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Nutri Sci 631 > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Nutrition status factors

A 
Human biology factors
Lifestyle factors
Food and nutrient factors
Environmental factors
System factors
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2
Q

What is the purpose of nutrition care?

A

To restore a state of nutritional balance by influencing factors contributing to the imbalance

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3
Q

What is the nutrition care process? 4 steps

A 
-Systematic problem solving method
Four steps:
Nutrition assessment
Nutrition diagnosis
Nutrition intervention
Nutrition monitoring and evaluation
-Includes a system of standardized nutrition language
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4
Q

Standardized language

A

Uniform terminology used to describe practice
Provides a common language for documentation and communication
Nutrition diagnostic terminology
Nutrition assessment, monitoring and evaluation terms
Nutrition intervention

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5
Q

Consistent structure and framework of NCP

A

Provides high quality care
Addresses
Process of care (systematic and consistent steps of NCP)
Content of care (evidence-based practice guides)
Guides critical thinking

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6
Q

STEP 1: NUTRITION ASSESSMENT

A 
Obtain and verify appropriate data
AND’s Evidence-Based Guides for Practice
Cluster and organize assessment data
Food/nutrition-related history
Anthropometric measurements
Biochemical data, medical tests, and procedures
Nutrition-focused physical findings
Client history
Evaluate data using reliable standards
  Comparative standards domain
  Scientifically valid
  Formulate nutrition prescriptions
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7
Q

STEP 2: NUTRITION DIAGNOSIS

A

Direct link between assessment and intervention
Describes a problem for which nutrition-related activities provide the primary intervention
NOT a medical diagnosis
Three domains
Intake, clinical, and behavioral-environmental
PES statements
Problem: Diagnostic label
Etiology: Factors related to cause or existence of problem
Signs and symptoms: Defining characteristics
Stated as “problem (P) related to etiology (E) as evidenced by signs and symptoms (S)

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8
Q

HOW IS A PES STATEMENT CREATED?

A 
Evaluate nutrition assessment 
  Find patterns and relationships among data and causes
Identify the problem(s)
  Focus on those that can be treated by nutritional intervention
Validate and confirm problem(s)
  Use signs and symptoms
Explore the etiology 
  Focus on a nutrition related causes
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9
Q

HOW ARE PES STATEMENTS EVALUATED?

A 
Problem
Can a dietetics practitioner impact it?
Etiology
Is it the root cause?
Is there an intervention that can address it
”Signs and symptoms
Can they be measured?
Are they sensitive to the intervention?
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10
Q

STEP 3: NUTRITION INTERVENTION

A 
Prioritize the nutrition diagnoses
Write the nutrition prescription
Set goals
Plan the intervention
Implement the intervention
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11
Q

STEP 4: NUTRITION MONITORING & EVALUATION

A

Monitor progress
Monitor, measure and evaluate on a planned schedule
Measure outcomes
Nutrition, clinical and health status, patient/client centered, and health care utilization
Evaluate outcomes
Create outcomes management system
Contribute to the body of evidence-based research

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12
Q

DOCUMENTATION of NCP

A 
Standardized language
Relevant, accurate, and timely
Variety of formats are acceptable:
SOAP
Focus notes
PIE
ADIME
Electronic Medical Records
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13
Q

Three Phases of Digestion

A

 Cephalic- thought, taste, smell stimulates vagus to kick out HCL
 Gastric- mix up food, eating
 Intestinal- begins in SI, inhibitory phase - releases CCK to slow digestion

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14
Q

Swallowing and Dysphagia

A 
A complex act requiring
 integration of 6 cranial nerves
 synchronization of muscle patterns
 domination of the respiratory system
 invocation of autonomic system
Swallowing is divided into 3 stages
 oral
 pharyngeal
 esophageal
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15
Q

Swallowing – Phase I

A 
Oral phase – voluntary
-food + saliva
 chewing
 tongue movement
 bolus formation
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16
Q

Symptoms of impaired swallowing- phase l

A

↓ lip closure
↓ rotary jaw movement
 mucositis
xerostomia

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17
Q

Swallowing – Phase II

A 
 Pharyngeal phase
 peristalsis forces the   
bolus back & downward
 respiration ceases
 larynx pulls upward,    
covering the trachea
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18
Q

Symptoms of impaired swallowing- Phase ll

A

delayed/absence of swallow reflex
↓ bolus movement thru pharynx
↓ laryngeal closure

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19
Q

Swallowing – Phase III

A 
 Esophageal phase
 upper esophagus sphincter
relaxes, peristaltic wave
moves the bolus down the
esophagus
 breathing resumes
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20
Q

Symptoms of impaired swallowing- Phase lll

A

 food bolus remains in the esophagus due to ↓ peristalsis
 food returns into the pharynx and/or spills to the
airway due to esophageal obstruction

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21
Q

Diseases/Conditions Associated with

Dysphagia

A

 Acute neurological: stroke or closed head injury
 Chronic neurological: ALS, Parkinson’s, MS,
Alzheimer’s, dementia
 GI disease: GERD, hiatal hernia, achalasia,
gastroparesis
 Malignancy: head and neck cancer, mucositis,
esophagitis due to chemotherapy or radiation
therapy

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22
Q

Symptoms of Dysphagia

A 
 drooling
 residue in mouth
 difficulty chewing
 poor bolus formation
 slow oral transit time
 sore mouth
 gagging/spitting
 choking
 lump in throat sensation
 compensatory behaviors
 chin‐tuck
 tilt head on one side
 changes in eating habit
 eat very slowly
 change food preference
 leave food on plate
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23
Q

Dysphagia ‐ Diagnosis

A

 Oral swallow study ‐ videofluorographic
 observe swallowing of 3 liquid consistencies with barium
‐ thin liquid (“water‐like”)
‐ semi‐solid (“pudding‐like”)
‐ solid (“cookie‐like”)
 assess
‐ bolus direction, transit time, and clearance
‐ function of the upper esophageal sphincter
‐ whether aspiration occurs

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24
Q

Severe Consequence of Dysphagia –

Aspiration Pneumonia

A 
Aspiration: entrance of materials below level of
the vocal cords, into the airway
Signs of aspiration:
 coughing during/after swallowing/meals
 increased secretions
 wet gurgly voice
 fever
 chest sounds
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25
Q

Dysphagia – Treatment

A

Speech/Physical therapy
 oral exercises: chin tuck, tongue strengthening exercise
Dietary modification
 increase caloric density (supplement) and meal frequency
Eating environment modification
 simplify/focus: ↓ distraction (e.g., TV/talking) while eating
 proper sitting position, avoid lying down <2 hr of eating
 supervise during eating

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26
Q

Dysphagia – Dietary Modification

A

Dry solids and thin liquids most challenging
Modify solid food texture
 small pieces and soft food: decrease oral manipulation,
conserve energy while eating
 pureed easiest to swallow but least appealing
 improve acceptance: temperature, smell, taste
Modify liquid viscosity
 thin liquid requires the most coordination/control,
most easily aspirated
 thickening agents: non‐fat dry milk powder, cornstarch,
and commercial products

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27
Q

National Dysphagia Diet

A 
 NDD: created to set standard terminology for a progressive diet to be used nationally in treating dysphagia
3 terms to describe solid food texture
 NDD‐1: pureed (“pudding‐like”)
 NDD‐2: mechanically altered (moist and soft textured)
 NDD‐3: dysphagia advanced
(all except very hard, sticky, crunchy)
4 terms to describe viscosity of liquids
 Thin
 Nectar‐like
 Honey‐like
 Spoon‐thick
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28
Q

GERD, Gastro-Esophageal Reflux

Disease.

A 
Backward flow of acidicstomach contents into esophagus
Symptoms: 
 heartburn
 dysphagia
 increased salivation
 hoarseness
 belching
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29
Q

GERD - Causes

A

 hiatal hernia
 reduced LES pressure
-smoking, pregnancy, smooth muscle relaxants
- Foods-chocolate, spearmint, peppermint, alcohol & caffeine
 increased abdominal pressure-obesity & tight clothes
 delayed gastric empty
 recurrent vomiting

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30
Q

GERD- major concern

A

Chronic inflammation can lead to Barrett’s esophagus with premalignant cells and increased risk for adenocarcinoma of the esophagus

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31
Q

Hiatal Hernia

A 
Outpouching of stomach through diaphragmatic hernia
 Pressure generated by
diaphragm forces acidic
contents into esophagus
= ↑ risk of GERD
 MNT = like GERD
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32
Q

GERD - Nutritional Care

A

 Avoid large, high-fat meals, esp 3-4 hr before retiring and lying down
 Stimulate acid secretion and delay gastric emptying
 Prevent pain and irritation during acute phase
 foods with an acid pH may cause pain when esophagus is inflamed: i.e. citrus juices, tomatoes and soft drinks
 Spices may also irritate during inflammation: i.e. chili
powder and black pepper
Prevent esophageal reflux
-Avoidance of foods that cause lowering of LES
-Dietary fat, alcohol, spearmint & peppermint, chocolate, coffee
Decrease acidity of gastric secretions
 avoid caffeine-containing beverages, coffee (regular
and decaf), alcohol and pepper
Tight-fitting clothes may increase risk of reflux
 Lose weight

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33
Q

GERD-Medical Management

A

 Elevate head of bed
 Avoid smoking
Drugs
 Antacids – Ca, Mg & Al- act fast but short
 Foaming agents- fast and long
 H2 receptor antagonists- block histamine, last 4-6 hrs
 Proton pump inhibitors -suppress acid production, last 24 hrs
 Prokinetics- strengthen pyloric sphincter and speed up gastric emptying

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34
Q

Eosinophilic Esophagitis (EoE)

A

genetic basis common in young men
 Inflammatory condition characterized by infiltration
of eosinophils within the esophageal mucosa.
 Symptoms: dysphagia, GERD no response to meds
 Diagnosis requires endoscopy with biopsy
 Food triggers EoE; standard allergy testing does
not identify the food trigger
 Common to eliminate all food allergens
 Soy, milk, egg, wheat, peanuts, tree nuts, seafood

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35
Q

Disorders of the Stomach

A 
 Dyspepsia
 Gastroparesis
 Gastritis
 Peptic Ulcer Disease
 Dumping Syndrome
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36
Q

Dyspepsia, upper GI tract discomfort

A

 Symptoms: vague abdominal pain, bloating,
nausea, regurgitation-vomiting, belching
 May be benign or symptoms of underlying
problems such as GERD, gastritis, peptic ulcer
disease, gall bladder disease, or cancer
 May also be due to diet, stress, and other lifestyle
factors if pathology is negative
 Dietary: avoid overeating and drinking, chew
thoroughly and eat slowly = sensible eating

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37
Q

Gastroparesis

A

 Delayed gastric emptying due to damage to
vagus nerve which controls peristalsis
 Complication of Type I DM
 Anorexia, nausea, vomiting, early satiety and
erratic glycemic control

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38
Q

Stomach – Functions

A 
• Mixing, acidification &amp; secretion
• Propulsion, regulates flow of
chyme to duodenum
• Digestion and Absorption
• carbohydrate- stops
• protein-begins whey 
• lipid- short chain fatty acids (breastmilk, some dairy products)
• alcohol- 20%
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39
Q

Stomach – Secretions

A

●1-3 L/d gastric juice: water, mucus, HCl, enzymes & electrolytes
●Parietal cells – HCl & intrinsic factor
●Chief cells – pepsinogen & lipase
●Enterochromatin-like cells – histamine
G cells –gastrin & D cells-somatostatin

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40
Q

Functions of HCl

A
  • Pepsinogen → Pepsin
  • Denatures proteins
  • Bacteriostatic
  • Releases B-12 from food and increases solubility of Ca, Fe etc.
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41
Q

Gastritis

A

 General term for inflammation and tissue
damage from erosion of mucosal layer of
stomach.
 Symptoms: belching, anorexia, abdominal pain,
vomiting

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42
Q

Pathophysiology of Gastritis

A 
Acute Gastritis
 H. pylori
 Alcohol, food poisoning,
 NSAIDs – aspirin, ibuprofen &amp; naproxen
Chronic Gastritis
 Type A - automimmune
 Type B – H. pylori
 Increases with age, achlorhydria
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43
Q

Peptic Ulcer Disease, PUD

A

 Pathology: erosion through the muscularis mucosa into
the submucosa; complications of GI bleed resulting in
melana (black tarry stools), hemorrhage and perforation
 Most common cause is Helicobacter pylori

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44
Q

Peptic Ulcer Disease causes and symptoms

A 
 Primary cause: H. pylori not diet
-NSAIDS can worsen
- Ethanol can worsen symptoms but doesn’t cause
Presenting symptoms
-Epigastric pain &amp; burning sensation
Stress Ulcers, prevent in ICU
-Metabolic stress - ↑ corticosteroids
- Factors that decrease blood supply-smoking or shock
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45
Q

Gastric Ulcer

A 
 Associated with
widespread gastritis
and inflammation often
in antrum of stomach
 antral hypomotility and
gastric stasis occur
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46
Q

PUD –Diagnosis and Treatment

A

 Diagnosis: endoscopy with biopsy
 Treatment
 FDA approved regimens of 3-4 medications to treat
H. pylori infection (Table 14.16)
 Combinations of the PPI Omeprazole and antibiotics
 Medications to suppress acid secretion (Table 14.17)
 Antacids and cytoprotective agents

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47
Q

MNT: PUD

A

 Diet is not a causative factor for PUD
Restricts only foods known to increase acid secretion
or cause direct irritation to gastric mucosa
 Caffeine and coffee, decaf or regular
 Alcohol
 Black and red pepper
Milk or cream increase net acid production
“Acidic” foods don’t matter
 ? Frequent small meals for increased comfort
 < acid at one time but overall net ↑ in acid output

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48
Q

Complications of PUD→Surgery

A

 Hemorrhage
 Perforation
 Obstruction of Pyloric Sphincter

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49
Q

Gastric Surgery- Vagotomy

A

partial or total severance of the vagus nerve innervating the stomach to decrease cholinergic stimulation & acid production

50
Q

Gastric surgery- Pyloroplasty

A

 enlargement of the pyloric sphincter

 inflammation can cause strictures in this area with delay in stomach emptying

51
Q

Gastric surgery- other types

A

 Partial gastrectomy with Billroth I or II
 Sleeve gastrectomy
 Roux-en-Y procedure (gastric bypass)

52
Q

Dumping Syndrome

A

 Seen when there is no pylorus for control and nutrients
enter the duodenum or jejunum too quickly
 Cause: large amounts of food (especially simple
carbohydrates) in duod/jejunum cause fluid to move
quickly in to dilute the high osmotic load

53
Q

Symptoms: Dumping Syndrome

A 
Early, within 10-20 min of eating
 decrease blood volume-weakness, dizzy and rapid
heart rate
Intermediate, 20-30 min after eating
 abdominal distention
 bloating, flatulence, pain, diarrhea
Late, 1-3 hr after eating
 reactive hypoglycemia after eating simple CHO
54
Q

MNT: Dumping Syndrome

A

 Small meals, spread throughout the day
 High-protein, moderate fat foods, complex carb
 Avoid concentrated (hypertonic) sweets
 No liquids with meals
 liquids with meals increase GI transit
 small amounts of fluid during day, 1 hr after meal
 Lactose may need to be reduced because of
rapid transit time
 Lying down and avoiding activity an hour after
eating may help slow gastric emptying
 Risk of ↓ absorption due to low stomach acid
 vitamin B12,
 iron
 calcium

55
Q

Post-Surgical Diet Progressions

A

Clear Liquid -> Full Liquid -> Soft Diet – Low in fiber, 10-15g
-not for people with poor dentition
Controversial
Note: Specific foods allowed in these diets are designated by health care institutions in their diet manuals.

56
Q

Liquid Diets - clear liquids

A

– purpose: to supply fluid & energy in a form that
requires minimal digestion & stimulation of the GI
tract.
– composition: water and carbohydrates
• Inadequate in calories and essential nutrients
• Limit to 24-48 hr
• Foods: broth, tea, clear fruit juices, gelatin, and
carbonated beverages

57
Q

Liquid diets- full liquids

A

– purpose: transition between clear liquids & solid
food; used for patients who are unable to chew,
swallow, or digest solid food
• Variant = Jaw Fracture/Blenderized Diet, Table 14.7
– composition: consists of food that are liquid or
semi-liquid at room temperature
• Clear liquids, cream soups, milk, pudding, ice cream
and yogurt
• May present problem with large amounts of lactose

58
Q

Study Guide Questions

A

Review 3 stages of swallowing and symptoms & diagnosis of dysphagia.
Define aspiration and discuss treatment & diet modification for dysphagia.
Review digestion & absorption of CHO, PRO and FAT (see Nelms p 383-87). Review where nutrients are absorbed in the GI tract.
Review the structure and function of the stomach including secretions.
Review secretion of HCl from gastric parietal cells and acid suppression therapy for GERD and peptic ulcer disease (PUD).
Define GERD and its etiology. Describe MNT and rationale for GERD.
Describe EoE and its relationship to food intake.
Define dyspepsia, gastroparesis and gastritis.
What causes PUD? Describe MNT & underlying rationale for PUD?
Why does dumping syndrome occur after gastric surgery-describe symptoms? Describe MNT and rationale for dumping syndrome.
Describe post-surgical diet progression and controversy regarding the efficacy of progression from liquid to solid foods.

59
Q

NUTRITIONAL STATUS

A

Reflects nutrient stores
Determination of nutritional risk (if it is going to cause problems)
excesses vs deficiencies
Need to understand pathophysiology, treatment, and clinical course of disease

60
Q

Screening

A

Process of identifying patients, clients,
or groups who may have a nutrition diagnosis and
benefit from nutrition assessment and intervention
by a registered dietitian.”

“Process of gathering key pieces of information correlated to nutrition risk”

Can be performed by diet techs or other trained personnel

Standards of Practice include nutrition assessment

61
Q

Screening must be done within

A

48 hours of admission

62
Q

Tools for Data Collection

A 

DETERMINE checklist- elderly 

Subjective Global Assessment

Malnutrition Screening Tool (MST) - asks about weight loss and appetite 

Malnutrition Universal Screening Tool 
(MUST)

Sensitivity and specificity: those with nutrition 
problems correctly identified and those without will 
fall into low risk category 

Others: growth charts, Minimum Data Set, 
etc.
63
Q

COCHRANE REVIEW OF

SCREENING

A

The study conducted in primary care
reported that physicians were receptive to the screening intervention, but
the intervention did not result in any improvements in the malnutrition detection rate or nutritional intervention rate.
no evidence for either way, not proved to be effective or ineffective, more studies need to be conducted

64
Q

ASPEN SCREENING

SURVEY

A 
Nurses most frequently conducted the screen
Validated screening tools used

Malnutrition Screening Tool
Nutrition Risk Classification 
Simple Screening Tool
Subjective Global Assessment
When validated screening tool not used

92% used weight loss history
82% trouble chewing and swallowing
80% diet history of poor oral intake
24% included options such as medical conditions
65
Q

NUTRITION

ASSESSMENT

A

Foundation of the nutrition care process
systematic method for obtaining, verifying and interpreting data
Identifies nutrition-related problems, their causes,
and significance

66
Q

SUBJECTIVE DATA COLLECTION

A

Obtained during interviews
Interviewer’s observations
-Collected through patient interview
Economic situation
Support systems
Food insecurity
INFORMATION REGARDING EDUCATION, LEARNING & MOTIVATION
Ability to communicate
history of previous nutrition interventions and response to them
Education level, attention span, and readiness to learn

67
Q

OBJECTIVE DATA

COLLECTION

A

Information from a verifiable source such as medical record
anthropometrics: height, weight, bmi, weight change

Biochemical: albumin, hemoglobin, hematocrit, lipids, MCV, MCHC, MCH, ect

Physical findings: edema, oral health, grip strength, subcutaneous fat loss, muscle mass

Client history: past medical records, age, gender

68
Q

OBJECTIVE DATA:

ANTHROPOMETRICS

A 
Nutrition care indicator: height

Age < 2 : length
Age > 2 : standing height
Using stadiometer
Alternatives: arm span; knee height
Nutrition care indicator: weight 

Balance beam &amp; electronic scales
Wheelchair &amp; bed scales
Amputation calculations
69
Q

ANTHROPOMETRICS:
NUTRITION CARE
CRITERIA
– INFANTS/CHILDREN

A

Evaluation and interpretation of height and
weight

Growth charts: compare with reference population
Weight for height
Percent weight for height

Body mass index (BMI)
Overweight: 85th - < 95th percentile of BMI for age
Obesity: > 95th percentile of BMI for age
Underweight: < 5th percentile of BMI for age

70
Q

ANTHROPOMETRICS:
NUTRITION CARE
CRITERIA –
ADULTS

A

Evaluation and interpretation of height and weight

Usual body weight (UBW)
Percent UBW and percent weight change

% UBW= (current weight/usual body weight) x100
% weight change= ((current weight- UBW))/UBW) x 100

Reference weights
Body mass index (BMI)
Waist circumference

71
Q

OBJECTIVE DATA: BODY
COMPOSITION
MEASUREMENTS

A

Body composition: distribution of body compartments as part of total weight

Fat mass vs. fat free mass
Fat mass, body water, osseous mineral, protein

Most concerned with metabolically active tissue and fluid status

72
Q

BODY COMPOSITION:

SKINFOLD MEASUREMENTS

A

Estimates energy reserves in subcutaneous tissue
Advantages: minimally invasive, requires min. equipment
Disadvantages: requires practice for reliable performance

Interpretation and evaluation of skinfold measure
At risk: < 5th or > 95th percentiles

73
Q

BODY COMPOSITION:
BIOLECTRICAL
IMPEDANCE
ANALYSIS (BIA)

A

Based on conduction of electric current through fat (current takes longer) and bone
Advantages: quick, safe, portable and non-invasive
Disadvantages: affected by other factors like recent exercise, dehydration. not appropriate for people with major water shifts like edema

74
Q

BODY COMPOSITION:

OTHER INDICATORS

A

Hydrostatic (underwater) weighing
Most accurate, less available

Dual energy X ray absorptiometry (DXA)
Considered precise (see Figure 3.18), expensive

Air displacement plethysmography (example: BodPod)
Comparable to DXA and hydrostatic weighing, have to sit very still in minimal clothing

75
Q 
OBJECTIVE DATA: 
BIOCHEMICAL 
ASSESSMENT AND 
MEDICAL TESTS AND 
PROCEDURES
A 
Measurement of nutritional markers and indicators found in blood, urine, feces, tissue

Protein assessment

Immunocompetence

Hematological

Vitamin/mineral levels

Others
76
Q

SOMATIC PROTEIN

ASSESSMENT

A

Nutrition care indicator: creatinine height index
Correlates daily urine output of creatinine with height
taller= more creatinine output
Nutrition care criteria: interpretation and evaluation of
creatinine height index
See Table 3.8
Uses ratio of 24 hour output to expected output
Tells kidney function, if low then kidney isn’t clearing bloo d as efficiently

77
Q

Nutrition care indicator: nitrogen balance

A


In healthy individual, nitrogen excretion should equal nitrogen intake

Used in critical care, when nutritional support is being provided, and in research

Requires 24 hour urine collection

Nutrition care criteria: interpretation and evaluation
of nitrogen balance
Formula accounts for all sources of nitrogen loss

Nitrogen Balance = in vs out
= Protein intake/6.25- (UUN + 4 + 6 for every L output)

Positive= building muscle, growing
Negative= breaking down tissue, starving, muscle wasting
78
Q

Visceral protein assessment:

A 
Non-skeletal proteins 

Albumin

Transferrin

Prealbumin/transthyretin

Retinol binding protein (RBP)

Fibronectin (FN)

Insulin like growth hormone (IGF-1)

C-reactive protein (CRP)
79
Q

Albumin

A

plasma transporter protein, most abundant visceral protein. Increases with dehydration, metabolic stress, inflammation, surgery all affect

80
Q

Transferrin

A

Transports iron, affected by iron status

81
Q

Prealbumin/transthyretin

A

Transports thyroxine (thyroid protein) and vita A, decreases with illness/metabolic stress

82
Q

Retinol binding protein (RBP)

A

Transports retinol (vita A), takes from liver to other tissues, elevated with renal failure, decreased with metabolic stress, vita a deficiency, etc.

83
Q

Fibronectin (FN)

A

glycoprotein, for cell growth and development and wound healing

84
Q

Insulin like growth hormone (IGF-1)

A

hormone, anabolic, promotes growth

85
Q

C-reactive protein (CRP)

A

marker of inflammation, helps immune system function

86
Q

Lymphocytes

A

b and t cells, increase with infection, too low=poor immune system
Immunocompetence
Total lymphocyte count (TLC)

87
Q

Hematological assessment

A

Hemoglobin (Hgb)
oxygen transporter, need iron to make
Hematocrit (Hct)
volume percentage (%) of red blood cells in blood
MCV, MCH, and MCHC
mean corpuscular volume, Mean corpuscular hemoglobin
Ferritin- stores iron
transferrin- transports iron
protoporphyrin- storage/binding of iron, ring structure of heme

Serum folate, serum B12 (absorption)
-macrocytic anemia, folate can mask b12 deficiency

88
Q

OTHER LABS WITH

CLINICAL SIGNIFICANCE

A 
Lipid status- LDL, HDL, etc. 
Electrolytes
BUN- kidney function 
Creatinine (Cr)
Serum glucose
Vitamin/mineral assessment
89
Q

NUTRITION-FOCUSED

PHYSICAL FINDINGS

A

Assess for signs and symptoms consistent
with malnutrition or nutrient deficiencies.

Inspection, palpation, percussion, and
auscultation

90
Q

FUNCTIONAL

ASSESSMENT

A

Skeletal muscle function or strength

Patient’s perception on Subjective Global Assessment
Perception of self-care abilities and environment

ADL/ IADLs- activities of daily living
showering, eating, dressing, shopping, cooking

Handgrip dynamometry
Included in proposed criteria for malnutrition diagnosis

91
Q

NUTRITION CARE
INDICATOR:
TWENTY-FOUR
HOUR RECALL

A

Recall of all food and drink for a 24 hour period
USDA multiple pass approach
Advantages: short administration time, little cost, negligible risk for client
Disadvantages: may not reflect normal eating pattern

92
Q

NUTRITION CARE
INDICATOR:
FOOD RECORD/FOOD DIARY

A

Client documents intake over specified period of
time- 3 to 7 days
Advantages: doesn’t rely on memory, may be more representative of normal eating pattern
Disadvantages: validity issues if client alters or misrepresents, substantial burden on client

93
Q

NUTRITION CARE
INDICATOR:
FOOD FREQUENCY
QUESTIONNAIRE

A

Retrospective
Foods organized into groups and client identifies how often and in what quantities specific foods are consumed
Advantages: inexpensive and requires minimal time
Disadvantages: self-administrated, so has lower response rates, may not include ethnic or child appropriate foods

94
Q

NUTRITION CARE
INDICATOR:
OBSERVATION

A

Observation of food intake/“calorie count”

Food weighed before and after intake
Measures “actual” intake
Advantages: can be very accurate
Disadvantages: time consuming, have to rely on other healthcare professionals

95
Q

NUTRITION CARE

CRITERIA Evaluation and interpretation using:

A 

U.S. dietary guidelines

USDA food patterns 

Diabetic exchanges/carbohydrate counting

Individual nutrient analysis

Computerized dietary analysis

Daily Values/Dietary Reference Intakes
96
Q

NUTRITION CARE
CRITERIA:
ENERGY AND PROTEIN
REQUIREMENTS

A

Indirect calorimetry: most accurate method
BEE+PA+TEF= TEE
Basal energy expenditure (BEE) or basal metabolic rate
(BMR)
Approximately 60-75% of energy requirement
May substitute Resting Energy Requirement (REE) or Resting Metabolic
Rate (RMR): approximately 10% higher than BEE

Physical activity (PA)
Most variable
Approximately 15-20 %of energy requirements

Thermic effect of food (TEF)
Energy needed for absorption, transport, and metabolism of nutrients
Estimated at 10% of energy requirements

Total Energy Expenditure (TEE)

97
Q

ESTIMATION OF ENERGY

REQUIREMENTS

A

Choice of method based on patient condition

Several prediction equations available
Choice of equation based on patient characteristics

98
Q

Harris benedict energy equation

A

used for non obese patients

99
Q

Mifflin St. Jeor energy equation

A

used for obese patients

100
Q

PROTEIN

REQUIREMENTS

A

Measurement of protein requirements
Nitrogen Balance

Estimation of protein requirements
RDA for protein
.8 g/kg body weight 

Metabolic stress, trauma, and disease
1-1.5 g/kg

Protein-kilocalorie ratio (grams N: non-protein calories)
1:200 healthy
1:150 to 1:100 if requirements higher
101
Q

INTERPRETATION OF
ASSESSMENT DATA:
NUTRITION DIAGNOSIS

A

Determine specific nutrition related problems as
identified in nutrition assessment

International Classification of Disease criteria: document of PES

102
Q

MALNUTRITION
DIAGNOSIS:
AND/ASPEN
CONSENSUS

A

Identification of 2 or more of the following 6 characteristics:

Insufficient energy intake
Weight loss
Loss of muscle mass
Loss of subcutaneous fat
Localized or generalized fluid accumulation
Diminished functional status as measured by handgrip strength

103
Q

Nutrition Support

A 
When enteral 
nutrition
(EN,
tube
feeding
into
the
gut)
or
parenteral
nutrition
(PN,
infusion
of
nutrients
into
a
vein)
is
needed
to
maintain
or
restore
nutritional
status.
104
Q

When Does Metabolic Stress Occur?

A 

Trauma =motor vehicle accidents, gunshots, stab 
wounds, falls, head injury &amp; burns

Sepsis – response to infection

Severe inflammation such as Pancreatitis

Systemic Inflammatory Response (SIRS)
Multiple organ dysfunction syndrome (MODS)  

Major Surgery
Esophagectomy
Pancreatic resection
105
Q

ASPEN-
American Society for Parenteral
and Enteral Nutrition formed in 1975

A


Interdisciplinary professional organization

Mission: to improve patient care by advancing
the science and practice of nutrition support

Publications:
Journal of Parenteral and Enteral Nutrition (JPEN)
Nutrition in Clinical Practice (NCP)

106
Q

Nutrition Support Team; Members of ASPEN

A 

MD – often a surgeon

RN – in ICU or general ward

Pharmacist 

RDN – often Certified Nutrition Support 
Clinician (CNSC)
107
Q

ASPEN/SCCM Guidelines for Nutrition

Support in Adult Critically Ill Patients

A


Assess patients on admission to ICU for nutrition risk,
and calculate both energy & protein requirements to
determine goals of nutrition therapy.

Initiate EN within 24-48 hr following onset of critical
illness & admission to ICU (assumes hemodynamic
stability), and increase to goals over the first week.

Take steps to reduce risk of aspiration or improve
tolerance to gastric feeding.

Start PN early when EN is not feasible or sufficient in
high-risk or poorly nourished patients.

EN =delivery of nutrients by tube into GI tract -
preferred

PN = administration of nutrients intravenously

108
Q

Indications for EN

A

•Functional GI tract

•Impaired
nutrient
ingestion
•Swallowing
dysfunction
•Inability to 
consume
adequate
nutrition
orally
–can’t or wont 
•Impaired
digestion,
absorption,
metabolism of upper GI tract
109
Q

Advantages of EN vs PN

A
  • Lesscostly
  • Lessinfection–supportslocaland systemicimmunefunction –Providestrophic stimulus to maintaingut
  • Reducesmetabolicstress –Insulinresistanceandhyperglycemia –Hepaticdysfunction
110
Q

Parenteral Nutrition (PN)

A


Definition:
Provision of nutrients directly into the
bloodstream intravenously (peripheral or
central vein)

Nutrients must be in a predigested state
and sterile

Caution, PN is “artificial feeding”:
“If the gut works use it”

PN is life-saving; but, it is not physiologic 
and induces many complications
111
Q

Outline: PN Solutions

A 
Protein = Amino Acids

Carbohydrate = Dextrose

Lipid = Lipid Emulsions- Complex

Electrolytes, Vitamins, &amp; Trace Elements

Fluid

Compounding Methods, NS 520

Calculation of PN Solutions 

Complications
112
Q

Indications for nutrition

support - parenteral nutrition

A 

Gastrointestinal incompetency

Short bowel syndrome 

Ileus or GI bleed

High-output fistula or perforated SI

Hemodynamic instability- GI ischemia 

Premature birth

Major gastrointestinal surgery; postop 
after resection or transplant
113
Q

Indications for PN

A 

Critical illness with poor enteral 
tolerance or accessibility; 10-15%

Multi-organ system failure

Major trauma, TBI or burns 

Bone marrow transplantation

Acute respiratory failure with ventilator 
dependency and GI malfunction
114
Q

ENFeedingTube:AccesstoGITract

A

• Vianasalpassage–short term,<3weeks
–Nasogastric–RDs mayinsertthistubeinsomefacilities
•Useifnormalgastricemptying&lowriskofaspiration
• Alertpatientwithnormalgagreflex
– Nasoduodenal
• Useif↑riskofaspirationandgastricreflux
– nasojejunal
• Impairedgastricmotility&emptying
• Proximalobstruction
• UpperGIsurgeryorgastrectomy
• Pancreatitis

115
Q

Stomal sites for enteral access:

RequiresSurgicalIncision

A 
►Gastrostomy
 •Longterm(>3wks)&amp;hometubefeeding
 •Percutaneous
endoscopicgastrostomy, PEGtube 
►Jejunostomy 
•Percutaneous 
endoscopicjejunostomy, PEJ tube 
•Usewhenriskofrefluxordisease requiresbypassofstomach&amp;duodenum
116
Q

Enterostomies: Whyisn’ttherea duodenostomy?

A

duodenum dives deep, cant get to it easily from the outside

117
Q

DeterminationofENFeedingSite

A

• Durationoftubefeeding
• Site/presenceofobstruction
• Reflux/aspirationpotential
–Degreeofconsciousness

118
Q

TubeFeeding:3DeliverySystem

A 
• Bolus–intostomachviasyringe 
• Intermittent–gravitydriporpump
• Continuousdripviapump 
– Precisevolume,constantrate 
– Reduceschanceofaspiration
 – Reducesosmoticdiarrhea
 – Intojejunumorduodenum
119
Q

FirstSteptoDetermineRateof AdministrationofTubeFeeding

A

• Determineenergyandproteinneeds
–25‐35kcal/kgforBMI20‐30;1.2‐1.5gpro/kg
– 11‐14kcal/kgactualbodywtforBMI30‐50;2‐2.5g pro/kgidealbodywt(ASPEN/SCCM2016Guidelines)
• Selectanenteralnutritionproduct –Kcal/mlformula
• Determinetotalmlofformulaneeded/day‐goal –1800kcal/day÷1.5

120
Q

FormulaComposition

A
  • Osmolality=mOsm/kgsolvent –Sizeandnumberofnutrientparticlesinasolution definesitsosmolality –Generalpurposeformulasusually300‐500 mOsm/kg–close toosmolalityofbodyfluids
  • Isotonic=300mOsm/kg;equaltoblood –Nutrientdenseformulasandhydrolyzedformulas higherinosmolality(500‐900mOsm/kg)
  • →riskofdiarrheaifadvancedtooquickly
121
Q

CategoriesofEnteral Formulas

A
  • Generalpurposeorpolymeric –Completeformulathatrequiresdigestion –1to1.5kcal/ml;lactosefree;300‐500mOsm/kg
  • Defined/HydrolyzedorSemi‐elemental • Diseasespecific
  • Modular–provide CHO,PROorFATassingle nutrients –Fortifyanexistingformulaorcreateanewformula fromcomponents
122
Q

StudyGuideforEN

A
  • Definenutritionalsupport
  • Describeindications&examplesfortheuseofEN.
  • DescribeindicationsandexamplesfortheuseofPN.
  • Whatfactorsaffectwhethernasoenteral or stoma feeding is used?
  • Whatdeterminestheosmolalityofanenteralformula?
  • HowdogeneralpurposeENformulasandoralnutritional supplementsdiffer?
  • Howdoesthecompositionofaformulaaffectitsosmolalityandthe riskofdiarrhea

Nutri Sci 631 (1 decks)

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