by Mary Ellen Posthauer RDN, CD, LD, FAND
Last month I discussed the importance of implementing a system for screening the nutritional status of individuals. When the screening tool triggers nutrition, timely referral is critical. Each facility should establish the appropriate time frame for completion of a nutrition assessment. For example, is 24 hours appropriate in acute care and seven days in a skilled nursing facility? Establish a time frame appropriate for your facility and adhere to it.
The registered dietitian (RD) should complete the nutrition assessment, document the results in the medical record, and communicate the results to the appropriate team members. Failure to communicate with the team often results in a delay in implementing the nutrition interventions. Individuals with pressure ulcers (PrUs) or wounds are all candidates for an in-depth assessment. Additional conditions requiring immediate assessment and intervention include unplanned weight loss, dysphagia, poor appetite or the inability to consume adequate food or fluid.
The assessment includes interpretation and analysis of medical, nutritional, biochemical data and food-medication interactions; obtaining anthropometric measurements; and an evaluation of visual signs of poor nutrition, oral status, chewing/swallowing ability, and/or diminished ability to eat independently.
Anthropometric measurements include height, weight and body mass index (BMI). Obtaining an accurate height and weight is important, since these values are the basis for calculating body mass index (BMI) and caloric requirements. BMI is highly correlated with body fat, but increased lean body mass or a large body frame can also increase the BMI. It is generally agreed that a normally hydrated individual with a BMI > 30 is obese and an individual with a BMI ≤ 20 is considered underweight.
Individuals should be weighed on a calibrated scale, at the same time of the day, and wearing the same amount of clothing. Specialty beds often are equipped with a device to weigh an immobile individual. The RD evaluates the severity of the weight loss considering the effect of recent surgery, edema, diuretic therapy, and other traumatic events. Significant weight loss places an individual at increased nutritional risk and has a negative effect on wound healing. Several studies support the theory that unintentional weight loss of 5% in 30 days or 10% in 180 day is a predictor of mortality in the elderly. During the interview with the individual or caregiver, the RD inquires about the individuals’ usual body weight (UBW) over the past few months. UBW is used to calculate the percentage of weight lost or gained over time thus determining the significance of any weight change.
The obese patient is also at risk for PrU development and healing may be delayed when the diet recommended/ordered is inadequate in nutrients including protein. When healing PrUs is the goal, the healthcare team should evaluate the risks versus the benefits of recommending a low calorie diet.
Physical Signs of Poor Nutrition
The individual who presents with a thin, frail, wasted appearance is usually indicative of inadequate energy intake. Physical signs of under-nutrition and protein depletion are evidenced by changes in the hair, skin or nails, such as thin, dry hair, brittle nails or cracked lips. Ashen skin, fatigue, and thin, concave nails with raised edges maybe indicative of iron deficiency. Individuals with missing or decayed teeth, or ill-fitting dentures often reduce their intake of difficult to chew protein foods, thus restricting their caloric intake and increasing the chance for weight loss. Bleeding or inflamed gums could indicate vitamin C or riboflavin deficiency. If untreated, individuals with swallowing problems or dysphagia may become dehydrated, lose weight, and develop pressure ulcers. Loss of dexterity and/or the ability to self-feed is a risk factor often resulting in poor oral intake. These conditions can be roadblocks to wound healing.
Collaboration with other members of the team is an important piece of the assessment process. The RD may collaborate with the speech therapist, responsible for screening, evaluating and treating swallowing problems, or the occupational therapist that works to strengthen the individual’s ability to eat independently, and the physician responsible for the over-all care of the individual.
Additional assessment parameters will be discussed next month.
About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Panel and the American Dietetic Association’s Unintentional Weight Loss work group.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.
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