NSC 325 Exam 2 review

Fluid Balance in elderly

-1 kg (2.2 lb.) = 1 liter 1) Fluid requirements: Typically 1.5-3 liters/d 25 mL/kg- 40 mL/kg depending on age 35 mL/kg up to age 55 30 mL/kg >56-75 y.o. 25 mL/kg for > 75 y.o 2)Clinical status influences: A. Less fluid needed: Congestive heart failure End-stage liver disease End-stage renal disease B. More fluid needed: Diarrhea Fluid lost from wound drainage 3) Fluid Losses: •Urine output = ~1.5 liters/day •Insensible losses = 500 mL - 1 liter/d •Miscellaneous - 150 mL/d •Other: •NG output in hospitalized patients •Vomiting/GI losses (e.g., fistulas, wounds, stool)

Fluid Shifts

-1st space shifting: normal distribution between ICF & ECF -2nd space shifting: excess accumulation of fluid in the interstitial tissue -3rd space shifting: fluid shifts into spaces that typically have little fluid

Physical Manifestations in elderly

-Body weight -Skin turgor 1) Physical examination: a. Extremities b. Abdominal exam 2)Vitals: a. Blood pressure, respirations, heart rate & temperature b. I/Os [input/output] c. Level of consciousness d. Thirst

Atrial Natiuretic Peptide (ANP)

-Cardiac hormone -increases due to pressure in atria -opposes renin-angiotensin-aldosterone system -stimulates excretion of Na++ & water -decreased vasoconstriction and increased vasodilation

Benefits of EN

-GI barrier function and morphology (GALT & MALT) -First-pass metabolism: promotes normal function -Promotes normal gall bladder function-> release of CCK -Secretion of IgA-> decreases bacterial adherence & translocation -Reduced infectious complications: pneumonia, sepsis, intra-abdominal abscess -decreases overall complications and costs compared with PN •Timing - Clinical Guidelines: 1) Critically ill: "window of opportunity" A. w/in 24-48 hours-> < infectious complications & decreased LOS •Hemodynamically stable: ✓ MAP, fluid intake & medications [pressors (dopamine, epinephrine, norepinephrine, etc.) - if increased, don't feed] •Cumulative caloric deficit associated with > LOS and complications •Non-critically ill: inadequate oral intake for 7-14 days or decrease intake for 7-14 days expected

Disease Specific Formulations: Supplements/Modulars

-Increase calories: benecalorie (330 kcals/container); home feedings - add oil/milk/juice -Increase protein: promod, liquaCel [16 g protein/oz.], etc. -Fiber: benefiber, etc. -Wound healing/wasting: Juven (HMB)/arginaid (arginine) -Glutamine -MCT oil -Powders: mix with 30 mL warm water and flush down the feeding tube

Anti-diuretic Hormone (ADH)/Vasopressin

-Produced in hypothalamus -> stored in pituitary -Controls blood volume by increasing/decreasing excretion of water -Release stimulated by decreased blood volume increased osmolality -> kidneys retain water: -Can also be released by pain, surgery, stress and some medications

Aldosterone

1) secreted by adrenal gland in response to angiotensin II 2)kidney retain Na & water 3)increases in fluid & Na levels 4)Decreases K+ reabsorption 5)Maintains BP & fluid balance

Contradictions

1)Absolute -GI not available -No access -Total bowel obstruction -Hemodynamically unstable -Aggressive support not warranted/desired -Harm out weights benefits 2)Relative -Vomiting/diarrhea -High output fistula -Ileus -GI bleed -Severe acute pancreatitis

Acid-Base Balance

1)Acid = any substance that releases hydrogen ions in a solution 2)Base = any substance that accepts hydrogen ions in solution 3)pH range: arterial blood level 7.35-7.45 = acid-base balance Regulated by: Kidneys Lungs Buffering systems (form weaker acids/bases) 3)Balance maintained by lungs & kidneys a. Kidneys: regulate hydrogen ion secretion and HCO3- resorption b. Lung: control alveolar ventilation-> alter depth & rate of breathing •Acid-base disorders can differentiated based whether arise from renal or pulmonary causes

Type of Infusion Methods

1)Bolus -Volume infuses via gravity generally thru a syringe for 10-15 min -Use ONLY for gastric feedings 2)Intermittent -Similar to bolus but infuses longer - 30-45 mins; use for gastric feedings 3)Continuous -Infuses slowly over the hour; can run for any length of time: 8, 12, 20 or 24 hours -Can be used for gastric or small bowel feedings -Requires a feeding pump for infusion

EN Administration

1)Continuous infusion: a.Start at 30 mL/hr & advance by 25-30 mL/hr every 8 hours until at goal rate; ↓ MIV to avoid fluid overload 2)Bolus infusion: a.Start at 150 mL for the first feeding; ↑ to 240 mL for the second & then ↑ to 350-400 mL per feeding at the final stop b.Only ↑ feedings as tolerated - √ing for signs of complications •Continue EN until 60% of nutritional needs met via an oral diet when transitioning off EN

EN complications

1)Mechanical -Tube pulled out -Tube clogs/kinks 2)Metabolic -Electrolyte abnormalities -Acid/base abnormalities -Hyperglycemia -Refeeding syndrome 3)GI -Elevated gastric aspirates -Aspiration -Diarrhea/constipation -Low flow state (check MAP) -GI bleed -Most common

Enteral Formulas

1)Micronutrients & Electrolytes a.Most meet needs with 1200-2000cc b.Low electrolyte formulas for renal patients 2)Fiber a.May help normalize GI fxn b.Blood glucose control 3)Hydration: need to determine % of free water the formula will provide compared to your calculated fluid requirements a.There will be gap that needs to be "filled" with exogenous free water (I.V. in hospital/tube flushes at home)

Where to Delivery (bowel sounds or stool output NOT needed for EN)

1)Short-term feedings (<4 weeks): -Naso/orogastric (NG) = nose/mouth to stomach -Naso/oroduodenal (ND) = nose/mouth to duodenum -Nasojejunal (NJ) = nose/mouth to jejunum 2)Long-term feedings (> 4 weeks): Gastrostomy/PEG/PEGJ/Jejunostomy

Trouble shooting EN complications

1)Vomiting/aspiration/elevated gastric residuals? -Put feeding tube in the small bowel -If on high protein/ fiber / fat formula- change formula to decrease these components •Diarrhea: -✓ formula components - > fat in formula can cause diarrhea-> change to standard or peptide-based -Consider changing to fiber formula or use fiber modular (benefiber) -✓ medications or for C. dif infection •Constipation: ✓ water/ fiber intake/✓ medications

A 45 y.o. female has chronic kidney disease as manifested by a GFR of 38 (normal: >60). Based on a pH of 7.1, what type of acid-base disorder does she likely have? A.Metabolic acidosis B.Respiratory acidosis C.Metabolic alkalosis D.Respiratory alkalosis

A.Metabolic acidosis 7.1 is below range so it is more acidic, and GFR relates to kidneys so it is metabolic

Which of the following can potentially develop due to a patient who is on Nexium? A.Vitamin A toxicity B.Zinc deficiency C.Folate and calcium deficiencies D.Vitamin B12 & iron deficiencies

A.Vitamin B12 & iron deficiencies

A 22 y.o. male just had surgery to repair his abdomen after experiencing a gunshot wound. His pH is 7.49. He has a NG tube to low continuous suction. What type of acid-base disorder is he likely developing? A.Metabolic acidosis B.Respiratory acidosis C.Metabolic alkalosis D.Respiratory alkalosis

C.Metabolic alkalosis pH is 7.49 which is higher than range so it is alkalosis, NG tube to low continuous suction, take out gastric acid from stomach so its metabolic

Mr. Carrington has been in the hospital 3 times in the past month for pneumonia. The team thinks it is related to aspiration of food & liquids and is planning to place a feeding tube. Which of the following would you recommend for Mr. Carrington? A.Nasogastric tube B.Nasoenteric tube C.PEG D.Jejunostomy tube

C.PEG has persistent aspiration, and will probably continue to happen, so no oral route should occur, will be long term so PEG is best option

Nutrition Support

Enteral: via feeding tube into GI tract Parenteral: intravenously administered directly into bloodstream EN preferred route: GI immunology

Fiber & Fluid for elderly

FIBER: •Diets typically low in fiber •Fiber goals: •Women: 20 gms/d or 14 gms/1000 kcals •Men: 31 gms/d or 14 gms/1000 kcals •Encourage > intake of fruits, veggies & whole grains •Decrease intake of fast & processed foods FLUIDS: •Subclinical dehydration is common •Assess adequacy of fluid intake •Assess coffee/soda/water/alcohol intake •Assess if fluid intake should be increased or decreased based on clinical status •Typically 25 mL/kg

13. What do the following abbreviations stand for: NG ____________________ ND ____________________ NJ ____________________ G-tube ____________________ J-tube ____________________ PEG ____________________ PEJ __________________

NG-> nasogastric ND-> nasoduodenal NJ-> nasojenunal G-tube-> gastrostomy J-tube-> jejunostomy PEG-> percutaneous endoscopically-placed gastrostomy PEJ-> percutaneous endoscopically-placed jejunostomy

Would you start EN in this patient who is a 20 y.o. male admitted to the ICU this morning after sustaining a closed head injury due to a scooter accident on the U of A campus? He is comatose, intubated and sedated.Ht: 6' Current Wt: 180 lbs. UBW: 173 lbs.Meds: warfarin, antibiotics, lasixVitals: BP: 120/80 Temp: 98.8 MAP: 58, 56 MIV @ 130 mL/hr I/Os: 2400/1200 Yes or NO

NO; map is less than 60, 58-56, means that he has inadequate function of GI, we have to wait till map increases

Bolus infusion Nutrition Prescription 1500 kcals/d, 75 g of protein, 1600mL to meet hydration -plan is to use 1.5 kcal/mL formula which provides 62.7 g of protein/L & 100% of RDIs in 1000 mL

Step 1 -8am: start w/ 1/2 can (150mL) for 1st feeding; flush w/ 60 mL before/ after feeding -11am :increase feeding to 1 can & flush w/ 60 before/ after feeding -2pm: increase feeding to 1.5 cans & flush w/ 60 mL before/after feedings -5pm: blous 1.5 & flush w/ 60 mL of water before/ after feeding -if tolerating increase EN volume, flush feeding tube in between feeding w/ 110 mL of water Step 2: Next day: give 1 can @ 8am, 11am, & 5pm flush w/ 60mL of water before & after feeding; give 1.5 cans @ 2pm & flush w/ same amount before and after feeding. flush tube in between all feedings w/ 110mL (this will be 3x a day; its 10mL more than needs but keeps measure simple)

Continuous Infusion

Step 1: Always start EN at 30 mL/hour Step 2: Decrease MIV by same amount: Ex:MIV running at 90 mL/hour before EN starts, then start EN @30 mL/hr and MIV to 60 mL/hr; eventual desired GOAL RATE: 65 mL/hr & free water needs are 1800 mL/day; formula provides 82% free water Step 3: Increase EN to goal rate mL/hr since you are so close & MIV by mL/hr Ex:EN @ 30 mL/hr thus to 65 mL/hr & MIV to 22 mL/hr since you are at your EN goal rate so adjust MIV to fill gap in free water needs Formula @ goal rate of 65 mL/hr will provide 1279 mL of free water per day [65 x 24 = 1560 mL/d of which 82% is free water] 1560 x .82 = 1279 mL/d of free water Needs = 1800 mL/d EN providing= 1279 mL/d GAP= 1800 - 1279 = 521 mL still needed so use MIV 521 divided by 24 hours in the day = 21.7 mL/hr so round up to 22

Cellular Classification

TBW func of: wt, age, sex, & body fat TBW: 50-60% Intracellular: 66% of TBW transcellular: 3% Extracellular: 30% Interstitial/ intravascular -fluid compartments separated by selectively permeable membranes that control movement of water & solutes

Fluid Distribution w/ pressures

The movement of the arterial solution from the point of injection through the blood vascular system. •Movement of fluids: •Oncotic pressure: allow fluid movement into the interstitial space; controlled by albumin (large molecule) •Hydrostatic pressure: focuses fluid & solute ècapillary wall pressure •çè inside/outside of capillary walls drives movement •"third-spacing" accumulation of excess fluid in the interstices (edema) è can move back into ECF but can result in severe volume depletion

All of the following describe the behavior of fat cells except: a. # of fat cells decreases with weight loss b. storage capacity for depends on both cell number and cell size c. Fat cells are larger in size in obese people compared with normal-weight individuals d. The number increases several-fold during the growth years and tapers off when adult status

a. # of fat cells decreases with weight loss

Which of the following adipokines is associated with antioxidant benefits? a. Adiponectin b. Leptin c. Tumor-necrosis factor d. Amylin

a. Adiponectin

All of the following GI peptide hormones have effects that decrease food intake except: a. Ghrelin b. Amylin c.Glucagon-like peptide 1 d.Insulin

a. Ghrelin

Scott, a 68 y.o. male, will be undergoing surgery for a knee replacement tomorrow. During your nutrition assessment, you noted that Scott is 5'8" and weighs 210 lbs (stable). Due to knee problems he has difficulty walking, even to the mailbox. Which of the following might you suspect based on this information? a. Scott may have sarcopenia obesity b. Scott is malnourished c. Scott is underweight d. Scott may have chronic disease related malnutrition

a. Scott may have sarcopenia obesity

Which of the following is a feature of elderly people and water metabolism? a. They do not feel thirsty or recognize dryness of the mouth b. They have a higher total body water content compared with younger adults c. They show increased frequency of urination which results in higher requirements d. They frequently show symptoms of overhydration such as mental lapses and disorientation

a. They do not feel thirsty or recognize dryness of the mouth

Oncotic pressure controls fluid movement via albumin concentration. a. True b. False

a. True

who is edentulous has a. no teeth b. low immunity c. difficulty swallowing d. diminished muscle mass

a. no teeth

Which of the following is true regarding adiponectin? a.Hormone secreted by adipose tissue b.Increased levels are associated with metabolic syndrome c.Decreased levels are associated with greater insulin sensitivity d.All of the above e.None of the above

a.Hormone secreted by adipose tissue

Which nutrition support infusion method can be used when feeding in the small bowel? a. Intermittent feeding b. Continuous feeding c. Bolus feeding d. A & B

b. Continuous feeding

low levels of adiponectin are associated with all of the following EXCEPT? a. Metabolic syndrome b. Increased insulin sensitivity c. Dyslipidemia d. Type 2 Diabetes e. Hypertension

b. Increased insulin sensitivity

Enteral nutrition, when indicated, is preferred over parenteral nutrition for what reason(s)? a. Eliminates the risk of refeeding syndrome b. Maintenance of gut integrity c. Because it is more sterile d. All of the above

b. Maintenance of gut integrity

Which of the following is NOT a potential tube placement site for long-term enteral feedings? a.Percutaneous endoscopically-placed gastrostomy b. Nasoduodenal c. Jejunostomy d.All of the above

b. Nasoduodenal

M.R. is an 85 y.o. female who had a CVA with hemiparesis (paralysis). She has had dysphagia for the past 3 weeks and cannot feed herself due to the hemiparesis. Which nutrition support modality, if needed, would best accommodate her needs? a. Nasoduodenal b. PEG c. TPN d. Oral

b. PEG

Patients receiving loop or thiazide diuretics have increased _________ needs: a. Vitamin D b. Potassium c. Vitamin K d. Iron

b. Potassium

At what nutritional oral intake level should nutrition support be discontinued? a. 40% b. 50% c. 60% d. 75%

c. 60%

A patient has just been placed on Warfarin and the physician has asked you to meet with them for nutrition counseling. Which of the following would you recommend? a. Supplement with vitamin K to counteract the effects of warfarin b. Skip a dosage of warfarin if recent meals were high in vitamin K c. Keep daily vitamin K intake constant d. Avoid intake of vitamin K entirely

c. Keep daily vitamin K intake constant

Which of the following is NOT an indication for enteral nutrition? a.Dysphagia b.Vegetative state c.Mean arterial pressure of 55 d.Anorexia

c. Mean arterial pressure of 55

John has been prescribed Prednisone, a corticosteroid, and is worried about some of the drug's side effects. Which of the following should he consider? a. Eating calorically dense foods due to decreased appetite b. Avoid using salt and limiting foods high in sodium c. Protein, calcium, and vitamin D supplements if oral intake is inadequate d.Both a and c e.All of the above

c. Protein, calcium, and vitamin D supplements if oral intake is inadequate

Exercise is typically recommended for weight management. Which of the following promotes the retention of skeletal muscle mass? a. Cardiopulmonary fitness b. Jogging 5 times per week for 30 minutes c. Resistance training d. Walking 10,000 steps day

c. Resistance training

A patient receiving continuous nasojejunal feedings has developed significant diarrhea. Which of the following is the most appropriate initial action for the management of this patient? a. Terminate enteral feedings and initiate parenteral nutrition b. Change infusion method to bolus feedings c. Review the patient's medication administration record d. Switch to a fiber-containing enteral formula

c. Review the patient's medication administration record

Sam had bariatric surgery 2 years ago. He is now in the ICU in critical condition due to a major infection and pneumonia. He is intubated and sedated with an IV in place for fluid support. Which of the following feeding modalities would be the best for Sam at this point in time? a. Start oral feedings with a clear liquid diet b. Start parenteral nutrition since he has a peripheral line c. Start nasojejunal feedings for nutrition support d. Keep Sam NPO until he is extubated (off the breathing machine) and

c. Start nasojejunal feedings for nutrition support

Which of the following factors affect the absorption of an orally administered drug? a. GI motility b. Drug concentration c. Drug solubility d. All of the above

d. All of the above

Which of the following is a common gastrointestinal complication of enteral nutrition support? a. Aspiration b. Diarrhea c. Constipation d. All of the above

d. All of the above

John is 60 years old and has been experiencing numbness in his hands for the past 3 months. His doctor suspects that John is not producing enough hydrochloric acid, an intrinsic factor, and encourages him to eat more foods containing vitamin B12. What is wrong with this suggestion? a. People missing intrinsic factor cannot digest foods containing vitamin B12 and will develop diarrhea b. Intrinsic factor is not associated with vitamin B12 and eating more foods containing it would have no effect on John's health c. It is improbably that a lack of hydrochloric acid production and intrinsic factor are associated with the numbness that John is experiencing d. Because John is not producing intrinsic factor, he cannot efficiently utilize vitamin B12 from natural sources and would need a vitamin B12 supplement

d. Because John is not producing intrinsic factor, he cannot efficiently utilize vitamin B12 from natural sources and would need a vitamin B12 supplement

Which of the following is considered a diabetic formulation? a. Jevity b. Ensure Complete c. Osmolite d. Glucerna

d. Glucerna

Siena is a 44 year old female who is obese. Losing 5% of her current weight would be beneficial for risk reduction of which of the following? a. Gallbladder, heart, and pancreatic disease b. Depression, cancer, and low blood pressure c. Type 2 diabetes, heart disease, and osteoporosis d. Heart disease, type 2 diabetes, and stroke

d. Heart disease, type 2 diabetes, and stroke

Today is day 2 of enteral nutrition via a NG tube for Jenna. Based on the following information, what would you determine the problem to be? Ht: 5' 7" Current Wt: 129 lbs. Usual Wt: 120 lbs. MAP: 65 Gastric residuals: 150 mL, 120 mL, 100 mL Labs: Sodium: 134 (135-145) Potassium: 3.2 (3.5-5.5) Chloride: 101 (99-112) Bicarb: 26 (22-29) fasting glucose: 91 (65-99) BUN: 13 (8-24) Creatinine: 0.7 (0.6-1.1) Albumin: 2.9 (3.5-5.5) WBC: 13 (4-11) Ca++: 7.8 (8.5-10) Phosphorus: 1.2 (2.5-4.5) Magnesium 1.0 (1.5-2.5) a. Aspiration b. Low flow state c. Elevated gastric residuals d. Refeeding syndrome

d. Refeeding syndrome (low phos, low Mg)

Fluid status can be assessed by evaluating which of the following? a.Input and output b.Assessment of mucous membranes c.Evaluation of skin turgor d.All of the above

d.All of the above

Alana is a 33 y.o. female. She is 5' 3" and currently weighs 189 lbs. She is healthy and just had her labs checked with the following results: Na: 136 (135-145) K: 3.8 (3.6-5.5) Cl: 101 (101-111) HCO3: 26 (21-31) BUN: 11 (5-20) Cr: 0.8 (0.6-1.2) Glucose: 116 (70-99) Alb: 4.5 (3.5-5) GFR: 120 (>90) Phos: 2.9 (3- 4.5) Ca: 9.2 (8.5-10.5) H/H: 12.9/38 (14-17/40-54) Vitamin D: 22.7 (30-100) CRP: 7 (<0.1) Based on the above information, which of the following may be influencing her labs? a.Age b.Gender c.Height d.Weight List labs that the answer you chose above is affecting:

d.Weight glucose, CRP, vitamin D

5. What is not a step involved in reassessment of EN? a. Access b. Tolerance c. Medications administered d. Both A and C e. All of the above

e. All of the above

Which of the following factors contribute to the etiology of obesity? a. Sedentary lifestyle b. Age c. Medications d. Genetics e. all of the above

e. All of the above

which of the following is associated with sarcopenia? a.Age b.Sedentary lifestyle c.Obesity d.Endocrine abnormalities e.All of the above

e.All of the above

Interventions for Obesity

•3-pronged approach è target: •Diet •Exercise •Behavior(most imprt) •Last approach: bariatric surgery -Lap band & gastric sleeve: restrictive procedures -Roux-en-Y - malabsorptive procedures -BMI > 40 or >35 w/> 2 comorbidities

Assistance Programs

•A variety of nutrition assistance programs are available: •Meals-on-Wheels: home delivered meals based on eligibility •Mobile meals: home delivered meals based on eligibility •Congregate meals: funded community-based nutrition program based on the Older Americans Act

Nutrition Assessment: Drug interaction

•Add to your assessment paragraph any potential drug-nutrient interactions (DNIs) •Only list drugs related to nutrition •List the drug and the interaction -Patient at risk for B12 deficiency due to long term use of Nexium -Tube feeding can decrease the bioavailability of Dilantin -With warfarin prescribed, a steady vitamin K dose from the diet is needed

Dilantin (Phenytoin)

•Anti-convulsant (seizures) •Interacts with food •Continuous tube feedings decreases bioavailability •Stop tube feedings 1-2 hrs before and after oral administration •Problem: tube feedings < adequate •IV form available •Ca, Mg and aluminum can also ê bioavailability

Micronutrients for elderly

•Assess diet to determine if intake adequate in terms of vitamins, minerals 7 trace elements •Many elderly diets are insufficient in calcium, vitamin D, zinc, magnesium, vitamin B12, and vitamins C & E •Supplementation may be required to fill gaps but food should be recommended first •Many older adults take vitamin, mineral & botanical supplements for a variety of reasons - assess necessity as well as benefit/harm ratio

Do obese ICU patients benefit less from early EN in the first week of hospitalization, due to their nutrition reserves, than their lean counterparts?

•Based on expert consensus, we suggest that early EN start within 24-48 hours of admission to the ICU for obese patients who cannot sustain volitional intake.

Which formula should be used when initiating EN in the critically ill patient?

•Based on expert consensus, we suggest using a standard polymeric formula when initiating EN in the ICU setting. We suggest avoiding the routine use of all specialty formulas in critically ill patients in a MICU and disease-specific formulas in the SICU. 1) One Exception: use a immune-enhancing formula in the post-surgical population; these formulas should not be routinely used in the MICU. •Examples of immune-enhancing formulas = Oxepa & Impact

#2: Behavior Modification: Other Half

•Behavior -Readiness for change -Relationship with food -Environment -Alcohol/late night eating -Depression •Realistic client goals •Patient Centered •Self-monitoring - log •Attitude: -Self-talk conversation

Intervention -> 3 Pronged Attack: Dietary Intake

•Beneficial -Fiber: 20-27 g/d -Ad lib low carb è kcal intake, BW & FM ê vs high carb -Eating breakfast; é fiber & 20% of calories è snacking & meal intake -Ca++: DRI for age -> protein = satiety (20% of kcals w/30% fat & 50% carb) -< portion sizes -Eat 4-5 meals/d w/> consumption in am NO EVIDENCE -Low glycemic diets -Grapefruit diets -Blood-type -Eating fruit/other separately

Classification of Obesity (68% of US adults are overwt or obese)

•By BMI= [kg/m2] A. 25-29.9 = overweight B.≥30 = obese 1)World Health Organization (WHO) classifications: a. Class I: BMI = 30-34.9 kg/m2 b. Class II: BMI = 35-39.9 kg/m2 c. Class III: BMI > 40 kg/m2 •Waist Circumference: (M) > 40"' (F) > 35" •By % IBW a. 110-120% = overweight b. >120% = obesity c. >200% = morbid obesity

Diuretics

•Commonly prescribed for edema and hypertension •Adverse effects related to nutrition: •Loop diuretics (lasix): increase excretion of potassium, magnesium, sodium and calcium •Thiazide diuretics (HCTZ): -Increase excretion of potassium & magnesium -Most Americans on low K+ & Mg++ -Most labs not checked •Potassium-sparing (spirolactone & aldactone) -Increase potassium levels

Warfarin

•Coumadin - oral anticoagulant è reduces hepatic production of 4 vitamin K-dependent clotting factors; inhibits conversion of vitamin K to an usable form •Ingestion of vitamin K in the usable form opposes the action of warfarin & allows the production of more clotting factors •More drug needed for therapeutic levels •✓ INR levels for adequate drug levels •Nutrition counseling = consistent vitamin K intake •High vitamin K foods = dark green leafy •<1 serving/d of high vitamin K foods •<3 servings/d of moderate high vitamin K foods •Be consistent in intake •? Role of genetic polymorphisms in INR/PT levels •High vitamin K: -Kale, spinach (fresh/boiled), swiss chard, collards, turnip greens •Moderate vitamin K: -Brussels sprouts, spinach (raw), green leaf/endive lettuce, broccoli -Consider multivitamin/mineral supplements as a source

obesity is associated with which of the following metabolic problems? •A. the adipocytes increase adiponectin and decrease leptin levels •B. the adipocytes increase the synthesis of cholecystikinin •C. the adipocytes attract macrophages to the dying fat cells which increases HDL levels •D. the adipocytes release proinflammatory substances that lead to insulin resistance

•D. the adipocytes release proinflammatory substances that lead to insulin resistance

Disease Specific Formulations: Diabetes

•Diabetes: -Goal - blood glucose 80-150 mg/dl to improve morbidity and outcomes •Diabetic formulations (Glucerna/Diabetisource): -Low carb (34% - 40% of tkcals) -Higher fat (40% - 49% of tkcals) -10-15 g/L of fiber -Better glycemic control -Insufficient evidence to support use -Acute care: > fat may result in é gastric residuals w/gastric feedings -Not very useful to control blood glucose levels in the hospital - don't use

Fluid Pressures (Starling's Law)

•ECF and ICF fluid shifts occur with changes in pressure w/i the compartments •Fluid flows ONLY when there is a DIFFERENCE in pressure •3 types of body fluids: •Isotonic •Hypotonic Hypertonic

Overhydration

•Edema •Abnormal accumulation of fluid in the intercellular tissue or body cavities -Pitting (indentation caused by applying pressure to the swollen area with a finger) -Non-pitting (usually in arms/legs, no persistent indentation) -Peripheral (swelling in feet and legs) -Pedal -Pulmonary •Ascites (excess abdominal/peritoneal fluid) •Anasarca (widespread/generalized edema)

nutrition intervention

•Energy: -Overall energy needs may be less but also elevated w/clinical status such as presence of dialysis, pressure ulcers, etc. -Maintain calorie balance to achieve healthy wt. •Protein: -Many experts recommend minimum 1 g/kg - adjust based on clinical status (.8-1 g/kg for long-standing diabetes or chronic renal insufficiency) -Space protein intake out between three meals (~20 g/meal) -Primary constituent for muscle mass -Inadequate intake leads to sarcopenia & fraility -Most fractures result due to falls which occur b/c of muscle weakness

Disease Specific Formulations: GI disorders/malabsorption

•GI disorders/ malabsorption (Peptamen /Peptamen Bariatric/Vital AF 1.2/ Vivonex RTF): 1)Peptide-based formulas commonly used a.Contain hydrolyzed proteins (small peptides) and free amino acids b. MCT oil/low fat c. Prebiotics - enhance fluid and electrolyte absorption •? Result diarrhea and enhance absorption •Studies inconclusive

Food-Drug Interactions

•Includes: Effects of a medication on nutritional status/effect of food/ nutrient on drug •Pharmacodynamics: study of the biochemical & physiologic effects of a drug/mechanism •Pharmacokinetics: study of the time course of a drug in the body involving absorption, distribution, metabolism & excretion of the drug •Pharmacogenomics->genetic heterogeneity -50% of therapeutic Warfarin doses could be predicted -Slow vs. fast acetylation - metabolism -Different activity of the CY P450 systems

Fluid Distribution

•Intracellular fluid -> fluid within the cell •Extracellular fluid: -Interstitial fluid -> fluid around the cell -Intravascular fluid -> fluid within the blood vessel (e.g., vein, artery) •Transcellular: fluid within body cavities •Osmotic pressure DRIVES fluid distribution •Sodium DRIVES extracellular fluid distribution

Recap of Acid-base

•Normal pH = 7.35-7.45 •pH < 7.35 = acidemia •pH > 7.45 - alkalosis •Lungs, kidneys & buffering systems responsible for balance •Alterations in organ function -> imbalances •Compensation possible •Treatment targets underlying primary problem

Nutrition Assessment: Anthropometrics

•Obesity: has increased in the elderly •Associated w/> risk for the chronic diseases •Weight loss goal: 10% in 6 months •Malnutrition: •Evaluate weight history •40% to 60% of hospitalized patients are malnourished •Older women more likely to be underwt. •Challenges: changes in height and difficulties obtaining weight as elderly maybe unable to stand on scale

Nutrition Assessment: Biochemical data

•Particular problems in the elderly that can affect labs: •Dehydration as well as overhydration & edema •Check renal function - declines due to chronic disease common •? Diabetes - increases with aging and weight •Lipid panel - ? On statin drugs •? Anemia - check iron, B12 & folate status as deficiencies common in this population •Assess for drug-nutrient interactions - may affect biochemical findings

Corticosteroids

•Prednisone, solumedrol •Commonly prescribed for inflammatory conditions-> rheumatoid arthritis, IBD, asthma, lupus •Cause Na++ & water retention •Enhance excretion of potassium & calcium •Impairs Ca++ intestinal absorption -risk for osteoporosis •Supplementation: -Calcium & vitamin D/Ensure adequate protein

Body Composition & wt loss

•Problematic & variable •Feeding studies in healthy-> weight loss ~60-70% loss in fat & ~30-40% loss in muscle mass •Weight gain: 87% wt. gain FM •REE increase & decresse based on LBM

Objective of Nutrition Support

•Provide nutrition when oral nutrition not possible 1)Maintain/improve nutritional status a. Weight b. Lean Tissue Mass 2)Promote wound healing 3)Avoid deficiencies 4)Maintain gut integrity (enteral) •Do no harm

Physiologic Changes w/Aging

•Sarcopenic obesity: •Loss of lean muscle mass in individuals w/excess adipose tissue •Taste & Smell: declines are normal but occur at different rates and at different ages •Can adversely affect: -Appetite -Food choices -Nutrient intake •Dysgeusia: altered taste -could be age-related, due to medications prescribed or medical conditions such as allergies, history of head/neck cancers, etc. •Hyposmia: decreased sense of smell May use more seasonings to flavor food: particularly salt •Immunocompetence: immune response is slower & less efficient •Oral health: tooth loss, use of dentures & xerostomia (dry mouth) can result in difficulties w/chewing & swallowing •Polypharmacy: taking 5 or more drugs/d - many can cause taste changes and dry mouth •GI changes: -Dysphagia: difficulty swallowing -Achlorhydria: decreased gastric acid production->B12, iron & vitamin D deficiency -Constipation: causes - poor fluid & fiber intake along w/decreased physical activity -? Malabsorption due to medications prescribed, surgical history (e.g., bariatric surgery), or medical conditions such as pancreatic cancer •Neurologic: reduction in cognition, steadiness, reaction time & coordination -Affects ability to purchase & prepare meals •Depression: can impact eating •Issues with ambulation related to neuropathy, amputations, &/or poor circulation •Frailty & failure to thrive: can lead to malnutrition

Adverse effects of obesity

•Some types of cancers •Gallbladder disease •Neurodegeneration •Osteoarthritis •Asthma •Depression •Infertility •Cluster of metabolic disorders: •CVD •Type 2 diabetes •Metabolic Syndrome •Fatty liver disease (NASH) •Hypertension •Neurodegeneration

Dehydration

•Weight will be lower •Laboratory data may be altered: •Increased sodium, chloride, BUN, albumin & hemoglobin & hematocrit (H & H) •Dry mucous membranes •I/Os: more input than output •Poor skin turgor: tented skin on the back of the hand

Exercise - Benefits

•decreased risk for chronic diseases (CVD, DM, Cancer, etc) •Enhanced insulin sensitivity •Enhanced action of Hormone Sensitive Lipase •Improved LDL-C & HDL-C levels •decrease visceral adiposity - less inflammation •Helps maintain weight loss

Enteral Nutrition Support Checklist

•✓EN indicated? •✓ ? Place feeding tube; where? •✓ Based on location & clinical status - what type of infusion method appropriate •✓ Based on clinical status and long-term goals - what type of formula is optimal •✓ Risk for refeeding syndrome (K, Phos & Mg) •✓ Monitoring/Evaluation: •✓ Feedings infusing - ? Goal rate ( mL/hr w/continuous feeds or "cans" w/bolus feeds •✓ ? Tolerating - ? Gastric residuals, diarrhea, constipation, not taking formula b/c too "full"