Overall nutritional assessment is undertaken to determine the severity of nutrient deficiencies or excess and to aid in predicting nutritional requirements. Pertinent information is obtained by determining the presence of weight loss, chronic illnesses, or dietary habits that influence the quantity and quality of food intake. Social habits predisposing to malnutrition and the use of medications that may influence food intake or urination should also be investigated. Physical examination seeks to assess loss of muscle and adipose tissues, organ dysfunction, and subtle change in skin, hair, or neuromus-cular function reflecting frank or impending nutritional deficiency. Anthropometric data (arm circumference and muscle area) and biochemical determinations (creatinine excretion, albumin, pre-albumin, total lymphocyte count, and transferrin) may be used to substantiate the patient's history and physical findings. It is imprecise to rely on any single or fixed combination of the previous findings to accurately assess nutritional status or morbidity. Appreciation for the stresses and natural history of the disease process, in combination with nutritional assessment, remains the basis for identifying patients in acute or anticipated need of nutritional support.
A fundamental goal of nutritional support is to meet the energy requirements for metabolic processes, core temperature maintenance, and tissue repair. Failure to provide adequate nonprotein
Table 2 Energy equivalent of substrate oxidation (per gram)
Substrate O2 consumed (l/g) CO2 produced (l/g) Respiratory quotient kcal/g Recommended daily need g/kg/day
Table 3 Caloric adjustments above basal energy expenditure (BEE) in hypermetabolic conditions
Adjustment above BEE
Normal/moderate malnutrition 25-30
Mild stress 25-30
Moderate stress 30
Severe stress 30-35
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