Nfs 260 Exam 1

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Evidence Based Health Care

Back 1

Conscientious use of current best evidence in making decisions about the care of individual patients in the delivery of health services.

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Evidence Based Dietetics Practice

Back 2

The use of systematically reviewed scientific evidence in making food and nutrition practice decisions by integrating best available evidence with professional expertise and client values to improve outcomes

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Advantages of using evidence-based practice

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-To improve patient outcomes
-To improve safety, quality,
efficiency
-To take advantage of “exploding”
biomedical knowledge

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Nutrition screening

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Meant to figure out those in immediate need of nutrition services
*Most likely not done by a dietitian (ex: nurse)

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Medical nutrition therapy

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-Dietitian creates a meal plan for specific people (ex:diabetes)

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Key considerations for Evidence based practice

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-Must be consistent with ADA Scope of Practice Dietetic Framework
-based on the best available evidence including research, national guidelines, policies, consensus statements, expert opinion and quality improvement data
-Best available evidence is based on the hierarchy of evidence
-Systematic review of scientific evidence is an ongoing process
-involves continuing evaluation of outcomes which becomes part of the evidence base
-applies to individuals clients, customers and communities

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Sources of information

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-Evidence analysis library (EAL = found on eatright.org)
-Cochrane library (has the world's best medical research)
-United States Department of Health and Human Services (HHS)
-Agency of Healthcare Research and Quality (AHRQ = to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. It emphasizes evidence-based practice, outcomes and effectiveness, and effective health care.)
-National Guidelines Clearinghouse (a comprehensive database of evidence-based clinical practice guidelines and related documents with syntheses and comparisons)
-National Institutes of Health (NIH)
-Office of Dietary Supplements (ODS)
-National Cancer Institute (NCI)
-National Institute for Digestive Diseases and Kidney (NIDDK)
-National Center for Complementary and Alternative Medicine (NCCAM)
-National Heart, Lung, and Blood Institute (NHLBI)
-National Library of Medicine (NLM)
-Food and Drug Administration (FDA)
-Center for Disease Control (CDC)

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ADA Evidence Analysis Library

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-Synthesis of best available nutritional research in an online user-friendly library
-33 EAL projects
-Abstracted articles and worksheets
-ADA Evidence-Based Nutrition Practice Guidelines

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Evidence Analysis Process Steps

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-Select topic and appoint expert work group
-Define question and determine inclusion and exclusion criteria
-Conduct literature review for each question
-Analyze articles/critical appraisal
-Overview table/evidence summary
-Develop conclusion statement and assign grade
-Publish on-line EAL
***rigorous and systematic

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What is the basis of Evidence Based Practice?

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-Research
-Expertise of the professional
-The client

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Qualities of experts in critically analyzing articles

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• Must have at least Master’s degree; many have PhD’s
• Trained at ADA’s EA workshop
• Mentored by ADA Staff and Lead Analysts
•Read and analyze articles

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ADA’s Evidence-Based Guidelines

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-Use best available evidence in making clinical decisions
-Use a systematic process for identifying, assessing, analyzing and synthesizing evidence as a basis for development
-Promote use of professional expertise where evidence is weak or lacking

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Transition from evidence to guideline

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-Review
-Formulation (Recommendations, Algorithms, Introduction, Appendices)
-Glossary
-External review
-Publish on EAL

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What is dietetics as a profession?

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The integration and application of principles derived from the sciences of food, nutrition, management, communication and biological, physiological, behavioral, and social sciences to achieve and maintain optimal human health.

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Dietitian

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a professional person who is a translator of the science and art of foods, nutrition, and dietetics in the service of people-whether individually or in families or larger groups: healthy or sick: and at all stages of the life cycle.

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What are the areas of practice of a dietitian?

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-Dieto-therapy (later diet and disease, medical nutrition therapy, clinical nutrition)
-Teaching (instructed dietetics students, nurses, physicians, and patients)
-Social welfare (community nutrition)
-Administration (institutional management, food systems management or management of food and nutrition)

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Scope of Dietetics Practice Framework

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A flexible decision-making structure that empowers practitioners to provide safe, effective, and timely health care services.

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Four assumptions of a dietetics

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-Each individual professional is different
-Many not be able to practice in all aspects of the field
-Practice areas only in which they are competent in
-Pursue additional education and experience

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Three building blocks of a dietitian

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-Foundation knowledge
-Evaluation resources
-Decision aids

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Five characteristics of a profession

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-A code of ethics
-A body of knowledge
-Education
-A level of autonomy
-A Service

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Standards of Practice (SOP)

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-Describes competent level of practice related to direct patient care
-Based on Nutrition Care Process and Model (NCPM) and CADE core competencies
-Describes responsibilities for which RDs and DTRs are accountable

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Standards of Professional Performances (SOPP)

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-Describes competent level of behaviors that characterize professional roles. Includes activities related to:
-Provision of services
-Application of research
-Communication and application of knowledge
-Utilization and management of resources
-Quality of practice
-Continued competence
-Professional accountability

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When to use a decision tree

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When trying to determine whether a specific activity or service falls within your individual scope of practice

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Application of Scope of Dietetics Practice

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-Emphasizes the dietetic practitioner’s accountability
-Places decisions about boundaries in the hands of the practitioner
-Intended to be used by students, DTRs, RDs at both the entry and advanced levels of practice

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Values of the Code of Ethics

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-Customer focus
-Integrity
-Innovation
-Social Responsibility

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Nutritional services are mostly in...

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Hospital settings

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Clinical Nutrition Manager

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Directs activities of clinical dietitians, diet technicians, and dietetic assistants

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Registered Clinical Dietitian (RD)

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Provides nutrition care for patients

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Dietetic Technician (DTR)

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Assists clinical dietitian

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Dietetic Assistant/Aid or Diet Clerk

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Assist RD and/or DTR in routine aspects of nutrition care

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Clinical dietetics should be based on...

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-Evidence Based Practices
-Outcomes which are measurable
-Reimbursement of knowledge gained to spread

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Preventative Nutrition Therapy

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The use of nutritional care to prevent or postpone degenerative disease

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Steps of the nutrition care process

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-Assessment
-Diagnosis (originally done by doctors)
-Intervention
-Monitoring and Evaluation

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Purposes of the nutrition care process

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-Improve consistency and quality of care provided
-Enhance predictability of outcomes

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Nutrition Diagnosis

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Identifying and labeling a problem that describes a nutrition problem that the dietetics professional is responsible for treating independently
***P(label)E(factors causing)S(findings)statements
***Not a medical thing (do not say people have high blood pressure)

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Nutrition intervention uses...

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-Planning (decide which method will most benefit the patient i.e. Nutrition prescription = increase calories)
-Implementation (can refer to someone else)

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Nutrition intervention is direct towards

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The etiology

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Purpose of nutrition monitoring and evaluation

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-Evaluate whether the efforts were effective or not (testing needs to be preplanned)

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Main goal of the NCP

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Performance improvement

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What is ICD-9CM used for

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Codes for disease states (diagnose medical conditions)

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4 types of diagnoses

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-Intake
-Clinical
-Behavioral
-Environmental

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Etiology

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-Cause/Contributing Risk Factors
-Must be linked to the problem
-Allows more accurate monitoring/eval
-Determines if intervention will solve the problem or not

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How to determine the defining characteristics of signs and symptoms

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-Evidence based
-Research and practice
-Must be tested and agreed upon

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Pattern recognition

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The patient presents with signs and symptoms that fit previously learned patterns or pictures
(can be visual i.e. goiter)
***If sign is present than highly likely that the disorder is present

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Can use a medical diagnosis only in the...

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Signs/Symptoms of PES (ex: as evidence by high blood pressure)

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Logical algorithm approach

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Ask every question possible (strategy of exhaustion)
*Used by the inexperienced

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Hypothetico-deductive reasoning

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-Gather clues
-Form list of potentials
-Rule in or rule out based on further probing/testing

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Increasing physical activity is an example of a...

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nutrition prescription (related to energy balance)

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Feeding assistance includes...

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-The equipment
-The actual person

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Initial/Brief Nutrition Education

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-Priority modifications
-Survival Skills

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Comprehensive Nutrition Education

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-Recommended Modifications
-Advanced or related topics
-Result interpretation
-Skill Development

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Much of nutrition counseling can be done...

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On an outpatient basis

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Cognitive Behavioral Therapy

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Premise that human behavior is learned and related to internal and external factors (antecedents &
consequences)
***Goal directed, Process oriented, and Facilitated through problem solving tools

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Health Belief Model

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-----Psychological model focuses on individual’s attitudes and beliefs to explain and predict health behaviors----
-Perceived susceptibility
-Perceived severity
-Perceived benefits
-Perceived barriers
-Cue to action
-Self efficacy
*Person needs to accept they have a medical condition in order for this to work

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Social Learning Theory

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Human behavior is a triadic, dynamic, and reciprocal interaction of personal factors, behavior, and the environment
(Attention, Retention [i.e. "I figured out what I was doing wrong], Motivation)
*Person needs to recognize the problem

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Transtheoretical/Stages of Change

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Assessing a participant’s interest (or motivation) to change and then adjusting the intervention strategy to their “stage of change”
(Precontemplation, Contemplation, Preparation, Action, Maintainence)

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Motivational interviewing strategies

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-Express empathy
-Develop discrepancy
-Avoid argumentation
-Roll with resistance
-Support self-efficacy

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Four Stage Counseling

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-Clarify expectations
-Identify problem
-Develop goals and actions
-Verify plan of action
***Needs to be done with a client

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Problem Oriented Medical Record(POMR) includes...

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-Data base = subjective and objective information about the patient and is the basis for the problem list
-Problem list (usually developed by a physician)
-Initial Care Plan = expected outcomes, plans for further data collection and a patient teaching plan (how the physician can manage the patient)
-Progress notes = Monitoring client's care usually in the form of SOAP notes (other health care professionals can put notes here)
***only step that can have different formats
-Discharge summary = Expectations for the client when they leave (usually done by a physician or someone like a social worker

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SOAP Notes

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-Subjective = something the patient or patient's friend tells you
-Objective = something you can verify (ex: x-ray info or lab data)
-Assessment = Interpretation of subjective and objective info
-Plan = Interventions and actions to be taken (usually includes prescriptions)

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Assessment, Diagnosis, Intervention, Monitoring/Evaluation (ADIM(E))

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-Assessment = subjective and objective info of SOAP notes (ex: lab values)
-Diagnosis = assessment of SOAP (PES statements are listed and prioritized)
-Intervention = Plan of SOAP
-Monitoring/Evaluation = Plan of SOAP
*SOAP doesn't specifically talk about monitoring

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The main parts of the plan in the nutrition care process include

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-Nutrition Diagnosis
-Rx
-Education Provided
-F/U

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Harris Benedict works best with a...

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1.1 factor as it accurately predicted 61% of the time

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Indirect calorimetry is ideal due to...

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Variation in patients and none of the energy equations accurately predicted REE

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General diet

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-Supplies people with the RDA of nutrients in those who do not require medical nutrition therapy
***Used to promote health and reduce the risk for chronic diseases

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Soft diet

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Used by patients postoperatively or patients with mild gastrointestinal problems or patients who are weak or have poor dentition
*Modified fiber, texture, and seasoning (no lettuce or fresh veggies)

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Mechanical soft diet

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-Designed to minimize the amount of chewing necessary to ingest food
-Used by patients with limited chewing ability, those with head and neck surgery, dental problems or esophageal strictures
(Blenderize, grind, etc)

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Blenderized liquid diet

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-Used for patients after oral surgery, those with chewing or swallowing dysfunction or with strictures or anatomical irregularities
-Consists of fluids and foods blenderized to a liquid form

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Full Liquid Diet

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-Designed for conditions requiring nourishment that is easily digested and consumed or that has minimal residue
-Used for patients undergoing diagnostic tests, following surgery, or those with chewing, swallowing or dental problems
-Consists of foods that are liquid or become liquid at body temperature
*Adequate nutrition if well planned

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Clear liquid diet

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-Used prior or after bowel surgery, after IV feeding or after acute GI disturbances
***Inadequate nutritionally

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Fiber Restricted Diet

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-Used in acute phases of ulcerative colitis, Crohn’s disease or diverticulitis, preoperatively and postoperatively
***Decrease fecal output

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Less fiber =

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Narrower colon
(use less fiber for diverticulitis)

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Residue

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**Unabsorbed dietary elements and total post digestive luminal contents present following digestion
-Dietary fiber
-Endogenous connective tissue (from tough meats or cells of digestive lining)
-Salts such as bile salts or milk salts

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Enterocutaneous fistuals

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Hole which leaches out food and bacteria into the abdominal cavity

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Indications for use of enteral nutrition

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-Inadequate oral intake for five days in patients with protein-calorie malnutrition
-Oral intake <50% of needs for previous five to seven days in previously well-nourished patients

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Contraindications for use of enteral feeding

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-Complete obstruction of the small or large intestine = ileus
-Severe diarrhea without response to medication
-Intractable vomiting
-High output external fistulas
-Severe acute pancreatitis
-Hypovolemic or septic shock
-Extremely poor prognosis
-Patient’s or guardian’s wish to forgo enteral support

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Types of enteral formulas

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-Modular
-Elemental (usually used further down in the small intestine)
-Polymeric (similar to boost but without flavor)
-Disease specific

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Why a point .5 kcal/ml formula would be used

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when there is mucosal damage or unused GI tract (less nutrients needed)

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% of macronutrients used in enteral feeding formulas

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-15% protein
-55% CHO (watch lactose)
-Rest of % = 30 (including EFA and fat soluble vitamins)

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Path of sized triglycerides

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-LCT = enter micelles to form chylomicrons and enter the lyphatic system
-MCT = enter hepatic circualtion

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Vitamin not included in enteral formulas

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k (increases or decreases blood coagulation)

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Example cases for choosing enteral formulas

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-NPO or gastroenteritis = low-osmolality, lactose free
-Transition from TPN to tube = low residue

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Renal solute load

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What the kidney is trying to get rid of such as end products of protein (N) and elctrolytes

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Tube further down in the G.I. tract =

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less aspiration and less nutrient absorption

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Frequency and administration of providing enteral feeding

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-Intermittent drip - 20 to 30 minutes or 60 to 90 minutes
-Continuous 16-24 hours

-Start at 20-50 ml/hr
-Increase rate 10-25 ml/hr every 4 to 12 hours

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Refeeding syndrome

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can result from providing enteral nutrition to quickly to a stressed patient
(hallmarks are hypokalemia and hypophosphotemia)

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Most formulas contain...

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70% to 85% water

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Types of parenteral nutrition

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-Total Parenteral Nutrition (TPN) - all nutrients given via vein
-Central Parenteral Nutrition (CPN) - big vein (superior vena cava = dilutes nutrients quickly)
-Peripheral Parenteral Nutrition (PPN) - small vein (subclavian vein = sends nutrients to superior vena cava)
-Total Nutrient Admixture (TNA) - all components of TPN mixed together (mix fat into mixture)

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Very cold formulas can cause...

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Cramping and diarrhea

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What decreases osmolality?

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fat
***only replace CHO with fat to decrease osmolality

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Trace elements

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-Chromium
-copper
-zinc
-manganese
-Standard solutions
**Selenium important

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Considerations for PPN

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-Higher fat-lower osmolarity
-Use more dilute forms of nutrients
-Fluid level increased to get nutrients in

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CPN complications

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Catheter related problems
Metabolic problems
Gastrointestinal complications