Section: 2-1



PURPOSE:

To provide instruction on obtaining accurate measurements critical to the nutrition assessment of the patient and to identifying patients at risk.

CONSIDERATIONS:

1. Medical nutrition therapy (MNT) is the process of assessing the patient, identifying treatment goals, developing the nutrition care plan and applying specific interventions through multidisciplinary team approaches.

2. A nutritional assessment should be performed on all patients upon admission.

3. The nutrition assessment includes but is not limited to:

a. Subjective data.

b. Objective data.

c. Physical assessment.

d. Planning and interventions.

e. Evaluation or outcome measures.

4. Patients determined to be at risk nutritionally should be referred to a Registered Dietitian (RD).

EQUIPMENT

Cloth measuring tape

Scales

Calculator

Blood pressure cuff, stethoscope and thermometer

PROCEDURE

1. Explain the procedure to the patient/caregiver.

2. Obtain the following patient measurements for nutritional assessment:

a. Vital signs.

b. Weight and height; accurate height and weight measurements should be collected at the time of assessment (self reported height and weight or weights provided by the caregiver should not be accepted).

c. Obtain measurements in the following manner:

1. Weight:

• Follow manufacturer’s recommended guidelines for specific type of scales used.

• Always use the same scale and attempt to weigh patient at the same time and wearing similar types of clothing.

• Frequency of weights should be performed per physician’s order or monthly if unspecified.

• Scales should be balanced before obtaining the patient’s weight.

• Patient should stand without support, and wear no shoes.

• Floor scales should be placed on a solid surface, not carpet. For accurate measurements, obtain an average of 2-3 weight measurements.

2. Height:

• Measure the patient without him or her wearing shoes; for accurate measurements, obtain an average of 3 measurements.

• Using a cloth measuring tape measurements can be taken with the patient standing or lying flat in the bed. For bilateral amputee patients, the measurement of the arm span is roughly equal (within 10%) to patient’s original height.

3. Waist circumference: assesses patient’s risk for various chronic disease conditions such as Diabetes, Cardiovascular disease among others.

• Place a tape measure around bare abdomen just above hip bone. Be sure that the tape is snug, but does not compress skin, and is parallel to the floor.

• Instruct patient to relax and exhale, for an accurate measurement.

• Goal: Women less < 35 inches and Men less < 40 inches.

3. Alternatives to height and weight measurements:

a. Mid-arm circumference (MAC): Measurement may be monitored as a general measurement of changes in patient’s status. MAC does not determine weight status.

1. Use a cloth measuring tape to measure the circumference of the arm at the midpoint-between the elbow and shoulder bone; always measure the same arm; record the measurement in centimeters; measure the MAC monthly at the same time of the month.

b. Knee height (KH): To estimate height and weight measurements based on KH, use the guidelines found in Appendix A – Estimating Patient Height and Weight.

2. KH is the measure of length in centimeters between the top of the knee to the bottom of the heel when the knee and heel are both positioned at right angles to the tibia.

c. Frame size: Using a cloth-measuring tape measure the wrist circumference just distal to the styloid process at the wrist crease on the prominent arm.

4. Determine patient’s Desirable Body Weight (DBW):

a. The National Institutes of Health (NIH) defines Desirable (normal or ideal) Body Weight (DBW). The following guide may be used to calculate DBW of medium-frame persons (subtract 10% for small or add 10% for large frame persons):

b. Women: Allow 100 pounds for first 5 feet of height, plus 5 pounds for each additional inch.

c. Men: Allow 106 pounds for first 5 feet of height, plus 6 pounds for each additional inch.

5. Determine Body Mass Index (BMI): BMI is an index of a person’s weight in relation to height; it is determined by dividing the weight in kilograms by the height in meters squared.

6. Determine patient’s weight status using the following guide:

a. BMI < 20 = underweight

b. BMI 20-25 = normal

c. BMI 26-30 = overweight

d. BMI > 30 = obese

7. Adjusted Body Weight (AjBW) is recommended for calculating the energy requirements of persons who are 125% or more of their DBW. To determine AjBW use the following guide:

[Note: AjBW = [(Actual body weight – desirable body weight) x 0.25] + DBW.]

a. Determine whether weight loss or gain is desirable; establish a calorie level by adding or subtracting 500 calories from the estimated energy requirements (EER) to produce a 1-pound weight gain or loss per week, respectively; the established calorie level must be discussed with and accepted by the patient for successful diet adherence.

b. Use AjBW to calculate energy requirements of obese individuals who are 125% or more than their DBW.

c. Patients with Congestive Heart Failure (CHF) may have 30-50% higher energy requirements.

d. Patients with Depleted Protein Stores (DPS) (e.g., as a result of pressure ulcers, burns, surgery, cancer, sepsis, and hospitalization) require 150-300 calories per gram of nitrogen ratio, depending on the severity of their condition; nitrogen grams are calculated by dividing the required protein grams by 6.25, then multiplying the outcome by 150-300 calories.

e. Patients diagnosed with Failure To Thrive (FTT) require 30-35 calories per kilogram of Actual Body Weight (ABW).

8. Protein requirements are based on grams of protein per kilogram of ABW or DBW and are condition-specific; the following are formulas used to calculate protein requirements for specific patient statuses:

a. Normal healthy adults: ABW (kg) x 0.8 g.

b. Geriatric patients: ABW (kg) x 0.8 to 1 g.

c. Patients with DPS: ABW (kg) x 1.25 to 1.5 g.

d. Patients diagnosed with FTT: ABW (kg) x 1 to 1.5 g.

e. Obese patients: DBW (kg) (used for estimated lean weight) x 1.5 g.

9. Fluid requirements are based on milliliters of free water fluid per kilogram of ABW and are condition-specific; a minimum of 1500 mL is recommended unless contraindicated by patient’s clinical condition; the following are fluid requirements for specific patient statuses:

a. Normal healthy adults: ABW (kg) x 30-35 mL.

b. Geriatric patients: ABW (kg) x 30 mL.

c. Patients with DPS: ABW (kg) x 30-35 mL.

d. Patients diagnosed with FTT: ABW (kg) x 30 mL.

e. Obese patients: ABW (kg) x 25 mL.

d. Patients with CHF: ABW (kg) x 25 mL.

10. The following should be considered when assessing a patient’s nutritional intake:

a. Food diary: Use a food diary to record the patient’s intake for a 24-hour period. Clinicians may use any tool for recording food intake; however, consideration should be given to provide directions appropriate to the patient and/or caregiver’s abilities.

b. To determine the patient’s understanding of diet instructions use the following guide: Can patients do the following?

1. Name 3 foods and portion sizes allowed on their diet.

2. Identify the times of the day they are supposed to eat meals.

3. Identify a 1-cup, 2-cup, 1-tablespoon and 1-teaspoon measuring utensil from their kitchen.

4. Name a snack food they are allowed to eat on their diet.

5. Describe a sample menu for 1 day.

6. Tell you the name of their diet and the reason why it is important to follow the diet.

AFTERCARE:

1. Document the following in the patient’s medical record:

6 Vital signs.

7 Height: measure at least annually for patients 65 years or older.

8 Frame size: Obtain the wrist measurement of the prominent arm whenever height is measured.

9 Weight: Frequency per physician’s orders or at least monthly.

10 Nutrient requirements: State method used and show calculations for listing calories, protein, and fluid requirements; these parameters should be recalculated whenever the patient’s condition changes.

11 Comparison between food intake nutrient levels and requirement of nutrients.

12 Modifications suggested to patient/caregiver.

13 Communication to physician and/or caregivers.

c. Referrals to other disciplines.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download