NTP chapter 3
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Transcript of NTP chapter 3
© Cengage Learning 2016
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