User Guide - Link 3 - Nestlé Health Science
Contents
1. Neuropsychological problems Score 0 Severe dementia or depression 1 Mild depression 2 No psychological problems Review patient medical record Professional judgment Ask nursing staff or caregiver The patient s caregiver nursing staff or medical record can provide information about the severity of the patient s neuropsychological problems dementia If a patient cannot respond i e one with dementia or is severely confused ask the patient s personal or professional caregiver to answer the following questions or check the patient s answers for accuracy Questions A B C D G J K L M O P 7 Nestle Nutrition INSTITUTE Body mass index BMI weight in kg height in m Score 0 BMI less than 19 1 BMI 19 to less than 21 2 BMI 21 to less than 23 3 BMI 23 or greater Determining BMI BMI is used as an indicator of appropriate weight for height BMI is calculated by dividing the weight in kg by the height in m Appendix 1 BMI weight kg height m Before determining BMI record the patients weight and height on the MNA form 1 2 an Convert subject s weight to metric using formula 1kg 2 2lbs Convert subject s height to metric using formula 1inch 2 54cm If height has not been measured please measure using a stadiometer or height gauge Refer to Appendix 3 If the patient is unable to stand measure height using indirect methods such as2. 0 viewsselfas being malnourished 1 isuncertain of nutritional state 2 viewsselfas having no nutritional problem O P In comparison with other people of the same age how does the patient consider his her health status 0 0 notasgood 0 5 doesnotknow 1 0 asgood 2 0 better Ew O Q Mid armcircumference MAC in cm 0 0 MAC lessthan 21 0 5 MAC 21to 22 1 0 MAC 22orgreater m a R Calfcircumference CQ in cm 0 CCless than 31 1 CC 31 orgreater CJ BAERE Screening score og LCA Assessment max 16 points Total Assessment max 30 points Malnutrition Indicator Score 17 to 23 5 points at risk of malnutrition E malnourished O Less than 17 points Mini Nutritional Assessment MNA The MNA is a screening and assessment tool that can be used to identify elderly patients at risk of malnutrition The User Guide will assist you in completing the MNA accurately and consistently It explains each question and how to assign and interpret the score Introduction While the prevalence of malnutrition in the free living elderly population is relatively low the risk of malnutrition increases dramatically in the institutionalized and hospitalized elderly The prevalence of malnutrition is even higher in cognitively impaired elderly individuals and is associated with cognitive decline Patients who are malnourished when admitted to the hospital tend to have longer hospital stays exp
3. 8 31 1 94 x knee height 0 14 x age Stature cm 79 69 1 85 x knee height 0 14 x age Stature cm 82 77 1 83 x knee height 0 16 x age Stature cm 82 21 1 85 x knee height 0 21 x age Stature cm 89 58 1 61 x knee height 0 17 x age Stature cm 84 25 1 82 x knee height 0 26 x age Stature cm 85 10 1 73 x knee height 0 11 x age Stature cm 91 45 1 53 x knee height 0 16 x age Stature cm 94 87 1 58 x knee height 0 23 x age 4 8 Stature cm 94 87 1 58 x knee height 0 23 x age Stature cm 74 7 2 07 x knee height 0 21 x age Stature cm 67 00 2 2 x knee height 0 25 x age Stature cm 52 6 2 17 x knee height Stature cm 73 70 1 99 x knee height 0 23 x age Stature cm 96 50 1 38 x knee height 0 08 x age Stature cm 89 63 1 53 x knee height 0 17 x age Stature cm 1 924 x knee height 69 38 Stature cm 2 225 x knee height 50 25 Nutrition INSTITUTE 18 Appendix 6 MEASURING MID ARM CIRCUMFERENCE Ask the patient to bend their non dominant arm at the elbow at a right angle with the palm up 2 Measure the distance between the acromial surface of the scapula bony protrusion surface of upper shoulder and the olecranon process of the elbow bony point of the elbow on the back of the arm 3 Mark the mid point between the two with the pe
4. A Guide to Completing the Mini Nutritional Assessment MNA Nestle utrition INSTITUTE Last name First name A Complete the screen by filling in the boxes with the appropriate numbers Mini Nutritional Assessment MNA Sex Date L D Number Add the numbers for the screen If score is 11 or less continue with the assessment to gain a Malnutrition Indicator Score A Has food intake declined overthe past 3 months due to loss of appetite problems chewing or swallowing difficulties severe loss of appetite moderate loss of appetite no loss of appetite pi 2 B ht loss during the last 3 months weight loss greater than 3 kg 6 6 Ibs does notknow weight loss between 1 and 3 kg 2 2 and 66 lbs o Wei 0 1 2 3 noweight loss nung ity bed orchair bound abletogetout of bed chair but does not go out goes out m n oz nN amp D Has suffered psychological stress or acute disease in the past 3 months 0 yes 2 m El E ae sh ciudad severe dementia ordepression milddementia 2 nopsychological problems M F Body Mass Index BMI weightin kg height in m2 0 BMllessthan19 1 BMI 19toless than 21 2 BMI21toless than 23 3 BMI 23 or greater gil Screening score ERS O T 12pointsorgreater Normal notat risk no need to complete assessment 11 pointsorbelow Possible malnutrition continue assessment Assessment G_Lives independently not in a nursing home or hosp
5. No 6 Meat fish or poultry every day Yes No 0 0 if 0 or 1 Yes answer s 0 5 if 2 Yes answers 1 0 if 3 Yes answers Ask the patient or nursing staff or check the completed food intake record 6 Do you consume any dairy products a glass of milk cheese in a sandwich cup of yogurt can of high protein supplement every day Do you eat beans eggs How often do you eat them Do you eat meat fish or chicken every day 7 Nestle Nutrition INSTITUTE Consumes two or more servings of fruits or vegetables per day Score 0 No 1 Yes Ask the patient check the completed food intake record if necessary 6 Do you eat fruits and vegetables 6 How many portions do you have each day A portion can be classified as One piece of fruit apple banana orange etc One medium cup of fruit or vegetable juice One cup of raw or cooked vegetables M How much fluid water juice coffee tea milk is consumed per day Score 0 0 Less than 3 cups 0 5 3 to 5 cups 1 0 More than 5 cups Ask patient How many cups of tea or coffee do you normally drink during the day Do you drink any water milk or fruit juice What size cup do you usually use A cup is considered 200 240ml or 7 802 7 Nestle Nutrition INSTITUTE N Mode of Feeding Score 0 Unable to eat without assistance 1 Feeds self with some difficu
6. al notch with the pen 2 Ask the patient to place the left arm in a horizontal position 3 Check that the patient s arm is horizontal and in line with shoulders 4 Using the tape measure measure distance from mark on the midline at the sternal notch to the tip of the middle finger 5 Check that arm is flat and wrist is straight 6 Take reading in cm utrition INSTITUTE Calculate height from the formula below Females Height in cm 1 35 x demispan in cm 60 1 Males Height in cm 1 40 x demispan in cm 57 8 Source http www rxkinetics com height_estimate htm Accessed December 12 2006 16 Appendix 5 MEASUREMENT OF KNEE HEIGHT 4 Take two measurements in immediate 6 Knee height is one method to determine auccession They should agree within 0 5 statue in the bed or chair bound patient and is measured using a Sliding knee height caliper The subject must be able to bend the knee and the ankle to 90 degree angles Have the subject bend the knee and ankle of one leg at a 90 degree angle while lying supine or sitting on a table with legs hanging off the side of the table Place the fixed blade of the knee caliper under the heel of the foot in line with the ankle bone Place the fixed blade of the caliper on the anterior surface of the thigh about 3 0 cm above the patella Be sure the shaft of the caliper is in line with and parallel to the long bone in the lower leg tibia and i
7. ansky N Berner Y Koren Morag N Perelman L Knobler H Levy S Poor nutritional habits are predictors of poor outcomes in very old hospitalized patients Am J Clin Nutr 2005 82 784 791 Vellas B Villars H Abellan G et al Overview of the MNA It s history and challenges J Nutr Health Aging 2006 10 455 465 Guigoz Y Vellas J Garry P 1994 Mini Nutritional Assessment A practical assessment tool for grading the nutritional state of elderly patients Facts Res Gerontol 4 supp 2 15 59 Guigoz Y The Mini Nutritional Assessment MNA review of the literature what does it tell us J Nutr Health Aging 2006 10 465 487 Murphy MC Brooks CN New SA Lumbers ML The use of the Mini Nutritional Assessment MNA tool in elderly orthopaedic patients Eur J Clin Nutr 2000 54 555 562 Malone A Anthropometric Assessment In Charney P Malone E eds ADA Pocket Guide to Nutrition Assessment Chicago IL American Dietetic Association 2004 142 152 Osterkamp LK Current perspective on assessment of human body proportions of relevance to amputees J Am Diet Assoc 1995 95 215 218 Hickson M Frost G A comparison of three methods for estimating height in the acutely ill elderly population J Hum Nutr Diet 2003 6 1 3 Chumlea WC Guo SS Wholihan K Cockram D Kuczmarski RJ Johnson CL Stature prediction equations for elderly non Hispanic white non Hispanic black and Mexican American persons developed from NHANES III data J Am Di
8. e 0 0 Not as good 0 5 Does not know 1 0 As good 2 0 Better Ask patient 6 How would you describe your state of health compared to others your age Then prompt Not as good as others of your age Not sure As good as others of your age Better Again the answer will depend upon the state of mind of the person answering the question Q Mid arm circumference MAC in cm Score 0 0 MAC less than 21 0 5 MAC 21 to 22 1 0 MAC 22 or greater Measure the mid arm circumference in cm as described in Appendix 6 Nutrition INSTITUTE 11 R Calf circumference CC in cm Score 0 CC less than 31 1 CC 31 or greater Calf circumference should be measured in cm as described in appendix 7 Measure the calf at the widest area Take additional measurements above and below the widest point to ensure that the first measurement was the largest Final Score Total the points from the assessment section of the MNA maximum 16 points 6 Add the assessment and screening scores together to get the total Malnutrition Indicator Score Maximum 30 points 6 Check the appropriate box indicator If the score is greater than 23 5 points the patient is in a normal state of nutrition and no further action is required If the score is less than 23 5 points refer the patient to a dietitian or nutrition specialist nutrition intervention Until a dietitia
9. easure height without shoes using a stadiometer height gauge or if the patient is bedridden by knee height or demispan see Appendices 4 or 5 Convert inches to centimeters 1inch 2 54cm ID number e g hospital number Date of screen Nutrition INSTITUTE Screening MNA SF Complete the screen by filling in the boxes with the appropriate numbers Then add together the numbers to determine the total score of the screen If the score is 11 or less continue on with the assessment to determine the Malnutrition Indicator Score Key Points Ask the patient to answer questions A E using the suggestions in the shaded areas If the patient is unable to answer the question ask the patients caregiver to answer Using the patients medical record or your professional judgment answer any remaining questions Has food intake declined over the past three months due to loss of appetite digestive problems chewing or swallowing difficulties Score 0 Severe decrease in food intake 1 Moderate decrease in food intake 2 No decrease in food intake Ask patient Have you eaten less than normal over the past three months If so is this because of lack of appetite chewing or swallowing difficulties If yes have you eaten much less than before or only a little less If this is a re assessment then rephrase the question gt aoa a Q Has the amount of food you have eaten changed
10. erience more complications and have greater risks of morbidity and mortality than those whose nutritional state is normal By identifying patients who are malnourished or at risk of malnutrition either in the hospital or community setting the MNA allows clinicians to intervene earlier to provide adequate nutritional support prevent further deterioration and improve patient outcomes Mini Nutritional Assessment MNA The MNA provides a simple and quick method of identifying elderly patients who are at risk for malnutrition or who are already malnourished It identifies the risk of malnutrition before severe changes in weight or serum protein levels occur The MNA may be completed at regular intervals in the community and in the hospital or long term care setting The MNA was developed by Nestl and leading international geriatricians and remains one of the few validated screening tools for the elderly It has been well validated in international studies in a variety of settings and correlates with morbidity and mortality a Nestle INSTRUCTIONS TO COMPLETE THE MNA Before beginning the MNA please enter the patient s information on the top of the form Name Gender Age Weight kg To obtain an accurate weight remove shoes and heavy outer clothing Use a calibrated and reliable set of scales If applicable convert pounds lbs to kilograms 1kg 2 2lbs Height cm M
11. et Assoc 1998 98 137 142 Cheng HS See LC Sheih Estimating stature from knee height for adults in Taiwan Chang Gung Med J 2001 24 547 556 Donini LM de Felice MR De Bernardini L et al Prediction of stature in the Italian elderly J Nutr Health Aging 2004 8 386 388 Guo SS Wu X Vellas B Guigoz Y Chumlea WC Prediction of stature in the French elderly Age amp Nutr 1994 5 169 173 Mendoz Nunez VM Sanchez Rodriguez MA Cervantes Sandoval A et al Equations for predicting height for elderly Mexican Americans are not applicable for elderly Mexicans Am J Hum Biol 2002 14 351 355 Tanchoco CC Duante CA Lopez ES Arm span and knee height as proxy indicators for height J Nutritionist Dietitians Assoc Philippines 2001 15 84 90 Shahar S Pooy NS Predictive equations for estimation of statue in Malaysian elderly people Asia Pac J Clin Nutr 2003 12 1 80 84 A Nestle 20 Nutrition INSTITUTE
12. ital 0 m 1 yes O H Takes more than 3 prescription drugs per day 0 yes 1 no al Pressure sores or skin ulcers 0 yes 1 no O Ref Vellas B Villars H Abellan G etal Overview of the MNA Its History and Challenges J Nut Health Aging 2006 10 456 455 Rubenstein LZ Harker JO Salva A Guigoz Y Vellas B Screening for Undernutrition in Geriatric Practice Developing the Short Fom Miri Nutritional Assessment MNA SF J Geront 2001 564 356 377 oz Y The Mini Nutritional Assessment MNA Review of the Literature What does it tell uz J Nutr Health Aging 2006 10466 487 Nestl 1994 Revision 2006 N67200 12 99 10M For more information www mna elderly com Nestle utrition INSTITUTE J How many full meals does the patient eat daily 0 1 meal 1 2meals 3 meals O 2 K Selected consumption markers for protein intake Atleastone serving of dairy products milk cheese yogurt perday yesO noO Two or more servings of legumes or eggs per week yes nol Meat fishorpoultryeveryday yes nol 0 0 ifOorlyes O5 if2yes 1 0 if3yes a L Consumes two or more servings of fruits or vegetables per day 0 m 1 yes O M How much fluid water juice coffee tea milk is consumed per day 0 0 lessthan3cups 0 5 3toScups 1 0 more than 5 cups Ek N otep eeng unable to eat without assistance self fed with some difficulty i self fed without any problem jE 2 O Self view of nutritional status
13. lty 2 Feeds self without any problems Ask patient Patient medical record information from caregiver Are you able to feed yourself Can the patient feed himself herself Do you need help to eat Do you help the patient to eat Do you need help setting up your meals opening containers buttering bread or cutting meats Patients who must be fed or need help holding the fork would score 0 Patients who need help setting up meals opening containers buttering bread or cutting meats but are able to feed themselves would score 1 point Pay particular attention to potential causes of malnutrition that need to be addressed to avoid malnutrition e g dental problems need for adaptive feeding devices to support eating O Self View of Nutritional Status Score 0 Views self as being malnourished 1 ls uncertain of nutritional state 2 Views self as having no nutritional problems Ask patient How would you describe your nutritional state Then prompt Poorly nourished Uncertain No problems The answer to this question depends upon the patient s state of mind If you think the patient is not capable of answering the question ask the caregiver nursing staff for their opinion 7 Nestle Nutrition INSTITUTE 10 P In comparison with other people of the same age how does the patient consider his her health status Scor
14. measuring demi span half arm span or knee height See Appendices 4 and 5 If height cannot be measured either directly or by indirect methods use a verbal or historical height to calculate a BMI Verbal height will be the least accurate especially for bedridden patients and patients who have lost height over the years Using the BMI chart provided Appendix 1 locate the patient s height and weight and determine the BMI It is essential that a BMI is included in the MNA without it the tool is not valid Fill in the appropriate box on the MNA form to represent the BMI of the patient To determine BMI for a patient with an amputation see Appendix 2 The screening section of the questionnaire is now complete Add the numbers to obtain the screening score A score of 12 points or greater indicates Patient is not at nutrition risk There is no need to complete the rest of the questionnaire Rescreen at regular intervals A score of 11 points or less indicates Patient may be at risk for malnutrition Please complete the full MNA assessment by answering questions G R 7 Nestle Nutrition INSTITUTE Assessment MNA Lives independently not in a nursing home Score 0 No 1 Yes Ask patient This question refers to the normal living conditions of the individual Its purpose is to determine if the person is usually dependent on others for care For example if the patient is in the hospital because
15. n Source Moore MC Pocket Guide to Nutrition 4 Ask the patient to let the arm hang loosely and Diet Therapy 1993 by his her side 5 Position the tape at the mid point on the upper arm and tighten snugly Avoid pinching or causing indentation 6 Record measurement in cm 7 If MAC is less than 21 score 0 If MAC is 21 22 score 0 5 If MAC is 22 or greater score 1 0 Source PEN Group A pocket guide to clinical nutrition Assessment of nutritional status British Dietetic Association 1997 Appendix 7 MEASURING CALF CIRCUMFERENCE AON The subject should be sitting with the left hanging loosely or standing with their weight evenly distributed on both feet Ask the patient to roll up their trouser leg to uncover the calf Wrap the tape around the calf at the widest part and note the measurement Take additional measurements above and below the point to ensure that the first measurement was the largest An accurate measurement can only be obtained if the tape is at a right angle to the length of the calf and should be recorded to the nearest 0 1 cm A Nestle 19 Nutrition INSTITUTE References Guigoz Y Vellas B Garry PJ Assessing the nutritional status of the elderly The Mini Nutritional Assessment as part of the geriatric evaluation Nutr Rev 1996 54 S59 S65 Fallon C Bruce Eustace A et al Nutritional status of community dwelling subjects attending a memory clinic J Nutr Health Aging 2002 6 Supp 21 Kag
16. n is available give the patient caregiver some advice on how to improve nutritional intake such as Increase intake of energy protein dense foods e g puddings milkshakes etc 6 Supplement food intake with additional snacks and milk for If diet alone does not improve the patient s nutritional intake the patient may need oral nutritional supplements 6 Ensure adequate fluid intake 6 8 cups glasses per day Follow Up 6 Re screen all patients every three months 6 Please refer results of assessments amp re assessments to dietitian doctor and record in medical record Nutrition INSTITUTE 12 Appendices Appendix 1 Bopby MASS INDEX TABLE Weight pounds Height feet and inches so Sy Sr 53 54 5S 56 57 58 59 S10 Sil 60 61 6r 63 64 25 26 27 25 29 2B 27 26 2 25 TE b gis gisis zie Jg le s s is ee ioe Mauna 150 1525 155 1575 160 1625 165 1675 170 1725 175 17275 180 182 5 185 1875 190 Height centimetres T Underweight Weight Appropriate Overweight Obese suuesBoj1y 3463M Source Adapted from Clinical Guidelines on the Identification Evaluation and Treatment of Overweight and Obesity in Adults The Evidence Report National Institute of Health National Heart Lung and Blood Institute Aen INSTITUTE 13 Appendix 2 DETERMINING BMI FOR AMPUTEES 6 To determine the BMI for amputees first determine the patient
17. of an accident or acute illness where does the patient normally live 6 Do you normally live in your own home or in an assisted living residential setting or nursing home Takes more than 3 prescription drugs per day Score 0 Yes 1 No Ask patient Patient medical record Check the patient s medication record ask nursing staff ask doctor ask patient l Pressure sores or skin ulcers Score 0 Yes 1 No Ask patient Patient s medical record 6 Do you have bed sores Check the patients medical record for documentation of pressure wounds or skin ulcers or ask the caregiver nursing staff doctor for details or examine the patient if information is not available in the medical record GA Neste utrition INSTITUTE How many full meals does the patient eat daily Score 0 1 meal 1 2 meals 3 3 meals Ask patient Check food intake record if necessary 6 Do you normally eat breakfast lunch and dinner 6 How many meals a day do you eat A full meal is defined as eating more than 2 items or dishes when the patient sits down to eat For example eating potatoes vegetable and meat is considered a full meal or eating an egg bread and fruit is considered a full meal Selected consumption markers for protein intake 6 Atleast one serving of dairy products per day Yes No 6 Two or more servings of legumes or eggs per week Yes
18. s estimated weight including the weight of the missing body part 2 Use a standard reference see table to determine the proportion of body weight contributed by an individual body part Multiple patient s current weight by the percent of body weight of the missing body part to determine estimated weight of missing part Add the estimated weight of the missing body part to patient s current weight to determine estimated weight prior to amputation 6 Divide estimated weight by estimated body height to determine BMI WEIGHT OF SELECTED BODY COMPONENTS It is necessary to account for the missing body component s when estimating IBW Table Percent of Body Weight Contributed by Specific Body Parts Body Part Percentage Trunk w o limbs 50 0 Hand 0 7 Forearm with hand 2 3 Forearm without hand 1 6 Upper arm 2 7 Entire arm 5 0 Foot 1 5 Lower leg with foot 5 9 Lower leg without foot 4 4 Thigh 10 1 Entire leg 16 0 References cited Malone A Anthropometric Assessment In Charney P Malone E eds ADA Pocket Guide to Nutrition Assessment Chicago IL American Dietetic Association 2004 142 152 Osterkamp LK Current perspective on assessment of human body proportions of relevance to amputees J Am Diet Assoc 1995 95 215 218 3 Calculate energy intake kcal d Example 80 year old man amputation of the left lower leg 1 72 m 58 kg 1 Estima
19. s over the ankle bone lateral malleolus Apply pressure to compress the tissue Record the measurement to the nearest 0 1 cm Nutrition INSTITUTE cm Use the average of these two measurements and the person s chronological age in the Country and ethnic group specific equations in the following table The value calculated from the selected equation is an estimate of the person s true stature The 95 percent confidence for this estimate is plus and minus twice the SEE value for each equation Source http www rxkinetics com height_estimate htm Accessed December 12 2006 17 Using population specific formula calculate height from standard formula Gender and ethnic group Non Hispanic white men U S SEE 3 74 cm Non Hispanic black men U S SEE 3 80 cm Mexican American men U S SEE 3 68 cm Non Hispanic white women U S SEE 3 98 cm Non Hispanic black women U S SEE 3 82 cm Mexican American women U S SEE 3 77 cm Taiwanese men SEE 3 86 cm Taiwanese women SEE 3 79 cm Elderly Italian men SEE 4 3 cm Elderly Italian women SEE 4 3 cm French men SEE 3 8 cm French women SEE 3 5 cm Mexican Men SEE 3 31 cm Mexican Women SEE 2 99 cm Filipino Men Filipino Women Malaysian men SEE 3 51 cm Malaysian women SEE 3 40 Equation Stature cm 7
20. since your last assessment QUE INSTITUTE B Involuntary weight loss during the last 3 months Score 0 Weight loss greater than 3 kg 6 6 pounds 1 Does not know 2 Weight loss between 1 and 3 kg 2 2 and 6 6 pounds 3 No weight loss Ask patient medical record if long term or residential care Have you lost any weight without trying over the last 3 months 6 Has your waistband gotten looser 6 How much weight do you think you have lost More or less than 3 kg or 6 pounds Though weight loss in the overweight elderly may be appropriate it may also be due to malnutrition When the weight loss question is removed the MNA loses its sensitivity so it is important to ask about weight loss even in the overweight Mobility Score 0 Bed or chair bound 1 Able to get out of bed chair but does not go out 2 Goes out Ask patient Patient s medical record Information from caregiver 6 Are you presently able to get out of the bed chair 6 Are you able to get out of the house or go outdoors on your own 7 Nestle Nutrition INSTITUTE D Has the patient suffered psychological stress or acute disease in the past three months Score 0 Yes 1 No Ask patient Patient medical record Professional judgment Have you suffered a bereavement recently Have you recently moved your home Have you been sick recently
21. te body weight Current body weight Proportion for the missing leg 58 kg 58 kg x 0 059 61 4kg 2 Calculate BMI Estimated body weight body height m 61 4 1 72x 1 72 20 8 6 Recommended energy intake 5 9 6 Empirical formula 30 kcal kg day 30 kcal kg d X 61 4 kg 61 4 x 0 059 1 832 kcal day Conclusion Corrected BMI is 21 and estimated energy intake is 1 800 1 900 A Nestle 14 Nutrition INSTITUTE Appendix 3 MEASURING HEIGHT USING A STADIOMETER _ Ensure the floor surface is even and firm 2 Have subject remove shoes and stand up straight with heels together and with heels buttocks and shoulders pressed against the stadiometer 3 Arms should hang freely with palms facing thighs 4 Take the measurement with the subject standing tall looking straight ahead with the head uprights and not tilted backwards 5 Make sure the subjects heels stay flat on the floor 6 Lower the measure on the stadiometer until it makes contact with the top of the Accessed at head htto Avww ktl fi oublications ehrm product2 part 7 Record standing height to the nearest iii5 htm centimeter Qne e INSTITUTE Appendix 4 MEASUREMENT OF DEMISPAN 6 Demispan half arm span is the distance from the midline at the sternal notch to the tip of the middle finger Height is then calculated from a standard formula 1 Locate and mark the edge of the right collar bone in the stern
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