Harborview Medical Center Nutrition Assessment in the Inpatient Setting Patient’s with Pressure Ulcers For HMC Wound Care Nurses Katie Farver RD, CNSD Harborview Medical Center Seattle, Washington kef@u.washington.edu 8-11-09

Components of Nutrition Assessment Diet History Medical History Weight 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- Electrical Impedance *Serum Proteins (albumin & prealbumin, CRP) *Vitamin and mineral assays *Loss of subcu fat *Muscle wasting *Concave appearance *Hair *Nails

Diet History Quality and quantity of nutrition Support intake prior to admit/during admit Quality and quantity of food Intake prior to admit/during admit

Medical History Sample Drug-Nutrition Interaction GI Disease Sample conditions effecting intake Sample Drug-Nutrition Interaction GI Disease Chronic Alcoholism Critical Illness Stroke Anorexia Nervosa Dementia Pancreatitis Renal Disease 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 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 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 Assessment Photos courtesy of Katy Wilkens, MS, RD NW Kidney Center, Seattle, WA

Wasted Clavicle

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

The Arm Bend arm and pinch at triceps. Only pinch the fat, not the muscle. Normal: fingers don’t meet Abnormal: fingers meet

Forearm Forearm: often better site than upper arm for assessing fat Upper arm fat disposition changes as women age

Wasting in the hands

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

The Legs showing muscle wasting

Quadriceps and Knees

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

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

Vitamin C Deficiency Petechia Cork Screw Hair

Nutrition Assessment is Complex Clinical Dietitians at HMC 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

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