PHAR 503 EXAM III Lecture Review

(11/6) Garofalo Lecture: Nutritional Assessment Nutritional Disorders

- Malnutrition: “Acute, sub-acute, or chronic state of nutrition, in which varying degrees of overnutrition or undernutrition with or without inflammatory activity have led to a change in body composition and diminished function” – American Society for Parenteral and Enteral Nutrition (ASPEN) – Multidisciplinary organization

o Overnutrition: Has increased in recent years, as determined by the prevalence of self-reported obesity o Undernutrition: Often encountered in hospitalized patients (15-60%), it varies greatly by disease state.

Generally, undernutrition concerns the lack of adequate calories, proteins, or other nutrients either due to (1) inadequate intake (2) impaired absorption, or (3) altered metabolism

§ Complications: Increased morbidity and mortality, ßQoL, ÝHospitalizations + length of stay, decreased lean body mass, and overall cellular/sub-cellular/organ function impairment

- Protein-Calorie Malnutrition – There are 2 main disorders to be familiar with o *Kwashiorkor: Loss of visceral/circulating protein (albumin), preservation of body muscle and fat

§ Sx: Accumulation of fluid in the belly, due to the loss of oncotic pressure, pitting edema (legs) § This is a rapid onset acute disorder associated with catabolic stress & impaired immune response

o *Marasmus: Lose skeletal muscle and body fat, but preservation of visceral proteins. No edema § Sx: Prominent ribs, scapula protruded, ~skin and bones. Slow onset of weight loss. § More associated with chronic disease states, long standing illnesses, immune system intact.

o *Mixed Picture: When catabolic stress is superimposed on pre-existing marasmus. Ex: Cancer+Acute ill Nutrition Care Process – Goal: Maintain existing lean body mass

- Screening: Required by The Joint Commission to occur within the first 24 hours of hospital admission. Most often completed by the admission nurse. At risk? Referred

o Specific assessment tools have been designed for each setting and population o Tools: MUST, MST, NSI, NRS 2002

TOOL: Malnutrition Universal Screening Tool (MUST) - BMI, Weight loss, Acute illness

TOOL: Malnutrition Screening Tool (MST)

- Weight loss, Appetite - Many false positives. Strange parameters

TOOL: Nutrition Screening Initiative (NSI) [Elderly] - Considers the trends associated with certain

decisions and dentition.

TOOL: Nutrition Risk Screening (NRS 2002) [ICU] - Left Side: Assesses nutrition Status - Right Side: Assesses severity - Used in the ICU, Score ³ 5 à PN early!

This is meant to be used as an adjunct to your studying, the best way to review is to redo the recitations and reproduce those

answers. Good luck! Let me know if you find any errors. Treat the pt not the numbers!

Nutrition Assessment (Continued)

- Sx: ASPEN and ESPEN have a consensus on the hallmark symptoms used to diagnose malnutrition (need 2 of 6) o Insufficient energy intake o Weight loss o Loss of muscle mass o Loss of subcutaneous fat o Localized or generalized fluid accumulation o Decreased functional status (measured by hand-grip strength). Note: this is often unavailable, we can also

make a judgement based on the patients ability to perform certain actions, like walking up stairs - Disease: Commonly Implicated Disease states: DM, Pancreatitis, Cancer, AIDS, Kidney disease, Liver disease

o Note: Simple dx of pancreatitis is not sufficient, the cause of hyperlipidemia must be determined. - PSHx: Common relevant surgical factors: Bowel resection, liver/pancreatic procedures - Meds: Medications involved in absorption, food interactions, altering of taste, or catabolism may play a role

o Glucose Metabolism: Corticosteroids, Protease Inhibitors, b-blockers, Thiazides, Antipsychotics o Protein Metabolism: Corticosteroids, Tetracyclines o Fat Metabolism: Corticosteroids, HIV Meds, Orlistat o Electrolyte Disturbances: Corticosteroids, Diuretics, Antacids, Laxatives o Gastrointestinal Disorders: Nausea, Dysguesia (distortion of taste sense), Malabsorption, Bowel motility o Supplemental vitamin, mineral, or herbal intake

- Food Intake: Must evaluate whether patient is meeting EER (Estimated Energy Requirements) on a daily basis o Acute Illness: Non-severe: < 75% EER for > 7 days Severe: < 50% EER for ³ 5 days o Chronic Illness: Non-severe: < 75% EER for ³ 1 mo Severe: £ 75% EER for ³ 1 mo

- Unintended Weight Loss: When evaluating a patient’s weight loss, must consider hydration status/edema/ascites

- PE: Physical exam is important for finding the Sx at the top of this page, as well as other signs of micro and macronutrient deficiencies. Particularly important are signs of inflammation

o Specific: Fever or Hypothermia Non-specific: Tachycardia, Hyperglycemia o Loss of subcutaneous fat: orbital, triceps, ribcage o Loss of muscle mass: temples, clavicles, shoulders, interosseous, scapula, calf o Fluid accumulation: generalized or localized

- Labs: Monitor Albumin, Transferrin, Pre-albumin, Retinol binding protein, CRP o These labs currently are not recommended for the assessment of nutrition status. Albumin, however is

useful to estimate protein requirements. Normal values = [3.5-5.5g/dL] o Indirect calorimetry: Used in critically ill hypermetabolic patients to determine adequate calorie

administration. It requires expensive equipment and a trained operator. § Resting Energy Expenditure = REE = [3.9*(VO2) + 1.1*(VCO2)] *1.44

- Nitrogen Balance: Monitored during a patient’s recovery phase of an illness. Involves 24 hour urine collection to ensure adequate protein administration by testing Urinary Urea Nitrogen (UUN), Nitrogen in versus Out.

o N2 (in) = Protein/6.25 N2 (out) = UUN (g/mL) *24hour urine volume +2-4 (insensible losses) (11/9) Garofalo Lecture: Nutritional Elements and Requirements Nutritional Elements include the micro and macronutrients. The estimated needs are based on individual factors:

- Gender, Age, Anthropometrics (Height+Weight), Activity/Injury, Nutritional Status, Concomitant Disease states Requirement: Water: Estimated needs are dependent upon the patient’s volume status

- Dehydration: 45mL/kg/day - Post-Operative: 40mL/kg/day

- Euvolemia: 35mL/kg/day –Standard- - Elderly or CHF: 30mL/kg/day

- Alternative Method: Has tiered, body weight contributors, tends to overestimate in adults – No thanks.

Memorize these – Noticing 2 of 6 is sufficient for a diagnosis!

IBW: M= 50 + 2.3kg*(inch over 5ft) F= 45 + 2.3kg*(inch over 5ft)