1. بسم الله الرحمن الرحيم

2. Nutritional assessment in hospitalized patients
M. Safarian, MD PhD.

3. Nutrition Care Process Steps
Nutrition Assessment
Nutrition Diagnosis
Nutrition Intervention
Nutrition Monitoring and Evaluation
The 4 quadrants around the core represent the four steps of the nutrition care process: nutrition assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation.
Each of the steps is preceded by the word nutrition. This was a conscious decision to make the Nutrition Care Process unique and specific to dietetics professionals.
Even though each step builds on the previous one, the process is not linear. Critical thinking and problem solving will frequently require that dietetics professionals revisit previous steps to reassess, add, or revise nutrition diagnoses; modify intervention strategies; and/or evaluate additional outcomes.
The first step we’ll look at is the Nutrition Assessment

5. Nutritional Assessment
Anthropometric assessment
Clinical evaluation
Biochemical, laboratory assessment
Dietary evaluation

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

7. Anthropometric methods in ICU
Weight
Height estimation
Mid-arm circumference
Skin fold thickness
Head circumference

8. Weight

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

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

11. Adjusted body weight
Used when actual body weight is more than 120% of IBW:
ABW=IBW+ 25% of (actual body weight - IBW)

12. Height in ICU patients

13. Alternative measurements Estimating Height from ulna length

15. Estimations of height

17. Body composition (BIA)
Very popular
Safe
Noninvasive
Portable
Rapid

19. Skin Fold Thickness Represent an estimation of body fat percent
Best sites for measurement:
Triceps
Biceps
Sub scapular
Super iliac

20. Skin Fold Thickness Practical problems:
calliper measurements will be inaccurate, misleading and unreliable in many instances:
Personal errors
Practical problems
Between individual variation
population specific’
Low sensitivity

21. Skin Fold Thickness

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

28. Mid arm circumference

29. 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

30. Clinical assessment

31. General: muscle wasting

32. Wasting in the hands 32

33. Wasting Clavicle 33

34. The Legs showing muscle wasting34

35. Quadriceps and Knees 35

36. Flaky paint dermatosis: protein deficiency

37. Essential fatty acid deficiency syndromes (EFADs)

39. Zinc deficiency

42. Zinc deficiency

46. Vitamin C deficiency
Perifolicullar pitichea

60. dermatitis
dementia
diarrhea
death
Pellagra
niacin deficiency

61. Biochemical, laboratory assessment

62. The possibilities of biochemical monitoring
On-line monitoring (cardiosurgery – pH, minerals (K), the electrodes are localized on central cateter, possibility to check parameters on-line.
bed side monitoring (glycaemia, urine /protein, pH, blood../,oximeter O2 saturation, acidobasis, drugs /dg.strips)
Biochemical analysis

63. 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

64. Biochemical parameters
Total protein, albumine, prealbumine
CRP
TSH
Basic analysis are made at the first,must be done within 90minutes

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

66. Monitoring

67. Enteral Nutrition Monitoring:
Clinically assess the patient for abdominal distension, fullness, bloating, discomfort
Place the pt on his/her right side for minutes before checking a RV to avoid cascade effect
Seek transpyloric access of feeding tube
Raise threshold for RV to mL
Consider stopping RV checks in stable pts
Rees Parrish C. Enteral Feeding: The Art and the Science. Nutr Clin Pract 2003; 18;75-85.

68. متشكرم