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NTP chapter 3
1.
© Cengage Learning
2016 Nutrition Therapy and Pathophysiology | 3e Nelms | Sucher | Lacey | Roth Marcia Nelms, PhD, RD, LD Diane Habash, PhD, RD, LD The Ohio State University Nutrition Assessment: Foundation of the Nutrition Care Process Chapter 3
2.
© Cengage Learning
2016 Nutrition Assessment • Foundation of the nutrition care process • Systematic method for obtaining, verifying, and interpreting data • Identifies nutrition-related problems, their causes, and significance
3.
© Cengage Learning
2016 Nutritional Status • Reflects nutrient stores – Excesses vs. deficiency • Determination of nutritional risk – Need to understand pathophysiology, treatment, and clinical course of disease
4.
© Cengage Learning
2016 An Overview: Nutrition Assessment and Screening • AND – “Process of identifying patients, clients, or groups who process of gathering key pieces of information correlated to nutrition risk” – Standards of Practice include nutrition assessment • JCAHO – Screening must be done within 48 hours of admission
5.
© Cengage Learning
2016 Subjective Data Collection • Obtained during interviews – From patient, family members, significant others, client’s perception • Interviewer’s observations • See Table 3.1
6.
© Cengage Learning
2016 Subjective Food- and Nutrition- Related History Assessment
7.
© Cengage Learning
2016 Objective Data Collection • Information from a verifiable source such as medical record • See Table 3.2
8.
© Cengage Learning
2016 Objective Nutrition Assessment Information with Examples
9.
© Cengage Learning
2016 Client History • Collected through patient interview – Economic situation – Support systems – Food insecurity: See Figure 3.1
10.
© Cengage Learning
2016 Prevalence of Food Insecurity, Average 2010–2012
11.
© Cengage Learning
2016 Information Regarding Education, Learning & Motivation • Ability to communicate • Education level, attention span, and readiness to learn • History of previous nutrition interventions and response to them
12.
© Cengage Learning
2016 Tools for Data Collection • DETERMINE checklist • Subjective Global Assessment • Malnutrition Screening Tool (MST) • Malnutrition Universal Screening Tool (MUST) – Sensitivity and specificity
13.
© Cengage Learning
2016 Food and Nutrition Related History • General types – Retrospective – Prospective • Key qualities – Validity – Reliability
14.
© Cengage Learning
2016 Nutrition Care Indicator: Twenty-Four Hour Recall • Recall of all food and drink for a 24 hr. period • USDA multiple pass approach • Advantages – Short administration time, very little cost, and negligible risk for the client • Disadvantages – May not reflect typical eating patterns
15.
© Cengage Learning
2016 A 24-Hour Recall Form
16.
© Cengage Learning
2016 Nutrition Care Indicator: Food Record/Food Diary • Client documents intake over specified period of time • Advantages – Does not rest on client’s memory and may be more representative of typical eating patterns • Disadvantages – Validity issues if client alters intake or misrepresents intake; substantial burden on client
17.
© Cengage Learning
2016 A Food Diary
18.
© Cengage Learning
2016 Nutrition Care Indicator: Food Frequency • Retrospective – Foods organized into groups and client identifies how often and in what quantities specific foods are consumed • Advantages – Inexpensive and requires minimal time • Disadvantages – Self-administered, so has lower response rates; may not include ethnic or child- appropriate foods
19.
© Cengage Learning
2016 Example of a Food Frequency Instrument: MEDFICTS
20.
© Cengage Learning
2016 Nutrition Care Indicator • Observation of food intake/“calorie count” – Food weighed before and after intake – Measures “actual” intake
21.
© Cengage Learning
2016 Nutrition Care Criteria • Evaluation and interpretation using: – U.S. dietary guidelines – USDA food patterns – Diabetic exchanges/carbohydrate counting – Individual nutrient analysis • Computerized dietary analysis – Daily Values/Dietary Reference Intakes
22.
© Cengage Learning
2016 Anthropometrics • Nutrition care indicator: height/stature – Age < 2 – length – Age > 2 – standing height • Using stadiometer – Alternatives: arm span; knee height • Nutrition care indicator: weight – Balance beam & electronic scales – Wheelchair & bed scales – Amputation calculations
23.
© Cengage Learning
2016 Anthropometrics: Nutrition Care Criteria – Infants/Children • Evaluation and interpretation of height and weight – Growth charts: compare with reference population • Weight for height • Percent weight for height – Body mass index (BMI) • Overweight 85- < 95% of BMI for age • Obesity > 95% of BMI for age • Underweight < 5th percentile
24.
© Cengage Learning
2016 Anthropometrics: Nutrition Care Criteria – Adults • Evaluation and interpretation of height and weight – Usual body weight – Percent usual body weight and percent weight change – Reference weights – Body mass index (BMI) – Waist circumference
25.
© Cengage Learning
2016 Body Composition Measurements • Body composition – distribution of body compartments as part of total weight – Fat mass vs. fat free mass • Fat mass, body water, osseous mineral, protein – Most concerned with metabolically active tissue and fluid status
26.
© Cengage Learning
2016 Nutrition Care Indicator: Skinfold Measurements • Estimates energy reserves in subcutaneous tissue • Advantages – Minimally invasive, requires minimal equipment • Disadvantages – Requires practice for reliable performance • See Figure 3.15
27.
© Cengage Learning
2016 Mid-Upper Arm Muscle Area in Adults
28.
© Cengage Learning
2016 Nutrition Care Criteria: Skinfold Measure • Interpretation and evaluation of skinfold measure – At risk: < 5th or > 95th percentiles – See Table 3.7
29.
© Cengage Learning
2016 Interpretation of Triceps Skinfold Measurements
30.
© Cengage Learning
2016 Nutrition Care Indicator: Biolectrical Impedance Analysis (BIA) • Based on conduction of electric current through fat and bone • See Figure 3.17
31.
© Cengage Learning
2016 Bioelectrical Impedence Analysis (BIA)
32.
© Cengage Learning
2016 Anthropometric/Body Composition Measurements • Nutrition care criteria: interpretation and evaluation of BIA – BIA not appropriate for patients who have experienced major shift in water balance and distrubution • Phase angle should be used
33.
© Cengage Learning
2016 More Nutrition Care Indicators • Hydrostatic (underwater) weighing – Most accurate, less available • Dual energy X ray absorptiometry (DXA) – Considered precise (see Figure 3.18) • Air displacement plethysmography – Comparable to DXA and hydrostatic weighing
34.
© Cengage Learning
2016 DXA
35.
© Cengage Learning
2016 Biochemical Assessment and Medical Tests and Procedures • Measurement of nutritional markers and indicators found in blood, urine, feces, tissue – Protein assessment – Immunocompetence – Hematological – Vitamin/mineral levels – Others
36.
© Cengage Learning
2016 Somatic Protein Assessment • Nutrition care indicator: creatinine height index – Correlates daily urine output of creatinine with height • Nutrition care criteria: interpretation and evaluation of creatinine height index – Uses ratio of 24 hour output to expected output – See Table 3.8
37.
© Cengage Learning
2016 Expected 24-Hour Creatinine Excretion
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2016 Somatic Protein Assessment (cont’d.) • Nutrition care indicator: nitrogen balance – In healthy individual, nitrogen excretion should equal nitrogen intake – Used in critical care, when nutritional support is being provided, and in research – Requires 24 hour urine collection • Nutrition care criteria: interpretation and evaluation of nitrogen balance – Formula accounts for all sources of nitrogen loss
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2016 Protein Assessment • Visceral protein assessment: non skeletal proteins – Albumin – Transferrin – Prealbumin/transthyretin – Retinol binding protein (RBP) – Fibronectin (FN) – Insulin like growth hormone (IGF-1) – C-reactive protein (CRP)
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2016 Visceral Protein Assessment Overview
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2016 Other Biochemical Assessments • Immunocompetence – Total lymphocyte count (TLC) • Hematological assessment – See Table 3.10
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2016 Routine Admission Laboratory Measurements
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2016 Nutrition Care Indicators for Hematological Assessment • Hemoglobin (Hgb) • Hematocrit (Hct) • MCV, MCH, and MCHC • Ferritin, transferrin saturation, protoporphyrin • Serum folate, serum B12
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2016 Other Labs with Clinical Significance • Lipid status • Electrolytes • BUN • Creatinine (Cr) • Serum glucose • Vitamin/mineral assessment – Not routinely done
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2016 Nutrition-Focused Physical Findings • Assess for signs and symptoms consistent with malnutrition or nutrient deficiencies • Inspection, palpation, percussion, and auscultation
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2016 Functional Assessment • Skeletal muscle function or strength – Patient’s perception on Subjective Global Assessment • Perception of self-care abilities and environment – ADL/ IADLs • See Table 3.11 – Handgrip dynamometry • Included in proposed criteria for malnutrition diagnosis
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2016 ADLs
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2016 Nutrition Care Criteria: Energy and Protein Requirements • Indirect calorimetry – BEE + PA + TEF = TEE – Basal energy expenditure (BEE) or basal metabolic rate (BMR) • Approximately 60% of energy requirement • May substitute Resting Energy Requirement (REE) or Resting Metabolic Rate (RMR): approximately 10% higher than BEE
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2016 Indirect Calorimetry • Physical activity (PA) – Most variable – Approximately 15 to 20% of energy requirements • Thermic effect of food (TEF) – Energy needed for absorption, transport, and metabolism of nutrients – Estimated at 10% of energy requirements • See Figure 3.22
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2016 Indirect Calorimetry: The Most Accurate Method
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2016 Estimation of Energy Requirements • Choice of method based on patient condition – See Figure 3.23 • Several prediction equations available – Choice of equation based on patient characteristics – See Table 3.12
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2016 Applying Evidence-Based Guidelines
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2016 Estimation of Energy Requirements
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2016 Energy Requirements of Common Daily Activities
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2016 Protein Requirements • Measurement of protein requirements – Nitrogen Balance • Estimation of protein requirements – RDA for protein • .8 g/kg body weight – Metabolic stress, trauma, and disease • 1-1.5 g/kg – Protein-kilocalorie ratio • 1:200 healthy • 1:150 to 1:100 if requirements higher
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2016 Interpretation of Assessment Data: Nutrition Diagnosis • Determine specific nutrition related problems as identified in nutrition assessment – See Figure 3.24 • International Classification of Disease criteria • Document using PES
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2016 Etiology-Based Malnutrition Definitions
Editor's Notes
Table 3.1 Examples of Subjective Food-/Nutrition-Related History Assessment
Table 3.2 Objective Nutrition Assessment Information with Examples
Figure 3.1 Prevalence of Food Insecurity, Average 2010–2012
Figure 3.4 24-Hour Recall Form
Figure 3.5 Food Diary
Figure 3.6 Example of a Food Frequency Instrument: MEDFICTS
Figure 3.15 Mid-Upper Arm Muscle Area in Adults
Table 3.7 Interpretation of Triceps Skinfold Measurements
Figure 3.17: Bioelectrical Impedence Analysis (BIA).
Figure 3.18: DXA. DXA is increasingly recognized as a reference method to assess body composition.
Table 3.8 Expected 24-Hour Creatinine Excretion in Men and Women of Ideal Weight
Table 3.9 Visceral Protein Assessment Overview
Table 3.10 Routine Admission Laboratory Measurements
Table 3.11 Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL)
Figure 3.22 Indirect Calorimetry The most accurate method of assessing resting energy requirements is to use indirect calorimetry
Figure 3.23 Applying Evidence-Based Guidelines for Estimation of Energy Needs
Table 3.12 Estimation of Energy Requirements
Table 3.13 Energy Requirements of Common Daily Activities
Figure 3.24 Etiology-Based Malnutrition Definitions
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