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	James L. Holly, M.D.

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EPM Tools - Nutrition Assessment Tutorial

One of the most neglected areas of acute and critical care is nutrition. Also, one of the most litigated areas in long-term residential and/or nursing home care is malnutrition.

SETMA’s Nutrition Assessment Template makes it possible to objectively document a patient’s nutritional status in regard to:

Risk Factors for Malnutrition
Physical Signs and Symptoms of Malnutrition
Chemical and Metabolic Indications of Malnutrition

The Nutrition Template can be launched from the:

AAA Home

Nutrition Assessment

SETMA Navigation Bar of Patient Data Master template
SETMA Navigation Bar of Nursing Home Master template

The laboratory nutritional assessment of a patient can be completed by:

Going to the Plan Template on the GP Master Suite of Templates and
Opening the Lab Charge Posting Template.
At the bottom of the fifth column of that template, there is a button entitled “Nutritional Risk.”
When clicked 8 lab studies are highlighted in blue.
The boxes next to each of these should be clicked which will order all of the test necessary to properly evaluate the patient’s nutritional status.
The ICD-9 Codes for Malnutrition should be used with this set of tests.

Nutrition Assessment

The Nutrition Template is organized into four sections from top to bottom. They are:

Top Section:

The following patient data is pulled from other parts of the EMR:

Age
Weight
Height
BMI
Body Fat %
Basal Metabolic Rate – there is a help button which gives details about the patient’s BMR. If the BMR is not displayed, it it is simple to go to AAA Home, click on Master GP, go the Nursing template, click in the box beside BMR, add the patient’s level of activity and click “OK.” The BMR is automatically calculated and displayed on the Nutrition Template.
Protein Requirements – Among the very important aspects of a patient’s nutritional status is appropriate protein intake. In the first help button to the right of the Nutrition button two definitions are given:

Workmanship – a form of malnutrition caused by inadequate protein intake
Erasmus -- a form of failure to grow with emaciation in face of a fair appetite.

Nutrition Assessment

The second section of the Nutrition Assessment is composed of three columns:

Risk Factors for Malnutrition

Inappropriate Food Intake
Poverty
Social isolation
Dependence and/or Disability
Acute of chronic Diseases/conditions
Chronic medication use
Advanced aged (80+)
Late-Life Paranoia
Swallowing Disorders
Oral Problems
Nonsocial Infections
Wandering or Other Dementia-related Behaviors
Hyperthyroidism/Hyperglycemia/Supernaturalism
Epicenter Problems
Inability to feed self
Eating Problems
Low-salt, low-cholesterol Diets
Stones (Cholinesterase)
Depression
Unable to turn and position

Nutrition Assessment

This check list not only provides an excellent risk stratification for nutritional compromise in a patient but also provides an excellent guide to evaluation of nutritional problems.

Midway down the first column and next to the Risk Factors for Malnutrition are two buttons:

Meds with Nutritional Risk – this is the list of common medications which can contribute either to decrease appetite or to decrease absorption. Any patient at nutritional risk ought to be evaluated for the possibility of avoiding these medications.

Nutrition Assessment

Nutritional Risk Questionnaire – based on the following categories, a score of 10 or higher places the patient at a high risk of malnutrition. The categories are:

Level of Consciousness/Mental Status
Self-feeding ability
Weight Status
Oral health status
Food intake
Fluid intake
Snacks/Supplements
Food Preferences
Medications
Lab Values
Predisposing Conditions

Nutrition Assessment

Column 2:

Physical Signs and Symptoms of Malnutrition

Involuntary Weight Loss – 5% in 30 days
Involuntary Weight Loss – 10% in 180 days
Wasting of Fat and Muscle Tissue
Flaking Dermatitis
Sparse, thin hair that is easy to pull out
Transverse lines on Nails
Abdominal distension
Hepatomegaly
Parotid Gland enlargement
Anorexia
Depression
25% of meals left uneaten at two thirds of meals.

Column 3:

Print Button -- this creates a document for the Nutritional Assessment Template

Malnutrition Information -- these are provider education pieces on nutrition

Definitions
Adverse Affects
Biochemical Indicators
Incidence and Awareness
Monitoring
Nutritional Assessment
Risks

Nutrition and the Elderly – these are provider education pieces

Age Change in Body Composition
Causes of PEM
Drug Tx Weight Loss in Elderly
Ethical Issues about Nutrition
Nutrient Functions
Undernutrition in the Elderly

The third section from top to bottom is:

Chemical and Metabolic Indications of Malnutrition

Albumin
Prealbumin
Cholesterol
Transferrin
Total Protein
Magnesium
Calcium
Blood Urea Nitrogen
Urine urea nitrogen -- there is an “info” button which explains what urine urea nitrogen is.
Creatinine

Nutrition Assessment

To the right of this section are two buttons:

Check for new lab – this populates the lab results with the most current lab.

Nutrition Assessment

Laboratory Dates – this tells you when the lab was done.

Nutrition Assessment

The last section from top to bottom has two buttons and is entitled “Orders/Guidelines”

Nutrition Assessment

General – launches a pop-up entitled Loss of Appetite/Malnutrition Guidelines

Nutrition Assessment

Family Suggestions – six suggestions which can be made to the family to improve the nutrition of their loved one.

Nutrition Assessment

The “Print” button creates a document with all of the information competed on this template. The information also is added to the document of the Master GP and the Master Nursing Home chart notes.

Nutrition Assessment

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