1、Introduction to Clinical Nutrition,NFSC 370 D. Bellis McCafferty,Illness,Malnutrition,Example : Cancer,Altered Food Intake,Altered Digestion and Absorption,Altered Metabolism,Altered Nutrient Excretion,Examples: Loss of appetite, altered food likes/dislikes, difficulty chewing and swallowing, reduce
2、d saliva secretion,Examples: radiation enteritis, surgical resection of GI tract, diarrhea,Example: increased energy needs due to altered energy use in cancer,Examples: fecal loss of fat-soluble vitamins and calcium in clients with cancers that affect enzyme secretion or bile salt production,Clinica
3、l 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 Dietitia
4、n Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistant Pharmacist Speech Therapist Occupational Therapist Social Worker,The Nutrition Care Process,Identifying and meeting a persons nutrient and nutrition education needs. Five steps: 1. Assess Assessment of nutritional status 2. A
5、nalyze Analyze assessment data to determine nutrient requirements 3. Develop Develop a nutrition care plan to meet patients 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
6、.,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 dise
7、ase 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
8、 (whos at risk?) Meds can alter intake, absorption, metabolism, etc. Foods can alter absorption, metabolism, & excretion of meds.,Historical Information,Socioeconomic History - factors that affect ones ability to purchase, prepare, & store food, as well as factors that affect food choices themselves
9、. 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 Historyanalyzing eating habits, food intake, lifes
10、tyle, 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 rec
11、all 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 Laborat
12、ory 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
13、 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 Da
14、ta - physical measurement of the body,anthropos = human metric = measureIndirect 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 Hei
15、ght and Weight,BMI Body Mass Index wt (kg)ht (cm)2or 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
16、 Measures Using Height and Weight,Cons: BMI can misclassify up to one out of four people. Does not account for fat distribution Doesnt account for LBM - may misclassify frail/sedentary or very muscular peopleMet Life Insurance weight-for- height tables Weights based on lowest mortality,Example: Heig
17、ht 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 u
18、nder 5 tall, subtract 2 lb. per inch under 5) * Amputations, immobility:,7%,43%,Whole arm 6.5%,Whole leg 18.5%,Below elbow 3% Hand 1%,Above knee 13% Below knee 6%Foot 1.8%,Interpretation%IBWActual (present) weight X 100 = %IBWIBWexample: 56” woman weighs 160#. What is her % IBW? 160 130 = 123%,Inter
19、preting % IBW, 200% IBW = morbidly obese (or 100# over IBW) 120 % (130%) = obese110 - 120 = overweight90 - 109 = normal80 - 89 = mildly compromised nutrition status (mild malnutrition) 70-79 = moderate 70% = severe,Anthropometric Data Measures Using Height and Weight,Assessing “Usual Body Weight”Act
20、ual (present) weight X 100 = % UBWUBWexample: 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 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),
21、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 tricep
22、s 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 d
23、ifficult 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 Accu
24、racy 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 whats happening on the inside of the body Automated measurements of several bloo
25、d 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.,Nor
26、mal hydration,Overhydrated = diluted blood,Dehydrated = 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, an
27、d 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 di
28、seasedRemember, when kcals are inadequate, protein is used to make glucose.,Laboratory Analyses: Biochemical Tests Of Protein Status,Serum Albumin:50% total serum proteinHelps maintain fluid and lyte balanceTransports many nutrients, hormones, drugs, etc.Used as indicator of protein status (visc. pr
29、otein stores)Half life _3.5-5.0 = adequate2.8-3.4 = mildly depleted2.1- 2.7 = moderately depleted2.1 = 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
30、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
31、 Fe deficiency present, doesnt 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/dlMild 150-200 mg/dlModerate 100-149
32、mg/dlSevere 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 t
33、han albumin,Laboratory Analyses: Biochemical Tests Of Protein Status,Prealbumin Levels : Levels :Normal: 15-40 mg/dlMild: 10-15 mg/dlModerate: 5-10 mg/dlSevere: 5 mg/dl,Laboratory Analyses: Biochemical Tests Of Protein Status,Nitrogen Balance Studies (usually only used in severe metabolic stress) 1.
34、 Track the patients 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,Amino Acids C-C-NC-C-N,Urea (BUN) N-C-N,Excreted via kidneys (UUN),Remember how this works?,N balance (g) = protein intake - (UUN
35、+ 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 nitrogen0 or - = + =Goal for repletion :,Laboratory Analyses: Biochemical Tests Of Immune Function,Total WBCs Normal: 5,000-10,000/mm3 Possible critical values: 30,000/mm3 H
36、igh vs. low values?Total Lymphocyte Count (TLC) Measured from % lymphocytes and total WBC count Equation: TLC = % lymphocytes X Total WBC/mm3Normal: 1500 mm3Mild: 1200 - 1500Moderate: 800-1199Severe: 800What do unusually high numbers indicate?,Laboratory Analyses: Hematological Assessment looking at
37、 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 females14-
38、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 _, _ RBCsMales: 42%-52%Females: 37%-47%,Laboratory Analyses: Hem
39、atological 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 di
40、sease (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, antidepressant
41、s and several other drugs.Normal Fasting:,Blood Urea Nitrogen (BUN) Major end product of protein metabolism Levels with impaired _ function Also with:,Amino Acids C-C-NC-C-N,Urea (BUN) N-C-N,Excreted via kidneys (UUN),Laboratory Analyses: Other Labs Used in Nutrition Assessment,Creatinine (blood) Br
42、eakdown 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,
