Nutrition Assessment in the Inpatient Setting Patients with Pressure Ulcers For HMC Wound Care Nurses Katie Farver RD, CNSD Harborview Medical Center Seattle,

Nutrition Assessment in the Inpatient Setting

Patient’s with Pressure UlcersFor HMC Wound Care Nurses

Katie Farver RD, CNSDHarborview Medical Center

Seattle, [email protected]

8-11-09

Components of Nutrition Assessment

Diet History MedicalHistory

Weight History

Body Comp Biochemical Data

Physical Assessment

*Eating Habits*Potential Deficiencies*Reasons for sub-optimal intake*Food Resources

*Conditions effecting digestion or ability to eat*Drug-nutrient interactions

*Actual, Usual and BMI

*Skinfold*Bio-ElectricalImpedance

*Serum Proteins (albumin & prealbumin, CRP)

*Vitamin and mineral assays

*Loss of subcu fat*Muscle wasting*Concave appearance*Hair*Nails

Diet HistoryQuality and quantity of food Intake prior to admit/during admit

Quality and quantity of nutrition Support intake prior to admit/during admit

Medical HistorySample conditions effecting intake

• GI Disease• Chronic Alcoholism• Critical Illness• Stroke• Anorexia Nervosa• Dementia• Pancreatitis• Renal Disease

Sample Drug-Nutrition Interaction

• Insulin• Coumadin• MAOI Inhibitors• HAART • INH

Weight History

• Weight Loss over last 6 months evaluated:– <5% insignificant– 5-10% potentially

significant– >10% significant

• BMI = weight(kg)/height(m)²– <18.5 underweight– 18.5-24.9 normal,

healthy– 24.9-29.9, overweight– >30 obese

Body Composition Measurements

Underwater Weighing Skin Fold Measurements

Biochemical Assessment

Sources of Error• Biological Variation• Preanalytical variation• Analytical variation• Postanalytical variation

Factors Influencing Concentration

• Synthesis rate• Secretion rate• Clearance rate

• Catabolic rate• Distribution• Other

Synthesis rate

• Substrate availability• Hepatic function• Metabolic response to

injury• Corticosteroids• Inflammatory Response

Secretion and Clearance Rate

• Cofactor availability• Hepatic Function• Renal Function

Distribution and Other

• Metabolic response• Hydration • Drainage and fistula

losses• Analytical Method• Patient position on

blood draw

Biochemical Markers of Protein Status

• Assessing Protein-Calorie Malnutrition– Albumin– Pre-Albumin

Serum Protein levels are not reliable during inflammation

Albumin

• Half-life - 20 days• Under/over hydration, liver function• Function– Oncotic pressure, transport, nutritive reserve

• Determinants of synthesis– Oncotic pressure, hormones, negative acute-

phase reactant, nutrition support, aging, drugs

Transthyretin - TTY (Prealbumin)

• Half-life - 1-2 days• Transports thyroid hormones and Vitamin A in

Retinol Binding Protein Complex• Negative acute-phase reactant• > 65% energy needs met, • <50% energy needs met• Elevated in Renal Disease • Elevated with steroid therapy

C-Reactive Protein

• Positive acute-phase protein• Reacts with Somatic C Polysaccharide of

Strep. Pneumoniae• Half-life 5 hours• Changes with acute & chronic inflammation• Helps interpret Transthyretin and Albumin

How many of our patients are not experiencing acute stress?

Biochemical Markers of Micronutrient Status

• Nutritional Anemias– B-12– Iron– Copper

• Vitamins– A– B Vitamins– Vitamin D

• Minerals– Zinc

• Antioxidants– Vitamin C– Vitamin E– Selenium

Lipid and Glycemic Status

• Lipids– Total Cholesterol– HDL/LDLs– Homocysteine– Triglycerides

• Glycemic Control– Blood Glucose– HgA1C

Physical AssessmentPhotos courtesy of Katy Wilkens, MS, RD

NW Kidney Center, Seattle, WA

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Wasted Clavicle

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The Shoulder and Elbow

• The shoulder• Normal: rounded or

sloped• Abnormal: square, can

see acromion process• The elbow well

padded and not showing cartilage definition

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The Arm

• Bend arm and pinch at triceps. Only pinch the fat, not the muscle.

• Normal: fingers don’t meet

• Abnormal: fingers meet

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Forearm

• Forearm: often better site than upper arm for assessing fat

• Upper arm fat disposition changes as women age

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Wasting in the hands

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The calf muscle

• Grip the calf• Normal: muscle

obvious, top of calf is larger than bottom

• Abnormal: muscle reduction, “stick legs, ankles the same as upper leg

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The Legs showing muscle wasting

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Quadriceps and Knees

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The Ankles

• Good indicator of edema, but only in patients who walk

• Check for sacral edema as well.

• Overnourished patients can be harder to assess

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The back side

• In hospitalized patients, the back may not be easily accessible.

Vitamin C Deficiency

Petechia Cork Screw Hair

Nutrition Assessment is Complex

• Putting the pieces together is challenging

• Step-wise approach to assessment

• Call 744-4612 anytime for consults (seen within 24 hours)

• Call RD directly if urgent– ICU – assigned by team– Acute Care – assigned by

floor

• Clinical Dietitians at HMC

Where to find nutrition information in ORCA

• Admit Nursing History• Weight trending• Dietitian and Dietetic Technician Notes• Enteral and TPN Flow Sheets• Discharge nutrition counseling