Assessment of the Hospitalized Patients

1. Assessment of the Hospitalized Patients

2. Introduction: • Recent estimates of the prevalence of protein-energy malnutrition (PEM) among hospitalized patients typically range from 20% to 50%. • Elderly and more acutely ill patients are MORE likely to have PEM than younger and less acutely ill patients.

3. Introduction: • Appropriate nutritional support of these patients can result in faster recovery and shorter hospital stays, which translate into reduced health care expenditures. • Another reason that nutritional assessment of hospitalized patients is important is our increasing capability to provide nutritional support to these patients through enteral and parenteral routes.

4. Goals of Assessing Nutritional Status of the Hospitalized Patient: • Patients who are nutritionally at risk need to be identified through a process known as nutritional screening. • Once a patient is shown to be at nutritional risk, a more in-depth nutritional assessment should be done to determine the severity and causes of the patient’s nutritional impairment. Although both undernutrition and overnutrition can negatively affect health, most frequently it is undernutrition (particularly, protein-energy malnutrition) that is of greatest concern in hospitalized patients.

5. Goals of Assessing Nutritional Status of the Hospitalized Patient: • The risk of the patient’s undernutrition worsening his or her condition, Causing a related disease, or possibly resulting in death. • The patient should be monitored to ensure an appropriate response to nutritional support.

6. Nutritional Screening: • Nutritional screening “is the process of identifying characteristics known to be associated within nutrition problems. Its purpose is to pinpoint individuals who are malnourished or at nutritional risk”. • Screening should be done on all patients within the first 24 to 48 hours following admission. • Box 1 outlines the characteristics of the nutritional screening process.

7. Box: 1.

8. Nutritional Screening: • Screening can be greatly facilitated by using a checklist or form on which pertinent patient information can be entered. • Once completed, this form can be placed in the patient’s medical record (often referred to as the patient’s chart”). • An example of the nutritional screening from is shown in figure 1.

9. Figure: 1. An example of a form that can be used to screen patients for nutritional risk. * Dara Al-Disi*

10. Box: 2

11. Nutritional Assessment: • Once nutritional screening has identified a patient to be at nutritional risk, a nutritional assessment should be done to: • Determine the severity and causes of the patient’s nutritional impairment, • Evaluate whether the nutritional impairment is a factor contributing to the worsening of the patient’s medical condition • Monitor the patient’s response to nutritional support.

12. Nutritional Assessment: • Because no single measurement or test by itself is capable of providing information sufficient to evaluate a patient’s nutritional status, a variety of available measurements and test must be used. • It is important to note that some of this information is routinely collected by the medical and nursing staff and is recorded in the patient’s medical record. • This basic information includes the patient’s stature, usual and present weight, and past and current dietary practices, any significant changes in eating habits; and the presence of any nutrition-related problems.

13. 1. History: • The first step in clinical assessment of nutritional status. • Can be obtained from the medical record and from interviews with the patient or others knowledgeable about the patient’s habits. • Include the medical history; entries made by physicians, nurses, social workers, and other members of the health care team; and medical records from previous admissions. • Other essential components of a patient’s history include pertinent facts about past and current health, use of medications, and personal and household information.

14. 2. Dietary Information: • Includes the patient’s food preferences, allergies and intolerances, and usual eating pattern (timing and location of meals and snacks). • Data should also be collected about the amount of money available forpurchasing food, ability to obtain and prepare food, eligibilityfor and accessto food assistance programs, and use of vitamin, mineral, and other supplements.

15. 2. Dietary Information: • A 24-hour recall or simple food frequency questionnaire can provide important data on usual eating patterns and can help generate additional questions on dietary intake. • Hospitalized patients’ food intake can be evaluated by a calorie count, in which the caloric and nutrient value of foods eaten from the patient’s tray for 1 or more days are calculated and recorded.

16. 3. Physical Examination: • Two of the most important measurements to obtain are body weight and stature (or length, in the case of infants and young children unable to stand without assistance). • Marked weight loss is generally viewed as a manifestation of seriousdisease. • Weight is an important variable in equations predicting energy expenditure and in Quetelet’s index.

17. 3. Physical Examination: • Recent changes in body weight are a better indicator or nutritional status than are static weight measurements. This can be done using the following equations:

18. 3. Physical Examination: • A weight loss <5% is considered small. • A 5% to 10% weight loss is considered potentially significant. • A weight loss > 10% is considered definitely significant. • A change in body weight > 1 lb/d (0.5 kg/d) indicates fluid shifts and not a true change in body weight. • The rate of weight loss is as important to consider as the amount lost. A 12% weight loss during the past 6 months is more significant than a similar weight loss during the past 12 months.

19. Estimating Body Weight: • It is estimated that about 22% of hospitalized adults receiving nutritional support have no record of body weight. • When it is difficult or impossible to obtain a patient’s body weight directly, it can be estimated from various anthropometric measures (that is, knee height, midarm circumference, calf circumference, and subscapular skin-fold thickness) using the equations given in Table 3. and 4. • The decision of which equation to use will depend on the patient’s age and the anthropometric measures that can be obtained or are available.

20. Table: 3. Equations for Estimating Body Weight in Persons 65 Years of Age and Older from Anthropometric Measures. * Dara Al-Disi*

21. Table: 4. Equations for Estimating Body Weight from Knee Height (KH) and Midarm Circumference (MAC) for Various Groups: * Dara Al-Disi*

22. Estimating Body Weight: • If a patient has had an amputation, patient’s current body weight can be adjusted to account for the weight of the amputated body part. • Table 5 show the percent of total body weight contributed by individual body parts that are frequently amputated. • These values are then used in the following equation to calculate adjusted body weight.

23. Table: 5.Percent of Total Body Weight Contributed by Individual Body Parts:

24. Estimating Body Weight: • Suppose you have a patient whose current weight is 157 lb and whose leg has been amputated at the right knee (right lower leg and foot removed). Table 5, it can be seen that the lower leg and foot contribute approximately ?? of total body weight. • Given this information and the equation, adjusted body weight (weight without amputation) can be calculated.

25. Determining Energy Requirements: • 24 hr energy expenditure is primarily determined by resting energy expenditure, the thermic effect of food, the thermic effect of exercise, and whether disease or injury is present. 24-EE = REE + TEF + TEE + TED

26. Determining Energy Requirements: • Basal metabolic rate (BMR) is defined as the lowest rate of energy expenditure of an individual. • It is calculated from oxygen consumption measured over a 6- to 12-minute period when the subject is in a postabsorptive state (no food consumed during the previous 12 hours) and has rested quietly during the previous 30 minutes in a thermally neutral environment (room temperature is perceived as neither hot nor cold). • The true BMR occurs in the early morning hours of deep sleep.

27. Determining Energy Requirements: • Obtaining a truly basal metabolic measurement is impractical in most instances. • Therefore, a more appropriate term for metabolic rate or energy expenditure in the awake, resting, postabsorptive subject is resting energy expenditure (REE), also known as resting metabolic rate. • The term REE is used in the scientific literature to represent energy expenditure measured by indirect calorimetryunder conditions that are as controlled as the clinical situation allows.

28. Figure: 15. The components of 24-hour energy expenditure in healthy persons.

29. A. Measuring Energy Expenditure: • Calorimetry is the measurement of energy expenditure. • Direct calorimetrymeasures the body’s heat output, whereas indirect calorimetrydetermines energy expenditure by measuring the body’s oxygen consumption and carbon dioxide production. • Because energy expenditure measurements using direct and indirect calorimetry are performed in a laboratory, they may not accurately represent energy expenditure of free-living subjects (i.e., persons living at home and engaged in typical work and leisure-time activities). • To more accurately measure the energy expenditure of free-living subjects, researchers can use two other methods; doubly labeled water and the bicarbonate-urea method.

30. Direct Calorimetry: • Cumbersome and expensive in practice. • It requires a highly sophisticated chamber or specially designed suit, which allows measurement of both the sensible heat given off by the body and the latent heat of vaporized water from the lungs and skin. • Measurements may require a subject to the confined within the chamber for 24 hours or longer. • Consequently, this approach is not suitable for critically ill patients.

31. Figure 16a The USDA Human Nutrition Research Center’s Direct Calorimeter. Two researchers are shown operating the calorimeter while a subject can be seen inside the unit. Source: Photo courtesy of Dr. James L. Seale. U.S. Department of Agriculture. Agriculture Research Service, Beltsville Human Nutrition Research Center, Energy and Protein Research Laboratory, Beltsville, MD.

32. Figure: 16b The interior of the USDA Human Nutrition Research Center’s direct calorimeter provides a small but comfortable living space to subjects undergoing energy expenditure measurements lasting as long as 24 hours. Sources: Photocopy courtesy of Dr. James L. Seale, U.S. Department of Agriculture, Agriculture Research Service. Beltsville Human Nutrition Research Center, Energy and Protein Research Laboratory, Beltsville. MD.

33. Indirect Calorimetry: • Based on the fact that energy metabolism ultimately depends on oxygen utilization (VO2) and carbon dioxide production (VCO2). • Thus, expired air contains less oxygen and more carbon dioxide than inspired air. Where the volume of expired air is known and the differences in oxygen and carbon dioxide concentration in inspired and expired air are known, the body’s energy expenditure can be calculated. • Such as; closed circuit calorimetry, Open circuit calorimeters.

34. Figure: 17. An example of a computerized metabolic monitor in operation. This unit uses indirect calorimetry to determine a patient’s resting energy expenditure. The plastic hood allows expired air to be collected without the annoyance of a mask or mouthpiece.

35. Estimating Energy Needs: • In most clinical settings, energy expenditure usually is not measured. • Instead, it is estimated using one of numerous available formulas, of which two of the most common are shown in Table 7.

36. Table: 7. Examples of Equations for Estimating Resting Energy Expenditure in Healthy Persons: * Dara Al-Disi*

37. Box:3. Activity Factors Used to Account for the Thermic Effect of Executive. * Dara Al-Disi*

38. Figure: 18. Effect of various stresses on resting energy expenditure in hospitalized patients. Source: From Long CL. Schaffel N, et al. 1979. Metabolic response to injury and illness. Estimation of energy and protein needs from indirect calorimetry and nitrogen balance. Journal of Parenteral and Enteral Nutrition 3:452-456.

39. Box: 4. Estimating Resting Energy Expenditure (REE) and 24-Hour Energy Expenditure Using the World Health Organization (WHO) Equations: * Dara Al-Disi*

40. Table: 8. Injury Factors Used to Account for the Thermic Effect of Disease and Injury: * Dara Al-Disi*

41. Energy Expenditure in Disease and Injury: • Of all the conditions in table 8burns have the greatest potential for increasing energy expenditure. • When caloric intake fails to adequately meet energy expenditure in burn patients, weight loss, delayed wound healing, and poor clinical outcome will result. • A number of equations or approaches have been proposed for estimating the energy and protein needs of burn patients. • Several of these are shown in table 9.

42. Table: 9. Equations for Estimating the Energy Requirements of Patients with Burns. * Dara Al-Disi*

43. Determining Protein Requirements: • Protein serves as a functional component of body tissues and enzymes and as a fuel source. • The protein needs of healthy, nonpregnant, nonlactating adults generally can be met with an intake of 0.8g/kg body weight per day. • In trauma or burn patients, protein catabolism increases markedly, as does protein loss, as indicated by urinary nitrogen excretion. • Nitrogen makes up about 16% of protein and serves as a convenient way of measuring protein intake and losses.

44. Protein Losses in Disease and Injury: • Figure 19, shows how urinary nitrogen losses vary over time among different conditions. • The normal range of urinary nitrogen loss is represented by the figure’s light horizontal bar. • Partial or total starvation in the unstressed person often results in reduced nitrogen losses as the body attempts to spare protein. • The opposite is true in trauma or burn patients, which are usually associated withincreased protein catabolism and urinary nitrogen losses.

45. Figure: 19. Effect of various stresses on urinary nitrogen excretion in hospitalized patients.

46. Estimating Protein Needs: • In practice, there is no single best method for conclusively determining the amount of protein that should be in the diet of patients suffering from trauma, burns, and other injuries. • The protein requirements of these patients can only be estimated. • Three approaches are commonly used basing; • Protein intake on body weight, • caloric intake • Or nitrogen balance.

47. Table: 10. Suggested Ranges of Protein Intake per Kilogram of Body Weight During Peak Catabolic Response for Various Injuries and Conditions in Adults:

48. Estimating Protein Needs: 1.If the energy needs of a patient are reasonably well defined, these can be used to estimate protein requirements. 2. Some authorities consider 1g of nitrogen (or 6.25 g of protein) for every 150 nonprotein kilocalories to be an adequate daily protein intake for critically ill adults and adults with burns when the percent body surface area burned is < 10. When injuries are very severe or the burn involves more than 10% body surface area, 1g of nitrogen is recommended for every 100 nonprotein kilocalories.

49. Estimating Protein Needs: 3. Nitrogen balance involves 24-hour measurement of protein intake and an estimate of nitrogen losses where N Bal = nitrogen balance; protein intake = protein intake in g/24 hours; and UUN = urine urea nitrogen in g/24 hours. Protein intake N Bal = 6.25 - UUN – 4 • Protein intake is divided by 6.25 to arrive at an estimate of nitrogen intake. Because protein is 16% nitrogen, dividing grams of protein by 6.25 gives you grams of nitrogen.

50. Thank u 4 listening REMEMBER : SLEEP WELL , EAT BALANCED DIET, AND EXERCISE WILL HELP TO ATTAIN GOOD RESULTS