Nutrition Assessment in the Inpatient Setting Patient

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Nutrition Assessment in the Inpatient
SettingPatients with Pressure UlcersFor HMC
Wound Care Nurses

• Katie Farver RD, CNSD
• Harborview Medical Center
• Seattle, Washington
• kef_at_u.washington.edu
• 8-11-09

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Components of Nutrition Assessment
Diet History Medical History 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- Electrical Impedance Serum Proteins (albumin prealbumin, CRP) Vitamin and mineral assays Loss of subcu fat Muscle wasting Concave appearance Hair Nails
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Diet History

• Quality and quantity of nutrition Support intake
  prior to admit/during admit

• Quality and quantity of food Intake prior to
  admit/during admit

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Medical History

• Sample conditions effecting intake

• Sample Drug-Nutrition Interaction

• GI Disease
• Chronic Alcoholism
• Critical Illness
• Stroke
• Anorexia Nervosa
• Dementia
• Pancreatitis
• Renal Disease

• Insulin
• Coumadin
• MAOI Inhibitors
• HAART
• INH

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Weight History

• Weight Loss over last 6 months evaluated
• lt5 insignificant
• 5-10 potentially significant
• gt10 significant

• BMI weight(kg)/height(m)²
• lt18.5 underweight
• 18.5-24.9 normal, healthy
• 24.9-29.9, overweight
• gt30 obese

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Body Composition Measurements

• Underwater Weighing

• Skin Fold Measurements

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Biochemical Assessment
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Sources of Error

• Biological Variation
• Preanalytical variation
• Analytical variation
• Postanalytical variation

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Factors Influencing Concentration

• Synthesis rate
• Secretion rate
• Clearance rate

• Catabolic rate
• Distribution
• Other

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Synthesis rate

• Substrate availability
• Hepatic function
• Metabolic response to injury
• Corticosteroids
• Inflammatory Response

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Secretion and Clearance Rate

• Cofactor availability
• Hepatic Function
• Renal Function

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Distribution and Other

• Metabolic response
• Hydration
• Drainage and fistula losses
• Analytical Method
• Patient position on blood draw

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Biochemical Markers of Protein Status

• Assessing Protein-Calorie Malnutrition
• Albumin
• Pre-Albumin

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Serum Protein levels are not reliable during
inflammation
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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

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Transthyretin - TTY (Prealbumin)

• Half-life - 1-2 days
• Transports thyroid hormones and Vitamin A in
  Retinol Binding Protein Complex
• Negative acute-phase reactant
• ? gt 65 energy needs met,
• ? lt50 energy needs met
• Elevated in Renal Disease
• Elevated with steroid therapy

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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

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How many of our patients are not experiencing
acute stress?
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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

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Lipid and Glycemic Status

• Lipids
• Total Cholesterol
• HDL/LDLs
• Homocysteine
• Triglycerides

• Glycemic Control
• Blood Glucose
• HgA1C

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Physical AssessmentPhotos courtesy of Katy
Wilkens, MS, RDNW Kidney Center, Seattle, WA
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Wasted Clavicle
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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

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The Arm

• Bend arm and pinch at triceps. Only pinch the
  fat, not the muscle.
• Normal fingers dont meet
• Abnormal fingers meet

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Forearm

• Forearm often better site than upper arm for
  assessing fat
• Upper arm fat disposition changes as women age

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Wasting in the hands
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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
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Quadriceps and Knees
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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

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The back side

• In hospitalized patients, the back may not be
  easily accessible.

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Vitamin C Deficiency

• Petechia

• Cork Screw Hair

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Nutrition Assessment is Complex

• Clinical Dietitians at HMC

• 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

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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