Katie Farver RD, CNSD Harborview Medical Center Seattle, Washington kef@u.washington 8-11-09

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

3. Components of Nutrition Assessment

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

5. Medical History Sample conditions effecting intake Sample Drug-Nutrition Interaction Insulin Coumadin MAOI Inhibitors HAART INH • GI Disease • Chronic Alcoholism • Critical Illness • Stroke • Anorexia Nervosa • Dementia • Pancreatitis • Renal Disease

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 • 18.5-24.9 normal, healthy • 24.9-29.9, overweight • >30 obese

7. Body Composition Measurements Underwater Weighing Skin Fold Measurements

8. Biochemical Assessment

9. Sources of Error • Biological Variation • Preanalytical variation • Analytical variation • Postanalytical variation

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

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 • 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 - 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

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 AssessmentPhotos courtesy of Katy Wilkens, MS, RDNW 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. Clinical Dietitians at HMC Nutrition Assessment is Complex • 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

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