SING 3

Nutrition Assessment in Challenging Patients

Enrico N. Cembrano, R.N-D

October 8, 2014

Outline

Learning Objectives

I. Anthropometrics

II. Nutrition Assessment in Challenging Cases

III. Key Points

Learning Objectives

1. Identify cases where specialized nutrition assessment is needed.

2. Explain assessment methods and related equations.

3. Apply and integrate the learned information to actual practice.

4. Realize the value of accurate nutrition assessment as part of nutrition care management.

Assessment (and Re-

Assessment)

Diagnosis

Intervention

Monitoring and

Evaluation

*Adapted from the Academy of Nutrition and Dietetics

The Nutrition Care Process*

Screening

Nutrition Assessment’s

Basic Components

• Height

• Weight (incl. changes)

• BMI

• Waist circumference

• CBC

• Electrolytes

• Serum proteins

• Relevant blood exams

• Urinalysis

• Fecalysis

• Vital signs

• General physical

assessment (skin,

muscle, face)

• Fluid status

• Bowel habits

• Food intake record

or Food intake recall

• FFQ

• Food allergies

• Food habits/

preferences

• Medical

• Drug

• Psycho social

PART II

Anthropometrics • Knee Height

• Arm Span

• Ulna Length

• Desirable Body Weight

• Adjusted weight for amputees

• Evaluation of body weight & weight loss

Knee Height

Height Estimation Formula using

Knee Height Females: 𝐻𝑡 (𝑐𝑚) = 84.88 − (0.24 𝑥 𝑎𝑔𝑒 𝑖𝑛 𝑦𝑟) + (1.83 𝑥 𝑘𝑛𝑒𝑒 ℎ𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑐𝑚)

Males: 𝐻𝑡 𝑐𝑚 = 64.19 − 0.04 𝑥 𝑎𝑔𝑒 𝑖𝑛 𝑦𝑟 + (2.02 𝑥 𝑘𝑛𝑒𝑒 ℎ𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑐𝑚)

Example: 80 year old male, knee height of 50 cm

𝐻𝑡 𝑐𝑚 = 64.19 − 0.04 𝑥 𝟖𝟎 + (2.02 𝑥 𝟓𝟎)

𝐻𝑡 𝑐𝑚 = (64.19 − 𝟑. 𝟐) + (𝟏𝟎𝟏)

𝐻𝑡 𝑐𝑚 = 𝟔𝟏 + 𝟏𝟎𝟏

𝑯𝒕 𝒄𝒎 = 𝟏𝟔𝟐

*2007 ASPEN Nutrition Support Core Curriculum

Height Estimation Formula using

Knee Height (FILIPINOS)

Females: 𝐻𝑡 𝑐𝑚 = 89.68 + 1.53 𝑥 𝑘𝑛𝑒𝑒 ℎ𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑐𝑚 − (0.17 𝑥 𝑎𝑔𝑒 𝑖𝑛 𝑦)

Males: 𝐻𝑡 𝑐𝑚 = 96.5 + 1.38 𝑥 𝑘𝑛𝑒𝑒 ℎ𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑐𝑚 − (0.08 𝑥 𝑎𝑔𝑒 𝑖𝑛 𝑦)

Example: 80 year old male, knee height of 50 cm

𝐻𝑡 𝑐𝑚 = 96.5 + 1.38 𝑥 𝟓𝟎 − (0.08 𝑥 𝟖𝟎)

𝐻𝑡 𝑐𝑚 = (96.5 + 𝟔𝟗) − 𝟔. 𝟒

𝐻𝑡 𝑐𝑚 = 𝟏𝟔𝟓. 𝟓 − 𝟔. 𝟒

𝑯𝒕 𝒄𝒎 = 𝟏𝟓𝟗. 𝟏

Tanchoco et al, Arm span and knee height as proxy indicators for height. J Nutritionist-Dietitians’ Assoc Philippines 2001;15:84-90.)

Demispan

Source: HIckson M, Frost G. A comparison of three methods for estimating height in the acutely ill elderly population. J Hum Nutr

Diet 2003;6:1-3. In “A guide to completing the Mini Nutritional Assessment Short Form (MNA-SF)”

Females:

𝐻𝑡 𝑐𝑚 = 1.35 𝑥 𝑑𝑒𝑚𝑖𝑠𝑝𝑎𝑛 𝑐𝑚 + 60.1

Males:

𝐻𝑡 𝑐𝑚 = 1.4 𝑥 𝑑𝑒𝑚𝑖𝑠𝑝𝑎𝑛 𝑐𝑚 + 57.8

Ulna Length

Souce: http://www.bapen.org.uk/pdfs/must/must_explan.pdf

Desirable Body Weight (DBW)

Estimation

1. Tannhauser’s Method

𝐷𝐵𝑊 𝑘𝑔 = 𝐻𝑡 𝑐𝑚 − 100 (Deduct 10% to the answer for Filipino stature/ small frame)

2. Hamwi Method 𝑀𝑎𝑙𝑒: 106 𝑙𝑏𝑠 48 𝑘𝑔 𝑎𝑡 5 𝑓𝑡 152 𝑐𝑚

+ 6 lbs (2.7 kg) for every inch over 5 ft.

𝐹𝑒𝑚𝑎𝑙𝑒: 100 𝑙𝑏𝑠 45 𝑘𝑔 𝑎𝑡 5 𝑓𝑡 + 5 lbs (2.3 kg) for every inch over 5 ft.

Then Apply ± 10 lbs (4.5 kg) for large/ small frame individuals.

Diet Manual, Nutritionist- Dietitian’s Association of the Philippines, 2010

Adjusted Weight for Amputees

Steps

1. Establish pre- amputation

Ideal Body Weight (PA-IBW).

2. Determine the total % of

missing body parts.

3. Get the missing wt by

multiplying total % missing

body parts to PA-IBW

4. Subtract the missing body

weight to the PA-IBW

Example

Below Knee Amputation, Left

1. IBW (pre BKA)- 60 kg

2. BKA % value- 5.9

3. Missing wt =

60 kg x .059 = 3.5 kg

4. Adjusted wt =

60 kg - 3.5 kg = 56.5 kg

Modified from Morris J, Dietitian’s Guide to Assessment and Documentation, Jones and Bartlett Publishers, 2011

Osterkamp LK. Journal of the American Dietetic Association, 1995;95:215-218 in Nutrition Screening and Assessment, ASPEN

Nutrition Support Core Curriculum , 2007

Percent Body Weight Contributed by Individual Body Parts

Evaluation of Body Weight

% 𝐼𝐵𝑊 =𝐶𝑢𝑟𝑟. 𝑤𝑡.

𝐼𝐵𝑊 𝑥 100

% IBW Degree of Malnutrition

80-90 Mild

70-79 Moderate

0-69 Severe

*Adapted from Blackburn G and Bistrian B. Nutritional and Metabolic Assessment of the Hospitalized Patient. J Parenter Enteral Nutr.

1977;1(1):11-22, in Nutrition Screening and Assessment, ASPEN Nutrition Support Core Curriculum , 2007

Evaluation of Weight Loss

% 𝒓𝒆𝒄𝒆𝒏𝒕 𝒘𝒕 =𝒖𝒔𝒖𝒂𝒍 𝒘𝒕 𝑼 − 𝒄𝒖𝒓𝒓𝒆𝒏𝒕 𝒘𝒕(𝑪)

𝒖𝒔𝒖𝒂𝒍 𝒘𝒕 (𝑼)𝒙 𝟏𝟎𝟎

Time Significant

Loss (%)

Severe

Loss (%)

1 wk. 1 to 2 > 2

1 mo. 5 > 5

3 mos. 7.5 > 7.5

6 mos. 10 > 10

*Adapted from Blackburn G and Bistrian B. Nutritional and Metabolic Assessment of the Hospitalized Patient. J Parenter Enteral Nutr.

1977;1(1):11-22, in Nutrition Screening and Assessment, ASPEN Nutrition Support Core Curriculum , 2007

Nutrition Assessment and Risk Level

PART III

Nutrition Assessment in

Challenging Cases

• Thermal Burns

• Chronic Kidney Disease

• Chronic Liver Disease

Burn Classification

Burn Severity

https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=111&seg_id=2138, accessed Sept 15, 2014

Severity Children & Elderly Adults

Minor <10% TBSA <15% TBSA

Or full- thickness burns <2% TBSA

Moderate 10- 20% TBSA 15- 25% TBSA

Or full- thickness at <10% TBSA (non- critical areas)

Severe

>20% TBSA >25% TBSA

Or full- thickness (3rd degree) at >10% TBSA

Burns in critical areas*

Complicated burns (e.g. with DM, CKD, elderly)

TBSA- Total Body Surface Area

*Critical areas- face, hands, feet, genitalia, perineum, major joints

“Rule of

Nines”

Nelms, et al.,, 2010

Consequences

Burn Injury

• Fluid and electrolyte imbalance

• Accelerated loss of Lean Body Mass (LBM)

• High risk for infection

• Hyperglycemia

• Reduce evaporative water losses.

• Restore fluid and electrolyte balance.

• Promote wound healing and graft retention.

• Achieve positive nitrogen balance.

• Avoid overfeeding.

• Restore skin’s protection.

Nutrition Management Objectives

Escott- Stump S, Nutrition and Diagnosis- Related Care (2011)

Nutrition Assessment

• Height

• Weight (pre- burn)

• BMI

• Daily wt. changes

• Measured EE

• SAlbumin, prealbumin (˅)

• CRP

• SGOT (˄)

• Alk Phos (˄)

• Glucose (˄)

• Na+(˅),K+,Ca++,Mg++

• Chol, TG

• WBC, TLC

• pCO2, pO2

• Nitrogen balance

• Burn classification &

severity

• Edema

• Fluid status

• Vital signs (BP,

temp, RR, HR)

• Allergies

• Intake VS requirements

• Co- morbidities

• Drug Hx

PEW in CKD

Ikizler et al, Kidney International (2013) 84, 1096–1107; doi:10.1038/ki.2013.147;

• Retard progression of renal failure

• Maintain or improve nutritional status

• Preserve lean body mass

• Control uremic symptoms and reduce

complications.

• Control blood pressure.

• Control blood glucose and lipid levels.

• Maintain optimal quality of life

Nutrition Management Objectives

Escott- Stump S, Nutrition and Diagnosis- Related Care (2011)

Nutrition Assessment

• Height

• Weight (actual, usual

and dry)

• BMI

• Waist circumference

• MUAC, TSF

• Urinalysis (Albumin, crea ratio)

• Albumin, transferrin

• Crea, BUN, Uric Acid

• GFR, Cystatin-C

• Na+, K+, Ca++, Phos, Mg+

• S. bicarbonate

• Glucose, HbA1c

• Lipid profile (TChol, TG)

• Nitrogen Balance

• Edema

• Fluid status

• BP

• Muscle wasting

• Handgrip Strength

• Gen. Physical

assessment

• Allergies

• Appetite/ taste changes

• Food preferences/ habits

• Food record/ recall

• Intake VS requirements (kcal, protein, fat, Na+, K+, Ca++,

Phos, fluid, vitamins & minerals)

• Co- morbidities

(DM, HPN)

• Dialysis frequency

• Socio- eco

Relevant Blood Tests CKD stage

related

Infection/

Inflammation

related

Malnutrition related

Albumin (˅)

Alkaline Phos.

PTH ˄ or ˅

BUN

K+ (˄)

Phos (˄)

S.Bicarbonate (˅)

Albumin (˅)

CRP (˄)

Ferritin (˄)

Creatinine (˅)

Ferritin (˅)

Prealb./Transthyretin (˅)

Glucose (˅)

Cholesterol (˅)

Na+, K+ (˅)

Ionized Ca++, Mg++ (˅)

Phos (˅)

Adjusted edema- free body weight

Use if actual edema- free BW is <95% or >115% of SBW

aBWef = BWef + [(SBW - BWef) x 0.25] Where: BWef = actual edema- free body weight (post- HD/ post- drain CPD)

SBW = Standard/ Ideal body weight

Example:

Male, Ht = 1.7 m, actual BW = 80 kg (127% SBW), IBW = 63 kg

aBWef = 80 + [(63 – 60) x 0.25]

= 80 + [-17 x 0.25]

= 80 – 4.3

= 75.7 or 76 kg

Nutrition in Chronic Renal Failure, K/DOQI Guidelines, American Journal of Kidney Diseases, VOL 35, NO 6,

SUPPL 2, JUNE 2000

Physical Assessment

7- Point

SGA

Rating guide:

7

6

Very Mild/

Normal

5

4

3

Moderate

2

1

Severe

malnutrition

MIS

Summation of

scores:

0 Very Mild/

Normal

30 Severe

malnutrition

Liver Cirrhosis and Malnutrition

Bemeur et al, Role of Nutrition in the Management of Hepatic Encephalopathy in End-Stage Liver Failure, Journal of Nutrition and

Metabolism, 2010,doi:10.1155/2010/489823

Nutrition Management Objectives

• Delay progression of scar tissue and support

Residual liver function.

• Provide supportive treatment for ascites, edema,

muscle wasting, weight loss, esophageal varices

and portal hypertension

• Provide adequate nutrition to maintain/ replete

nutritional stores

• Correct nutritional deficiencies

Escott- Stump S, Nutrition and Diagnosis- Related Care (2011)

Nutrition Assessment

• Height

• Weight (ideal/ dry

wt.)

• BMI

• MUAC, TSF

• Edema/ Ascites

• Bowel changes

• Muscle wasting

• Handgrip Strength

• Physical assessment

• Behavioral changes

• Allergies

• Appetite/ taste changes

• Food preferences/

habits

• Food record/ recall

• Intake VS requirements

• Co-

morbidities

• Socio- eco.

• CBC, WBC

• ALT, AST(˄)

• PT (prolonged?), INR

• Crea, Bilirubin (˄), Alk Phos (˄)

• S. ammonia (˄?)

• Alb (˅), Globulin, Transferrin

• Trig (˄), Chol (˅?), Gluc (˄/ ˅?)

• Na+, K+, Ca++, Mg+

Physical

Assessment

Jaundice

Ascites

Abdominal Veins

Palm Erythema

Bruises

Ankle edema

Muscle wasting

Escott- Stump S, Nutrition and Diagnosis-

Related Care (2011)

Royal Free Hospital- Global Assessment

(RFH-GA)

Morgan et al, HEPATOLOGY, Vol. 44, No. 4, 2006, 823-35

Key Points

• Nutritional assessment should be individualized.

• No single parameter can predict nutrition status.

• Most parameters obtained during assessment should also be monitored.

• Effective nutrition management depends on an accurate and concise nutrition assessment.