1. UNIT 4 NS270 NUTRITIONAL ASSESSMENT AND MANAGEMENT Amy Habeck, RD, MS, LDN

2. Recognition  Presentation download  Good sources  Excellent writing skills

3. Unit 4 Learning Objectives: 1) Practice Calculations 2) Review- Nutrition and Diet Therapy a) Chapter 7 – Assessment of the Hospitalized Patient 3) Answer your questions

4. Assessing Nutritional Status  Screening of hospitalized patients  Completed within first 24-48 hours  Identifies characteristics known to be associated with nutrition problems Malnutrition Nutritional risk What are some diagnoses that put a patient at increased nutritional risk?

5. Examples of diagnoses that indicate nutritional risk  Dysphagia  Bowel resection  FTT  COPD  Pressure ulcers  Cancer  HIV/AIDS  Stroke or hemiparesis  GI bleeding  Crohn’s disease  Organ transplant  CAD  DM  Pancreatitis  SBO  Short bowel syndrome

6. Nutritional Assessment  Ht  Wt  UBW  History  Diagnosis  Test results  Anthropometric measurements  Biochemical measures  REE  Specialized nutritional assessment

7. Case Study  Helen is a 72 y.o.  Hx: osteoporosis with compression fx KH=knee height=16.5 inches A= age=72  How can you estimate her height? table 7.1, page 219 Same type of question as #1

8. Case Study  Helen is a 72 y.o.  Hx: osteoporosis with compression fx  How can you estimate her height? Table 7.1 page 219 S=75.00 +(1.91 KH)-(0.17A) S=stature KH=knee height A= age

9. Case Study-Estimate Stature S=75.00 +(1.91 KH)-(0.17A) S=stature KH=knee height in cm KH=16.5 inches KH=16.5 in x 2.54cm/in=41.91cm A= age=72 S=75.00+(1.91x41.91)-(0.17x72) S=75.00+80-12.2 S=142.8 cm

10. Evaluating Desirable Body Weight-  Hamwi equations  Men 5’ = 106# + 6# for every additional inch +/- 10%  Women 5’=100# + 5# for every additional inch +/- 10%  Height-weight tables  What are some of the limitations of the height-weight tables?

11. Let’s Practice-Number 4  48 year old patient, Ms. Geneva  Female  Height: 5’6”  Actual body weight: 155#  What is her desirable or ideal body weight?  Use the Hamwi equation  Page 170-171

12. Let’s Practice  48 year old patient, Ms. Geneva  Female  Height: 5’6”  What is her desirable or ideal body weight?  Women: 5’=100 + (5x6) +/- 10%  130+/- 10% or 130x.9 to 130x1.1  117-143#

13. %IBW  48 year old patient, Ms. Geneva  Female  Height: 5’6”  Actual body weight: 155#  Calculate her percent IBW using the IBW determined by the Hamwi equation on previous slide.

14. %IBW  48 year old patient, Ms. Geneva  Female  Height: 5’6”  Actual body weight: 155#  Calculate her percent IBW using the IBW determined by the Hamwi equation.  IBW: 117-143#  Actual body weight/IBW x 100=  155/117-143 x100=132-108% IBW

15. Amputation Adjustments-number 2  Page 225, table 7.5  48 year old patient, R BKA (right leg, below knee amputation)  Female  Height: 5’6”  Actual body weight: 155#  What percentage of her body weight would the right below knee amputation represent?  How would you adjust her IBW to account for the loss of the partial limb?

16. Amputation Adjustments  What percentage of her body weight would the right below knee amputation represent?  Lower leg represents 7.1% (5.3+1.8) of body weight  How would you adjust her IBW to account for the loss of the partial limb?  Adjusted weight= current weight/(100-% amp) x 100  Adjusted weight=155/(100-7.1) x 100 = 166.8#

17. Calculate BMI based on adjusted body weight-number 3 P176, classification table 6.6  Adjusted weight=155/(100-7.1) x 100 = 166.8#  Ht= 5’6”=66”  BMI based on adjusted body weight= BMI=ABW(pounds)/ht(in)/ht(in)x703= BMI=166.8/66/66x703=26.9

18. Using Anthropometric Measures to estimate weight-practice  Number 5  Known: MAC and CC (both in cm)  Equation: page 224, table 7.3  Female: (MAC x 1.63)+(CCx1.43)-37.46  Male: (MACx2.31)+(CCx1.5)-50.10  Sample: MAC=30 cm, CC=34cm, female  (MAC x 1.63)+(CCx1.43)-37.46=  (30 x 1.63)+(34x1.43)-37.46=  48.9+48.62-37.46=60kg  60kgx2.2pounds/kg=132

19. Using Anthropometric Measures to estimate weight-practice  Number 6  Known: KH and MAC (both in cm)  Equation: page 225, table 7.4

20. 24 Hour Energy Expenditure  What factors make up the energy expended in a 24 hour period?  How is BMR measured?

21. 24 Hour Energy Expenditure  24 hour energy expenditure=  Resting energy expenditure  Thermic effect of food  Thermic effect of exercise  Thermic effect of disease or injury  24 hour EE=REE+TEF+TEE+TED  How is BMR measured?  6-12 minutes period in post-absorptive state  30 minutes of quiet rest preceeding testing  Thermally neutral environment  Measure oxygen consumption

22. Calculating REE  Calculate the REE for Ms. Geneva  What results do you get with each of the methods below? Harris-Benedict WHO National Academy of Sciences  How do they compare?  Which method do you like better and why?  Apply an activity factor for average activity to each of your results. List the answer separately.

23. Ms. Geneva-Harris Benedict  48 year old female patient, s/p R BKA  Height: 5’6”=66inx2.54cm/in=167.6cm  Actual body weight: 155#x1kg/2.2#=70.5kg  REE=655.1+9.6W+1.9S-4.7A  REE=655.1+(9.6x70.5)+(1.9x167.6)-(4.7x48)  REE=655.1+676.8+318.4-225.6  REE=1425 kcal/day

24. Ms. Geneva- WHO  48 year old female patient, s/p R BKA  Height: 5’6”=66inx2.54cm/in=167.6cm  Actual body weight: 155#x1kg/2.2#=70.5kg  REE=8.7W+829  REE=8.7x70.5+829  REE=613.4+829  REE=1442kcal/d

25. Ms. Geneva- NAS  48 year old female patient, s/p R BKA  Height: 5’6”=66inx2.54cm/inx1m/100cm=1.68m  Actual body weight: 155#x1kg/2.2#=70.5kg  REE=247-(2.67xA)+(401.5xht)+(8.6xwt)  REE=246-(2.67x48)+(401.5x1.68)+(8.6x70.5)  REE=245-128.2+674.5+606.3  REE=1398kcal/d

26. Compare  Harris Benedict  REE=1425kcal/d  WHO  REE=1442kcal/d  NAS  REE=1398kcal/d  How do you think these equations compare?  Which one is easiest to use and remember?

27. Calculate TEE for Overweight Adults-number 9  Complete the calculations for Ms. Geneva using the TEE equation in Table 7.10 on page 235.  Use an activity factor for active adults.

28. Calculate TEE for Overweight Adults  48 year old female patient, s/p R BKA  Height: 5’6”=66inx2.54cm/in=167.6cm  Actual body weight: 155#x1#/2.2kg=70.5kg  TEE=448-(7.95xage)+PA x(11.4x Wt + 619x ht)  TEE=448-(7.95x48)+1.27 x(11.4x70.5+619x1.68)  TEE=448-(7.95x48)+1.27 x(803.7+1039.9)  TEE=448-384.6+1.27 x 1843.6  TEE=448-384.6+2341.4  TEE=2405kcal/d

29. Injury Factors  Assume our same patient, Ms. Geneva, has undergone major surgery.  How does that affect her energy requirements?  What do you estimate her energy requirements to be after the surgical procedure?

30. Injury Factors – Major Surgery  What do you estimate her energy requirements to be after the surgical procedure?  Major surgery increases energy requirements by a factor of 1.1-1.3 times original TEE  TEE=2405kcal/d x (1.1 to 1.3)  TEE=2646-3127kcal/d

31. Estimating Protein Needs-number 11  Estimate Ms. Geneva’s protein needs for an individual who has undergone major surgery.  How can you determine if she is meeting her protein requirements?  P 239, table 7.13

32. Estimating Protein Needs  Estimate Ms. Geneva’s protein needs for an individual who has undergone major surgery.  Moderate stress level: 1.2-1.8 gm/kg  How can you determine if she is meeting her protein requirements?  UUN  Calorie count assessment

33. Nitrogen Balance  Ms. Geneva  Protein intake: 84 gm protein  Determined from 24 hour calorie count  UUN = 10  Measured from 24 hour urine collection  Is she is positive or negative N2 balance?  How did you calculate it?

34. Nitrogen Balance  Ms. Geneva  Protein intake: 84 gm protein  UUN = 10  Is she is positive or negative N 2 balance?  Negative nitrogen balance  How did you calculate it?  See next slide

35. Calculating Nitrogen Balance  Ms. Geneva  Protein intake: 84 gm protein  UUN = 10  How do you calculate N 2 Balance?  N 2 balance = (protein intake/6.25) – UUN-4  N 2 balance=(84 gm/6.25)-10-4  N 2 balance=13.44-10-4  N 2 balance=-0.56

36. EER-number 8 sample  P 233-234, table 7.9  EER for males >19 years  PA=physical activity factor  Ht in m= 1.78m, wt in kg=90.5, PA=1.11 (low active), age=45  EER=662-9.53(age)+PA x(15.91x wt+539.6 x ht)  EER=662-9.53(45y)+1.11 x(15.91x 90.5kg+539.6 x 1.78m)  EER=662-428.85+1.11 x( 1439.9+ 960.49)  EER=662-428.85+1.11 x( 2400.39)  EER=662-428.85+ 2664.4  EER=2897.55 kcal

37. Ireton-Jones-number 10  Ireton-Jones recommended for overweight individuals in critical condition  Activity factors (AF): box 7.3, page 233  Injury factors (IF): table 7.11, page 237  Obesity factor: 1=BMI>27, 0=BMI<27  IJEE: 629-11(age)+25(wt)-609(obesity factor)

38. Questions About Assessment of Hospitalized Patients?

39. Farewell  Thank you for your kind attention and participation!  Email any time - ahabeck@kaplan.edu