Gathering Data for Nutritional Assessment

Before asking the patient questions for your assessment, make sure to introduce yourself and set the agenda for the discussion.

You may review your patient’s chart or obtain information from them directly. You will need to gather information on the following:

1. Clinical Data: past medical history, history of presenting illness (HPI), imaging, investigations, pathology, scheduled procedures, consultations, medical orders (medications, infusions), clinical documentation (fluids in and out, bowel movements, drains and tubes, vitals, and documentation of symptoms), medical plan, disposition plan
2. Anthropometric Data: weight, height, BMI, weight change, % weight change, % usual body weight, physical assessment, subjective global assessment.
3. Nutritional Requirements: energy, protein, and fluid
4. Biochemical Data: laboratory values (blood, urine, feces, sputum, tissue, wounds, drains etc.).
5. Dietary Data: current/ recent hospital diet order(s), current intake/ recent intake/ baseline intake, dietary restrictions, allergies/ intolerances, eating behaviours and patterns, calorie counts, supplements, previous nutrition/dietitian interventions.

The components reviewed in each section are common considerations but you may need to consider other factors depending on your patient.

Subjective Global Assessment

According to the Canadian Malnutrition Task Force:

Subjective global assessment (SGA) is the gold standard for diagnosing malnutrition. SGA is a simple bedside method used to diagnose malnutrition and identify those who would benefit from nutrition care. The assessment includes taking a history of recent intake, weight change, gastrointestinal symptoms and a clinical evaluation.

Use of the SGA varies among institutions. If you do not use the SGA, you can still follow the procedures for assessment by taking the history described above.

Case Study: Meet Carson

Throughout this section’s case study, you are a Registered Dietitian in General Surgery. The patient you are assessing is a 50 year old male named Carson.

Clinical Data

Clinical data can include, but is not limited to:

• Reason for visit: hospital visit or RD consult.
• Past medical history (PMHx): health history to date.
• History and presenting illness (HPI): symptoms, surgeries, prognosis, tests (i.e. CT scan, ultrasound).
• Current medical orders: IV infusions, medications, consultations.
• Clinical documentation: Fluids intake (i.e. oral, IV, TPN/EN) and output (i.e. urine, vomit, bowel movements, drains (i.e. catheter, chest tube, surgical site drain) and suctioning (i.e. oral secretions, OGT to straight drain), documentation of tubes (i.e. G-tube vs. NGT) and lines (i.e. PICC), vitals.
• Medical care plan and disposition: chemotherapy, radiation therapy, scheduled surgery, transfer to different floor, rehab facility, treatment facility, long term care, home.

Assessments of Swallowing

Speech-language pathologists (SLP) are concerned with the identification, assessment, treatment, rehabilitation and prevention of communication and/or swallowing disorders.

Videofluoroscopic Swallowing Study (VFSS) is a radiographic procedure that provides a direct, dynamic view of oral, pharyngeal, and upper esophageal function during swallowing. During this procedure, the SLP presents various food and liquid consistencies mixed with barium. The barium is necessary to view structures via videofluoroscopy during the swallow.

The VFSS allows the SLP to assess if food goes into the airway instead of the stomach (aspiration), which part of the swallow is affected, which food and liquid consistencies are safest to swallow, and if certain positions or strategies improve the swallow.

Nutrition in Dysphagia Management

Dysphagia is the medical term for swallowing difficulties. For more information about dysphagia and its causes, read this “Dysphagia 101” resource from Nestle Health Science.

The epiglottis muscle is responsible for making sure food or drinks go down your esophagus into the stomach (avoiding the airway). Normally, the airway should close as foods or liquids enter the throat to make sure a swallow is successful. Often, for people with dysphagia, this function can be impaired, leading to food or liquid going into the airway; this is a safety concern for aspiration.

To manage dysphagia, an SLP will complete an assessment and determine the safest dysphagia diet (liquid consistency, food texture, or NPO). Thickened beverages and texture-modified foods may help with swallowing safety by improving control and slowing down the movement of boluses in the mouth and throat. This gives more time to close off the airway so the liquids can travel down the esophagus to the stomach.

The tables below provide an overview of food and drink consistencies for those with ranging degrees of dysphagia, and are based on information from the International Dysphagia Diet Standardisation Initiative (IDDSI).

Depending on your hospital or clinic, you may encounter IDDSI terminology and standardization. The IDDSI Framework provides common terminology to describe food textures and drink thickness. IDDSI tests are intended to confirm the flow or textural characteristics of a product at the time of testing.

Anthropometric Data

Assessment of Body Weight

Body weight is the most used indicator of nutritional status, as it is used for calculating fluid, protein, and energy requirements.

Obtaining height and age is often necessary to further interpret body weight. Body Mass Index (BMI) is commonly used as a classification to evaluate health risk, as demonstrated in the table below. Master’s tables are used for adults aged 65+.

It is important to consider if the weight you are using needs to be adjusted for fluid retention or if the patient has an amputation. For the most accurate estimations, using a weight as close to a “dry weight” is best.

It is also important to use other markers of weight, including % weight change and % usual body weight during your assessment to further evaluate your patient’s weight. The calculations in the tables below will help you interpret the findings in regard to severity and indication of malnutrition.

Physical Assessment

SGA Guidance

Another important assessment strategy is to physically evaluate your patient. It is important to go into your patient’s room to evaluate physical signs and symptoms of malnutrition. The SGA provides guidance on how to complete a physical examination by using a head to toe method for the assessment of muscle wasting, subcutaneous fat, and fluid retention.

Other Physical Signs & Symptoms

There are other physical signs and symptoms of nutritional deficiencies. This table provides a general overview of the sites of the body to consider, the physical examination, and the potential nutritional deficiencies or metabolic status associated with the assessment.

Nutritional Requirements

Energy Requirements

Predictive equations are for estimation purposes only. The most accurate data will provide the most accurate estimation, but without indirect calorimetry this is the best we can achieve. As a result, there is a need for frequent re-assessment of energy requirements.

Factors affecting the accuracy of estimated requirements include:

• Acute or chronic respiratory distress syndrome
• Large open wounds or burns
• Malnutrition with altered body composition
• Underweight, obesity, limb amputation, peripheral edema, ascites
• Multiple or neurological trauma
• Multisystem organ failure
• Postoperative organ transplantation
• Sepsis
• Systemic inflammatory response syndrome
• Paralytic or barbituate agents

Predictive Equations

Here are three commonly used predictive equations. There are other predictive equations you may use, depending on your area of practice. Accuracy varies by equation and population. Experience is helpful for an accurate selection and utilization of these predictive equations.

• Dietary Reference Intakes (DRI)
  • EER: age, physical activity, weight, height
  • Males: EER (kcal) = 662 − 9.53A + PA × (15.91W + 549.6H*)
  • Females: EER (kcal) = 354 − 6.91A + PA × (9.36W + 726H*)
• Harris Benedict (HB)
  • REE: weight, height, age
  • Males: REE (kcal) = 66.5 + 13.75W + 5.0H − 6.78A
  • Females: REE (kcal) = 655.1 + 9.56W + 1.85H − 4.68A
• Mifflin-St.Jeor (MSJ)
  • REE: weight, height, age
  • Males: REE (kcal) = 9.99W + 6.25H − 4.92A + 5
  • Females: REE (kcal) = 9.99W + 6.25H − 4.92A − 161
• Estimated Calories/kg

Activity Factors

Most predictive equations evaluate resting energy expenditure (REE), meaning you need to consider physical activity energy expenditure in addition to the original calculation. The activity factor (AF) is applied to the REE value. Activity factors are not to be used with DRI equations.

Stress Factors

Most predictive equations evaluate resting energy expenditure (REE), meaning you may need to consider energy expenditure from stress. The stress factor is applied to the REE value.

Protein Requirements

This table represents general guidelines for protein requirements according to how hypermetabolic your patient is. Consider your individualized patient to determine the most accurate protein requirement. Experience using these methods is helpful. You can consider calculating requirements using various methods and compare values.

The following table represents a more detailed overview of protein requirements specific to various clinical conditions. This may be more useful for you during practice than the general guidelines, if your patient’s clinical status is reflected in this table.

Fluid Requirements

This table represents general guidelines for calculating fluid requirements. Consider your individual patient prior to determining the best method to use. Experience using these methods is helpful. You can calculate requirements using various methods and compare values.

Biochemical Data

Laboratory Values

IV Solutions

Here is an overview of common IV solutions used in hospital. It is important to review which IV solution(s) your patient is receiving as it could be providing a patient with energy/ dextrose. Different IV solutions are also chosen in various clinical scenarios. This needs to be considered when you are creating a nutrition care plan.

Dietary Data

Obtaining accurate dietary data can vary based on your patient (e.g.  family members present, patient’s cognitive ability, flow sheets or calorie counts, etc.), as well as the setting (e.g. inpatient compared to outpatient).

If possible, collect the following information:

• Diet order(s): Important for a representation of daily intake while in the hospital (can include enteral nutrition & supplements).
• Dietary recall: 24 hr recall (if recent admission or representation of food consumption in hospital), common eating patterns, or short-term and long-term representation of eating patterns or typical foods.
• Calorie counts: Depending on the patient, you may order calorie counts to monitor/determine how much/ what they are eating in hospital.

Refeeding Syndrome

Refeeding syndrome is a concern for any patient who has been without consistent or adequate nutrition for a prolonged period. It is a series of metabolic events that occur as a result of reinstitution of nutrition (carbohydrates) to patients who are starved or severely malnourished. Refeeding syndrome is characterized by low potassium, magnesium, and phosphate with/or without fluid retention.

Serious complications can be avoided by:

• Thorough nutritional assessment
• Appropriate identification of patients at risk
• Slow initiation of feeding
• Careful monitoring

The table below outlines complications of refeeding syndrome.

An additional refeeding complication is Hyponatremia 2° hyperglycemia, which can result in: heart failure, arrhythmia, respiratory failure, pulmonary edema, renal failure, muscle cramps, fatigue, fluid retention, swelling/edema.

Risk factors for refeeding syndrome include:

• Suboptimal or no nutritional intake for > 5 days
• Postoperative
• Elderly with multiple comorbidities and decreased physiological reserve
• Cancer diagnosis
• Chronically malnourished: anorexia nervosa, chronic alcoholism, marasmus, prolonged fasting or low energy diet,  morbid obesity with profound weight loss, malabsorptive syndrome (i.e. IBS, chronic pancreatitis, short bowel syndrome), high electrolyte losses (i.e. diarrhea, high output fistula, vomiting)
• Uncontrolled diabetes (i.e. electrolyte depletion, diuresis)
• Long term use of antacids
• Long term use of diuretics
• BMI <18.5
• Ongoing unintentional weight loss