1. MALNUTRITION IDENTIFICATION ~ REAL LIFE CASE STUDIES PRESENTED BY PROVIDENCE ALASKA MEDICAL CENTER & ST. ELIAS DIETITIANS (PAM HORAN & SIENA VANUCCI)

2. WHY LONGER HOSPITAL STAYS INCREASED RISK OF WOUND INFECTION INCREASED FLUID AND ELECTROLYTE IMBALANCE DEPRESSED VENTILATOR RESPONSE DECREASED RESPONSE TO CERTAIN CHEMOTHERAPEUTIC REGIMENS DEPRESSED IMMUNE MECHANISMS GREATER CHANCE OF READMISSION SUFFER HIGHER RATES OF COMPLICATION AND DEATH Studies find that one in every three (33%) patients admitted to a hospital in the United States suffers from malnutrition or is becoming malnourished.

3. TOOLS TO ASSIST WITH ASSESSMENT PICTURES CARDS FROM CLEVELAND CLINIC THE PATIENT OBSERVATION SCALE/STANDIOMETER

5. CASE STUDY – TBI 45 YO MALE WHO SUSTAINED A WORK-RELATED TRAUMA WHILE ON A COMMERCIAL FISHING BOAT. HT: 70” ADMISSION WT: 95.5 KG STATUS/INJURIES: TBI, MULTIPLE RIB FRACTURES, ANKLE FX, WOUND TO LOWER LEG WITH WOUND VAC. US: IN ICU, NON-RESPONSIVE, NPO WITH TUBE FEEDINGS INITIATED VIA NG TUBE (PLACED DAY 3 OF HOSPITAL STAY). BED BOUND SINCE INJURY. HX: PATIENT WAS A HEALTHY, ADULT MALE. TYPICAL DIETARY PATTERN WAS TWO LARGE MEALS AND TWO SNACKS PER DAY. EXERCISED REGULARLY AND HAD NO FUNCTIONAL DEFICITS. PHYSICAL ASSESSMENT ON HD 7: MILD EDEMA 1+ TO ALL EXTREMITIES. DARK CIRCLES CAN BE SEEN SURROUNDING EYES WITH MODERATE LOSS OF SUBCUTANEOUS FAT SURROUNDING ORBITALS. SPOUSE REPORTS THAT PATIENT’S TEMPLES ARE SLIGHTLY SUNKEN AND HIS CLAVICLE IS MORE PRONOUNCED THAN NORMAL. REPORTS LOWER EXTREMITIES LOOK UNCHANGED. SPOUSE ALSO REPORTS THAT PATIENT APPEARS MORE PALE THAN NORMAL CURRENT WT: 91 KG LABS: CRP 127.5 H ALB 3.1 L PREALBUMIN: 16 L

6. CASE STUDY – TBI NUTRITION DIAGNOSIS: SEVERE MALNUTRITION IN THE CONTEXT OF ACUTE ILLNESS/INJURY CRITERIA MET: SEVERE WEIGHT LOSS OF 4.5 KG OR 4.7% IN ONE WEEK, ORAL INTAKE <50% WHILE WAITING FOR NG PLACEMENT MODERATE BODY FAT DEPLETION TO ORBITAL AREA. OTHER KEY IDENTIFIERS INCLUDE ELEVATED CRP, SHOWING ACUTE INFLAMMATION.

7. CASE STUDY - BC 69 YO FEMALE WITH BREAST CANCER WHO HAS BEEN UNDERGOING CHEMOTHERAPY TREATMENTS AND RADIATION FOR THE PAST TWO MONTHS. HT: 55” PRE-TREATMENT, WT: 72.7 KG HX FROM INTERVIEW: DECREASE IN APPETITE WITH POOR ORAL INTAKE DUE TO FEELING NAUSEATED AND WEAK FROM CHEMOTHERAPY TREATMENTS, CONSUMING ABOUT 50% OF HER NORMAL. SHE GETS TIRED MORE EASILY, ESPECIALLY WHEN RUNNING ERRANDS. SHE HAS TO TAKE FREQUENT BREAKS. DECREASED STRENGTH PHYSICAL ASSESSMENT: DARK CIRCLES UNDER HER EYES THAT ARE SLIGHTLY HOLLOW. RIBS ARE APPARENT. SLIGHT DEPRESSION AT HER TEMPORAL REGION. CLAVICLES ARE BARELY PRONOUNCED. LOWER LEGS SEEM SMALLER THAN NORMAL WITH DECREASE MUSCLE MASS. SKIN IS PALE AND SCALY DRY CURRENT WT: 67.3 KG LABS: CRP 25 H ALB 2.9 L PREALBUMIN 15 L

8. CASE STUDY - BM NUTRITION DIAGNOSIS: MODERATE MALNUTRITION IN THE CONTEXT OF CHRONIC ILLNESS CRITERIA MET: 5.4 KG WT LOSS OR 7.4% IN TWO MONTHS ORAL INTAKE <50% FOR TWO MONTHS DECREASE IN FUNCTIONAL ABILITY DUE TO WEAKNESS MODERATE MUSCLE AND FAT WASTING TO ORBITAL, TEMPORAL, RIB, CLAVICLE AND LOWER LEG AREAS.

9. CASE STUDY - ET 78 YO MALE WITH HX OF ETOH ADMITTED WITH HYPOTHERMIA AND MULTIORGAN FAILURE AND HAD SUFFERED AN MI. HT: 165 CM, ADMIT WT: 52.6 KG STATUS: STABILIZED. FOUND TO HAVE GIB, REMAINS NPO. CONFUSED, GOING THROUGH WITHDRAWAL. HAS A STAGE II PU TO COCCYX AND L ELBOW. HX FROM PT INTERVIEW: CONFUSED BUT REPORTED A USUAL WT OF 59 KG. NO OTHER RELIABLE INFORMATION AVAILABLE. PHYSICAL ASSESSMENT - TRICEPS: LITTLE FAT WHEN PINCHED WITH FINGERS. - RIBCAGE: RIBS VISIBLE, VERY PRONOUNCED DEPRESSION BETWEEN RIBS - TEMPLES: HOLLOW - CLAVICLES: PROTRUDING, PROMINENT - SHOULDERS: SQUARE LOOK, BONES PROMINENT

10. CASE STUDY - ET NUTRITION DIAGNOSIS: SEVERE MALNUTRITION IN THE CONTEXT OF SOCIAL/ENVIRONMENTAL CIRCUMSTANCES CRITERIA MET: WT LOSS 5.6 KG OR 11% WT DECLINE OVER UNKNOWN TIMEFRAME DEPLETED BODY FAT: TRICEPS, RIBCAGE DEPLETED MUSCLE MASS: TEMPLES, CLAVICLES, SHOULDERS OTHER: FRAGILE SKIN WITH STAGE II PU TO COCCYX AND L ELBOW, HX ALCOHOL ABUSE

11. CASE STUDY - PD 79 YO MALE WITH HX PARKINSON’S DZ AND COPD ADMITTED AFTER COMPLAINTS OF WEAKNESS AND MULTIPLE RECENT FALLS R/T BRADYCARDIA AND DECONDITIONING. HT: 167.6 CM, UBW: 66 KG HX FROM PT INTERVIEW: EATING 1-2 MEALS/DAY AT HOME, MORE IF HE HAS PREPARED FOOD AS HE IS HAVING DIFFICULTY PREPARING MEAL FOR HIMSELF. EDENTULOUS PT; DENTURES DID NOT TRAVEL TO THE HOSPITAL WITH HIM. PT LIKES ENSURE-TYPE DRINKS; DOES NOT CONSUME THEM AT HOME DUE TO EXPENSE. CURRENT WT: 62 KG PHYSICAL ASSESSMENT: THIN APPEARANCE AND LOOSE HANGING SKIN VERY PRONOUNCED DEPRESSIONS BETWEEN RIBS LABS: WNL

12. CASE STUDY - PD NUTRITION DIAGNOSIS: SEVERE MALNUTRITION IN THE CHRONIC ILLNESS CIRCUMSTANCES CRITERIA MET: 4 KG WT LOSS OR 5.9% IN ~ 1 MONTH PT TYPICAL INTAKE OF 1-2 MEALS/DAY MEETS <75% OF ESTIMATED NEEDS DIMINISHED FUNCTIONAL CAPACITY: DECONDITIONING, WEAKNESS, AND DECLINE IN PHYSICAL FUNCTIONING WITH HISTORY OF RECENT FALLS

13. BARRIERS RD COMFORT TOUCHING PATIENTS TIME COMMUNICATION DOCTOR/PROVIDERS PATIENT TRAINING ON NOURISHED PEOPLE OBESITY MASKING SIGNS OF MALNUTRITION MICRONUTRIENT DEFICIENCIES

14. HOW CAN WE IMPROVE? JUST DO IT EDUCATION WITH OUR PATIENTS EDUCATE STAFF/PROVIDERS RESCREEN THROUGH THE HOSPITAL STAY IMPLEMENTATION OF PEDIATRIC MALNUTRITION SCREENING DO WE NEED TO IDENTIFY ALL CRITERIA MET

15. THANK YOU! QUESTIONS?