به نام خدا

1. به نام خدا

2. زهرا عرب دانشجوی کارشناسی ارشد پرستاری ویژه درس مراقبتهای پرستاری ویژه دی ماه 88 NUTRITIONAL ASSESSMENT

3. NUTRITION MALNUTRITION

5. مروری بر مطالعات ☼در مطالعه پیچارد و همکاران در 2009 : ◂20 -60%بیماران بستری درهمه رده های سنی سوء تغذیه دارند. ◂در بیماران بخش های ویژه بالای 40% می باشد. ◂در زمان بستری 30% بیماران سوء تغذیه دارند. ◂درکمتر از 25% بیماران زمان پذیرش بررسی تغذیه ای انجام می شود. ◂ازمواردشناخته شده سوء تغذیه، 41% وزن شدند. ☼در ایرانطبق آمار سازمان فائو در1385: 4% افراد(2/7میلیون) که بعد از یمن بیشترین جمعیت سوء تغذیه در خاورمیانه می باشد.

6. MALNUTRITION CLAUDE PICHARD.2009

7. افراد درمعرض خطر سوء تغذیه • کاهش وزن بیشتراز10%در6ماه گذشته یا>5%دریک ماه • وزن >20%یا<20%وزن ایده ال • بیماری مزمن • افزایش نیازهای متابولیک • اختلال دردریافت موادغذایی به علت بیماری یا جراحی • رژیم نامناسب برای مدت 7روز • مصرف مداوم بیشترازسه نوع دارو • فقر

8. Malnutrition is associated with; • Increased morbidity and mortality • Delayed wound healing • Increased length of hospitalization • Increased complications • Immunosuppression • Organ impairment

9. Comparison of Nutrition Screen and Nutrition Assessment

10. Features of the Admission Nutrition Screening Tool A.Diagnosis If the client has one or more of the following condition,circle it, proceed to section E and consider the client AT NUTRITIONAL RISK. If the client has none of these condition,proceed to section B. ●Anorexia nervosa /bulimia nervosa ●Cachexia (temporal wasting,muscle wasting, cancer,cardiac disease) ●Coma ●Diabetes ●End_stage liver disease ●End- stage renal disease ●Malabsorption (celiac sprue,ulcerative colitis,crohn’s disease,short- bowel syndrome) ●Major gastrointestinal surgery within the past year ●Multiple trauma(closed-head injury,penetrating trauma,multiple fractures) ●Pressure ulcers ●Nonhealing wounds

11. B.Nutrition Intake Historory If the client has one or more of the following manifestations,circle it,proceed to section E,and consider the client AT NUTRITIONAL RISK.If the client has none of these manifestations,proceed to section C. ●Diarrhea(>500ml for 2 days) ●Vomiting(>5days) ●Reduced intake(1/2normal intake for more than 5 days) C.Ideal body weight standards Compare the client’s current weight for height to a chart of ideal body weight.If the client weighs less than 80%of ideal body weight,proceed to section E and consider the client AT NUTRITIONAL RISK.If the client weighs more than 80% of ideal body weight,proceed to section D.

12. D.Weight History Any recent unplanned weith loss? No--------Yes--------Amount---------(Ib or Kg) If yes,within the past---------weeks or----------months Current weight---------- Usual weight------------ Height----------- Find percentage of weight loss:Usual wt-Current wt x 100 =-------%wt loss Usual wt Compare the percentage of weight lost with the values on the following chart;circle the applicable value. If the client has experienced a significant or severe weight loss,proceed to section E and consider the client AT NUTRITIONAL RISK.

13. E.Nurse Assessment Using the above criteria,what is this client’s nutritional risk?(check one) ---------------------LOW NUTRITIONAL RISK ----------------------AT NUTRITIONAL RISK

14. Assessing nutritional status Collection of four types of information; ♠Anthropometric measurements (weight,height) ♠Biochemical data (hb,hct,Alb,preAlb,Transferin,lymp) ♠Clinical signs(physical examination) ♠Diet and health history

15. BMI=WEIGHT÷HEIGHT² For men; height=6419-(0.04×age in years)+(2.02×knee height[cm]) For women; height=84.88-(0.24×age in years)+(1.83×knee height[cm])

16. Calculating Body Frame Size Wrist Circumference Method r= Heigh(cm) Wrist circumference(cm) Men Women

17. Calculating Body Frame Size Elbow Breadth Method

18. Nutrition and cardiovascular alterations ♣Overweight or obsity;underweight♣Abdominal fat ♣Elevated serum chol,lDl,Tig ♣Wasting of muscle and subcutaneous fat A B C

19. ♣Sedentary lifestyle ♣Excessive intake of saturated fat, chol,alcohol, Na ♣Angina,respiratory difficulty,or fatigue during eating medication that impair appetite (e.g.,digitalis,quinidin) D

20. ♣UnderweightSlide 14 ♣Elevated pco2 related to overfeeding ♣Edema,dyspnea,signs of PE related to fluid volume excess Nutrition and pulmonary alterations A B C

21. ♣Poor food intake related to dyspena, unpleasant taste in the mouth from sputum production or bronchodilator therapy; endotracheal intubation preventing oral intake D

22. ♣Underweight ♣Hyperglycemia(with corticosteroid use) ♣Wasting of muscle and subcutaneous fat related to disuse or to poor food intake Nutrition and neurologic alterations A B C

23. ♣Poor food intake related to altered state of consciousness,dysphagia or other chewing or swallowing difficulties,ileus resulting from spinal cord injury or use of pentobarbital ♣Hypermetabolism resulting from head injury ♣pressure ulcers D

24. ♣Underwight(may be masked by edema) ♣Electrolyte imbalances ♣HpoAlb related to protein restriction and aminoacid losses in dialysis ♣Anemia ♣Hypertriglyceridemia Nutrition and renal alteration A B

25. ♣Wasting of muscle and subcutaneus tissue ♣Poor dietary intake related to protein and electrolyte restrictions and alterations in taste C D

26. ♣Underweight related to malabsorption, anorexia,or poor intake ♣HypoAlbuminemia ♣Hypomagnesemia ♣Anemia Nutrition and gastrointestinal alterations A B

27. ♣Wasting of muscle and subcutaneus ♣Confusion,nystagmus, and/or peripheral neuropthy related to thiamine deficiency (alcohol abuse) ♣Steatorrhea C D

28. Nutrition support

29. ORAL INTAKE ADEQUATE? YES NO NO YES NON-FUNCTIONAL GI TRACT PARENTRAL ROUTE Diet+supplements>75%of needs NO No futher intervention (monitor for change in status) Short-term<3week Long-term>3weeks Monitor for change in status Initialeenteral feedings assess GIaccess obstruction YES Peripheral standard IV cathters Central standard central lines NO Pripheral extended dwell catheters Centeral tunneled catheters and parts PICC Gastric obstruction Jejunostomy Inadequate intake >4-6weeks Nasopharyngeal obstruction Esophagostomy Esophageal obstruction Gastrostomy

30. YES NO YES NO YES NO YES NO NO YES

32. مروری بر مطالعات ◀ در مطالعه پیچارد کلود-2009: از200 نفرکه سوء تغذیه داشتند 55 نفر زمان ترخیص بررسی تغذیه ای شدند و از این تعداد41 نفر10-5% کاهش وزن داشتند. ◀ در مطالعه بوکنکام -2009: از دلایل دریافت نامناسب انرژی در بیماران، عدم گزارش پرستاران می باشد. ◀به طورمتوسط 75-25%اطلاعات گزارش می گردد.

33. Evaluating response To Nutrition support ☻Anthropometric measurements(daily weights, I&O) ☻Biochemical evaluation(serum levels of BUN, electrolytes,BS,Ca,Ph,Alb,Tig,…) ☻Physical examination

34. Organisation of Nutrition Support 3. NICE Guidelines for Nutrition Support in Adults 2006

35. Reference 1 pichard.C, Thibault.R, Heidegger.C, Genton.L;Enternal and parenteral nutrition for critically ill patients;Alogical combination to optimize nutritional support.Clinical Nutrition Suplements 2009; 4: 3-7. 2 .Urden.L, stacy.K, E.lough.M. Thelan’s critical care Nursing.5th edition; Mosby;2008.pp:94-119 3.Morton.P, Fontaine.D. Critical Care Nursing:Aholistic Approch.9thedition;WoltersKluwer,lippincott Wilkins;2008. pp:1015-1017 4.Black.J, Hawks.J. Medical Sergical Nursing.7thedition;Elsevier; 2005.pp:670-700 5. Bockenkamp.B, Jouvet.P, Arsenault.V, Beausejour.M, Annepelletier.V;Assessment of caloriec prescribed and delivered to critically ill children.e-spen,the European e-Journal of clinical Nutrition and Metabolism 2009; 4:e172-e175

36. THANK YOU