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What is the Nutrition Prescription?

Concise statement of plan to best meet patient/client’s nutrition needs (developed by the RD)


What is the Nutrition Prescription NOT?

the admit/current diet order (MD orders)


What is the PURPOSE of the Nutrition RX?

To communicate RD’s nutrition/ diet recommendations (based on complete assessment)


What is found within the Nutrition RX?

-Content should be related to the PES statement;
-EX: if problem= inadequate energy intake, then nutrition RX should address meeting energy needs;
-Enmount of desired weight gain/specific time period (ie:wk)


What should the RX include?

1. Energy level;
2. Amount of desired weight gain/specific time period (i.e.:wk);
3. May include specifications of:
-meals & snacks
-supplemental feedings;
-enteral feedings;
-Environmental changes to promote intake;
-% energy from specific macronutrients


Items from the IDNT that might be in the RX:

-Number, size, frequency of meals;
-Macronutrient rec’s (specify gm/day or %kcal);
-Micronutrient rec’s ;
-Bioactive substances;
-Texture/ consistency of solid or liquids;
-Liquid diet (ie: clear/ full);
-Food groups/ exchanges/ servings;
-Enteral/ parenteral feedings (specify formula/solution, rate, access, schedule)


What are the 4 categories of Intervention Strategies?

1. Food and/or Nutrient Delivery
2. Nutrition Education
3. Nutrition Counseling
4. Coordination of Nutrition Care
**Use IDNT terminology


What are some CLINICAL goals for Monitoring/Eval?

1. Weight gain/loss (specify amt/time frame);
2. Protein status: biochemical indicators, physical findings, body composition;
3. Biochemical Assessment(LDL C, serum glu,Hgb A1C);
4. Hydration status indicators: biochemical, physical findings, anthropometrics, cognitive function


What are some BEHAVIORAL goals for Monitoring/Eval?

1. Change in eating behavior (e.g. increasing fruit and vegetable intake);
2. Change in nutrition knowledge/ awareness ;
3. Change in environment/continuum of care?;
4. Provision of nutrient intake (ie: energy intake, enteral/parenteral feedings)


What is Enteral Nutrition?

-Feeding through the GI tract via a tube, catheter, or stoma that delivers nutrients distal (after) the oral cavity → Nutrient intake that is NOT consumed orally;
-“Enteral or Tube Feeding”;
-NO “volitional” intake


What are the indications for the need of Enteral Nutrition?

**FUNCTIONAL GI tract, but cannot adequately feed (orally) themselves;
Recommended for patients:
-Altered mental status;
-Swallowing dysfunction;
-Upper GI disorders → Bypass by insertion of tube past dysfunction


What Nutrition Diagnoses could indicate Enteral Nutrition?

-Increased energy expenditure;
-Involuntary weight loss;
-Inadequate oral food/beverage intake ;
-Inadequate fluid intake ;
-Increased nutrient needs;
-Biting/chewing difficulties;
-Impaired swallowing;
-Impaired nutrient utilization


What are the CONTRAINDICATIONS to Enteral Nutrition?

**DO NOT utilize enteral tube feeds;
Serious medical conditions of GI tract =
-Diffuse peritonitis (inflammation/infection of the peritoneal lining of abdominal cavity);
-GI bleeding;
-Obstruction or ileus that prevent passing of intestinal contents;
-Intractable vomiting or diarrhea not responsive to medical treatment


ADAVANTAGE of Enteral Nutrition

-Reduced hospital stay;
-Reduced surgical interventions;
-Reduce rate of infectious complications in critical care patients;
-Improved wound healing;
-Maintenance of GI function


When might Enteral be used along with Parenteral Nutrition?

-Even when pt. cannot meet all nutritional needs through EN, trophic or “trickle” may be prescribed with parenteral to minimize villous atrophy and prevent bacterial translocation → Keeps protective villi alive and maintains immunity ;
-“Use It or lose it”


DISADVANTAGES of Enteral Nutrition

-Potential difficulty of administration;
-Poor tolerance;
-Difficulty meeting nutritional requirements
→ Minimize disadvantages by careful patient selections through nutrition physical and standard protocols


What decisions need to be made about implementing Enteral Nutrition?

1. GI Access;
2. Formula;
3. Delivery schedule;
4. Duration


What is a Nasogastric tube feed?

Nose → stomach;
-Normal GI function;
-Stimulates normal digestion;
-Meds can be placed in tube;
-Bedside insertion;
-Can potentially cause aspiration, discomfort, nasal irritation and tube displacement


What is a Nasoduodenal tube feed?

Nose → duodenum (intestine);
-Normal SI function, but need to bypass stomach;
-Tube insertion bedside;
-Can lead to discomfort and tube displacement


What is a Nasojejunal tube feed?

Nose → ileum (intestine);
-Normal SI function, but need to bypass stomach;
-Tube insertion bedside;
-Can lead to discomfort and tube displacement


What is a Gastrostomy tube feed?

Directly into stomach (surgically through skin);
-Normal GI function but need to bypass upper GI;
-Long-term feeding access;
-Reduced risk of tube displacement;
-Allows bolus feedings;
-Surgical procedure accompanied with possible irritation or infection


What is a PEG (percutaneous endoscopic gastrostomy)?

Directly into stomach (laparoscopic through skin);
-Normal GI function but need to bypass upper GI;
-Long-term feeding access;
-Outpatient procedure w/o anesthesia;
-Less expensive and lower risk of displacement;
-Allows bolus feedings;
-Risk of irritation and infection


What is Jejunostomy tube feed?

Directly into jejunum (through skin);
-Normal GI function but need to bypass part of GI;
-Long-term feeding access;
-Surgical procedure with risk of irritation and infection;
-Small lumen of tube, so risk of clogging increased


What needs to be assessed to determine the appropriate formula for Enteral feeding?

-Medical diagnosis;
-Nutrition diagnosis;
-Skin breakdown;
-Weight (weight loss/gain);
-Tolerance of previous tube feedings;
-Risk of aspiration;
-PO or NPO;


What are the most common formulas used for Enteral Feedings?

1. Jevity
2. Jevity 1.2
3. Jevity 1.5


Other formulas

-Glucerna 1.0, 1.2, 1.5;


What the 3 different type of delivery schedules for Enteral Feeding?

** Enteral nutrition delivery is usually regulated by a small, programmable feeding pump;
1. Bolus;
2. Intermittent;
3. Continuous


What are Bolus Feedings?

-Rapid administration of formulas of 240-480 ml of formula several times a day;
-Calculate amount needed in number of cans per feeding and how many times per day
-Example: 2 cans three times/day and 1 can HS = Mimics 3 meals and a bedtime snack
*Note: 1 can = 240 ml


When might bolus feeding be appropriate?



What are Intermittent Feedings?

-Administered several times a day;
-Administered a little slower than bolus;
-Usually over 20-30 minutes;
-Uses a pump to administer formula;
-If a pump is not available then can use gravity drip


What are Continuous Feedings?

-Administered over 8-24 hours daily;
-Uses a pump to control the feeding rate;
-Preferred in acute care settings;
-GI tolerance is best with continuous feedings;
-Disadvantage: limited mobility
--How to overcome- adjust feeding schedule to feed over 8-12 hours rather than 24 hours


When should Continuous Feedings be chosen?

-Pt often has residuals;
-Cannot tolerate large amounts of volume at a time;
-Not active;
-Not attending rehab therapy


How should a Continuous Tube Feed be INITIATED?

If a NEW TF patient =
Start at 45-50 ml/hr and progress by 10-20 ml/hr every 8 hours until goal rate is obtained


How should a Bolus Tube Feed be INITIATED?

If a NEW TF patient =
-Initiate 120 ml (1/2 can) every 3 hours for 2 feedings;
-Then increase by 120 ml every 2 feedings to final goal volume per feeding


How are water needs determined with CONTINUOS Tube Feeds?

*Need to determine if the pump AUTO FLUSHES


If the pump auto flushes...

-If so, the pump will automatically provide 25 ml of water/hour;
-This will provide an additional 600 ml of water/24 hours;
-Make sure this provides enough fluid for patient


How would you check to see if provision of fluid is adequate?



What is the pump does NOT auto flush for a Continuous Tube Feed?

-Determine the amount of water provided by the formula;
-Subtract amount of water provided by formula from fluid needs you have calculated for the patient


Example of Water Calc (NO auto flush)

-Fluid needs calculated = 1800 ml/day;
-Water in formula provides 1150ml/day;
-Difference is 650ml;
-Divide 650 by 3 = 217ml/flush;
-Round to nearest 25ml = 225 ml/flush;
-225ml/flush X 3 = 675 ml water provided by flushes + 1150 water provided by formula = 1825 ml total water


What is the most a Water Flush should ever be?

Water flushes should not exceed 275-300 ml/flush → Typically 150-175 ml/flush 3-4 times a day (TID or QID)


How should water flush recommendations be written?

1. Flush 225 ml water 3 times/day to provide a total of 1825 ml/day
2. Could be 175 ml 4 times/day to provide a total of 1850 ml/day


How are water flushes determined for BOLUS Feedings?

1. Calculate the amount of water provided from total number of cans given per day;
2. Subtract the amount of water in formula from estimated fluid needs;
3. Write the recommendation the same as continuous feeding
**All water flushes should be rounded up to the nearest 25, 50, 75, or 100 ml


What is monitored for tolerance of Tube Feeds?

1. Residuals;
2 Intake/Output;
3. Nausea/Vomiting;
4. Diarrhea/Constipation;
5. Weight;
6. Labs;
7. Aspiration


What are Residuals?

-Undigested feeding solution remaining from previous feeding;
-May result from =
•High volume
•High rate
•Not tolerating a specific formula


How often are Residuals checked?

-~every 4-6 hours;
-MDs write order to stop feeding if =
1. residuals are > 1.0-1.5 times the hourly rate or
2. > 150 ml before the next bolus or intermittent TF
**Controversial topic
-You need to monitor nurses notes;
- If residuals are too high, TF may be held


How is Intake/Output used to monitor tolerance?

-If intake > output, could be dehydrated;
-→ increase flushes or change formula (that is less concentrated so lower kcal/ml)


How is Nausea/Vomiting used to monitor tolerance?

-Decrease volume by increasing kcal/ml ;
-Change formula to a higher kcal concentration;
-Example: Change Jevity 1.2 to Jevity 1.5;
-Spread out the flushes;
-Spread out the bolus feedings


How is Diarrhea/Constipation used to monitor tolerance?

-Change formula with more fiber;
-Check medications;
-Consider possible bacterial etiology (diarrhea)


What labs are check for tolerance of Tube Feed?

-Glucose, BUN, Cr, K, Na…;
-May need to change formula;
-Increase flushes or even decrease flushes if over hydrated;
-Medications may need to be adjusted;
-Monitor for dehydration or even over-hydration


How is aspiration monitored for tolerance of tube feed?

-Look in nurses notes;
-Xray results, formula coming out of mouth or out of tube;
-HOB at or > 30 degrees;
-Continuous feeding may help improve aspiration or decrease risk of aspiration


What are the characteristics of a successful nutrition counselor?

-Respect all clients;
-Be genuine = real person;
-Consider client’s feelings, experiences, beliefs;
-Be flexible, non judgmental, optimistic;
-Consider client’s role in family, culture;
-Provide structure – explain what you will do/ why/ how


How do you establish rapport?

- Use open ended questions (Begin with “what”, “why”, “how”; “Can you tell me more about….?”);
-Share control;
-Demonstrate sincere concern;
-Utilize active listening → Clients often need to talk/ express feelings;
-Watch for non verbal responses


What are the component of effective communication?

-Listening sensitivity vs. information expert;
-Body language shows client is important ( Eye contact, Posture, gestures);
-Terminology client can understand → Use handouts! ;
-Don’t argue or insist / roll with resistance;
-Be open;
-Encourage discussion/ explore why patient is resistant


What is the traditional model of RD counseling?

-Used same intervention technique for everyone;
-Used change process matched to action and maintenance stages;
-PROBLEM: many clients in pre-action stage/ not ready to change;
-RESULT: POOR success!


What are the current counseling guidelines?

-Assess readiness to change;
-Raise awareness of disease, diet concerns (discuss how nutrition “can help with” …);
-Address client concerns;
-Correct misinformation (be non judgmental);
-Provide education


What are the stages of change/

1. Pre contemplation (client not aware of problem/ needs info)
2. Contemplation (ambivalence/ discrepancy/ to change or not to change)
3. Preparation (identify options/set short term goals/ action plan)
4. Action (client engages in actions of change)
5. Maintenance (provide support, additional education/ revise goals, action plan)
6. Relapse (normal / anticipate/ restart change process)


What else can help the patient?

-Help client visualize self in healthy lifestyle → Privilege vs punishment;
-Identify unhealthy behaviors and healthier alternatives;
-Identify unhealthy thoughts/ attitudes and strategies for change (CBT);
-Realistic goal setting (1-2 behavioral goals)


How do you identify unhealthy behaviors and strategies?

-How to change environment (Stimulus control);
-Strategies for healthier food and exercise choices


What is realistic goal setting?

-Acceptable, Achievable , Appropriate;
-Using guidelines presented, emphasize client choices re: action plan;
-Ask what client is willing to change (remember, most people don’t want to change; can negotiate such as reducing # soft drinks). ;
-Discuss options for goals (present to client in writing if possible);
-Example: If you have identified need to increase F/V, decrease sodium, increase dairy, patient can identify a category they would prefer to start with.


What are tools that can be used in counseling?

-Self monitoring tools = Offer possibilities: what they are, how they work;Client participates in choice of tools, frequency used;
-Support sense of self efficacy → Help client identify small successes in past and present;
-Follow up plan- develop with client;
-Relapse Management;
-On going support


What should a counselor DO?

-Choose/develop handouts carefully (quality vs quantity);
-Be creative with handouts: think color, interest, easy to read;
-Utilize form/contract to document goals with client;
-Place educational information in front of client


What should a counselor AVOID?

-saying “on a diet”;
-reading your PES statement to the client;
-using “ words” like “intaking”;
-referring client to internet source for basic information you should be providing;
-using .coms as additional resources


What should/not be in a sample menu?

1. Do not include deli turkey or fruited yogurt;
-Foods should be healthy, yet accessible;
-Consider client schedule, time, use of restaurant food, budget, familiar foods, family meals;
2. Look over menu with client and allow for questions and requests for changes;
-Though you will not have time to go through each menu item, you should focus on a few specific areas of the menu and be willing to adjust according to patient preferences or schedule.;
3. Leave room on menu to make adjustments with client during session


How common is CVD in the US?

**CVD remains the leading cause of death in U.S=
- estimated 1 in 3 adults in U.S. have one or more types of CVD;
-even though relative rate of death from CVD declined by 32% from 1999-2009, 1 in every 3 deaths still attributed to CVDl;
-“The total direct and indirect cost of CVD and stroke in the United States for 2009 is estimated to be $312.6 billion”


What causes a large portion of death from CHD?

-More than ½ of the deaths from CHD are related to ISCHEMIA (impaired blood flow) → From constriction or obstruction;
-Most CVD deaths seen with older persons (>65yrs), 1/3 of deaths occur prematurely (in persons <75yrs per above reference);
-Almost 50% of decrease due to identification of risk factors;
-Remainder due to treatment (includes Increased detection/mgt of HTN)


What is the Specialized Conduction System of the Heart?

-Electrical activity initiated in the heart at the SA node.;
-The change in electrical energy potential (depolarization) in SA node causes atria to contract.;
-Depolarization carried from atria to ventricles by AV node.;
-Depolarization of AV node is carried into the ventricles by bundle of His which splits into rt.;
-And L branches.;
-Depolarization is spread through ventricles by Purkinje fibers


What is the Cardiac Cycle?

-Repeating contraction/relaxation of the heart:
1. Systole (contraction )
2. Diastole (relaxation)
= Force exerted on the walls of blood vessels during contraction and relaxation of the VENTRICLES: “systolic blood pressure” and “diastolic blood pressure” respectively


What is Stroke Volume?

volume of blood ejected with each contraction of LV


What regulates Stroke Volume?

-End-diastolic volume (EDV) ;
-Mean arterial blood pressure (MAP);
- Strength of ventricular contraction
→ All additively contribute to the volume of blood ejected!!


What is End Diastolic Volume (EDV)?

How much blood is in the left ventricle at the END of relaxation period (prior to next contraction)


What is Mean Arterial Pressure?

-average force of the blood against the wall during the cardiac cycle;
-regulated by cardiac output and total peripheral resistance


What is the Ejection Fraction?

-Percentage of the blood within the left ventricle that is ACTUALLY ejected during contraction → used to determine the functioning of the heart;
-A small ejection fraction can lead to enlargement of the heart, due to the attempt to pump more blood; Largely due to increased resistance of circulation


What is involved in the regulation of Mean Arterial Pressure?

1. Sympathetic/ parasympathetic nervous system
— Parasympathetic – decreases heart rate
— Sympathetic – increases heart rate
2. Renin-angiotensin system
3. Renal function — Renin is secreted by the kidneys!


What hormones are involved in the regulation of MAP?

-Angiotensin II


How does Epinephrine affect MAP?



How does Angiotensin II affect MAP?



How does Vasopressin affect MAP?



What are the purposes or differences in the JNC 7 and JNC 8?

-Publication of many new studies.;
-JNC 7 were NOT all randomized control trials, but JNC 8 are ALL randomized control trials;
-Need for a new, clear, and concise guideline useful for clinicians.
-Need to simplify the classification of BP.


What were the changes between the JNC6 and the JNC7?

-JNC 7 Normal BP 120/160/>100 (no more stage 3)


What is Hypertension?

Chronic elevation in blood pressure


What are the classification of BP?

1. Normal
2. Pre-HTN
3. HTN Stage 1
4. HTN Stage 2


JNC 8 Normal BP

<80 mm Hg diastolic



120-139 systolic or 80-89 diastolic


JNC 8 HTN Stage 1

140-159 systolic or 90-99 diastolic


JNC 8 HTN Stage 2

>/equal to 160 or >/equal to 100


What are the JNC 8 subgroup recommendations: 60 and over?

< 150 systolic/< 90diastolic
**Target BP used to be for 80y/o, now reduced to 60y/o


What are the JNC 8 subgroup recommendations: Under 60?

< 140 systolic /< 90 diastolic


What are the JNC 8 subgroup recommendations: Over 18 with CKD (kidney disease)?

< 140 systolic /< 90 diastolic


What are the JNC 8 subgroup recommendations: Over 18 with DM?

< 140 systolic /< 90 diastolic


ASH/ISH 2014 Recommendations for HTN management for patients with DM

-WITHOUT chronic renal disease = angiotensin converting enzyme inhibitor or angiotensin receptor blocker;
- WITH chronic renal disease or proteinuria = angiotensin converting enzyme inhibitor or angiotensin receptor blocker


What does JNC 8 state about Beta-Blockers?

Beta-blockers are NOT a preferred anti-HTN agent in absence of comorbid conditions (CHF, CAD)


What is the definition of HTN in children?

-BP—95th percentile or greater, adjusted for age, height, and gender


How to treat children with HTN?

-Use lifestyle interventions first, then drug therapy for higher levels of BP or if insufficient response to lifestyle modifications;
-Drug choices similar in children and adults, but effective doses are often smaller;
-Uncomplicated HTN not a reason to restrict physical activity.


What are the CVD Risk Factors?

-Hypertension* → Metabolic syndrome;
-Cigarette smoking
-Obesity* (BMI >30 kg/m2) → Metabolic syndrome
-Physical inactivity
-Dyslipidemia* → Metabolic syndrome (any abnormalities in the lipid panel)
-Diabetes mellitus* → Metabolic Syndrome ;
-Microalbuminuria or estimated GFR <60 ml/min → Impaired renal function; Defect in the nephrons of the kidneys so large proteins that should NOT be excreted and passing through basically h
-Age (older than 55 for men, 65 for women);
-Family history of premature CVD → (men under age 55 or women under age 65)


Why is Microalbuminuria a risk factor for HTN?

→ Impaired renal function; Defect in the nephrons of the kidneys so large proteins that should NOT be excreted and passing through basically holes in the nephrons of the kidneys, so protein is lost;


Why is the age-of-risk GREATER for women?

-After women go through menopause and lose production of estrogen which is PROTECTIVE, so they get more time of decreased risk;
-Until about age 65, their female hormones ward off HTN and CVD


What are the identifiable causes of HTN?

**Secondary HTN =
-Sleep apnea
-Drug-induced or related causes
-Chronic kidney disease
-Primary aldosteronism
-Renovascular disease
-Chronic steroid therapy and Cushing’s syndrome
-Thyroid or parathyroid disease


What is Primary HTN?

Greater proportion of CVD is IDIOPATHIC (unknown)


How are considerations for HTN different in women?

-Oral contraceptives may increase BP, and BP should be checked regularly. In contrast, HRT does not raise BP.*;
-Development of HTN—consider other forms of contraception.*;
-Pregnant women with HTN should be followed carefully. Methyldopa, BBs, and vasodilators, preferred for the safety of the fetus. ACEI and ARBs contraindicated in pregnancy.


What is the prevalence of HTN in the US?

HTN prevalence ~ 78 million people in the United States (AHA report 2013).


What is the relationship of BP to CVD?

-Continuous, consistent, and independent of other risk factors.;
-Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg;
-No evidence to support treating to this low of a level, so target 140/90


What does Pre-HTN indicate?

-Prehypertension signals the need for increased education to reduce BP in order to prevent hypertension;
→ PreHTN was implemented in the JNC7 (2003)


How does HTN relate to risk of a myocardial infarction (MI)?

-175/105 = 8X risk of MI;
-155/95 = 4X risk of MI;
-135/85 = 2X risk of MI
→ Systolic must be < 120 for maximum benefit


What is the prevalence of HTN across ethnic groups and gender?

Rates vary by ethnic group and gender =
-LOWEST prevalence: Hispanic/ Latino
-Mexican American: HIGHER rates
-HIGHEST rates: Black males and females → African American population is overall at the greatest risk!!
-Prevalence RISE dramatically with AGE


What is the prevalence of HTN in the US by age group?

*NHANES data =
-45-54 = 31%;
-55-64 = 48%;
-65-74 = 65%;
-75+ = 78%


What is the trend of HTN in older persons?

-More than two-thirds of people over 65 have HTN.*;
-This population has the LOWEST rates of BP CONTROL. * → Need to focus on simply CONTROLLING the BP of older people


Are there differences in treating HTN in older people?

-Treatment, including those with isolated systolic HTN, should follow SAME principles outlined for general care of HTN. → Diagnosis can be with an elevated systolic or diastolic!
(Still have HTN even if controlled);
-Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets


What are the consequences of HTN?

-HTN = strong risk factor for CVD morbidity/mortality;
1. HF
2. Kidney Failure
3. MI, Stroke, Aneurysms
4. Vision problems


What organs are affected by HTN?

*END-ORGAN Damage =
1. Brain - hemorrhage, stroke;
2. Eyes - retinopathy;
3. Circulatory - peripheral vascular disease;
4. Kidneys - renal failure, proteinuria;
5. Heart — LVH, CHD, CHF


What is Heart Failure?

CHF – heart can’t pump adequately to meet the need of all the tissues


What is Renal Failure?

CRF – secondary to the impairment of the nephrons and tubule malfunctions; and decreased blood flow


What are the comorbidities of HTN?

1. Coronary Artery Disease (50%);
2. Left Ventricular Hypertrophy (15-20%);
3. Ischemic Stroke (77%);
4. Chronic Kidney Disease (8-15%);
5. DM (75%);
6. Peripheral Artery Disease(74%)


How might HTN lead to CAD?

Starts with an injury to the arterial wall and develops CAD (“injury” could be the HTN and the stretching of the arterial wall)


What 3 conditions are very strongly correlated to one another?

-Very strong correlation be HTN, DM and Renal Disease;
-Getting blood pressure under control is key relating to the other diseases


What is the incidence of End Stage Renal Disease (ESRD) in relation Systolic BP?

A systolic BP > 140 exponentially increases (more than doubles) the risk of ESRD;
-83% of black men with >140;
-32% of white men with >140


What is Dementia?

-Dementia and cognitive impairment occur more commonly in people with HTN. ;
-Reduced progression of cognitive impairment occurs with effective antihypertensive therapy.


What is the are the etiologies of HTN?

-Primary/essential – idiopathic (90%);
-Secondary – result of another chronic condition


What are the LIFESTYLE factors that contribute to PRIMARY HTN?

-Lack of activity;
-Smoking and tobacco use ;
-Genes affecting mechanisms that regulate sodium balance;
-Inflammatory response (General overall inflammation with obesity)


What Dietary factors contribute to HTN?

-High sodium
-Low potassium
-Low fruit/veggie intake
-Low fiber
-Low calcium
-Low water intakes; High intakes of sugary beverages
-High alcohol consumption


What are some pathophysiological factors that contribute to HTN?

-Excessive secretion of vasopressin & angiotensinogen;
-Renal disease;
-Adrenal disorders;
Neurological disease:


Excessive vasopressin and angiotensinogen and HTN

-Causes vasoconstriction and damages arterial walls


Smoking and HTN

-Mechanism unclear;
-Interference with Nitric Oxide;
-Impairs relaxation ;
-Prevents antioxidant protective effects on free radical formation and oxidative stress


Renal Disease and HTN

-Decreased blood flow leads to release of ATII;
-Leads to vasoconstriction & increased blood volume;
-Ultimately increased arterial pressure


Adrenal Disorders and HTN

-Excessive secretion of hormones = Epinephrine + norepinephrine = vasoconstriction


Neurological Disease and HTN

-May impact medulla oblongata & upset balance between sympathetic and parasympathetic nervous system so normal BP not maintained;
-Sympathetic =INCREASES;
-Parasympathetic = DECREASES


What is the JNC 8 target BP for all conditions?

-NO evidence to support an increased benefit of a lower target (used to be 130/80 for kidney disease, CAD, and DM)


What were the 3 objectives of the JNC 7?

1. Assess lifestyle and other CVD factors → Obesity, dyslipidemia, DM, smoking, inactivity…;
2. Reveal any identifiable causes of HTN;
3. Assess the presence or absence of organ damage


What are the main treatment goals for HTN?

Reduce risk of CVD and Renal disease


How are the treatment goals achieved?

-Weight reduction, physical activity, nutrition therapy;
-Pharmacological Intervention


What is included in the Nutr. Assessment for HTN?

1. Diet Hx: Identify dietary factors and patterns
2. Medical Hx/ Current Medical Diagnosis
3. Biochemical Assessment
4. Lifestyle assessment: Identify additional risk factors
5. Evaluate need for weight control


What are the possible IDNT Nutr. Diagnoses for HTN?

1. Excessive energy intake
2. Excessive or inappropriate intake of fats
3. Excessive sodium intake
4. Inadequate calcium, fiber, potassium, or magnesium intake
5. Overweight/obesity
6. Food and nutrition knowledge deficit
7. Physical inactivity


What are the Nutr. interventions for HTN?

-Nutrition RX
-Prioritize methods to meet DASH dietary goals;
-Possible interventions:
2. Weight loss
3. Decrease Sodium
4. Moderate Alcohol
5. Physical Activity
6. (Smoking Cessation)


What are the recommended lifestyle modifications to lower BP?

1. Reduce weight;
2. Adopt DASH diet;
3. Reduce sodium intakes;
4. Increase physical activity;
5. Moderate alcohol consumption
**Combining 2 or more of these modifications may or may not have an additive effect on blood pressure reduction.


What is the effect of a weight reduction?

-Maintain normal body weight (BMI 18.5-24.9) = 3-20mmHG systolic reduction


What is the effect of adopting DASH?

-Rich F/V, low fat dairy, reduce fat = 8-14mmHG systolic reduction


What is the effect of reducing sodium intakes?

-Less than 2300mg/1500mg a day = 2-8mmHG systolic reducition


What is the effect of increasing physical activity?

-Aerobic activity >30 min/day most days = 4-9mmHG systolic reduction


What is the effect of moderating alcohol consumption?

-Men 2, Women 1 = 2-4mmHG systolic reduction


What was the DASH Study?

-1997 (NEJM, 1997);
-11 week study, 459 adults;
-Mean baseline BP: ~131.3/84.7 mmHg;
-3 groups: (Na intakes constant for all 3 groups- 3gm)
1. Control diet (normal american);
2. Diet rich in fruits and vegetables;
3. Combination diet → rich in f/v and low-fat dairy, with reduced saturated fat and total fat. → Gained big support!


What were the results of DASH?

*COMBO diet =
1. Reduced BP in subjects with HTN AND without HTN more than the f/v diet or control;
2. Those with HTN had greater results
— SBP decreased 11.4 mmHg more than control group;
— DBP decreased 5.5 mm Hg more than control group


What were the other findings of DASH?

1. Changes in BP:
— w/in 2 weeks of starting diet
— maintained for the next 6 weeks.
2. Reductions in BP:
— all participants (men, women, minorities…)
— in participants WITHOUT HTN → Overall beneficial, protective and preventative


What was the DASH Sodium Study?

-2001 Study;
-412 participants;
-Randomized to either Control diet or DASH diet;
-Results =Reduction of blood pressure: all Na+ levels in both groups


What were the results of the Control group for DASH-Sodium?

Control group:
-High → intermediate= 2.1 mmHg reduction of SBP
-Intermediate → low= additional 4.6 mmHg reduction of SBP


What were the results of the DASH group for DASH-Sodium?

DASH group:
-High→ intermediate= 1.3 mmHg reduction of SBP
-Intermediate → low= additional 1.7 mmHg reduction of SBP


Where were the comparative results of DASH-Sodium?

Control vs DASH (low sodium ~ 1500 mg Na/d)=
- Those without HTN: SBP was 7.1 mmHg lower ;
-Those with HTN: SBP was 11.5 mm Hg lower


Wha was the Premier Study?

Research Questions:
1. What happens when people have to obtain/prepare own food?
2. What would effect be if combined DASH diet with lifestyle changes known to decrease BP
3. Primary outcome: blood pressure and HTN status


What were the participants groups for Premier?

-810 subjects (w/ pre-hypertension or stage I HTN);
-Randomly assigned to 1 of 3 groups
1. Advice only
2. Established Recommendations
3. Established plus DASH


What was the treatment for the “Advice Only” group?

-1 time education session (usually RD);
-Gave instruction on factors that affect BP;
-Weight, Na intake, physical activity and DASH;
-Provided handouts;
-1 visit for 30 minutes;
-No counseling on behavior change and no other contact


What was the treatment for the “Established Recommendations” group?

-Behavioral counseling on established recommendations for BP mgt ;
-18 sessions w/ trained prof. over 6 mos.;
-Goals set for subjects =
1. weight loss of at least 15 lb at 6 months for those with BMI of 25 or greater
2. At least 180 min/wk of moderate activity
3. no more than 2300 mg Na/day
4. daily intake of 1 oz or less of alcohol for men, and ½ oz for women
5. *** saturated fat (≤ 10%), total fat (≤ 30%)
6. NO goals for f/v or dairy → DIFFERENCE form DASH


What was the treatment for the “Established plush DASH” group?

1. SAME 4 goals as Established, PLUS goals set for DASH
2. 9-12 servings of f/v each day;
3. 2-3 servings of low-fat dairy products;
4. Reduced saturated fat intake (≤ 7% kcal);
5. Reduced total fat intake (≤ 25% kcal)


What was the contact pattern with the Premier groups that received recommendations?

-Contact pattern was the same in both groups;
-Subjects kept food diaries, recorded exercise, monitored calorie and Na intake;
-Established plus DASH- also recorded f/v, dairy, and monitored fat intake


What were the results of Premier?

1. Overall mean changes:
— Advice only: SBP ↓ 6.6 mmHg
— Established: SBP ↓ 10.5mmHg
— Established plus DASH: SBP ↓ 11.1 mmHg
2. Mean changes in those with HTN
— Advice only: SBP ↓ 7.8 mmHg
— Established: SBP↓ 12.5 mmHg
— Established plus DASH: SBP ↓ 14.2 mmHg


Summary of DASH

1. Low in saturated fat, cholesterol and total fat;
2. Focus is on fruits, vegetables, fat-free or low-fat dairy products → 9 fruits/veggies a day!! KNOW;
3. Whole grains → Fiber!;
4. Fish, poultry, beans, seeds, and nuts;
5. Limited red meats and processed meats;
6. Fewer sweets, added sugars, sugary beverages than typical diet


What are the DASH nutrient goals for a 2000kcal diet?

Fat = 27%;
Sat. Fat = 6%;
Protein = 18%;
CHO = 55%;
Chol = 150mg;
Sodium = 2300mg (1500mg gets even lower);
Potassium = 4700mg;
Magnesium = 1250 mg;
Fiber = 30g


What are the DASH food group recommendations for a 2000kcal diet?

-Grains = 6-8;
-Veggie = 4-5;
-Fruits = 4-5;
-Lowfat/FF dairy = 2-3;
-Lean meats, poultry, fish = 6 or less;
-Nuts, seeds = 4-5/wk;
-Fat and oils = 2-3;
-Sweets = 5 or less/wk;
-MAX sodium = 2300mg/day


What are the DASH meal patterns?

-Other kcal levels from 1200-3100 kcal/d can be found in 2010 DGAs (1600, 2600, 3100 kcal in Pennington Guide posted-Moodle)


What are the differentiations in sodium recommendations?

-MAX = 2300mg/day
(2300 is the UL for sodium for those 14 years and older);
-1500 mg/day = Additional lowering benefits


Who should only consume 1500mg/day sodium?

Recommended for: (DGA 2010)
1. 51 years and older
2. African Americans
3. Those with HTN or on HTN meds
4. Those with Diabetes
5. Those with chronic kidney disease


What are the different sodium nutrient labels?

-Sodium free: less than 5 mg/serving;
-Very low sodium: 35 mg or less/serving;
-Low sodium: 140 mg or less/serving;
-Reduced sodium: at least 25% reduction than regular version;
-Light sodium: 50% reduction;
-Unsalted or No Salt Added: no salt added during processing (not a sodium-free food)
** Remember > 20% DV = High; < 5% DV= Low


What is the AI for Potassium?

**Counters the effects of Sodium!
-AI=4700 mg/d


What is the In-Office BP Measurement Technique?

Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm.


What is Ambulatory BP Monitoring?

-Indicated for evaluation of “white-coat” HTN;
-Absence of 10–20% BP decrease during sleep may indicate increased CVD risk.


What is the method of Ambulatory BP Monitoring?

-ABPM is warranted for evaluation of “white-coat” HTN in the absence of target organ injury. ;
-Ambulatory BP values are usually lower than clinic readings.;
-Awake, individuals with hypertension have an average BP of >135/85 mmHg and during sleep >120/75 mmHg.;
-BP drops by 10 to 20% during the night; if not, signals possible increased risk for cardiovascular events.


What is Self-Meausurement BP Monitoring?

-Provides information on response to therapy;
-May help improve adherence to therapy and evaluate “white-coat” HTN;
-Home measurement of >135/85 mmHg is generally considered to be hypertensive.;
-Home measurement devices should be checked regularly.


What are the routine tests for monitoring HTN?

1. Electrocardiogram
2. Urinalysis → Looking for Renal disease and kidney problems (especially relating to sodium levels);
3. Blood glucose, and hematocrit ;
4. Serum potassium, creatinine, or the corresponding estimated GFR (glomerular filtration rate), and calcium → Indicate kidney function;
5. Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides


What are the optional tests for monitoring HTN?

-Measurement of urinary albumin excretion or albumin/creatinine ratio = Albumin should be too large to pass through the nephrons, but with kidney problems albumin will be excreted;
-More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved


What needs to be included int he Nutr. Rx?

-Type of diet = DASH → Simplifies diet order!;
-Level of sodium (2300 mg or 1500 mg);
-Energy level (for weight maintenance or weight loss);
-Any other specific recommendations to decrease or increase


What are the overall MNT goals for patients with HTN?

-Achieve and maintain a healthful weight ;
-Reduce blood pressure ;
-Reduce risk for diabetes, kidney disease, and cardiovascular disease


What are possible education/counseling intervention for HTN?

-Dietary Approaches to Stop Hypertension Eating Plan
-Limit alcohol intake
-Reduce intake of excessive sodium
-Identify and limit food sources of saturated fat, cholesterol, total fat, and sodium
-Discuss ways to increase f/v, nuts, beans, low fat dairy foods
-Describe seasoning alternatives to salt and high-sodium sauces
-Educate on use of food labels/ to monitor sodium and fat
-Discuss strategies for making wise food choices when eating outside the home
-Discuss the importance of increasing fluids as fiber intake increases/ strategies to increase fluids
-Discuss kcal level needed for weight management
-Include physical activity: role in BP mgt/ goal setting
-Support smoking cessation


What is the needed Monitoring/Eval for patients with HTN?

-Treatment plans
-Blood pressure
-Laboratory values
-Current dietary intake
-Ability to chew, swallow, and consume adequate nutrients
-Physical activity habits
-Weight and weight changes
-Readiness for education


What are the current Physical Activity recommendations for adults in the US?

1. Moderate-intensity* aerobic physical activity for a minimum of 30 minutes on 5 days each week, or
2. Vigorous-intensity† aerobic physical activity for a minimum of 20 minutes on 3 days each week, or
3. Combinations thereof for adults between the ages of 18 and 65 years,
4. Muscle-strengthening activities for a minimum of 2 nonconsecutive days each week.


What counts as moderate-intensity?

Exemplified by a brisk walk; noticeably accelerates heart rate.


What counts as vigorous-intensity?

Exemplified by jogging; causes rapid breathing and a substantial increase in heart rate.


What factors affect physical activity?

-Economic status
-Education level
-Beliefs and attitudes about being overweight or obese
-Beliefs and attitudes about exercise
-Medical conditions and health problems
-Energy level
-Time constraints
-Social responsibilities
-Social support
-Concerns about safety


What are they types of BP meds?

-ACE Inhibitors
-Beta Blockers
-Angiotensin-2 Receptor Blockers
-Calcium Channel Blockers
-Aldosterone Blockers


What are the types of Diuretics?

1. Loop = Furosemid (lasix), Bumetanide (bumex)
2. Thiazide = HCTZ (hydrodiuril)


What is the mechanism of Loop Diuretics?

1. Decrease blood volume by inhibiting renal sodium, chloride and potassium reabsorption in Loop of Henle àincreased urinary output;
2. Increasing prostoglandinsà vasodilation


What is the mechanism of Thiazide Diuretics?

-Also inhibit renal sodium, chloride and potassium reabsorption = but in distal tubules and ascending loop of Henle


What are Aldosterone Antagonists?

**Potassium sparing diuretics;
-Generic name: spironolactone
- Brand name: aldactone
-Food/drug interactions: hyperkalemia;
-Potential side effects: vomiting, diarrhea, GI distress (and more)


How do Aldosterone Antagonists work?

1. How it works: interupt aldosterone stimulation;
2. INCREASES sodium and water excretion (also effects Na+/K exchange in renal tubules;
— Aldosterone would lead to Na+ retention in the renal tubules, so the ANTAGONIST prevents this function and renal stimulation, so in response cause retention of Potassium


What are the possible FOOD-DRUG interactions for DIURETICS?

-Glucose Intolerance
-Avoid Natural Licorice


What are the possibles SIDE EFFECTS interactions for DIURETICS?

*WATER Excretion!;
Side Effects:
-Diarrhea/ Constipation
-Dry Mouth
-Leg cramps


What are the ACE Inhibitors?

-Benazepril (Lotensin)
-Enalapril (Vasotec)
-Captopril (Capoten)
-Lisinopril (Prinivil, Zestril)
-Quinapril (Accupril)
0Ramipril (Altace)


How do ACE Inhibitors work?

-VASODILATORS = Decrease peripheral vascular resistance.;
-Interfere with formation of angiotensin II from angiotensin I (competitively block ACE);
-This causes the blood vessels to relax and allow blood to flow more easily so blood pressure goes down;
→ NO angiotensin II formed, NO thirst triggered, NO aldosterone triggered from the adrenal cortex → No Sodium retention, No water retention = LOWER BP


What are the possible FOOD-DRUG Interactions of ACE Inhibitors?

-Hyperkalemia ;
-Avoid Natural Licorice → Have “aldosterone-like” activities


What are the possible SIDE EFFECTS of ACE Inhibitors?

-Hypotension/ postural hypotension;
-Rash or itching;
-Allergic reaction


What are the possible BENEFITS of ACE Inhibitors?

-Protective effect on kidneys**;
-Less likely to effect BG


What are Beta-Blockers?

→ Decrease heart rate and cardiac output.*;
1. Drug Food Interactions → Calcium may interfere with absorption;
2. Side effects =
— Nausea, diarrhea, GI distress
— With Diabetes, beta blockers may hide some warning signs of hypoglycemia


What are the Angiotensin-2 (AT-2) Receptor Antagonists/ Blockers (ARB’s)?

-Irbesartan (avapro);
-Losartan (cozaar)*;
-Telmisartan (micardis);
-Valsartan (diovan)*


How do AT-2 Receptor Antagonists work?

1. Work in different way, but produce similar effects to ACE Inhibitors;
2. May be better tolerated than ACE Inhibitors because they produce less cough;
3. They shield blood vessels from AT-2, so vessels become wider and BP goes down


What are the Possible Food-Drug Interactions/Side Effects/ Benefits (ARB’s)?

-Side effects: → Nausea, Dizziness;
-Food-Drug Interactions: → Hyperkalemia


What are the Calcium Channel Blockers?

-Amlodipine (norvasc)
-Felodipine (plendil)
-Nifedipine (adalat, procardia)
-Verapamil (calan, isoptin)


How do Calcium Channel Blockers work?

1. Decreased calcium entering muscle cells of heart and blood vessels = decreased contraction of vascular smooth muscle which leads to VASODILATION;
2. This causes blood vessels to relax and blood pressure goes down.


What are the possible Food-Drug Interactions/Side Effects/ Benefits of Calcium Channel Blockers?

*Food-Drug Interactions:
— Grapefruit juice (especially with felodipine)
— Limit caffeine
— Avoid or limit alcohol
— Avoid natural licorice
*Side Effects
— Edema legs and feet
— Nausea, heartburn


What major hormones affect fluid and electrolyte balance?

1. RAAS (Renin-Angiotensin-Aldosterone System) – driven by DECREASING hydrostatic pressure;
2. Vasopressin (hormone) – released by the pituitary; AKA antidiuretic hormone (ADH)


How does RAAS influence fluid balance?

1. Baroreceptors in blood vessels – stimulated by low hydrostatic pressure due to low blood volume ;
2. Renin (hormone) is released, converting angiotensinogen to angiotensin I;
3. Angiotensin I becomes angiotensin II → as volume increases aldosterone (hormone) from the adrenal cortex;
4. Aldosterone makes kidneys RETAIN Na+ ;
5. Na+ concentration then rises, osmotic pressure increases retaining fluid in blood;
6. Blood volume is then returned to normal levels


How does Vasopressin influence fluid balance?

-Stimulated by 1) high osmolality of ECF and 2) decreasing hydrostatic pressure by baroreceptors in the blood vessels ;
-Vasopressin leads retention of fluid by kidney tubules → Increases blood volume and lowers osmolality


What is stimulated once RAAS creates Angiotensin II?

1. Vasopressin increased = water retention;
2. Thirst mechanism activated = increase fluid intake;
3. Arteriolar vasoconstriction = increase fluid intake


What regulates SODIUM levels?

**Great influence on HTN;
1. RAAS – as water balance is controlled by vasopressin and aldosterone sodium is also regulated as well → stimulated by LOW blood volume/pressure ;
2. ANP (atrial natriuretic peptide = antagonist to RAAS); OPPOSITE to RAAS – released when arterial blood pressure increases; Causes increased urinary excretion of sodium and fluid to lower blood volume and thus osmolality concentration increases