Medical Nutrition Therapy Final Exam – Flashcards
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Direct Calorimetry
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Heat production parallels energy expenditure
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Indirect Calorimetry
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Oxygen consumption parallels energy expenditure, clinical measure of TEE
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Doubly labeled water
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Ingest water labelled with isotopes of oxygen and hydrogen; measures O2 and H disappearance from the body; Easier in free-living; Research studies as a measure of TEE.
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Mifflin-St. Jeor Equation
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Energy expenditure estimation used more commonly for healthy and non-stressed individuals. Would need to multiply by a stress factor if used for sick individuals.
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Sources of fluids in PN/EN pt
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Maintenance IV fluids; medications given via IV drip, Water flushes given with crushed medications; water flushes to keep tubes patent; water contained in EN or PN
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Sources of fluid loss in pt
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chest tubes, percutaneous drains (biliary/pancreatic), wound drainage, ostomies/stool/urine, NG tube suction, excessive drooling, fistulas, increased insensible losses (burns, tracheostomies, fever, kinder beds)
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Clinical or physical signs of nutritional deficiency
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Dehydration, edema, muscle wasting, decreased subcutaneous fat, clinical symptoms of vitamin/mineral deficiencies
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When can you use Albumin, Pre-albumin, and transferrin to assess protein status?
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In stable patients, with good renal function. If pt is stress/inflammed the levels will not reflect protein status. TYN and UUN do not account for wound losses.
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General Characteristics of EN
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Fed into GI track; Fed enterally; mimics the composition of normal diet in liquid form (polymeric, hydrolyzed)
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General Characteristics of PN
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Fed outside GI tract; fed parenterally (intravenous, large or small veins, central or peripheral); concentrated monomeric formulas: glucose, free amino acids, lipids)
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Oral Liquid Supplements
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Used when nutritional needs are not met by standard diet alone, often used to supplement a normal diet, commercially available, lactose and gluten free, high protein, high calorie nutrient dense foods and liquids.
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Indications for EN support
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Cancer of the head and neck; radical surgery to the upper GI tract neck, oral pharynx, or upper respiratory track; esophageal cancer; dysphagia; gastroparesis; gastric outlet obstruction; mild malabsorptive disease (Crohn's disease, SBS, pancreatitis); inability to meet nutrient needs by intake alone (as with burn, trauma, sepsis and chemo pts); depressed mental status; neurological impairment; paralysis; P.O. intake less than cooler and protein needs (often d/t cancer and anorexia); correction of malnutrition d/t chronic disease.
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Indications for EN support in children
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Congenital abnormalities of the mouth, esophagus, stomach or intestines; malabsorption as with cystic fibrosis, Crohn's, fat malabsorption; sucking and swallowing disorders (premature); brain injury; developmental delay; neuromuscular disorders; cerebral palsy; failure to thrive.
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Indications and notes for NGT (nasogastric)
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Inadequate oral intake; high needs; Intubated/sedated; relatively functional GI tract; normally used short term
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Indications and notes for nasoduodenal or nasojejunal
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Functional lower GI tract (proximal injury/surgery); inadequate gastric motility (high residuals); esophageal reflux. These routes require continuous drip feeding d/t bypassing gastric emptying
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Indications and notes for gastrostomy
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Esophageal injury or obstruction; inability to swallow; anticipate EN needed for > 4 weeks. Long term usage. Caution: GERD and intractable vomiting
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Indications and notes for Jejunostomy
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Obstruction/surgery proximal to jejunum; UGI stricture or fistula; inadequate gastric motility. Use long term transpyloric continuous drip
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Continuous Drip EN
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Used in ICU settings; better tolerated in sick in-patient; less N, D, cramping, and bloating; may reduce risk of aspiration pneumonia; generally requires infusion pump (intestine); can by cycled in homecare puts with good tolerance to EN.
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Bolus EN
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Gastric feeding (cannot be used post-pyloric); appropriate for long-term feedings; allows mobility for pt; allows mealtime feedings that mimics normal eating patterns; usually 50-500cc/feeding
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Intermittent EN
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Given "drip" method; gravity garage or pump; feeding bag; may give same volume as bolus but over a longer time period; can be given nocturnally at increased rate to allow daytime mobility; used to transition to oral feedings; used for intestine feedings to increase mobility.
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Indications for use of standard EN formula
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normal GI function with mild/moderate stress
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Indications for use of high protein, high Kcal EN formula
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hypermetabolic, volume restrictions, high protein
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Indications for use of elemental/partially hydrolyzed EN formula
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Malabsorption, bowel rest, pancreatitis
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What does low residue mean?
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Only a small amount of the EN is getting to the colon.
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Complications of EN
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Diarrhea, Constipation, Bloating, Nausea/vomiting, high residuals, aspiration, naso-pharyngeal irritation, clogged tube, hyperglycemia, hypoglycemia, dehydration, hypokalemia, hypophosphatemia
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Complications of overfeeding on EN
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hyperglycemia, lipogenesis, fluid and fat gain vs LBM, immunosuppression (XS lipid and linoleic acid), excess CO2 production, increased minute ventilation.
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Complications of underfeeding on EN
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loss of lean tissue, skin breakdown, poor wound healing, immundysfunction. Intake is often <75% of order
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What is the most serious life-threatening complication of enteral therapy?
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Aspiration/Pneumonia
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Benefits of EN
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Stimulates immune barrier function at GI; attenuates bacterial translocation; physiologic presentation of nutrients; maintains gut mucosal integrity; attenuates hypermetabolic response; simplifies fluid/electrolyte management; more "complete" nutrition that PN; provides iron, fiber, glutamine, phytochemicals that are not found in PN; less infectious complications; stimulates return of bowel function; less expensive.
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MNT for flatulence
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Low fructose diet, reduce gas forming foods, increase physical activity
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Causes of flatulence
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Swallowed air, distention, cramping, high fiber (raffinose), high fructose diets.
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Constipation is defined as
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low stool caliber, hard stool, no BM for 3 days
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Causes of constipation (systemic etiology)
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Side effect of medication (narcotics, NSAIDs); metabolic endocrine abnormalities, such as hypothyroidism, uremia (renal failure), hypercalcemia, systemic neuromuscular disease (ALS), spina bifida, Parkinson's disease, lack of exercise, bedridden hospitalized or LTC (any sedentary lifestyle); ignoring the urge to defecate; vascular disease of the large bowel; poor diet low in fiber; pregnancy
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Causes of constipation (gastrointestinal etiology)
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cancer; diseases of the upper GIT; Diseases of the large bowl resulting in failure of propulsion along the colon (colonic inertia) and/or failure of passage through anorectal structures (outlet obstruction); IBS; anal fissures or hemorrhoids; laxative abuse; stimulants; patients of opioids.
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Constipation: Nutrition-related contributing factors
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Low intake of fruits, vegetables and whole grains; consumption of the typical refined American diet; decreased fluid intake, water; increased consumption of caffeinated beverages; dairy products (milk and hard cheese); laxative abuse (senna, castor, phenylphthalenin)
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Laxatives
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senna, castor, phenylphthalein
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Constipation MNT
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High (non-soluble) fiber diet; increase intake of whole grain cereals; increase intake of f&v (raw or cooked w/ skins and hull), and legumes; increase water to 8 cups of water per day; OTC fiber supplements of fermentable fibers (psyllium, methylcellulose)
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Types of diarrhea
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Osmotic, secretory, exudative, medication induced, malabsorptive
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Osmotic diarrhea is caused by
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overconsumption of sugars (fructose, lactose intolerance)
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Secretory diarrhea is caused by
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bacteria, viruses, toxins
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Exudative diarrhea is caused by
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HFD, mucus, fluid, electrolytes, blood, plasma proteins, Crohn's, UC, radiation
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What medications can cause diarrhea
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antibiotics (AAD)
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Malabsorptive diarrhea is caused by
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decreased absorptive surface (celiac) or low bile or pancreatic enzymes (steatorrhea)
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What electrolytes are lost with excess fluid loss
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sodium and potassium
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What is the leading cause of nosocomial diarrhea
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Clostridium difficile
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Clostridium difficile
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leading cause of nosocomial diarrhea; opportunistic proliferation of pathogenic organisms associated with antibiotic therapy and chronic use of PPIs; spore forming and spread via tube feedings from pt to pt. Causes colitis, secretory diarrhea, colon dilation (magacolon), peritonitis, can be fatal; diagnosed by still sample, tx w/ antibiotics
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Diarrhea MNT
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Oral fluids/electrolytes (carbonated beverages, sports drinks-potassium, soups, vegetable juice, isotonic liquids); avoid-sugar alcohol, fructose, lactose; w/ servere acute vomiting use IV hydration; with chronic diarrhea check zinc status; do not need to with hold food.
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BRAT Diet
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not evidence based to treat diarrhea, high CHO and fructose, bananas, rice, applesauce and toast.
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Tropical spruce
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Infectious diarrhea d/t bacterial overgrowth d/t mucosa atrophied/inflamed d/t decreased absorption. Can result in multiple vitamin and mineral deficiencies (low HCl and IF)-folic acid, B12
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Irritable bowel syndrome nutrion-related presenting features
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Alternating diarrhea and constipation, dyspepsia, bloating, distention, incomplete evacuation, mucus in stool, discomfort after eating. R/o lactose intolerance or other GI dx. IBS is a diagnosis of exclusion
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IBS-MNT
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Soluble fiber (normalize transit time), eliminate offending foods, low FODMAP (?), individualized to pt d/t variability in food tolerances. Probiotics (bifidobacterium infantis)
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What is not allowed on a low FODMAP diet
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fructose, lactose, oligosaccharides (fructans or galactans), polyols.
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Small Intestine Bacterial Overgrowth (SIBO)
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Bacterial overgrowth from stasis in the intestine, obstruction, radiation enteritis, fistula, IBD, IBS, or removal of ileocecal valve, surgical repair. Bacterial will cause a loss of bile salt function resulting in steatorrhea, bacteria use B12 resulting in def.
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SIBO Tx
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antibiotics for bacterial overgrowth, probiotics and probiotics to regain normal cultures. Limit refined CHO *increase whole grains, veggies and oligosaccharides. May use MCT, Low FODMAP, B12 supplement
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Common tests for malabsorption
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Direct stool examination; fecal fat test; C-xylose absorption test; breath test; pancreatic exocrine deficiency; schilling test (B12 malabsorption, protein losing enteropathy); Intestinal biopsy looking for celiac, eosinophilic enteritis, giardiasis, Crohn's disease.
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Primary lactose intolerance
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deficiency in lactase brought on by gradual decline in lactase production
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Secondary lactose intolerance
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intestinal infection or destruction of mucosal cells, intractable diarrhea, Crohn's and gluten sensitive enteropathy
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Tests used to diagnose lactose intolerance
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Breath Hydrogen test or lactose tolerance test
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Lactose intolerance MNT
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decrease consumption of lactose containing foods/milk; lactase enzyme replacements and treated milk products added to diet; calcium and vitamin D supplements; Identify hidden sources of lactose (milk solids, whey, casein)
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Nutritional concerns with steatorrhea
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loss of energy/wt loss; loss of fat soluble vitamins; loss of ca and mg; increased absorption of oxylate (urolithiasis)
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MNT for steatorrhea
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low fat diet; MCT supplements; water forms of fat soluble vitamins
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Etiologies of celiac disease
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genes (familial or HLA class II), immune (antigliadin Ab), gliadin intolerance, damaged mucosa (decrease absorptive surface)
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Gold standard for diagnosis of celiac disease
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endoscopic tissue biopsy
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MNT for celiac disease
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Gluten free diet
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Dermatitis Herpetiformis
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Red, raised, small or large blisters that burn and itch intensely, not unique to celiac disease.
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Ulcerative colitis
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is a mucosal disease of the large intestine, including the rectum
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Crohn's disease
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may involve any part of the GIT; most in distal ileum and colon; segments of inflamed bowel.
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Ulcerative Colitis nutrition-related presenting features
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Chronic diarrhea, frequent watery stools; up at night; bloody diarrhea; fever; anorexia; wt loss; low hgb, hct, albumin, and potassium; elevated ESR and CRP
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Ulcerative Colitis - MNT
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oral fluids and electrolytes; low fiber, low residue (acute phases); may add soluble bulking agent to prevent constipation and diarrhea; monitor zn levels w/ chronic persistent diarrhea; monitor Hgb, HCT, f/u with Fe studies indicated with anemia, etiology is GI bleed depletes iron.
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Crohn's Disease - MNT
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Crohn's disease can lead to severe malnutrition. May require complete bowel rest (PN or EN hydrolyzed/elemental, low fat formulas); nutrition must be individualized and monitored (electrolytes, fluid status, wt, growth in children, anemia, fat soluble vitamins, pre-albumin, CRP-inflammation, zinc). Tropic feeds. Similar to UC, low fiber; low residue. High protein, high calorie; may benefit from MCT, vitamin and mineral supplementation, lactose restriction prn.
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Fistula
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Abnormal opening between organs. Caused by birth defects, trauma, inflammatory disease, malignant disease, enterocutaneous post surgery
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Fistula MNT
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Restore fluid and electrolyte balance, PN may be necessary and depends on location of the fistula, enteral nutrition may be possible using predigested formulas, oral diets
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Short bowel syndrome
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Loss of 70-75% of the small bowel (100-120 cm of small bowel w/o colon or 50 cm of small bowel with colon). Results in wt loss, diarrhea, decreased transit time, malabsorption, dehydration, loss of electrolytes, hypokalemia; steatorrhea; B12 def; loss of fat soluble vitamins; fatty acid mineral soaps with ca, zn, and mg.
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SBS MNT
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1) PN, 2) slow introduction of EN, focus on glutamine, nucleotides, SCFAs first (tropic feeds); MCT for fat soluble vitamins; evaluate narcotics. Eventually the remaining bowel will increase its absorptive surface.
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MNT for Ileostomy or Colostomy
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Nutrition needs very; avoid gas and odor forming foods; fluid and electrolyte needs; B12 supplement
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Diverticulosis nutrition-related issues
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High refined carbohydrate, high fat low fiber "western" diet contributes to disease
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Diverticulosis MNT
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High fiber, low fat. Special focus on soluble fibers
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Soluble fiber supplements
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metamucil, fibercon, citrucel, psyllium
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Colorectal Cancer Nutrition-related contributing factors
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High fat, low fiber, refined "western" diet; low ca and FA intake; high alcohol (beer) intake; high meat intake; obesity; tobacco.
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Colorectal cancer nutrition-related protective factors
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whole grain, FA, ca, vit D, multivitamin, PA and NSAIDs
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Screening for GI disease: What is the most important indicator
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unintentional wt loss
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Screening for GI disease: "flags" in diet hx
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Changes in appetite; N, V, & D; chewing/swallowing problems; food intolerances; supplements; pre and probiotics; typical intake/ability to take fluids
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Screening for GI disease: "flags" in lab values
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Vit B12, FA, Ferritin, vitamin D
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Achalasia
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Failure of esophageal neurons, in ability to relax the LES, MNT- Liquids not tolerated
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Odynophagia
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Painful swallowing, as with the canker sores as a result of oral and esophageal cancers. MNT-liquids better tolerated than solids
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Nutrition-related presenting characteristics for dysphagia
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Pt c/o food sticking in throat; aspiration pneumonia; wt loss; PEM
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Dysphagia MNT
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Modify texture and consistency of pets diets per recommendations of swallow study. Avoid acidic foods and alcohol to help with symptoms. Correct nutritional deficiencies, prevent further wt loss, utilize high protein, high calorie food choices, oral supplements and EN
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EGD
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Esophagogastroduodenoscopy, used to evaluate GERD
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GERD
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Backward flow of the stomach or duodenal contents into the esophagus, result of competency of the LES
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Esophagitis
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Inflammation, ulceration, erosions, scarring of the esophagus. D/t reflux, ingestion of corrosive agent, infection, intubation, radiation, eosinophilic infiltration, NSAIDs,
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Barrett's Esophagus
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Precancerous condition; risk factors: prolonged GERD, mae gender, >50 yo, family hx
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Hiatal hernia
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out-pouching of a portion of the stomach into the chest through esophageal hiatus of the diaphragm
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Hiatal Hernia MNT
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wt reduction and decreasing meal size. May require surgery
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GERD/Hiatal hernia nutrition-related presenting characteristics
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S exacerbated by fried foods, spicy foods, large meals, over-eating, alcohol, caffeine, and dietary indiscretion. pt c/o heart burn after large meals; chronic GERD may cause dysphagia, dental erosions
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MNT for GERD
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Prevent pain and chemical irritation of esophageal mucosa (avoid acidic foods, alcohol, spiced foods); Prevent reflux (avoid foods that lower LES pressure i.e. high fat, greasy, alcohol, carminatives, chocolate. Avoid eating 2-4 hrs before bed; raise head of bed; avoid PA immediately following meals; avoid wearing tight fitting clothing; avoid overeating. Reduce Acidity of Gastric Contents (proton pump inhibitors, H2 receptor antagonist, antacids)
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Omeprazole/prilosec
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Proton pump inhibitors, decrease Mg.
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H2 receptor Antagonists
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cimetidine (Tagamet); Ranitidine (Zantac)
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Antacids
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Magnesium and Aluminum hydroxide, calcium carbonate, magnesium phosphate
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Ingesting too many magnesium based antacids can
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cause diarrhea and deplete phosphorus.
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MNT for cancers of the oral cavity, pharynx and esophagus
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Modify texture and consistency of pets diets per recommendations of swallow study. Avoid acidic foods and alcohol to help with symptoms. Correct nutritional deficiencies, prevent further wt loss, utilize high protein, high calorie food choices, oral supplements and EN; f/u with nutritional plan. Tx of cancer may cause nutritional issues (decreased saliva production, tooth decay, swallowing difficulties, tooth extractions).
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Esophagectomy MNT
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individualized NTRI plan and f/u, nutritional support (TF), slow progression to oral feedings. Monitor dumping syndrome, nutrient malabsorption, recommend liquid multivitamins and B12
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What is required for normal RBC synthesis
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Functional bone marrow, EPO, protein, iron, B12, FA, Vit C, B6
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What lab measures RBC size
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MCV
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What lab measures RBC production
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Reticulocytes
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Anemia
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decrease in the oxygen-carrying capacity of blood d/t decreased hemoglobin
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Which anemias are affected by alcohol consumption
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Folic acid, B12, GI bleeding, Immune suppression, liver disease, impaired biosynthetic processes
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What medications can result in anemia
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NSAIDS, Steroids, antacids, H2 blockers, anticoagulants, myelosuppressive drugs, vitamin antagonists
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Microcytic Anemias
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IDA, ACD, Thalassemia, Sideroblastic
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Causes of macrocytic anemia
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B12 and FA deficiencies, pernicious anemia, liver disease, hypothyroidism, drugs (FA and B12 antagonists, antivirals)
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Normocytic anemias
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ACD/AI, pregnancy, bleeding, renal failure, cirrhosis, CLL, CML
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What medications can result in anemia
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NSAIDS, Steriods, antacids, H2 blockers
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What anemia patients my responds well to EPO tx
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pt with renal disease, rheumatoid arthritis, HIV, multiple myeloma
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What anemias should not be tx with iron?
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blood loss, ACD/AI, thalassemia, sideroblastic, lead toxicity, sickle cell (?)
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