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FSHN 450- Unit 1

4 moral principles governing behavior of health care professionals autonomy, non-maleficence, beneficence, justice
Nancy Cruzan case family wanted feeding tube removed, hospital removed
feeding should be initiated... immediately upon achieving medical stability
feeding can be discontinued at a later date... if authorized by the individual/ indicated w/ permanent unconsciousness
terminally ill: therapeutic diets should be... liberalized to all extents (let them enjoy foods they like)
over-arching ethical responsibility of the RD knowing how to achieve what is wanted
1991 patient self-determination act medicare/medicaid providers must inform patients of their right to prepare advance directives and refuse treatment
HIPPA health insurance privacy and portability act; assures confidentiality of medical records
Dx diagnosis
Tx treatment
D/C discharge
3 benefits of MNT/ parenteral nutrition prolonged life, improved mental state, prevent further loss of function
4 costs of MNT/ parenteral nutrition cost, burden to family, prolonged pain/suffering, risk of infection
JCAHO joint commission on accreditation of health care organizations
___% of all hospital patients (__%) elderly are... 40/60 are malnourished or at risk for malnutrition
LOS length of stay
m&m morbidity and mortality
7 malnutrition indices nutrition related disease, recent unintended weight loss, BMI <19 or >25, age >75 or <12, biochemical, special diet, recent procedures
critical numbers for unintended weight loss 10% in 6 months or 5% in month
dyslipidemia macrophages become lipid laden and can't fight infection (elevated VLDL and low HDL)
overweight BMI 25-30
stage 1 obesity 30-35
stage 2 obesity over 35
two nutrition questions upon admission are you on a special diet? have you experienced unintended weight loss recently?
MNA mini nutrition assessment- for elderly
MNA 6 questions BMI, weight loss, illness/stress, mobility, dementia/depression, appetite
MUST malnutrition universal screening tool (MNA is better)
MUST 3 indices BMI, weight loss, acute illness (malnutrition universal screening tool)
DETERMINE nutrition screening in elderly (disease, eating poorly, tooth loss, economic hardship, reduced social contact, multiple medications, involuntary weight loss, need assistance w/ self care, elderly (>80))
7 nutrition assessment indices anthropometric, biochemical, drug/diet interactions, procedures, feeding modality, socio/psycho, ability/willingness to change
4 groups at risk for low health literacy elderly, minorities, immigrants, low income
QOL quality of life
health literacy/cancer later screening, treatment not understood, poor decisions about accepting treatment
low health literacy had ___ more___ and ____ longer ____ 6% more hospitalizations, 2 days longer LOS
two widely used health literacy tests TOFHLA (test of functional health literacy in adults) short (7-10 min) or long (18-22 min), REALM (rapid estimate of adult literacy in medicine) *3 minutes
new health literacy test NVS (newest vital sign)
5 diet interactions: corticosteroids impaired glucose tolerance, protein loss, calcium loss from bone, sodium retention/edema, potassium losses
2 diet interactions: diuretics K/Mg/Zn, some may cause K retention
how much protein if on corticosteroids >1.5 g/kg/day
low potassium can cause what? and what may it be due to? cardiac arrhythmias, diuretics
what is the "big" drug diet interaction? anti-coagulant coumadin
coumadin anti-coagulant that interferes w/ vitamin K (must have a constant intake and not sudden large amounts) *new drugs don't have this problem but they're expensive
4 herb/supplement interactions w/ coumadin ginko, ginger, ginseng, fish oil
albumin normal range 3.5-5 g/dL
transferrin normal range 200-400 mg/dL
prealbumin normal range 20-50 mg/dL
hemoglobin/hematocrit cutoffs F: 12 g/dL, 36% M: 13 g/dL 39%
MCV mean corpuscular volume (HCT x 10/ RBC)
normal MCV 75-98 femtoliters
microcytic anemia <75 fL (iron deficiency)
macrocytic anemia >98 (folate or B12 deficiency)
hypersegmentation >5 segments of the nucleus; preceeds macrocytic anemia
hamwai formula females 100 for 5 feet, 5# per inch over 5 feet
hamwai formula males 106 for 5 feet, 6# per inch over 5 feet
BK below knee
AK above knee
kcal non obese 25-30 kcal/kg
kcal obese 22-25 kcal/kg ideal body weight
when to use harris benedict? not ideal in hospital patients
correction of harris benedict for obese individuals IBW + (OBW-IBW)*.25 **commonly used but controversial
ireton jones equation for critically ill patients sex 1= male 0=female T= trauma, B= burn **ventilator patients
Penn State uses RMR, Ve, Tmax two equations: non obese, obese <60 yrs; obese >60 yrs
mifflin- st. jeor healthy individuals, non ICU hospital
critically ill w/ RMR measurement Penn state
which equation: adult weight management mifflin
which equation: kidney disease KDOQI (23-25 kcal/day)
which equation: critically ill non-obese Mifflin x 1.25 or Penn State
which equation: critically ill obese Penn state or mifflin
which equation: critically ill ventilated ireton jones/ penn state
which equation: heart failure mifflin or harris-benedict
which equation: cancer harris benedict
which equation: unintended weight loss 25-35 kcal/kg
normal protein needs 0.8-1.0 g/kg/day
elderly protein needs 1-1.1 g/kg/day
when are protein needs higher? burn, multiple trauma, systemic infection
when are protein needs lower? kidney, liver
hospital protein needs non obese 1.2-2
hospital protein needs obese 2 ideal BW for class I/II, 2.5 ideal BW class III
surgery/trauma protein 1.5-2
brain injury protein 1.5-2.2
acute spinal cord injury protein 2
what 3 enzymes are increased after heart attacks? lactate dehydrogenase, alanine amino transferase, aspartate amino transferase
gamma glutaryl transpeptidase GGT very specific to liver
LFT liver function tests
amylase and lipase LFT- if elevated it's due to pancreatitis
PT prothrombin time (liver, drugs, vitamin K)
albumin:globulin increased ratio w/ liver disease (liver breaks down globulins)
bilirubin jaundice, liver function
BUN 10-23 mg/dL (increased in kidney disease, decreased in liver disease)
creatinine .6-1.2 mg/dL increased in kidney disease
CRP c-reactive protein elevated in: trauma, infection, vasculitis, malnutrition inflammation, kidney disease *risk factor for CHD
ADL activities of daily living
3 places for deficiency: eyes, mouth, tongue
muscle depletion areas scapula area and clavicle
mouth cracks b vitamin deficiency
lower lid becomes pale w/ anemia
white of eye turns ___ if ____ yellow, jaundice
cornea spot vitamin A deficiency
spooning iron deficiency
stomatitis (tongue swelling) deficiency in iron, niacin, riboflavin, B12, folic acid
3 sources of fluids food, beverage, metabolism
4 losses of fluids feces, sweat, skin/lungs, urine
what would BUN be if dehydrated? 30
what would BU be with renal disease? way higher than normal range of 23-25 mg/dL
third spacing fluid sequestering elsewhere (inflammation) or obstruction
ascites accumulation of fluid in abdominal cavity (liver disease)
peritonitis inflammation of membrane around abdominal cavity
moderate hypovolemia 5-10%; electrolyte fluids
severe hypovolemia 10-15% iv fluids
body weight hydration 1st 10: 100 ml/kg, 2nd 10: 20 mL/kg 20mL/kg <50 years 15 mL/kg >50 years
kcal intake and water adult 1 mL/kcal child 1.5 mL/kcal
extracellular electrolytes Na, Ca2+, Cl-, HCO3-
intracellular electrolytes K+, Mg2+, PO43-
pH of body 7.35-7.45
3 functions of electrolytes maintain osmotic equilibrium and control fluid shifts, maintain pH balance, maintain electrochemical neutrality
fish bone notation cations, anions, kidney/hydration, ca/gluc/po4
hypokalemia K <3.5 (diuretics, GI losses)
hyperkalemia K >5.5 K+ sparing diruetics, adrenal insufficiency, antihypertensive drugs
hyponatremia heavy sweat losses Na <135, fluid overload
hypernatremia insensible sweating, excess NaCl administration Na > 145
hypo-bicarbonate metabolic acidosis <22 mmol/L
hypochloremia <98 mEq/L (vomiting)
hyperchlormia >107 mEq/L (ketoacidosis, kidney failure, excess saline)
pCO2 range 35-45 mm Hg
pO2 range 80-95 mm Hg
O2 sat 95-99%
HCOe 22-26 mmol/L
hypoventilation decrease in pH
hyperventilation increase in pH
Hamburg shift movement of Cl- in and out of RBC to maintain neutrality and changes in bicarbonate
ADIME assessment diagnosis intervention monitoring evaluation
PES problem etiology signs/symptoms (___ R/T ____ AEB ____)
for every ___ decrease in pH, there is a corresponding ___ increase in __ .1, .6-1.2 mEq/L serum K+
hypoxia increase in anaerobic metabolism
acidosis could be due to... diabetic ketoacidosis, loss of intestinal fluid (HCO3-), renal failure (retention of H+ ions)
alkalosis could be due to... loss of upper GI fluid, ingestion of antacids
increase calories in nutrition support= decrease in water
NGT naso-gastric tube
c/o complaint of
PEG percutaneous endoscopic gastrostomy
enzyme in acid base buffering carbonic anhydrase
D/C discharge
d/c discontinue
what is added long term to feeding tubes? fiber and ultra trace minerals
osmolarity of EN 200 mOsm/L; isotonic (hypertonic not ideal, should be started slowly)
3 modes of administration for EN continuous, intermittent, cyclic
1 F= .33 mm
who needs low CHO EN? diabetics (40-45, normally 50-55)
who needs low protein EN? kidney patients (4%)
"high nitrogen" EN 15% or higher protein
1 kcal/mL is __% water 85%
2 kcal/mL is ___% water 70%
types of EN products (6) lactose free, milk based, blenderized, polymeric, fiber-containing, disease specific
polymeric formulas nutren1.0 etc.
5 disease specific EN products diabetes (glucerna), COPD, renal, liver, trauma
diabetes EN high fat, low carb, low glycemic
COPD EN high fat for low RQ
renal EN low protein
liver EN low fat, high BCAA
trauma EN more protein and nutrients known for immune support
pediatric EN high P, Ca, protein
bariatric EN high protein, low calorie
critically ill/malabsorbing EN MCT, amino acids, peptides, sugars
modular products EN not often used since there are products for most disorders
4 issues with EN access, microbial, metabolic complications, gastric residual volumes
gastric residual volume EN; difficult to measure, indicates if stomach is functioning (not used in Europe)
refeeding syndrome begin to re-synthesize TG, protein, carbs; use up the rest of electrolytes doing this and then the levels drop
2 drugs that stimulate gastric emptying erythromycin and metaclopromide
4 ways to decrease risk of aspiration EN 30-40 degree bed, continuous, prokinetic drugs, post-pyloric placement
fistula adhering of 2 epithelial membranes due to inflammation
nonocclusive bowel necrosis lack of oxygen to the gut (occurs with EN in unstable patient)
when is TPN required non functional GI, comatose w/out gag reflex, excessive needs >2000kcal/day, adjunct to chemo
infusaport outpatient, 90 degree needle
triluminal catheter 1 for TPN, 1 saline, 1 antibiotics
PPN used for pre-term babies, high fat (coats vein), low osmolarity to prevent pressure on veins
PN kcal CHO 3.4
PN kcal protein 4.3
lipids in PN should not exceed 1g/kg/day
CHO name in PN dextrose monohydrate
CHO notation PN D5W if 5%
which 2 vitamins are most important in PN w/ the shortage? thiamin and folic acid
MCT kcal 7 kcal/g
recommendations for vitamins due to shortage PN (4) multivitamin if tolerated, don't use pediatric products, give thiamin and folate each day, B12 monthly
complications of TPN (6) refeeding syndrome, azotemia, hyperglycemia, hypertriglyceridemia, cholestasis, hepatic steatosis, sepsis
Hepatic Steatosis fatty liver disease (occurs w/ too many kcals/fat during TPN)
azotemia elevated BUN/ammonia
cholestasis gallbladder sludge from not being used during TPN (removal eventually)
monitoring TPN weight daily, electrolytes daily until stable (2-3 days after), biochemical weekly, glucose every 6 hours until stable
__% of kids have allergies 8%
___% of adults have peanut allergy 1.3%
two most common allergies in children peanut and milk
4 most common allergies in adults peanut, tree nut, shellfish, wheat/gluten
5 accredited methods to identify food allergy skin prick test, intradermal, serum IgE, allergen specific IgE, food elimination, oral food challenges
total serum IgE elevated if allergic to something (must be IgE mediated)
what to eat w/ food elimination tests lamb, rice, carrots, apples
oral food challenges done with supervision; very small amounts administered
GI tract allergy symptoms (4) vomiting, diarrhea, abdominal pain, malabsorption
skin allergy symptoms (4) rash, hives, inflammation, angioedema
uticaria hives
erythemia skin inflammation
respiratory allergy symptoms (3) asthma, coughing, rhinitis, sinusitis
6 unproven symptoms of food allergies behavioral, adhd, eat infections, neurologic, musculoskeletal, migraine
otitis media middle ear infections
Children who outgrow peanut allergy display a shift from __ to ___ as tolerance develops Th2 to Th1
Th2 increased production of Il4 and Il5
Th1 production of INF-y
OIT oral immunotherapy
oral immunotherapy provide increasingly greater amounts of heat denatured food antigens major effect is temporary desensitization
EPIT epidermal immunotherapy (antigen applied to skin in effort to develop tolerance)
SLIT sublingual immunotherapy (nanogram amounts of antigen applied under the tongue)
rework reuse of a certain amount of dough from previous batches
gluten free <220 ppm
LES lower esophageal sphincter- pressure higher than intra-gastric
GERD gastro-esophageal reflux disorder
5 possible causes of GERD hiatus hernia, smoking, birth control, scleroderma, blockage of pylorus
hiatus hernia upper part of stomach protrudes through diaphragm (obesity)
scleroderma breakdown of connective tissue leading to GERD
pyrosis heartburn
4 effects of untreated GERD ulceration of esophagus, scarring, dysphagia, barrett's esophagus (precancerous overgrowth)
two main diagnoses of gerd endoscopic esophagoscopy, barium swallow
3 medications for GERD metoclopromide (emptying), antacids, h2 receptor blockers, proton pump inhibitors
drug nutrient interaction of H2 receptor blockers B12 deficiency due to lack of acid for IF
surgical treatment of GERD funduplication
4 general principles of MNT for GERD low fat, small meals (ish), limit hypertonic solutions, avoid carminitives (gas from stomach; spearmint, peppermint, garlic, onion)
what 3 substances to avoid w/ GERD alcohol, smoking, coffee
avoid what after eating w/ GERD reclining position
PP post prandial
DES diffuse esophageal spasm, esophageal sphincter fails to relax
achlasia dialated esophagus w/ bird beak sphincter
diagnosis of DES EGD, barium swallow
EGD endoscopic gastric duodenoscopy
treatment of DES balloon dilation or botox
mnt for des (3) semi soft foods, small frequent feedings, supportive therapy
gastric acidity physiology gastrin, histamine, and acetylcholine interact in stimulating HCl secretion
PUD peptic ulcer disease
causes of peptic ulcer disease nsaids/steroids, hyperacidity from food poisoning/alcohol, radiation induced inflammation and damage to mucosa, pernicious anemia, H. pylori, trauma
how do nsaids work? inhibit prostaglandin E and this aids in mucosa of stomach/small intestine
Zollinger-Ellison syndrome (ZES) tumor of pancreas and duodenum that leads to PUD
procedure for ZES Whipple (removal of head of pancreas, ducts, duodenum) need elemental tube feed
when will pain be felt for gastric vs. duodenal ulcers? stomach: upon eating; duodenal: 2-3 hours after
bleeding ulcers diagnosis dark stools, coffee grounds vomit
two ways to diagnose H. pylori specific IgG or urease biproducts if given urea
triple therapy for gastritis two antibiotics + proton pump inhibitor/Histamine 2 receptor blocker
proton pump inhibitor side effects connstipation, diarrhea, abdominal pain, dry mouth, MI?
histamine 2 receptor blockers constipation/diarrhea, B12 status
bezoars fibrous clumps from calcium with fiber (antacids)
Mg containing antacid side effect diarrhea
calcium and aluminum containing antacids side effect constipation
what deficit is common w/ GERD and PUD? food and nutrition related knowledge deficit
dumping syndrome stomach emptying too fast (after surgery)- diarrhea
treat dumping syndrome smaller meals, less sugar
Created by: melaniebeale