What is the Subjective Global Assessment-SGA

(has 2 parts)?

SGA:

1. Incorporates History, PE, Subjective analysis

2. Uses 5 guidelines:

Weight

Height

Dietery intake

GI symptoms

Functional capacity

Physical signs ( wasting of arms)

Weight

Height

Dietery intake

GI symptoms

Functional capacity

Physical signs

SGA guideline of Wt loss:

Looks at how many months in the past?

How are they classified?

Looks at how many months in the past?

6 months

How are they classified?

Severe  >10%

Moderate >5-10%

Mild >5%

SGA guideline-Dietary intake:

What is it based on?

Normal / Abnormal based on oral intake

kcal/nutrients

SGA guideline-GI symptoms:

What is it?

SGA guideline-Functional Capacity:

What is this based on?

Classified as:

 bedridden

less than fully active

 fully active

SGA guidelines-Physical signs:

What is being looked at?

Subcutaneous fat loss in:

Triceps & midaxillary line at lower ribs

Muscle wasting in:

 Temporal muscles

Deltoids

Quadriceps

How is BMI measured?

2 methods

BMI=wt in kgs/ht in meters squared

BMI=(wt in lbs/ht in inches squared ) X 705

How are these BMI measured:

Underweight

Healthy weight

Overweight

Obese

Underweight=  <18.5

Healthy weight= 18.5-24.9

Overweight= 25-29

Obese= >/30

Ideal Body Weight

Estimated ideal body weight in kg

What is the IBW for:

Males

Females

Males

IBW= 110# + 5# for each inch over 5 feet

Females

IBW= 100# + 5# for each inch over 5 feet

What are these:

Vitamin & mineral assessment

Hematological assessment

Lipid status

Electrolytes

BUN/Crea

Serum Glucose

Hydration status

Visceral protein assessment

Nitrogen balance

Na: 135-145 mEq/L

Cl:  98-196 mEq/L

BUN:  8-26 mg/dL

Hematocrit:  37-47% women & 40-54% men

Serum osmolality:  275-295 m Osm/kg

All are elevated with fluid deficit

&

All are decreased with excess

Specific Gravity:  1.003-1.030

elevated with fluid decrease & decreased w/ excess

Osmolality:  50-1400 mOsm

elevated with fluid decrease & decreased w/ excess

What are the 3 Plasma Proteins:

levels

function

half life

Albumin:  3.5-5 mg/dL

Most abundant

Half life:  21 days

Transferrin:  215-380 mg/dL   Transports protein for Fe

Half life: 10 days

Effected by Fe status, when Fe low transferrins elevated

Prealbumin (Transthretin): 18-38 mg/dL

Carrier of thyroid hormone thyroxine (T4) & Retinol

Half life:  2 days

Good indicator or acure diet changes

Error in urine collection

Failure to account for renal impairment

Inability to measure nitrogen losses from wounds, burns, diarrhea, vomitting

Error in oral intake

Nitrogen Balance=(nitrogen) Intake - (nitrogen) output

Nitrogen intake= dietary protein intake/6.25g

Nitrogen output= UUN-4

What is happening in terms of nitrogen balance:

More nitrogen is consumed than excreted

Body is building more tissue than breaking it down

Occurs during growth, healing, pregnancy

Anabolism

What is happening in terms of Nitrogen balance?

Less nitrogen consumed than excreted

Body is breaking down more protein than building it

Occurs during illness, inadequate intake, stress

Catabolism

Burns

Trauma

Surgery

ADH=Water rentention

Renin= Sodium retention

Catacholamines=Hyperglycemia

ACTH=Glucogenesis/Hyperglycemia

Hypermetabolism

Preteolysis & Nitrogen Loss

Gluconeogenesis & Glucose utilization

Metabolic rate

Oxygen consumption

Proteolysis & use of AA for energy

Ureagenesis & urinary nitrogen excretion

Hepatic synthesis of acute phase protein

Hepatic production of albumin & prealbumin

Glycogenolysis

Gluconeogenesis

Determining calorin needs:

Harris Benedict Equation

Men

BMR=66=(13.7x wt kg) + (5 x ht cm) - (6.8 X age-yrs)

Women

BMR=655 + (9.6 X wt kg) + (1.8 X ht cm) - (4.7 X age-yrs)

Low stress  1.2 x BEE

Moderate stres 1.2-1.3 X BEE

Severe stress  1.3 - 1.5 X BEE

Major burn 1.5-2 X BEE

Normal determination of fluid

30 mL/kg actual body wt

use range of 20-40 mL under/overhydration

normal= 0.8g protein/kg

stressed state or decreased protein stores

1-2 g protein/kg

Correct vitamins/minerals deficiencies

Correct electrolyte imbalances

Repelete protein

Monitor lab work

Check labs prior to surgery

Goal:  Maximize nutritional status

T/F

If the gut is working do not use it.

False

If the gut is working use it!

What type of nutrition is this:

Evaluate bowel function

Evaluate hemodynamics status

Iniate feeding within 1st 24-48hr of admission

Advance feeding to goal within 48-72 hrs

Elevated HOB>/=35 degrees to prevent aspiration

Maintains physiology of gut mucosa

Maintains GALT (gut assoc. lymphoid tissue)

Coast effective

What are these:

Nasogastric/Orogastric

Nasoenteric

Gastrostomy-PEG

Jejunostomy-PEJ

What type of feeding is this?

Typically used in acute settings

Increased time for absorption

Better tolerance

What method of feeding is this:

Usually given over 30-60 minutes every 4- 6 hrs

What method of feeding is this?

Large amt of feeding given over a few minutes-1 hr

Gastric feeding only

Used for non-critically ill pt

Often used in home settings

What type of enteral formula is this:

Intact nutrients

Lactose free

 Low osmolarity

Caloric density & protein levels vary

What type of enteral formula is this:

Predigested/elemental nutrients

Absorptive benefits

More elemental the product the higher the osmolality

What type of disease specific enteral formula is this?

Lower % of carbs

Higher in protein & fat

Contains soluble & insoluble fiber

What type of disease specific enteral formula is this?

Na, K, Phos restricted

Calorically dense/volume restricted (most 2 cals/mL)

Protein- dialysis formulas high % protein & non-dialysis formulas low % protein

What disease specific enteral formula is this?

Volume restricted

T/F

Tube formula alone does not meet fluid needs.

True

Fluid needs free water in TF formula

Nutritional needs

Choose route

Feeding schedule

Formula

Abdominal distention

Passage of flatus & stool

Abdominal pain

 High residuals (hospital dependent)

Inappropriate cessation of TF should be avoided

In absence of other s/s of intolerance continue TF with residuals <500 mL

Danger of ileus development with stop/start method of TF & prolonged npo status

What is this?

IV solution containing:

Dextrose

Amino Acids

Emulsified fats

Trace elements

Vitamins

Minerals

Parenteral Nutrition

Which one is this:  TPN-total parenterl nutrition or

 PPN- peripheral parenteral nutrition

Short term use only (up to 14 days)

inability to meet caloric needs

intolerance to hypertonic solutions

decreased risk of septic complications

PPN

Peripheral Patenteral Nutrition

Which one is this:  TPN or PPN

Requires central access

Ability to meet all of pt nutritional needs

increased risk of septic complications

TPN

Total parenteral nutrition

Amino acids

Lipid-fat

Dextrose

Electrolytes

Decreased secretions of insulin (no CHO intake)

Fat/Protein metabolized for energy

Intracellular loss of electrolytes (phosphate)

After starvation, pt now eats:

there is a shift from fat to CHO metabolism

Insulin secretion increases

Stimulates uptake of phosphate

Leads to Profound Hypophasphatemia

Serum phosphate concentration <1.5 mg/dL

nl= 2.5-4.5 mg/dL

Rhabdomyolysis

Leukocyte dysfunction

Respiratory failure

Cardiac failure

Arrhythmias

Hypotension

Seizures

Coma

Sudden Death

What are the consideration with diet advancement?

Ability to chew & swallow food, may need thickened liquids

Dentition

Need for therapeutic diet

Manipulation of GI tract during surgery

Ostomy creation, Bowel resection

Encourage PO diet if applicable

Encourage ambulation-mvmt aids returnof peristalsis

Monitor flatus, stool, bowel sounds

Enteral/Parenteral nutrition may need to continue for post op healing

Consider supplement

Post op pts may need elevated nutrition needs

Arginine

Glutamine

Omega 3 fatty acids

Vitamin C

Zinc

Which post op nutritional supplement is this?

Fuels immune response

Essential precursor to protein synthesis

Enhanced wound healing observed with large doses

Which post op supplement is this?

Sustrate in fast growing cells

Stimulates proliferation of fibroblasts

Major AA lost during tissue injury

Which post op nutritional supplement is this?

Anti inflammatory

Stimulates T-cell & natural killer cell activity

Which post op nutritional supplement is this?

Well documented to aid in wound healing

Essential in collagen synthesis, intracellular matrix of bone/skin/blood vessel wall/connective tissue

Which post op nutritional supplement is this?

Needs are increased during cell proliferation & protein synthesis.

What types of diets are these?

Clear liquid diet

Full liquid

Low residue

House

Cardiac

 Diabetic

Renal

Clear liquid diet:  Juice w/ no pulp, broth, tea, gelatin

Full liquid: Milk, ice cream, nutritional supplements

Low residue: Low fiber diet, avoid veggies/fruits/ oatmeal

House:  No dietary restrictions

Cardiac: Low fat, low sodium (2 gm)

 Diabetic: Carb controlled 1800,2000,2200,2400 kcals

Renal: Reduced Potassium-2 gm, phosphorus, sodium-2gm