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Nutrition Assessment in the Inpatient Setting Patients with Pressure Ulcers For HMC Wound Care Nurses Katie Farver RD, CNSD Harborview Medical Center Seattle,

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Presentation on theme: "Nutrition Assessment in the Inpatient Setting Patients with Pressure Ulcers For HMC Wound Care Nurses Katie Farver RD, CNSD Harborview Medical Center Seattle,"— Presentation transcript:

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

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3 Components of Nutrition Assessment Diet HistoryMedical History Weight History Body CompBiochemical 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 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 GI Disease Chronic Alcoholism Critical Illness Stroke Anorexia Nervosa Dementia Pancreatitis Renal Disease Sample Drug-Nutrition Interaction 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 – 18.5-24.9 normal, healthy – 24.9-29.9, overweight – >30 obese

7 Body Composition Measurements Underwater WeighingSkin Fold Measurements

8 Biochemical Assessment

9 Sources of Error Biological Variation Preanalytical variation Analytical 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 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 Assessment Photos courtesy of Katy Wilkens, MS, RD NW Kidney Center, Seattle, WA

23 23 Wasted Clavicle

24 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 25 The Arm Bend arm and pinch at triceps. Only pinch the fat, not the muscle. Normal: fingers dont meet Abnormal: fingers meet

26 26 Forearm Forearm: often better site than upper arm for assessing fat Upper arm fat disposition changes as women age

27 27 Wasting in the hands

28 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 29 The Legs showing muscle wasting

30 30 Quadriceps and Knees

31 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 32 The back side In hospitalized patients, the back may not be easily accessible.

33 Vitamin C Deficiency PetechiaCork Screw Hair

34 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 Clinical Dietitians at HMC

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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