363 CUMULATIVE FINAL
Purpose of evaluating dietary Intake Data?
To compare nutrients consumed to nutrients required to help client set specific goals to improve nutrient intake
Lipid Panel Values
Total Cholesterol -Optimal is <200 -Normal/borderline high 200-239 -Hypercholesterolemia >240 HDL - Normal is >60 - Elevated CVD risk Men: <40 Women <50 LDL -Optimal is <100 - Elevated risk is >130 Triglycerides -Normal is <150 -Borderline high is 150-199 - High is 200-499 - Very high is >500
Inversely proportional to transferrin saturation Increases with iron deficiency
Total Iron Binding Capacity (TIBC)
These lab values would be included in a standard fasting lipid panel.
Total chol (<200 mg/dL normal; > 240 mg/dL = hypercholesterolemia. LDL (calculated) (<100 mg/dL optimal; <130 mg/dL normal) HDL (>60 mg/dL protective; < 40 mg/dL in men and < 50 mg/dL in women indicates increased risk of CVD TG
Tests to Evaluate Protein Energy Malnutrition (PEM): 24-Hr Urine Urea Nitrogen (UUN)
(Sensitive measure of protein (nitrogen) balance that requires a 24 hour collection of urine and actual protein intake -generally only used with TPN and tube feeding -Results can direct accurate provision of protein in nutrition support (anabolism vs catabolism)
Arm Muscle Area (AMA)
[MAC- (3.14 TSF)]2/4 X 3.14 (where MAC & TSF are in mm) **Important note: this formula gives you the answer in mm2; convert your answer to cm2 by dividing by 100. Then subtract a factor of 10 for men, 6.5 for women to correct the AMA for the presence of bone (Heymsfield correction factor). Most tables will be in cm2, and many will already have applied this correction factor to deduct bone mass. Do not need to memorize
The Old Rule of Thumb for Weight Loss not backed by evidence
- 1 lb of fat = 3500 kcal - Deficit of 500 kcal/day x 7 days = negative balance of 3500 calories in a week - Typically recommend 500 kcal deficit per day for 1 lb of weight loss per week. *however, there isn't much evidence to support this - lots of individual variation to this rule*
Determining fluid needs: ml/kg method based on age
- 16-30yo (active): Provide 40 ml/kg - 20-55yo: Provide 35 ml/kg - 55-75yo: Provide 30 ml/kg - >75yo: Provide 25 ml/kg Pt is 77yo and weighs 60 kg - 60kg x 25ml=1500mL/day of fluids
Protein Energy Malnutrition Tests
- 24 hour Urine Urea Nitrogen - Creative Heigh Index
Methods for Collecting Dietary Intake Data
- 24-hour recall - Food Frequency Questionnaire (FFQ) - Diet Diary - Nutrient Intake Analysis (Calorie Count)
Four methods for determining fluid needs
- 30 to 35 ml/kg - 1 ml fluid per calorie consumed - 1500 mL + method - ml/kg method based on age
Your patient is a 74 YOM who weighs 190 lbs. You estimated his nutritional needs to be 1950 kcals. Use each method to estimate his fluid needs.
- 30-35 mL/kg = 2591-3024 mL - 1 mL/kcal = 1950 mL - 1500 mL+ = 2495 mL - 30 mL/kg (age) = 2591 mL
Energy Requirements of Fever
- 7% increase in REE with each degree above 98.6°F (13% increase in REE with each degree above 37°C) - Adjustment must be made to REE Example: If REE = 1300 kcal and temperature is 101.2°F - 101.2°F - 98.6°F increase = 2.6°F increase in temp - 2.6° x 7% = 18.2 % increase in REE - 1300 kcal x 0.182 = 236.6 kcal increase - New REE adjusted for fever = 1300 + 237 = 1537 kcal
Physical Examination - Percussion
- A method of tapping body parts with fingers, hands, or small instruments as part of a physical examination - Often done to detect body organ borders, shape, and position - May be done to detect the presence or absence of fluid in body areas - Not frequently done by the dietitian in a nutrition-focused exam - can determine ascites, fluid accumulation, or bowel obstruction with this technique
Cytochrome P450 enzyme system
- A multi-enzyme complex present in the smooth endoplasmic reticulum of cells in the liver, kidneys, GI tract, blood-brain barrier, and other tissues - Many medications are metabolized by these enzymes
Diabetic Diets
- ADA _______kcal Diet (1200, 1600, 1800, 2200, 2500, etc.) - Nutritionally complete - Provides diets with set number of CHO per meal/snacks - The American Diabetes Association says there is no standard "ADA Diet." However, this diet order would ensure consistent CHO intake during an inpatient visit. - No Concentrated Sweets (More liberalized diet but still restrict sugar and sweets for diabetics)
Diabetic Diet
- ADA calorically specified diet (1200, 1600, 1800, 2200, 2500, etc) - there is no standard ADA diet, but this will ensure consistent CHO intake during an inpatient visit - Provides nutritionally complete diets with set number of CHO meal/snacks - No concentrated sweets
NDD Level 3
- Advanced - soft foods that require more chewing ability - Most regular foods except very hard, sticky, or crunchy items - Bread, rice, cake, shredded lettuce and tender, moist meats are allowed - Mixed textures are expected to be tolerated (e.g., canned soup) - NO hard, difficult to chew fruit and vegetables with skins, nuts and seeds, etc
Liver Function Tests (LFT's)
- Alanine Aminotransferase (ALT) - Aspartate Aminotransferase (AST) - Alkaline Phosphatase (ALP) - Bilirubin (byproduct of RBC breakdown excreted by the liver)
Negative acute phase proteins
- Albumin, transferrin, prealbumin, RBP - levels will decrease as part of an acute inflammatory response - in these states, hepatic transport proteins are not an accurate indicator of nutritional status
Total Parenteral Nutrition (TPN)
- All of a patients nutrient needs are administered intravenously as a last resort due to a non functioning GI tract, bowel obstruction, etc - Used as a last resort (enteral is preferred) because it can lead to complications such as infection, metabolic and fluid issues
Neutropenic Diet restricts ingestion of
- All uncooked vegetables and most uncooked fruits - Raw or rare-cooked meat, fish, and eggs - Pts should avoid salad bars, fruit bars, and deli counters - Raw dairy - Soft mold-ripened and blue-veined cheese, including Brie, Camembert, Roquefort, Bleu, Gorgonzola, etc. -Ground pepper and other fresh ground spices
Energy needs for the mechanically-ventilated critically ill obese adult
- Energy needs should be determined by indirect calorimetry if possible -If indirect calorimetry is not available, the RD should use the Penn State University [PSU (2003b)] equation in critically ill mechanically-ventilated adults with obesity who are <60 years of age. For obese patients > 60 yo, the PSU 2010 equation should be used
Energy needs for non-obese critically ill mechanically-ventilated adults:
- Energy needs should be determined by indirect calorimetry if possible -If indirect calorimetry is not available, the RD should use the Penn State University [PSU (2003b)] equation in non-obese critically ill mechanically- ventilated adults. Research indicates that this equation has the best prediction accuracy in non-obese patients
Alkaline Phosphatase (ALP)
- Enzyme present in the liver, bile ducts, and bone - Elevated blood levels may indicate liver damage or a blocked duct
Proteins are important for many bodily functions, such as:
- Enzymes are proteins. - Many hormones are proteins. - Plasma membrane proteins - Plasma proteins - Structural proteins (muscle, skeletal matrix, collagen, keratin, and visceral proteins)
Determining Energy Needs for Children
- Estimated Energy Requirement (EER) prediction equations from the IOM are typically used - These equations already take into account a physical activity level, so you would not multiply by an AF
Mifflin St. Jeor Equation
- Estimates resting energy expenditure (REE); According the Academy of Nutrition and Dietetics' EAL, this equation is the most accurate for both normal weight and obese healthy individuals. W = weight in kg, H = height in cm, A = age in yr - Male 9.99W + 6.25H - 5A + 5 - Female 9.99W + 6.25H - 5A - 161
Harris-Benedict Equation
- Estimates resting energy expenditure (REE); Found to overestimate REE in normal weight and obese by 7% to 27% W = weight in kg, H = height in cm, A = age in yr - Male REE = 66.47 + 13.75W + 5H - 6.76A - Female REE = 655.1 + 9.56W + 1.85H - 4.68A
Tests to Evaluate Glucose Homeostasis
- Fasting Serum or Plasma Glucose -Glycosylated Hemoglobin (HbA1c) - Urine glucose
Visceral Adipose Tissue(VAT)
- Fat that lies beneath the abdominal muscle and surrounds the internal organs - Associated with increased risk for type 2 diabetes and CVD
Nutrition Intervention falls under one of four categories:
- Food and/or Nutrient Delivery - Nutrition Education - Nutrition Counseling - Coordination of Nutrition Care
What steps of the Nutrition Assessment are used to identify signs and symptoms?
- Food/Nutrition history (24-hour recall, diet history, GI symptoms - Biochemical data, medical tests and procedures (Laboratory data (prealbumin, LFTs), bowel surgery) - Anthropometric measures (Height, weight, BMI) - Nutrition-Focused Physical Findings (Skin condition, blood pressure) - Client history (Past medical history, family and social history, cultural beliefs)
Medicare Part B coverage of Medical Nutrition Therapy (MNT) services provided by a registered dietitian
- For beneficiaries with a diagnosis of diabetes or renal disease only (at the present time; RDs are advocating to expand this coverage to other diagnoses.) - Referral must be made by a physician - Coverage includes an initial assessment and f/u visits - An additional, separate diabetes self-management training (DMST) benefit is available to Medicare beneficiaries with a diagnosis of diabetes. - A Medicare provider number called a "National Provider Identifier" is required for healthcare providers who independently bill the Centers for Medicare and Medicaid Services (CMS)
Assessment of Pediatric Malnutrition
- For pediatric patients, growth is assessed by growth charts for age and gender. - Z scores are statistical measures that tell how a data point compares to normal data. Is it above average or below average? - Basically, the z score tells you how many units of standard deviation (SD) a child is from the norm for his/her reference group for age.
What is drug absorption affected by?
- Gastrointestinal pH: • Achlorhydria is common among older adults. • May be exacerbated by antacids, PPIs, or H2 blockers - Gastric emptying and motility (oral drugs) - Food: Some drugs should be taken with food in order to maximize their absorption. Other meds should be taken in the absence of food for optimal absorption.
Physical Examination - Inspection
- General observation that progresses to a more focused observation - Uses senses of sight, smell, hearing - Most frequently used technique *If you are not looking for something, you will likely not see it*
BMP Lab Panels
- Glucose - Calcium - Sodium - Potassium - CO2 - Chloride - Blood Urea Nitrogen (BUN) - Creatinine
CMP lab panels
- Glucose - Calcium - Sodium - Potassium - CO2 - Chloride - Blood Urea Nitrogen (BUN) - Creatinine - Albumin - Total Protein - Alkaline Phosphate (ALP) - Alanine Aminotransferase (ALT) - Aspartate Aminotransferase (AST) - Bilirubin
Hydrostatic (Underwater) Weighing
- Gold standard for determining fat vs. lean mass - Direct measure of whole-body density - Object submerged in water equals the volume of water the object displaces - Procedure is impractical for casual use
Calf Muscle inspection
- Grip the calf - Normal: muscle obvious, top of calf is larger than bottom - Abnormal: muscle reduction, "stick legs", ankles the same as upper leg
Exchange Lists for Meal Planning
- Groups foods into "rough equivalents" for protein, fat, carbohydrate, and kcals - Developed by the American Diabetes Association and American Dietetic Association - A method of meal planning to help ensure adequate but not excessive intake of a particular nutrient
Body Shapes
- Gyroid (pear): lower body fat; benign obesity (isn't thought to pose as great of a risk) - Android (apple): upper body fat (central obesity); greater risk of chronic disease such as heart disease, stroke, diabetes, hypertension, some cancers
Children's Growth
- Height and weight of children evaluated against several norms - Percentiles based on anthropometric measurements performed on a nationally representative sample of children of same sex and age - Data mapped on growth charts
Computer-Based Nutrition Analysis Programs
- If available, these can be used to determine daily nutrients consumed by your client - Some are computer software programs that must be purchased - Some are web-based and are typically free - Clients/patients can also use these to record dietary intake and receive daily feedback on nutrient intake
Treatment for pressure injuries
- Increased protein needs - Ensure adequate hydration (note fluid losses from exudate and/or circulating air beds) - Ensure adequate micronutrient intake (although the National Pressure Ulcer Advisory Panel notes no evidence base for supplementation of vitamins and minerals above the RDAs for wound healing).
Carbohydrate Counting
- Increases patient's flexibility. - More patients on insulin count carbs than use other methods of meal planning. - Takes more time and attention to track the carbs throughout the day. - Assess your patient's ability and determination
Low sodium diet
- Indicated for many disease states (e.g., HTN, CVD, heart failure, liver disease, kidney disease) - strict ~250 - 1,000 mg - moderate ~2 g
Low Sodium Diet
- Indicated for many disease states (htn, cvd, heart failure, liver disease, kidney disease) - Can be strict (250-1000 mg) or moderate (2g)
Blood Urea Nitrogen (BUN) Test
- Indirect and rough measurement of renal function - measures amount of Urea Nitrogen in the blood formed in the liver from ammonia produced during the breakdown of amino acids and other nitrogenous compounds - Excreted in urine by the kidney - Normal Range: 8-23 mg/dL - High values: renal disease, dehydration, GI bleeding, high protein intake - Low values: liver disease, over hydration, etc
Indirect Calorimetry
- Indirect calorimetry derives REE by measuring CO2 production and O2 consumption - Weir Equation - converts CO2 production and O2 consumption to REE - REE = 1.106 (CO2) + 3.941 (O2) - RMR is measured at rest (but not sleeping); no activity; fasted state; thermoneutral environment (~23 degrees C for humans)
Skinfold Measurements
- Indirect method of estimating percent body fat - Assumes ~50% of body fat is subcutaneous - Measured in mm with calipers - Take measurements on the right side of the body. - Typically take at least 2 measurements with ~15 seconds between each - Interpreted against percentile tables
Advantages of Anthropometrics
- Inexpensive - Easy to obtain - if devices are calibrated and/or used correctly - Noninvasive - Valuable in combination with other assessment tools - Most valuable when accurate measurements are recorded over time.
Disadvantages of Anthropometrics
- Inherent error in measuring technique (Are devices calibrated? Are you measuring height & weight correctly?) - Tissue variability - Inaccurate application of raw data - Do take into account ethnic, familial and environmental factors!
Usual Daily Intake
- Interview pt about typical consumption habits on average day - Useful tool for assessment of diet quality
Total Parenteral Nutrition (TPN)
- Intravenous administration, via a central venous catheter, of the total nutrient requirements of a patient with gastrointestinal dysfunction. -Used when the GI tract is non-functional (e.g., a bowel obstruction, fistula, etc.) - Associated with more complications than enteral nutrition, so enteral nutrition is preferable if possible. "If the gut works, use it!"
24-Hr Urine Urea Nitrogen (UUN) is not accurate for people with what conditions?
- Large non-urinary nitrogen losses - Diuresis - Fluid retention - Renal failure - Certain medications (e.g., corticosteroids) - Imprecise urine collection
Factors that Affect RMR
- Lean body mass (primarily skeletal muscle metabolism) = primary determinant of RMR - Age - Body size - Gender - Hormones - Temperature - Metabolic stress - Genetics - Other factors: Caffeine and nicotine slightly, transiently increase REE.
No added salt diet
- Least restrictive - regular diets with no salt added
Limitations to the use of serum albumin as a biomarker of malnutrition
- Long half-life (14-20 days) - not a sensitive indicator of recent nutrition - Inflammation, infection, burns, or trauma may cause low albumin levels independent of nutritional status (negative acute phase protein). - Low levels are also seen with fluid retention (hemodilution), ESLD, and heart failure. - Levels may be normal (or even elevated) in patients with starvation (e.g., marasmus, anorexia nervosa). - Levels may be falsely high with blood transfusions or dehydration.
Cardiac Diet
- Low fat (particularly saturated fat), low sodium - Used for patients with cardiovascular disease - May include egg substitutes and increased fruits, vegetables, and fiber - No fried foods - No added salt
Cardiac Diet
- Low fat (particularly saturated fat); low sodium - Used for patients with cardiovascular disease - May include egg substitutes and increased fruits, vegetables, and fiber - No fried foods, No added salt
Hemoglobin (Hb or Hgb)
- Main component of RBC's composed of heme + globulin that is the vehicle for O2 transport in blood - Low Hgb suggests anemia, but it doesn't distinguish the cause (nutrient deficiency, blood loss, or another underlying condition). - Normal range: M 14-18 g/dL F 12-16 g/dL
Hemoglobin (Hb)
- Main component of RBC's composed of heme + globulin that is the vehicle for O2 transport in the blood - Low Hb suggests anemia, but doesn't distinguish the cause (nutrient deficiency, blood loss, another underlying condition) - Normal Range: Men: 14-18 g/dL Women: 12-16 g/dL
Serum Ferritin:
- Main iron storage protein in the body directly proportional to the body's total iron storage pool - Positive acute phase respondent (not reliable during acute/chronic inflammatory states) - Values will be low in iron deficiency - Cytokines increase ferritin synthesis and cause it to leak from RBC's into plasma, artificially raising serum ferritin
Electrolytes - Bicarbonate (HCO3-)
- Major anion in acid-base balance - Normal range: 23-30 (may be identified as CO2 on some lab reports) - Levels regulated by the kidney
Electrolytes - Chloride (Cl-)
- Major anion of extracellular fluid - Normal range: 90-110 - Helps manage fluid balance and acid-base balance - Hypochloremia = low values - Hyperchloremia = high values
Electrolytes - Sodium (Na+)
- Major cation in extracellular fluid - Normal range: 136-145 - Manages water distribution and electrical neutrality - Hyponatremia = <136 - Hypernatremia = >136
Electrolytes - Potassium (K+)
- Major cation in intracellular fluid - Normal range: 3.5-5 - Important for electrical potential across cell membranes - Hypokalemia = low values - Hyperkalemia = high values
Low Fat Diet
- May be indicated for fat malabsorption, GERD, weight loss, etc - Nutritionally complete - Fat restriction may be expressed in grams or % kcal (e.g. 10-15% kcal from fat)
Limitations of FFQs
- May not represent usual foods or portion sizes chosen by pts - Requires a literate population and depends on ability of the subject to describe the diet. - Cannot be used over short time periods
Weight
- Measure of nutritional adequacy - Crude evaluation of overall fat and muscle stores
Creatine Height Index:
- Measure of skeletal muscle mass that requires 24 hour urine collection - Measurement wouldn't be accurate if the person has renal disease or excessive protein intake, or if they have an amputation or paralysis - Normal Range/adequate muscle mass: 80-100% - Moderate deficit: 60-80% - Severe deficit: <60% Serum Creatine Lab Test: sensitive index of renal function; used to calculate GFR (levels below 60 mL for more than 3 months indicate chronic kidney disease) - Normal range: 0.6-1.6 mg/dL - Low value: <0.6 suggests muscle wasting due to aloe deficiency - High value: >1.6 suggests renal insufficiency (or ever dehydration)
Assessing Body Frame Size - Wrist Circumference
- Measure right wrist -Arm flexed at elbow with palm facing upward r= Height (cm)/Wrist circumference (cm)
Assessing Body Frame Size - Elbow Breadth
- Measured with calipers - Patient stands straight with upper right arm perpendicular to body - Forearm flexed to 90 degree angle with palm facing subject - Feel for widest bony width of elbow - Place heads of calipers over this area
Mean Corpuscular Hemoglobin Concentration (MCHC)
- Measures average concentration of hemoglobin in RBC - Can be low due to iron deficiency; cells appear hypochromic
Air Displacement Plethysmogram (BOD POD)
- Measures body volume based on air displacement - Density = mass/volume - We can use measurements of body density to estimate body fat and fat-free mass
Bioelectrical Impedance Analysis (BIA)
- Measures impedance of the body's tissues to an electrical current to estimate body's fat-free mass and fat mass - Pros: Is safe, portable, fast, and relatively inexpensive - Cons: Estimates of body fat are based on regression equations; hydration status may skew results
Total Iron Binding Capacity (TIBC)
- Measures proteins available to bind to iron - Increases with iron deficiency
Mean Corpuscular Volume (MCV)
- Measures the average size of RBC's that helps to differentiate between the different types of anemia - Microcytic anemia: small RBC's characteristic of iron deficiency - Normocytic anemia: RBC's of normal size often associated with anemia of chronic disease (chronic infection, tissue injury) that might be seen in early iron deficiency anemia - Macrocytic anemia: large fragile RBC's characteristic of folate and/or B12 deficiency; pernicious anemia
Mean Corpuscular Hemoglobin (MCH)
- Measures the average weight of hemoglobin in RBC's - Weight can be low due to iron deficiency or blood loss - Weight can be high due to macrocytic anemia (folate or B12 deficiency)
NDD Level 2
- Mechanical Altered -cohesive, moist, semisolid foods, requiring some chewing, cooked fruits or vegetables - NO bread, dry cake, rice, cheese cubes, corn, peas
Normal range Hemoglobin (Hgb or Hb):
- Men: 14-18 g/dL - Women: 12-16 g/dL
Normal range Hematocrit (Hct):
- Men: 42-52% - Women: 37-47%
The Joint Commission (formerly known as JCAHO or Joint Commission on Accreditation of Healthcare Organizations) requires
- Monitoring - Preventing - Counseling for drug-nutrient interactions
Limitations of Retinal binding protein (RBP) as a biomarker of malnutrition
- More expensive than prealbumin and not often used to monitor nutritional status - Decreased values suggest acute catabolism, severe liver disease, zinc deficiency, vit A deficiency - Increased values seen in renal disease
Usual Body Weight (UBW)
- More useful than ideal weight for ill patients - Comparing present weight to UBW allows assessment of weight changes - Dependent on person's memory
Activity Thermogenesis
- Most variable component of TEE - All activity counts - NEAT = non-exercise activity thermogenesis (e.g., fidgeting) - Usually estimate this be multiplying TEE by an energy factor (1.2, 1.3, etc)
Limitations to the use of serum prealbumin as a biomarker of malnutrition
- Negative acute phase protein (hepatic synthesis decreases during an acute phase response) - Levels often normal in "uncomplicated" malnutrition and decreased in well-nourished pts with recent stress/trauma -Levels may increase with corticosteroid medications, oral contraceptives, or pregnancy - Not accurate in renal or liver disease.
Causes of Dysphagia
- Neurological disorders/conditions (MS, Stroke, Alzheimers) - Diseases or conditions affecting head and neck (Head and neck cancer, trauma to swallowing structures) - Developmental problems (premature birth, cerebral palsy) - Aging process - Certain medications
Sodium (Na+)
- Normal range: 136-145 mEq/L - Major cation in extracellular fluid - Manages water distribution and electrical neutrality - Values <136 mEq/L = hyponatremia - Values >145 mEq/L = hypernatremia
Serum Pre-albumin (transthyretin)
- Normal range: 15-36 mg/dl - Negative acute phase respondent (don't rely on this value alone - Values often normal for "uncomplicated malnutrition" and decreased in well-nourished patients with recent stress/trauma Increased values with corticosteroid use, pregnancy, oral contraceptives) - Not accurate with renal or liver disease - Values <15 suggest malnutrition, liver damage, zinc deficiency, or acute inflammation - Short half life of 2 days (more sensitive index of nutritional status than albumin) - Synthesized in the liver
Transferrin Saturation:
- Normal range: 20-40% - Measure of the amount of transferrin bound to iron - Negative acute phase respondent - Levels decrease with iron deficiency - Sensitive test for hemochromatosis (levels increase)
Bicarbonate (HCO3-)
- Normal range: 23-30 mEq/L - Major anion in managing acid-base balance - Levels are regulated by kidney - Note: serum values of bicarbonate may be identified as CO2 on lab reports
Serum Albumin
- Normal range: 3.5-5 g/dl - Major transport protein in the blood - Long half life of 14-20 days (less sensitive index of nutritional status than pre-albumin) - Negative acute phase respondent - Maintains colloid osmotic pressure (waster distribution) - Low levels associated with liver damage - Widely used as a nutrition screening tool in American hospitals but is only fair index of malnutrition (don't rely on this value alone to detect malnutrition) - Synthesized in the liver
Potassium (K+)
- Normal range: 3.5-5.0 mEq/L - Major cation in intracellular fluid - Important for electrical potential across cell membranes - Low values = hypokalemia - High values = hyperkalemia
Normal range Fasting glucose:
- Normal range: 70-99 mg/dL - Diagnostic for diabetes: > 126 mg/dL
Chloride (Cl-)
- Normal range: 90-110 mEq/L - Major anion in extracellular fluid - Helps manage fluid balance and acid-base balance - Low values = hypochloremia - High values = hyperchloremia
C-Reactive Protein (CRP)
- Normal range: < 1.0 mg/dL - Synthesized in liver - Elevated levels reflect any type of inflammation in the body - Reduction in levels marks recovery from inflammatory response
C-reactive protein (CRP):
- Normal range: <1.0 mg/dL - Synthesized in the liver - Positive acute phase respondent - Elevated levels reflect any type of inflammation in the body; reduction in levels marks recovery from inflammatory response
Adequate Intake (AI)
- Nutrient recommendation based on observed or experimentally determined approximation - Sufficient scientific evidence is not available to calculate RDA or EAR
Low-Fat Diet
- Nutritionally complete - May be indicated for fat-malabsorption, GERD, weight loss, etc. - Fat restriction may be expressed in grams or % kcals (e.g., 10-15% kcals from fat)
BMI Percentiles
- Obese: >/= 95th percentile - Overweight: >/= 85th and <95th percentile - Normal Weight: >/= 5th and <85th percentile - Underweight: >5th percentile
In children ages 2 to 19, BMI is assessed by age and sex specific percentiles
- Obese: BMI >/= 95th percentile - Overweight: BMI >/= 85th and <95th percentile - Normal Weight: BMI >/= 5th and <85th percentile - Underweight: BMI > 5th percentile *In children from birth to age 2, the CDC uses a modified version of The Who criteria
Actual Body Weight (ABW)
- Obtained at examination - Can be influenced by fluid status - Weight loss could be from dehydration or nutritional inadequacy - Weight gain could be from edema
Anthropometrics
- Obtaining physical measurements of a patient and relating them to reference standards - Evaluate overnutrition or undernutrition - Monitor effects of nutrition intervention
Normal range LDL cholesterol:
- Optimal: < 100 mg/dL - Elevated risk: 130 mg/dL
Energy needs for the critically ill adults on mechanical ventilators
- PSU(2003b) - Validated in 2009 and also referred to as Penn State equation: RMR = Mifflin(0.96) + VE (31) + Tmax (167) - 6212 - PSU(2010) - Validated in 2010 and also referred to as Modified Penn State equation: RMR = Mifflin(0.71) + VE (64) + Tmax(85) - 3085 - Tmax is maximum body temperature in the previous 24 hours (degrees Celsius); VE is minute ventilation (liters per minute) at the time of measurement read from the ventilator.
Hematocrit (HCT):
- Percent of RBC's in total blood volume; depends on the number of RBC's and their size - Normal Range: Men: 42-52% Women: 37-47%
Signs of Vitamin C Deficiency
- Petechiae - large areas of bleeding or purpura - Fragile bleeding gums - Corkscrew hairs - Poor wound healing -food sources: citrus, peppers, broccoli, strawberries, tomatoes
Estimating Energy Expenditure
- Prediction equations use gender, age, height, and weight to determine REE - Remember, these equations only estimate resting energy expenditure - Only part of the total daily energy expenditure - Must multiply by an activity factor - Two equations widely used are Harris-Benedict and Mifflin St. Jeor -don't consider TEF because it is only ~10%
Neutropenic Diet
- Prescribed for patients with immune impairment (e.g., receiving chemotherapy, pre-bone marrow transplantation, post-transplantation, acute AIDS crises) and lower than normal neutrophil counts (neutropenia) -Diet designed to limit ingestion of bacteria and other organisms on food. - Somewhat controversial
Neutropenic Diet
- Prescribed for patients with immune impairment (receiving chemotherapy, pre bone marrow transplant, post transplant, acute AIDS crisis, etc) and lower than normal neutrophil counts (neutropenia) - Diet is designed to limit ingestion of bacteria and other organisms on food; somewhat controversial - Restricts: All uncooked vegetables and most uncooked fruits - Raw or rare cooked meat, fish, eggs - Raw dairy & soft mold ripened cheeses - Fresh ground spices - Patients should avoid salad bars, fruit bars, and deli counters
PES format
- Problem (diagnostic label): Describes alterations in the clients nutritional status (Must use standardized terms from the NCP) - Etiology: Cause of the problem - Signs or Symptoms (S/S): Defining characteristics— Indicate presence of the problem *Problem—related to—Etiology— as evidenced by—Signs or Symptoms*
Bilirubin
- Produced from the breakdown of RBCs; normally passed on to liver where it is excreted in bile - Elevated blood levels may indicate liver damage
Goals of the Dietary Guidelines for Americans
- Promoting adequacy of nutrient intake - Reducing risk of diet-related disease
Things to remember with Anthropometric measurements
- Proper technique is important: establish measurement accuracy, several clinicians take same measurement and compare results - Can take >20 times to become proficient
Nutrient Intake Analysis (Calorie Count or Plate Waste Study)
- Prospective data - Practical only in an institutional setting (not an outpatient setting) - Identify & document dietary inadequacy - 48- or 72-hour collection of all food/fluid intake - Obtained by documenting food/fluid left on a tray after a meal - Direct Observation/Meal Rounds (Optimal to identify physical difficulties affecting intake)
Normal range HDL cholesterol:
- Protective: >60 mg/dL - High risk for men: < 40 mg/dL - High risk for women: < 50 mg/dL
Serum Transferrin:
- Protein that transports iron in the blood - Increases with iron deficiency - Inversely proportional to transferrin saturation
Full Liquid Diet
- Provides liquids that are either clear or opaque (Whole milk, custard, pudding, strained cream soups, eggnog, ice cream, Ensure/Boost) - Fat and lactose may be a problem - Liquefied solids may be provided (Potato soup) - Commonly used as transition from clear liquid to solid food; post-surgery, GI irritation, etc. - Can be nutritionally complete
Daily Food Record/Diary
- Pt documents dietary intake as it occurs - Prospective data - Usually completed by the client - Often used in outpatient clinic settings - Food and amounts eaten should be recorded at the time of consumption - record food as its consumed or shortly thereafter - Include preparation, serving size - Encourage client to use scale, measuring cups/spoons, or portion size guide - Electronic food diaries and smart phone apps may ease respondent burden - Usual length: 3-Day or 7-Day (accuracy declines with longer duration, include a weekend day, individual may alter diet due to recording process)
NDD Level 1
- Pureed - homogenous, very cohesive, pudding-like, requiring very little chewing ability - pureed chicken, mashed potatoes, gravy, pureed carrots, pureed broccoli, chocolate pudding
Low Residue Diet
- Purpose is to significantly decrease fecal volume and promote bowel rest - Prescribed for acute inflammatory states, partial obstructions, bowel preps, etc - Provides very little fiber - eliminates fibrous fruits + veggies, whole grain products, legumes, meat and shellfish with tough connective tissue - Remaining fecal matter is bacteria and sloughed GI cells
Example of evidence-based goals:
- Reduce percentage of total calories from fat to 20-35% per day - Eat out 2x/wk (instead of 6x/week). - Pack a lunch the night before to take to work each day *Set client driven, behavioral/lifestyle changes to help client achieve goal*
Interpretation of Height & Weight
- Reference standards based on statistical sample of US population - Individual measurements compared to standard population, not an established standard - Useful in determining nutrition status in adults
Goals of the Diet Order
- Restore nutrient status and affected organ - Accommodate an altered GI function and altered nutritional needs
Goals of the "Diet Order"
- Restore nutritional status - Rest or relieve affected organ - Accommodate altered GI function - Accommodate altered nutrient needs
The 24-hour Recall
- Retrospective/Collects information on everything eaten in the previous 24- hour day (i.e. everything eaten yesterday) - One day may not be an accurate indication of a person's typical dietary intake - An average of 3 days is optimal (2 weekdays and 1 weekend day). If you are only able to collect 1 day, then inquire about whether that was a "typical" day
Diet History
- Review of an individual's typical food patterns and food selection - Aversions / intolerances - Physical and/or social barriers affecting intake - Cultural or religious dietary practices - Potential food-drug or supplement-drug interactions - Fad diets or distorted, disordered eating - Usual daily intake
Diet History
- Review of an individual's typical food patterns and food selection - Aversions / intolerances - Physical and/or social barriers affecting intake - Cultural or religious dietary practices - Potential food-drug or supplement-drug interactions - Fad diets or distorted, disordered eating - Usual daily intake - Any dietary history
Vitamin D Deficiency
- Rickets in children - Osteomalacia in adults - Many other more subtle s/s (muscle weakness, HTN, etc.) -food sources: milk
Thermic Effect of Food (TEF) or Diet-induced Thermogenesis
- Rise of metabolic rate above basal level after eating - Reflects the energy expended to digest, metabolize, and store food - ~10% of TEE - Not very practical to measure
Lab Tests for Iron deficiency anemia
- Serum iron - Serum ferritin - TIBC - Transferring saturation - Soluble transferri receptor
Retinol Binding Protein (RBP):
- Serum protein sometimes used as a biomarker of nutritional status - Normal range: 2.6-7.6 mg/dL - Synthesized in the liver - Binds with pre-albumin to transport retinol (vitamin A) in the blood - Very short half life (10-12 hrs)
Simplified Portable RMR Measurement System
- Similar methodology as the metabolic cart, but it only measures O2 consumption - Assumes a standard RQ of 0.85 - Not used for research, but provides a clinically acceptable measurement of RMR
Body composition prediction methods
- Skinfold thickness - Circumferences - Bioelectrical Impedance Analysis (BIA) Robust - better measurement - Underwater weighing - Bod Pod -Dual Energy X-ray Absorptiometry (DXA)
Frame size adjustment for Hamwi Formula
- Small frame: subtract 10% from IBW - Large frame: add 10% to IBW
Indicators of normal oral health
- Smooth lips without sores - Dull red tongue without swelling - Normal taste/smell - Normal gums and teeth • Note any lesions, swelling, or bleeding. • Note any teeth that are missing, cracked, or in poor condition.
Psychosocial factors that may influence nutritional intake:
- Socioeconomic status - Food procurement - Functional ability to perform ADLs - Hx of drug or EtOH dependency - Social support system - Cultural food practices
Carbohydrate Counting - Sugar alcohols
- Sorbitol, manitol, xylitol are partially absorbed -When counting CHO for products made with sugar alcohols, you can subtract half of the grams of sugar alcohol listed on the food label from the total grams of carbohydrate.
Regular Diet
- Standard, house, general, full diet, nutritionally adequate - Patient has no dietary restrictions, no modifications
Direct methods of height measurements
- Statiometer (stadiometer) or measuring rod - Person must be able to stand
Estimating Protein Requirements
- Stress of illness increases catabolism causing negative nitrogen balance - Increased protein breakdown = Increased protein requirement - Diet therapy should focus on providing adequate energy to spare protein for synthesis of tissue
Ideal Body Weight/Hamwi formula - Frame Size Adjustment:
- Subtract 10% for small frame - Add 10% for large frame
Physical Examination - Palpation
- Tactile examination to feel pulsations, organs, masses, or infiltration - Deep palpation will not frequently be a part of nutrition assessment, but it is important to be able to interpret the results of exams by other members of the healthcare team
Normal range Hemoglobin A1c (HbA1c):
- Target range for good glycemic control in a diabetic pt: < 7%
Estimated Average Requirement (EAR)
- The daily intake level estimated to meet the nutrient requirement of 50% of healthy individuals in a life stage and gender group - Only used to assess nutrient adequacy of populations
Viscosity Types
- Thin: water, milk, juice, coffee, tea, carbonated drinks, gelatin, ice cream, broth bases soups - Nectar thick: fruit nectars, maple syrup, ensure, eggnog, some cream based soups - Honey Thick: honey - Spoon thick: pudding
Clear Liquid Diet
- Transition from NPO to regular foods; commonly used after surgery - Minimizes digestive work and gut residue - Nutritionally inadequate (only 600-900 kcal and little protein) - Only intended for 3-4 days of use - Broth, gelatin, strains fruit juices, clear beverages, popsicles, enlive, resource breeze
Most common skin fold measurement areas
- Triceps skinfold (TSF) - Biceps - Subscapular - Suprailiac -Upper thigh
Body Composition
- Two-compartment model of body composition = fat mass and fat-free mass - Not always applicable in acute or critical care settings - Validity depends on the accuracy of the measuring technique - Changes in body composition are gradual. - Best detected when multiple measurements are taken over a long period of time (Typically 3-4 wks to see change in body composition)
Dual-Energy X-ray Absorptiometry (DXA)
- Typically used to assess bone mineral density - Fat and lean tissue compartments are also measured in the process - Commonly used in research setting to quantify fat mass and fat-free mass.
Kosher prepared products are identified with an emblem on the package
- U = Union of Orthodox Jewish Congregations of North America - K = Organized Kashrus Laboratories
Anthropometric weight measurement
- Use calibrated scale - Weigh same time, same day, same type of clothing - No shoes, outer jackets or wallets
Anthropometric height measurement
- Use stadiometer or wall tape - No shoes or caps - Read at eye level
Measuring Length/Height - Recumbent lengths
- Used for infants, children who cannot yet stand - Plot recumbent lengths for children on Birth-to-24-Month growth chart - Also for comatose, critically ill, and those unable to be moved - Not indicated for patients with musculoskeletal irregularities or contractures
Renal Diet
- Used for patients with renal failure and is highly variable in hospital settings - Controlled amounts of fluid and protein - Limit potassium (bananas, tomatoes, potatoes, salt substitute, chocolate, greens), sodium, and phosphorus (dairy, dark sodas, dry beans and peas, whole grains)
Full Liquid Diet
- Used to transition from clear liquid to solid foods - Provides liquids that are either clear or opaque - Fat and lactose may be a problem - Liquified solids can be provided - Can be nutritionally complete - Examples: Whole milk, custard, pudding, strained cream soups, eggnog, ice cream, ensure/boost, liquified potato soup
Use of Dietary Intake Methods
- Useful for one-on-one with patients or clients in counseling practice - Formal methodology well-suited for collecting clean, valid data for large number of persons (Research studies, NHANES, etc.)
Head Circumference
- Useful in children birth to 24 months - Indicator of non-nutritional abnormalities - Malnutrition must be very severe to affect head circumference - Can be followed on growth charts
Circumference Measurements
- Waist Circumference - Mid-arm Circumference (MAC - arm muscle area AMA, arm fat area AFA) - Head Circumference - in children up to 3 years of age - Calf Circumference (proxy of muscle loss in older adults)
Some things to note about height and weight measurements:
- Weight is a more sensitive measure of nutritional adequacy than height. - Tendency of most people to overestimate height + underestimate weight = underestimated BMI - Height may be decreased in older adults.
Most common specimen types for analysis of nutrients and nutrient-related substances
- Whole blood (RBCs, WBCs, platelets) - Plasma (liquid component of blood) - Serum (fluid after blood clotted) - Blood cells - Erythrocytes (RBCs) - Leukocytes (WBCs) - Urine - Feces
Glycosylated Hemoglobin (HbA1c)
- a measure of how much glucose adheres to hemoglobin of red blood cells. The higher a person's blood glucose, the higher his Hb A1C - good estimate of long-term glycemic control. - Normal HbA1c for someone without diabetes = < 5.7% -Monitors effectiveness of diabetes therapy over the past few months: - HbA1c < 7% in diabetics is considered good glycemic control
Serum Ferritin
-Primary iron storage protein in body directly proportional to body's total iron storage pool -Not reliable in acute or chronic inflammatory states (positive acute phase respondent) - Cytokines increase ferritin synthesis and cause it to leak from RBC's into plasma, artificially raising serum ferritin
First Steps to the Nutrition Focused Physical Exam
-Review medical record, labs, H&P, etc -Introduce yourself, and explain why your here -Ask the patients permission before starting the assessment and explain what to do with each step -Identify their concerns
Respiratory Quotient (RQ)
-Substrate metabolism is indicated by the RQ.; RQ = vCO2/vO2 i.e., the ratio of CO2 produced to O2 consumed - Determines proportion of energy coming from fats and carbohydrates -Typically it is a mixture of carbohydrates and fats that are being used for energy...not just one
Areas for inspection for subcutaneous muscle loss
-Temporal area -Clavicles -Side of Shoulders (deltoid muscles) -Triceps -Chest -Hands -Quadriceps (check for muscle wasting)
Head circumference measurement guidelines
-ages 2mo to 7 yo -infant held on parent lap -hair things should be removed -technician on right side of child - around head, tape extends above ears -objective is to find the largest portion of the head -recorded to nearest mm
waist circumference guidelines
-bony landmark noted and mark (palate the hip bone o locate the right illium, mark) -place measuring take around trunk at mark, make sure level and horizontal -tightened slightly without pressing skin -recorded in cm to nearest mm
Subscapular Skinfold measurement guidelines
-mark each side on right side the body -subject standing upright, shoulders relaxed, arms hanging loosely at sides -technician stands behind and gently palpates the lower tip of the triangular bone -skinfold lifted up 2 cm or 3/4 of inch above the point where caliper will be placed -separate muscle and fat -calipers placed perpendicular -measure after 3 seconds -measured in mm to nearest tenth **note if fat and muscle can not be separated. cannot record measurements**
Tricep Skinfold measurement guidelines
-measured on right upper arm at point previously marked -shoulders relaxed, hanging at sides -technician behind the patient, pinch just above the mark
knee height guidelines
-only on adults age 60+ years -legs dangle freely off table -measured from foot to knee -foot is raised slightly by technician -recorded in cm to nearest mm
Areas for inspection for subcutaneous fat loss
-orbital region (surrounding the eye) -upper arm region (triceps) -Thoracic and lumbar region (ribs, lower back, midaxillary line)
Suprailiac Skinfold measurement guidelines
-point anterior to the waist circumference mark -standing with feet together -place thumbs at intersecting marks, and above the mark, grab skin and separate subcutaneous fat from muscle -apply calipers
thigh Skinfold measurement guidelines
-same placement/positioning as thigh circumference measurement -right thigh at point previously marked -most weight on left leg, soles flat on floor -skinfold taken up just above mark, 2 cm from fingers
Upper leg length guidelines
-sit on measuring table with legs freely dangling - sliding caliper positioned on the distal end of the femur on both sides of the patella. draw line above the caliper tool to signify where measurement should end - horizontal bar should touch interior surface of the thigh -place measuring tape at crease just below anterior superior iliac spine -measure from crease to line -subject should raise thigh slightly to ensure correct length -taken to nearest mm and divided by 2 to indicate the midpoint
buttocks circumference guidelines
-stand upright with feet together and weight evenly distributed -tighten pants fabric -technician on right side at eye level of the hip region -tape goes around largest point of buttocks -recorded in cm to nearest mm
Standing Height measurement guidelines
-standing height -hair ornaments, buns, etc should be removed - toes pointed slightly outward at 60 degree angel, feet flat on floor, look straight ahead. - contact points: heels, buttocks, shoulder blades, back of head -frankfort plane: eyes & ears in straight line -deep breathe to allow spine to straighten -headboard lowered to head -recorded to nearest mm
Arm circumference guidelines
-standing measurement -right arm hanging loosely no flexing -stand on right side, measuring tape around arm at mark, not tightly -recorded to nearest mm
thigh circumference guidelines
-step back with left food to shift -right leg forward and slightly bent not holding weight -measure where mark is, tighten slightly but dont press skin -recorded in cm to nearest mm
Elbow breadth measurement guidelines
-subect stands facing technician -right arm extended forward to form 90 degree angel, fingers point up -technician palpates those two bones, soft tissue compressed firmly -measured in cm to nearest mm
Sitting height measurement guidelines
-subject sits on box with posterior buttocks, shoulder blades, and head touch backboard -head positioned in Frankfort plane -deep breath and sit up tall -recorded to nearest mm
Biacromial breadth measurement guidelines
-subject sits upright, shoulders relaxed, hands on lap -technician stands behind, measured lateral borders of shoulder bones -pressure applied -measured in cm to nearest mm
Biiliac breadth measurement guidelines
-subject standing upright with feet together and waist exposed -technician stands behind subject -measure at the borders of the iliac, soft tissue compressed firmly -measured in cm to nearest mm
Wrist breadth measurement guidelines
-subject standing, arm extends right arm to front, palm of the hand down -caliper held between thumbs and index fingers -palpate to find the bones, gently tighten soft tissue -recorded to nearest mm
Recumbent length height measurement guidelines
-used for children under 3 yo - parent encourages and comforts child who is restless -support head in Frankfort plane -leg alignment, toes pointed upward with soles perpendicular to foot piece -recorded in cm to the nearest mm
Healthy individuals have a ______ nitrogen balance
0
What is the DRI for protein?
0.8 grams of protein per kilogram of body weight, or 0.36 grams per pound.)
RDA values (grams/kg/day) for Protein - Male & Female ages greater than 19 yrs
0.80 g/kg/day
RDA values (grams/kg/day) for Protein - Male & Female ages 14-18 yr
0.85 g/kg/day
RDA values (grams/kg/day) for Protein - Male & Female ages 3-13 yr
0.95 g/kg/day
Exchange Type and Amount - Sugar, 1 Tbsp
1 CHO
Exchange Type and Amount - Cookies, 2 small or 1 large
1 CHO, 1 fat
Exchange amount for legumes (starchy beans)
1 Starch Exchange, 1 Lean meat
1 ½ oz distilled spirits (vodka, gin, rum) =
1 alcohol eq.
5 oz dry red/white wine =
1 alcohol eq.
12 oz regular beer (4.9%) =
1 alcohol eq. + 1 CHO
12 oz light beer (4.2%) =
1 alcohol eq. + ½ CHO
Gram to mg conversion
1 gram = 1000 mg
Liter to mL conversion
1 liter = 1000 mL
A patient reports eating the following foods that he counts as "free foods" from the exchange lists: garlic, fat-free cream cheese, sugar-free hard candy, and angel food cake. Which of the foods would you tell the patient is not a free food on the exchange lists?
1 slice of angel food cake
According to the exchange lists, which of the following would count as one starch exchange (15 grams of carbohydrate)?
1 slice of bread 1/3 cup pasta 1/2 cup corn
Iron deficiency anemia stages
1) Decreased iron stores - reduction in serum ferritin concentration 2) Early functional deficiency - increased soluble transferrin receptor levels 3) Iron deficiency anemia - decreased hemoglobin, MCV, and transferrin saturation
What are the four stages in the patient interview?
1) Preparation 2) Initiation 3) Maintenance (Communication, Control) 4) Termination
Collecting a 24-hour Recall: 1st pass
1st pass = quick list - This is a quick, first pass where you get general foods - "What's the first thing you had to eat yesterday"? - "What's the next thing you had after that."? Etc., etc. - Think of it like a grocery list. You won't gather a lot of detail on the first pass. - You will gather information such as "I drank 1 glass of milk," or "I had a tuna salad sandwich."
For the purposes of carbohydrate counting, how many servings of CHO would a meat sandwich with two pieces of bread contain?
2
Exchange Type and Amount - Frosted cake, 2 x 2 inch square
2 CHO, 1 fat
1 apple, 2 tablespoons peanut butter, 1/3 glass grape juice =
2 Fruit, 2 High-Fat Meat
Meal consumed: 2 slices toast, 1 tablespoon peanut butter, 8 oz fat-free milk =
2 Starch Exchanges, 1 High-Fat Meat Exchange, 1 Fat-Free Milk Exchange
3 oz chicken breast (no skin), 2/3 cup pasta, 1 cup cooked green beans =
2 Starch, 3 Lean Meat, 2 Vegetable
Complementary proteins
2 or more proteins that provide all of the essential amino acids when eaten together (do not need to eat them together)
Basic starting point for a diabetic meal plan
2-3 servings of non-starchy vegetables 2 servings of fruit 6 servings of grains, beans, and starchy vegetables 2 servings of low-fat or fat-free milk ~6 oz meat or meat substitutes Adjusted accordingly for specific kcal needs
You calculate your patient's energy needs as 1910 kcals/day. Together, you decide that 45% kcals from CHO would be a good goal. How many grams of CHO do you recommend each day?
215 g/day
Collecting a 24-hour Recall: 2nd pass
2nd pass = Get Details - How much milk did you drink? What kind of milk was it? - What kind of bread was your sandwich made of? What was in the tuna salad? How much did your spread on your sandwich? Did you eat all of the sandwich? - How was the food prepared? Fried in what type of oil? - Was there any ice in the beverage? (decreases calories by 1/3) - Was the skin left on the poultry / fat trimmed off of the meat? - Did you drink the milk left in the cereal bowl? Be sure to ask about the time, location, portion size, and preparation of each food item.
Stouffer's Frozen Lasagna lists the following values per serving on its Nutrition Facts Panel: 560 kcals, 27 gm fat, 1560 mg sodium, 45 gm CHO, 27 gm pro, 115 mg chol, and 5 gm fiber. How many CHO servings would your patient with diabetes count for a serving of this entrée?
3
Exchange Type and Amount - Fruit pie, 2 crusts, 1/6 of 8 inch pie
3 CHO, 2 fat
The normal range for albumin.
3.5 - 5.0 g/dL
Normal range - Serum Albumin
3.5-5 g/dL
How many calories in CHO?
4
How many calories in PRO?
4
Women ideal body weight per the Hamwi Formula
45.5 kg + 2.2 kg per every inch over 5 feet.
1 Nonstarchy Vegetable Exchange =
5 g CHO, 2 g Pro, 25 kcal
1 Fat =
5 g Fat, 45 kcal
Unintentional wt loss is: Significant if =
5% in 1 month 7.5% in 3 months 10% in 6 months
Albumin makes up ______% of plasma proteins.
60%
Normal resting heart rate
60-100 bpm
Your patient is a 62 YO F admitted with 38% TBSA (total body surface area) 3rd degree burns. She weighs 145 lbs and is 5'4". Estimate her current protein needs. 65.9 kg
65.9 kg x 1.5 g/kg = 99 g 65.9 kg x 2 g/kg = 132 g
How many calories in Alcohol?
7
1 Lean Meat =
7 g protein, 0-3 g fat, 45 kcal per ounce
1 Medium-Fat Meat =
7 g protein, 4-7 g fat, 75 kcal
1 High-Fat Meat =
7 g protein, 8+ g Fat, 100 kcal
A slice of bread is 80 kcals and has 15 grams of carbohydrates. What percentage of kcals in the bread comes from carbohydrates?
75% of the calories in this piece of bread come from CHO
How many calories in FAT?
9
Optimal levels of LDL
< 100 mg/dL Optimal
Total cholesterol levels
< 200 mg/dL = desirable 200-239 mg/dL = borderline high 240 >/= is High/hypercholesterolemia
Normal range C-reactive protein (CRP)
<1.0 mg/dL
Interpreting levels of Triglycerides:
<150 mg/dL Normal 150-199 mg/dL Borderline 200-499 mg/dL High > 500 mg/dL Very High
Bradycardia resting heart rate
<60 bpm
Percent Ideal Body Weight
= (ABW/IBW) x 100 - Desirable range is 90-110% - Deviation from optimal range could suggest under or over nutrition
Percent of Usual Weight
= (ABW/UBW) x 100 - 85-90% UBW suggests malnutrition - 75-84% UBW suggests moderate malnutrition - <74% UBW suggests severe malnutrition
Percent Weight Change
= (UBW-ABW)/UBW x 100
Percent of Usual Weight
= (actual weight/usual weight) x100 - 85% to 90% UBW: may suggest mild malnutrition - 75% to 84% UBW: may suggest moderate malnutrition - <74% UBW: may suggest severe malnutrition
Tachycardia resting heart rate
> 100 bpm
Elevated levels of LDL
> 130 mg/dL Elevated Risk
Unintentional wt loss is: Severe if =
>5% in 1 month >7.5% in 3 months >10% in 6 months
Decide where the statement would be placed in an ADIME. Note: Pt exhibits marked wasting of muscle and fat, suggestive of protein-calorie malnutrition.
A - assessment
What is a National Provider Identifier (NPI)?
A National Provider Identifier (NPI) is a unique number required for healthcare providers who independently bill the Center for Medicare and Medicaid Services (CMS). It is ten digits in length and is unique to each individual who applies.
carotenodermia
A benign side effect of high beta-carotene intake; a condition characterized by yellowing of the skin.
Drug/nutrient interaction
A drug affects the action of a nutrient in the body. (ex corticosteroids and calcium metabolism)
Common drug-nutrient interactions: Methotrexate (MTX)
A folic acid antagonist • Commonly prescribed to treat cancer and rheumatoid arthritis • Inhibits an enzyme (dihydrofolate reductase) that converts folate to its active form • A special form of folic acid (reduced form that requires no activation) is commonly given with methotrexate to prevent megaloblastic anemia.
Food/drug interaction
A food, or one of its components, interferes with the therapeutic action of a drug in the body. (ex vitamin K and coumadin)
Subjective Global Assessment (SGA)
A method of rating a patient's nutritional status based on: - features of a medical hx (recent weight loss, changes in diet, presence of GI symtpms, and patients functional capacity) - physical exam (Loss of subcutaneous fat, Muscle wasting, Presence of edema or ascites) - Categories of nutritional status = A (nourished), B (mildly malnourished), C (severely malnourished) - edema assessed in the ankles
Cultural Competence
A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in crosscultural situations
Scurvy
A vitamin C deficiency disease marked by bleeding gums, weakness, loose teeth, and broken capillaries under the skin.
jaundice
A yellowing of the skin and eyes; caused by blockage of bile duct, hepatitis, cirrhosis
Xerosis
Abnormal dryness of skin and mucus membranes; Could signal dehydration or insufficient protein,vitamin A, niacin, etc.
azotemia
Accumulation of BUN and creatinine in blood
Hand care
Actions to prevent skin irritation.
Ideal Body Weight/Hamwi formula - Obesity Adjustment:
Adjusted ideal body weight (AIBW) is calculated as follows: Men: AIBW=[(actual weight-IBW)´0.38]+IBW Women: AIBW=[(actual weight-IBW)´0.32]+IBW
Your patient is taking a monoamine oxidase inhibitor for depression. Which foods should he avoid to prevent a hypertensive crisis?
Aged cheeses and fermented soy foods
Liver Function Tests (LFTs)
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST), Alkaline Phosphatase (ALP), Bilirubin
Prospective Medical Nutrition Therapy for Food-Drug Interactions
All education offered when the patient first starts a drug
Body fluids
Blood; excretions like urine, faeces, vomit; meconium; lochia; secretions like saliva, tears, sperm, colostrum, milk, mucous secretions, wax, vernix; exudates and transudates like lymphatic, pleural fluid cerebrospinal fluid, ascitis fluid, articular fluid, pus (except sweat); organic samples like tissues, cells, organ, bone marrow, placenta.
Cyanosis
Bluish color to the skin or mucus membranes that is usually due to a lack of oxygen; Could signal a lung or cardiovascular disorder (or an eating disorder)
Educating Our Patients to be Wise Consumers when purchasing supplements
Buyer Beware of: •Claims that sound too good to be true and terms such as "miraculous cure" and "secret ingredients." •Products or diagnostic tools advertised as quick and effective for a wide variety of ailments. •Advertisements based on amazing testimonials of a few people. •Advertisements that claim products or therapies are "clinically proven" but lack references to support those claims. •"Limited time offers" and advance payment requirements. •Health information from websites that are selling products or products sold by multilevel marketing pyramid models.
Initial classification of anemias begins with the
CBC (complete blood count)
White blood cell count "with differential" (CBC with diff)
CBC test that provides the number and types of WBCs (neutrophils, lymphocytes, monocytes, eosinophils, and basophils) that may help clinicians pinpoint the type of infection a pt may have (e.g., bacterial vs viral)
Energy in food can be estimated by Atwater Equivalents
CHO = 4 kcals/g PRO = 4 kcals/g FAT = 9 kcals/g ETOH = 7 kcals/g
You estimate your client's energy needs as ~1900kcals/day. How many grams of carbohydrate should she consume for a goal of 55% kcals from carbohydrate?
CHO intake should be around 262 g/day
Consistent intake of what kind of foods is best for diabetics?
CHO; and eat with protein
Ideal Body Weight/Hamwi formula - Amputee Adjustment:
Calculate and subtract the percentage of total body weight contributed by individual body parts: Entire leg (and foot): 18.5% Above the knee: 13.0% Below the knee: 6.0% Foot: 1.8% Entire arm (and hand): 6.5% Forearm (and hand): 3.0% Hand: 1.0%
Wat major foods affect blood glucose levels
Carbohydrates (starch, fruit, milk) are the major foods that affect blood glucose levels
Anemia
Characterized by reduced number of RBC's OR decreased hemoglobin content of blood (not a disease but a symptom) *oxygen carrying capacity of the blood is decreased
Anemia
Characterized by reduced number of RBC's or decreased hemoglobin content of the blood; not a disease but a symptom in which oxygen carrying capacity of the blood decreases
Nutrition Assessment
Completed by Registered Dietitian (RD or RDN); Step 1 of the Nutrition Care Process (NCP); Purpose is to gather information in order to make a judgment about nutrition status
The foundation of diabetes meal planning is:
Consistent CHO intake throughout the day.
When would hair specimen samples be used?
Could be used to test for heavy metal toxicities or certain trace minerals - Results could be easily confounded by external contaminants
Critical site
Critical sites are associated with risk of infection. They either correspond to body sites or medical devices that have to be protected against harmful germs (called critical sites with risk of infection for the patient), or body sites or medical devices that potentially lead to hand exposure to body fluids and bloodborne pathogens (called critical sites with body fluid exposure risk).
Traditional Health Beliefs and Practices:
Culture can also determine how a person defines health, recognizes illness, and seeks treatment.
Moon-shaped face
Cushing's syndrome; PCOS
In which section of an ADIME note would your PES statement be documented?
D - Nutrition Diagnosis
All of the following are common side effects of corticosteroid medications except:
Decreased appetite and weight loss
Skin turgor
Decreased turgor may signal dehydration.
Transferrin saturation ________ with iron deficiency and _________ with hemochromatosis.
Decreases; Increases
Dietary history should include
Economics / food procurement, Physical activity, Ethnic or cultural background, Home life and meal patterns, Appetite, Attitude toward food and eating, Allergies, intolerances, or food avoidances, Dental and oral health, Gastrointestinal factors, Chronic disease, Medication, supplements and herbal remedies, Recent weight changes, Dietary or nutritional problems (as perceived by the pt)
Most Common Food Allergies - Infants and children
Eggs, Fish, Milk, Peanuts, Soy
The Beers Criteria provide guidance for clinicians to weigh the risks and benefits of prescribing certain medications to:
Elderly adults
Signs of Iron Deficiency
Fatigue, Pallor/pale skin , Koilonychia, Stomatitis -heme iron: animal foods -non heme iron: plants -spinach, raisins, iron cookware
Buffalo Hump
Fatty pad or hump between the shoulders; Cushing's Syndrome; Body produces excess cortisol
Types of tests using stool samples
Fecal fat, Fecal occult blood test, Tests for pathogenic bacteria, viruses, or parasites
Primary storage protein for iron in the body
Ferritin Low in iron deficiency
Collecting a 24-hour Recall: Final pass
Final pass = Forgotten foods and dietary supplements - Read through your list one last time with the client, asking about anything he/she may have forgotten. - Ask about "night eating." Inquire about vitamins, minerals, herbs, or any other dietary supplements.
Most Common Food Allergies - Adults
Fish, tree nuts, peanuts, shellfish, wheat
Roadblocks in Obtaining Dietary Intake Data
Focus on the diet = people consciously or unconsciously alter intake - Obese individuals = more likely to underreport - Underweight individuals, older adults, and pts with eating disorders = more likely to over-report - Respondents may try to simplify recording or impress interviewer (Affects validity of data)
A cancer patient taking methotrexate may need supplemental:
Folate
The cancer chemotherapy agent methotrexate acts as an antagonist to:
Folate
Food/Nutrition- Related History
Food and nutrient intake, food and nutrient administration, medication, complementary/alternative medicine use, knowledge/beliefs, food and supplies availability, physical activity, nutrition quality of life
Monitoring and Evaluation
Determine degree of progress being made toward goals or desired outcomes
Food Frequency Questionnaire (FFQ)
Determines how frequently foods or food groups are consumed. - Pt chooses a frequency for which each food is eaten. - Often used in conjunction with 24-Hour Recall - Review of food consumed per day/week/month - FFQ organizes foods into groups with common nutrients Most FFQs include questions on portion sizes and cooking methods
Long-term use of antibiotics often causes which of the following side effects?
Diarrhea
Gastrointestinal side effects of Antibiotics
Diarrhea - when normal flora of the large intestine are destroyed by the antibiotics, opportunistic pathogens (such as clostridium difficile) can colonate.
Which of the following statements is true concerning dietary supplements?
Dietary supplement manufacturers are required to follow Current Good Manufacturing Practices (CGMPs).
Ultrasound and Magnetic Resonance Imaging (MRI)
Does not use ionizing radiation - not common, very expensive
Pressors
Dopamine, Histidine, Tyramine Tyramine acts as vasoconstrictor that raises blood pressure
Drug Interactions can occur as
Drug to Food Drug to Drug Drug to Supplement Drug to Alcohol
Determining fluid needs: 30-35mL per weight in kg
E.g., 30yo female weighs 70 kg - 70kg x 30 mL = 2100 mL of fluid - 70kg x 35 mL = 2450 mL of fluid
Determining fluid needs: 1 mL fluid per calorie consumed
E.g., You determine that a pt's energy needs are 2200 kcal/day. - 2200 kcal x 1 mL = 2200 mL of fluid per day
Premise of the Exchange System
Foods grouped into basic types — starches, fruits, milk & milk products, meat & meat substitutes, fats, etc. The patient is given a meal pattern based on calorie needs. The meal pattern specifies how many of each group can be eaten at a given meal or snack. Patients can exchange or trade foods within a group because they're similar in nutrient content and the manner in which they affect blood glucose.
Common drug-nutrient interactions: Corticosteroids (e.g. prednisone)
May be prescribed for COPD, rheumatoid arthritis, autoimmune diseases, etc. Many nutrition-related side effects: • Hypercalciuria - Calcium and vitamin D supplements are recommended with long-term corticosteroid therapy. • Sodium and fluid retention • Hyperglycemia • Hyperphagia and weight gain • Dyspepsia
Measures the average weight of Hb in RBCs
Mean Corpuscular Hemoglobin (MCH) Low in iron deficiency High in B-12 or folate deficiency
MCHC (Mean Corpuscular Hemoglobin Concentration)
Measures average concentration of Hb in RBC - Could be low due to iron deficiency (cells appear hypochromic)
MCV (Mean Corpuscular Volume)
Measures average size of RBC that helps differentiate normocytic, microcytic, and macrocytic anemia - Low in microcytic anemia (smaller than normal RBC's) - High in macrocytic anemia (larger than normal RBC's)
MCH (Mean Corpuscular Hemoglobin)
Measures average weight of Hb in RBC expressed as picograms/cell - Can be low due to iron deficiency or blood losses - Can be high due to macrocytic anemia (e.g., folate or B-12 deficiency)
Which of the following medications would likely increase appetite?
Megestrol acetate (Megace ®) Oxandrolone (Oxandrine ®) Dronabinol (Marinol®)
Urinalysis
Microscopic examination of urine sediment that assess appearance of the urine and detects substances or cellular material in urine; can indicate metabolic or kidney disorders -testing done with dipstick
Indication for hand hygiene
Moment during health care when hand hygiene must be performed to prevent harmful germ transmission and/or infection.
Cured meats, aged cheeses, and soy sauce should be avoided by a patient taking:
Monoamine oxidase inhibitors (MAOIs)
Food Allergies
Most common - Adults: Fish, tree nuts, peanuts, shellfish, wheat Most common - Infants & Children: Eggs, fish, milk, peanuts, soy
Additional side effects of radiation for head and neck CA
Mucositis and oral lesions, Xerostomia, Dysphagia
Which method is most accurate in collecting a 24-hour recall?
Multi-pass method
Someone who is _________ would most likely fast during the holy month of Ramadan.
Muslim
A hemoglobin value of 13 g/dL would be:
Normal for a female but low for a male
Conditionally essential amino acids
Not essential in normal conditions, but the body may be incapable of producing adequate amounts of these amino acids during times of illness and stress
The Plate Method can be appropriate for
Older adults, Patients overwhelmed with new DM diagnosis, Low-literacy levels, Cognitive difficulties, Patients who have difficulty with structure
What does an RQ value of 1.0 indicate?
Only carbohydrate is being used for energy
Adequate Intake (AI)
Only established when an EAR (and thus an RDA) cannot be determined because the data are not clear-cut enough; based on experimental data or determined by estimating the amount of a nutrient eaten by a group of healthy people and assuming that the amount they consume is adequate to promote health.
What does an RQ value of 0.70 indicate?
Only fat is being used for energy
Measuring Length/Height - Arm span and knee height
Options for those who cannot stand or stand straight - Scoliosis - Kyphosis - Cerebral Palsy - Muscular Dystrophy - Contractures - Paralysis
Ideal Body Weight/Hamwi formula - Disability Adjustment:
Paraplegia: Subtract 5%-10% from IBW Quadriplegia: Subtract 10%-15% from IBW
Diabetic Wounds
Peripheral neuropathy and poor circulation pose a risk for foot ulcers in diabetics.
Client History
Personal history, medical/health/family history, treatments and complementary/alternative medicine use, and social history
This term is used to describe the effects of a drug on the body. It includes the desired therapeutic/clinical effects as well as side effects of the medication.
Pharmacodynamics
Which term describes the movement of a drug through the body by absorption, distribution, metabolism, and excretion?
Pharmacokinetics
Which term is used to describe the movement of a drug through the body by absorption, distribution, metabolism, and excretion?
Pharmacokinetics
Nutrition-Focused Physical Findings
Physical appearance, muscle and fat wasting, swallow function, appetite, and affect
Normal eyes
Pink conjunctiva without discharge, bright and clear, Sclera without spots, Clear cornea, Moist membranes
Nutrition Intervention
Plan and implement purposeful actions to address the identified nutrition problem(s) - Set goals and expected outcomes that are client driven (Determine a POA) - Based on scientific principles or the best available evidence (EAL) - When setting goals prioritize nutrition diagnosis based on Severity of problem, Patient need and perception of importance of problem (client driven), and Likelihood of impact by intervention
Decide where the statement would be placed in a SOAP. Note: Wife reports that patient is in denial about diabetes diagnosis and is noncompliant with previous diet education.
S - subjective
Less commonly used specimen sample types
Saliva, Nails, Hair, Sweat
Renal Function Tests
Serum Creatinine, Blood Urea Nitrogen (BUN)
To count carbohydrates using a food label, what items do you need to look at on the food label?
Serving size, total carbohydrate, fiber, and sugar alcohols
Nutrition Assessment Information gathered depends on
Setting, Health status of individual, Initial or follow-up assessment
The key reason prealbumin is a more sensitive index of nutritional status compared to albumin.
Shorter half-life (2 days compared to 14-20 days; half-life = amount of time for something to fall to ½ its original value)
Unintentional weight loss:
Significant 5% in 1 month 7.5% in 3 months 10% in 6 months Severe >5% in 1 month >7.5% in 3 months >10% in 6 months
R value (wrist circumference) based on frame size and gender
Small - woman: >11.0 - male: >10.4 Medium - woman: 10.1-11.0 - male: 9.6-10.4 Large - woman: <10.1 - male: <9.6
Microcytic anemia
Small RBCs often associated with iron deficiency
Why use Nutrition-Focused Physical Assessment (NFPA)?
Some nutritional deficiencies may not be identified by other assessment approaches; Some signs of nutritional deficiency are not specific; Must be distinguished from non-nutritional etiologies; its rare to find a deficiency in isolation
MW is a 78-year-old male on warfarin therapy. Which food should be eaten in moderation or in a consistent manner?
Spinach
Tests to Evaluate CVD Risk
Standard fasting lipoprotein profile (lipid panel) - Total cholesterol, LDL, HDL, TG
Which of the following meals would be appropriate for a Jewish patient who follows a kosher diet?
Steamed shrimp, roasted potatoes, and corn
Physical Examination Equipment
Stethoscope, Penlight/flashlight, Tongue depressor, Scales and stadiometers, Reflex hammer, Calipers, Tape measure, Blood pressure cuff
Evaluation
Systematic comparison with baseline or previous status, intervention goals, and/or recommended standards
Blood pressure measurement (mm Hg)
Systolic/Diastolic
Some examples of non-nutritional causes of anemia:
Thalassemia, Sickle Cell Anemia, Chronic renal failure, Anemia of chronic disease
Non nutritional causes of Anemia
Thalassemia, sickle cell anemia, chronic renal failure, anemia of chronic disease
Estimated Average Requirement (EAR)
The amount of a nutrient that is estimated to meet the requirement of half of all healthy individuals in a given age and gender group. This value is based on a thorough review of the scientific literature.
Sign
a clinical manifestation or change in condition identified by the examiner
Symptoms
a clinical manifestation or change in condition perceived by the patient
Orthostatic hypotension
a drop in blood pressure upon standing; No set numbers, but defined by reported symptoms of light-headedness, dizziness, or syncope (fainting) when standing -may be indicative of dehydration
HIPAA
a federal law that protects the privacy and security of patients' "protected health information."
Creatinine
a product of skeletal muscle, and is excreted in urine by the kidneys in a constant proportion to the mass of muscle in the body
Lacto-vegetarian
a vegetarian who consumes dairy products
The Plate Method
a visual aid used as a way to illustrate proper diabetes meal planning - half plate with non starchy veggies, 1/4 with starch, 1/4 with protein, milk/yogurt on the side, fruit on the side
Food allergy
an immune system response/reaction that occurs when the immune system reacts to a normally harmless food protein that the body has erroneously identified as harmful.
Pallor
an unusual paleness of the skin; Could indicate an anemia
Sickle Cell Anemia
another genetic disorder
ADIME
assessment, diagnosis, intervention, monitoring and evaluation
Skin tears
associated with thin skin and aging and/or dehydration; could also indicate possible protein malnutrition
Accuracy of prediction methods of body comp assessment ________ as obesity increases.
decrease
Common drug-nutrient interactions: Lipase inhibitors (Orlistat, Xenical®, Alli®)
decrease fat absorption • May also decrease absorption of fat-soluble vitamins
Leukopenia
decreased WBC - Compromised immune function, disrupted bone marrow function, malnutrition
Bioavailability
degree to which a drug or other substance reaches the circulatory system and becomes available to the target organ or tissue
Medicare coverage for medical nutrition therapy services (MNT) is available to beneficiaries who have a diagnosis of (choose all that apply):
diabetes & renal disease
DAP
diagnosis, assessment, plan
Someone taking orlistat may experience ___________ as a side effect.
diarrhea
Sorbitol is commonly used as an inactive ingredient in medications, but it may cause the following side effect:
diarrhea
Gastrointestinal side effects of Sorbitol
diarrhea - Commonly used as an excipient in liquid medications
What is crucial step in meal planning for Diabetics?
diet history - 24-hour recall & food records, Daily routine, Food preferences/aversions, Self efficacy and motivation
Inches to meters conversion
divide height in inches by 39.37
Lacto-ovo-vegetarian
does not eat meat but DOES eat dairy products and eggs.
With inflammation or an acute phase response, albumin and prealbumin will _________ irrespective of nutrition status.
drop
When are RDA's for protein greater?
during times of growth (lactation, childhood, etc), bodily stress
You reviewed labs for a 77-year-old female patient who had just been hospitalized with a CVA. Her lab profile indicates _______________, which could elevate her risk for another stroke or cardiovascular event.
dyslipidemia
Abnormal Hair Signs
easily pluckable, sparse hair, flag sign, corkscrew hairs, hirsutism
Clubbed nails
enlarged nails curved over fingertips; can be caused by CVD, lung disease, thyroid disease, inflammatory bowel diseases, other infection
Goiter
enlargement of the thyroid gland; iodine deficiency
gastrostomy or jejunostomy enteral nutrition
enteral nutrition where tube is placed directly through the skin into the stomach or small bowel.
Aspiration
entry of a foreign substance into the respiratory tract
Skin inspection
examined by inspection and palpation -inspect thespian for color and uniform appearance -any lesions, tears, bruising, edema, rashes, or flakiness -palpate for moisture, temperature (should be soft and even), turgor discolorations
Hirsutism
excessive hair growth due to elevated levels of androgens in women; cushings syndrome and PCOs
Serum iron as an indicator of anemia
fairly poor indicator - fluctuates
Medications that pose a food-drug interaction with grapefruit should be taken one hour before or two hours after consuming grapefruit juice.
false
True or False: Serum Iron is a good indicator of iron status.
false
Carbohydrate counting takes into account all of the following food groups except:
fat
Visceral adipose tissue:
fat that its beneath the abdominal muscle and surrounds the internal organs; associated with an increased risk for diabetes and CVD
Visceral fat
fat that surrounds the organs; is not visible from the outside, it is associated with numerous diseases.
Someone taking a lipase inhibitor may need to supplement:
fat-soluble vitamins
Residue
fecal content contributed by diet
Angular stomatitis
fissures at the corners of the mouth; characteristic of riboflavin deficiency
Serving sizes made simple - 1 cup
fist
Ascites
fluid accumulates in the abdominal cavity; can be caused by alcoholic cirrhosis or another liver disease; weight not accurate
Bitot's spots
foamy, gray, triangular spots of keratinized epithelium on the conjunctiva; more progressive sign of vitamin a deficiency
Nectar-like viscosity
fruit nectars, maple syrup, Ensure, eggnog, and some cream-based soups
Thalesemia
genetic disorder that results in inadequate Hb production
Patients with decreased ___________ may have decreased renal excretion.
glomerular filtration rate (GFR) • GFR tends to decline with age. • Consequently, drugs may remain in circulation longer in older adults and renal pts.
Personal Protective Equipment (PPE)
gloves, gowns, face shields, goggles
glucosuria
glucose in urine, caused by diabetes mellitus, renal diabetes, alimentary glucosuria
Assessment of pediatric malnutrition
growth is assesses by growth charts for age and gender
Possible signs of bulimia nervosa or frequent vomiting include
bilateral paratid enlargement or rotten teeth
more progressive sign of vitamin a deficiency
bitots spots
hematuria
blood in the urine; caused by hemorrhage in the urinary tract
Vital Signs
blood pressure, heart rate, respiratory rate, temperature
Respiratory Rate
bpm = breaths per minute Count respirations while holding pulse so pt is unaware of monitoring Normal= 14-20 bpm
Biacromial breadth:
breadth measurement from lateral ends of shoulder bones
How would a dietitian in private practice obtain an NPI?
by downloading a hard copy of the application or applying online
Carbohydrate Counting - Non-nutritive sweeteners
have a negligible effect on blood glucose (e.g., saccharin, aspartame, neotame, acesulfame potassium, sucralose, stevia)
Which of the following terms is used to describe the degree to which patients/clients have the capacity to obtain, process, and understand basic health information?
health literacy
1 calorie =
heat (energy) required to raise the temperature of one gram of water by 1 °C.
is non heme or heme iron absorbed more efficiently?
heme iron. but you can increase absorption of non heme iron by eating it with vitamin C
Hemaglobinuria
hemoglobin in the urine; caused by excessive hemolysis of red blood cells
A __________________ WBC count could indicate an infection.
high
Biiliac Breadth Measurement:
hip bone breadth measurement
Suprailian Skinfold Measurement:
hip bone skinfold measurement
Blood pressure
hydrostatic pressure exerted on the walls of arteries
Where are hepatic transport proteins synthesized?
in the liver
Where are most drugs metabolized?
in the liver
An excipient is a(n):
inactive ingredients
Leukocytosis
increased WBC - Infection, trauma, stress, inflammation, leukemia
Interactions can result in _______ or _______ drug action.
increased; decreased
Beau's lines
indentation that run across the nails that can be caused by uncontrolled DM, circulatory disease (PAD), malnutrition (zinc deficiency)
Bloodborne Pathogens
infectious microorganisms that are spread by exposure to blood or "other potentially infectious material."
Periodontal disease
inflammation of the gingiva with infection caused by oral bacteria and subsequent destruction of the tooth attachment apparatus.
Gingivitis
inflammation of the gums (gingiva).
Glossitis
inflammation of tongue and lips; Sign of iron deficiency or deficiency of several B-vitamins (especially vitamin B-12)
Pressure injuries
injuries to skin and underlying tissues that result from prolonged pressure ("pressure ulcers" or "bed sores" or "decubitus ulcers")
Negative energy balance
intake < expenditure; could lead to malnutrition or excessive catabolism of lean tissue for energy
Energy Balance
intake = expenditure; goal
Positive energy balance
intake > expenditure; can lead to obesity
The nutrition ________________ component of the Nutrition Care Process entails purposeful planned actions intended to positively change a nutrition related behavior, environmental condition, or aspect of health status
intervention
IER
intervention, evaluation, revision
Parenteral exposure
introduction of bloodborne pathogens through a break in the skin (e.g., needle stick)
Mucous membrane exposure
introduction of bloodborne pathogens through the eyes, nose, or mouth from a splash or spray of infected fluids.
cataracts
clouding of the lens
Complete blood count (CBC)
comprehensive blood test that includes: - Red blood cell (RBC) count - Hematocrit (Hct) - Hemoglobin (Hb or Hgb) - Mean corpuscular volume (MCV) - Mean corpuscular hemoglobin (MCH) - Mean corpuscular hemoglobin concentration (MCHC)
Cretinism
condition of congenital hypothyroidism in children that results in a lack of mental development and dwarfed physical stature; the thyroid gland is either congenitally absent or imperfectly developed; iodine deficiency
Honey-like viscosity
consistency of honey
The gastrointestinal side effect commonly seen when narcotic drugs such as codeine and morphine are administered is:
constipation
Gastrointestinal side effects of Narcotics
constipation (often severe)
Pinpoint hemorrhaging (petechiae)
could indicate vitamin C deficiency
What gives us a quick source of creatine app for muscle contraction?
creatine-phosphate
Heme
iron containing pigment of RBC's
Gastrointestinal side effects of Aspirin & other NSAIDs
irritation of stomach mucosa; Risk of ulceration and GI bleeds
ketonuria
ketones in the urine; caused by diabetes mellitus, starvation, high-fat diets
Globulins
key building blocks for antibodies, clotting factors, etc.
pernicious anemia
lack of mature erythrocytes caused by inability to absorb vitamin B12 into the bloodstream
Cyanosis of the nails
lack of oxygen in the blood; can be caused by congenital heart disease or pulmonary disease
What is the primary determinant of RMR?
lean body mass (primarily skeletal muscle metabolism)
Concomitant intake of protein and _______________ may decrease the therapeutic effect of the medication
levodopa
Albumin, Prealbumin, and RBP are synthesized in this organ.
liver
Most medications are metabolized in the _______________.
liver
A loss of 16g of N =
loss of 1 lb of tissue
Chronic renal failure results in a loss of what hormone?
loss of erythropoietin (EPO) - a hormone made by the kidneys that signals RBC synthesis in the bone marrow
Anosmia
loss of smell (hyposmia = diminished smell)
Edentulism
loss of teeth (full or partial)
A prealbumin level of 13 mg/dL would be considered ________
low
Appetite suppressants
many meds have anorexia as a side effect
Which of the following medications could be given to a patient with cancer or AIDS to stimulate food intake?
marinol
Neutral or pareve Kosher foods
may be eaten in natural state. Grains, fruits, vegetables, eggs, tea, coffee; foods free of meat, poultry or dairy.
Reform Jews
may or may not conform to any Jewish dietary laws
Low levels of hepatic transport proteins
may prompt you to further assess for PEM, but they should be evaluated in light of pt's clinical condition
What does an RQ value > 1.0 indicate?
may represent overfeeding or lipogenesis
TIBC (total iron binding capacity)
measure of proteins available to bind iron - Increases with iron deficiency, while transferrin saturation decreases.
Subscapular Skinfold Measurement:
measurement of skin fold of scapula
What is the base unit for Conventional Lab Units?
mg/dL - dL = 100 mL - 10 dL = 1 L - 1 g = 1000 mg - 1 kg = 1000 g - 1000 μg = 1 mg
What does an RQ value of 0.85 indicate?
mixed diet - all macros are being used for energy
What is the base unit for SI Units (International System)
moles per liter
Why is Mifflin St Jeor equation more popular?
most accurate - Harris Benedict is know to overestimate by about ~10%
Inches to cm conversion
multiply heigh in inches by 2.54
Anticholinergic drugs
muscle relaxers, antidepressors, antihypertensives, etc
Normal Hair
natural shine, consistent color and quantity, fine to course texture
Side effects of certain drugs, such as ______, ______, _____ etc. may compromise nutrition.
nausea, anorexia, dysgeusia,
Catabolism
negative N balance -indicative of increased protein needs
Early sign of vitamin A deficiency?
night blindness
Anabolism
nitrogen intake > nitrogen losses - Represents nitrogen retention - Growth, pregnancy, healing from major injuries/wounds
Catabolism
nitrogen losses > nitrogen intake - Represents body nitrogen losses - Associated with trauma/severe stress, starvation
Is a higher than normal weight velocity of a pediatric patient a good sign?
no - could be an indicator of malnutrition
Skin
normally soft, moist turgor with instant recoil, smooth appearance -epidermis and dermis
Medications may interfere with the way certain _______ are processed by the body.
nutrients
Start with the ______________- in order to plan a nutrition intervention
nutrition diagnosis - Excessive fat intake related to frequent consumption of fast food meals as evidenced by fat calories greater than 55 percent of total calories per day and pt report of eating out 6 days per week
Reconstructionists
observance varies from very strict to none, based on individual conscience
All of the following can help improve intercultural communication
observe how clients make eye contact; let clients determine their own personal space; observe how clients use silence
Conservative Jews
observe laws in their own homes, but accept deviations when away from home
What does an RQ value of 0.82 indicate?
only protein is being used for energy
Serving sizes made simple - 3 ounces
palm of hand
Sources of individual variation between pharmacokinetics and pharmacodynamics
physiological variables, pathologic variables, genetic variables, drug interactions
serum
plasma without clotting factors
Inherently non-kosher
pork, fish without scales & fins, shellfish
Anabolism
positive N balance (pregnancy, wound, healing) - intake of nitrogen to the body is greater than the loss
Assume all human blood and body fluids are
potentially infectious, and handle them with appropriate protective measures!
proteinuria (albuminuria)
presence of protein in urine; caused by kidney damage, nephritis, bladder infection
PES
problem, etiology, symptoms
PIE
problem, intervention, evaluation
PHI
protected health information
To maximize the benefits of anti-Parkinson's medications, a patient may redistribute ____________ intake around his medication schedule.
protein
Flag sign
protein energy malnutrition sign - Alternating bands of depigmented and normal-colored hair representing alternating periods of poor protein intake and normal protein intake
Complete protein (high quality proteins, high bioavailable proteins)
protein food that provides all 9 of the essential amino acids; ex animal products, eggs
Globulin
protein portion of RBC's
Spoon-Thick Viscosity
pudding
Purpura
purplish-red bruises usually occurring in people with thin, easily damaged skin; More commonly due to anticoagulant meds, but could be indicative of insufficient vitamins C or K
Lipodystropy
redistribution of body fat; common in AIDS and Cushings Syndrome
Common drug-nutrient interactions: Antacids, PPIs, and H2 blockers
reduce stomach acid, and may also reduce absorption of vitamin B12 (and possibly iron and calcium)
In what situations/conditions would a Creatinine-Height Index measurement be less accurate?
renal disease or excessive meat intake, amputation/paralysis
Meat, Poultry, and cheese kosher foods
require special processing to be kosher
Cheilosis
scaling of the lips and painful cracking in the corners of the mouth; characteristic of riboflavin deficiency
SAP
screen, assess, plan
Corkscrew hairs
scurvy (vitamin c deficiency)
The eating habits of children can be assessed by 24-hr recall, food records, or FFQ, but any of those methods most often requires a
surrogate - someone familiar with the respondent (parent, spouse, child, etc.) who may assist the person with reporting dietary intake
Dysphagia
swallowing difficulty
Edema
swelling caused by excess fluid trapped in your body's tissues - can be assessed as absent, mild, moderate, or severe
AE is an 80-year-old female instructed by her physician to begin taking aspirin 81 mg daily. What advice would you give her to prevent a potential issue or interaction with this drug?
take with food
Azotemia
term used to describe elevated levels of BUN, creatine, and other nitrogenous wastes in the blood
What does the phrase "treat the whole patient not the lab value" mean?
that no single value is diagnostic (labs are inherently imprecise) - make sure to consider the patient as a whole not Justine sign/symptom
When we talk about the absorption of medications, we are talking about
the absorption across the intestinal epithelium into the blood
What was recently added to the Beer's Criteria as a medication to be avoided?
the appetite stimulant, megestrol (megace)
Energy =
the capacity to do work
evidence-based practice
the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research
Parenteral Nutrition
the delivery of nutrients intravenously
Subcutaneous fat
the jiggly fat visible just under the skin; normally harmless and may even protect against some diseases.
Most medications are excreted by _______
the kidneys; However some medications may be eliminated by feces or bile.
Atwater equivalents
the metabolizable energy available from food once you ingest and metabolize it (i.e. how many calories are in a gram of CHO); rough estimates as this varies slightly from person to person based on biochemical makeup
Basal Metabolic Rate (BMR)
the minimum amount of energy required to keep the body alive when in a rested and fasting state
White Blood Cell Count (WBC)
the number of WBC in a mm3 of blood assessed via CBC - Index of immune function
Polypharmacy
the use of multiple drugs to manage various diseases
Subcutaneous Adipose Tissue (SAT)
thefat right underneath skin
Wernicke-Korsakoff Syndrome
thiamine deficiency secondary to alcoholism
Liquid viscosities
thin, nectar-like, honey-like, spoon-thick
Serving sizes made simple - 1/2 cup
thumbs up, bottom two fingers
Serving sizes made simple - 1 tsp
tip of pointer finger
Serving sizes made simple - 1 tbsp
tip of thumb
What is the main goal of any cholesterol treatment?
to lower LDL cholesterol
What is the purpose of nutritional assessment?
to obtain, verify, and interpret data needed to identify nutrition-related problems, their causes, and significance.
Private insurance coverage for MNT by a registered dietitian varies between different plans and different states.
true
Fecal Fat Test
type of stool sample test for fat malabsorption (aka steathorrhea)
Systolic
ventricular contraction
Diastole
ventricular relaxation
Eating iron absorption from non-heme sources can be enhanced when eaten with
vitamin c
Thin viscosity
water, milk, juice, coffee, tea, carbonated drinks, gelatin, ice cream, sherbet, sorbet and broth-based soups
How to calculate BMI?
weight (kg) / height (m^2) 1 - convert weight from lbs to kg (divide weight in lbs by 2.2) 2 - convert height from inches to meters (divide height in inches by 39.37 to get heigh in meters) 3 - Calculate BMI (weight in kg / height in meters squared)
Leukcytes
white blood cells
Jaundice
yellow staining of the skin and sclerae (the whites of the eyes) by abnormally high blood levels of the bile pigment bilirubin; can indicate liver or gallbladder disease.
Mark is a healthy 22-year-old male. He weighs 165 pounds. What is his RDA for protein?
~60 g PRO/day
Excipients and Food-Drug Interactions
• "Inactive ingredients" in drugs, added as buffers, fillers, binders, flavorings, preservatives, coatings, etc. - Can be derivatives of wheat, soy, peanuts, egg, lactose, sorbitol, mannitol • People may have allergies or sensitivities to excipients. • Labeling laws require all drug ingredients, including excipients, to be identified.
Nutrition Assessment
• 1st step of the Nutrition Care Process • Obtain, verify, and interpret data to identify nutrition problems • Foundation for progressing through the other 3 steps of the Nutrition Care Process • Data should be collected and interpreted using evidence based standards • Ongoing
Nutrition Diagnosis
• 2nd step of the Nutrition Care Process • Identify and label specific nutritional problems - Based on the results of the nutrition assessment - Not the same as the medical diagnosis • Determine causes/contributing risk factors • Nutritional problems include actual problems, not risk for developing • Explicit statement of nutrition diagnosis
ADIME Charting
• A = Assessment (Subjective & Objective) - Only pertinent assessment information • D = Diagnosis - Written as a PES statement • I = Interventions • M = Monitoring • E = Evaluation
Paragraph style / narrative notation
• A brief, narrative entry of a few sentences that states only what is necessary • Typically used to update ongoing patient care - Follow-up notes to a previous longer SOAP note - Day-to-day progress notes on a patient you are following intensively
The Beer's Criteria
• A useful resource for prescribing clinicians to weigh the risks and benefits of medications for older adults. • Categorizes "potentially inappropriate medications" for older adults into 3 groups
Judaism
• Adhere to Kashrut dietary laws, which may vary among different groups • Kosher foods are "fit and proper," according to laws originated in the Torah and fit into 3 categories - neutral, meal/poultry/cheese, inherently non-kosher • Kosher meat must come from an animal that chews its cud and has split hooves (e.g., cows, sheep, etc.) and all blood must be removed • Many dairy products are not kosher because meat derivatives are used during manufacturing (rennin in cheese, gelatin in frozen milk products) • Permissible poultry includes domesticated species of chickens, Cornish hens, ducks, geese and turkeys. • Fish with scales & fins may be eaten without ritual slaughter. Frogs, eels, catfish, shark meat, shellfish, are prohibited. • Allowable fish and eggs may be eaten with any type of meal. • Jewish Sabbath is sundown Friday to sundown Saturday during which time no food may be cooked • Sabbath dinner on Friday evening is usually the most substantial of the week, served with challah (bread).
Pressor Agents in Foods and Beverages: Foods/Beverages to Avoid if on an MAOI inhibitor
• Aged cheeses and meats • Soy sauce, tofu, miso, and tempeh • Broad beans • Sauerkraut • Tap beer (also imports and craft beers) • Meat, fish, or poultry stored longer than 3‐4 days in the refrigerator
National Dysphagia Diet (NDD)
• Aim to establish standard terminology and practice applications of dietary texture modification in dysphagia management • 3 Levels of NDD (Level 1-Pureed, Level 2-Mechanical Altered, Level 3-Advanced)
Mormonism
• Alcohol and caffeinated beverages are prohibited. • Moderation in all foods • Fasting is practiced.
Progress Notes
• All health care team members who initiate and apply patient care should document the status of their caregiving actions and the patient's response • These notes describe the daily progress in the healthcare environment • In chronological order • Includes nutrition care record
Guidelines for Charting
• Always chart in black ink if not on a computer. • Always identify your entry with date, time of day, and service with which you are associated. • Do not obliterate information with liquid paper or scribbling (legally, this is "tampering with evidence"). • Write legibly. • Chart promptly - within 24 hrs of seeing patient. • Complete sentences are not necessary, but grammar and spelling should be correct. • Chart only clinically pertinent information • Use institutionally approved symbols & abbreviations. • Always sign the note with name and professional credentials (unless on a computer, which puts an "esignature" for you).
Droplet / Airborne Precautions
• In addition to standard precautions and contact precautions, a mask is worn upon entry into the patient's room. • In some cases (e.g., tuberculosis), an N95 respirator mask may be necessary.
Positive acute phase respondents
• Increases inflammatory response • CRP and other cytokines
Blood Urea Nitrogen (BUN) lab test
• Indirect and rough measurement of renal function - measures amount of urea nitrogen in the blood (serum) formed in liver from ammonia produced during breakdown of amino acids and other nitrogenous compounds - Excreted in urine by kidney. • Normal range: 8-23 mg/dL - High values suggest renal disease or dehydration - High values also seen with GI bleeding, high protein intake, etc. - Low values suggest liver disease, over- hydration, etc.
SOAP - Subjective
• Information reported by pt and/or family/caregivers • Information in this section cannot be definitely proven. • Can include: - Pt's appetite - Reported weight changes - Current supplement consumption - N/V/D/C
Roman Catholic
• Law of fasting typically applies to Ash Wednesday and Good Friday. • On a fasting day, one full meal and two very small meals are allowed, plus liquids as desired. No eating between meals. • Law of Abstinence no longer obligated on Fridays, but applies to Ash Wednesday, Good Friday, and all other Fridays of Lent. Abstinence involves avoiding meat and soup or gravy made with meat. • Laws of fasting and abstinence do not apply to the very young or old, or ill persons.
Drug Interactions: Protein foods and levodopa
• Levodopa is typically the first-line of treatment for Parkinson's Disease. • Levodopa = precursor to the neurotransmitter dopamine • Sinemet® = carbidopa/levodopa • Large, neutral amino acids compete with levodopa for transport proteins in the gut and at the bloodbrain barrier. To achieve the best therapeutic effect from levodopa, it often helps to redistribute protein around levodopa dosing. • Common side effects of Sinemet ® : • Nausea • Anorexia • Dysgeusia
Serum Albumin
• Major transport protein in blood • Maintains colloid osmotic pressure (water distribution) • Widely used nutrition screening tool in American hospitals • Fair index of malnutrition at best (don't rely on this value alone for malnutrition status) • Low levels associated with liver damage • Normal range: 3.5-5 g/dL
Hinduism
• Many Hindus are vegetarian. • Beef is strictly prohibited. • Other products from the cow such as milk, yogurt, etc. are permitted. • Alcohol may be avoided by some Hindus. • Various fasting days are observed.
Hepatitis C Virus (HCV)
• May lead to cirrhosis or end stage liver disease • Can survive up to 7 days in dried blood • No vaccine is available.
SOAP - Objective
• Measurable data obtained from the patient's chart • Information in this section is factual and can be confirmed by others • Can include: - Medical info (PMH, current problems, etc.) - Lab results - Anthropometrics - Dietary intake info - Medical orders (diet order) - Meds
Beers Criteria 3 groups of "potentially inappropriate medications" for older adults
• Medications that should be avoided in all older adults • Medications that are potentially inappropriate for individuals with certain comborbidities • Medications to be used with caution
Drugs indicated for appetite stimulation
• Megestrol acetate (Megace), Oxandrolone (Oxandrine), Dronabinol (Marinol) • Must weigh the side effects of these meds with their benefits
Common drug-nutrient interactions: Monoamine oxidase inhibitors and tyramine
• Monamine oxidase inhibitor medications (MAOIs) are a class of antidepressants. • Pressors = Dopamine, Histidine, Tyramine Tyramine acts as vasoconstrictor that raises blood pressure. • MAOIs inhibit the breakdown of monoamines like tyramine, so concomitant intake foods rich in tyramine and other pressor agents may cause a dangerous rise in BP leading to hypertensive crisis.
Islam
• No alcoholic beverages • Coffee, tea, and other caffeinated beverages are discouraged. • No pork or pork by-products • Meats & fowl must be ritually slaughtered • Halal = foods that are permitted under Islamic dietary laws • Haram = prohibited foods • Ritual fasts - longest is Ramadan - Ninth month of the Islamic year is devoted to prayer, fasting, and charity. - During this month, one meal is eaten before dawn, and one meal eaten after sunset. - No food or drink is consumed between sunrise and sunset.
Serum Prealbumin (Transthyretin)
• Normal range: 15-36 mg/dL - Values < 15 suggest malnutrition, liver damage, zinc deficiency, or acute inflammation (but this is a negative acute phase protein so do not rely on this value) • Short half-life (~2 days) •Not a sensitive index of improving nutritional status during inflammation
Serum Total Protein
• Normal range: 6.4-8.3 g/dL • Assay of all proteins in blood. • Used to monitor progression of a disease state where wasting is a clinical feature (Cancer, kidney disease, immune disorders, liver disease, and malnutrition) • NOT a sensitive indicator of nutritional status (Does not reflect status during acute phase response (inflammation))
There are a series of 4 steps that are involved in quality nutrition care:
• Nutrition Assessment • Nutrition Diagnosis • Nutrition Intervention • Nutrition Monitoring and Evaluation
Categories of Nutrition Diagnosis Terminology - Clinical
• Nutritional findings or problems identified that are related to medical or physical conditions • Swallowing difficulty (NC-1.1), unintended weight loss (NC-3.2)
Categories of Nutrition Diagnosis Terminology - Behavioral Environmental
• Nutritional findings or problems related to knowledge, attitudes, or beliefs, physical environment, or food safety and supply - Impaired ability to prepare foods/meals (NB-2.4), Limited access to food (NB-3.2)
The Medical Record
• Patient Record or Medical Chart • Legal document of care provided • Communication tool - "If it wasn't documented, it wasn't done." • Provides an evaluation tool for hospital accreditation, quality assurance programs, peer review, and cost effectiveness of care protocols • IS CONFIDENTIAL PATIENT INFO!!!
Hematocrit (Hct)
• Percent of RBCs in total blood volume • Depends on the number of RBCs and their size • Normal range: M 42-52% F 37-47%
Good Hand Hygiene
• Perform hand hygiene between physical contact with different patients. • Perform hand hygiene after any direct contact with patients. • Wash hands after using the bathroom, smoking, eating, or applying makeup. • Clean your hands by rubbing them with an alcohol-based hand sanitizer for routine hygienic hand antisepsis if hands are not visibly soiled.
Passover celebration has many traditions:
• Prepared kosher foods must be labeled Kasher L'Pesach, certified by rabbinical authority. • Home is thoroughly cleaned and all leavened products are removed for Passover. • Matzo commonly eaten during this time. - Flour and grains are not used due to natural leavening agents
Categories of Nutrition Diagnosis Terminology - Intake
• Problems related to intake of energy, nutrients, fluids, bioactive substances through oral diet or nutrition support • Excessive energy intake (NI-1.3), inadequate enteral nutrition infusion (NI-2.3)
Identifying patients who may benefit from supplementation
• Pts with medical conditions or medications affecting how the body absorbs or uses nutrients (e.g., corticosteroids>>Ca++, food allergies, GI tract surgeries that prevent absorption, etc.) • Age-related changes in taste, smell, dentition, and gastrointestinal function -Can impair food intake and nutrient absorption, so for some older adults, supplementation may helpful to ensure adequate intake of nutrients that would otherwise come from food
Pressor Agents in Foods and Beverages: Use with caution if on an MAOI inhibitor
• Red or white wine (2‐4 oz/day) • Coffee, cola, and other caffeinated beverages • Pizza • Bottled beer • Liqueurs or distilled spirits (two 1 ½ oz. servings/day)
There are 2 supporting systems of the NCP:
• Screening and Referral System • Outcomes Management System
Cultural Awareness
• Self-assessment: As a first step toward cultural competence, a health care provider examines his/her own cultural background, identifying areas of bias. • A culturally competent health professional seeks knowledge and understanding about the cultural norms of clients. • Avoid stereotyping.
Serum Creatinine lab test
• Sensitive index of renal function - elevated serum creatinine may indicate kidney dysfunction - Normal range: 0.6 - 1.6 mg/dL - Low creatinine (< 0.6) suggest muscle wasting due to calorie deficiency - High creatinine (>1.6) suggest renal insufficiency (or severe dehydration) - Used along with other factors such as gender, age, ethnicity etc. to calculate estimated Glomelular Filtration Rate (eGFR) - GFR levels below 60 mL/min/1.73 m2 for 3 or more months are a sign of chronic kidney disease (CKD).
Temporalis Muscle inspection
• Standing in front of the pt, observe the temple region as he/she turns head to left and right • Gently palpate the temple region
Negative acute phase respondents
• Synthesis decreases under stress • Albumin, transferrin, prealbumin, RBP
Who writes in the medical record?
• The Health Care Team: - M.D., Physician's Assistant (PA) - Nurse - Pharmacist - Dietitian - Social Worker (or Case Manager) - Respiratory, Physical, Occupational, & Speech Therapists - All others involved in direct patient care
What is the Nutrition Care Process?
• The Nutrition Care Process and Model is the framework for the critical thinking process used by dietetics professionals as they provide nutrition services to their clients/patients • Patient or client is the central focus
Explain the effect of grapefruit juice on the cytochrome P450 3A4 enzymes in the small intestine
• The blood levels of certain medications can be amplified up to 5x if they are taken with grapefruit juice. • The effects of grapefruit on enzyme inhibition can last up to 72 hours, so it isn't sufficient to merely ingest the grapefruit at a different time of day from the medication.
Other potentially infectious material:
• The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids • Any unfixed tissue or organ (other than intact skin) from a human • HIV-containing or HBV-containing cell or tissue cultures
Human Immunodeficiency Virus (HIV)
• The virus that causes Acquired Immune Deficiency Syndrome (AIDS) • Survives seconds to minutes outside the body • No vaccine is available.
Common drug-nutrient interactions: Antihypertensive medications and potassium
• Thiazide and Loop diuretics - increase potassium excretion; Supplementation may be necessary. • Potassium-sparing diuretics - decrease potassium excretion; Avoid potassium supplements and KCl salt substitutes • ACE-inhibitors and angiotensin II receptor blockers (ARBs) - decrease potassium excretion; Avoid potassium supplements and KCl salt substitutes
Clear Liquid Diet
• Transition from NPO to regular foods • Commonly used after surgery • Minimizes digestive work • Minimizes gut residue • Nutritionally inadequate- Provides 600-900 kcal/d, little protein • Does not meet RDA for protein or vit/min - Vitamin C may be exception • Intended for < 3-4 days use
Summary of Universal (Standard) Precautions
• Treat all human blood, tissue, and body fluids as potentially infectious. • Wear appropriate PPE. • Wash hands often. • Obtain a Hepatitis B Vaccine • If you are exposed, report the exposure to your supervisor immediately
Diet Liberalization
• Use your best clinical judgment • Consider if: - Dietary restrictions will not significantly improve or prolong life - Restrictions decrease intake significantly (i.e. do more harm than good)
Contact Precautions
• Used along with standard precautions for patients with infections that may be spread by contact with skin, equipment, or environmental surfaces. • Gloves are worn for all patient-care activities. • Use of noncritical care equipment (e.g., blood pressure cuffs) should be dedicated to a single patient.
Renal Diet
• Used for patients with renal failure • Highly variable in hospital settings • Typically include: - Controlled amounts of fluid - Controlled amounts of protein - Limit potassium (Bananas, tomatoes, potatoes, salt substitute, chocolate, greens) - Limit sodium - Limit phosphorus (Dairy products, dark sodas, dry beans and peas, whole grains, etc.)
Hepatitis B Virus (HBV)
• Usually transmitted by blood-to-blood contact • May lead to cirrhosis or end stage liver disease • Can survive up to 7 days in dried blood • Get a HBV vaccination!
Interpreting levels of HDL:
• Values >60 mg/dL considered protective • Men: Values < 40 mg/dL risk factor for CVD •Women: Values < 50 mg/dL risk factor for CVD
Seventh Day Adventists
• Vegetarian diet is encouraged. • Do not use caffeine or alcohol.
Buddhism
• Vegetarian diets are encouraged (although many Buddhists may consume fish). • Moderation in all foods • Buddhist monks frequently fast and may avoid solid foods after a certain hour of the day.
Drug Interactions: Vitamin-K rich foods and the anticoagulant warfarin (Coumadin®)
• Warfarin works by inhibiting hepatic synthesis of vitamin-K dependent clotting proteins. • So, vitamin K intake should be kept consistent to optimize the warfarin therapy (broccoli, brussels sprouts, cabbage, etc) • Alcoholic beverages can increase the effect of warfarin. EtOH should be limited to 1-2 servings occasionally.
Examples of open-ended questions:
• What foods do you commonly eat? • Are there any foods you avoid? • Do you regularly try new foods? Are there any new foods you have recently eaten for the first time? • What foods do you typically buy? • Where do you buy food? • Are you able to get the types of food you need? • How did you prepare this meal? • Who eats meals with you?
What is protected health information?
• Written documentation from medical records (including paper records and electronic databases) • Spoken or verbal information including voicemail messages • Photographic images • Audio and video recordings
Department of Justice Criminal Penalties for HIPAA Violations:
• Wrongfully accessing or disclosing PHI: fines up to $50,000 and up to 1 yr in prison • Obtaining PHI under false pretenses: fines up to $100,000 and up to 5 yrs in prison • Wrongfully using PHI for commercial activity: fines up to $250,000 and up to 10 yrs in prison • HIPAA criminal and civil fines can be enforced against individuals as well as covered facilities. • A HIPAA violation could be grounds for immediate dismissal from your internship!
Side effects of anticholinergic medications
• Xerostomia - may impair taste and swallowing; increases the risk for dental caries • Urinary retention • Confusion, dizziness • Constipation
The healthcare provider may disclose relevant information if the provider does one of the following:
• obtains the patient's agreement • gives the patient an opportunity to object, and the patient does not object • decides from the circumstances based on professional judgment, that the patient does not object
Low Residue Diet
• provides very little fiber (fiber, undigested starches & sugars, minerals, connective tissue and gristle from meat) • Eliminates fruiting veggies that are fibrous, whole grain products, legumes, meat and shellfish with tough connective tissue) • remaining fecal material = bacteria and sloughed GI cells • Purpose: significantly decreases fecal volume and promotes bowel rest - Prescribed for acute inflammatory states, partial obstructions, bowel preps, etc.
Orthodox Jews
• strict law observance; will eat away from home only in kosher restaurants or homes with kosher kitchens • Orthodox Jews do not eat meat and milk in the same meal - These foods be prepared or served with the same dishes or utensils. - After meat has been eaten, some time must pass before milk can be ingested. - Milk may be consumed just before consuming meat. - For ease, meals may be "milk meals" (milchig) or "meat meals" (fleischig).
Open-minded Skepticism: Educating our Patients to be Wise Consumers
•Discuss dietary supplements with your patients, and have the resources available to find answers to their questions. •Instruct pts to treat dietary supplements like medications, keeping an updated list of all supplements and dosages. •Remind pts that "all natural" doesn't necessarily mean "all safe."
Consistent Carbohydrate Meal Pattern
•Starchy foods like bread, cereal, rice, crackers •Fruit and fruit juices •Milk and yogurt •Dried beans •Starchy vegetables like potatoes and corn •Sweets and sugars
1 kilocalorie (kcal) =
1000 calories
1 Nonfat (Skim), Low-fat (1%) Milk =
12 g CHO, 8 g Pro, 0-3g fat, 100 kcal
1 Reduced-Fat (2%) Milk =
12 g CHO, 8 g Pro, 5 g Fat, 120 kcal
1 Whole Milk =
12 g CHO, 8 g Pro, 8 g Ft, 160 kcal
What is the average life span for red blood cells?
120 days
Using the Hamwi Formula, calculate the ideal body weight (IBW) in pounds of a female, medium frame, with a height of 65 inches.
120 pounds
Elevated blood pressure
120-129/80
Normal blood pressure
120/80
High blood pressure (hypertension) stage 1
130-139/80-89
You are teaching carbohydrate counting to a patient with a recommended intake of 210 g/CHO per day. How many carbohydrate servings is this?
14
High blood pressure (hypertension) stage 2
140+/90+
1 Starch Exchange =
15 g CHO, 3 g Pro, 0-1g Fat, 80 kcal
Fruit Exchange =
15 g CHO, 60 kcal
1 serving CHO =
15 grams •1 slice of bread or 6" tortilla •½ cup or hamburger bun •1 Tbsp sugar, honey, or jam •¼ large baked potato •¼ serving of a medium French fries •½ ice cream or sherbet •2" brownie or cake •½ cup starchy vegetables or beans •1/3 cup pasta or rice
Normal Range- Serum Prealbumin (transthyretin)
15-36 mg/dL
Computed Tomography (CT Scan)
Involves use of ionizing radiation - not common, very expensive
Iodine Deficiency
Iodine is required for the synthesis of thyroid hormones thyroxine (T4) and triiodothyronine (T3). T4 is converted to the active form of T3. Thyroid hormones regulate a wide variety of processes such as glucose homeostasis, heart rate, blood pressure, body temperature, and growth/development. -results in goiter (enlarged thyroid) and can cause the birth defect cretinism -table salt is iodized
Elevated serum BUN and creatinine could indicate impairment of the ____________.
Kidneys;
LDL (low density lipoprotein) calculation
LDL-C is calculated: LDL = (TC) - (HDL) - (TG/5)* *note: this formula is accurate only if TG <400
Biochemical Data, Medical Tests, and Procedures
Lab data (e.g., electrolytes, glucose) and tests (e.g., gastric emptying time, resting metabolic rate)
Which type of vegetarian likely consumed the following meal: cheese omelet, canned peaches, and black coffee?
Lacto-vegetarian
Vegetarian Diet Patterns
Lacto-vegetarian, Lacto-ovo-vegetarian, Vegan
Macrocytic anemia
Large, fragile RBCs often associated with folate and/or B-12 deficiency; pernicious anemia
This term is used to describe an elevated white blood cell count (WBC).
Leukocytosis (indicative of infection, also possibly trauma/stress, leukemia)
Plasma
Liquid part of blood
Elevated AST, ALT, alkaline phosphatase, and bilirubin would redflag this condition.
Liver disease.
Hamwi Formula for estimating IBW:
Women = 100 lb for 5 ft + 5 lb for every inch over 5 feet - Under5ft: 100 lb-2.5 lb per inch under 5ft Men = 106 lb for 5 ft + 6 lb for every inch over 5 feet - Under 5ft: 106 lb -3 lb per inch under 5ft
Abnormal waist circumference levels
Women > 35" (88 cm) Men > 40" (102 cm)
Abnormal waist circumference values:
Women >35 inches Men >40 inches
Anticholinergic medications commonly cause:
Xerostomia
Koilonychia
spoon shaped conch nails; occurs normally in children and usually resolves with aging nutrition causes include iron deficiency and protein deficiency
Which class of medication reduces LDL-cholesterol levels by inhibiting the hepatic synthesis of cholesterol?
statins
SOAPIER
subjective, objective, analysis/assessment, plan, intervention, evaluation, revisions
SOAP
subjective, objective, assessment, plan Prior to ADIME, the most common method of documenting nutrition care plans
Amputee Adjustments for Hamwi Formula
subtract below value from IBW - Entire leg (and foot): 18.5% - Above the knee: 13% - Below the knee: 6.0% - Foot: 1.8% - Entire Arm (and hand): 6.5% - Forearm (and hand): 3% - Hand: 1% - Trunk without extremities: 50%
Disability Adjustments for Hamwi Formula
subtract below value from IBW - Paraplegia: 5-10% - Quadriplegia: 10-15%
Sodium-Restricted Diets
Low sodium, no added salt - for patients with heart failure or end stage liver disease
Gyroid Body shape (pear)
Lower body fat (gynoid) - Benign obesity (isn't thought to pose as great of risk)
Decide where the statement would be placed in an ADIME. Note: Schedule appointment in 1 week to f/u on diet diary and self-monitoring of blood glucose.
M/E - monitoring/evaluation
Which of the following lab values would be most helpful in distinguishing between microcytic and macrocytic anemia?
MCV
Measures the average size of RBCs
MCV Microcytic anemia - iron Macrocytic anemia - folate and/or B-12
A patient is taking warfarin (Coumadin). What MNT education should this patient receive?
Maintain consistent vitamin K intake.
MUST tool
Malnutrition Universal Screening Tool
Common drug-nutrient interactions: Statin drugs (HMG-CoA reductase inhibitors)
Reduce endogenous synthesis of cholesterol • However, they also affect endogenous synthesis of coenzyme Q10. • So, it is sometimes recommended that patients taking statin meds also take 100mg of supplemental CoQ10.
Activity and Injury Factors
Represents a % increase above the REE - If an activity factor of 1.3 is used it is a 30% increase beyond the REE - REE = 1450 calories x 1.3 activity factor - TEE = 1885 calories
Monitoring
Review and measurement of status at scheduled times
Dietary Guidelines for Americans
Revised every 5 years by the Department of Agriculture (USDA) and the Department of Health and Human Services (HHS)
Food intolerance
an adverse reaction to a food that does not involve the immune system
Red blood cell count (RBC)
- Determines the total number of red cells (erythrocytes) in a sample of blood - Low RBC count suggests anemia, but it doesn't distinguish the cause (nutrient deficiency, blood loss, or another underlying condition).
Hypertension crisis (consult your doctor immediately)
180+/120+
Methods Used to Evaluate Dietary Intake?
- Dietary Reference Intakes - Dietary Guidelines - Exchange Lists for Meal Planning - Food Labels with Daily Values - Nutrition Analysis Programs (computer software or web-based)
Measurement/Estimation of Energy Expenditure
- Direct calorimetry (only used in animal research) - Doubly-labeled water (only used for research) - Indirect calorimetry: A gold-standard for measurement of RMR; Used for research and clinical applications - Prediction equations
Skin lesions
Any pathological change in skin; Could signal a variety of nutrient deficiencies: protein, folate, zinc, vitamin C, niacin, riboflavin
Resting Energy Expenditure (REE) or Resting Metabolic Rate (RMR)
- Energy expended in activities needed to sustain normal body functions and homeostasis (breathing, blood circulation, CNS, maintenance of body temperature - ~60-70% TEE - Estimate of BMR - Used for practical purposes
Medical Record Sections
- Demographics - MD Orders (including the diet order) - History and Physical (H&P) • Chief complaint of present illness, PMH, Review of symptoms (ROS), etc. - Graphic Sheets (flow sheets) - Lab Reports - Radiology Reports - Medication Records - Progress Notes: MD, Nursing, RD, Social Work, Therapists - PT, OT, SLP, etc. - Consultation Reports - Discharge Summary
Total cholesterol normal range
- Desirable: <200 mg/dL - Hypercholesterolemia: > 240 mg/dL
Alcohol Exchange =
100 kcals
Waist Circumference
- Correlates with visceral fat stores - Higher levels of visceral adipose tissue are associated with health risks (DM, CVD, etc.) - Minimum waist = measured between bottom of rib cage and umbilicus - Waist circumference provides an easily obtained estimate of visceral adipose tissue. - Waist-to-hip ratio provides no assessment advantage over waist circumference alone.
Characteristics of dehydration
- Dark urine - Decreased skin turgor - Dry mouth, lips, and mucous membranes - Dry or sunken eyes - Weight loss - Lowered body temperature - High serum Na+ and BUN on labs
The Nutrition Diagnosis is written as a
"PES statement."
% Ideal Body Weight
% IBW = (ABW/IBW) x 100 - "Desirable" range is 90 - 110% IBW (IBW+/- 10%) - Deviation away from this range may suggest under- or over-nutrition - However, note that IBW does not adjust for age or race and does not specify fat mass vs. fat-free mass; it's validity is questionable, but it is widely used by clinicians.
% Weight Change
% wt change= (UBW - ABW)/UBW x 100
Limitations of 24-hour Recall
- Data entry and interviewing can be labor intensive - Relies on memory - One recall may not capture habitual intake - Underreporting / Over-reporting frequently occur
Diet Modifications for Pts with Poor Intake
- Allow pt to select from a menu - Cater to pt's food preferences - Ensure psychological needs at mealtimes are met: room temp, clutter on bedside table, offensive odors, lighting in room - Ensure physical needs are met: (feeding or set-up assistance- bedside table/meal tray within easy reach- pt assisted to wash hands and sit up for meals - orthopedic utensils, if appropriate) • Increase number and size of servings • Double servings of foods the patient will eat • Add foods that might not normally be on the tray - extra butter or olive oil for vegetables - sour cream or plain yogurt for potatoes - grated cheese to vegetables, soups, casseroles - Stir dried skim milk powder into milk beverages, soups, mashed potatoes, casseroles, hot cereals, etc. to increase protein and calories. • Concentrated sources of nutrients can also be added with commercial supplements such as - Beneprotein (protein) - Polycose (CHO)- Microlipid (fat) - Diet orders for "small frequent feedings" - set up for 4-6 meals/d, OR- serve patient 3 meals and 1-3 snacks - Caution: can be self-defeating if pt eats calorie dense snacks e.g. milkshakes, peanut-butter/crackers, etc. then is not hungry for next meal. - If ordering snacks for a pt, it is your responsibility to monitor the intake of the snack - stop it if not being eaten, or change it if reducing pt's meal intake.
The "ABCDs" of Nutrition Assessment
- Anthropometrics - Biochemical - Clinical - Diet Hx
Indirect methods of height measurements
- Arm Span Measurement provides a proxy measure of ht - Recumbent Length (tape measure) - Knee Height (calipers) Knee ht in cm is entered into equations to estimate ht.
Serum Total Protein:
- Assay of total proteins in the blood - Normal Range: 6.4-8.3 g/dL - Commonly used to monitor progression of disease states where muscle wasting is a clinical feature (cancer, kidney disease, immune disorders) - Poor indicator of nutritional status
Recommended Dietary Allowance (RDA)
- Average daily intake level of nutrient needed to meet the requirements of almost all healthy individuals (97-98%) - Serve as goal intake for individuals, not populations
How is weight interpreted?
- BMI - Usual weight - Actual weight
Components of Total Energy Expenditure (TEE)
- Basal Energy Expenditure (BEE) 60-70% of TEE - Activity 20-30% of TEE (varies) - Thermic Effect of Food (TEF) 10% of TEE Activity+thermogenesis+Basal Metabolic Rate
Metabolic Panels
- Basal Metabolic Panel (BMP): glucose, electrolytes, BUN, creatine - Complete Metabolic Panel (CMP): glucose, electrolytes,BUN, creatine, liver function tests (LFT's), albumin
24-hour recall best practices
- Before the interview, train the respondent in approximating portion sizes, etc. - Start with "What is the first thing you ate or drank yesterday?" - Don't ask leading questions. Ex: "What did you have for breakfast?" is a leading question. It suggests that you expected them to have had breakfast. They might not tell the truth if they think you will judge them. - End with "Was yesterday a typical day's intake for you?" Make a notation of "typical" or "atypical - lower/higher than usual (birthday, Thanksgiving, sick, etc.)
What is drug distribution affected by?
- Body Composition: Obese/older pts have greater proportion of adipose tissue to lean body mass & Fat-soluble drugs may have longer half lives - total body water (TBW) which decreases with age: water soluble drugs can be more concentrated - Low serum albumin: More of the drug remains unbound, so its therapeutic effect may be amplified
Acanthosis nigricans
- Brown to black, poorly defined, velvety hyperpigmentation of the skin. - It is usually found in body folds, such as the posterior and lateral folds of the neck, the armpits, groin, navel, forehead and other areas. - Associated with insulin resistance, diabetes, and other endocrine disorders
Factors to consider in choosing a method to assess dietary intake
- Characteristics of the patient/client/participant (Literacy, memory, commitment, age, etc.) - Validity of Data (degree to which data measures what it is intended to measure - does the method actually reflect usual intake?) - Reliability of data (correlates with consistency and reproducibility of data)
How can I monitor?
- Check weight - Obtain lab tests - Food diary or 24-hour recall - Calculate tube feeding infusion - Review I's and O's - Etc.
Medical History Description of physical problems
- Chief complaint - Present/Past Illnesses, Surgeries - Family Medical Hx (History) - Allergies / Intolerances - ETOH/Drug Use - Medications - Wt. History - ROS: GI, Pulmonary, CV, HEENT
Signs of Vitamin A Deficiency
- Chronic dry eye (xerosis of the conjunctiva and/or cornea) - Night blindness or impaired night vision - Hazy, softened cornea (advanced stages) - Bitot's spots - Follicular hyperkeratosis (gooseflesh) -food sources: leafy green veggies, yellow or orange veggies
Nutrition Assessments typically encompass
- Client history (includes medical hx and social hx) - Food/Nutrition-Related History - Anthropometric Measurements - Biochemical Data, Medical Tests, and Procedures - Nutrition-Focused Physical Findings
Information collected in nutritional assessments?
- Client history (includes medical hx and social hx) - Food/Nutrition-Related History (i.e., Diet History) - Anthropometric Measurements - Biochemical Data, Medical Tests, and Procedures - Nutrition-Focused Physical Findings
Soluble Transferrin Receptor
- Concentrations in the blood rise early in iron deficiency and in proportion to the magnitude of the deficit - High levels = iron deficiency
Important things to remember when interpreting labs
- Consider pt's age, sex, dx, meds, hydration status, etc. - Determine whether a lab value represents a fasted or postprandial sample - Refer to the lab's acceptable range (can be different based on age, sex, etc) - Consider non-nutritional causes for abnormal lab values (acute illness/injury can trigger dramatic changes in lab results) - Note units of measure (Conventional vs SI)
General considerations for Nutrition-Focused Physical Exam (NFPE)
- Consider the underlying medical condition (if known) -Use clinical judgement - Practice universal precautions: wash hands, clean any equipment thoroughly between patients, wear gloves or other protective clothing when indicated
National Dysphagia Diet:
- aim to establish standard terminology and practice applications of dietary texture modification in dysphagia management Level 1 (Pureed): - Pureed, homogenous, very cohesive, pudding-like, requiring very little chewing ability - Ex: Mashed potatoes, gravy, pureed carrots/chicken/broccoli, pudding Level 2 (mechanically altered): - cohesive, moist, semisolid foods, requiring some chewing, cooked fruits/veggies - No bread, dry cake, cheese cubes, corn, peas, rice Level 3 (advanced): - soft foods that require more chewing ability - most regular foods except very hard, sticky, or crunchy items - Ex: Bread, rice, cake, shredded lettuce, and tender moist meats are allowed - No hard, difficult to chew fruit and vegetables with skins, nuts, seeds, etc
Cachexia
- an emaciated condition characterized by loss of skeletal muscle mass associated with a disease state - Often has associated inflammation and increased resting metabolic rate, whereas simple starvation is characterized by decreased metabolic rate.
Fat distribution types
- android body shape (apple) - gyroid body shape (pear)
Protein energy malnutrition
- general term for inadequate energy and protein intake that can manifest in skin and hair, wasting of muscles, ridging on nails, etc -Severe states: kwashiorkor, marasmus, cachexia
Kwashiorkor
- inadequate protein intake with reasonable caloric (energy) intake - characterized by edema & easily pluckable hair and skin problems - most common between the ages of 1 and 4 years ("sickness of weaning")
Glycosolated Hemoglobin (HGB A1C)
- measure of how much glucose adheres to hemoglobin of red blood cells - good estimate of long term glycemic control - Normal: <5.7% - Goal for Diabetics <7%
Transferrin Saturation
- measures the amount of transferrin that is bound to iron - decreases with iron deficiency -sensitive test for hemochromatosis - Normal transferrin saturation = 20-40%
All amino acids can be consumed in the diet, primarily through
- meats, fish, poultry - eggs - milk and other dairy foods - legumes - soy foods - other vegetables and grains (e.g. wheat gluten)
Transferrin
- protein that transports iron in the blood -increases with iron deficiency
24 hour Urine Urea Nitrogen (UUN):
- sensitive measure of protein (nitrogen) balance which requires 24 hour urine collection generally used with TPN and tube feeding - Normal nitrogen balance = 0 in healthy adults - Catabolism = intake<losses (negative value associated with stress, sever trauma, starvation, etc) - Anabolism = intake>losses (positive value - could indicate impairment of the kidneys) - Nitrogen Intake equation: protein intake (gm/day) / 6.25 Nitrogen losses equation: UUN (gm/day) + 4 gm Not accurate in these cases: - Large non-urinary nitrogen losses - Diuresis - Fluid retention - Renal failure - Certain medications (corticosteroids) - Imprecise urine collection
Regular Diet
- standard, house, general, full diet - Pt has no dietary restrictions - Diet has no modifications or restrictions - Nutritionally adequate
Dysphagia:
- swallowing difficulty - Causes: Neurological disorders/conditions (MS, stroke, Alzheimers); Diseases/conditions affecting head and neck (head and neck cancers, trauma to swallowing structures;) Developmental problems (premature birth, cerebral palsy); Aging process; Certain medications - Difficult consistencies: Thin liquids, stringy foods, mechanically intensive foods, mixed consistencies, pills
Subcutaneous adipose tissue:
- the fat right underneath the skin - Assume that 50% of body fat is subcutaneous
When is parenteral nutrition used?
- when the GI tract is non-functional -last resort as it can lead to complications such as infection, metabolic, and fluid issues
Upper arm length guidelines
-90 degree bend -palm up -mark a horizontal line at the upper most edge of the posterior border of the ocromio process -measure from line to tip of elbow -divide by 2 to find midpoint where skin fold and circumference measurements should be taken
Soluble Transferrin Receptor
-Concentrations in blood rise early in iron deficiency and in proportion to the magnitude of deficit -high levels indicate iron deficiency
Xerostomia
-Dry mouth -Seen in poorly controlled diabetes mellitus, several autoimmune diseases and as a consequence of radiation therapy and many medications -Lack of saliva impedes all aspects of eating...
Weight Measurements guidelines
-Infants wear diapers -children and adults wear underwear and gown, paper pants and slippers -stand in the center of the scale, feet close together, hands at sides, look straight ahead -digital read out, recorded in kg to 2 decimal places
Stomatitis
-Inflammation of the oral mucosa -May be associated with HIV, autoimmune diseases, or radiation therapy for CA -Causes severe pain and ulceration of the gingiva, oral mucosa, and palate → painful eating
Mid-Arm Circumference (MAC)
-Is used in combination with TSF to calculate Arm Muscle Area (AMA) - Estimate of skeletal mass vs. fat stores - Reliable indicator of skeletal (somatic) protein & protein-energy malnutrition (PEM)
Tests to Evaluate Protein Energy Malnutrition (PEM): Creatinine-Height Index
-Measure of skeletal muscle mass that requires an accurate 24-hr collection of urine - Normal range: 80-100% of predicted value* indicate adequate muscle mass - 60-80% of normal range indicates moderate deficit - <60% of normal range indicates severe deficit
Basal Energy Expenditure (BEE) or Basal Metabolic Rate (BMR)
-Minimal amount of energy needed to sustain life (~60-70% of TEE) - Constant on a daily basis - Measured under very strict laboratory conditions for research purposes only - BMR is rarely measured; instead, RMR (or REE) is measured as an estimate of BMR
Temperature
-Normal= 98.6 F -May vary normally (~97-99 F) -A febrile state can increase REE and insensible fluid losses
Marasmus
-Overall energy deficiency and plasma protein levels may be WNL -Stunted growth, poor skin and visible bones
MNT - Food & Drug Interactions
1. Diet History - Inquire about use of alcohol, vit/min, herbal or other supplements; genetic problems, wt changes, appetite/intake changes, taste problems, GI problems 2. Provide pt with basic info about possible food-drug interactions - Take with or without food, indications for vit/min requirements, excipients that may be a problem 3. Discuss potential side effects that may affect nutrition (N/V/D/C) - High fiber and fluids with constipating drugs (Ditropan) - How to control side effects - Probiotics (Lactobacillus acidophilus, Saccharomyces boulardii) or psyllium (Metamucil) to control antibioticassociated diarrhea 4. Provide diet information that will support drug action - Low fat diet with cholesterol-lowering drug
Which 4 nutrient recomendations are used to create Dietary Reference Intakes (DRIs)?
1. Estimated Average Requirement (EAR) 2. Recommended Dietary Allowance (RDA) 3. Adequate Intake (AI) 4. Tolerable Upper Intake Level (UL)
What are the 5 domains of nutritional assessment?
1. Food/Nutrition- Related History 2. Anthropometric Measurements 3. Biochemical Data, Medical Tests, and Procedures 4. Nutrition-Focused Physical Findings 5. Client History
How should the RD initiate the interview?
1. Knock on the door 2. Address client with his/her name to confirm they are the correct client, using the appropriate title. Appropriate titles include "Mr., Mrs., Ms., Dr.," and for children, their first name. 3. Introduce self. This is done by stating your own name, profession, and by defining your role. Introduce yourself with the title by which you'd prefer to be addressed. 4. Request permission to interview in in-patient settings, and inquire if it is a convenient time. 5. Make time at the beginning to establish rapport with the client and put them at ease. Having a relaxed manner, with smooth flowing speech and smooth gestures will convey a feeling of relaxation. (hand shaking, small talk, inquire about the patient's comfort) 6. Explain objectives of the interview - at this point, do not go into complex detail. 7. Determine the client's understanding of his/her condition and feelings about it. Inquire about, and let the client express his/her level of knowledge and specific nutrition questions. This provides a starting point for the interview and an idea of the direction it needs to go.
Best indicators of Iron-deficiency anemia by iron deficiency stage
1. depleted stores - decreased ferritin concentration 2. Early functional deficiency - increased soluble transferrin receptor 3. Iron deficiency anemia - decreased hemoglobin, MCV, and transferrin saturation
RDA protein - moderate stresses
1.0-1.5g/kg BW - Moderate stress needs, Post op, small wounds (stageI and II)
RDA values (grams/kg/day) for Protein - Male & Female ages 1-3 yr
1.05 g/kg/day
RDA values (grams/kg/day) for Protein - Pregnancy (2nd half)
1.1 g/kg/day
RDA values (grams/kg/day) for Protein - Male & Female 7 months old
1.2 g/kg/day
RDA values (grams/kg/day) for Protein - Lactation
1.3 g/kg/day
RDA protein - severe stresses
1.5-2.0g/kg BW - sever stress needs, critical fever, sepsis, large wounds, trauma, burns
Due to the increasing portion sizes in the US, ________ of a large bagel and _________ of a large baked potato is now considered 1 starch exchange
1/4 large bagel; 1/4 large baked potato
What are the building blocks of proteins?
Amino acids
Alcohol-based formulation
An alcohol-containing preparation (liquid, gel or foam) designed for application to the hands for hygienic hand antisepsis.
Anaphylaxis
An extreme, often life-threatening, allergic reaction to an antigen
Nitrogen Balance Studies
An indirect method of determining protein requirement; Valuable for pts maintained on nutrition support (tube feeding or TPN)
Anemia of chronic disease
Anemia associated with a variety of infectious, inflammatory, or neoplastic diseases
Retinol Binding Protein (RBP)
Another serum protein sometimes used as a biomarker of nutrition status - Normal range: 2.6-7.6 mg/dL - Synthesized in liver - Binds with prealbumin to transport retinol (vitamin A) in the blood - Very short half-life (~10-12 hours)
Whole-room Calorimeter
Another variation of indirect calorimetry; only used for research purposes; very costly
Appetite stimulation is a side effect to what types of medications?
Antipsychotics, antidepressants, corticosteroids, etc
Hand hygiene
Any action of hygienic hand antisepsis in order to reduce transient microbial flora (generally performed either by handrubbing with an alcohol-based formulation or handwashing with plain or antimicrobial soap and water).
Clean / aseptic procedure
Any care activity that implies a direct or indirect contact with a mucous membrane, non-intact skin, an invasive medial device. During such a procedure no germs should be transmitted.
Invasive medical device
Any medical device that enters the body either through a body opening or through a skin or mucous membrane breaking.
Culture
Attitudes and behaviors that are characteristic of a group or community that includes language & communication, actions, customs, beliefs, and values
This term is used to describe elevated levels of BUN, creatinine, and other nitrogenous wastes in the blood.
Azotemia (also sometimes called uremia)
Body Mass Index
BMI = weight (kg)/height (m2) - Correlates with body fatness as well as weight - Indicative of over- or under-nutrition and is predictive of associated health risks - Does not take into account differences in race, sex, age, and body composition
Meal Plan should be based on __________ & encourage ________
Based on history/food record; Encourage variety from all food groups
Common lab panels in the hospital include the BMP and CMP. What are these acronyms?
Basic metabolic panel = glucose, electrolytes, BUN, and creatinine Complete metabolic panel = glucose, electrolytes, BUN, and creatinine`, albumin, LFTs
Why is hypertension called the silent killer?
Because it has no symptoms
Subcutaneous fat loss inspection - Arm
Bend arm and pinch at triceps Only pinch the fat, not the muscle - Normal: fingers don't meet - Abnormal: fingers meet
Supplementation of fat-soluble vitamins may be necessary for someone taking:
Bile acid sequestrants
Whole blood
Blood from which none of the elements have been removed. It is usually referred to as blood, collected from a doner and anticoagulated for the purpose of blodd replenishment for a recipient
1st law of thermodynamics, and how does this relate to nutrition?
Energy cannot be created or destroyed; this goes for human energy as well - we take in energy in the form of macronutrients, which are broken down via several different metabolism processes and converted into energy we can use
Soluble transferrin receptor concentrations are ____________ with iron deficiency.
Elevated
Which of the following would not be classified as a dietary supplement according to the Dietary Supplement Health and Education Act of 1994 (DSHEA)?
Ensure shakes
nasogastric or nasoenteral enteral nutrition
Enteral nutrition via nose - can be placed through the nose into the stomach or small bowel
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
Enzymes involved in hepatic amino acid metabolism - Elevated blood levels may indicate liver damage
Retrospective Medical Nutrition Therapy for Food-Drug Interactions
Evaluation of symptoms to determine if medical problems might be the result of food drug interactions
What are the two strategies for learning consistent CHO meal patters?
Exchange lists & Carbohydrate counting
Nitrogen balance
Expected state for a health adult (Nitrogen balance = N intake - N losses) N intake = protein intake (gm/day) ÷ 6.25 N loss = UUN (gm/day) + 4 gm
Hamwi Formula
F = 45.5 kg + 2.2 kg per every inch over 5 feet. M = 48 kg + 2.7 kg for each inch over 5 feet
True or False: RBP and Serum Total Protein are commonly used to monitor nutrition status.
False - RBP has a very short half-life, but it's no better than PAB (and PAB is much cheaper). Serum Total Protein is commonly used to monitor disease states such as cancer, but it's a poor indicator of nutritional status.
"Free" Foods
Foods that can be eaten freely (normal portion sizes), or added in moderation, above the meal pattern; contain less than <20 calories Water, calorie-free beverages, butter flavoring (fat free), Spices, pepper sauce, lemon juice, lime juice, nonstick pan spray, Vinegar, Mustard, Worcestershire or soy sauce, bouillon or broth (fat-free), gelatin (sugar-free), gum (sugar-free), sugar substitutes (aspartame, saccharin or acesulfame-K), BBQ sauce (1 - 2 T), cocktail sauce (1 - 2 T), dill pickles (1 1/2 large), jam or jelly (low-sugar or light; 1 - 2 T), ketchup (1 to 2 T), margarine, fat free (4 T), mayonnaise, fat-free (1 T), Miracle Whip salad dressing, fat free (1 T), nondairy creamer (2 T) , pancake syrup, sugar-free (1 - 2 T), pickle relish (1 T) , salad dressing, fat-free (1 T), salsa (1/4 cup), sour cream, fat-free (1 T), soy sauce, regular or light (1 T) , sweet and sour sauce (1 T) , sweet pickles, bread-and-butter (2 slices), sweet pickles, gherkin (3/4 ounce), teriyaki sauce (1 T), cream cheese, fat-free (1 T), cocoa powder, unsweetened (1 T), cranberries sweetened with sugar substitute (1/2 cup) , hard candy
Carbohydrate Counting - Fiber
For CHO counting purposes, if a serving of a food contains > 5 grams of dietary fiber, you can subtract ½ of the grams of dietary fiber from the total CHO serving of that food.
Example of CHO Counting
For a patient who needs ~2000 kcals/day: - 2000 kcals x 50% AMDR for CHO = 1000 kcals - 1000 kcals ÷ 4 kcals/gram CHO = 250 grams CHO/day - 250 gm CHO ÷ 15 gm CHO/exchange = ~16-17 CHO exchanges/day
Activity Factors
For non-stressed patients: - 1.2 - Bed rest (confined to bed) - 1.3 - Ambulatory / light activity - 1.4-1.9 Normal activity depending upon someone's daily activity level *do not need to memorize*
Sodium Restricted Diets
For patients with heat failure or end stage liver disease - Low sodium, no added salt
Assessment of pediatric nutrition
For pediatric patients, growth is assessed by growth charts for age and gender -z score shows how many standard deviations a child is from the norm for his/her reference group of age
Ideal body weight Adjustment for amputation
Hand 0.7% Forearm and hand 2.3% Trunk without extremities 50% Entire arm 5.0% Foot 1.5% BKA 5.9% AKA 11.0-15.0% Entire leg 16.0%
Main component of RBCs that binds oxygen.
Hb Male 14-18 g/dL Female 12-16 g/dL
This lab gives you an idea of someone's estimated average blood glucose levels over the past few months.
HbA1C Goal for diabetics = <7%
% of RBCs in total blood volume
Hct Male: 42-52% Female: 37-47%
Nutrition-Focused Physical Exam (NFPE)
Head to toe assessment tailored to each patient; Systems approach (Organized, logical); Moves from global to more defined (Based on results of medical and nutrition histories)
Retrospective MNT Protocol
Look for possible food-drug interactions - Complete nutrition history - Complete medical history • Look for other possible reasons for the symptom - Date of drug initiation; date of symptom onset - Research reported drug side effects to assess the likelihood the symptom actually results from the drug.
Hemochromatosis
Genetic disease that leads to too much iron absorption and storage, characterized by extremely high levels of iron in the body - 60-100% transferrin saturation - Treated with phlebotomy, chelation therapy, low-Fe diet
Thalassemia
Genetic disorder that results in inadequate Hb production
Determining fluid needs: 1500 mL + method
Give 1500 mL for the first 20 kg of BW - If <50yo, give 20 ml/kg for remaining kg BW - If >50yo, give 15 ml/kg for remaining kg BW Pt is a 45yo male and weighs 85 kg - 1500 mL for the first 20 kg - Remaining 65 kg x 20 ml/kg = 1300 ml - Estimated fluid needs are 2800 ml/day
MT is a 56-year-old female recently diagnosed with hyperlipidemia. She is prescribed simvastatin. Which food would she want to avoid?
Grapefruit
A patient taking _________________ may benefit from supplemental coenzyme Q10.
HMG-CoA reductase inhibitors
Anthropometric Measurements
Height, weight, body mass index (BMI), growth pattern indices/percentile ranks, and weight history
Why does drug metabolism decline with aging?
Hepatic metabolism tends to decline with aging because the liver prioritizes ethanol metabolism, alcohol can pose dangerous food-drug interactions.
Tolerable Upper Intake Level (UL)
Highest level of daily nutrient intake that is unlikely to have adverse health effects
What types of events will reprioritizes liver's protein synthesis?
Hormonal and cell-mediated stress will result in an overall decrease in negative acute phase respondents and an increase in positive acute phase respondents
Pharmacodynamics
How a medication affects the body Includes both the therapeutic/clinical effects we want to achieve from the drug as well as side effects.
Pharmacokinetics
How the body affects a medication; Includes Absorption, Distribution, Metabolism, Excretion
Someone taking a potassium-sparing diuretic for hypertension may be at risk for:
Hypokalemia
Name the terms for low serum sodium and potassium.
Hyponatremia, hypokalemia.
Energy Needs of Overweight/Obese Adults
If possible, RMR should be measured by indirect calorimetry - If RMR cannot be measured - Mifflin-St. Jeor equation using ACTUAL weight is the most accurate for estimating RMR for overweight and obese individuals - An energy deficit below TEE is necessary for weight loss
Subcutaneous Fat Loss/Muscle Loss Assessment
Inspect for loss of fullness or loose-fitting skin; may see loose skin in older adults who are not malnourished
Physical Examination Techniques
Inspection, Palpation, Percussion, Auscultation
Vegetarians and complement proteins
In the past, dietitians would advise vegetarian clients to complement protein foods at each meal. Research has since shown that it is not necessary to complement amino acids at every meal. It is still wise, however, to consume a variety of plant foods over the whole day to ensure adequate intake of essential amino acids
PES examples
Inadequate protein intake related to changes in appetite as evidenced by 24-hour recall showing an average daily protein intake that is 40% less than estimated requirements Swallowing difficulty related to post-stroke complications as evidenced by results of swallowing study and reports of choking during mealtimes
Oxandrolone (Oxandrin) is prescribed to:
Increase appetite and facilitate weight gain
An elevated CRP value signifies ______________.
Inflammation Positive acute phase respondent
Injury Factors
Injury factors may be applicable for stressed/ill persons - 1.1-1.2 for localized infection or injury, minor surgery - 1.35 for skeletal trauma - 1.3-1.55 for moderate stress, severe localized infection - 1.6 for major sepsis or cancer - 1.75 for severe stress, major surgery, severe sepsis - 2.0+ for severe burns or closed head injury - However, neither the Harris Benedict nor the Mifflin St. Jeor equations are the best choice for critically ill patients on mechanical ventilators. *do not need to memorize - just need to know to multiply this number by REE to get TEE*
Side effects of chemotherapy
Nausea, Vomiting, Anorexia, Dysguesia
Evaluating nitrogen balance
Negative = catabolism 0 = catabolism Positive = anabolism
Pellagra
Niacin deficiency resulting in the 4-Ds - dementia, dermatitis, diarrhea, and death
Vitamin A deficiency can result in
Night blindness and Bitot's spots
Nitrogen Balance
Nitrogen balance = nitrogen intake - nitrogen losses - Nitrogen intake=grams of protein intake/6.25 - Nitrogen losses = urinary urea nitrogen (UUN) + 4 grams (Non-urea urinary nitrogen + fecal nitrogen + miscellaneous losses from skin, sweat) Nitrogen balance (g) = (protein intake in grams/6.25g nitrogen per g of pro) - (UUN excretion in g + 4 g) - Nitrogen balance for adults should be 0 (normal homeostasis)
You would most likely document your nutrition assessment in this section of the medical record:
Progress Notes
Nitrogen Balance Practice
Protein intake: 90 g protein 24hr UUN: 20g N - Nitrogen intake = 90/6.25 = 14.4gN - Nitrogen losses = 20 + 4 = 24g N - Intake - Losses = 14.4 - 24 = -10 Negative Nitrogen Balance
Wrist circumference assessment (R)
R=height (cm)/wrist circumference (cm) Small - Women: >11.0 - Men: >10.4 Medium - Women: 10.1-11.0 - Men: 9.6-10.4 Large - Women: <10.1 - Men: <9.6
Determines the total # of erythrocytes in sample of blood
RBC
The most common measurement for assessing folate status is
RBC folate concentration.
Normocytic anemia
RBCs of normal size often associated with anemia of chronic disease (e.g., chronic infection, tissue injury, etc.) - May be seen in early iron deficiency anemia
People who are underweight and/or who are chronically dieting have lower
REE/RMR
What can we use to estimate BMR/BEE?
REE/RMR
Your patient is an 84 YOF with a current weight of 225 lbs and height of 5'6". Use Mifflin St. Jeor to calculate her REE.
REE=9.99W+6.25H-5A-161 W = 102.27 kg; H = 167.64 cm 9.99(102.27) + 6.25(167.64) - 5(84) - 161 1022+1048-420-161 REE = 1489 calories *multiply times activity factor to esteem TEE; multiple by injury factor if patient is diseased or int he hospital
Recommended Dietary Allowance (RDA)
The average daily dietary intake of a nutrient that is sufficient to meet the requirement of nearly all (97-98%) healthy persons. This is the number to be used as a goal for individuals.
Linguistic Competence
The capacity to communicate effectively and convey information in a manner that is easily understood by diverse audiences
Health Literacy
The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions
Enteral Nutrition
The delivery of nutrients directly into the stomach or small intestine by a feeding tube
How should a dietitian prepare for an interview with a patient?
The dietitian should obtain the name, address, age, occupation, religion, referral reason, etc., (sources include medical chart, nurse, social worker, etc.)
Tolerable Upper Intake Level (UL)
The highest continuing daily intake of a nutrient that is likely to pose no risks of adverse health effects for almost all individuals. As intake increases above this amount, the risk of adverse effects increases.
Which method of meal planning for diabetes would be most appropriate for a patient with low-literacy skills or cognitive impairment?
The plate method
Follicular hyperkeratosis (gooseflesh)
Vitamin A deficiency
Urine Glucose
There is not normally glucose in the urine, but when glucose levels exceed the kidneys threshold for reabsorption (blood glucose > 180 mg/dL) it spills over into the urine causing glycosuria - Normal range: Negative -Evaluation of hyperglycemia, effectiveness of DM therapy
Why are Laboratory Tests a critical part of the nutrition assessment?
They provide more objective data (compared to other measures such as diet hx or physical examination) that can support subjective judgment and assessment findings
Beriberi
Thiamine deficiency characterized by muscle weakness, poor coordination, mental confusion, peripheral neuropathies, sometimes edema (wet beriberi vs. dry beriberi)
Dysphagia: Common Problem Consistencies
Thin Liquids Particulate Foods Stringy Foods Mechanically Intensive Foods Mixed Consistencies Pills
Fecal occult blood test
Type of stool sample test for "hidden" blood losses in feces - May indicate a GI bleed, colorectal cancer, etc
Nutrition Screening
Typically precedes the NCP provided by the RD/RDN that quickly identifies individuals at nutritional risk Examples: - Malnutrition Universal Screening Tool (MUST) for adults - Mini Nutritional Assessment (MNA) - for older adults
Side effects
Undesirable effects of a drug may affect nutritional status.
Android body shape (apple)
Upper body fat (android or central obesity) - Greater risk of chronic diseases - heart disease, stroke, diabetes, hypertension, some cancers
Physical Examination - Auscultation
Use of a stethoscope to listen to body sounds (Heart, lungs, blood vessels, bowel sounds)
Heart Rate
Usually assessed by radial pulse; bpm - Count pulsations for 15 seconds and multiply by 4 - If irregular, count for a full 60 seconds
dyslipidemia
abnormal blood lipid levels, including high total, low-density lipoprotein, and triglyceride levels as well as low high-density lipoprotein levels
A patient with elevated BUN and serum creatinine may likely have _______________.
abnormal renal function
Components of pharmacokinetics
absorption, distribution, metabolism, excretion
Vegan
abstains from animal products • Ensure adequate intake of calcium, iron, zinc, vitamin B-12 and vitamin D
Obesity Adjustments for Hamwi Formula
adjusted ideal body weight - Men: (Actual weight - IBW)x0.38 + IBW - Women: (Actual weight - IBW)x0.32 + IBW
Blood levels of _______________ would be expected to decrease during an acute phase inflammatory response.
albumin
Hepatic Transport Proteins
albumin, prealbumin, transferrin, retinol-binding protein
What is stronger and less irritating than soap?
alcohol based gel
Dysgeusia
altered taste
Nonessential amino acids
amino acids that can be produced endogenously
Essential amino acids
amino acids that must be consumed in the diet
Half-life
amount of time it takes for the blood concentration of a drug to decrease by ½ of its steady state level
Which of the following foods is strictly prohibited by Hindu dietary practices?
beef
The energy in food can be measured by
calorimetery
Pitting edema
can be checked by momentarily pressing the area (e.g., the ankle) with a finger and then looking for a persistent depression where the finger was.
Lower-than-normal _______________ could indicate iron deficiency anemia
serum ferritin
Lab Tests for Iron-deficiency Anemia
serum iron, serum ferritin, TIBC, transferrin saturation, Soluble Transferrin Receptor
Carbohydrate Counting - Sucrose
should be counted as a carbohydrate source (1 Tbsp = 15 g)
What do we detect in a nutrition focused physical exam?
signs and symptoms
Petechiae
small pinpoint hemorrhages in the skin; vitamin c deficiency
Normal nails
smooth, translucent, slightly curved nail surface, firmly attached to nail bed, nail bed with brisk capillary refill
Electrolytes
sodium, potassium, chloride, Bicarbonate
Lanugo (latin - wool)
soft, downy hair covering the body; common with anorexia nervosa
Privacy Safeguards
• Avoid conversations involving PHI in public common areas such as hallways, stairwells, or elevators. • Keep documents containing PHI in locked cabinets or locked rooms when not in use. • Do not leave materials containing PHI on desks, countertops, etc. • Do not remove any PHI in any form from the designated work area unless you are authorized to do so by your supervisor. • Never take photographs in patient care areas. • Arrange computer screens so they are not visible to unauthorized persons. • Log in with your own password, and log off before leaving the computer. • Do not share passwords. • No PHI is permitted on any social networking sites (Twitter, Facebook, etc.) • No PHI is permitted in text messages or chat platforms. Follow your organizations policy regarding email and fax transmission.
The Exchange System
• Based on "Choose Your Foods: Exchange Lists for Diabetes" • Published by the Academy of Nutrition and Dietetics and the American Diabetes Association
Lab Tests for B-vitamin deficiency
• Before treatment, is important to determine which B-vitamin is deficient. • Folate and B-12 deficits result in macrocytic, megaloblastic anemia • Vitamin B-12 status can be assessed by directly measuring B-12 in the blood or a methylmalonic acid test (MMA) - MMA is a functional biomarker that accumulates when vitamin B-12 is inadequate.
Arterial Blood Gases (ABGs)
• Blood draw from an artery (painful) used to assess acid-base disorders - Partial pressure of oxygen (PaO2) - Partial pressure of carbon dioxide (PaCO2) - Blood pH
What to look for when inspecting a patients via physical examination
• Body habitus • Positioning or muscle contractors (the tightening/shortening of the muscles) • Is the pt ambulatory? • Any amputations? • Feeding devices (feeding tubes, vascular access devices) • Level of consciousness • Ability to communicate • General affect = "observable manifestations of a subjectively experienced emotion"
Examples of what can be ingested on clear liquid diet
• Broth• Gelatin • Strained fruit juices • Clear beverages • Popsicles • Enlive • Resource Breeze
Supplement manufacturers must disclose:
• Composition • Purity • Identity of ingredients
SOAP - PLAN
• Course of actions to be taken to resolve ALL the problems discussed in 'A' • All problems planned for in 'P' must be mentioned in sections 'S', 'O', or 'A' • All plans must be PATIENT FOCUSED* for optimal effectiveness
Intercultural Communication:
• Courtesy and respect are cross-cultural. • Establish rapport. • Be attentive to verbal and nonverbal cues from the client. • Let clients determine their personal space. • Observe how clients make eye contact. • Note how clients use silence. • Ask open-ended questions
Common drug-nutrient interactions: Bile acid sequestrants such as cholestyramine (Questran®)
• Decrease reabsorption of cholesterol in bile in the small intestine • May also may decrease the absorption of fat-soluble vitamins. So, supplemental vitamins A, D, E, and K are often recommended.
Age-related changes and medication adherence
• Decreased visual acuity, hearing loss, and/or cognitive impairment may hinder a patient's understanding of instructions. • Depression • Dysphagia
SOAP - Assessment
• Educated, professional interpretation of the data provided in 'S' & 'O' sections (PES statement) • Calculations for nutritional needs (kcals, pro, fluid) • The place to express clinical judgment about what may be wrong with, or what may help, a pt • For the RD, these comments pertain to the pt's nutritional status • Important: The indicators for any problems discussed in the Assessment section MUST appear in either sections 'S' or 'O'
Nutritional Supplements examples
• Ensure Plus • Boost • Glucerna • Enlive • Nepro • Mighty Shakes • Magic Cup
Fasting Serum or Plasma Glucose
• Evaluation of diabetes • Normal range: 70-99 mg/dL (fasting) • Fasting levels > 126 mg/dL diagnostic for diabetes • Hypoglycemia = blood glucose < 70 mg/dL
Regulation of Dietary Supplements
• Food and Drug Administration (FDA) approval is not necessary for products sold as dietary supplements. • In fact, in order for a dietary supplement to be removed from the market, the burden of proof falls on the FDA to provide sufficient evidence that the product is unsafe. Due to limited resources, the FDA typically only pursues dietary supplement recalls after adverse events are reported by consumers. • Also, the FDA doesn't regulate the amount of each ingredient in a product or the serving size recommended by the manufacturer.
Signs and Symptoms (S/S) of Inadequate Nutrition - Overview
• General appearance • Fat/Muscles (L of subcutaneous fat and/or muscle wasting, Edema) • Vital signs • Hair and Nails • Skin• Wounds • Eyes • Oral cavity
Signs & Symptoms of Inadequate Nutrition
• General appearance • Fat/Muscles(Lack of subcutaneous fat and/or muscle wasting, Edema) • Vital signs • Hair and Nails • Skin • Wounds • Eyes • Oral cavity
Guidelines to wearing gloves
• Gloves should be worn any time you are in contact with blood, body fluids, or mucous membranes. • Cover any cut or sore on your own hands with a bandage before putting on gloves. • Inspect your gloves for tears or punctures. • Remove gloves and wash hands immediately after patient contact.
Electronic Health Record (EHR)
• Health care facilities were required to demonstrate "meaningful use" of the EHRs by 2014.
Dietary Reference Intakes (DRIs)
• Helpful in advising patients/clients about appropriate supplementation of vitamins and minerals. • The DRIs include not only Recommended Dietary Allowances (RDAs) but also tolerable upper limits (ULs) for micronutrients. The UL for any particular nutrient represents the maximum daily amount that is thought to pose no harm. • The DRIs also stratify recommendations by age and gender.
MNT for chemotherapy
• High kcal/protein supplements • Cold liquids through a straw or ice chips for pain • Room temperature food without strong odors • Remember food safety • Consider enteral nutrition support
