Gathering Data for an Assessment

Gather the following information for your assessment:

1. Clinical Data: History of presenting illness (HPI), 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, % usual body weight, physical assessment, subjective global assessment.
3. Nutritional Requirements: energy, protein, and fluid.
4. Biochemical Data: Laboratory values.
5. Dietary Data: Estimation of caloric/protein/ fluid requirements, hospital diet order, dietary restrictions, allergies, eating behaviour and patterns, 24 hour recall, calorie counts, supplements, previous nutrition interventions.

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

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.

You can refer to the SGA Form (PDF, 2017) from Dr. Jeejeebhoy and the Canadian Malnutrition Task Force for further practice.

Watch the video below (6:36) from UC San Diego Health. It demonstrates a nutrition-focused physical exam for identifying malnutrition. Note: captions were not uploaded for this external video, but you can read a read a transcript for the video (PDF) instead.

Clinical Data

Clinical data can include, but is not limited to:

• Reason for visit: hospital visit or RD assessment.
• 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 (IV or oral), relevant consultations (i.e. RD, Speech Language Pathologist (SLP), Physiotherapist (PT),  Gastroenterologist, etc.).
• 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), and vitals.
• Medical care plan and disposition: chemotherapy, radiation therapy, scheduled surgery, transfer to different floor, rehab facility, treatment facility, long term care, home.

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.

Important considerations to identify include:

• adjustments in weight (i.e. amputations, fluid retention)
• if this is the most appropriate weight to use for calculations (i.e. are you overfeeding or underfeeding?)
• the weight you are feeding

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+.

Physical Assessment

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.

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

The table below 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

The table below 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.

Electrolyte Requirements

The table below represents general guidelines for electrolyte requirements, in consideration of clinical factors. Determination of the best method to use needs to be considered in the context of the individual and their current electrolyte status and bloodwork. This can vary tremendously based on the situation.

Biochemical Data

Laboratory Values

IV Solutions

Here is an overview of common IV solutions used in hospital.  IV solutions contribute calories and other nutrients, so they need 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.

Assessment summary