![\"Step](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_1-assess-1024x132.png\")
\r\n- \r\n \t
- Clinical Data<\/strong>: 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.<\/li>\r\n \t
- Anthropometric Data<\/strong>: Weight, height, BMI, % weight change, % usual body weight, physical assessment, subjective global assessment.<\/li>\r\n \t
- Nutritional Requirements<\/strong>: energy, protein, and fluid.<\/li>\r\n \t
- Biochemical Data<\/strong>: Laboratory values.<\/li>\r\n \t
- Dietary Data<\/strong>: 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.<\/li>\r\n<\/ol>\r\nBefore asking the patient questions for your assessment, make sure to introduce yourself and set the agenda for the discussion.\r\n
Subjective Global Assessment<\/h2>\r\nAccording to the\u00a0<\/span>Canadian Malnutrition Task Force:\r\n
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.<\/blockquote>\r\nYou can refer to the SGA Form (PDF, 2017)<\/a> from Dr. Jeejeebhoy and the Canadian Malnutrition Task Force<\/a> for further practice.\r\n\r\nWatch 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)<\/a>\u00a0instead.<\/em>\r\n\r\n[embed]https:\/\/www.youtube.com\/watch?v=6ny2FLW_Z3o[\/embed]\r\n
\r\n Case Study: Meet Sam<\/h2>\r\n<\/header>\r\n
\r\n\r\n![\"Sam](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2021\/08\/Inpatient_Actor-300x169.jpg\")
\r\n\r\nYour patient, Sam Stevenson<\/em>\r\n\r\nYou are a Registered Dietitian (RD) in the Gastroenterology unit of a hospital. The patient you are assessing is a 42 year old male named Sam Stevenson. You have been following this patient but your assessment (for the purposes of the case study) is on day 2 post-operation\/ hospital admission.\r\n\r\n<\/div>\r\n<\/div>\r\nClinical Data<\/h1>\r\nClinical data can include, but is not limited to:\r\n
- \r\n \t
- Reason for visit<\/strong>: hospital visit or RD assessment.<\/li>\r\n \t
- Past medical history<\/strong> (PMHx): health history to date.<\/li>\r\n \t
- History and presenting illness<\/strong> (HPI): symptoms, surgeries, prognosis, tests (i.e. CT scan, ultrasound)<\/li>\r\n \t
- Current medical orders<\/strong>: IV infusions, medications (IV or oral), relevant consultations (i.e. RD, Speech Language Pathologist (SLP), Physiotherapist (PT), \u00a0Gastroenterologist, etc.).<\/li>\r\n \t
- Clinical documentation<\/strong>: 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.<\/li>\r\n \t
- Medical care plan and disposition<\/strong>: chemotherapy, radiation therapy, scheduled surgery, transfer to different floor, rehab facility, treatment facility, long term care, home.<\/li>\r\n<\/ul>\r\n
\r\n Sam's Clinical Data & Documentation<\/h2>\r\n<\/header>\r\n
\r\n\r\nReview Sam\u2019s clinical data. Take note of components that you think may be of importance for a nutrition care plan or to consider in the context of his patient care.\r\n- \r\n \t
- Age<\/strong>: 42-year-old male<\/li>\r\n \t
- HPI<\/strong>: 5-year history of Crohn\u2019s disease, frequent hospital admissions for pain and diarrhea, worsening frequency of flares.<\/li>\r\n \t
- Admission<\/strong>: 3 days ago for intense pain, diarrhea, nausea and decreased appetite \u2013 unable to work for the past 2 weeks \u2013 poor dietary intake \u2013 has lost over 15 kg over the past two months and 3 kg over the last two weeks.<\/li>\r\n \t
- Pathology<\/strong>: Crohn\u2019s disease.<\/li>\r\n \t
- Operations\/ Procedures<\/strong>: Investigation reveals ischemic tissue in the ileum \u2013 GI surgeon performs an ileocaecal resection removing 70 cm of the terminal ileum. Temporary ileostomy to allow the colon to rest (re: extensive inflammation).<\/li>\r\n \t
- Consultations<\/strong>: RD consult for diet order progression and ileostomy education.<\/li>\r\n \t
- Medications<\/strong>:\r\n
- \r\n \t
- Prednisone (a corticosteroid): On a daily dose of 10 mg\/day for the past 2 months. MD increased dose to 30 mg\/day IV while in hospital.<\/li>\r\n \t
- Metronidazole (an antibiotic): MD prescribed 500 mg IV while in hospital (post-op)<\/li>\r\n \t
- Pantoprazole (a proton pump inhibitor): MD prescribed 40 mg IV while in hospital (post-op)<\/li>\r\n \t
- Look up each of these medications and determine why Sam is receiving them and the potential side effects<\/em><\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
- Medical plan<\/strong>: Medical Doctor (MD) plans for Sam to stay in hospital for ~3-5 days post-op for monitoring (pending possible complications). Temporary ileostomy \u2013 plan to complete resection in 3 months.<\/li>\r\n \t
- Disposition plan<\/strong>: home once stable.<\/li>\r\n<\/ul>\r\nReview Sam's clinical documentation. Note that your assessment is on day 2 post-op.\r\n
- \r\n \t
- Day 0 (day of his surgery) post-op<\/strong>: patient was [pb_glossary id=\"1662\"]NPO[\/pb_glossary] (with ice chips)<\/li>\r\n \t
- Day 1 post-op<\/strong>: patient was ordered clear fluids.<\/li>\r\n \t
- Symptoms<\/strong>: On day 0, nurse reports that patient was complaining of nausea and fatigue \u2013 consumed a cup of ice chips. On day 1, nurse reports that patient is feeling better, is drinking clear fluids (water, juice ~ 800 mL\/day) consistently and is walking around the ward (infrequently). Patient still fatigued and weak.<\/li>\r\n \t
- Infusions<\/strong>: MD ordered (on day 0 of post-op) IV \u2154 and \u2153 @100 mL\/hour = 2400 mL\/day<\/li>\r\n \t
- Ostomy output<\/strong>: Day 0 = 200 cc; day 1 = 1200 cc; referred to as an \u2018active ileostomy\u2019<\/li>\r\n \t
- Urine output<\/strong>: Day 0 = 720 mL (~30 mL\/hour); Day 1 = 1,500 mL (~60 mL\/hour)<\/li>\r\n<\/ul>\r\nAs your assessment is taking place on day 2 post-op, you would have access to 2 days worth of important clinical documentation and information to inform your next steps for the nutrition care plan.\r\n\r\nA key component is the assessment of fluid intake and ostomy output at this stage. We need to make sure the ostomy is functioning, referred to as an active ileostomy, before progressing Sam\u2019s diet. Fluid intake is an important component of his care plan in regard to preventing dehydration and electrolyte imbalance given his recent surgery. Urine output is important in reviewing Sam\u2019s fluid balance.\r\n\r\n<\/div>\r\n<\/div>\r\n
Anthropometric Data<\/h1>\r\n
Assessment of Body Weight<\/span><\/h2>\r\nBody weight is the most used indicator of nutritional status, as it is used\u00a0for calculating fluid, protein, and energy requirements.\r\n\r\nImportant considerations to identify include:\r\n
- \r\n \t
- adjustments in weight (i.e. amputations, fluid retention)<\/li>\r\n \t
- if this is the most appropriate weight to use for calculations (i.e. are you overfeeding or underfeeding?)<\/li>\r\n \t
- the weight you are feeding<\/li>\r\n<\/ul>\r\nObtaining 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\u2019s tables are used for adults aged 65+.<\/span>\r\n
- Day 1 post-op<\/strong>: patient was ordered clear fluids.<\/li>\r\n \t
- Medical plan<\/strong>: Medical Doctor (MD) plans for Sam to stay in hospital for ~3-5 days post-op for monitoring (pending possible complications). Temporary ileostomy \u2013 plan to complete resection in 3 months.<\/li>\r\n \t
- HPI<\/strong>: 5-year history of Crohn\u2019s disease, frequent hospital admissions for pain and diarrhea, worsening frequency of flares.<\/li>\r\n \t
- Past medical history<\/strong> (PMHx): health history to date.<\/li>\r\n \t
- Anthropometric Data<\/strong>: Weight, height, BMI, % weight change, % usual body weight, physical assessment, subjective global assessment.<\/li>\r\n \t
![\"The](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2021\/08\/OAJNN.MS_.ID_.555552.G016-300x196.jpg\")
The interosseous muscle is depressed in a patient with muscle wasting. ![\"Hollow,](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2021\/08\/Periorbital_darkness-254x300.jpeg\")
Hollow, dark circles under the eyes. ![Photo by Serdar G.<\/a>,](\"https:\/\/commons.wikimedia.org\/wiki\/File:Periorbital_darkness.jpg\"){kind=link}