Nutritional management and Nourishment
   

Nutritional management & Nourishment

 

Nutritional management of patients in a rehabilitation setting often involves dealing with patients on a nutritional spectrum ranging from debilitated individuals who are undernourished to patients who have been admitted for complications of obesity.

 
 
 

Evaluation of nutritional status

 

Height and weight measurements are probably the most important set of vital signs in nutritional assessment.

Height

Formulas for the calculation of ideal body weight (IBW) based on patient height include the following:


Hamwi calculation: Appropriate for patients aged less than 65 years; this calculation is adjusted for gender
Metropolitan scale (1959): Weights were obtained from approximately 5 million healthy life insurance policyholders who were tracked by insurance companies for approximately 20 years
Geriatric Weight Scale: For patients aged more than 65 years No matter which calculation method is used, the IBW needs to be adjusted for frame size, spinal cord injury (SCI), and amputation.
  Weight

The following calculation can be used to determine whether IBW or actual body weight (ABW) should be employed in feeding calculations:

Percentage IBW = (actual body weight [ABW]/IBW) x 100

The following parameters can then be used:

If ABW is less than IBW, use ABW to determine nutritional needs
If ABW is greater than IBW but less than 120%, use IBW to determine nutritional needs
If ABW is greater than 120% of IBW, use the adjusted or relative body weight to calculate needs: IBW + (ABW - IBW x 0.25)
 
 
 

Protein status

Visceral and somatic protein status are used as biochemical indices in the evaluation of nutritional status. Visceral proteins used in such assessments include the following:

Albumin: Not a definitive measure of visceral protein status, but it reflects the complex relationship between synthesis, degradation, and distribution
 
Transferrin: Makes a better nutritional marker of visceral protein status than does albumin owing to transferrin’s shorter half-life (8-9 days) and smaller body pool size
Prealbumin: Excellent nutritional marker owing to its small total body pool and very short half-life (2 days)
 
 

Nitrogen balance

 

Nitrogen balance studies measure the net change in the body's total protein. An estimate of nitrogen balance can be obtained by measuring urinary urea nitrogen (UUN) and comparing it with nitrogen intake during that same time.

 
 

Hematologic measurements

 

Serum hemoglobin and hematocrit may reflect a generalized state of malnutrition.

Malnutrition

Malnutrition can be categorized using the following terms:

Marasmus: Applies to a typical starved patient
 
Kwashiorkor: Applies to a typical hypermetabolic or catabolic patient
Protein/calorie malnutrition: Typically applies to a marasmic patient who becomes hypermetabolic or catabolic
 
   
 
 

Calculation of nutritional needs

 
 

The Harris-Benedict formula has for many years been considered the criterion standard for predicting calorie requirements in acutely ill, hospitalized patients, although it may overestimate energy needs. Requirements are calculated as follows:

Marasmus: Applies to a typical starved patient
 
 
 

Protein needs

 

 

The following factors need to be considered when estimating protein needs:

Metabolic rate
Body protein reserves
Calorie intake
 
Nutritional status
Disease state
Stress associated with critical illness
  Age
 
 
 

Hydration or fluid needs

 
 

These must be addressed within each nutritional assessment because they affect lab interpretation and nutritional intervention. Various methods exist to determine fluid requirements, including calculations based on weight, age and weight, energy, and fluid balance.

 
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