Major burns
1.11.21.21.21.31.5-
1.2
1.4
1.4
1.4
1.4
1.6
* Refer also to nutrition support and specific clinical lectures
Estimating Protein / Nitrogen
Requirements
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From measuring Nitrogen losses from the body (urine, faeces,
fistulae/drain losses, burn exudates)
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Urinary nitrogen excretion can be estimated by measuring urinary
urea nitrogen(UUN) excretion from a 24hr urine sample.
Estimating Protein / Nitrogen
Requirements
Using RDA’s
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Healthy adult
0.75g/kg BW
Increased metabolic needs during periods of stress
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Mild/intermediate stress state
eg surgery, fractures
1-1.5g/kg BW
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Cancer
1.2-1.5g/kg BW
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Multiple trauma,
1.5+/kg BW
extensive burns(>30%)
Biochemical Data
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Used to assess body stores
Altered by lack of nutrients, medications, metabolic
changes during illness or stress
Interpret results carefully
Fluid status distorts results
“Stressed” states (infection, surgery) effects results
Use reference values established by individual lab
Hematological Indices
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Determine nutritional anemias
Transferrin: Fe transport protein
TIBC: total Fe binding capacity
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Indicates number of free binding cites on transferrin
Fe deficiency: increased transferrin levels, decreased saturation
Ferritin: Fe storage protein, increases during inflammation
Depressed hemoglobin is an indicator of Fe deficiency anemia
Nitrogen balance
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Goal for repletion is a positive nitrogen balance
24-hr record of protein intake and urine
collection is required
Done within 48 hr after initiation of nutrition
therapy
Results not valid in conditions with high protein
losses (burns or high-output fistulas)
N balance = protein intake/6.25 – (urinary urea
N + 3 or 4)
Estimation of Nutrient Needs
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Predictive equation for energy (calorie) needs
Harris Benedict uses age, height, and weight to estimate basal
energy expenditure (BEE), the minimum amount of energy
needed by the body at rest in fasting state
In men:
BEE (kcal/day) = 66.5 + (13.8 X W) + (5.0 X H) – (6.8 X A)
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In women:
BEE (kcal/day) = 655.1 + (9.6 X W) + (1.8 X H) – (4.7 X A)
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Where W = weight in kilograms, H = height in centimeters
and A = age in years
BEE is multiplied by an activity factor and injury factor to
predict total daily energy expenditure
Activity Categories
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Confined to bed = 1.0-1.2
Out of bed = 1.3
Very light = 1.3
Light = 1.5 (women), 1.6 (men)
Moderate = 1.6 (women), 1.7 (men)
Heavy = 1.9 (women), 2.1 (men)
Indirect calorimetry/Metabolic Cart
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Measures CO2 produced and O2 consumed in critically ill
patients on ventilators
Calculates resting metabolic rate based on gas exchange
Respiratory quotient calculated
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Corresponds to oxidation of nutrients
CHO: 1:1 ratio of CO2 produced/O2 consumed
Lipid: 0.7:1 ratio
Protein: 0.82:1 ratio
Mixed diet: 0.85:1 ratio
Overfeeding/lipogenesis: >1.0
Injury Categories
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Surgery
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Infection
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Mild = 1.0-1.2
Moderate = 1.2-1.4
Severe = 1.4-1.8
Trauma/Cancer
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Minor = 1.0-1.1
Major = 1.1-1.2
Skeletal = 1.2-1.35
Blunt = 1.15-1.35
Head trauma treated with steroids = 1.6
Burns
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Up to 20% body surface area (BSA) = 1.0-1.5
20-40% BSA = 1.5-1.85
Over 40% BSA = 1.85-1.95
Take Home Massage
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Increase your nutritional knowledge
Take care of your proficiency
Make good relationship
Make a bridge between sciences and practice
Be responsible for patients
Do not excaudate nutrition
Do not undermined nutrition
Patients are Central Care of
Nutrition
The relationship
between the patient &
the dietetics
professional(s)
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collaborative
client-focused
individualized
Thanks for your attention