1. 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

3. 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

4. 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

5. 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

6. 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
normal, healthy
, overweight
>30 obese

7. Body Composition Measurements
Underwater Weighing
Skin Fold Measurements

8. Biochemical Assessment

9. Sources of Error Biological Variation Preanalytical variation
Postanalytical variation

10. Factors Influencing Concentration
Synthesis rate
Secretion rate
Clearance rate
Catabolic rate
Distribution
Other

11. Synthesis rate Substrate availability Hepatic function
Metabolic response to injury
Corticosteroids
Inflammatory Response

12. Secretion and Clearance Rate
Cofactor availability
Hepatic Function
Renal Function

13. Distribution and Other
Metabolic response
Hydration
Drainage and fistula losses
Analytical Method
Patient position on blood draw

14. Biochemical Markers of Protein Status
Assessing Protein-Calorie Malnutrition
Albumin
Pre-Albumin

15. Serum Protein levels are not reliable during inflammation

16. 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

17. Transthyretin - TTY (Prealbumin)
Half-life 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

18. 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

19. How many of our patients are not experiencing acute stress?

20. 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

21. Lipid and Glycemic Status
Lipids
Total Cholesterol
HDL/LDLs
Homocysteine
Triglycerides
Glycemic Control
Blood Glucose
HgA1C

22. Physical Assessment Photos courtesy of Katy Wilkens, MS, RD NW Kidney Center, Seattle, WA

23. Wasted Clavicle

24. 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

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

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

27. Wasting in the hands

28. 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

29. The Legs showing muscle wasting

30. Quadriceps and Knees

31. 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

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

33. Vitamin C Deficiency
Petechia
Cork Screw Hair

34. Nutrition Assessment is Complex
Clinical Dietitians at HMC
Putting the pieces together is challenging
Step-wise approach to assessment
Call anytime for consults (seen within 24 hours)
Call RD directly if urgent
ICU – assigned by team
Acute Care – assigned by floor

35. 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