Nutritional Assessment

Nutritional Assessment 4/3/08

I Goals of Nutritional Assessment
A. To meet the pt’s nutrient needs
B. To meet the pt’s nutrition education needs
II Elements of Nutritional Assessment
A. Historical data
1. medical (past surgeries? HBP?)
2. medication (including diet supplements and herbals) (Pt may not know why he/she is on meds, only that the doc prescribed them)
3. diet history
a. 24 hour recall (what they ate in a typical day. Students will frequently have to do a 3 day recall with 1 day being non-typical such as a weekend)
b. food frequency questionnaires (How often do you drink? When was the last time you...?)
c. food diaries: 3-5 day record of actual food consumed
d. direct observation (in a health care setting, such as a hospital)
e. obtain additional information from pt/caregiver interview
i. economics (income, food budget, eligibility for food stamps) (Homeless people have less access to certain foods.)
ii. physical activity (occupation, exercise, sleep, handicaps) (Bus drivers with diabetes are being counseled.)
iii. ethnic, religious or cultural background (some foods are not acceptable such as meat, pork, non-kosher, etc.)
iv. appetite, meal patterns, food preferences
v. allergies, food intolerances, food aversions
vi. any nutritional problems perceived by pt (some people avoid foods they may have had problems with 20 years ago. Perception is reality to some people.)
B. Anthropometric Measurements (measurement of man)
1. height
2. weight
a. ideal/usual/adjusted/desired body weight
3. head circumference: for infants and toddlers
C. Lab Data (blood and urine tests)
1. albumin, pre-albumin
a. protein in the cells/cellular protein
b. maintains acid/base balance and pressure in the cell.
c. The “bouncer”, decides what goes in and out.
d. Keeps K+ in, Na+ out.
e. Maintains osmotic pressure.
f. If protein is missing, fluid flows in and out. This explains swollen stomach of protein malnutrition (Kwashiorkor).
g. If above a certain level in urine, kidneys won’t function properly.
h. The half life of albumin is 21 days. That means 21 days before you see a change of level in the urine. B/c albumin takes such a long time to change, we use pre-albumin tests. In these we see the effects of change quicker.
2. hematological (blood tests): tests for different anemias
3. hydration status (urine tests): dehydrated patients will have higher levels of certain things because the urine is not diluted.
4. diagnostic
D. Other factors
1. gastrointestinal status
2. skin integrity
3. cognition
4. chronic diseases
III Risk factors for malnutrition
A. Poor po (per mouth) intake (<75%> 3 days) (they may not be eating)
(Must eat entree, not just dessert and juice)
B. NPO or clear liquid diet > 5 days
1. Clear liquid diets provide calories but no protein. 3x a day of a clear diet can kill a patient.
2. It is a non-residue diet. No fiber. Purpose is when Dr does not want intestines working before and directly after surgery. Also for certain diagnostic tests. Pt can starve to death if given many surgeries and tests without resting or going on different diet.
C. Low albumin (<3.0 / prealbumin <10) Risk of malnutrition
D. Unintentional weight loss
E. Parenteral / enteral nutrition (see below)
F. Chronic wounds, pressure ulcers: skin integrity is compromised in malnutrition
IV Nutrition Care Plan
A. Process
1. Assess nutritional status (chronic illness? Height, weight, etc)
2. Analyze assessment data
3. Develop nutrition care plan
4. Implement the plan
5. Evaluate and reassess if necessary (after a period of time)
B. Macro nutrient needs
1. calories (depends on cofactors such as wounds or major surgery)
a. 25 – 35 kcal/kg body weight
2. protein (a high protein diet)
a. 1.2 – 1.5 gram/kg body weight
b. RDA = 0.8 gram/kg body weight
3. fluids
a. 1 ml/kcal per day
V Nutrition Therapy (Whenever you are in a health care facility you are considered to be on a “diet”. Not to lose weight. Regular diet, restricted diet, etc.)
A. Oral
1. liquids (most restrictive diet)
a. means foods that are liquid at room temperature.
b. clear
c. full: dairy products, milk, ice cream, yogurt, thin cereal. Pt receives some protein from this.
2. mechanically altered
a. soft
b. chopped
c. pureed
1. baby food is not nutritional (nutritionally dense) enough for adults. Pureed food is better.
3. nutrient restricted
a. low Na
b. low K
c. low fat
4. regular
B. Nutrition support
1. intravenous
2. tube feedings
VI Parenteral nutrition (over the GI tract, bypasses the GI tract)
A. Nutrients delivered intravenously (does not mess with osmolarity of blood)
B. Can provide total nutrition
1. proteins (amino acids)
a. cannot use whole proteins b/c that must go through the GI tract to be digested.
2. carbohydrates (dextrose)
a. dextrose is same as glucose (blood sugar)(***that’s what I wrote, but I’m not sure it is correct. Maybe they are broken down the same way)
3. fats (microlipids) (micro keeps it stable)
4. vitamins (multivitamin solution) (individually water based)
a. fat soluble vitamins ADEK are found only in fat, but there are water based ones for parenteral nutrition. Fat can’t be digested in the blood stream, must go through GI.
5. minerals (electrolytes
6. water
C. Types
1. TPN: Total Parenteral Nutrition
a. delivered via central line
i. jugular or aorta
ii. surgical procedure
iii. large tube allows nutrients to go in fast.
iv. Does not disturb osmolarity of blood
b. meets 100% nutrition needs
c. long term support (> 5 days) (for pts not on a regular diet for more than 5 days)
2. PPN: Peripheral parenteral nutrition
a. delivered through peripheral vein (vein is smaller than the central line, so it is not as concentrated as TPN)
b. short term supplement (< 5 days)
c. meets protein needs (but not caloric, too many calories will blow up the vein)
VII Enteral nutrition
A. tube feedings
1. must have a functioning GI tract
2. must have the ability to digest and/or absorb nutrients (Does not have to digest, but must be able to absorb)
3. If tube is placed in stomach, pt able to digest. Digestion occurs in the duodenum (1st part of small intestine) and stomach. Therefore if there is a tumor in the stomach and they can’t digest, put the tube in the jejunum so it can absorb.
B. types of tubes
1. nasal (short term)
a. nasogastric: tube in stomach, must be able to digest
b. nasojejunal: tube in jejunum, must be able to absorb
2. gastrostomy
a. percutaneous endoscopic gastrostomy (PEG)
i. tube directly into stomach. Done by a surgeon.
ii. can go about normal business.
b. jejunostomy (PEJ)
i. for individuals not able to digest
c. ostomy: opening
VIII Formula selection
A. Standard formula
1. equivalent of a regular diet
2. complete at a reasonable volume
a. 1500 ml = reasonable volume (don’t want to take 8 hrs to deliver feeding)
b. complete: must meet RDA for all nutrients.
c. protein must be digested so can’t have PEJ
3. contains whole protein, protein isolates
4. low osmolarity
5. relatively inexpensive (b/c using alot) $9 - $10 case
B. Hydrolyzed formula
1. elemental (predigested)
a. B/c predigested can be put into PEJ tube.
b. already broken down
2. peptide based and free amino acids (proteins in form of amino acids or very short chains)
3. carbs in simple forms
4. fats in short chains
5. very expensive
C. Modular formula
1. Single nutrient (CHO, protein) Can mix and match to custom make formula.
2. Good if pt needs more of one nutrient than the others. Can add the extra nutrient to a standard formula. Ex: Add extra protein to a standard formula instead of doubling or tripling the amount of standard formula.
3. Added in a way that has no taste, so carbs aren’t sickeningly sweet.
4. Protein shakes that body builders use are modular formulas.
5. Add high protein broths and jello to clear diets for those on a long term clear diet.
D. Disease specific
1. renal: protein, electrolytes, volume controlled
2. hepatic (liver): high branched chain amino acids (check your notes for chain amino acids....metabolized where?)
3. pulmonary: high proteins, low carbs
a. b/c carbs break down into H2O and CO2. Will make the lungs work harder to rid CO2.
b. If lung capacity diminished CO2 will stay in the blood. Don’t want that.
c. Protein makes up for the extra calories missing when you reduce the amount of carbs.
4. glucose intolerance: carbohydrate steady (to avoid high/low sugar)
a. sustained release of carbs to keep blood sugar levels normal
5. trauma: conditionally essential amino acids
a. very expensive
b. Under normal circumstances our body produces more than enough conditionally essential amino acids. During growth or trauma (gun shots, burns, etc) we need more.
IX Distinguishing Characteristics that all formulas must have
A. nutrient density (1.2 kcal/ml) (isocaloric)
1. If cutting down on volume we may raise to 2.0 kcal/ml
B. Osmolarity (isotonic vs. hypertonic)
1. Osmosis: water moving from higher to lower
2. isotonic: equal to body
3. isotonic formula: 300mOsm/Kg H20 (300 milliliters osmos per kg of water)
4. What this means is if the formula is too concentrated, fluid will move out of the cells causing diarrhea, and dehydration. An isotonic solution or close to 300mOsm is best.
C. residue and fiber
1. soluble fiber will absorb water (gel up) to form stool and stop diarrhea
2. fiber helps with constipation
D. fructo-oligo-saccharides: short chained saccharide group
1. oligo: scant. No flavor. Breaks down into di & mono
E. Arginine and glutamine (conditionally essential amino acids)
1. If pt not eating, villi in intestines will dry up. Bacteria will grow in-between the villi. Then the bacteria will go into the body and cause sepsis. (Bacterial translocation)
2. Glutamine will prevent this. Even if pt not eating, a drop of glutamine will be enough.
F. Phytochemicals: may help prevent disease/chronic illness
X Enteral Nutrition Complications
A. aspiration: possibly resulting in pneumonia
1. liquids entering the lungs
2. most critical
B. hydration status: over hydration or dehydration
1. we need to hydrate at a reasonable volume to prevent this
2. ratio of solvent to solute must be correct
C. GI tolerance: nausea, vomiting, diarrhea, constipation
D. Malabsorption: impaired digestion or absorption
E. Contamination: microbial
1. big issue
2. temp can add to problem. For example, if we are pureeing meat and the meat has been left on the counter, microbes can enter.