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by: Ellen Abshire


Ellen Abshire
GPA 3.79


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Class Notes
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This 15 page Class Notes was uploaded by Ellen Abshire on Saturday September 12, 2015. The Class Notes belongs to FDNS 4520 at University of Georgia taught by Fischer in Fall. Since its upload, it has received 63 views. For similar materials see /class/202622/fdns-4520-university-of-georgia in Forensic Science at University of Georgia.

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Date Created: 09/12/15
FDNS 4520 Test 1 Study Guide Be familiar with 1 Calculation of energy and protein needs for a patient Equations for energy calculation will be provided 2 Parenteral Nutrition 0 What are the indications and contraindications for use of parenteral nutrition 0 Indications o Nonfunctional GI Tract I Severe nausea and vomiting I Shortgut syndrome I IBD I Acute pancreatitis 0 Should be at risk of moderate to severe nutrition I GI toxicity during cancer treatment and malnutrition present I Preoperativer for severely malnourished pts I Projected nonfunctional GI tract postsurgically for 7 days Refractory IBD With severe malnutrition Renal failure Pancreatitis if bowel rest gt7 days needed I Food passing through stomach stimulates pancreas and increases pain Shortbowel syndrome lt 60 cm Eating disorders with severe malnutrition and pt can t tolerate enteral Severe refractory diarrhea Severe malnutrition severe catabolic illness 0 GI obstruction high output fistula gt500 mLday o What kinds of components are in parenteral nutrition formulations O O 0000 0 Protein I Crystalline amino acids 320 I 4 kcaIg I Special formulas for renal failure and liver disease 0 Liver disease more branched chain aa 0 Carbohydrate I Dextrose monohydrate 570 I 34 kcaIg 0 Fat I Emulsions of soybean oil or soybean and safflower oil I 10 11 kcalmL I 20 20 kcalmL I 30 30 kcalmL I Can decrease osmolarity I Essential fatty acids Electrolytes Vitamins not RDA amounts because going directly into bloodstream Trace Minerals I Not all are in solution I Iron Sterile water 0 O O O Define central vs peripheral delivery of parenteral nutrition How does a clinician choose between central and peripheral nutrition 0 Central Parenteral Nutrition CPN 0 Large central vein I fasterflow larger diameter solution is diluted much more quickly 0 Total Parenteral Nutrition TPN 0 Nutrient needs are high 0 Fluid restricted pts 0 Peripheral Parenteral Nutrition PPN 0 Peripheral vein 0 Nutrient needs are not high and osmolarity of solution needed is lt900 mOsmL 0 Expected need for nutrition is short term 720 days 0 Transition from parenteral to enteral intake Define osmolarity vs osmolality How are these used by a clinician o Osmolarity mOsmL I Max for PPN 900 mOsmL 0 gt600 mOsmL risk of vein damage I Most central PN are gt 1800 mOsmL I Osmolarity g dextroseL x 5 g aaL x 10 electrolytes Parenteral calculations as on calculations handout from Kathy Hammond 0 Focus on problems 17 on calculations Complications of parenteral feeding 0 Mechanical Devicerelated I Infectious o lndwelling vascular access devices pose greatest risk of bloodstream infection 0 Most common organisms causing infection with CPN are coagulasenegative Staphylococci Staph aureus Enterococci 0 Can result from o Endogenous skin flora that travel along catheter 0 Direct contamination o Distant site contamination o Contamination of infused solution I Noninfectious o Occlusion o Thrombotic I Swelling of vessels such as in arm and neck I Clotting increases risk of infection 0 Nonthrombotic I External clamps kinking constricting sutures o Hyperglycemia I Increased risk with diabetes critical illness overfeeding sepsis medications I Poor glucose control associated with increased infection rates organ failure days on ventilation and mortality I To prevent 0 Avoid overfeeding start lt2025 kcallkg 0 Limit CHO to no more than 35 mglkglmin in critically ill 0 Monitor medications Dwabetes hrnndexnese m ne mare than 200 gld e Hypenrwg yce demwa TG have 400 mgIdL acceptame dunng F39N vvnen serum TG gt 100 mgIdL mcreased Hskfur pancreatms Cendmens mcreasmg Hsk rena fame hyperg ycerma hwgher g ucucumcmds rwtma Hness hver ase genetu hyperhpwdemwa serne medmatmns mcmdmg prupufu Tu prevent Prewde Samn uf ka nern hpwds Use nntmuuushpwd mmer MumturTGs e Refeedmg Sndrume WWW summrwmm Hypomagmszlmu n whan mem lelm m mm nllcunlyl m mumn cupid0n e an and mm mmmee Rafeadlng syndrome Running nwucn In annbmmn VGlMqupI r 00mm cl meme 1 7 0mm 21 x w a v05 1 x a m FImdnn Mnlnll mmquot mums 5 Acnommnugysmu Rwsk mcreased by Prepnged fas ung AN severe ma numtmn Murbwd ubesm thh rapwd Wt ms 0 Cannery Chmer ma nutrmun frum mrrhusws cachexwa COPD ma absurptwe msease CrmcaHy m ptvvhu s thh madequate nutrmun fur gt7 days Tu p t Start F39N at1520 kcallkg and mcrease aneras d Lnnn dextruse m 100200 gld or2 mglkglmin ur has Supp y prutem 3115 glkg aw Suppxernentwnn mamer mu mg pp Ementthh K M P if needed priono feeding Mumtur ne ectru ytes g ucuse md ba ance and advance F39N un y Wnen 9 Sta E e Acute acahmmUS enexeeyspps rare Ca se y dwsruptmn uf pped supp y m 93H b adder due m msruppen uf mrcmatmn ur m ammatmn 0 Metabolic Bone Disease Monitoring Parenteral Nutrition Treated with surgery or providing enteral nutrition to stimulate GB 0 Elevated liverenzymes and bilirubin Risk increases with GI disorders liver disease malnutrition and sepsis In adults most common cause is fatty liver formation 0 To prevent impact on liverfunction Avoid excess kcal and excess CHO gt5 mglkglminld Limit lipids to 1 glkgld Cycle PN for 1216 hours allows for mobilization of fat and glycogen from liver Interest in whether choline and Lcarnitine supplementation is beneficial Longterm PN years increases risk Parameter Initiation Critically Stable CBC 1wk 1wk PT 1wk 1wk BUN Creatinine 1d for 3 d 1d 12wk Electrolytes 1d for 3 d 1d 12Wk Serum glucose 1d for 3 d 1d 12wk Serum TRG After bag 1 1wk 1wk Liver function 1wk 1mos Weight 1d 1d Fluid balance 1d 1d Initiation of Parenteral Nutrition Clinical Condition PN delivery Pt with normal hydration normal blood glucose TRG electrolytes Full volume with full nutrients except start dextrose at 12 goal rate Fluid overload with normal blood glucose TRG electrolytes Partial fluid volume with full macronutrients Dehydration with hyperglycemia amp TRG gt 400 mgdL Full fluid volume with partial macronutrients Refeeding Syndrome Risk Partial volume with partial macronutrients 0 General terminology related to parenteral nutrition 0 Formula compounding 2in1 o Dextrose amino acids 0 Lipids in separate bag I Dextrose amino acids and lipids o Lipid is kept separate until use 3 Electrolytes substances that dissociate into cations and anions in water 0 Total body water 4565 BW 0 Major extracellular electrolytes O O O O Na 136145 mEqL Ca2 45 55 mEqL or 96106 mEqL HCO3 2226 mEqL 0 Major intracellular electrolytes O O O K 3550 mEqL Mg2 1525 mEqL Phosphorus 2550 mgdL o Osmolality of Blood 0 O mOsmkg blood2 Na mEqL K mEqL glucose mgdL18 BUN mgdL28 Used to determine serum tonicity I Tonicity osmotic pressure of a solution I Often dictates transfer of fluid from intracellular to extracellular fluid 0 Sodium Imbalance O O Hyponatremia lt135 mEqL I Decreased Na or increased fluid or both I Rarely occurs from inadequate intake I Could occur from Diuretic use Administration of IV fluids without Na Hyperglycemia shift of water into blood to reduce osmolality due to high levels of glucose 0 Abnormal increase in ADH which conserves water but not Na I Plasma Na reflects extracellular H2O balance regulated by kidneys at distal tubule I When serum Na lt120 mEqL see nausea vomiting lethargy confusion cramps I Hypotonic hypervolemic tx 0 Consider free water restriction 0 IV with mildmoderate hyponatremia may use 12 NS or NS I IV Severe may need N Na at higher concentrations 0 Guidelines for rate of correction 12 mEqLhour Hypernatremia I Increase in sodium or decrease in water so serum Na gt 145 mEqL 0 Always hypertonic 0 Normally renal system will excrete excess Na I Symptoms are neurological lethargy or agitation I Some causes 0 Dehydration 0 Excessive water losses due to fever open wounds Increase water intake if cause is fluid loss with inadequate replacement IV tx o Decrease or discontinue administration of Na with replacement of water deficit Potassium Imbalance Small changes in blood K may mean major changes in ICF K Only 2 in total body K is in ECF K is needed for normal neuromuscularfunction Hypokalemia lt 35 mEqL Causes 0 O O O Phosphate Hypophosphatemia Malabsorption Hyperparathyroidism Refeeding Syndrome Signs Respiratory and CNS disturbances Hypophosphatemia Tx 0 O o Redistribution refeeding syndrome 0 Renal disorders 0 Mg depletion required to regulate the NaK ATPase pump 0 Vomiting and diarrhea 0 Loss of K 0 Loss of gastric acid metabolic alkalosis kidney excretes more bicarbonate and Kfollows 0 Loss of GI fluids decreased ECF volume and aldosterone stimulates Na retention and facilitates K excretion Clinical signs 0 Muscle weakness shallow respiration dysrhythmias Tx supplemental or IV K Hyperkalemia Causes 0 Inadequate excretion of K due to renal failure most common cause 0 Excessive use of Ksparing diuretics o Acidosis when H ions are excreted they are exchanged with K o Hemolysis of RBC or Ieukocytosis thrombocytosis results in movement of K from ICF to ECF 0 Excessive IV K Clinical Signs Tx 0 Muscle weakness paralysis o Parathesias 0 Cardiac dysrhythmias Dialysis and Krestricted diet for renal dysfunction longterm 0 Various IV protocols are available to treat 0 Oral phosphate from food or supplement 0 IV only for moderate to severe depletion Hyperphosphatemia Due to renal failure or cell destruction 0 Causes I I oTX I I 0 Blood pH 735745 TX is dietary restriction or phosphate binders CA orAl supplements 0 Magnesium Hypomagnesemia common in ICU Poor intake alcoholism diuretics Malabsorption Refeeding syndrome Hypophosphatemia but high levels of ionized Ca 0 Clinical Signs Cardiac arrhythmia muscle weakness mental changes Resistant hypokalemia Diet and supplements which can cause diarrhea IV for moderatesevere o AcidBase Balance 0 Equilibrium state of H ion concentration 0 Kidneys lungs and buffering systems maintain blood pH Lungs normally compensate for acidbase disturbance in mins kidneys are much slower Regulate C02 which combines with H2O to form carbonic acid alter rate and depth of ventilation 0 Normal Arterial Blood Gas Values PC02 3545 mmHg P02 80100 mmHg HCO3 z 2226 mEqL 0 Changes in AcidBase Disorders TX should focus on primary change AcidBase Disorder pH Primary Change Compensatory Change Metabolic acidosis l l HCO3 l PC02 Metabolic alkalosis T T HCO3 T PC02 Respiratory acidosis l T PC02 T HCO3 Respiratory alkalosis T l PC02 l HCO3 o AcidBase Disorders 0 Metabolic Alkalosis renal or metabolic system Decreased H from losses or increased bicarbonate retention 0 Vomiting 0 Increased ingestion of alkali 0 Loss of Cl Metabolic Acidosis renal or metabolic system 0 Increased production ingestion or retention of H or decreased bicarbonate lungs will respond with hyperventilation to compensate Ketoacidosis from diabetes High fat low CHO resulting in ketosis Uremia renal failure Diarrhea 0 Respiratory Alkalosis o Decreased H2003 from excessive expiration of 002 and water I Anxiety I Intense exercise I Early sepsis I Head trauma I Decreased P002 I Compensation decreased renal acid excretion 0 Respiratory Acidosis 0 Increased retention of 002 increased H2003 I D I Increased P002 I Compensation increased renal acid secretion 4 Quality assurance in a healthcare setting 0 Quality assurance the process of preventing identifying and solving problems in an organization Know the main organizations that are responsible for quality assurance in health care organizations 0 The Joint 00mmision o Assure adequate healthcare for public 0 Accredits gt19000 healthcare organizations 0 Independentnonprofit 0 Survey every 3 years 0 Set performance expectations 0 Centers for Medicare and Medicaid Services 0MS o Maintains oversight of the survey and certification of all care providers serving Medicare and Medicaid beneficiaries 0 Survey completed by state 0 Georgia Office of Regulatory Services 0 Part ofthe GA Department of Human Resources What types of indicators can be used to assess quality of care 0 0hosen for Clarity Appropriateness Availability of relevant data Ability to indicate problem or key area of care Discrete 0 Minimal collection time 0 Types of Clinical Indicators 0 Process Indicators actual completion of an expected outcome I 0alorie and protein goals for pts are documented in medical record I Pts who are NPO gt5 d without nutrition support I Pts are screened andor assessed within 2472 hours of admittance 0 Outcome Indicators I of pts with wt loss gt 10 of admission wt BAD I of pts with low serum albumin I Pts describe appropriate food choices for 0V disease management after inpt education Functional Outcomes physical social Behavioral and Knowledge Outcomes food selection preparation 0 O O O I Clinical Outcomes biochemical anthropometric Iab values body wtcomposition o SententiaI Event Indicators all occurrences warrant investigation I pts receiving TPN with 2 blood glucose levels gt 250 on consecutive days who do not receive treatment within 1 day of 2nd Iab report I pts do not receive TPN when gut will be dysfunctional for gt 8 days 0 Comparative Rate Indicators I Further assessment if trend is shown I Can occur even with stateoftheart care 0 Nutrition Indicators 0 Patient safety 0 Patient centeredness 0 Effectiveness o Efficiency 0 Timeliness 0 Equity 0 Consideration of pt wishes o Evidencebased protocols 0 Protocols for nutrition support 0 Consult response time in 24 hr 0 Consistent care for all 5 What are SOP and SOPP How are these used 0 Standards of Practice SOP 0 Describe minimum level of competence for RDs who provide direct patient client or resident care 0 Formatted based on NCP I Assessment I Diagnosis I Intervention I Monitoring and evaluation 0 Define how the RD used the NCP correctly to provide competent care to patients 0 Standards of Performance Practice SOPP 0 Address behaviors related to professional roIes 0 Apply in all practice settings 0 Formatted based on professional behaviors I Provision of services Application of research Communication and application of knowledge Management of resources Quality in practice I Accountability 0 What is Scope of Practice 0 Defines the boundaries limits and details of allowed practice as authorized by law 0 ADA position papers 0 Organizational priviIeging 6 What are some ofthe sources you can use to find systematically reviewed evidencebased practice literature 0 Why promote evidence based practice FDN34520 Final Exam Study Guide 1 Assessment of desirable body weight weight change and body mass index 0 Desirable weight actual wtdesirable wt X 100 o How to assess weightheight o MenBW106poundsllbforfirstS 6lbforeachinchoverS39 0 Women BW100 lbfor rst 95 lbforeach inchoverS o Weightchange Usual WtActual Wt X100 Percent weight loss Usuath 0 BMI o Desirable1852499 h w m o 0verweight325299 W116 W115 o 0besity330 1quot 13927quot gt27quot Grade30349 lmh 5 o 590 39 Gradell35399 I Gradelll40 6ml1 IPo gtIPo o Underweightlt185 2 Calculation of energy and protein needs fora delEllL yEquaLrurrs IUI g 3 Types of Laboratory values used for nutrition assessment and patient assessment Blood glucose 7099 mgdL Serum CHOL desirable lt200 mgdL Serum albumin 3550 gdL Hemoglobin o Males 135175gdt o Females1216gdL Hematocrit o males4054females3747 Measuresforirondeficiency 0 Serum ferritin males 15200 ugLfemales12150 ugL o unnamed o TIBC250450ugdt o Hematocrit o Hemoglobin 0 Measures for 312 de ciency o MMA o Homocysteine levels FDNS4520 Final Exam Study Guide 0 Serum B12 0 Schilling test 4 Parenteral Nutrition 0 What are the indications and contraindications for use of enteral and parenteral nutrition 0 Indications I Nonfunctional GI Tract I Severe nausea and vomiting I Shortgut syndrome I IBD I Acute pa ncreatitis Should be at risk of moderate to severe nutrition I GI toxicity during cancer treatment and malnutrition present I Preoperativer for severely malnourished pts I Projected nonfunctional GI tract postsurgically for 7 days Refractory IBD with severe malnutrition Renal failure Pa ncreatitis if bowel rest gt7 days needed Food passing through stomach stimulates pancreas and increases pain I I Shortbowel syndrome lt 60 cm 0 What kinds of components are in parenteral nutrition formulations as compared to enteral nutrition formulations 0 Protein crystalline amino acids 320 4 kcalg o Carbohydrate Dextrose monohyd rate S70 34 kcalg 0 Fat emulsions of soybean and safflower oils I 10 11 kcalmL I 20 20 kcalmL I 30 30 kcalmL o Vitamins less than the RDA since going directly into bloodstream 0 General terminology related to parenteral nutrition 5 Quality assurance the process of preventing identifying and solving problems in an organization Know the main organizations that are responsible for quality assurance in health care organizations 0 The Joint Commission I Assures adequate healthcare for public I Accredits healthcare orgs I Independent nonprofit I Set performance expectations FDNS4520 Final Exam Study Guide 0 CMS Maintains oversight of the survey and certification of all care providers serving Medicare and Medicaid beneficiaries completed by state 0 GA Office of Regulatory Services Part of the GA Dept of Human Resources 0 What types of indicators can be used to assess quality of care 0 Clinical Indicators I Process indicators I Calorie and protein goals for patients are documented in the medical record I Pts who are NPO id without nutrition support I Pts are screened andor assessed within 72 hours of admittance I Outcome indicators I Functional Outcomes physical social I Behavioral Outcomes food selection preparation I Clinical Outcomes biochemical anthropometric clinical I Of pts with weight loss gt 10 of admission weight I Of pts with low serum albumin I Pts describe appropriate food choices for CV disease management I Sentential event indicators I All occurrences warrant investigation I Patients receiving TPN with 2 blood glucose levels gt250 mg on consecutive days who do not receive treatment within 1 day of 2nd lab report I Pt is NPOE 5 days without nutrition support I Pts do not receive TPN when gut will be dysfunctional for 38 days 0 Comparative rate indicators 0 Nutrition indicators 7 Insurance reimbursement o What are the main types of managed care organizations 0 Purpose Limit health care costs 0 Govern provision of services 0 Manage allocation of benefits 0 Health Maintenance Organizations HMO I Provides comprehensive medical services for fixed prepaid premium I Participants use participating providers I members prepay premium for services primary care physician screens pts receiving medical care coordinates medical services and referrals primary care physician can refer to a dietitian for nutritional care FDNS4520 Final Exam Study Guide 0 Preferred Provider Organizations PPO I Managed care company provides higher of costs when preferred provider is used I Preferred provider agree to provide services at negotiated discount fees I formed by health care providers who contract with insurance companies or employers I paid with fee for service but is discounted I dietitians can become PPO providers or can contract services to physician PPOs o What provisions does Medicare have for MNT 0 Medicare Part B covers 3 hours of MNT in first year and 2 hours each subsequent year 0 MNT services covered 0 Type 1 and 2 diabetes 0 Gestational diabetes 0 Nondialysis kidney disease 0 Postkidneytransplant 8 Nutrition Diagnosis PES Statements and ADIME note structure 9 Define the difference between registration and Iicensure What is Scope of Practice I Licensure o Occurs through legislative action in a state and protects public 0 Assures that only qualified individuals can call themselves dietitians and can practice dietetics in a state 0 Most states use RD eligibility requirements 0 Gives a person a legal right to practice in a state differs among I Registration 0 National certification by CDR o Assures competency in practice and protects health and welfare of public I Scope of practice 0 Defines the boundaries limits and details ofallowed practice as authorized by law 0 Defined by the legislature for each licensing group 10 Nutrition Counseling vs nutrition education I Nutrition education 0 Providing information 0 Giving advice 0 Not likely to induce change in majority 0 Assess learning needs 0 Plan nutrition education as a continuum of learning I Start with essential information FDNS4520 Final Exam Study Guide I Afterpt has mastered basics move on to reinforce knowledge focus on indepth knowledge enable patient to take charge 0 Choose educational methods I Individualized vs group counseling I Selfstudy 0 Choose educational tools I Nutrition counseling 0 quotProviding listening advice guidance or direction regarding an action or decision to help a person change Individualized O 0 Client centered Rogerian Theory I Providing only knowledge will not elicit change I Telling the client is not effective need to be supportive of their efforts to learn and change 0 Counselor needs to I Accept clients be nonjudgmental I Exhibit congruence within the counseling relationship I Express empathy I Communicate acceptance congruence and empathy to client 0 Be familiar with stages of change most are in stages 13 1 Precontemplation assess knowledge and increase selfawareness and focus on benefits of change 2 Contemplation assess knowledge values beliefs decrease barriers 3 Preparation support selfefficacy and decisionmaking set goals 4 Action help with selfmanagement 5 Maintenance help with selfmanagement and relapse prevention 6 mm Be able to identify a realistic measurable client goal Be familiar with the concepts of motivational interviewing o What activities facilitate behavior change What are the main approaches used for a person who is ready to change Unsure about change Not ready to change What are the methods suggested in the text for dealing with resistance behaviors What is behavior modification I When you alter previously learned behavior I Encourage the development of new behaviors I Move the client to assuming responsibility to change FDNS4520 Final Exam Study Guide I Determine cues for eating I Remove negative cues having problem foods and introduce positive cues Restrict behavior to one set of cues I Roleplay new responses to old antecedents Preplan behavior to control antecedents I Arrange consequences that will maintain desirable behaviors Cognitivebehavioral theory I Theory based on assumptions 0 All behavior is learned and can be unlearned 0 Behavior is related to internal and external factors I Counseling focus on 0 Thinking and its effect on behavior 0 Desired behavior change is result of changing thought processes and cognitions I Counseling helps clients 0 Identify antecedents to behavior 0 Identify inappropriate behavior 0 Analyze consequences of behavior both positive and negative 0 Plan goals to modify environment and cognition to reduce target behaviors Social learning theory Theory based on modeling Person learns by observing someone modeling a desired behavior I ConceptsA person s ability to change is influenced by 0 Characteristics in person ie beliefs 0 Environment 0 Behavior I Concepts and counselor strategies 0 Reciprocaldeterminism o Behavioral capability o Expectations 0 Selfefficacy Observational learning 0 Reinforcement O


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