Clinical Nutrition Basics

Clinical Nutrition Basics for RD Exam

What are the 5 steps in the Nutrition Care model?

Assessment

Diagnosis

Intervention

Monitoring

Evaluation

ADIME

Before starting NCP what needs to happen first?

A screening by any member of the healthcare team to find risk of malnutrition

Per Joint Commision, they have 24 hours from admission to be screened

Nutrition screening vs assessment?

Screening: assess for risk of malnutrition by any healthcare team member

Assessment: Complete assessment of pt by an RD

SGA Tool

Subjective global assessment

Looks at med hx, physical exam, intake, wt changes, GI s/s, edema

MNA screening tool

Mini nutritional assessment

For pt >65 yr old (not not assess wt changes)

(My Nana Aged >65yr)

NSI

Nutrition screening initiative

A determine checklist

Used for the elderly

GNRI

geriatric nutrition risk index

albumin and wt changes

Used for geriatrics

MST

malnutrition screening tool

wt loss and poor intake - for acute hospitalized patients

MUST

malnutrition universal screening tool

Intake, weight changes, and BMI

NRS

Nutrition risk screening

wt loss and poor intake - for hospitalized med/surg pts over 70 years

What are the ABCDEs?

anthropometrics

biochemical data (labs)

clinical history (PMH)

Diet hx (24 hr recall, food journal)

Exam (NFPEs)

What are the 3 domains of diagnosis in NCP?

(ICB= I cook bread)

Intake (always address first)

Clinical (chewing/swallowing difficulty, altered GI function, etc)

Behavioral-Environmental (nutrition knowledge deficit, undesirable food choices)

What occurs during the intervention?

Must resolve the etiology from the nutrition diagnosis (PES Statement)

Nutrition education, EN/PN nutrition, med adjustment recs, referrals

What occurs during monitoring and evaluation?

What will be monitored and evaluated next time pt is seen; foundation for next assessment when cycle restarts

Ex. PO, GI tolerance, BM, skin integrity, chewing/swallowing ability

Waist circumference?

Risk for chronic disease

>40” in males

>35” in females

Waist-to-hip ratio

Risk for heart disease

>1 in males

>0.8 in females

Waist/Hip=W-to-H ratio

Female IBW

100lb for first 5 ft + 5lb for each additional inch

Male IBW

106lb for first 5 ft +6lb for each additional inch

How do amputations affect IBW?

Amputations decrease IBW

(100-% amputation)/100

% for amputations

Entire leg - 16%

BKA - 6%

Entire arm - 5%

Forearm w/ hand - 2.3%

IBW with Spinal Cord Injury (SCI)

Quadriplegia = - 10-15% from IBW

Paraplegia = - 5-10% from IBW

% weight change calculation?

(UBW- ABW)/UBW x 100

% Wt change at risk criteria

>2% in 1 week

>5% in 1 month

>7.5% in 3 months

>10% in 6 months

>20% in 1 year

Protein Balance/Urine Urea Nutrition (UUN)

Tells negative/positive nitrogen balance

How to calculate protein balance?

(g PRO per day/ 6.25) - (Urine urea nitrogen +4)

If given total urinary nitrogen do (TUN +2)

What is Acid/base balance?

Blood pH always needs to be in balance for optimal health

Optimal range: 7.35-7.45 pH

What is the pH for acidosis?

<7.35 pH

What is the pH for alkalosis?

>7.45 pH

What 2 organs help ensure blood pH is always maintained?

The lungs (respiratory) and kidneys (metabolic)

What do the lungs do for acid/base balance?

Control supply of carbonic acid (H2CO3) which is acidic

Hyperventilation = losing carbonic acid (respiratory alkalosis)

Hypoventilation = Retain carbonic acid (respiratory acidosis)

Optimal range for H2CO3 (carbonic acid)?

35-45

What do the kidneys do for acid/base balance?

Control our supply of bicarbonate (HCO3) which is alkaline

Bicarb retention → Metabolic alkalosis

Bicard excretion → Metabolic acidosis

What is the optimal range for HCO3 (bicarbonate)

24-28

Cause and compensatory method for respiratory acidosis?

Cause- hypoventilation from emphysema in lungs

Compensatory- Kidneys retain bicarbonate to increase pH

Carbonic acid above 45

Cause and compensatory method for respiratory alkalosis?

Cause- hyperventilation from anxiety, heavy exercise

Compensatory- Kidneys excrete excess bicarb to decrease pH

carbonic acid below 35

Cause and compensatory method for metabolic alkalosis?

Cause- Vomiting (losing acid), diuretics (losing acid)

Compensatory- Lungs hypoventilate to retain carbonic acid and decrease pH

Bicarb above 28

Cause and compensatory method for metabolic acidosis?

Cause- renal insufficiency, diarrhea, DKA, or starvation (increased acid from ketones)

Compensatory- Lungs hyperventilate to get rid of carbonic acid and increase pH

Bicarb below 24

Extracellular electrolytes

outside of cells

Na, Ca, Cl, Bicarbonate

Intracellular electrolytes

Inside cells

K, Magnesium, Phos (REFEEDING LABS)

Normal lab range for Sodium

135-145 mEq/L

Normal lab range for Potassium

3.5-5 mEq/L

Normal lab range for Chloride

96-106 mEq/L

Normal lab range for magnesium

1.5-2.5 mEq

Normal lab range for Calcium

9-11 mg/dL

Normal lab range for phosphorus

3-4.5 mg/dL

Albumin

Protein made in liver

Decreases during inflammation and with increased CRP

High levels can be due to dehydration

Lab range: 3.5-5

Transferrin

Iron transported

Increases when iron is low

Lab value: >200

Prealbumin

Also increases during inflammation

Short half life

Lab value: 16-40 (PAB)

RBP (retinol binding protein)

Transports retinol

shortest half life

Lab value: 3-6

Hemoglobin

Protein in RBCs that transports oxygen to tissues (contains iron)

Lab values:

Males:14-18

Females: 12-16

Pregnant: 11+

Infants: 10+

Hematocrit

% of your blood that is made up of RBCs

Lab values:

Male: 42-52%

Females: 36-48%

Pregnant: 33%

Newborn: 44-64%

Ferritin

Iron storage

Lab values

Male: 10-150

Females: 12-300

BUN

Blood urea nitrogen

Amount of urea in blood at a given time; related to PRO intake

Lab value: 10-20

Creatinine

Byproduct of muscle breakdown that leaves the body through urine; estimates muscle loss

Elevated BUN and CR is related to renal issues

Lab value: 

Male: 0.6-1.2

Female: 0.5-1.1

Total lymphocyte count (TLC)

amount of WBCs in body; too much may mean infection

May decrease in state of malnutrition

lab value: >2700

PT (prothrombin time)

amount of time to form a blood clot

blood thinners are trying to increase time

11-12.5 seconds

Adderall + Ritalin (dextroamphetamine and methylphenidate) for ADHD

Appetite suppressant, anorexia, nausea, wt loss

Oral contraceptives

decreases folate, vitamin b6, and vitamin C

Folate is necessary for pregnancy

Loop diuretics (furosemide, lasix, bumex)

decreases calcium, sodium, magnesium, thiamine, potassium

Thiazide diuretics (hydrochlorothiazide)

Decrease magnesium and potassium, increase calcium

Methotrexate (immune suppressor for cancer)

Decreases folate, need to take with folate

Methotrexate = folate

Statins (lipitor, zocor) drug/nutrient interactions

never with grapefruit or grapefruit juice

MAOIs (antidepressents)

avoid with high tyramine foods- can increase BP

Tyramine foods: aged, fermented, dried, pickled, smoked, spoiled foods

Focus on fresh foods!

Lithium carbonate (azilect, zelapar/antidepressant)

Increases appetite

required a balanced sodium and caffeine diet

Anticoagulants (warfarin/coumadin)

maintain consistent vit K intake

Isoniazid (TB medication)

Decreased b6 levels, interferes with vit D, calcium, phosphorus metabolism

Don’t take with food

Levodopa (parkinson’s meds)

Vitamin B6 and PRO decrease effect

Rec: Take in morning with low PRO meal and have most PRO at night

Comfrey use and interaction

Soothes nerves (makes you feel comfortable)

Can cause irreversible liver failure

Kava use and interaction

For anxiety (makes you less crazy)

May cause liver failure

valerian root use and interaction

soothes nerves (gives valuable rest)

Avoid in patients with liver disease

Ephedra use and interaction

Weight loss

Rapid heart rate, HA

Black cohosh use and interaction

Menopause

May cause blood clots

Echinacea use and interaction

Immunity

Avoid taking over 2 months

Licorice

For ulcers

Avoid with diuretics and hypertension meds

Saw palmetto

For the prostrate

Avoid with diuretics

St. John’s wort use and interaction

Avoid with warfarin, Coumadin, HTN meds, birth control, statins, MAOIs

Garlic use and interaction

Decrease cholesterol

Don’t use with warfarin

Ginger use and interaction

Decrease nausea

Don’t take with warfarin

Ginseng use and interaction

Immunity

Don’t take with warfarin

Ginkgo Biloba use and interaction

Decrease BP

Don’t take with warfarin or anticonvulsants (seizure meds for brain)