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126 Cards in this Set
- Front
- Back
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Explain ADIME
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Assessment- first step of the process. obtaining verifying and interpreting data to identify a problem.
Diagnosis- PES statement Intervention- specific actions used to remedy a specific problem. provision, education, counseling and coordination of care. Monitoring and Evaluation- review and measurement of the client's status at that time. Determine progress and goals or outcomes met. |
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What is a PES statement?
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Problem- describes alterations in the nutritional status of a patient. Here codes are used.
Etiology- Cause or contributing risk factor "as related to" Signs/Symptoms- "as evidenced by" specified diagnosis |
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What is a SOAP note?
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Subjective- patient's chief complaint
Objective- findings from physical examinations results from biochem and anthropometric tests. Assessment- A medical diagnosis Plan- diet rx |
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Who is most at risk for deficiencies?
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infants, children, pregnant women, low income, hospitalized patients and older adults
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What is nutritional status?
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A measurement of the degree to which the individual’s physiologic need for nutrients is being met
A balance between: Nutrient intake Nutrient requirements |
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How does nutrition imbalance play a role in over all health?
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Nutrition is an important factor in the etiology and management of several major causes of death and disability
Homeostasis within safe ranges of intake |
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_____% of hospitalized patients have some form of malnutrition
_____% of patients may have moderate malnutrition |
25
50 |
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What is the purpose for nutrtion screening?
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identify those that are malnourished or at nutritional risk and to see if more detailed assessment is warranted. Done by DTR, nurse or physician.
At-risk patients are referred to RD. |
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Define Aguesia
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loss of sense of taste
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Define dysgeisia
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diminished or distorted taste
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Define ansomia
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loss of smell
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What is considered significant weight loss?
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5% in 1 month
7.5% in 3 months 10% in 6 months anything above this exceeds above standards |
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What are the ranges for UBW?
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85-90%: mild malnutrition
75-84%: moderate malnutrition <74%: severe malnutrition |
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Why is hydration status important in assessment?
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Be observant of fluid status when performing nutritional assessments
Check medical history for vomiting and diarrhea, fever, excessive sweating, and edema |
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What are characteristics of fluid volume deficit?
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Wt loss over a short period of time
Decreased skin turgor Dry mucous membranes Postural hypotension Decreased body temp Decreased urine output Disorientation Changes in lab values: elevated due to concentration |
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What are characteristics of fluid volume excess?
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Characteristics of fluid volume excess:
History of congestive heart failure History of renal failure Wt gain over short period of time Peripheral edema Rales in lungs Polyuria Changes in lab tests – decreased levels due to hemodilution |
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What compnents can classify malnutrition?
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Can be based on:
Body weight Body fat Somatic and visceral protein stores Laboratory values |
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What is nutrition focused physical exam?
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An organized exam that progresses from head to toe
Combines physical exam, vital signs, and anthropometrics with info from medical record, lab data, and interviews With privilege comes responsibility! Do not subject the patient to unnecessary procedures or discomfort Much info can be obtained by reviewing findings of another health care professional |
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What are some assessment red flags?
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Depleted muscle
Dehydration Poor wound healing Chewing or swallowing difficulties Skin infections Mouth/tongue infections See Nutr. Focused Physical Exam handout |
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Describe functional nutrition assessment
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Treats the body as a whole instead of isolated signs and symptoms
Goal is to identify “triggers” of disease process, not just treatment Includes nutritional genomics, GI function, chronic inflammation, interpretation of nutritional biomarkers of cellular and molecular dysfunction Ex: looks at food intake patterns, toxins, sleep patterns, exercise, stress levels, antioxidant intake |
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IBW and %IBW calculations
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IBW - Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet.
Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet. %IBW = (Actual Weight x 100) / IBW |
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What consists of whole blood?
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RBC, WBC, platelets and plasma
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What are the specimen types for assessment?
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Whole blood
Serum Plasma Blood cells Erythrocytes (red blood cells) Leukocytes (white blood cells) Blood spots (dried whole blood from finger prick) Other tissues (scrapings or biopsies) Urine Feces Less common: saliva, nails, hair, sweat, breath test |
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What is a static assay?
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Static assays: actual level of nutrient in the specimen.
Ex: serum iron, hair zinc Does not reflect the amount of that substance stored in body pools that aren’t samples Recent dietary intake can influence level of nutrients in sample (reason for 8-12 hr fast) |
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What is a functional assay?
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Functional assays: measures the biochemical or physiological nutrient of interest. Ex: serum ferritin
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What is BMP?
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Basic Metabolic Panel
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What is CMP?
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Comprehensive Metabolic Panel
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What lab measures hydration?
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Serum sodium
Blood urea nitrogen Serum osmolality Urine specific gravity Decisions regarding hydration should not be based on labs only but in conjunction with other information such as physical exams and the clinical condition of the pt |
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What is the assessment for PCM?
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Acute Phase Response (APR): systemic response to acute or chronic inflammation associated with conditions such as infection, trauma, surgery, and cancer. An elevated temp or white blood cell count can indicate APR.
Cytokines are released that cause the liver to reprioritize the synthesis of proteins to those most critical for host defense and adaptive capabilities Hormonal and cell-mediated response to inflammatory stress releasing cytokines: Negative acute-phase respondents: proteins that decrease in concentration (due to decreased hepatic synthesis) during acute-phase response They decrease at least 25% in response to chronic or acute inflammation Ex: albumin, transferrin, pre-albumin, retinol-binding protein Positive acute-phase respondents: proteins that increase during acute-phase reponse Increase at least 25% in response to inflammation (due to hepatic synthesis) Ex: c-reactive protein (CRP) Change in the levels of these proteins is usually proportional to the severity of the illness/trauma and they will not return to normal until inflammatory stress subsides |
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What does BMP consist of?
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Glucose
Calcium Sodium Potassium CO2 Chloride BUN Creatinine |
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What does CMP include?
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BMP +
Albumin TP ALP ALT AST bilirubin |
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Nitrogen balance ______ a measure of protein anabolism and catabolism because true analysis requires consumption of a stable isotope to track protein use and valid urine collections (difficult without a catheter)
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is not
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What does nitrogen balance reflect?
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Reflect the balance between oral/enteral/parenteral nitrogen intake and renal removal of nitrogen containing compounds
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When using nitrogen balance to estimate protein status, remember:
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a + nitrogen balance may not mean protein catabolism has decreased, particularly in disease/trauma states
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What is the equation for protein intake?
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Equation: protein intake (g)/6.25 g – (g urinary urea N + 4)
Example: a person consumes 70 g of protein in 24 hrs and excretes 7 g of nitrogen as urea. 70/6.25 = 11.2 – (7+4) = .2 The person is in slightly positive nitrogen balance. |
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T or F
Albumin increases during stress or trauma and my reflect protein status. |
Albumin: caution- decreases during stress/trauma and may not reflect protein status.
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How are albumin levels affected?
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Albumin is neither sensitive to, nor specific for, acute protein malnutrition or the response to nutrition therapy
Levels are affected by the APR, hydration, disease state, and shifts from intravascular to extravascular spaces Albumin can be useful as a prognostic indicator of morbidity and mortality because it correlates with severity of illness |
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Explain assessment for protein calorie malnutrition for prealbumin
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Prealbumin: caution same as albumin but may reflect current dietary intake (most current 2-3 day intake) so it can be used to help determine if current nutritional intake is adequate or improving). Can’t be used as a sole criterion of malnutrition as it lacks sensitivity.
PAB levels are often maintained in uncomplicated malnourished patients and may be decreased in well-nourished patients who have undergone recent stress such as surgery |
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Does transferrin respond rapidly to changes in nutritient intake?
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no
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What does C reactive protein reflect?
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C-reactive protein: reflects any type of inflammation. When the CRP level decreases, pt is beginning anabolic stage and more intensive nutrition therapy should be addressed. Should not be used as a nutritional parameter but as a monitor of the presence, intensity, and recovery from an inflammatory process
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What is creatinine used to assess?
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Creatinine: Used to assess somatic protein status. Typically only used as a marker of muscle mass in research studies because the value can be affected by intake of muscle meats..
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Describe nutritional anemias
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Condition characterized by a reduction in the number of erythrocytes per unit of blood volume, or a decrease in hemoglobin content of blood to below the level of usual physiologic need
Defined as: Hemoglobin concentration below the 95th percentile Symptom, not disease |
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What are the classifications of anemia?
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Microcytic: iron deficiency
Macrocytic: folate or vitamin B12 deficiency Normocytic (inadequate iron use): chronic and inflammatory diseases such as cancer, rheumatoid arthritis Does not respond to iron supplementation |
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What are the lab tests for iron deficiency?
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Hematocrit or packed cell volume: affected by hydration
Hemoglobin- more direct measurement than hematocrit Serum iron- poor index of iron status due to day-to-day changes Total iron-binding capacity (TIBC) : doesn’t detect decreasing iron stores and pre-anemic iron deficiencies Transferrin saturation: same as TIBC Ferritin: indicates size of body’s stored iron Effects of inflammation: can falsely elevate ferritin levels thus masking iron deficiency Serum transferrin receptor (sTfR) test: not affected by inflammatory status. An increase in serum levels correlates with iron deficiency |
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What are the macrocytic anemias associated with B vitamin deficiencies?
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Megaloblastic anemia: folate deficiency
Folate most often measured in whole blood (whole blood folate vs. serum folate levels more closely reflects tissue stores) Pernicious anemia: vitamin B12 deficiency B12 measured in serum or methylmalonic acid levels Homocysteine: levels build up when folate or B12 is lacking (sensitive to folate/B12 deficiencies) |
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What are markers for malabsorption?
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Malabsorption syndrome is a condition in wich several nutrients are abnormally absorbed. In almost all disorders, fat is not absorbed normally
Fecal fat test Fat-soluble vitamins (ADEK impaired absorption) Vitamin D |
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What are the lipid indices of cardiovascular risk?
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Total cholesterol
LDL: pattern A & B HDL: HDL2a, HDL2b, HDL2c, HDL3a, HDLdb IDL VLDL Lp(a) |
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What are the markers for inflammation?
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hs-CRP- a marker of inflammation that has been identified as a risk factor for CVD independent of lipid status
Homocysteine: same as CRP |
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What are some markers for oxidative stress?
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Free oxygen radical test
Other tests (Table 8-5) |
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What is used to determine BMI in children?
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BMI is not used BUT BMI % is used only
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What is C-diffidus?
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Painful diarrhea can be caused by prolonged use of antibiotics (5+ days) in IV therapy decreasing immune system
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aguesia
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loss of sense of taste from meds or age
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dysguesia
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poor taste, deminished
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Anosmeia
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with out smell
raises risk of food poisening |
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poorly fit dentures
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problematic for eating and chewing can cause unintentional weight loss
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What are the guidelines for unintentional weight loss and when does it become a severe case?
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5% 1 month
7.5% 3 months 10% 6 months +10% Severe |
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What are the guidelines for UBW% on unintentional weigh tloss?
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mild 85-95%
Moderate 75% Severe <74% |
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What are the waist circumference measurements for body composition?
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40+ M
35+ F BMI >35 waist measurement doesn't predict risk ppl < 60" may not be an indicator, too short |
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ascites
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in stomach swelling
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Dehydration _________ lab values.
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increases
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Excess fluid _________ labs
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decreases
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Excess Fluid
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CHF
RF Wt gain peripheral edema polyuria decrease labs |
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Static assay
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exact content, not stores
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functional assay
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stored, available for use
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What parts of the BMP is for kidney fiunction?
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BUN
Creatanine |
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Urinalysis looks at?
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Glucose
Protein Blood - for UTI and High WBC |
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What is APR?
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acute phase response
response to acute or chronic inflammation cytokine released liver synthesizes protein to repair body. |
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What is negative response APR?
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protein down 25% in presence of APR.
albumin, pre-albumin and transferrin down in response to inflammation. *inflammation masks stages of anemia |
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What is positive APR?
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c-reactive protein (CRP) increase due to inflammation. Very hard for nutrition intervention CRP needs to go down before MNT is affective.
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What is ESR?
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erythrocyte sedimentation rate
arthritis which is in a constant inflammation state |
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Explain nitrogen balance
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NOT an indicator for protein metabolism
+N balance usually pregnant women, babies and children -N balance burn victim, ill or astronauts Wounds excrete substances |
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Explain albumin in terms of indication.
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APR decrease stress and trauma
17-20 half life not a good indicator to notice nutrition therapy increases dehydration indicates liver function *indicator for morbidity and mortality a marker for visceral protein maintains osmotic pressure. fluids can leak into other parts of the body chronic ascites Normal ranges 3.5-5 g/dL |
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Explain pre-albumin in terms of indication.
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2-3 day half life
great indicator for nutrition intervention Indicates APR normal 16-40 mild 10-15 moderate 5-9 severe <5 |
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Explain transferrin in terms of indication.
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not reliable can indicate early detection of anemia
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Explain CRP in terms of indication.
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CRP + APR can indicate inflammation
gingivitis increases CRP levels plaque can break away in inflammatory state |
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Explain creatanine in terms of indication.
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only good in healthy people
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How would you dx with a Hg below 95%?
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anemia
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Is anemia a symptom or a disease?
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symptom
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Macrocytic anemia is typically from what vitamin deficiency?
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folate or B12
megaloblastic -folate Pernicious anemia -B12 |
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When Hct and Hg is down what does that indicate?
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late stage anemia
always look at prior to surgery |
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What are the ranges for Hg?
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M -14-16
F - 12-14 transfusion will be done only when Hg is <8 |
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Inflammation can falsely indicate ferritin levels masking what deficiency?
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iron
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______ of all doctor visits include a prescription.
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2/3
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What is the C P 450 enzyme?
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It breaks down drugs in the liver. There are 30 enzymes.
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Iron is best absorbed taken on an ____________ stomach.
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empty
absorption can be reduced by 50% when taken with food. |
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What is the difference between absorption and adsorption?
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Absorption – taking drug into blood stream
Adsorption – food binds to drug affect efficiency ex fiber |
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What is the CP-450 enzyme system and why is it important to know about it in relation to drugs?
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The metabolism of the drugs it’s about 30 enzymes that are responsible.
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What is the protein recommendation for someone taking Levadopa?
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Don’t take with high protein foods, take meds am small protein throughout day then more at dinner.
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Can taking antacids interfere with efficacy of medications? Why or why not?
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Yes, it can affect the acidic environment. You may not absorb meds as well.
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An elderly female, without any current medical complications, has an albumin of 2.9 Is there a concern?
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Albumin is low, particularly uncomplicated could be malnourished.
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A person is taking Prednisone and complains of puffiness and body aches. What would you evaluate in their diet?
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Sodium, Potassium (muscle aches)
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A person is taking MAOI. What are some foods they must avoid? What could potentially happen if they don’t?
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Aged cheese, aged meats, tofu or soy products. It can cause hypertensive crisis.
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What does hepatotoxic mean?
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8. What does hepatotoxic mean?
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How does alcohol (ETOH) contribute to hypoglycemia?
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It inhibits gluconeogenesis
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Why can Elavil make foods taste different?
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Decreases saliva production
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On which lab test would I find hemoglobin and hematocrit values?
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Complete Blood Count and Differential
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In an Acute Phase Response, what is the reaction of the liver?
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Cytokines are released causing the liver to reprioritize the synthesis of proteins to those most critical for host defense and adaptive capabilities.
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Give an example of a negative APR and a positive APR.
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Negative acute phase respondents – decrease 25% in concentration during APR ex. Albumin, transferrin, pre-albumin, retinol binding protein
Positive APR – Increase 25% in response to inflammation CRP |
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What happens to albumin levels during a critical illness and why? What does this tell you about the patient?
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This is negative acute phase respondents and the albumin levels decrease 25% in response to chronic or acute inflammation. This can indicate cancer, infection, trauma and surgery
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Calculate the nitrogen balance for a patient that consumed 55 g of protein and had a urine urea nitrogen output of 13 g. What does this tell you about the patients current status?
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55 g/6.25 g – (13 g+ 4) = -8.2 This person is in a negative nitrogen balance.
If the nitrogen balance calculation is done in a controlled setting, such as a research hospital, it can be an indicator of protein catabolism. However, in most settings, it is not reliable and should be used as a "red flag" and an indicator that the patient's intake and health status should be monitored closely. |
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You started a patient on a nutritional supplement, Ensure, 3 times a day. Three days later, you want to see if there is improvement in the malnutrition. What would be the most appropriate lab to see if the supplement is helping? Why?
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Pre-albumin which has a 2-3 day half life. Indicates APR.
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A patient has a high CRP level. You are testing ferritin levels for anemia. What must you be cautious about?
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Inflammation can falsely indicate ferritin levels masking iron deficiency.
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What is the difference between megaloblastic anemia and pernicious anemia?
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Megaloblastic anemia folate deficiency
Pernicious anemia Vit B12 def |
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Why might a person with a BMI of 40 have a harder time losing wt and maintaining weight loss than someone with a BMI of 34?
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Those over 40 BMI have more fat cells and a harder time losing weight or maintaining
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Calculate DBW for a person who is 5’8” tall.
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IBW = 50 kg + 2.3 kg for each inch over 5 feet. Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet.
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A 40 year old male has a BMI of 24 and a waist circumference of 41 inches. Are you concerned?
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yes you are concerned
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What weight loss rate is recommended?
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10% current body weigh tin 6 months
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What is the primary concern for someone who loses weight rapidly? (averaging 3-4 # per week)
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losing water, unable to maintain in the long run, extreme caloric deficit. Changes RMR
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List 3 strategies that might help someone trying to lose weight.
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Increase fruit and vegetables
Journal Increase physical activity behavior modification nutrition education |
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What condition may develop as a result of fasting?
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gout
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Should an individual with a BMI of 34 and no co-existing conditions be considered for bariatric surgery?
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no, it should be used for those with BMI over 40 or over 35 with co-morbidity
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What is the difference between restrictive and malabsorptive bariatric surgery?
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restrictive reduces the capacity of the stomach
malabsorptive reduces capacity and absorption in the GI tract by bypassing the duodenum |
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A 5 year old boy has a BMI at the 97th% with no complications. Would you recommend weight loss?
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no you would maintain the weight
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What category of children is it acceptable to lose 1-2# per week?
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Children 7 + years with a BMI >35 with co-morbidity
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List 2 family behaviors that are associated with increased risk of pediatric obesity.
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parent controls or encourages to eat
rewards child with food sedentary behavior parental obesity or over weight |
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If energy restriction in children is warranted, kcal levels should not be less than ___________ for children 6-12 years and not less than _____________ for those 13-18 years.
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900
1200 |
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Which vitamin deficiency would cause macrocytic anemia?
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B12
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Which is a positive acute phase respondent?
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CRP
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Phentermine an appetite suppressant what is the maximize time it can be taken?
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3 - 6 weeks
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Phenobarbitol increases metabolism of which vitamins?
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vit D K and folic acid
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Which drug for RA requires you to take folic acid supplement?
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methotrexate
megaloblastic anemia |
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Lasik in crease excretion of which vitamins?
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potassium, magnesium, sodium, chloride, and calcium
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Prednasone decreases _______ excretion resulting in edema
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Sodium
Enhances potassium excretion. Low sodium high potassium diet also increases glucose levels |
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What is the HAMWI formula for IBW?
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HAMWI formula for IBW for individuals over 5 feet tall:
Men: 106 + 6 lb for every inch over 60 in Women: 100 + 5 lb for every inch over 60 in Add 10% if person has large frame, subtract 10% if person has small frame. If frame size is unavailable, assume medium. |
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What is the formula for TEE?
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(TEE)=REE x (activity factor) x (injury factor) ± 500 calories (for desired weight loss or weight gain, if applicable) + fever factor
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What are the activity factors?
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Activity factors
Comatose: 1.1 Confined to bed: 1.2 Out of bed: 1.3 Normal activities of daily living (ADLs): 1.5 |
