RD Domain II - Screening and Assessment
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What is the NCP
A standardized, consistent structure and framework used to provide nutrition care
What are the steps for NCP?
NCP differs from standardized care which infers what?
all patients receive the same care
Preliminary nutrition assessment techniques in nutrition screening is used to....
identify people who are malnourished or who are at risk for malnutrition.
Who can participate in the nutrition screening?
All health care team members (not part of the 4-step process, but serves a supportive role)
About how long should a nutrition assessment take?
During the nutrition assessment, you review...
client's history, labs, weight, physical signs
During the nutrition assessment, if no emerging nutrition problems exist what should be documented?
discharge from nutrition care is appropriate
Who mandates that nutrition risk is identified in hospitalized patients within ___ hours of admission?
- The Joint Commission (TJC)
- 24 hours
Nutrition assessment screening tools:
- Subjective Global Assessment
- Mini Nutritional Assessment
- Nutrition Screening Initiative
The nutrition assessment of individuals is initiated by....
referral/screening of individuals or groups for nutritional risk factors
Nutrition assessment makes comparisons between....
data collected and reliable standards
The nutrition assessment of individuals is....
on-going, dynamic process involving continual reassessment and analysis of patient/client/group needs
The nutrition assessment provides the basis for....
the Nutrition Diagnosis
What are the critical thinking skills needed for the Nutrition Assessment?
- Observe verbal/nonverbal cue that guide effective interviewing methods
- Determine appropriate data to collect
- Select tools and procedures and apply in valid, reliable ways
- Distinguish relevant from irrelevant, and important from unimportant data
- Validate, organize and categorize the data
Components of Nutrition Assessment
Components for Nutrition Assessment: Review what?
data for factors that affect nutritional and health status
Components for Nutrition Assessment: Cluster what?
assessment data for comparison with characteristics of a suspected diagnosis
Types of assessment data
- Food/nutrition related history
- Lab/medical tests
- Nutrition-focused physical findings
- Client history
Components for Nutrition Assessment: Identify what?
standards and criteria for interpretation and decision-making and compare to patient indicators
What are indicators?
clearly defined markers that can be observed and measured
what are indicators used for?
to monitor and evaluate progress towards nutrition outcomes
Indicators can be compared to....
nutrition care criteria
What all should be documented during the assessment?
- Date and time
- Pertinent data and comparison with standards
- Patients perceptions, values and motivation related to the program
- Changes in patient's level of understanding, behaviors, outcomes
- Reason for discharge
What are the parts to the Clinical Assessment?
- Physical assessment
- Signs, symptoms
- Medical hx
- Activity patterns
- Drug- medication- nutrition interactions
- Medical terminology
Types of Dietary Intake Assessments?
- Diet history- present pattern of eating
- (Don't ask leading questions)
- Food record- exact record of everything eaten in specific time period
- 24 hour recall- mental recall of everything eatenin previous 24 hours; quick tool to estimate sample daily intake; clinical setting
- Food frequency list- how often an item is consumed; community setting; quick way to determine intake on large numbers of people
Dietary Intake Assessment consists of....
- Analysis of dietary information
- Oral dietary supplements (vitamin, herbs, complementary medicines)
- Calorie counts should include protein needs
- Dietary intolerances, allergies
Medical/Family history shows
insight into nutrition-related problems
Economic/Social history consists of....
- Access to food
- Cultural/religious food patterns
- Psychological or behavioral lifestyles/preferences
- Food fads/cultism
- Level of education
- Nutrition knowledge/interest
Which religions do not eat meat?
halibut allowed, but not shrimp, catfish, lobster; preparation methods
DBW for medium frame women:
100 lbs for first 5' and 5 lbs per additional inch
DBW for medium frame man:
106 lbs for first 5' and 6 lbs per additional inch
DBW for small frame:
DBW amputations: entire leg
DBW amputations: lower leg with foot
DBW amputations: entire arm
DBW amputations: forearm with hand
DBW amputations formula:
(100 - % amputation) / 100 X IBW for original ht
% weight change formula
usual wt - actual wt / usual wt X 100
What the Triceps skinfold thickness (TSF) measures?
measures body fat and calorie reserves
standard Triceps skinfold thickness (TSF) for male and female:
- Male: 12.5 mm
- Female: 16.5 mm
What does the Arm muscle area (AMA) measure?
measures skeletal muscle mass (somatic protein)
How to determine arm muscle mass
Use triceps skinfold thickness (TSF) and arm circumference (AC) to determine
Standard arm muscle area (AMA) for male and female:
- Male: 25.3 cm
- Female: 23.2 cm
When is it important to measure arm muscle area (AMA)
in growing children
Body Mass Index is also known as what?
What does BMI compare?
weight to height
- lbs/in2 X 703 (lbs/in/in X 703)
BMI of a healthy adult:
BMI of healthy elderly:
Waist circumference >____Males and >_____ Females is independent risk factor for disease when BMI is 25-34.9
Waist/hip ratio differentiates between:
android and gynoid obesity
What is android obesity?
Central obesity (apple shape) with fat excess primarily in the abdominal wall and visceral mesentery.
What is android obesity associated with?
- glucose intolerance
- decreased sex hormone-binding globulin
- increased levels of free testosterone
- increased cardiovascular risk
What is gynoid obesity?
Fat distribution mainly to the hips and thighs (pear shape).
____ or greater in men and ____ or greater in women in waist/hip ratio indicates android obesity and increases risk of obesity related disease
Weight loss assessment technique:
get diet history then initiate calorie count
Nutrition focused physical exam: Hair:
Assessment: Thin, sparse, dull, dry, easily pluckable
Consideration: chemotherapy, vitamin C or protein deficiency
Nutrition focused physical exam: Eyes:
Assessment: Pale, dry, poor vision
Consideration: Vitamin A, Zn, or riboflavin deficiency
Nutrition focused physical exam: Lips:
Assessment: Swollen,red, dry, cracked
Considerations: Riboflavin, pyridoxine, niacin deficiency
Nutrition focused physical exam: Tongue:
Assessment: smooth, slick, purple, white coating
Considerations: vitamin or iron deficiencies
Nutrition focused physical exam: Gums:
Assessment: sore, red, swollen, bleeding
Considerations: vitamin C deficiency
Nutrition focused physical exam: Teeth:
Assessment: missing, loose, lose of enamel
Considerations: Ca deficiency, poor intake
Nutrition focused physical exam: Skin:
Assessment: pale, dry, scaly
Considerations: iron, folic acid, Zn deficiency
Nutrition focused physical exam: Nails:
Assessment: brittle, thin, spoon-shaped
Considerations: iron or protein deficiency
What is the most accurate measure of nutritional status?
Labs indicative for dehydration
Lab indicative for pressure ulcers
Labs for anemia screening
Serum albumin normal levels:
Where is serum albumin made?
- Liver @ 9-12 g/day
- ~60% is located in extravascular space
What does albumin do?
Maintain colloid osmotic pressure, facilitates transportation of substances, and functions as afree-radical scavenger
Serum albumin levels are related to
visceral protein levels (blood and organs)
What does serum albumin have to do with colloid osmotic pressure?
A form of osmotic pressure exerted by proteins, notably albumin, in a blood vessel's plasma (blood/liquid) that usually tends to pull water into the circulatory system. Proteins are the only dissolved substance in the plasma (2-3 x higher) and interstitial fluid (lower levels) that do not diffuse readily through the capillary membrane exerting osmotic pressure
Hypoalbuminemia is associated with
Serum albumin levels above normal range are likely due to
Serum albumin has a long or short half life
Serum albumin levels ______ reflect current protein intake
Serum transferrin normal levels:
Serum transferrin levels are related to
visceral protein levels
What is the serum transferrin level controlled by
iron storage pool
Serum transferrin levels rise with
Serum transferrin levels can be determined from
TIBC -- total iron binding capacity
TTHY transthyretin, PAB prealbumin normal levels:
TTHY transthyretin, PAB prealbumin has a long or short half life
TTHY transthyretin, PAB prealbumin picks up changes in protein status _______
What is the best protein lab to evaluate?
TTHY transthyretin, PAB prealbumin
Retinol-binding protein (RBP) normal levels:
Retinol-binding protein (RBP) circulates with...
Retinol-binding protein (RBP) has a half life of how long
shortest half life: 12 hours
What does Retinol-binding protein (RBP) do?
Binds and transports retinol
What is Hematocrit (Hct)?
volume of packed cells in whole blood
What is the normal Hematocrit (Hct) for men, women, and pregnancy?
- M: 44%
- W: 38%
- Pregnancy: 33%
What is Hemoglobin (Hb)?
Iron-containing pigment in RBC
Normal levels of Hemoglobin (Hb) for men. women, and pregnancy?
- M: 14-17 mg/dl
- W: 12-15 mg/dl
- Pregnancy: 11 mg/dl or less
Hemoglobin and Erythrocyte's relationship
Hemoglobin is found in the cytoplasm of a Erythrocyte cell (RBC). The Hemoglobin is the protein that contains iron and transports oxygen to the body giving Erythrocytes their red color.
Where are Erythrocytes produced?
Serum Ferritin normal levels for males and females:
- M: 12-300 ng/ml
- F: 10-150 ng/ml
What does the serum ferritin levels indicate?
Size of iron storage pool
Serum creatinine normal levels:
0.6 - 1.4 mg/dl
Serum creatinine is related to
Serum creatinine levels measure
Serum creatinine levels may indicate
renal disease, muscle wasting
Creatinine height index (CHI) normal %
Creatinine height index (CHI) formula:
ratio of creatinine excreted/24 hours to height
What does creatinine height index (CHI) measure?
estimates LBM -- somatic protein
What does 60-80% creatinine height index (CHI) level mean
mild muscle depletion
Blood urea nitrogen (BUN) normal levels:
Blood urea nitrogen (BUN) related to
related to protein intake
Blood urea nitrogen (BUN) an indicator of
BUN: creatinine ratio
Blood urea nitrogen (BUN) levels need to be under _____ for renal patients
Urinary creatinine clearance levels:
115 +/- 20 ml/minute
Urinary creatinine clearance measures what?
GFR -- glomerular filtration, renal function
Total lymphocyte count (TLC) levels:
<2700 cells/cu mm
What does total lymphocyte count (TLC) measure?
Total lymphocyte count (TLC) moderate depletion levels:
Total lymphocyte count (TLC) severe depletion levels:
When do total lymphocyte count (TLC) decrease?
in Protein-Energy Malnutrition (PEM)
C-reactive protein (CRP) is the marker of what?
acute inflammatory stress
as C-reactive protein levels decline, it indicates....
when nutritional therapy would be beneficial
Free erythrocyte protoporphyrin (FEP) is the direct measure or
toxic effects of lead on heme synthesis
Free erythrocyte protoporphyrin (FEP) levels increase....
in lead poisoning
What happens during lead poisoning?
lead depletes iron leading to anemia and displaces calcium in bone leading to zinc deficiency
Prothrombin time (PT) rate:
11.0-12.5 seconds; 85-100% of normal
What prolongs Prothrombin time (PT)
Prothrombin time (PT) evaluates...
What will alter rate of Prothrombin time (PT)
Change in vitamin K intake
The hair analysis is not used in the...
The hair analysis is useful for measuring...
intake of toxic metals
Assessment of energy requirements are based on...
activity factors and BEE
Sedentary energy requirements formula:
BEE X 1.2
Active energy requirements formula:
BEE X 1.3
Stressed energy requirements formula:
BEE X 1.5
Estimated energy requirements (EER) for men and women:
for each year below 30.....
- m: add 10 calories/day
- w: add 7 calories/day
Estimated energy requirements (EER) for men and women:
for each year above 30.....
- m: subtract 10 calories/day
- w: subtract 7 calories/day
Nutrition assessment of individuals -- Pediatric issues consist of...
- growth charts
- accuracy of measurements
- accuracy of documentation
- CDC definitions for overweight, obese, normal range
decreases fat absorption by binding lipase
Statins (HMG CoA reductase inhibitors):
- decreases LDL, TG
- increases HDL
Mineral oil, cholestyramine:
decreases absorption of fat, fat-soluble vitamins
decreases folate, B6, Carbon (C)
deplete potassium (K+), magnesium (Mg), calcium (Ca), sodium (Na), chlorine (Cl)
- decreases potassium (K+), magnesium (Mg)
- absorb calcium (Ca)
decreases vitamin K
decreases bone growth, CHO intolerance
Lithium carbonate (antidepressant):
- increase appetite, weight gain
- maintain consistent sodium (Na) and caffeine intake to stabilize levels
- if Na or caffeine are restricted, lithium excretion decreases leading to toxicity
Anticoagulant (warfarin Na):
- antagonizes vitamin K (consistent intake essential)
- avoid Ginkgo biloba extract, garlic, ginger (may increase bleeding)
- avoid high dose vitamin A and E
administered in oil, consider fat calories
decreases folic acid, vitamins B12, D, K, B6
hyperlipidemia, hyperglycemia, hyperkalemia, hypertension
Isoniazed (treats TB):
- depletes pyridoxine, peripheral neuropathy
- don't take with food
- interferes with vitamin D and calcium (Ca) supplements
sedative effect, weight gain, increase appetite
dry mouth, hypoglycemia
abdominal pain (upset stomach)
Vitamin B6 and protein:
- decrease effectiveness of L-dopa (levodopa) which controls Parkinson's symptoms
- give most protein at evening meal
- take drum in AM
decreases therapeutic blood levels of anti-seizure medications (Phenytoin, Dilantin)
Hypertension (HTN) if taken with MAOI (monoamine oxidase inhibitor)
If on MAO inhibitor drug....
interaction releases norepinephrine which raises BP
Motivational level -- High:
keen interest, presence in voluntary, has high expectations as to applicability of subject to life
Motivational level -- Low:
mandatory attendance, little interest in topic, may feel there are more important things to do
Educational level -- High:
- has some previous knowledge of topic or has broad base to which new information can be added
- understands complex ideas and rationales
- verbally oriented
Educational level -- Low:
lacks formal education beyond high school, probable not verbally oriented - more task oriented, reinforcement of learning is helping, allow time for learning
Situational assessment - Sophistication: Inexperienced:
young children, some adults lack nutritional training, need thorough introduction and background
Situational assessment - Sophistication: Moderate Experience
teachers, health educators, pts already instructed, emphasize review of material, recognize it for better use, move on to more complicated concepts
Situational assessment - Sophistication: Very Experienced:
"nutrition experts", limit audience participation at first, establish yourself as the expert, cite credentials, lecture format with audiovisuals
A1c levels for normal, increase risk for diabetes, and indication of diabetes:
- Normal: 4-5.6%
- Increased risk: 5.7-6.4%
- Indication of diabetes: 6.5%+
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