NutritionalNutritional AssessmentAssessment

IDENTIFICATION OF NUTRITIONAL IDENTIFICATION OF NUTRITIONAL DEFICIENCIESDEFICIENCIES

CLASSIFICATION OF MALNUTRITIONCLASSIFICATION OF MALNUTRITION

ESTIMATION OF NUTRITIONAL ESTIMATION OF NUTRITIONAL REQUIRMENTSREQUIRMENTS

Nutritional AssessmentNutritional Assessment

S.O.A.P.S.O.A.P.

SUBJECTIVE DATASUBJECTIVE DATA

OBJECTIVE DATAOBJECTIVE DATA

ASSESSMENTASSESSMENT

PLANPLAN

Nutritional AssessmentNutritional AssessmentNutrition Support TeamNutrition Support Team

PhysicianPhysician Dietitian Dietitian- - DiagnosisDiagnosis - Nutritional Assessment - Nutritional Assessment

- Placement of CVC- Placement of CVC - Enteral Nutrition - Enteral Nutrition- Team Leader- Team Leader - Transitional Feedings - Transitional Feedings

NurseNurse Pharmacist Pharmacist- Maintenance of CVC- Maintenance of CVC - Admixture Preparation - Admixture Preparation- Physical Assessment - Admixture Formulation- Physical Assessment - Admixture Formulation- Patient Training- Patient Training - Drug-Nutrient - Drug-Nutrient

InteractionsInteractions

Nutritional Nutritional AssessmentAssessmentSUBJECTIVE DATASUBJECTIVE DATA

• USUAL WEIGHTUSUAL WEIGHT

• RECENT CHANGES IN WEIGHTRECENT CHANGES IN WEIGHT

• FOOD ALLERGIES/ INTOLERANCESFOOD ALLERGIES/ INTOLERANCES

• SPECIAL DIETSPECIAL DIET

• 24 HOUR DIETARY RECALL24 HOUR DIETARY RECALL

Nutritional Nutritional AssessmentAssessmentSUBJECTIVE DATASUBJECTIVE DATA

• FOOD DRUG INTERACTIONSFOOD DRUG INTERACTIONS

• ALCOHOL / DRUG ABUSEALCOHOL / DRUG ABUSE

• VITAMIN / MINERAL SUPPLIMENTSVITAMIN / MINERAL SUPPLIMENTS

• ECONOMICSECONOMICS

• ACTIVITYACTIVITY

Nutritional Nutritional AssessmentAssessmentBODY COMPARTMENTSBODY COMPARTMENTS

SKELETON 10%

EXTRACELLULAR 20%

PLASMA PROTEIN 3%

VISCERAL PROTEINS 8%

SOMATIC PROTEINS 30%

ADIPOSE TISSUE 25%

Nutritional Nutritional AssessmentAssessmentBODY COMPARTMENTSBODY COMPARTMENTS

Serum Albumin, Transferrin

Arm Muscle CircumferenceBody WeightCreatinine Height Index

ASSESSED BYTriceps SkinfoldBody Weight

SKELETON 10%

EXTRACELLULAR 20%

PLASMA PROTEIN 3%

VISCERAL PROTEINS 8%

SOMATIC PROTEINS 30%

ADIPOSE TISSUE 25%

Nutritional AssessmentNutritional AssessmentOBJECTIVE DATAOBJECTIVE DATA

SOMATIC COMPARTMENTSOMATIC COMPARTMENT

• WEIGHT (ACTUAL)WEIGHT (ACTUAL)

• HEIGHTHEIGHT

• IDEAL BODY WEIGHT (IBW)IDEAL BODY WEIGHT (IBW)

FEMALE:IBW=100 LB +(5 LB X EVERY INCH >5 FT)FEMALE:IBW=100 LB +(5 LB X EVERY INCH >5 FT)

MALE: IBW=106 lb +(6 lb FOR EVERY INCH >5 FT)MALE: IBW=106 lb +(6 lb FOR EVERY INCH >5 FT)

Nutritional AssessmentNutritional AssessmentOBJECTIVE DATAOBJECTIVE DATA

SOMATIC COMPARTMENTSOMATIC COMPARTMENT

• ANTHROPOMETIRICSANTHROPOMETIRICS

• MID ARM CIRCUMFERENCE (MAC)MID ARM CIRCUMFERENCE (MAC)

• TRICEPS SKIN FOLD (TSF)TRICEPS SKIN FOLD (TSF)

• MID ARM MUSCLE CIRUMFERENCE (MAMC)MID ARM MUSCLE CIRUMFERENCE (MAMC)

MAMC=MAC MAMC=MAC cmcm – (TSF – (TSF mm mm X 0.314)X 0.314)

Nutritional AssessmentNutritional AssessmentOBJECTIVE DATAOBJECTIVE DATA

SOMATIC COMPARTMENTSOMATIC COMPARTMENT

< 800800-11991200-2000> 2000Total Lymphocyte Count (TLC)

2-3 d<55-1010-15>15Prealbumin

8 d<100100-150151-200>200Transferrin

20 d< 2.12.1-3.03.1-3.5> 3.5Albumin

t 1/2Severe ModerateMildNormalMARKER

Nutritional Nutritional AssessmentAssessmentCLASSIFICATION OF MALNUTRITIONCLASSIFICATION OF MALNUTRITION

• MARASUS MARASUS -DEPLETION IN THE SOMATIC -DEPLETION IN THE SOMATIC

COMPARTMENTCOMPARTMENT

• KWASHIORKORKWASHIORKOR -DEPLETION IN THE VISCERAL -DEPLETION IN THE VISCERAL

COMPARTMENTCOMPARTMENT

• MARASMUS-KWASHIORKOR MIXMARASMUS-KWASHIORKOR MIX -DEPLETION IN BOTH COMPARTMENTS-DEPLETION IN BOTH COMPARTMENTS

Nutritional Nutritional AssessmentAssessmentCASE STUDYCASE STUDY

Ms. A. is a 35-Y-O female that has been trapped in Ms. A. is a 35-Y-O female that has been trapped in chocolate factory for the past five months. She is 5 ft. tallchocolate factory for the past five months. She is 5 ft. talland weighs 200 lbs. She has been admitted to the hospitaland weighs 200 lbs. She has been admitted to the hospitalfor evaluation, following this traumatic experience. Onfor evaluation, following this traumatic experience. Onadmission her albumin is 2.0 and transferrin is 100.admission her albumin is 2.0 and transferrin is 100.

• What is her IBW?What is her IBW?

• Calculate her % of IBWCalculate her % of IBW

• What is her nutritional diagnosis?What is her nutritional diagnosis?

Nutritional Nutritional AssessmentAssessmentCASE STUDYCASE STUDY

Ms. A. is a 35-Y-O female that has been trapped in Ms. A. is a 35-Y-O female that has been trapped in chocolate factory for the past five months. She is 5 ft. tallchocolate factory for the past five months. She is 5 ft. talland weighs 200 lbs. She has been admitted to the hospitaland weighs 200 lbs. She has been admitted to the hospitalfor evaluation, following this traumatic experience. Onfor evaluation, following this traumatic experience. Onadmission her albumin is 2.0 and transferrin is 100.admission her albumin is 2.0 and transferrin is 100.F.F. What is her IBW?What is her IBW?

IBW = 100 lb + (5 X EVERY in OVER 5 ft)IBW = 100 lb + (5 X EVERY in OVER 5 ft)

IBW = IBW = 100 lb100 lb

I.I. Calculate her % of IBW Calculate her % of IBW ACTUAL WT / IBW = % IBWACTUAL WT / IBW = % IBW

200 lb / 100 lb = 200 lb / 100 lb = 200% IBW200% IBW• What is her nutritional diagnosis? What is her nutritional diagnosis? KWASHIORKORKWASHIORKOR

Nutritional Nutritional AssessmentAssessmentCASE STUDYCASE STUDY

Mr. B is a 24-Y-O male that has recently been returnedMr. B is a 24-Y-O male that has recently been returnedfrom captivity on a south sea island, where he was heldfrom captivity on a south sea island, where he was heldprisoner by 15 women. He is 6 ft. tall and weighs 125 lbs.prisoner by 15 women. He is 6 ft. tall and weighs 125 lbs.Upon admission to the hospital his serum albumin is 3.5 Upon admission to the hospital his serum albumin is 3.5 and his transferring is 175.and his transferring is 175.

H.H. B. What is his IBW?B. What is his IBW?

J.J. Calculate his % of IBW Calculate his % of IBW

• What is his nutritional diagnosis?What is his nutritional diagnosis?

Nutritional Nutritional AssessmentAssessmentCASE STUDYCASE STUDY

Mr. B is a 24-Y-O male that has recently been returnedMr. B is a 24-Y-O male that has recently been returnedfrom captivity on a south sea island, where he was heldfrom captivity on a south sea island, where he was heldprisoner by 15 women. He is 6 ft. tall and weighs 125 lbs.prisoner by 15 women. He is 6 ft. tall and weighs 125 lbs.Upon admission to the hospital his serum albumin is 3.5 Upon admission to the hospital his serum albumin is 3.5 and his transferring is 175.and his transferring is 175.F.F. B. What is his IBW?B. What is his IBW?

IBW = 106 lb + (6 X EVERY in OVER 5 ft)IBW = 106 lb + (6 X EVERY in OVER 5 ft)

IBW = IBW = 178 lb178 lb

I.I. Calculate his % of IBW Calculate his % of IBW ACTUAL WT / IBW = % IBW ACTUAL WT / IBW = % IBW

125 lb / 178 lb = 125 lb / 178 lb = 70% IBW70% IBW• What is his nutritional diagnosis? What is his nutritional diagnosis? MARASMUSMARASMUS

Nutritional Nutritional AssessmentAssessmentESTIMATION OF CALORIC REQUIRMENTSESTIMATION OF CALORIC REQUIRMENTS

HARRIS BENEDICT EQUATIONSHARRIS BENEDICT EQUATIONS

MALEMALEBEE = 66 + (13.7 X Wt) + (5 X Ht) – (6.8 X Age)BEE = 66 + (13.7 X Wt) + (5 X Ht) – (6.8 X Age)

FEMALEFEMALEBEE=655 + (9.6 X Wt) + (1.7 X Ht) – (4.7 x Age)BEE=655 + (9.6 X Wt) + (1.7 X Ht) – (4.7 x Age)

Wt in Kg Ht in cm Age in yearsWt in Kg Ht in cm Age in years

Nutritional Nutritional AssessmentAssessmentESTIMATION OF CALORIC REQUIRMENTSESTIMATION OF CALORIC REQUIRMENTS

HARRIS BENEDICT EQUATIONSHARRIS BENEDICT EQUATIONS

CAL REQ=BEE X ACTIVITY FACTOR X INJURY FACTORCAL REQ=BEE X ACTIVITY FACTOR X INJURY FACTOR

ACTIVITY FACTORSACTIVITY FACTORS• 1.2 CONFINED TO BED1.2 CONFINED TO BED• 1.3 AMBULATORY1.3 AMBULATORY• 1.4 ACTIVE1.4 ACTIVE

Nutritional Nutritional AssessmentAssessmentESTIMATION OF CALORIC REQUIRMENTSESTIMATION OF CALORIC REQUIRMENTS

HARRIS BENEDICT EQUATIONSHARRIS BENEDICT EQUATIONS

CAL REQ=BEE X ACTIVITY FACTOR X INJURY FACTORCAL REQ=BEE X ACTIVITY FACTOR X INJURY FACTOR

INJURY FACTORSINJURY FACTORS 1-1.2 MINOR SURGERY 1-1.2 MINOR SURGERY

2.1 SEVERE THERMAL BURN2.1 SEVERE THERMAL BURN1.2-1.5 PERITONITIS1.2-1.5 PERITONITIS 1.35 SKELETAL TRAUMA1.35 SKELETAL TRAUMA1.4-1.8 SEPSIS1.4-1.8 SEPSIS 1.75 AIDS1.75 AIDS1.14-1.37 SOFT TISSUE TRAUMA1.14-1.37 SOFT TISSUE TRAUMA

Nutritional Nutritional AssessmentAssessmentESTIMATION OF CALORIC REQUIRMENTSESTIMATION OF CALORIC REQUIRMENTS

SHORT CUT METHODSHORT CUT METHOD

• MAINTENANCE: MAINTENANCE: 30 KCAL/KG30 KCAL/KG

• MODERATE STRESS: 35 KCAL/KGMODERATE STRESS: 35 KCAL/KG

• SEVERE STRESS: SEVERE STRESS: 40 KCAL/KG40 KCAL/KG

(CRITICAL CARE PATIENT – PROVIDE (CRITICAL CARE PATIENT – PROVIDE 25 KCAL/KG)25 KCAL/KG)

Nutritional Nutritional AssessmentAssessmentESTIMATION OF PROTEIN REQUIRMENTSESTIMATION OF PROTEIN REQUIRMENTS

CALORIE TO NITROGEN RATION 150:1CALORIE TO NITROGEN RATION 150:1(1 GM NITROGEN = 150 KCAL)(1 GM NITROGEN = 150 KCAL)

1 GM NITROGEN =6.25 GM PROTEIN1 GM NITROGEN =6.25 GM PROTEIN

PROTEIN = PROTEIN = CAL X 1GM N/150 KCAL X 6.25 GM PRO/GM NCAL X 1GM N/150 KCAL X 6.25 GM PRO/GM N

EXAMPLE: EXAMPLE: 2000 KCAL /150 X 6.25 = 83.3 GM PRO2000 KCAL /150 X 6.25 = 83.3 GM PRO

Nutritional Nutritional AssessmentAssessmentESTIMATION OF PROTEIN REQUIRMENTSESTIMATION OF PROTEIN REQUIRMENTS

BASED ON WEIGHTBASED ON WEIGHT

0.5HEPATIC FAILURE

1-1.2RENAL FAILURE /DIALYSIS

0.8-1CHRONIC RENAL FAILURE

0.5-0.8ACUTE RENAL FAILURE

2MULTIPLE TRAUMA

0.8-1NORMAL PATIENT

GM/KG/DAYPATIENT STATUS

Nutritional Nutritional AssessmentAssessmentNitrogen BalanceNitrogen Balance

NNbalancebalance = N = Ninin – N – Noutout

= N= Ninin – (UUN+3) – (UUN+3)

Goal: Positive nitrogen balance of Goal: Positive nitrogen balance of 4-6 gm/day.4-6 gm/day.

Nutritional Nutritional AssessmentAssessmentNitrogen BalanceNitrogen Balance

What is the nitrogen balance of a What is the nitrogen balance of a patient who takes in 65 gm of protein patient who takes in 65 gm of protein per day in an enteral feeding and has a per day in an enteral feeding and has a measured 24 hr UNN of 7.2gm?measured 24 hr UNN of 7.2gm?

NNbalance balance = N= Ninin – (UUN+3) – (UUN+3)

=(65gm pro x =(65gm pro x 1gm N1gm N ) - ( 7.2gm+3gm) ) - ( 7.2gm+3gm) 6.25gm pro6.25gm pro

= 10.4 gm – 10.2 gm = (-0.2gm)= 10.4 gm – 10.2 gm = (-0.2gm)