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Nutrition Therapy and Pathophysiology | 3eNelms | Sucher | Lacey | Roth

Marcia Nelms, PhD, RD, LDDiane Habash, PhD, RD, LD

The Ohio State University

Nutrition Assessment:Foundation of the Nutrition Care

Process

Chapter 3

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Nutrition Assessment

• Foundation of the nutrition care process• Systematic method for obtaining, verifying,

and interpreting data• Identifies nutrition-related problems, their

causes, and significance

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Nutritional Status

• Reflects nutrient stores– Excesses vs. deficiency

• Determination of nutritional risk– Need to understand pathophysiology,

treatment, and clinical course of disease

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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

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Subjective Data Collection

• Obtained during interviews– From patient, family members, significant

others, client’s perception• Interviewer’s observations• See Table 3.1

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Subjective Food- and Nutrition-Related History Assessment

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Objective Data Collection

• Information from a verifiable source such as medical record

• See Table 3.2

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Objective Nutrition Assessment Information with Examples

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Client History

• Collected through patient interview– Economic situation– Support systems – Food insecurity: See Figure 3.1

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Prevalence of Food Insecurity, Average 2010–2012

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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

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Tools for Data Collection

• DETERMINE checklist• Subjective Global Assessment• Malnutrition Screening Tool (MST)• Malnutrition Universal Screening Tool

(MUST)– Sensitivity and specificity

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Food and Nutrition Related History

• General types– Retrospective– Prospective

• Key qualities– Validity– Reliability

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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

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A 24-Hour Recall Form

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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

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A Food Diary

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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

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Example of a Food Frequency Instrument: MEDFICTS

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Nutrition Care Indicator

• Observation of food intake/“calorie count”– Food weighed before and after intake– Measures “actual” intake

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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

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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

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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

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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

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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

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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

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Mid-Upper Arm Muscle Area in Adults

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Nutrition Care Criteria: Skinfold Measure

• Interpretation and evaluation of skinfold measure– At risk: < 5th or > 95th percentiles– See Table 3.7

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Interpretation of Triceps Skinfold Measurements

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Nutrition Care Indicator: Biolectrical Impedance Analysis (BIA)

• Based on conduction of electric current through fat and bone

• See Figure 3.17

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Bioelectrical Impedence Analysis (BIA)

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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

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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

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DXA

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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

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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

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Expected 24-Hour Creatinine Excretion

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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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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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Visceral Protein Assessment Overview

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Other Biochemical Assessments

• Immunocompetence– Total lymphocyte count (TLC)

• Hematological assessment– See Table 3.10

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Routine Admission Laboratory Measurements

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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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Other Labs with Clinical Significance

• Lipid status• Electrolytes• BUN• Creatinine (Cr)• Serum glucose• Vitamin/mineral assessment

– Not routinely done

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Nutrition-Focused Physical Findings

• Assess for signs and symptoms consistent with malnutrition or nutrient deficiencies

• Inspection, palpation, percussion, and auscultation

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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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ADLs

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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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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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Indirect Calorimetry: The Most Accurate Method

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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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Applying Evidence-Based Guidelines

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Estimation of Energy Requirements

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Energy Requirements of Common Daily Activities

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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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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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Etiology-Based Malnutrition Definitions