FNU 414 LAST EXAM EVER

NCP steps

assessment, diagnosis, intervention, monitoring and evaluation

domains for assessment

1. Food/Nutrition related history
2. Anthropometrics
3. Biochemical data, medical tests and procedures
4. Nutrition-focused physical findings
5. Client History
6. Comparative standards

anthropometrics

the measurement of the size, weight, and proportions of the human body

anthropometrics include the measurement of the human body in terms of the dimensions of

bone, muscle, adipose tissue

things in anthropometrics

1. Height/Length = infants are length, under 24 months old
2. Weight
3. Frame size
4. Weight change
5. BMI
6. Growth pattern indices/percentile ranks
7. Body compartment estimates

Food/Nutrition related history

Food and nutrient intake, medication/herbal supplement intake, knowledge, beliefs, food and supplies availability, physical activity, nutrition quality of life

Biochemical data, medical tests and procedures

Lab data (e.g., electrolytes, glucose, serum levels of micros, blood proteins) and tests (e.g., gastric emptying time, resting metabolic rate)

Nutrition-focused physical findings

Physical appearance, bilateral muscle wasting, subcutaneous fat loss, fluid status, swallow function, appetite, and affect

Client History

- age, gender, education level, food security, and socioeconomic data
- previous medical history and testing that impacts nutritional status

comparative standards

reference standards to evaluate the overall impact of the nutrition intervention on the client's nutrition diagnosis and health outcomes

PES statement

problem related to etiology as evidenced by signs/symptoms

intervention should have

1. nutrition prescription = exact recommendations based on evidence
2. goals = measurable; lose 1 lb per week, return BG to normal in 3 weeks
3. intervention = counseling, education how to make food, etc

what should monitoring/evaluation have

1. monitor = energy intake; evaluate via 24 hour recall
2. monitor = weight gain; evaluate wt every 2 weeks

adjusted IBW

[(100 - % amputation)/100] x IBW for original height

IBW

1. females = 100 lbs + 5 lbs(additional in) *if under 5', subtract 2.5-5lbs for every in.
2. males = 106 lbs + 6 lbs(additional in)
3. + - 10% for large or small body frame

%IBW

current wt/IBW x 100

%UBW

current wt/UBW x 100

% weight change

usual wt - current wt/usual wt x 100

BMI

kg/m^2 or 703.1 x (lbs/in^2)

nitrogen balance

1. nitrogen intake - output
2. g protein in 24 hrs/6.25 = intake
3. g UUN in 24 hrs + 4 = output

BMI categories adult

1. underweight =

BMI categories children

1. underweight =

estimating protein needs can be based off of:

1. body weight; 0.8 g/kg
2. energy intake; AMDR = 10-35% adults
3. nitrogen balance studies

AMDR for protein

1. adults = 10-35%
2. infants 1-3 y = 5-20%
3. 4-18 y = 10-30%

estimating calorie needs

factor method, body wt.,

estimating fluid needs

age, body weight, kcals consumed, fluid balance method, AI for water

AI for water

1. females = 2.7 L (11 cups)
2. males = 3.7 L (15.5 cups)

fluid balance method

urine output + 500 mL

fluid based on chronological age

1. 16-30 (active) = 40 mL/kg
2. 20-55 = 35 mL/kg
3. 55-75 = 30 mL/kg
4. >75 = 25 mL/kg

fluid needs based on kcal consumed

1 mL/kcal; infants need 1.5 mL/kcal

fluid needs based on body weight

30-35 mL/kg

Holliday-Segar method

1.

factor (rule of thumb) method

1. to lose = 20-25 kcal/kg
2. to maintain = 25-30 kcal/kg
3. to gain = 35-40 kcal/kg

drug-nutrient interactions (DNIs)

an interaction resulting from a physical, chemical, physiologic, or pathophysiologic relationship between a drug and a nutrient, multiple nutrients, food in general, or nutrition status

An interaction is considered to have clinical significance if it

alters therapeutic drug response or compromises nutrition status resulting in some degree of malnutrition

Clinical consequences of DNI's are related to alterations in the:

1. disposition of a drug or nutrient = absorption, distribution, and elimination; metabolism and excretion
2. the effect of the drug or nutrient = action of the drug or nutrient at the cellular level

Food-drug interaction (FDI)

Broad term referring to any interaction between a drug and food

5 Classifications of DNIs; Key ways drugs react in the body

1. Nutrition status impacts the drug
2. Food or Food component impacts the drug
3. Specific nutrient/dietary supplement impacts the drug (** these three are when nutrition or nutrients are impacting the drug)
4. The drug impacts nutrition status
5. The drug impacts a specific nutrient
(these two are when the drug is impacting nutrition status or nutrient)

mechanisms of DNIs

pharmaceutical, pharmacodynamic, pharmacokinetic

pharmaceutical

1. physical and chemical properties of drug molecules; 2. design and evaluation of drug delivery systems/dosage forms (PO, enteral, parenteral all make a difference)
3. monitoring of drug disposition (absorption, distribution, metabolism, excretion)
4. compatibility issues
5. solubility issues
6. stability issues

Pharmacodynamic:

1. Refers to the influence of the administered drug/nutrient on the body, organ, or tissues
2. Can be antagonistic, or can be additive

Antagonistic ex

warfarin (blood thinner) and vitamin K (blood clotter)

additive ex

warfarin (blood thinner) and vitamin E (blood thinner)

pharmacokinetic

1. the influence of the body on an administered drug
2. defined by changes in relevant parameters (such as bioavailability, clearance (mL/min or L/hr), volume of distribution (L/kg)
3. transporters and enzymes
4. Drugs and nutrients can impact pathways for transporters and enzymes; positive or negative

transporters are

proteins embedded in cell membranes allowing influx to or efflux from the cell

how drugs react in the body

1. Drug dissolves into a useable form (stomach)
2. Drug is absorbed into blood and transported to site of action
3. Body responds to drug and drug performs its function
4. Drug is excreted from body by kidneys, liver, or both

Nutritional status can influence

drug metabolism (PEM, obesity, micronutrient deficiency)

________________________ and ________________ are parameters most likely influenced by malnutrition

drug distribution, clearance

malnutrition influence to drug distribution example

low albumin causes less of nutrient to be bound to protein and more towards physiological process

obesity and drug response

fat-soluble drugs can accumulate in adipose tissue; prolonged clearance; increased toxicity; obesity decreases concentrations of other drugs

calculating dosages for obese patients

use estimates of LBM

More research is needed to determine dosing for __________________________________________________ and __________________________________

obese patients with poor nutritional status AND patients w/ simply poor nutrition status

oral drug administered with a meal

may influence the rate and/or extent of drug absorption

mechanisms of poor absorption when drug and meal are intaken together

1. Presence and type of food can alter gastric emptying
2. Chelation btwn some medicines and divalent (Mg2+, Ca2+, Zn2+, Fe2+)or trivalent (Al3+, Fe3+) cations decreases drug absorption; nutrients and drugs can bind together and neither are then absorbed

adsorption

1. the adhesion or a food or food component that decreases drug absorption
2. food components which can adsorb are fiber, phytates, oxalates

GI pH influence on eating food and drugs at the same time

some drugs need an acidic pH for best absorption

dietary protein and protein supplements

increase drug metabolism and, therefore, increase drug clearance before it's properly absorbed

grapefruit juice

contains substances which block cytochrome P450 and 1A2 in the intestines; increases oral drug bioavailability; increases drug accumulation; lasts up to 72 hrs

cytochrome P450

enzyme system responsible for metabolizing a wide range of substances

Medications that should not be taken with grapefruit juice

1. Cyclosporine = antirejection (immunosuppressant after organ transplant)
2. Buspar = antianxiety
3. Quinine = antimalarial
4. Halcion = insomnia
5. Statins = treat hyperlipidemia
6. Nifedipine = antihypertensive
7. Amiodarone = antiarrythmia

have similar effects on drugs as grapefruit

Seville oranges, pomelos, and tangelos

alcohol

affects body processes; interacts w/ drugs and influences types of medicines affecting brain and NS (like antidepressants)

as a general rule, medicines should never be taken with

alcohol

licorice contains

glycyrrhizic acid

licorice (glycyrrhizin, glycyrrhizic acid) can

1. increase cortisol levels
2. increase Na+ resorption by the kidneys
3. increase H2O retention
4. increase bp
5. increase K+ excretion
6. therefore, Natural licorice antagonizes action of diuretics and antihypertensive meds

natural licorice

antagonizes action of diuretics and antihypertensive meds

Medicines in which natural licorice should be avoided:

1. ACE Inhibitors (antihypertensive meds; usually have a -pril in the name)
2. Accupril
3. Altace
4. Capoten
5. Lotensin
6. Monopril
7. Prinivil
8. Vasotec
9. Zestril

Drugs can influence food intake through effects on GI tract:

1. Dysgeusia = altered taste
2. Hypogeusia = diminished taste
3. Dysosmia = altered smell
4. Hyposmia = diminished smell

Drugs which may cause dysgeusia:

1. Captopril (antihypertensive)
2. Cisplatin (antineoplastic agent for cancer)
3. Phenytoin (anticonvulsant)

drugs that chelate zinc and alter taste

Long term abt (Cipro, tetracycline = antibiotics)

enters saliva and causes a bitter taste

Biaxin (antibiotic)

can cause a metallic taste

Lunesta (insomnia)

medication that can alter taste

Glipizide (antihyperglycemic)

mucositis, stomatitis, glossitis, or cheilitis

inflammation of mucous membranes, mouth, tongue, lips; can decrease po intake

drugs that cause mucositis, stomatitis, glossitis, or cheilitis

antineoplastics = interleukin-2, and carboplatin

drugs that cause xerostomia

1. tricyclic antidepressants
2. antihistamines
3. antispasmodics (reduce muscle spasms in stomach, intestines, bladder)
4. antiemetics/antivertigo

xerostomia

dry mouth; alters taste, can cause dental caries, gum disease, stomatitis, glossitis

drugs that cause gastritis, ulceration, dyspepsia

1. NSAIDS = nonsteroidal anti-inflammatory drugs, aspirin, ibuprofen, Naproxen
2. Prozac, Zoloft, Paxil = antidepressants

gastritis

inflammation of gastric mucosa or stomach

dyspepsia

indigestion

ulceration

A shallow crater in which the skin or the mucous membrane is missing

drugs that can cause N/V

antineoplastic agents

drugs that slow peristalsis, causing constipation

1. Narcotics = codeine, morphine (opiod-induced constipation)
2. antipsychotics
3. antidepressants
4. antihistamines

why antibiotics can cause D

over long period of time, good bacteria destroyed makes diarrhea

drugs that can cause diarrhea

1. Antibiotics
2. weight loss meds
3. oral hypoglycemic agents
4. antineoplastic agents

why weight loss meds can cause D

lipase inhibitors; fat malabsorption is how they decrease wt

oral hypoglycemic agents

fermentation of undigested carbs; causes osmotic diarrhea; undigested carbs didn't break down and now draw water into large intestine

antineoplastic agents

destroy good and bad cells, diarrhea

drugs that can cause anorexia

1. Antineoplastic agents
2. antibiotics
3. bronchodilators
4. stimulants (ADHD meds)
5. appetite suppressants

drugs that can stimulate appetite and cause weight gain

1. antipsychotics
2. tricyclic antidepressants/other antidepressants
3. anticonvulsants
4. hormones (Oxandrin, megestrol acetate--Megace)
5. dronabinol (Marinol)
6. cyproheptadine (antihistamine) (Periactin)

when would appetite stimulants be ordered?

for anorexia, malnutrition

drugs that may increase glucose production/cause hyperglycemia

1. Corticosteroids (can cause steroid-induced diabetes), 2. antipsychotics
3. diuretics
4. niacin (nicotinic acid)
5. caffeine

Some drugs can cause hypoglycemia

1. Antidiabetic agents
2. quinine (antimalarial drug)
3. alcohol

drugs that decrease GI transit time and can cause steatorrhea/loss of fat soluble vits.

1. cathartic agents = speed up defecation
2. magnesium citrate = cleans bowel before surgery or bowel procedure
3. laxatives = softens stool

_____________ change pH of the stomach and cause chelation with minerals and decrease absorption

antacids

Higher stomach pH (alkaline)

decreases absorption of Fe, Ca, Zn, and Mg

Competitive binding and altered resorption causes some drugs to induce

nutrient excretion

drugs and nutrients that competitively bind and have altered absorption/excretion

1. D-Penicillamine
2. Diuretics (administered for hypertension) = can be K-sparing or not
3. Antineoplastic agents (Cisplatin) = decrease Mg and L levels
4. Antiepileptic meds (antiseizure) = increase metabolism of vit. D and therefore decrease bone health; could alter folate metabolism and lead to megaloblastic anemia

greatest risk for DNIs

1. Elderly
2. Malnourished
3. Polypharmacy
4. Patients with existing GI diseases
5. Patients on nutrition support
6. Obese
7. Critically ill
8. Transplant patients
9. Patients with chronic disease
****these last three are typically also polypharmacy and malnourished

Steps to Limit/Prevent DNIs

1. Identification of potential or existing DNIs from a thorough assessment of patient's history and physical examination.
2. How intervention will be done if needed and by who
2. Patient education is key
3. A policy/procedure describing how the DNI instructions will be provided must be written