8. آخرین ویرایش فرم ارزیابی تخصصی تغذیه

10. Nutrition Care Process Steps 1.Nutrition Assessment 2.Nutrition Diagnosis 3.Nutrition Intervention 4.Nutrition Monitoring and Evaluation

13. Nutritional care process

14. Nutritional Assessment 1.Anthropometric assessment 2.Clinical evaluation 3.Biochemical, laboratory assessment 4.Dietary evaluation

15. ESPEN guidelines Questions to be answered: 1.What is the condition now? 2.Is the condition stable? 3.Will the condition get worse? 4.Will the disease process accelerate nutritional deterioration?

16. Anthropometric methods in ICU 1.Weight 2.Height estimation 3.Mid-arm circumference 4.Skin fold thickness 5.Head circumference

17. Weight

18. Ideal Body Weight (kg) 1.Men=48+ 2.3 for each inch over 152 m 2.Women=45.3+2.3 for each inch over 152 cm 3.Correction for skeletal size:

19. Add 10% if SS is large Add 10% if SS is large Subtract 10% if SS is small Subtract 10% if SS is small Ideal Body Weight (kg)

20. Height in ICU patients Alternative measurements Estimating Height from ulna length

22. Estimations of height

23. Skin Fold Thickness معرف ميزان چربي زير پوستي و درنتيجه ميزان چاقي خواهد بود. محلهاي اندازه گيري : تريسپس، بايسپس،زير کتف و بالاي تيغه ايلياک. مشکلات عملي : 1. خطاي در اندازه گيري. 2. مشکلات اندازه گيري. 3. وارياسيون توزيع چربي در افراد مختلف ( فردي وجمعيتي ). 4. حساسيت کم.

24. Skin Fold Thickness

29. Mid arm circumference measured with a nonstretch measuring tape measured with a nonstretch measuring tape midway between the acromion and olecranon of the nondominant arm midway between the acromion and olecranon of the nondominant arm ≤ 15 cm: severe depletion of muscle mass ≤ 15 cm: severe depletion of muscle mass 16–19 cm: moderate depletion 16–19 cm: moderate depletion 20–22 cm: mild depletion 20–22 cm: mild depletion

30. Mid arm circumference

31. BMI estimation If MUAC is <23.5 cm, BMI is likely to be <20 kg/m2 If MUAC is >32.0 cm, BMI is likely to be >30 kg/m2

32. CLINICAL ASSESSMENT

33. General: muscle wasting

34. Wasting in the hands

35. The Shoulder and Elbow The shoulder Normal: rounded or sloped Abnormal: square, can see acromion process The elbow well padded and not showing joint

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

38. The Legs showing muscle wasting

39. Essential fatty acid deficiency syndromes (EFADs)

40. Zinc deficiency

42. Vitamine C Deficiency

52. Biochemical Assessment

53. Serum Protein levels are not reliable during inflammation

54. MUST TOOL Is recommended by ESPEN for community 4 steps. Biochemical markers of nutrition status:

55. Plasmatic proteins with short biologic half-life Albumin – -syntetizate in liver, half-life time is 21 days – Normal: 35-45g/l. – Decrease of alb: malnutrition – Trends of changes alb.levels during realimentation are criterium of succesfull terapy. – Acute decrease: acute phase response.

56. Biochemical markers of nutrition status: Transferin : syntesized in liver, – biolog HL: 8days. – Value 2-4g/l, RBP: syntesized in liver – Biolog half-life : 12h., – Normal value: 0,03-0,006g/l. – Acute phase reactant (negative)

57. Biochemical markers of nutrition status: P realbumin -syntesized in liver, – biolog.half-life:1,5 days. – Normal Value 0,15-0,4g/l. – Decrease in failure of proteosyntesis-indicator of acute protein malnutrition.

58. NUTRITIONAL ASSESSMENT Urine urea nitrogen (UUN): to evaluate degree of hypermetabolism (stress level): – 0 – 5 g/d= normometabolism – 5 – 10 g/d = mild hypermetabolism (level 1 stress) – 10 – 15 = moderate (level 2 stress) – >15 = severe (level 3 stress)

59. Biochemical parameters Na,K,Cl,Ca,P,Mg, osmolality - blood, urine Acidobasis, lactate urea, creatinin, creatinin clearence, Nitrogen balance bilirubine, ALT, AST, LDH, amylase, lipase cholesterol, triglycerides, glucose – blood, urine

60. Other biochemical parameters Trace elements /Zn,Se../ Vitamins Drugs /methotrexate, antiepileptics, antibiotics.../ Aminogram /glutamin../ Interleucins,TNF … Hormones /cortisol, glucagone, adrenaline../.

61. Monitoring

62. Enteral Nutrition Monitoring: Gastric Residuals Clinically assess the patient for abdominal distension, fullness, bloating, discomfort Place the pt on his/her right side for 15-20 minutes before checking a RV to avoid cascade effect Seek transpyloric access of feeding tube Raise threshold for RV to 200-300 mL Consider stopping RV checks in stable pts

63. Some Lab tests

64. Na serum levels Hypernatremia: Na over 150 mmol/l hyperaldosteronism hypovolemia renin- angiot-aldost. Hypothalamic damage Hypertonic hyperhydration Diabetes insipidus Brain death

65. K serum levels Hypokalemia: K under 3,5 mEq/L – Low intake, bigger uptake, or both – Emesis, diarrhoe / intestinal loss/ – Diuretics – Chemotherapy, antimycotics /renal tubules failure/ – Anabolic phasis – Hyperaldosteronism – Acute metabolic alcalosis

66. BUN (5-20 mg/dl ) Consider hydration and Nutrition. High level of urea – high intake of N, – increase catabolism – polytrauma-muscele loss – GIT bleeding – dehydration – low output- renal failure, Low level – malnutrition,serious hepatic failure- ureosyntetic cycle and gluconeogenesis dysfunction, pregnancy- increase ECF

67. ALT(SGPT) N V: M: 7-46 F:4-35 U/L High level – – hepatopathologia, – steatosis, – hepatitis, – cell damage,

68. AST(SGOT) High level – – hypoperfusion, – hepatitis, – cell necrosis, – muscles damage both aminotransferases increase during damage of hepatic cells during inf.hepatitis.

69. TG(10-190 mg/dl ) TG-increase – during sepsis, mainly on the begining, – monitorate during parenter á l nutrition with lipid emulsion Glycemia, serum, urine, Hypoglycemia below 2,5mmol/l-vital danger hyperglycemia- insulin.rezistence, recomendation level of glycemia 4,5-8,2 /2006/ better survive in ICU patient

70. Glucose Glycemia, serum, urine, Hypoglycemia below 2,5 mmol/l -(45 mg/dl ) vital danger hyperglycemia- insulin.rezistence Recomendation level of glycemia 4,5-8,2 (80-150 mg/dl )

71. P – serum levels(2.7-4.5 mg/dl ) Hypophosphataemia: under 1,9 mg/dl – Acute wastage of energy after succesfully resuscitation, overfeeding sy, anabolism (energetic substrates without K,Mg,P). Hyperphosphataemia – over 5,8 mg/dl – Renal failure – Cell damage

72. Urea Urea in urine Increase – catabolism, prerenal failure Decrease – chronic malnutrition, acute renal failure

73. Creatinine(0.5-1.1 mg/dl ) Serum levels of creatinine evaluation together with muscle mass, age, gender Increase – bigger offer- destruction of muscle mass, – low output-renal failure Decrease- – low offer-low muscle mass – malnutrition Creatinine clearence, excretion fraction -renal function N-balance – catabolism – the need of nitrogen Uratic acid – cell damage, arthritis uratica

74. Monitoring

76. Monitoring in PN therapy Variable to be monitoredInitialLater period WeightDailyWeekly serum glucoseDaily3/wk Electrolytes (Na +, K +, Cl - )Daily1-2//wk BUN3/wkWeekly Ca +, P,mg3/wkWeekly Liver function Enzymes3/wkWeekly Serum triglycerides weekly CBC weekly

77. Nutritional screening tools

78. Monitoring in PN therapy Variable to be monitoredInitialLater period Clinical status Daily Catetheter site Daily Temperature Daily Intake &Output Daily