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Harborview Medical Center

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Presentation on theme: "Harborview Medical Center"— Presentation transcript:

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

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