RD Exam: MNT

NCP

Nutrition Care Process. A standardized, consistent structure and framework used to provide nutrition care. This is different from standardized care, which infers that all patients receive the same care.

NCP Steps

ADIME

1. Assess, 2. Diagnose, 3. Intervention, 4. Monitor & Evaluate

Critical thinking

integrates facts, informed opinions, active listening, and observations. It is a reasoning process where ideas are produced and evaluated. It includes the ability to conceptualize, think rationally, think creatively, be inquiring, and think autonomously.

Nutrition screening

use of preliminary nutrition assessment techniques to identify people who are malnourished or who are at risk for malnutrition.

All health care team members can participate.

Brief 5-10 minutes.

Nutrition screening review

client's history, lab results, weight, physical signs

For nutrition screening to be effective

the mechanism must be accurate based on: specificity (can it ID patients without a condition), sensitivity (can it ID those who have the condition.

Mechanism must be effective as related to the chances that positive health outcomes will be achieved with the intervention.

If no emerging nutrition problem exists

document that discharge from nutrition care is appropriate

The Joint Commission and nutrition screening

nutrition risk identified in hospitalized patient within 24 hours of admission, but does not mandate a method of screening

Nutrition screening includes

1. Subjective Goal Assessment

2. Mini Nutritional Assessment

3. Nutrition Screening Initiative

Subjective Goal Assessment

History, intake, GI symptoms, functional capacity, physical appearance, edema, weight change

NO lab values, just talking

Mini Nutritional Assessment

Evaluates independence, medication therapy, number of full meals consumed each day, protein intake, fruits and vegetables, fluid, mode of feeding.

Often done in older population.

Nutrition Screening Initiative

Elderly

Nutrition assessment of individuals

Initiated by referral/screening of individuals or groups for nutritional risk factors.

Assessment makes comparisons between data collected and reliable standards.

Assessment is an on-going, dynamic process that involves continual reassessment and analysis of patient/client/group needs.

Assessment provides the basis for nutrition diagnosis.

Critical thinking skills needed in nutrition assessment include

1. Observe verbal/nonverbal cues that can guide effective interviewing methods

2. Determine appropriate data to collect

3. Select tools and procedures and apply in valid, reliable ways

4. Distinguish relevant from irrelevant, and important from unimportant data

5. Validate, organize and categorize the data

Nutrition assessment component

1. Review: review data for factors that affect nutritional and health status

2. Cluster: assessment data clustered for comparison with characteristics of a suspected diagnosis; food and nutrition related history, anthropometrics, lab/medical tests (biochemical), nutrition-focused physical findings, client history

3. These indicators are compared to identified standards and criteria for interpretation and decision-making

Indicators in nutrition assessment

are clearly defined markers that can be observed and measured.

Also used to monitor and evaluate the progress towards nutrition outcomes

What indicators are compared against

nutrition care criteria

Documentation in nutrition assessment

date and time, pertinent data and comparison with standards, patient's perceptions, values and motivation related to problem; changes in patient's level of understanding, behaviors, outcomes; reason for discharge

Dietary intake assessment

1. Diet history

2. Food recall

3. 24 hour recall

4. Food frequency lists

Diet history

present patterns of eating. Do not ask leading questions.

Food record

exact record of everything eaten in a specific period of time

24 hour recall

mental recall of everything eaten in previous 24 hours.

Quick tool to estimate a sample daily intake.

Clinical setting.

Food frequency lists

how often an item is consumed. Community setting. QUICK way to determine intakes of LARGE NUMBERS of people.

People do this by themselves.

Pertinent medical and family history

provides insight into nutrition-related problems

Physical findings

anthropometrics (body structure)

desireable body weight

Medium frame women

100 lbs for first 5 feet, add 5 lbs for each additional inch, subtract 5 lbs for each inch below

Small frame women

subtract 10% from Hamwi method

Large frame women

add 10% to Hawmi method

Medium frame men

106 lbs for first 5 feet, add 6 lbs for each additional inch, subtract 6 lbs for each inch below 5 feet

Small frame men

subtract 10% from Hamwi method

Large frame men

add 10% to Hamwi method

Amputations

entire leg: 16% of body weight

lower leg: with foot 6% of body weight

entire arm: 5% of body weight

forearm with hand: 2.3% of body weight

Amputation Estimated IBW

Estimated IBW = (100-%amputation)/100 x IBW for original body weight

Amputation % weight change

% weight change stresses significance of weight change

Used to assess potential nutrition risk**

[(usual weight - actual weight)/usual weight] x 100

Triceps skinfold thickness (TSF)

1. measures body fat reserves; measures calorie reserves

2. standard, male: 12.5 mm, female: 16.5 mm

Arm muscle area (AMA)

1. measure SKELETAL muscle mass (SOMATIC protein)

2. to determine: use triceps skinfold thickness and arm circumference

3. standard: male 25.3 cm; female 23.2 cm

4. important to measure GROWING CHILDREN

BMI body mass index, Quetelet Index

compares weight to height

1. weight in kg divided by height squared in meters; or weight in pounds divided by height in inches squared x 703

2. healthy adult 18.5 - 24.9; healthy for most elderly 24-29

3. BMI for age charts starting at age 2 when accurate stature can be obtained

Waist circumference

>40 males, >35 females is independent risk factor for disease when out of proportion to total body fat (with BMI of 25-34.9)

Measured in inches

Waist/hip ratio (WHR)

1. differentiates between android (apple) and gynoid (pear) obesity

2. WHR of 1.0 or greater in men, 0.8 or greater in women is indicative of android obesity and an increased risk for obesity-related diseases (diabetes, hypertension)

Nutrition focused physical exam

Hair

Skin

Eyes

Lips

Tongue

Gums

Teeth

Skin

Nails

Hair

Assessment: thin, sparse, dull, dry, brittle, easily pluckable

Considerations: vitamin C, protein deficiency

Eyes

Assessment: pale, dry, poor vision

Considerations: vitamin A, zinc or riboflavin deficiencies

Lips

Assessment: swollen, red, dry, cracked

Considerations: riboflavin, pyridoxine, niacin deficiencies

Tongue

Assessment: smooth, slick, purple, white coating

Considerations: vitamin or iron deficiencies

Gums

Assessment: sore, red, swollen, bleeding

Considerations: vitamin C deficiency

Teeth

Assessment: missing, loose, loss of enamel

Considerations: calcium deficiency, poor intake

Skin

Assessment: pale, dry, scaly

Considerations: iron, folic acid, zinc deficiency

Nails

Assessment: brittle, thin, spoon-shaped

Considerations: iron or protein deficiency

Dull, dry, brittle hair, what vitamin deficiency?

vitamin C

Serum albumin

3.5-5.0 g/dL

VISCERAL PROTEIN (BLOOD AND ORGANS)

Maintains colloidal osmotic pressure

Hypoalbuminemia associated with edema, surgery

LEVELS ABOVE NORMAL RANGE LIKELY DUE TO DEHYDRATION

LONG HALF-LIFE, DOES NOT REFLECT CURRENT PROTEIN INTAKE

Serum transferrin

>200 mg/dl

Visceral protein

Serum level controlled by iron storage pool

Rises with iron deficiency

Can be determined from TIBC (total iron binding capacity)

Transthyretin (TTHY) Prealbumin (PAB)

16-40 mg/dl

A SHORT HALF-LIFE; PICKS UP CHANGES IN PROTEIN STATUS QUICKLY

During inflammation, live synthesizes CRP at expense of PAB

Retinol Binding Protein (RBP)

3-6 mg/dl

Circulates with prealbumin; shortest half life (12 hours)

Binds and transports retinol

Hematocrit (Hct)

Men: 42-52%

Women: 35-47%

Pregnant women: 33%

Volume of packed cells in whole blood

Hemoglobin (Hgb)

Men: 14-17 g/dl

Women: 12-15 g/dl

Pregnant: < or equal to 11 g/dl

Iron-containing pigment of red blood cells

Erythrocytes are produced in bone marrow

Serum ferritin

Men: 12-300 ng/ml

Women: 10-150 ng/ml

Indicates size of iron storage pool

Serum creatinine

0.6-1.4 mg/dl

Related to muscle mass; measures somatic protein.

May indicated renal disease, muscle wastage.

Secreted by muscle, measure of somatic protein but helps identify kidney disease.

Creatinine Height Index (CHI)

80% normal

Ratio of creatinine excreted/24 hours to height

Estimates lean body mass - somatic protein

60-80% mild muscle depletion

Blood urea nitrogen (BUN)

10-20 mg/dl**

Related to protein intake

Indicator of renal disease

BUN:CREATININE RATIO NORMAL = 10-15:1

Urinary creatinine clearance

115 +/- 20 ml/minute

Measures GFR - glomerular filtration rate, renal function

Estimate includes body surface area (height and weight)

Total lymphocyte count (TLC)

>2700 cells/cu mm**

Measures immunocompetency

Moderate depletion: 900-1800

Severe depletion:

C-reactive protein (CRP)

Marker of acute inflammatory stress, INFLAMMATION NOT NUTRITION

AS IT DECLINES IT INDICATES WHEN NUTRITIONAL THERAPY WOULD BE BENEFICIAL

When elevated CRP decreases, PAB increases

Free erythrocyte protoporphyin (FEP)

Direct measure of toxic effects of lead on heme synthesis.

INCREASED IN LEAD POISONING.

Lead depletes iron leading to anemia, and displaces calcium in the bone leading to a zinc deficiency

Prothrombin time (PT)

11.0-12.5 seconds**, 85-100% of normal

anticoagulants prolong prothrombin time

evaluates clotting adequacy; change in vitamin K intake will alter rate

Hair analysis

not for nutritional assessment; useful in measuring intake of toxic metals

Activity factors and BEE

Sedentary: BEE x 1.2

Active: BEE x 1.3

Stressed: BEE x 1.5

EER for age

For each year below 30, add 7 kcal/day for women and 10 kcal/day for men.

For each year above 30, subtract 7 kcal/day for women, and 10 kcal/day for men.

Megestrol acetate (Megace)

appetite stimulant

Megace...Meg stuffs her face

Dextroamphetamine

appetite suppressant, anorexia, nausea, weight loss

"MethAMPHETAMINE causes anorexia"

Orlistat

decrease fat absorption by binding lipase; vitamin/mineral supplement "Orlistat decreases the fat (aborsption!)"

Marinol

appetite stimulant "Mari likes to eat!"

Methylphenidate (Ritalin)

anorexia, weight loss, nausea

Miranda Lambert song Ritalin, mother was rail thin

"Methylphenidate makes you too skinny to date"

Statins (HMG CoA reductase inhibitors)

decreased LDL, TG; increase HDL

Cholesterol management medication

Chemotherapy

malabsorption

Mineral oil, cholestyramine

decrease absorption of fat, fat-soluble vitamins

Glucocorticoids, antibiotics

protein deficits

Oral contraceptives

decrease folate, B6, C

"Free Birth Control at 6."

Loop diuretic

deplete thiamin, potassium, magnesium, calcium, sodium

"Tonks, Potter, Crookshanks, Malfoy and Snape lost their Froot LOOPS."

Thiazide diuretics

decrease potassium and magnesium, absorb calcium

Antibiotics

decrease vitamin K

Steroids

decrease bone growth, CHO intolerance

Methotrexate

decrease folate

ate-ate

Lithium carbonate (antidepressant)

Increase appetite, weight gain

Maintain consistent sodium and caffeine intake to stabilize levels

If sodium or caffeine are restricted, lithium excretion decreases, leading to toxicity

Should not be on low sodium diet when taking this "Lisa Car balance caffeine and sodium"

Anticoagulant (warfarin sodium)

antagonizes vitamin K (consistent intake essential)

Avoid Ginkgo biloba extract (GBE), garlic, ginger (may increase bleeding)

Avoid high dose of vitamin A or E

Propofol

Administered in oil

Fat calories 1.1 kcal/ml

Check TG

Intubated, ventilated nutrition support patient

Phenobarbital

decreased folic acid, vitamins B12, D, K, B6

Isoniazid (treats TB)

depletes pyridoxine, peripheral neuropathy, don't take with food, interferes with vitamin D, calcium, phosphorus

Cyclosporine

Immunosuppressant. Causes hyperlipidemia, hyperglycemia, hyperkalemia, hypertension "Cyclosporine - hyper"

Elavil (antidepressant)

sedative effect, weight gain, increased appetite "evil"

Vitamin B6 and protein

decrease effectiveness of L-dopa (levodopa) which controls symptoms of Parkinson's disease

Take drug in the morning with LIMITED PROTEIN (

Calcium

binds tetracycline

Tyramine

hypertension if take with MAOI (monoamine oxidase inhibitor)

1. Eliminate dopamine and restrict tyramine (monoamines). MAO inhibitors interact releasing norepinephrine which elevates blood pressure. Restrict aged, fermented, dried, pickled, smoked, spoiled foods.

2. Avoid hard, aged cheese (cheddar, Swiss), sauerkraut, some sausages, luncheon meats, tofu, miso, Chianti wine. Limit sour cream, yogurt, buttermilk

3. OK: cottage cheese, cream cheese. Good advice: buy, cook, eat fresh foods

Curcumin (turmeric)

may reduce inflammation, antioxidant, in curry powder

Yohimbe

elevates blood pressure "Yo him be having high blood pressure"

How many kcals does propofol provide?

1.1 kcal/ml

How to teach depends on

the NEEDS AND READINESS of the learner

Motivation level will affect

the attention span

High motivation

Keen interest

Presence is voluntary

Has high expectations as to applicability of subject to one's life

Low motivation

Mandatory attendance

Little interest in topic

May feel there are more important things he should do

Educational level

Not always related to amount of formal education