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This 23 page Study Guide was uploaded by Bailey Personette on Wednesday February 11, 2015. The Study Guide belongs to NUTR 480 at Purdue University taught by Mrs. Zoss in Fall. Since its upload, it has received 161 views.
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Date Created: 02/11/15
Components of nutrition assessment Anthropometrics 0 weight loss previouscurrent previous X100 0 1 kg 221 lbs 1 lb 045 kg 1 inch 254 cm 0 Adjusted BMI for amputees O 0 Estimated body weight current body wt kg 1proportion for missing leg Calculate BMI estimated body weight kg body height m2 adiusted weight is higher than actual weight 0 Other parameters to consider 0 00000 Biochemical Demispan distance from midline at the sternal notch to the web between the middle and ring fingers along outstretched arm Knee height patient must be able to bend both the knee and the ankle of one leg to 90 degree angle Calf circumference Skinfold Head circumference for an infant Girth or waisttohip ratio Laboratory test Implications interpretation etc Creatine height index 24 hour creatine measurement in urine marker for muscle mass Nitrogen balance UUN 24 hr UUN 24 hour urine collection keep track of protein intake during 24 hours negative nitrogen balance in catabolism Total protein not used in case of inflammatory response use Creactive protein before screens for kidney and liver disease 50 albumin and 50 globulin Albumin 3 week 12 life if patient has liver or kidney disease it is an indicator of morbiditymortality Prealbumin PAB reflects protein status 2 days half life negative acute phase reactant drops in inflammation increases in renal insufficiency and pregnancy Transferrin reflects ironstatus 8 days 12 life negative acute phase reactant increases in iron deficiency decreases in iron overload Retinol binding protein gene expression and embryo development negative acute phase reactant 12 hour 12 life Creactive protein CRP 57 hour 12 life positive acute phase reactant increases in inflammation diagnoses CVD Hematocrit red blood cell RBC whole blood looks at anemia increase altitudeincrease hematocrit Hemoglobin decrease in hemoglobin in pregnancy gt blood volume increases more dilute Ferritin storage protein for iron binds to iron tests how much iron you store positive acute phase reactant Serum iron iron in the blood circulating iron attached to transferrin Total ironbinding capacity increase decrease iron Serum homocysteine assessment of cardiac disease if increased then deficiency in folate or 312 genetic disorders are related Folate indicates alcohol consumption and macrocytic anemia Vitamin B12 greater level indicates liver disease or leukemia Methylmalonic acid M MA can detect folate and 312 deficiencies produced when protein breakdown in body Total cholesterol HDL LDL triglycerides Highdensity lipoprotein HDL negative risk factor for CVD good cholesterol protects against atherosclerosis Lowdensity lipoprotein LDL positive risk factor for CVD bad cholesterol Serum triglycerides assess risk of heart disease diagnoses metabolic syndrome Total cholesterolHDL ratio used when evaluating total cholesterol Blood glucose indicates diabetes prediabetes and insulin resistance Hemoglobin A1C amount of glycated hemoglobin reflecting how often blood glucose levels are high indicated kidney and liver disease from blood glucose levels Total lymphocyte count looks at abnormal lymphocytes in blood increase in indicates immune response Vitamin D bone health O Creactive protein CRP o Fibrinogen o Ferritin 0 Others Positive acute phase reactants increase in inflammation 0 Negative acute phase reactants decrease in inflammation o Albumin o Prealbumin o Transferrin o Retinolbinding protein 0 Corrected calcium equation serum calcium 08 4serum albumin 0 Use equation when albumin is low 0 Do not use if albumin is 4 and calcium is low 0 Corrected calcium goes up if low albumin and calcium o Measured in mgdL o Hyponatremia low sodium in the blood caused by excess water and kidneys not getting rid of urine or taking in excess water causes seizures and mental issues Hypernatremia high sodium in the blood caused by dehydration causes seizures and mental issues Hypocalcemia low calcium in the blood caused by deficit of parathyroid hormone and abnormal vitamin D metabolism causes muscle spasms and cardiac dysrhythmias Hypercalcemia high calcium in the blood caused by hyperparathydroidism malignancy cancer causes bone pain weakness and fatigue Hypokalemia low potassium in the blood caused by GI losses diarrhea vomiting renal losses loop diuretics refeeding syndrome causes cardiac dysrhythmias Hyperkalemia high potassium in the blood caused by inadequate excretion of potassium can stop your heart NaK pump HVDomagnesemia low magnesium in the blood caused by chronic alcoholism some medications fluid overload low phosphorous levels causes personality changes depression nausea vomiting lack of appetite Hvoermagnesemia high magnesium in the blood caused by excessive supplementation causes declining renal function 0 Magnesium is necessary for cellular energy metabolism Hvooohosphatemia low phosphorous in the blood caused by vitamin D deficiency hyperparathyroidism refeeding syndrome causes breathing problems HVDerphosphatemia high phosphorous in the blood caused by acute or chronic renal failure try to restrict phosphorous in the diet 0 Phosphorous plays an important in ATP for energy metabolism pH HCO3 Respiratory rate Metabolic acidosis low low high Metabolic alkalosis high high low pH PCO2 Renal net acid excretion Respiratory acidosis low high high Respiratory alkalosis high low low Clinical Metabolic kidneys Respiratory lungs m drinks food IV clinical metabolic water Output sensible losses urine and feces insensible losses lungs colon skin Microcvtic anemia associated with small red blood cells iron and vitamin B6 deficiency supplementation is used in deficiency Macrocvtic anemia associated with large red blood cells folate and vitamin 312 deficiency red blood cells cannot function properly Anemia of chronic and inflammatory diseases ACD red blood cells are normal size iron supplementation does not help leads to heart failure and cancer Pernicious anemia vitamin 312 deficiency vitamin 312 is malabsorbed because of lacking intrinsic factor Nutritionfocused physical assessment 0 Purpose helps ensure dietitian s role in the healthcare system allows an objective overall interpretation of the body as a whole assess head to toe 0 Four basic examination techniques I Inspection most frequently used by clinicians observe patients in the light obesity age I Palpation involved touching patient gt location of pain body temperature body texture I Percussion produces sounds to help determine if organs are solid or filled with liquid or gas I Auscultation listening to body sounds through stethoscope gt chest lungs abdomen bowel sounds should always be done last except when examining the abdomen gt do after inspection then do palpation and percussion o No bowel sounds ileus do not feed someone with an ileus I Findings from assessment general survey vital signs anthropometrics skin nails head and neck respiratory cardiovascular abdomen musculoskeletal neurological 0 Physical signs of nutrient deficiencies 0 Severe iodine deficiency cretinism and goitrogens can cause goiter by blocking the uptake of iodine from the blood by thyroid cells I Cabbage peanuts sweet potatoes turnips Vitamin A deficiency night blindness Thiamin deficiency beriberi Zinc deficiency hypogeusia is taste disorder reduced ability to taste things Copper deficiency neutropenia anemia and scurvylike bone disease and megadoses of zinc Selenium deficiency Keshan s disease Vitamin D phosphorus or calcium deficiency rickets disease in children involving impaired mineralization of growing bones 0 Vitamin D deficiency in adults osteomalacia seen in adults due to closures ofthe bone that are resistant to vitamin D OOOOOO Dietary 0 Methods for determining intake Diet record food diary food record food log Patient makes a record of all food and drink intake and the time of consumption gt Pros estimates can provide insight into eating habits gt Cons timeconsuming how many days requires correspondent cooperation analysis is laborous 24hour recall Interview help remember intake by asking questions about activities gt Pros quick inexpensive little burden on client gt Cons good memory is key underreport bad food overreport healthy food ASA24 unannounced automated selfadministered 24 hr may not be a good representation of diet used for epidemiologic surveillance behavior traits or clinical research Food frequency questionnaire selfadministered way to assess frequency of intake of certain foods Nutrient intake analysis calorie count used in inpatient settings not for freeliving individuals direct observation or inventory of food remaining after meals taken for 72 hours Diet history most comprehensive looks at usual patterns of food intake and variables that dictate food intake gt Pros lots of information is gathered gt Cons lots of time coding is difficult Components of total energy expenditure TEE O O O Basal metabolic rate BMR 6070 TEE amount spent that keeps you alive Thermic effect of food TEF energy used to digestmetabolize food protein requires the most energy Activity thermogenesis AT how much you expend above resting level I Exercise nonexercise activity thermogenesis NEAT 0 Includes maintaining posture and fidgeting Calculations O 0000 Respiratory quotient RQ volume of CO2 expiredvolume of O2 consumed I RQ 1 carbohydrate I RQ 085 mixed diet goal I RQ 082 protein I RQ 070 fat I RQ lt065 ketone production starvation Estimating water deficit in adults water deficit LTBW x current Na level140 I TBW 06 x weight kg for males I TBW 05 x weight kg for females obese individuals Fluid needs 3035 mlkg body weight RDA for protein for adults 08 gkg Older adults recommendation for protein 1012gkg not RDA yet Use MifflinSt Jeor for energy needs equation provided I Most reliable in nonobese and obese individuals nonhospitalized patients within Dietary supplements contains one or more of the following a vitamin mineral herb or other botanical amino acid concentrate metabolite constituent or extract 0 Dietary Supplement Health and Education Act DSHEA of 1994 regulation of dietary supplements Resources available for assessing dietary supplements O O O O O wwwnsforg wwwusporg wwwconsumerlablcom wwwnaturaldatabasecom wwwdsldnlmnihgov Nutrition Care Process 0 I Goals of NCP 0 Standardized language 0 Standardized structure of process 0 Improve quality of care 0 Document outcomes of nutrition care Nutrition assessment I A systemic process of obtaining verifying and interpreting data to make decisions about the nature and cause of nutritionrelated problems I An ongoing dynamic process with continual reassessment I Goal to obtain adequate information in order to identify nutritionrelated problems 1 collect 2 compare 3 interpret o Foodnutritionrelated history Anthropometric measurements Biochemical data medical tests and procedures Nutritionfocused physical findings 0 Client history I Gather signs gt objective data that is observed and found in medical record I Gather symptoms gt subjective data that the patient tells you 0 Nutrition diagnosis I Identifies the nutrition problem that the dietitian is responsible for treating independently I Not a medical diagnosis ex type 2 diabetes I Often temporary and will go away with nutrition intervention I Split up into intake clinical and behavioralenvironmental I PES statement Problem related to etiology as evidenced by signs and svmptoms 0 Problem use exact wording listed in eNCPT o Etiology cause of the problem 0 Signssymptoms evidence that problem exists 0 Nutrition intervention I Implement the nutrition intervention gt action phase of the NCP I A specific set of activities or materials used to address the problem by impacting etiology or resolving nutrition diagnosis I Contains food andor nutrient delivery nutrition education nutrition counseling and coordination of nutrition care 0 Nutrition monitoring and evaluation I Monitoring preplanned scheduled followup point I Evaluation comparing current findings to previous status intervention goals or reference standard A patient enters the NCP through referrals and screenings Nutrition screening I Goal to determine if a patient needs additional dietary intervention 0 Use for 65 years old and older I Nurse is responsible dietitian typically does not complete nutrition screening Diet orders 0 Clear liquid 0 Full liquid 0 Dysphagia diet General use of the EAL O 0 quotTo apply cutting edge synthesized research 3 videos online about EAL o Diagnosing of malnutrition from clinical characteristics 0 Starvationassociated malnutrition no inflammatory process 0 Chronic disease associated malnutrition inflammation is mild 0 Acute disease or injury associated malnutrition increased inflammation Acute may be superimposed on chronic ex Chronic disease can turn into acute if worsens 0 Systemic approach to nutrition assessment includes 0 History and clinical diagnosis Clinical signs and physical examinations Anthropometric data Laboratory indicators Dietary data 0 Functional outcomes 0 Clinical indicators of inflammation fever hypothermia lt95 degrees F tachycardia gt100 bpm 0 Normal healthy BMI range for elderly is gt23 but lt30 0 Clinical characteristics used to define malnutrition 0 Energy intake interpretation of weight loss and o Physical findings I Body fat loss of subcutaneous fat looks at orbitals triceps and fat overlaying ribs I Muscle mass muscle loss is wasting of temples clavicles shoulders scapula thigh etc I Fluid accumulation 4 is very deep pitting edema and lasts gt60 seconds I Reduced grip strength Minimum of 2 characteristics needed for a diagnosis of severe or nonsevere malnutrition 0 Serum albumin and prealbumin should be reviewed when assessing a patient for malnutrition 0 Interpretation of weight loss is actual usualusual x100 Blackburn formula OOOO Enteral feeding o Enteral nutrition is using the GI tract and feeding something into the stomach in liquid form 0 quotIf the gut works use it 0 When is it appropriate to use EN 0 Inability to eat 0 Inability to eat enough feeding tube 0 Impaired digestion and absorption and metabolism 0 Benefits of EN 0 Preservation of the mucosal barrier function and integrity don t worry of gut atrophy because you are using gut 0 Fewer incidences of hyperglycemia than PM 0 Lower costs than PM 0 Fewer complications than PM o What are indications for the use of EN o Functioning gut Inadequate oral intake for 5 days in patients with malnutrition Oral intake lt 5 of needs for previous 5 to 7 days in previously wellnourished patients Severe dysphagia swallowing issues Major full thickness burns just getting to eat enough calories will be hard usually using tube OOOO feeding Small bowel resection with concurrent PN Low output enterocutaneous fistulas connection between two things that should not be there skin o What are the contraindications for the use of EN Reason why not to suggest a tube feeding enteral O 0000 Complete obstruction of small or large bowel eus GI tract loses peristalsis after surgery Severe diarrhea without response to medication Intractable vomiting throwing up a lot High output external fistula measurement is greater than 500 ml a day 240 ml in a cup so over two cups Severe acute pancreatitis Hypovolemic when a patient has low pressure so blood not circulating well to GI tract because poor perfusion so dangerous to feed patient or septic shock Extremely poor prognosis Patients or guardian s which to not use nutrition support feeding tube some people are dead set against it Ethics who decides how long they should be on feeding tube 0 What factors should be considered when determining the access route for enteral nutrition 0 Anticipated duration of enteral tube feeding 0 Short term 2 months 0 Long term 6 months Conditions warranting pre or postpyloric access 0 Prepyloric access feed into before pyloric sphincter exit of the stomach o Postpyloric access feed after or below pyloric sphincter going into small bowel has to be in with a pump continuous feeding so doesn t cause distress 0 Availability of specialists to place feeding tube nursing and dietitian or physician can place some ofthem o How and why are nasogastricNG tubes placed 0 Enters body from nasal and goes down to stomach based on diameter Various sized 5 frenchs to 18 F I problems with stomach for example throwing up sucks out content in stomach so doesn t feel nauseated anymore or even to used to give medication Placement is relatively easy Avoid if severe coagulopathy not coagulating well or bleeding disorder some nasal no access to nasal passage and facial fractures esophageal obstruction 0 When might an oral gastric tube be utilized 00000 O Orogastric tubes OGTs Less incidence of sinusitis May be damaged by teeth Preferred if nasal or facial trauma head injuries sinusitis Are used for premature infants Xray confirmation of placement 0 What are the advantages of nasoenteric tubes What is another name for nasoenteric tube 0 Preferred if patient at high risk for aspiration breath something in your lungs you don t want in there ex Peppers esophageal reflux cardiac sphincter problem or delayed gastric emptying stomach wont empty as fast as want so tube feeding could go back up esophagus Smaller diameter than standard NGTs more comfortable because going through nose to small intestine May be difficult to place postpyloric or post ligament of Treitz Infusion pump is required because you are feeding into small bowel Sometimes referred to as small bowel feeding tube O 0 Xray confirmation of placement NJ continue to small bowel from stomach nasal jejunum NG just to stomach 0 Why is an infusion pump required for enteral nutrition with a nasoenteric tube 0 Because you are feeding into the small bowel NEED continuous feeding o What are the options for longterm prepyloric feeding tubes 0 0 000 O Gastrostomy insertion methods Percutaneous endoscopic gastrostomy PEG tube Placed by physicians endoscope in stomach has a light find a point on abdomen where make incision and cut through skin of abdomen Radiologic Surgical Easily cared for and replaceable Most invasive o What are the options for longterm postpyloric feeding tube 0 Jejuostomy I Insertion methods I Percutaneous gastrojejunostomy termination of tube in jejunum I PEJ just into jejunum I PEGJ dual lumen tubes with gastric and jejunal port always feed the food into the jejunum o Radiologic jejunostomy 0 Open surgery placement 0 Decreases risk of tube feeding related aspiration o Infusion pump required cannot rely on gravity 0 When selecting an enteral formula what factors should be considered OOOOOO Ability to meet the patients nutritional needs Caloric and protein density of formulas Gastrointestinal function of patientdiarrhea malabsorption Electrolyte content of formula Type of protein fat carbohydrate and fiber in product Viscosity of formula not much of a concern bc most tubes are large enough 0 Polymeric is a nutrient profile that requires everything has to be digested same as feeding a patient food All micronutrients intact and require nutrition Describe an elemental enteral formula Elemental protein content is amino acids Describe a semielemental enteral formula SemielementalProtein content is bi and tri peptides for protein content Parental Nutrition 0 Parenteral nutrition PN going directly into the blood stream bypass digestion Not used as much and more particular and done with an IV 0 When is it appropriate to use parenteral nutrition Gastrointestinal incompetency someone has an ileus can t feed them and you cannot use a tube because will throw it back up Critical illness with poor enteral tolerance or accessibility o INDICATIONS a lot like the contraindicates from enteral nutrition o Nonfunctional GI tract Massive small bowel resection severe diarrhea Intractable vomiting Acute severe pancreatitis Malnutrition Severe catabolism 000000 0 Contraindication o Functioning GI tract 0 Treatment less than 5 days anticipates Inability to obtain venous access 0 Prognosis that does not warrant aggressive support 0 What are the main differences between TPN and PPN O m Requires central venous access Can be administered peripherally Hyperosmoaity Lower osmolality Long term Temporary very dilute so osmolality does not go up What is the basal requirement for dextrose in PN 0 CH0 should provide 4060 of total kcal o Dextrose provides 34 kcalg o Basal requirement is 2 mgkgmin Maximum glucose oxidation rate is 5 mgkgmin Dextrose available in concentrations of 5 to 70 for mixing of solutions Potential adverse effects caused by dextrose o Hyperglycemia o Electrolyte imbalances o Hepatic steatosis fatty liver why you do not exceed the limit of 5 mgkgmin Respiratory decompensation producing more C02 so will affect or compromise breathing o What is the protein source in PN What are typical recommendations 0 Usual dose is 112 gmkgday 0 Up to 1525 gmkgday in critically ill patients o 4 kcalgm 0 Standard amino acid solutions 0 mixture of essential and nonessential amino acids 0 Composition pattern from highquality proteins such as egg white 0 Specialized amino acid solutions 0 Renal 0 Stress o Hepatic failure o Pediatric o What are the potential adverse effects of amino acids o Protein intolerance O elevated BUN in patients with renal impairment 0 Elevated ammonia in patients with hepatic impairment 0 O adverse neurologic effects hepatic encephalopathy o What is the source of fat for PN solutions 0 Oil in water emulsions I soybean oil or 5050 soybeansafflower oil soybean oil rich in essential FA linoleic acid Alphalinolenic acid omega 6longchainTG Purified egg phospholipid emulsified I 9kcalg fat 0 What is the caloric content of the IV lipid solutions 0 10 IV lipids 11 kcalml o 20 IV lipids 20 kcalml o What are the recommendations for the fat content of PN 0 Usually given as 1040 of daily total calories 0 Max fat dosage should not exceed 60 of calories 0 Max 225 gmkgday o 1 gmkgday or less in high stress 0 Contraindications to IV lipids 0 severe egg allergy 0 severe hypertriglyceridemia esp if pancreatitis o Are there any potential adverse effects from IV lipid emulsions 0 Fat overload syndrome 0 Immunologic dysfunction 0 Infusionrelated fever chills headache and back pain 0 What is propofol What is it used for O A sedative that is used in the ICU setting 0 Propofol contains 10 IV lipids 0 Provides 11 kcalml o What are the recommendations for vitamins and minerals in PM 0 Parental vitamin requirement differ from enteral vitamin requirements because of difference in efficiency of absorption and utilization parental nutrition will not be digested Vitamin K is not include in IV itamin preparations add mgweek if not contraindicated Mineral needs should be adjusted based on lab values 0 Vitamins are added just prior to administering TPN solution due to instability o What are the guidelines for fluid requirements in PM 0 Estimate fluid requirements with either I 1 ml water per kcal administered 2535 mlkg Fluid needs are increased with increased renal GI dermal or respiratory losses Fluid needs are decreased with cardiac or renal insufficiency In ICU fluid intake for nutrition support is often limited by need to administer medications 000 and blood products in fluid 0 What is a 2in1 solution for PM o Dextrose and amino acids are mixed together administered thru central venous access 0 Lipids are given separately peripherally o What is a 3in1 solution for PM 0 Also known as triple mix 0 Dextrose amino acids and lipids are combined and given thru central venous access 0 What parameters are monitored in patients on PN 0 Daily temps and lO s 0 Weight 23xweek 0 Blood sugars every 6 hrs initially daily to 2xweek when stable 0 Sodium potassium Cl bicarb BUN CR daily initially 2xweek when stable 0 Ca P mg 2x per week when stable 0 Liver function test LFT weekly when stable 0 Albumin transferrin or prealbumin baseline weekly monthly as needed 0 Nitrogen balance PRN 0 When can refeeding syndrome occur 0 Can occur in a patient who has been malnourished for daysweeks and develops hypophosphatemia and also hypokalemia and hypomagnesaemia when given a CHO load 0 What conditions may cause a patient to be a high risk for refeeding syndrome Some of theses conditions just don t eat well 0 Alcoholism Anorexia nervosa Chronic underfeeding Hepatic failure Malabsorption Morbid obesity with massive weight loss from fasting Proteinenergy malnutrition Prolonged fasting Prolonged parental nutrition 0 Respiratory alkalosis o What guidelines should be followed in order to avoid refeeding syndrome in patients on PN 0 CH0 in PM should be initiated at 2 mgkgmin about 100200 mgdstart off really low and slow 0 Monitor electrolytes P Mg and K levels 0 Electrolytes in PN solution can be adjusted based on lab values 0 Gradually increase TPN to goal rate OOOOOOOO Abbreviations BNPBtype natriuretic peptide in the blood in order to detect and evaluate heart failure OGTT oral glucose tolerance test used to be the gold standard for making the diagnosis of type 2 diabetes still commonly used to diagnose gestational diabetes BKA below knee amputation AKA above knee amputation BID twice a day TID three times a day QD every day QID four times a day Neurological Diseases What factors involved in neurologic disorders may complicate steps of the NCP 0 Cognitive impairment 0 Sensory impairment 0 Compromised ability to obtain prepare and feed oneself Hemiparesisstoke severe weakness in one side of the body hemianopsiahalfwithouteyes cant see half of their side of vision Aphasia Speech impairmentthinking of the right word but say another Dysphagiaca can not swallow What are common nutrition diagnoses with neurologic disorders Chewing difficulty Increased energy expenditure Inadequate energy intake Inadequate oral food and beverage intake Physical inactivity Poor nutrition quality of life Selffeeding difficulty Swallowing difficulty Underweight Inadequate access to food CVAstroke cerebrovascular accident Embolic stroke Thromboembolic stroke Transient ischemic attacks TIA mini stroke Intracranial hemorrhage gt Hemorrhagic is when there is a vessel that actually ruptures so get blood in brain most deadly Cant really live through as much gt Ischemic clot that will reduce blood flow to brain most common 85 of strokes o What nutrientdrug interaction is commonly a concern with stroke patients O 0000 Clot busting drugs tissue plasminogen activator TPA heparin Controlling intracranial pressure ICP RehabH a on Warfarin Coumadin same thing Vitamin K blood clotting warfarin interferes with vitamin K mechanism in blood clotting function I have a consistent vitamin K diet usually told to avoid food with vitamin K but that is not correct 0 What are the nutrition related risk factors for stroke 0 00000 BMIgt25 in women Weight gaingt 11 kg in 16 yrs in women Waistto hip ratiogt092 in men Diabetes HTN hypertension Elevated cholesterol in hemorrhagic stroke o What are potential nutritional roblems in stroke patients 0 Feeding difficulty problems with getting foods into mouth so shaking or weakness 0 Dysphagia risk for choking once food is in your mouth includes oral phase of swallowing o lmmobility contribute to a feeding difficulty muscle wasting and weight loss Will depend on severity of stroke and area of brain affected Malnutrition predicts poor outcomes Nutrition support may be needed until oral intake is adequate parenteral or enteral nutritionif the gut works USE IT Enteral is the best way 1 Head and Spine Trauma o Traumatic brain injury TBI Brain injury skull fracture openclosed and hemorrhage o Spinal cord Injury SCI Paraplegia 2 out of the 4 limbs are paralyzed spinal cord injury will have to be the legsif it high enough to get arms it will automatically be legs too Tetraplegiaall four limbs are paralyzed 1 Parkinson s Diseaseprogressive disabling neurodegenerative disease Affects about 1 of population gt 65 y Classic triad signs Tremor at rest Rigidity Bradykinesia Medical management Levodopamore dopamine in system bc Parkinson disease deals with problems in dopamine Drugnutrient interactions 1 Levodopa more dopamine to the system as Ldopa is a precursor to dopamine competitive absorption for dietary protein may want modified protein diet gt Possible nutrition concerns with PD 0 Dietary protein and Ldopa Sideeffects of medications ex Anorexia nausea dry mouth Dysphagia silent aspirations Constipationfiber and fluid adequacy Weight loss Selffeeding they have tremors that will hinder a Parkinson s disease patient to feed themselves Dietary protein interaction GI absorption competition with drug Possible interaction with pyridoxine gt Excessive amounts of pyridoxine may cause increased metabolism of Ldopa to dopamine in the periphery and not CNS decreasing therapeutic effectiveness 0 Alzheimer s Disease most common plaque formations in the brain and the brain deteriorates happens slowly and most common in the elderly not diagnosed until it begins to progress 0 Possible nutrition related concerns with AD 0 Medical management Nonsteroidal antiinflammatory drugs NSAIDS and aspirin Food sources of Vitamin E and omega3 F Possible nutrition related concerns gt Selffeeding they forget to eat someone give them cues to remember to eat gt Oral intake foods they used to like don t taste good to them anymore gt Weight management weight loss is a concern gt Behavioral Problems see Krause Table 417 pg 943 o Amyotrophic Lateral Sclerosis Lou Gehrig s disease 0 Progressive denervation and atrophy of muscles 0 Genetic oriented 0 Possible nutrition related concerns with ALS I No known therapy to cure the disease prevent malnutrition in these patients can slow the progression I Life expectancy is 26 years postdiagnosis I Possible nutrition related concerns Adequate intake of foods and fluids ncrease in resting energy expenditure metabolism going up but intake is reducing mmobiity Weight loss in both fat and lean body mass hard to do therapy after a while Chewing and difficulties and dysphagia Tube feeding can t consume enough orally Steven Hawking has lived to be 72 diagnosed when he was 21 o Epilepsy seizures and affects about 23 million people in the US 0 How to tonicclonic grand mal and absence seizure petit mal differ I Tonic clonic grand mal Seizure 12 minutes see it happening I Absence seizure petit mal few seconds I Drugnutrientinteractions o Phenytoin Dilantin antiepileptic drug used in patients with epilepsy 0 several nutrient interactions increases metabolism of Vitamin D and decreased Ca absorption folic acid interferes TUBE FEEDING INTERACTION 70 interference of absorption of Dilantin 0 stop tube feeding 2 hours before the drug given and give drug 2 hours after the tube feeding 2 Every time they give the medication it is 4 hours that the tube feeding being shut off Could miss restarting tube feeding at right time Not turn off tube feeding and turn up Dilantin but could also be a problem because feeding could be turned off and huge amount of Dilantin Dilantin given 2 to 3 times a day 1 Phenobarbital drugnutrient interactions increase vitamin D metabolism take without food 2 1 Ketogenic Diet treats epilepsy medical nutrition therapy Adkins is a ketogenic diet 2 0 Complete effectiveness for about 13 of patients Maintain stake of ketosis Must be strictly followed Discontinuation can be considered after 23 years if seizure free 1 o o o Multivitamin and mineral supplements necessary 1 Traditional 2 Initiated with 23 days of fasting 31 or 41 diet ratio of fat grams to grams protein carb 1 ModifiedAtkins 2 CH0 limited to 1020 gd 11 ratio of fat protein carb 1 MCT Oilbasedmedium 2 Some fat replaced by MCT oil makes ketosis more readily achievable allows for greater nonketogenic foods like fruits and veggies nonketogenic chained TG GuillainBarre Syndrome GBS Acuteonset inflammatory disease affecting proximal motor nerves Medical Management May progress to respiratory failure and paralysis of lower extremities or tetraplegia plasmapheresis filtering RBS replace albumin as a means oftherapy 1 Possible nutrition related concerns for 635 2 Increased energy and protein needs Swallowing difficulties Safe food handling INVOLVES Cjejuni INFECTION Immobility Multiple Sclerosis chronic disease affecting CNS where myelin sheath deteriorates transmission of electrical nerve impulses Majority of patents are mildly affected 25 million people in the world Association with vitamin D status associations don t equal causation ketones may inhibit neurotransmitters giving an anticonvulsant effect consumption of affecting No proven treatment to alter disease progression Maximizing recovery from attacks Prevent fatigue and infection Rehabilitation PT and OT Spasticity drugs Steroids Vitamin D supplementation for serum adequacy 1 Possible nutrition related concerns for MS 2 Many diets have been ruled ineffective ex Glutenfree allergenfree raw food diet Dysphagia Selffeeding Nutrition support Neurogenic bladder or bowel Potential for UTI dehydration constipation or diarrhea WernickeKorsakoff Syndrome WKS Caused by deficiencies of thiamin and niacin ooogd Occurs secondary to alcoholism Nutrition Management Eliminate alcohol Provide thiamin supplementation high thiamin foods 0 O O O o Adequate hydration O 0 May need dietary protein restriction Diabetes Type 1 Type 2 and gestational diabetes Type 1 Diabetes Immunemediated form of diabetes The body produces no insulin at all due to islet cell destruction IDDM insulin dependent diabetes mellitus or juvenile onset diabetes terms used in past Type 2 diabetes adult onset diabetes and noninsulin dependent diabetes not true anymore because it is not just adults adolescents sedentary too Insulin secretion going on but cells are not taking it up and not responsive to insulin so glucose not being taken up in cells Caused by a combination of older and if sedentary insulin resistance and insulin deficiency OBESE risk increases as get Gestational diabetes Diabetes associated with pregnancy a lot of overlap between diabetes states What are the parameters for an impaired glucose tolerance IGT OGTT 140 mgdL to 199 mgdL Oral glucose tolerance test fasting and give a certain amount of glucose to drink and then two hours after check blood glucose levels Values will determine if they have diabetes What conditions are IFG and IFT associated with These conditions are referred to as quotprediabetes recommendation physical active modified diet Obesity Dyslipidemia with high TG and or low HDL cholesterol HTM Meet three of them physician will diagnosis as metabolic syndrome What are the criteria for diagnosing diabetes with the A1C A1C 5764 prediabetes don t have to fast and shows what a persons blood 3 months Shows the life span of a blood cell sugar has been for 2 to PREFERED WAY NOW When should the A1C not be used to diagnosis diabetes Diabetes diagnosed when A1C 3 65 Confirm with a repeat A1C test Not necessary to confirm in symptomatic persons with PG gt200 mgdL If A1c testing not possible use previous tests Cannot be used during pregnancy bc of changes in red cell turnover so quick A1c gt 60 should receive preventive interventions prediabetes A1C reliable measure of chronic glucose levels values vary less than FPG and testing more convenient for patients can be done any time of the day What other laboratory tests can be used to diagnosis diabetes What are the corresponding parameters FPG 3126 mgdL no caloric intake for at least 8 hours 2h plasma glucose 3 200 mgdl during OGTT 75 g glucose dissolved in water In a patient with classic symptoms of hyperglycemia a random glucose 1200 mgdl 0 Need to confirm FPG or Zhr plasma glucose with repeat What are the individualized glycemic blood pressure and lipid goals for individuals with diabetes 0 Attain individualized glycemix blood pressure and lipid goals A1C lt7 with diabetes is good not a normal A1C but good control of blood sugar for people with diabetes Not good for a person without diabetes Blood pressure lt 14080 mm Hg LDL cholesterol lt100 mgdL TG lt150 mgdL HDL Cholesterol gt 40 mgdL for men HDL cholesterol gt 50 mgdL for women What are the other goals for MNT for adults with diabetes 0 Good control 0 o Achieve and maintain body weight goals 0 0 Delay or prevent complications of diabetes Poor wound healing kidney and amputation due to poor circulation diabetic neuropathy and loss of vision For whom is MNT recommended 0 MNT recommended for all individuals with Type 1 or 2 diabetes works with a team nurse physician dietitian and pharmacist O o Individualized MNT as needed Type 1 intensive flexible insulin therapy medicationinsulin pen or shot education program with carb counting Type 1 with fixed daily insulin doses with consistent CHO intake Type 2 portion control or healthful food choices may be a better option teaching to count carbs may not be necessary 3 meals a day and portion control may be all that is required What nutrition therapy strategies are recommended for all individual with diabetes Portion control for weight loss and maintenance Know what foods contain CHO Choose nutrientdense high FIBER foods Avoid sugar sweetened beverages 5535 Not necessary to subtract the amount of dietary fiber or sugar alcohols from total carbohydrates Substitute foods with higher in unsaturated fat saturated fat and trans bad Select leaner sources of protein and meat alternatives 0 O O O O O O O O O O O O O o No evidence to support use of vitamin and mineral supplements herbal products of cinnamon 0 0 Alcohol consumption moderate run the risk of hyperglycemia 0 Limit sodium intake to 2300 mgd What are additional recommendations for individuals taking sulfonylureas Oral agent 0 Moderate amounts of carbohydrate at each meal and snack CHO individualized to patients needs 0 0 To reduce risk of hypoglycemia run the risk of blood sugar going low Eat a source of CHO at meals Moderate amounts of CHO at each meal and snacks Do not skip meals can get low blood sugar low glucose PA may result in low blood glucose need to instruct them how to manage that and may need to bring a CHO source with them For individuals taking insulin what should they learn 0 Learn to count CHO or use another method of quantify CHO intake What are additional guidelines for individuals using an insulin pump or taking multipledaily injections 0 If no insulin pump or multipledaily injections Take mealtime insulin before eating Meas can be consumed at different times PAmay need to reduce dose INDIVIDUALIZED depend on intensity of PA Cardiovascular Disease and Obestiy Which groups are developed the newest guidelines for the management of cardiovascular disease CVD Development and Evolution National heart Lung and Blood institute NHLBI Newest CVD prevention guidelines The American heart association AHA and the American college of cardiology ACC 2 What is the focus of the new guidelines Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risks in adults from AHA and ACC Focuses on appropriate statin medication use and intensity therapy Includes the use of a risk calculator to assess the 10year atherosclerotic cardiovascular disease ASCVD risk 3 Describe the 4 groups of individuals identified to benefit from the statin therapy Group 1 patients with clinical diagnosed with some type of CVD ex Heart disease stroke all listed in article quotcholesterol guidelines ASCVD Group 2 Patients with LDLC 3 190 mgdL Group 3 patients 40 to 75 years old with DB and LDLC 70 to 189 mgdL without clinical ASCVD These 3 typically treated in the past with statins Group 4 patients without clinical ASCVD or DB who are 40 to 75 years old with LDLC 60 to 189 mgdL and as estimated 10year ASCVD risk of 75 or higher using the new Pooled Cohort Equation 4 What is the pooled Cohort Equation What does is assess ASCVD risk calculator What is the goal of high intensity statin therapy Which groups of individuals are identified to be treated with this regimen High statin intensity 0 Goal is to decrease LDLC level by gt50 O 0 Patient characteristics include Cinica ASCVD age 21 to 75 years LDLC 3190 mgdL Diabetes age 40 to 75 years with 10 year ASCVD risk75 Relatively new information may be controversial 6 What medications are included in the high intensity statin therapy 0 Medications Atorvastin Rosuvastatin 7 What is the goal of moderate intensity statin therapy 0 Goal is to decreases LDLC level by 30 to 40 8 Which groups of patients should be considered for this treatment plan 0 Patient characteristics include Agegt 75 yrs old with clinical ASCVD Patients who cannot tolerate highintensity therapy Diabetes 40 to 75 years old with 10year ASCVD risk lt 75 No diabetes 40 to 75 years old with 10 year ASCVD risk 3 75 9 What are some of the adverse effects of statin therapy How can the adverse effects be limited or avoided o Myalgia muscle pain no elevation in Creatinine Kinase up to 5 of patients 0 0 Severe myositis some elevation of CK O o Rhabdomyolysis extremely rare elevated CK levels 0 0 Avoid certain drug combinations 0 0 Use moderateintensity statins 10 List examples of nonstatin medications that might be considered 0 Consider nonstatin medications Cholesterolabsorption inhibitors Bile acid sequestrants Niacin Fish oil Really focus on statins the most 11 What are the recommendations for lowering LDLC with diet 0 Diet to lower LDLC O 0 Change dietary pattern to O o Emphasize intake of vegetables fruits and whole grains 0 0 Includes low fat dairy products poultry fish legumes nontropical vegetable oils and nuts 0 0 Limits intake of sweets sugar sweetened beverages and red meat Guidelines 0 5 to 6 total kcalories from saturated fat 0 0 Reduce calories from saturated fats O 0 Reduce calories from trans fat 12 What are the recommendations for lowering blood pressure with diet All the foods the same as before Guidelines 0 Lower sodium intake 0 0 2400 mg sodiumday O o if really high sodium intake just cut 1000 mg of sodium can lower blood pressure 0 0 Combine the DASH dietary pattern and lower sodium intake 13 What are the guidelines for physical activity in order to treat lipids or blood pressure 0 Lipids O 0 Blood pressure Both identical Aerobic physical activity 3 to 4 sessions per week 3040 minutes per week moderate to high intensity 14 From the Obesity Expert Panel of 2013 what are some of the evidence statements that were graded quothighquot 0 Some of the evidence statements grade high The greater the BMI the greater the risk of CVD and Type 2 diabetes Sustained weight loss of 35 can result in improved health Six months or more of lifestyle counseling results in the positive outcomes Anemias Microcytic anemia iron deficiency and vitamin 36 Lab values will indicate a reduced amount of hemoglobin in RBC Macrocytic anemia is a folate and vitamin 312 deficiency Anemia of chronic and inflammatory disease normocytic R3C normal size supplement of iron will not help and it is caused by chronic or acute blood loss EX Associated with chronic heart failure or cancer Pernicious anemia Decrease in number of RBC so vitamin 312 deficiency related to malabsorbtion because no intrinsic factor which is required for 312 absorption Lab tests due to iron deficiency Hematocrit O O 0 Hemoglobin O 0 Hemogram O o Ferritin O 0 Serum iron 0 0 Total iron binding capacity 0 0 RBC distribution width 0 0 Mean corpuscular volume Lab tests due to B vitamin deficiency macrocytic anemia Serum homocysteine detects if deficiency of vitamin 312 or folate Folate Vitamin 312 MMA detect of folate or 312
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