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Nutrition Assessment in the Inpatient Setting
Patient’s with Pressure UlcersFor HMC Wound Care Nurses
Katie Farver RD, CNSDHarborview Medical Center
Seattle, [email protected]
8-11-09
Components of Nutrition Assessment
Diet History MedicalHistory
Weight History
Body Comp Biochemical Data
Physical Assessment
*Eating Habits*Potential Deficiencies*Reasons for sub-optimal intake*Food Resources
*Conditions effecting digestion or ability to eat*Drug-nutrient interactions
*Actual, Usual and BMI
*Skinfold*Bio-ElectricalImpedance
*Serum Proteins (albumin & prealbumin, CRP)
*Vitamin and mineral assays
*Loss of subcu fat*Muscle wasting*Concave appearance*Hair*Nails
Diet HistoryQuality and quantity of food Intake prior to admit/during admit
Quality and quantity of nutrition Support intake prior to admit/during admit
Medical HistorySample conditions effecting intake
• GI Disease• Chronic Alcoholism• Critical Illness• Stroke• Anorexia Nervosa• Dementia• Pancreatitis• Renal Disease
Sample Drug-Nutrition Interaction
• Insulin• Coumadin• MAOI Inhibitors• HAART • INH
Weight History
• Weight Loss over last 6 months evaluated:– <5% insignificant– 5-10% potentially
significant– >10% significant
• BMI = weight(kg)/height(m)²– <18.5 underweight– 18.5-24.9 normal,
healthy– 24.9-29.9, overweight– >30 obese
Body Composition Measurements
Underwater Weighing Skin Fold Measurements
Biochemical Assessment
Sources of Error• Biological Variation• Preanalytical variation• Analytical variation• Postanalytical variation
Factors Influencing Concentration
• Synthesis rate• Secretion rate• Clearance rate
• Catabolic rate• Distribution• Other
Synthesis rate
• Substrate availability• Hepatic function• Metabolic response to
injury• Corticosteroids• Inflammatory Response
Secretion and Clearance Rate
• Cofactor availability• Hepatic Function• Renal Function
Distribution and Other
• Metabolic response• Hydration • Drainage and fistula
losses• Analytical Method• Patient position on
blood draw
Biochemical Markers of Protein Status
• Assessing Protein-Calorie Malnutrition– Albumin– Pre-Albumin
Serum Protein levels are not reliable during inflammation
Albumin
• Half-life - 20 days• Under/over hydration, liver function• Function– Oncotic pressure, transport, nutritive reserve
• Determinants of synthesis– Oncotic pressure, hormones, negative acute-
phase reactant, nutrition support, aging, drugs
Transthyretin - TTY (Prealbumin)
• Half-life - 1-2 days• Transports thyroid hormones and Vitamin A in
Retinol Binding Protein Complex• Negative acute-phase reactant• > 65% energy needs met, • <50% energy needs met• Elevated in Renal Disease • Elevated with steroid therapy
C-Reactive Protein
• Positive acute-phase protein• Reacts with Somatic C Polysaccharide of
Strep. Pneumoniae• Half-life 5 hours• Changes with acute & chronic inflammation• Helps interpret Transthyretin and Albumin
How many of our patients are not experiencing acute stress?
Biochemical Markers of Micronutrient Status
• Nutritional Anemias– B-12– Iron– Copper
• Vitamins– A– B Vitamins– Vitamin D
• Minerals– Zinc
• Antioxidants– Vitamin C– Vitamin E– Selenium
Lipid and Glycemic Status
• Lipids– Total Cholesterol– HDL/LDLs– Homocysteine– Triglycerides
• Glycemic Control– Blood Glucose– HgA1C
Physical AssessmentPhotos courtesy of Katy Wilkens, MS, RD
NW Kidney Center, Seattle, WA
23
Wasted Clavicle
24
The Shoulder and Elbow
• The shoulder• Normal: rounded or
sloped• Abnormal: square, can
see acromion process• The elbow well
padded and not showing cartilage definition
25
The Arm
• Bend arm and pinch at triceps. Only pinch the fat, not the muscle.
• Normal: fingers don’t meet
• Abnormal: fingers meet
26
Forearm
• Forearm: often better site than upper arm for assessing fat
• Upper arm fat disposition changes as women age
27
Wasting in the hands
28
The calf muscle
• Grip the calf• Normal: muscle
obvious, top of calf is larger than bottom
• Abnormal: muscle reduction, “stick legs, ankles the same as upper leg
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The Legs showing muscle wasting
30
Quadriceps and Knees
31
The Ankles
• Good indicator of edema, but only in patients who walk
• Check for sacral edema as well.
• Overnourished patients can be harder to assess
32
The back side
• In hospitalized patients, the back may not be easily accessible.
Vitamin C Deficiency
Petechia Cork Screw Hair
Nutrition Assessment is Complex
• Putting the pieces together is challenging
• Step-wise approach to assessment
• Call 744-4612 anytime for consults (seen within 24 hours)
• Call RD directly if urgent– ICU – assigned by team– Acute Care – assigned by
floor
• Clinical Dietitians at HMC
Where to find nutrition information in ORCA
• Admit Nursing History• Weight trending• Dietitian and Dietetic Technician Notes• Enteral and TPN Flow Sheets• Discharge nutrition counseling