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Introduction to Clinical Nutrition Power point--for Nurses

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Introduction to Clinical Nutrition Power point--for Nurses Powered By Docstoc
					  Introduction to
Clinical Nutrition
                                      Illness
                                   Example : Cancer



                          Altered                                        Altered
  Altered              Digestion and              Altered               Nutrient
Food Intake             Absorption               Metabolism             Excretion

Examples: Loss       Examples:                  Example:             Examples: fecal
of appetite,         radiation enteritis,       increased energy     loss of fat-soluble
altered food         surgical resection         needs due to         vitamins and
likes/dislikes,      of GI tract,               altered energy use   calcium in clients
difficulty chewing   diarrhea                   in cancer            with cancers that
and swallowing,                                                      affect enzyme
reduced saliva                                                       secretion or bile
secretion                                                            salt production




                                     Malnutrition
Clinical Nutrition
(Medical Nutrition Therapy)

Purpose
    To achieve or maintain good nutritional status.
American Dietetic Association
    Professional organization representing
     Registered Dietitians (RD) and Dietetic
     Technicians (DTR)
Patient Care: Team Approach
(Interdisciplinary)

   Physician
   Registered Dietitian
   Registered Nurse, Licensed Vocational
    Nurse, Certified Nursing Assistant
   Pharmacist
   Speech Therapist
   Occupational Therapist
   Social Worker
    The Nutrition Care Process
 Identifying and meeting a person’s nutrient and nutrition
  education needs. Five steps:
1. Assess Assessment of nutritional status
2. Analyze Analyze assessment data to determine
  nutrient requirements
3. Develop Develop a nutrition care plan to meet
  patient’s nutrient and education needs.
4. Implement: Implement care plan
5. Evaluate: Evaluate effectiveness of care plan:
  ongoing follow-up, reassessment, and modification of
  care plan.
THE PATIENT
SHOULD BE AN ACTIVE
PARTICIPANT IN THE CARE
PROCESS!
Assessing Nutritional Status
        Historical Information
        Physical Examination
        Anthropometric Data
        Laboratory Analyses
Historical Information
     Health History (medical history) - current
      and past health status
         diseases/ risk factors for disease
         appetite/food intake
         conditions affecting digestion, absorption,
          utilization, & excretion of nutrients
         emotional and mental health
Historical Information
 Drug History
      prescription & OTC meds
     illicit drugs
     nutrient supplements, HERBS and other
      “alternative” or homeopathic substances
      multiple meds (who’s at risk?)
Meds can alter intake, absorption, metabolism,
  etc.
Foods can alter absorption, metabolism, &
  excretion of meds.
 Historical Information
 Socioeconomic History - factors that affect one’s
  ability to purchase, prepare, & store food, as well
  as factors that affect food choices themselves.
     Food availability (know local crops/produce)
     occupation/income/education level
     ethnicity/religious affiliations
     kitchen facilities
     transportation
     personal mobility (ability to ambulate)
     number of people in the household
Historical Information
 Diet History—analyzing eating habits, food
  intake, lifestyle, so that you can set
  individualized, attainable goals.
     Amount of food taken in
     Adequacy of intake – omission of foods/food groups
     Frequency of eating out
     IV fluids
     Appetite
     Restrictive/fad diets
     Variety of foods
     Supplements (overlaps)
Historical Information
 Tools for taking a diet hx:
       24 hour recall
       Usual intake – can find trends, such as breakfast/snacks
       Food Frequency Questionnaire/Checklist
       Food Records
       Observing food intake
   Analysis of Food Intake Data
   INDIVIDUAL NEEDS FOR NUTRIENTS VARIES
Assessing Nutritional Status
      Historical Information
      Physical Examination
        Anthropometric Data
        Laboratory Analyses
    Physical Examination: “A picture is
    worth a thousand words.”

   weight status
   mobility
   confusion
   signs of nutrient deficiencies/malnutrition
       esp. hair, skin, GI tract including mouth and tongue
   Fluid Balance (dehydration/fluid retention)
    Physical Examination: “A picture is
    worth a thousand words.”
   Limitations of Physical Findings
       Depends on assessor!
       Many physical signs are nonspecific: ie. cracked
        lips from sun/windburn vs. from malnutrition,
        dehydration…
Assessing Nutritional Status
        Historical Information
        Physical Examination
        Anthropometric Data
        Laboratory Analyses
Anthropometric Data - physical measurement of
the body



anthropos = human         metric = measure

   Indirect assessment of body composition and
    development
   Used in Nutrition Assessment:
     Measures using height and weight

     Measures of body composition (fat vs. lean tissue)

     Functional Measures
Anthropometric Data
       Measures Using Height and Weight

 BMI Body Mass Index
  wt (kg)
  ht (cm)2

 or
      wt (lb) X 705
      ht (inches) 2
Anthropometric Data
      Measures Using Height and Weight


     18.5-24.9
     25+
     30+
     Pros:
         many studies have identified the health risks
          associated with a wide range of BMIs
         easy to look up on chart
         screening tool
Anthropometric Data
      Measures Using Height and Weight


     Cons: BMI can misclassify up to one out of
      four people.
         Does not account for fat distribution
         Doesn’t account for LBM - may misclassify
          frail/sedentary or very muscular people



  Met Life Insurance weight-for- height tables
         Weights based on lowest mortality
              Example: Height & Weight Table For Women
Feet Inches     SmallFrame    MediumFrame           LargeFrame
5' 1"           106-118       115-129               125-140
5' 2"           108-121       118-132               128-143
5' 3"           111-124       121-135               131-147
5' 4"           114-127       124-138               134-151
5' 5"           117-130       127-141               137-155
5' 6"           120-133       130-144               140-159
5' 7"           123-136       133-147               143-163
5' 8"           126-139       136-150               146-167
5' 9"           129-142       139-153               155-176
Weights at ages 25-59 based on lowest mortality. Weight in pounds
according to frame (in indoor clothing weighing 3 lbs.; shoes with 1"
heels)
Anthropometric Data
     Measures Using Height and Weight
 Assessing “Ideal Body Weight”
 Hamwi Equation:
  Females: 100# for first 5’ of height, plus 5# per
    inch over five feet
  Males: 106# for first 5’ of height, plus 6# per
    inch over five feet
  +/- 10% to calculate a range

 (for those under 5’ tall, subtract 2 lb. per inch
    under 5’)
 ** Amputations, immobility:
                   7%



                                 Whole
                   43%           arm
Below elbow 3%                   6.5%

Hand 1%

                         Whole
  Above knee 13%
                         leg
   Below knee 6%         18.5%

       Foot 1.8%
Interpretation

%IBW

Actual (present) weight   X 100 = %IBW
       IBW

   example: 5’6” woman weighs 160#. What
    is her % IBW?
   160  130 = 123%
Interpreting % IBW

     200% IBW = morbidly obese (or 100# over IBW)
     120 % (130%) = obese
    110 - 120 = overweight
    90 - 109 = normal
    80 - 89 = mildly compromised nutrition status (mild
      malnutrition)
    70-79 = moderate
    < 70% = severe
Anthropometric Data
       Measures Using Height and Weight

   Assessing “Usual Body Weight”

Actual (present) weight X 100 = % UBW
        UBW

   example: 110# female lost 10# over past month
   110/120 x 100 = 91.6% UBW, or loss of about 8%
Interpreting % UBW
85-90% mild
75-84% moderate
<75% severe
OR wt. change (unintentional weight loss)
            mild   moderate         severe
1 week             1-2%             >2
1 month             5               >5
3 months           7.5              >7.5
6 months 10        10-15            >15
Anthropometric Data
    Measures of Body Composition
    (fat vs. lean tissue)

Body Fat Measurements
 fatfold (skinfold)

 waist-to-hip ratios

 hydrodensitometry (hydrostatic weighing)

 bioelectrical impedance
Anthropometric Data
     Measures of Body Composition

Midarm muscle circumference – indirectly
  measures protein status by estimating arm
  muscle mass.
 Midarm circumference and triceps fatfold

 plug into an equation:
mmc (cm) = mc (cm) - [.314 x triceps fatfold (mm)]
Anthropometric Data
     Functional Measures of Nutrition Status

Hand Grip Strength
 Dynamometer

 Not appropriate w/arthritis/muscular disorders
Interpreting Measurements

   Requires caution
   Interpreting Measurements
       Sometimes difficult to measure 2’ mobility
        problems, injury, loose, hanging skin
       Hydration/dehydration affects weight, fatfolds, and
        MAMC
       Standards used are controversial
Summing Up

   Anthropometric measures provide valuable
    information regarding body wt. and
    composition
   Do not reflect nutrition status alone
   Accuracy requires on the skill of the assessor
   Caution interpreting results
Assessing Nutritional Status
        Historical Information
        Physical Examination
        Anthropometric Data
        Laboratory Analyses
Laboratory Analyses

   Help determine what’s happening on the
    inside of the body
   Automated measurements of several blood
    components from a single blood sample
   serum -



   plasma -
Laboratory Analyses
Interpreting Biochemical Tests
 Many can be skewed with fluid retention or
  dehydration.
 Over-hydration can cause _____ numbers

 Dehydration can cause ______ numbers

 These are clues that anthropometrics are
  probably skewed as well.
Normal          Overhydrated =   Dehydrated =
hydration       diluted blood    concentrated blood




   1 dl blood




  10 mg/dl           5 mg/dl          20 mg/dl
Laboratory Analyses:
Biochemical Tests Of Protein Status

   Somatic proteins - physical work
   Serum/visceral proteins (circulating proteins &
    proteins found in the liver, kidneys, pancreas,
    and heart)
      maintain fluid balance
      synthesize enzymes and hormones
      mount immune response
      heal wounds
   Therefore, protein status is an indicator of
    immune response.
Laboratory Analyses:
Biochemical Tests Of Protein Status



   Synthesized in the liver
       May reflect liver function
       Measurements skewed if liver diseased


   Remember, when kcals are inadequate, protein
    is used to make glucose.
Laboratory Analyses:
Biochemical Tests Of Protein Status

Serum Albumin:
      >50% total serum protein
      Helps maintain fluid and lyte balance
      Transports many nutrients, hormones, drugs, etc.
      Used as indicator of protein status (visc. protein stores)
      Half life ___________
               3.5-5.0 = adequate
               2.8-3.4 = mildly depleted
               2.1- 2.7 = moderately depleted
               <2.1 = severely depleted visceral protein
      stores
Laboratory Analyses:
Biochemical Tests Of Protein Status

Problems with albumin:
       not very sensitive, long half life
        levels reflect prolonged depletion, but
       normal levels may not reflect short term changes in
        nutritional status.
   Levels  :



   Remember, number affected by plasma
    volume, so  in over-hydration and  in
    dehydration.
Laboratory Analyses:
Biochemical Tests Of Protein Status

Serum Transferrin
 = (TIBC x 0.76) + 18
     Shorter half-life ____________
     Transports iron:

     If Fe deficiency present, doesn’t accurately reflect
      protein status
     Transferrin levels RISE with Fe deficiency! Inverse
      relationship
      levels may indicate __________________
      levels may indicate __________________
Laboratory Analyses:
Biochemical Tests Of Protein Status

     Levels  :
     Levels  :

                          Normal:     >200 mg/dl
                          Mild        150-200 mg/dl
                          Moderate    100-149 mg/dl
                          Severe      <100 mg/dl
Laboratory Analyses:
Biochemical Tests Of Protein Status

Prealbumin (thyroxine-binding prealbuin or
  transthyretin TTHY)
     Being used more: some facilities using in place of
      albumin
     Half life: ______________
     Sensitive indicator of protein status
     Good indicator of pt. response to MNT
      $$ to run than albumin
Laboratory Analyses:
Biochemical Tests Of Protein Status

Prealbumin
     Levels  :
     Levels  :

                          Normal:     15-40 mg/dl
                          Mild:       10-15 mg/dl
                          Moderate:   5-10 mg/dl
                          Severe:     <5 mg/dl
Laboratory Analyses:
Biochemical Tests Of Protein Status

Nitrogen Balance Studies
  (usually only used in severe metabolic stress)
1. Track the patient’s UUN (Urinary Urea Nitrogen)
2. 24 hour record of protein intake
3. Plug into nitrogen balance equation:

    N balance (g) = protein intake - (UUN + 4)
                        6.25
Remember how this works?




Amino Acids
                  Urea     Excreted via kidneys
C-C-N
                  (BUN)          (UUN)
C-C-N             N-C-N
    N balance (g) = protein intake - (UUN + 4)
                        6.25
   “4” represents non-urea N+ lost in feces, urine,
    skin, and respiration
   every 6.25 grams of protein contains 1 gram of
    nitrogen
        0 or - =
        + =

   Goal for repletion :
Laboratory Analyses:
Biochemical Tests Of Immune Function
   Total WBCs
   Normal: 5,000-10,000/mm3
   Possible critical values: <2500 or >30,000/mm 3
   High vs. low values?


     Total Lymphocyte Count (TLC)
      Measured from % lymphocytes and total WBC count
      Equation: TLC = % lymphocytes X Total WBC/mm3
                                     Normal: >1500 mm3
                                     Mild: 1200 - 1500
                                     Moderate: 800-1199
                                     Severe: <800

      What do unusually high numbers indicate?
Laboratory Analyses:
Hematological Assessment – looking at blood cells and
detecting anemias

    Hematology Assessment – morphology &
        physiology of blood cells. Helps detect the
        presence of anemias.
       Hemoglobin (Hgb, Hb)
           main functional constituent of the RBC, serving
            as the oxygen-carrying protein
            level may indicate depleted iron stores BUT
            

            

                                     12-16 g/dl females
                                      14-18 g/dl males
Laboratory Analyses:
Hematological Assessment

   Hematocrit (Hct) – % of RBCs in the total blood
    volume.
         Commonly used to diagnose Fe def., but also
        inconclusive
          values indicate incomplete Hgb formation, which is
        manifested by ____________, ______________
        RBCs

                                  Males: 42%-52%
                                  Females: 37%-47%
Laboratory Analyses:
Hematological Assessment

    Mean Corpuscular Volume (MCV) - the average
     volume (size) of a single RBC.
         levels:
         levels:

                           normal: 80-95m3
Anemias:
   Normocytic, normochromic anemia:
       Iron def detected early (RBCs)
   Microcytic hypochromic:
       Fe-def detected late (or lead poisoning)
   Microcytic, normochromic:
       Renal disease (2’ loss of EPO)
   Macrocytic, normochromic:
       B12 or folate def (or chemo)
Laboratory Analyses:
Other Labs Used in Nutrition Assessment
    Glucose
        Indicates glucose tolerance/diabetes.
        Levels  2° _______________, pancreatitis,
         pancreatic CA, & with use of steroids (solumedrol
         and prednisone),caffeine, antidepressants and
         several other drugs.

        Normal Fasting:
Amino Acids           Urea
C-C-N                 (BUN)            Excreted via kidneys
C-C-N                 N-C-N                  (UUN)

   Blood Urea Nitrogen (BUN)
       Major end product of protein metabolism
       Levels  with impaired ____________ function
       Also  with:
Laboratory Analyses:
Other Labs Used in Nutrition Assessment

    Creatinine (blood)
        Breakdown product of phosphocreatine, present
         in skeletal muscle
        Daily production of creatine, (and thus creatinine)
         depends on muscle mass
        Creatinine is excreted in ________ on a daily
         basis.
        If _________ function is impaired, Creatinine
         levels will rise (decreased clearance).
Laboratory Analyses:
Other Labs Used in Nutrition Assessment

    Sodium (Na+)
        Indicator of hydration level. Look at Na+ level to
         evaluate other labs.
        Overhydration -
        Dehydration -
    eg. albumin

				
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Description: Introduction to Clinical Nutrition