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Evaluation of Laboratory Data in Nutrition Assessment Cinda S. Chima, MS, RD.

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1 Evaluation of Laboratory Data in Nutrition Assessment Cinda S. Chima, MS, RD

2 Laboratory Data and the NCP Used in nutrition assessment (a clinical sign supporting nutrition diagnosis)Used in nutrition assessment (a clinical sign supporting nutrition diagnosis) Used in Monitoring and Evaluation of the patient response to nutritional interventionUsed in Monitoring and Evaluation of the patient response to nutritional intervention

3 Specimen Types Serum: the fluid from blood after blood cells and clot removedSerum: the fluid from blood after blood cells and clot removed Plasma: fluid from blood centrifuged with anticoagulantsPlasma: fluid from blood centrifuged with anticoagulants Erythrocytes: red blood cellsErythrocytes: red blood cells Leukocytes: white blood cellsLeukocytes: white blood cells Other tissues: scrapings and biopsy samplesOther tissues: scrapings and biopsy samples Urine: random samples or timed collectionsUrine: random samples or timed collections Feces: random samples or timed collectionsFeces: random samples or timed collections Less common: saliva, nails, hair, sweatLess common: saliva, nails, hair, sweat

4 Interpretation of Routine Medical Laboratory Tests Clinical Chemistry PanelsClinical Chemistry Panels Basic metabolic panelBasic metabolic panel Comprehensive metabolic panelComprehensive metabolic panel Complete blood countComplete blood count UrinalysisUrinalysis Hydration statusHydration status

5 Clinical Chemistry Panels: Basic Metabolic Panel (BMP) Also called Chem 7 Includes Electrolytes: Na+, K+, Cl-, HCO3 or total CO2Electrolytes: Na+, K+, Cl-, HCO3 or total CO2 GlucoseGlucose CreatinineCreatinine BUNBUN

6 Basic Metabolic Panel Charting Shorthand BMPNaClBUNglucose K+CO2Creatinine

7 Clinical Chemistry Panels: Comprehensive Metabolic Panel Includes BMP except CO2BMP except CO2 AlbuminAlbumin Serum enzymes (alkaline phosphatase, AST [SGOT], ALT [SGPT]Serum enzymes (alkaline phosphatase, AST [SGOT], ALT [SGPT] Total bilirubinTotal bilirubin Total calciumTotal calcium Phosphorus, total cholesterol and triglycerides often ordered with the CMP

8 Clinical Chemistry Panels: Complete Blood Count (CBC) Red blood cellsRed blood cells Hemoglobin concentrationHemoglobin concentration HematocritHematocrit Mean cell volume (MCV)Mean cell volume (MCV) Mean cell hemoglobin (MCH)Mean cell hemoglobin (MCH) Mean cell hemoglobin concentration (MCHC)Mean cell hemoglobin concentration (MCHC) White blood cell count (WBC)White blood cell count (WBC) Differential: indicates percentages of different kinds of WBCDifferential: indicates percentages of different kinds of WBC

9 Clinical Chemistry Panels: Urinalysis Specific gravity mg/ml pH 6-8 (normal diet) Protein 2-8 mg/dl Glucose Not detected KetonesNegative BloodNegative Bilirubin Urobilinogen units/dl NitriteNegative Leukocyte esterage Negative

10 Types of Assays Static assays: measures the actual level of the nutrient in the specimen (serum iron, white blood cell ascorbic acid)Static assays: measures the actual level of the nutrient in the specimen (serum iron, white blood cell ascorbic acid) Functional Assays: measure a biochemical or physiological activity that depends on the nutrient of interest (serum ferritin, TIBC)Functional Assays: measure a biochemical or physiological activity that depends on the nutrient of interest (serum ferritin, TIBC) (Functional assays are not always specific to the nutrient)(Functional assays are not always specific to the nutrient)

11 Assessment of Nutrient Pool

12 Assessment of Hydration Status Dehydration: a state of negative fluid balance caused by decreased intake, increased losses, or fluid shiftsDehydration: a state of negative fluid balance caused by decreased intake, increased losses, or fluid shifts Overhydration or edema: increase in extracellular fluid volume; fluid shifts from extracellular compartment to interstitial tissuesOverhydration or edema: increase in extracellular fluid volume; fluid shifts from extracellular compartment to interstitial tissues Caused by increase in capillary hydrostatic pressure or permeabilityCaused by increase in capillary hydrostatic pressure or permeability Decrease in colloid osmotic pressureDecrease in colloid osmotic pressure Physical inactivityPhysical inactivity Use laboratory and clinical data to evaluate ptUse laboratory and clinical data to evaluate pt

13 Hypovolemia Isotonic fluid loss from the extracellular space caused by Fluid loss (bleeding, fistulas, nasogastric drainage, excessive diuresis, vomiting and diarrhea)Fluid loss (bleeding, fistulas, nasogastric drainage, excessive diuresis, vomiting and diarrhea) Reduced fluid intakeReduced fluid intake Third space fluid shift, when fluid moves out of the intravascular space but not into intracellular space (abdominal cavity, pleural cavity, pericardial sac) caused by increased permeability of the capillary membrane or decrease on plasma colloid osmotic pressureThird space fluid shift, when fluid moves out of the intravascular space but not into intracellular space (abdominal cavity, pleural cavity, pericardial sac) caused by increased permeability of the capillary membrane or decrease on plasma colloid osmotic pressure

14 Symptoms of Hypovolemia Orthostatic Hypotension (caused by change in position)Orthostatic Hypotension (caused by change in position) Central venous and pulmonary pressuresCentral venous and pulmonary pressures Increased heart rateIncreased heart rate Rapid weight lossRapid weight loss Decreased urinary outputDecreased urinary output Patient cool, clammyPatient cool, clammy Decreased cardiac outputDecreased cardiac output Ask the medical team!!Ask the medical team!!

15 Treatment of Hypovolemia Replace lost fluids with fluids of similar concentrationReplace lost fluids with fluids of similar concentration Restores blood volume and blood pressureRestores blood volume and blood pressure Usually isotonic fluid like normal saline or lactated Ringers solution given IVUsually isotonic fluid like normal saline or lactated Ringers solution given IV

16 Hypervolemia Excess of isotonic fluid (water and sodium) in the extracellular compartmentExcess of isotonic fluid (water and sodium) in the extracellular compartment Osmolality is usually not affected since fluid and solutes are gained in equal proportionOsmolality is usually not affected since fluid and solutes are gained in equal proportion Elderly and those with renal and cardiac failure are at riskElderly and those with renal and cardiac failure are at risk

17 Causes of Hypervolemia Results from retention or excessive intake of fluid or sodium or shift in fluid from interstitial space into the intravascular spaceResults from retention or excessive intake of fluid or sodium or shift in fluid from interstitial space into the intravascular space Fluid retention: renal failure, CHF, cirrhosis of the liver, corticosteroid therapy, hyperaldosteronismFluid retention: renal failure, CHF, cirrhosis of the liver, corticosteroid therapy, hyperaldosteronism Excessive intake: IV replacement tx using normal saline or Lactated Ringers, blood or plasma replacement, excessive salt intakeExcessive intake: IV replacement tx using normal saline or Lactated Ringers, blood or plasma replacement, excessive salt intake

18 Causes of Hypervolemia Fluid shifts into vasculature caused by remobilization of fluids after burn tx, administration of hypertonic fluids, use of colloid oncotic fluids such as albuminFluid shifts into vasculature caused by remobilization of fluids after burn tx, administration of hypertonic fluids, use of colloid oncotic fluids such as albumin

19 Symptoms of Hypervolemia No single diagnostic test, so signs and symptoms are keyNo single diagnostic test, so signs and symptoms are key Cardiac output increasesCardiac output increases Pulse rapid and boundingPulse rapid and bounding BP, CVP, PAP and pulmonary artery wedge pressure riseBP, CVP, PAP and pulmonary artery wedge pressure rise As the heart fails, BP and cardiac output dropAs the heart fails, BP and cardiac output drop Distended veins in hands and neckDistended veins in hands and neck

20 Symptoms of Hypervolemia Anasarca: severe, generalized edemaAnasarca: severe, generalized edema Pitting edema: leaves depression in skin when touchedPitting edema: leaves depression in skin when touched Pulmonary edema: crackles on auscultationPulmonary edema: crackles on auscultation Patient SOB and tachypneicPatient SOB and tachypneic Labs: low hematocrit, normal serum sodium, lower K+ and BUN (or if high, may mean renal failure)Labs: low hematocrit, normal serum sodium, lower K+ and BUN (or if high, may mean renal failure) ABG: low O2 level, PaCO2 may be low, causing drop in pH and respiratory alkalosisABG: low O2 level, PaCO2 may be low, causing drop in pH and respiratory alkalosis

21 Treatment of Hypervolemia Restriction of sodium and fluid intakeRestriction of sodium and fluid intake Diuretics to promote fluid loss; morphine and nitroglycerine to relieve air hunger and dilate blood vessels; digoxin to strengthen heartDiuretics to promote fluid loss; morphine and nitroglycerine to relieve air hunger and dilate blood vessels; digoxin to strengthen heart Hemodialysis or CAVHHemodialysis or CAVH

22 Dehydration Excessive loss of free waterExcessive loss of free water Loss of fluids causes an increase in the concentration of solutes in the blood (increased osmolality)Loss of fluids causes an increase in the concentration of solutes in the blood (increased osmolality) Water shifts out of the cells into the bloodWater shifts out of the cells into the blood Causes: prolonged fever, watery diarrhea, failure to respond to thirst, highly concentrated feedings, including TFCauses: prolonged fever, watery diarrhea, failure to respond to thirst, highly concentrated feedings, including TF

23 Symptoms of Dehydration ThirstThirst FeverFever Dry skin and mucus membranes, poor skin turgor, sunken eyeballsDry skin and mucus membranes, poor skin turgor, sunken eyeballs Decreased urine outputDecreased urine output Increased heart rate with falling blood pressureIncreased heart rate with falling blood pressure Elevated serum osmolality; elevated serum sodium; high urine specific gravityElevated serum osmolality; elevated serum sodium; high urine specific gravity

24 Treatment of Dehydration Use hypotonic IV solutions such as D5WUse hypotonic IV solutions such as D5W Offer oral fluidsOffer oral fluids Rehydrate graduallyRehydrate gradually

25 Laboratory Values and Hydration: BUN Lab Test Hypo- volemia Hyper- volemia Other factors influencing result BUN Normal: mg/dl IncreasesDecreases Low: inadequate dietary protein, severe liver failure High: prerenal failure; excessive protein intake, GI bleeding, catabolic state; glucocorticoid therapy Creatinine will also rise in severe hypovolemia Adapted from Charney and Malone. ADA Pocket Guide to Nutrition Assessment, 2004.

26 Laboratory Values and Hydration Status: BUN:Creatinine Ratio Lab Test Hypo- volemia Hyper- volemia Other factors influencing result BUN: creatinine ratio Normal: 10-15:1 IncreasesDecreases Low: inadequate dietary protein, severe liver failure High: prerenal failure; excessive protein intake, GI bleeding, catabolic state; glucocorticoid therapy Adapted from Charney and Malone. ADA Pocket Guide to Nutrition Assessment, 2004.

27 Laboratory Values and Hydration: HCT Lab Test Hypo- volemia Hyper- volemia Other factors influencing result Hemato- crit Normal:Male:42-52% Female: 37-47% IncreasesDecreases Low: anemia, hemorrhage with subsequent hemodilution (occurring after approximately hours) High: chronic hypoxia (chronic pulmonary disease, living at high altitude, heavy smoking, recent transfusion) Adapted from Charney and Malone. ADA Pocket Guide to Nutrition Assessment, 2004.

28 Laboratory Values and Hydration: Alb, Na+ Lab Test Hypo- volemia Hyper- volemia Other factors influencing result Serum albumin Low: malnutrition; acute phase response, liver failure High: rare except in hemoconcentration Serum sodium Typical- ly Typical- ly can be normal or can be normal or, normal or, normal or Serum sodium generally reflects fluid status and not sodium balance Adapted from Charney and Malone. ADA Pocket Guide to Nutrition Assessment, 2004.

29 Laboratory Values and Hydration Status Lab Test normal Hypo- volemia Hyper- volemia Other factors influencing result Serum osmolality ( mosm/kg) Typically but can be normal or Typically but can be normal or Urine sp. Gravity Urine osmolality ( mosm/kg) Low: diuresis, hyponatremia, sickle cell anemia High: SIADH, azotemia, Adapted from Charney and Malone. ADA Pocket Guide to Nutrition Assessment, 2004.

30 Laboratory Values and Hydration Status Lab Test Hypo- volemia Hyper- volemia Other factors influencing result Serum albumin Low: malnutrition; acute phase response, liver failure High: rare except in hemoconcentration Serum sodium Typically can be normal or Typically can be normal or, normal or, normal or Adapted from Charney and Malone. ADA Pocket Guide to Nutrition Assessment, 2004.

31 Hypokalemia (K+< 3.5 mEq/L) renal losses (diuresis) renal losses (diuresis) GI losses (diarrhea, vomiting, fistula) GI losses (diarrhea, vomiting, fistula) K+ wasting meds (thiazide and loop diuretics, etc)K+ wasting meds (thiazide and loop diuretics, etc) Shift into cells (anabolism, refeeding, correction of glucosuria or DKA)Shift into cells (anabolism, refeeding, correction of glucosuria or DKA) Inadequate intakeInadequate intake

32 Hyperkalemia (K+>5.0 mEq/L) Decreased renal excretion as in acute or chronic renal failureDecreased renal excretion as in acute or chronic renal failure Medications, e.g. potassium sparing diuretics, beta blockers, ACE inhibitorsMedications, e.g. potassium sparing diuretics, beta blockers, ACE inhibitors Shift out of cells (acidosis, tissue necrosis, GI hemorrhage, hemolysis)Shift out of cells (acidosis, tissue necrosis, GI hemorrhage, hemolysis)

33 Serum Calcium Normal serum mg/dL (includes ionized calcium and calcium bound to protein, primarily albumin, and ions)Normal serum mg/dL (includes ionized calcium and calcium bound to protein, primarily albumin, and ions) Ionized calcium: mg/dLIonized calcium: mg/dL Normal levels maintained by hormonal regulation using skeletal reservesNormal levels maintained by hormonal regulation using skeletal reserves Ionized calcium is more accurate, especially in pt with hypoalbuminemia; evaluate before repleting Ca+Ionized calcium is more accurate, especially in pt with hypoalbuminemia; evaluate before repleting Ca+ Charney and Malone, 2004, p. 89

34 Hypocalcemia (serum calcium <9.0 mg/dL; ionized Ca+ <4.5 mg/dL) HypoalbuminemiaHypoalbuminemia HypoparathyroidismHypoparathyroidism HypomagnesemiaHypomagnesemia Renal failure, renal tubular necrosisRenal failure, renal tubular necrosis Vitamin D deficiency or impaired metabolismVitamin D deficiency or impaired metabolism

35 Hypercalcemia (serum calcium >10.5 mg/dL; ionized Ca+ >5.6 mg/dL) HyperparathyroidismHyperparathyroidism Some malignancies, especially breast, lung, kidney; multiple myeloma, leukemia, lymphomaSome malignancies, especially breast, lung, kidney; multiple myeloma, leukemia, lymphoma Medications: thiazide diuretics, lithium, vitamin A toxicityMedications: thiazide diuretics, lithium, vitamin A toxicity ImmobilizationImmobilization HyperthyroidismHyperthyroidism Charney and Malone, 2004, p. 91

36 Serum Phosphorus (normal mg/dL) Serum phos a poor reflection of body stores because <1% is in ECFSerum phos a poor reflection of body stores because <1% is in ECF Bones serve as a reservoirBones serve as a reservoir

37 Hypophosphatemia (<3.0 mg/dL) Impaired absorption (diarrhea, Vitamin D deficiency, impaired metabolism)Impaired absorption (diarrhea, Vitamin D deficiency, impaired metabolism) Medications: phosphate binding antacids, sucralfate, insulin, steroids)Medications: phosphate binding antacids, sucralfate, insulin, steroids) Alcoholism, especially during withdrawalAlcoholism, especially during withdrawal Intracellular shifts in alkalosis, anabolism, neoplasmsIntracellular shifts in alkalosis, anabolism, neoplasms Refeeding syndromeRefeeding syndrome Increased losses: hyperparathyroidism, renal tubular defects, DKA recovery, hypomagnesemia, diuretic phase of ATNIncreased losses: hyperparathyroidism, renal tubular defects, DKA recovery, hypomagnesemia, diuretic phase of ATN Charney and Malone, 2004, p. 93

38 Hyperphosphatemia (>4.5 mg/dL) Decreased renal excretion: acute or chronic renal failure (GFR<20-25 mL/min); hypoparathyroidismDecreased renal excretion: acute or chronic renal failure (GFR<20-25 mL/min); hypoparathyroidism Increased cellular release: tissue necrosis, tumor lysis syndromeIncreased cellular release: tissue necrosis, tumor lysis syndrome Increased exogenous phosphorus load or absorption, phosphorus containing laxatives or enemas, vitamin D excessIncreased exogenous phosphorus load or absorption, phosphorus containing laxatives or enemas, vitamin D excess AcidosisAcidosis

39 Hypomagnesemia <1.3 mEq/L (normal mEq/L) Decreased absorption: prolonged diarrhea, intestinal or biliary fistula, intestinal resection or bypass, steatorrhea, ulcerative colitis; upper GI fluid loss, gastric suctioning, vomitingDecreased absorption: prolonged diarrhea, intestinal or biliary fistula, intestinal resection or bypass, steatorrhea, ulcerative colitis; upper GI fluid loss, gastric suctioning, vomiting Renal losses: osmotic diuresis, DM with glucosuria, correction of DKA, renal disease with magnesium wasting, hypophosphatemia, hypercalcemia, hyperthyroidismRenal losses: osmotic diuresis, DM with glucosuria, correction of DKA, renal disease with magnesium wasting, hypophosphatemia, hypercalcemia, hyperthyroidism AlcoholismAlcoholism Inadequate intake: malnutritionInadequate intake: malnutrition MedicationsMedications Intracellular shift: acute pancreatitisIntracellular shift: acute pancreatitis Refeeding syndromeRefeeding syndrome

40 Hypermagnesemia (>2.1 mEq/L) Acute or chronic renal failureAcute or chronic renal failure

41 Assessment for Protein-Calorie Malnutrition Hormonal and cell-mediated response to stressHormonal and cell-mediated response to stress Negative acute-phase respondentsNegative acute-phase respondents Positive acute-phase respondentsPositive acute-phase respondents Nitrogen balanceNitrogen balance

42 Assessment for Protein-Calorie Malnutrition–contd Hepatic transport proteinsHepatic transport proteins AlbuminAlbumin TransferrinTransferrin PrealbuminPrealbumin Retinol-binding proteinRetinol-binding protein C-reactive proteinC-reactive protein CreatinineCreatinine ImmunocompetenceImmunocompetence

43 Hormonal and Cell-Mediated Response to Inflammatory Stress Acute illness or trauma causes inflammatory stressAcute illness or trauma causes inflammatory stress Cytokines (interleukin-1, interleukin-6 and tumor necrosis factor) reorient hepatic synthesis of plasma proteinsCytokines (interleukin-1, interleukin-6 and tumor necrosis factor) reorient hepatic synthesis of plasma proteins Although protein-energy malnutrition can occur simultaneously, interpretation of plasma proteins is problematicAlthough protein-energy malnutrition can occur simultaneously, interpretation of plasma proteins is problematic

44 Hormonal and Cell-Mediated Response to Inflammatory Stress Negative acute-phase respondents (albumin, transthyretin or prealbumin, transferrin, retinol-binding protein) decreaseNegative acute-phase respondents (albumin, transthyretin or prealbumin, transferrin, retinol-binding protein) decrease Positive acute-phase reactants (C-reactive protein, orosomucoid, fibrinogen) increasePositive acute-phase reactants (C-reactive protein, orosomucoid, fibrinogen) increase The change in these proteins is proportional to the physiological insultThe change in these proteins is proportional to the physiological insult

45 Nitrogen Balance Studies Oldest biochemical technique for assessment protein statusOldest biochemical technique for assessment protein status Based on the fact that 16% of protein is nitrogenBased on the fact that 16% of protein is nitrogen Nitrogen intake is compared to nitrogen output, adjusted for insensible losses (skin, hair loss, sweat)Nitrogen intake is compared to nitrogen output, adjusted for insensible losses (skin, hair loss, sweat)

46 Nitrogen Balance Studies Nitrogen balance in healthy adults is 0Nitrogen balance in healthy adults is 0 Nitrogen balance is positive in growing children, pregnant women, adults gaining weight or recovering from illness or injuryNitrogen balance is positive in growing children, pregnant women, adults gaining weight or recovering from illness or injury Nitrogen balance is negative during starvation, catabolism, PEMNitrogen balance is negative during starvation, catabolism, PEM

47 Nitrogen Balance Calculations Nitrogen balance = nitrogen intake (g/24 hours) –(urinary nitrogen [g/24 hours) + 2 g/24 hoursNitrogen balance = nitrogen intake (g/24 hours) –(urinary nitrogen [g/24 hours) + 2 g/24 hours Use correction of 4 g/24 hours if urinary urea nitrogen is usedUse correction of 4 g/24 hours if urinary urea nitrogen is used Nitrogen intake = (grams protein/24 hours)/6.25Nitrogen intake = (grams protein/24 hours)/6.25

48 Nitrogen Balance Challenges Urea nitrogen is highly variable as a percent of total nitrogen excretedUrea nitrogen is highly variable as a percent of total nitrogen excreted It is nearly impossible to capture an accurate nitrogen intake for patients taking food poIt is nearly impossible to capture an accurate nitrogen intake for patients taking food po Most useful in evaluating the appropriateness of defined feedings, e.g. enteral and parenteral feedingsMost useful in evaluating the appropriateness of defined feedings, e.g. enteral and parenteral feedings

49 Visceral Proteins: Serum Albumin Reference range: g/dlReference range: g/dl Abundant in serum, stable (half-life 3 weeks)Abundant in serum, stable (half-life 3 weeks) Preserved in the presence of starvation (marasmus)Preserved in the presence of starvation (marasmus) Negative acute phase reactant (declines with the inflammatory process)Negative acute phase reactant (declines with the inflammatory process) Large extravascular pool (leaves and returns to the circulation, making levels difficult to interpret)Large extravascular pool (leaves and returns to the circulation, making levels difficult to interpret) Therefore, albumin is a mediocre indicator of nutritional status, but a very good predictor of morbidity and mortalityTherefore, albumin is a mediocre indicator of nutritional status, but a very good predictor of morbidity and mortality

50 Visceral Proteins: Plasma Transferrin Reference range: mg/dlReference range: mg/dl Half-life: 1 weekHalf-life: 1 week Negative acute phase respondentNegative acute phase respondent Increases when iron stores are depleted so affected by iron status as well as protein-energy statusIncreases when iron stores are depleted so affected by iron status as well as protein-energy status Responds too slowly to be useful in an acute settingResponds too slowly to be useful in an acute setting

51 Visceral Proteins: Transthyretin (Prealbumin) Reference range: mg/dlReference range: mg/dl Half-life: 2 daysHalf-life: 2 days Negative acute-phase reactantNegative acute-phase reactant Zinc deficiency reduces levelsZinc deficiency reduces levels Due to short half-life, it is useful in monitoring improvements in protein- energy status if baseline value is obtained near the nadir as inflammatory response wanesDue to short half-life, it is useful in monitoring improvements in protein- energy status if baseline value is obtained near the nadir as inflammatory response wanes

52 Visceral Proteins: Retinol-Binding Protein Reference range: mg/dlReference range: mg/dl Half-life: 12 hoursHalf-life: 12 hours Negative acute-phase proteinNegative acute-phase protein Unreliable when vitamin A (retinol) status is compromisedUnreliable when vitamin A (retinol) status is compromised Elevated in the presence of renal failure, regardless of PEM statusElevated in the presence of renal failure, regardless of PEM status

53 Visceral Proteins: C-Reactive Protein Positive acute-phase reactantPositive acute-phase reactant Increases within 4-6 hours of injury or illnessIncreases within 4-6 hours of injury or illness Can be used to monitor the progress of the stress reaction so aggressive nutrition support can be implemented when reaction is subsidingCan be used to monitor the progress of the stress reaction so aggressive nutrition support can be implemented when reaction is subsiding Mildly elevated CRP may be a marker for increased risk for cardiovascular diseaseMildly elevated CRP may be a marker for increased risk for cardiovascular disease

54 Inflammation hs-CRPhs-CRP HomocysteineHomocysteine

55 Urinary Creatinine Formed from creatine, produced in muscle tissueFormed from creatine, produced in muscle tissue The bodys muscle protein pool is directly proportional to creatinine excretionThe bodys muscle protein pool is directly proportional to creatinine excretion Skeletal muscle mass (kg) = 4.1 = 18.9 x 24- hour creatinine excretion (g/day)Skeletal muscle mass (kg) = 4.1 = 18.9 x 24- hour creatinine excretion (g/day) Confounded by meat in dietConfounded by meat in diet Requires 24-hour urine collection, which is difficultRequires 24-hour urine collection, which is difficult

56 Markers of Malabsorption Fecal fatFecal fat Fat-soluble vitaminsFat-soluble vitamins Vitamin DVitamin D

57 Lipid Indices of Cardiovascular Risk Total cholesterolTotal cholesterol LDLLDL HDL: HDL2a, HDL2b, HDL2c, HDL3a, HDLdbHDL: HDL2a, HDL2b, HDL2c, HDL3a, HDLdb IDLIDL VLDLVLDL Lp(a)Lp(a)

58 Nutrition Diagnoses and Laboratory Indices Nutrition-related labs can be used either as diagnostic labels or a clinical signNutrition-related labs can be used either as diagnostic labels or a clinical sign

59 Examples of Nutrition Diagnostic Statements Related to Lab Values Altered nutrition-related lab values (NC- 2.2) related to excessive intake of saturated fat and cholesterol and genetic factors as evidenced by diet history and client history.Altered nutrition-related lab values (NC- 2.2) related to excessive intake of saturated fat and cholesterol and genetic factors as evidenced by diet history and client history. Inappropriate intake of food fats (saturated fat and cholesterol) (NI-5.6.3) related to frequent use of baked goods and fried foods as evidenced by diet history and elevated LDL and TCInappropriate intake of food fats (saturated fat and cholesterol) (NI-5.6.3) related to frequent use of baked goods and fried foods as evidenced by diet history and elevated LDL and TC

60 Examples of Nutrition Diagnostic Statements Related to Lab Values Excessive carbohydrate intake related to evening visits to Coldstone Creamery as evidenced by HS blood glucose and diet historyExcessive carbohydrate intake related to evening visits to Coldstone Creamery as evidenced by HS blood glucose and diet history


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