Medical Nutrition Therapy 1; Test 1 – Flashcards
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NCP
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- Nutrition Care Process - Systematic problem solving method developed by the AND that dietetics practitioners use to think critically, make decisions addressing nutrition related problems, and provide safe, effective, high quality nutrition care. -Evidence based approach
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NCP reason
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to increase demand and utilization of services provided by dietitians
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Components of NCP
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- Nutrition Assessment - Nutrition Diagnosis - Nutrition Intervention - Nutrition Monitoring and Evaluating
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Nutrition Assessment
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- Review psycho-social, functional and behavioral factors in addition to dietary data - Is on-going and dynamic - Obtain, verify, and interpret data - Compare to relevant standards to help identify possible problem areas
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Nutrition Diagnosis
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- Purpose is to identify and label the nutrition problem - NOT a medical diagnosis - EXPLICIT statement of nutrition diagnosis - Documentation is an on going process that supports all steps in the Nutrition Care Process
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Nutrition Intervention
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- Plan and implement purposeful actions to address the identified nutrition problem • Bring about change • Set goals and expected outcome • Client-driven • Based on scientific principles and best available evidence
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Nutrition Monitoring
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- Determine the progress that is being made toward the clients goals or desired outcomes - Monitoring- review and measurement of status at scheduled times
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Nutrition Evaulation
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- Determine the progress that is being made toward the clients goals or desired outcomes- Evaluation- systematic comparison with previous status, intervention, reference standard
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Nutrition monitoring and evaluation components
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-Monitor progress -Measure outcomes -Evaluate outcomes
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eNCPT
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-overview of the Academy of Nutrition and Dietetics Nutrition Terminology Reference Manual
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PES Statement
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- Problem, Etiology, and Signs and Symptoms; the format used in the NCP to write a nutrition diagnosis; it clarifies a specific nutrition problem and logically links the nutrition diagnosis to nutrition intervention and monitoring and evaluation
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PES Statement (Problem)
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- Describes alteration in the clients nutrition
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PES Statement (Etiology)
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- Cause or contributing factors
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PES Statement (Signs and Symptoms)
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- Defining characteristics
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Medical record
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-standard format for recording all aspects of medical care -legal document -communication tool -evaluation tool
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Types of medical records
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-Physicans orders -H & P (history and physical) -Lab tests -Progress Notes -Flow sheets -Consults
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SOAP Notes
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- Subjective (what family says) - Objective (factual data and lab results - Assessment (implementation of data) - Plan (implementation for care)
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SOAP Notes (Plan)
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- Specific objectives - Measurable outcomes - Evaluation
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Modified SOAP Notes
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- PES statement at conclusion - PES before plan/intervention
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ADI Format
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- A = Assessment section - D = Diagnosis statement (PES) - I = Intervention (plan recommendations, goals) - Scaled down from ADIME
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JCAHO Acronym
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- Joint Commission on the Accreditations of Healthcare Organizations
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JCAHO Standards
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- Nutrition Assessment - Adequacy of intake - Appropriateness of the route of delivery - Complications of therapy - Develop a plan - After implementation, evaluate effectiveness of the plan
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HIPAA Acronym
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- Health Information Portability and Accountability Act
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HIPAA Guidelines
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- Ink only - Date, Time, Signature - Chronological - Concise but thorough - Errors: crossed out but still readable (enter correction, date, time, sign)
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Nutrition Screening
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-Process of identifying patients, clients, or groups who may have a nutrition diagnosis and benefit from nutrition assessment by a RD - Rapid ID of clients who are malnourished or at risk of developing malnutrition
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What mandates when screens and assessment should be done
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-JCAHO
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Nutrition Screening Characteristics
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- Simple - Use readily available information - Specific for target population - Cost effective - Fast, quick and easy
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Checklist for signs of poor nutrition
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- DETERMINE
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Nutrition Assessment Purpose
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- Institue appropriate MNT - Monitor efficacy of MNT - Restore/maintain nutritional status
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Responsible for collecting nutrition assessment
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-RD -RDN's
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ABCD's of nutrition assessment
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-A = Anthropometrics Body measurements -B = Biochemical Blood/body fluid reports -C = Clinical Physical/mental signs and symptoms - D = Dietary Current and/or past FI
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Circumference of Head Measurement
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- Infant growth
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Circumference of Midarm Measurement
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- MAC - Energy and protein stores
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Circumference of Waist Measurement
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- Estimation of abdominal adiposity - Men <40 - Women < 35
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Circumference of Wrist Measurement
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- Estimation of frame size
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Stature height Measurement
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- Stadiometer - Standing height
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Knee Height Measurement
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- Measured for people with contracture, kyphosis, wheelchair bound
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Adjustments to IBW for Amputation
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- Foot = subtract 1.7 % - BKA = subtract 7% - AKA = Subtract 11%
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IBW Equation
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- Males = 106 lbs + 6 lbs for every in. over 5 ft. - Females = 100 lbs + 5 lbs for every in. over 5 ft.
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% IBW
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- (ABW / IBW) X 100
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% UBW
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- (ABW / UBW) X 100
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% Weight Change
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- [(UBW - ABW) / UBW] X 100
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Significant Weight Loss
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- 1-2 % over a week - 5 % over month - 10% over 6 months
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Severe Weight Loss
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- > 2% over a week - > 5% over a month - > 10% over 6 months
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Underweight BMI
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<18.5
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Normal BMI
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18.5-24.9
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Overweight BMI
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25-29.9
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Obese Class 1 BMI
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30-34.9
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Obese Class 2 BMI
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35-39.9
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Obese Class 3
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>40
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Energy Storage Assessment
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- TSF (triceps skin fold) - MAFA (Midarm fat area)
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Protein Storage Assessment
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- Estimate somatic (body) protein - Calculations use MAC and TSF
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Dehydration
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- Serious problem in elderly and children - Major cause of hospital admissions - Often associated with malnutrition - Causes false elevations of biochemical values
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Hydration status measured
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- Osmolality
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Components that effect Osmolality
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- Sodium - BUN - I/O - Clinical symptoms and BW
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Somatic Protein Assessment
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- Protein in the skeletal muscles - CHI (creatine height index)
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CHI
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- Creatine Height Index - Measures creatine in 24 hr. urine sample - Creatine is proportional to LBM
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Visceral (organ) Protein Assessment
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- Nitrogen Balance - Negative number = catabolism - Positive number = anabolism
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Visceral Protein Assessment
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- Serum Albumin - Prealbumin
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Albumin
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- Normally produced in liver - 1/2 life of 15-20 days - Indicator of long term PRO status - Indicator of malnutrition - Not accurate in ill
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Prealbumin
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- 1/2 life of 2 days - Indicator of short term effect of MNT -More expensive
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Best indicator of fat malabsorption
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-Fecal fat increase -Total cholesterol decrease -Coagulation decrease
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Biochemical measurements used to indicate CHO utilization
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-Blood glucose -Hemoglobin A1c -Blood insulin
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Blood glucose
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-CHO utilization biochemical marker -increased in uncontrolled diabetics -decreased in hypoglycemia
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Hemoglobin A1c
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-CHO utilization biochemical marker -Long term marker of chronic high BG levels
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Blood insulin
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-CHO utilization biochemical marker -Increased in glucose intolerance or insulin resistance
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Iron Deficient Anemia
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-microcyte, hypochromic -decrease MCV, Fe level, transferrin -increase transferrin iron binding capacity (TIBC)
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Clinical signs of Iron Deficient Anemia
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-fatigue -anorexia -pica -tachycardia -cold extremities -decreased immune fx -behavioral problems -kolilonchia, mouth changes
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Cobalamin deficient anemia
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- B12 Deficiency -macrocyte -megaloblastic -increase MCV, homocysteine
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B12 deficit common with
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-gastroectomy- removal of part of stomach -poor intake -loss of ileum
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Pernicious Anemia
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-lack of intrinsic factor -schillings test will distinguish deficit
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Folate Deficient Anemia
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-macrocyte -megablastic -Decrease serum folate, RBC folate
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Hemochromatosis
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continue to absorb iron while builds up in liver
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Kwashiorkor
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-Protein deficiency ALL criteria must be met -albumin <2.5 TLC < 900mm3 -body weight maintenance -Edema (swollen belly) -Protein intake < protein requirement
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Mild protein energy malnutrition
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-Any two of the following -Albumin 3.0-3.5 -TLC < 1500 mm3 - 80-89% of IBW - 85-95% of UBW
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Moderate protein energy malnutrition
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-Any two of the following -Albumin 2.5-2.9 TLC <1200 mm3 -70-79% IBW -75-89% UBW
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Severe protein energy malnutrition
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-All must be met -Albumin < 3.0 AND TLC < 900 mm3 -20% below UBW OR overt muscle wasting -Poor PO intake three or more consecutive days NPO
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Symptoms of edema
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-swollen extremities -persistent indentation -rapid weight gain
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Symptoms of dehydration
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-dry mucus membranes and skin -pinch test -rapid weight loss
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SGA definition
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-subjective rating based on clinical experience and judgement -cost effective and proven to be comparable to traditional assessment
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Techniques for dietary assessment
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-24 hr recall -food frequency questionnaire -Calorie count -Weighted food record -Diet history
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24 hr recall
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-easy to obtain and analyze -data: retrospective, depends on pets memory -may not reflect "usual" intake -accuracy: questionable
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Food frequency questionnaire
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-more involved than 24 hr recall -data: retrospective, depends on pt memory -better refection of "usual" intake
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Calorie Count
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-Data: depends on institution -Estimates portions of food consumed -recorded by: out pt, in house, pt care staff, RD, or dietary staff
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Weighed food record
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-Data: specifically measured when delivered -Detailed weight of all food offered prior to and after consumption -more accurate than calorie count -used mostly in research -may be matched with chemical analysis of food for specific nutrients
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Diet history
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-looks at current dietary patterns -Evaluates present and past eating ability -considers socio-cultural effects on food selection
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Indirect calorimetry
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-most accurate -measures CO2 expired and O2 consumed -Calculate RQ and REE -Used to determine primary fuel source Carb RQ near 1.0 Fat RQ near 0.7
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RQ
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-respiratory quotient
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REE
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-Resting energy expenditure
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RDA for protein
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0.8 +- /kg
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Nitrogen balance
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Maintenance: 1 g N/200 to 300 kcal Anabolism: 1 g N/100 to 150 kcal N bal= (24 hr dietary PRO/6.25)-(uuN+4)
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Purpose of Nutrition intervention
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-maintain or restore health and nutritional status -accommodate changes in digestion, absorption, or organ function -provide nutrition therapy through nutrient content changes
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House diet
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-served in hospitals and long term care in a minimum of 3 meals each day will meet a pats nutritional needs
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Changes to house diet
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-caloric level -consistency -single nutrient manipulation -preparation -food restriction -number, size, frequency of meals -addition of supplements
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Therapeutic diet
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-meal plan that controls the intake of certain foods or nutrients
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Modifications of meals and snacks
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-texture and consistency modifications for dysphagia and other conditions -soft diets -clear or full liquid diets -consider osmolality -hyperosmolar liquids may not be tolerated -preparation for specific medical test
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Clear liquid diet
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-diet consisting of liquids that contribute minimal residue to the gastrointestinal tract
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Clear liquid diet includes
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-fruit juices without pulp -carbonated drinks -broth -tea -coffee -water -popsicles -fruit ice -jell-o -liquid nutritional supplements
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Full liquid diet
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-diet consisting of all beverages allowed on clear liquid diets with addition of milk, ice cream, yogurt, and liquid nutritional supplements
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ASPEN
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America Society of Parental and Enteral Nutrition
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CNSD
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Certified Nutrition Support Dietitian
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EN
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Enteral Nutrition
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PN
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Parenteral Nutrition
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PEG
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PE gastrostomy (G-tube or g-button)
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PEJ
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PE jejunostomy (J-tube)
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NG
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Nasogastric
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TF
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Tube Feeding
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GALT
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Gut Associated Lymphoid Tissue
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Adv to EN
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-Reduced rate of infectious complications -Maintenance of GI function -Prevents translocation of normal GI bacteria -Reduced surgical interventions -Cost effective -Improved wound healing
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Disadvantages to EN
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-High gastric residual -Aspiration -Clogged tube -Diarrhea -Dehydration
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PN used for
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-Gut dysfunction -Inflammatory Bowel Disease -Tumor/obstruction -Acute pancreatitis -Ileus -Hemodynamic instability
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PN disadvantages
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-Translocation of bacteria -Cholestasis -Expensive
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EN feeding tube origin
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-Naso -Percutaneous Endoscopic
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EN feeding tube terminus
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-Gastic (G) into the stomach may use larger, more complex macronutrients -Duodenum (D) upper small intestine -Jejunum (J) both require smaller less complex molecules
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Most common combinations of EN feeding tubes
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-NG (Nasogastric) Short term enteral feeding of 3-4 weeks -ND or NJ (Nasoduodenal/Nasojejunal) Short term enteral feeding of 3-4 weeks -PEG (PE gastrostomy) Long term enteral feeding of >4 weeks -PEJ (PE jejunostomy) Use post pyloric feedings when puts have consistent intolerance or at risk for aspiration
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Bolus delivery style
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-may use with NG or PEG -Deliver large V in short time (> or = 240 cc) -Adv is it mimics normal intake -Disadv is N/V/D -contridictions are aspirations, small bowel access, controlled feeding rate required -Not for use in small bowel feeding
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Intermittent/Gravity delivery style
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-done at night -non critically ill and home TF -Requires slower infusion then bolus -controlled feeding rate required, overnight feeding -Not to be used for small bowel feeding
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Continuous delivery style
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-controlled feeding rate -small bowel feeding -malabsorption -diarrhea -dumping -pump regulates RATE (amount) of flow
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Tolerance to EN measured by
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-gastic residuals -stool frequency/consistency -abdominal distention -bowel sounds -flatulence -aspiration -problems with N/V -biochemical markers -changes in hydration status
