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
kef@u.washington.edu
8-11-09
Components of Nutrition Assessment
Diet History
Medical
History
Weight
History
*Eating
Habits
*Potential
Deficiencies
*Reasons
for suboptimal
intake
*Food
Resources
*Conditions *Actual,
effecting
Usual and
digestion or BMI
ability to eat
*Drugnutrient
interactions
Body Comp
Biochemical Physical
Data
Assessment
*Skinfold
*BioElectrical
Impedance
*Serum
Proteins
(albumin &
prealbumin,
CRP)
*Vitamin
and mineral
assays
*Loss of
subcu fat
*Muscle
wasting
*Concave
appearance
*Hair
*Nails
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
Medical History
Sample conditions effecting
intake
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GI Disease
Chronic Alcoholism
Critical Illness
Stroke
Anorexia Nervosa
Dementia
Pancreatitis
Renal Disease
Sample Drug-Nutrition
Interaction
• Insulin
• Coumadin
• MAOI Inhibitors
• HAART
• INH
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
Body Composition Measurements
Underwater Weighing
Skin Fold Measurements
Biochemical Assessment
Sources of Error
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Biological Variation
Preanalytical variation
Analytical variation
Postanalytical variation
Factors Influencing Concentration
• Synthesis rate
• Secretion rate
• Clearance rate
• Catabolic rate
• Distribution
• Other
Synthesis rate
• Substrate availability
• Hepatic function
• Metabolic response to
injury
• Corticosteroids
• Inflammatory Response
Secretion and Clearance Rate
• Cofactor availability
• Hepatic Function
• Renal Function
Distribution and Other
• Metabolic response
• Hydration
• Drainage and fistula
losses
• Analytical Method
• Patient position on
blood draw
Biochemical Markers of Protein
Status
• Assessing ProteinCalorie Malnutrition
– Albumin
– Pre-Albumin
Serum Protein levels are not reliable
during inflammation
Albumin
• Half-life - 20 days
• Under/over hydration, liver function
• Function
– Oncotic pressure, transport, nutritive reserve
• Determinants of synthesis
– Oncotic pressure, hormones, negative acutephase reactant, nutrition support, aging, drugs
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
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
How many of our patients are not
experiencing acute stress?
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
Lipid and Glycemic Status
• Lipids
• Glycemic Control
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– Blood Glucose
– HgA1C
Total Cholesterol
HDL/LDLs
Homocysteine
Triglycerides
Physical Assessment
Photos courtesy of Katy Wilkens, MS, RD
NW Kidney Center, Seattle, WA
Wasted Clavicle
23
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
24
The Arm
• Bend arm and pinch at
triceps. Only pinch the
fat, not the muscle.
• Normal: fingers don’t
meet
• Abnormal: fingers
meet
25
Forearm
• Forearm: often better
site than upper arm
for assessing fat
• Upper arm fat
disposition changes as
women age
26
Wasting in the hands
27
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
28
The Legs showing muscle wasting
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Quadriceps and Knees
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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
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The back side
• In hospitalized
patients, the back may
not be easily
accessible.
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Vitamin C Deficiency
Petechia
Cork Screw Hair
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
Where to find nutrition
information in ORCA
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Admit Nursing History
Weight trending
Dietitian and Dietetic Technician Notes
Enteral and TPN Flow Sheets
Discharge nutrition counseling