Nutrition Care for Individuals and Groups: In-Depth Study of Nutrition Diagnosis, Planning & Intervention, and Monitoring & Evaluation (Domain II)

What's the difference between a nutrition diagnosis and medical diagnosis?

Nutrition diagnosis:

Identification and labeling that describes an actual occurrence, risk of, or potential for, developing a nutritional problem that dietetics professionals are responsible for treating independently.

CHANGES AS THE PT'S RESPONSE CHANGES.

i.e. Undesirable overwt status

Medical diagnosis:

A disease or pathology that can be treated or prevented.

IT DOES NOT CHANGE AS LONG AS THE CONDITION EXISTS.

i.e. Type 1 DM

What's a good tip for choosing which diagnoses to prioritize if you have diagnoses from two domains?

Consider Intake Diagnoses as more specific to the nutrition professional.

What's the difference b/t Altered GI Function and Impaired Nutrient Utilization?

Altered GI Function:

Looks at problems INSIDE THE GI TRACT including EXOCRINE fxns of the liver and pancrease, with changes in digestion, absorption, and/or elimination.

Potential indicators: abnormal digestive enzyme and fecal fat studies, abdominal distention, n/v/d, steatorrhea, constipation, malabsorption, IBS, diverticulitis.

Impaired Nutrient Utilization:

Refers to problems with the METABOLISM OF NUTRIENTS once they have ENTERED THE CIRCULATORY SYSTEM. This includes the ENDOCRINE fxns of the pancrease, liver, pituitary, and parathyroid.

Potential indicators: thin, wasted appearance, abnormal liver fxn tests, pituitary hormones, hypoglycemia, hyperglycemia, renal failure, liver failure, inborn errors of metabolism.

Discharge plan begins on Day _____ of hospital stay.

Day one

What is the main cause of ulcers?

Helicobacter pylori bacteria (H. Pylori bacteria)

Dietary recommendations for ulcers:

Whatever doesn't aggravate the condition. Diet as tolerated. Avoid late night snacks.

Dietary recommendations for Hiatal hernia:

Small amounts at a time, avoid late night snacks.

Dumping Syndrome may result after a ______.

A gastrectomy (Billroth I, II)

Dietary recommendations for Dumping Syndrome:

Small, frequent, dry feedings. Fluids before or after meals (not during) to slow passage. restrict hypertonic concentrated sweets (simple sugars). Give 50-60% complex CHO, protein at each meal. Moderate fat. B12 injections may be needed. Lactose may be poorly tolerated d/t rapid transport.

Diet can relieve symptoms.

What is the difference b/t Tropical Sprue and Non-Tropical Sprue?

Tropical Sprue:

Bacterial, viral, parasitic infection.

Chronic GI disease, intestinal lesions, may also affect stomach.

May cause deficiencies of B12 and Folate.

Tx: antibiotics, high kcal, high protein, IM B12 and oral Folate supplements.

Non-Tropical Sprue:

Celiac disease, Gluten-induced enteropathy.

Gluten refers to storage proteins (prolamins: gliadin in wheat, secalin in rye, hordein in barley, avenin in oats).

Rxn to gliadin-affects jejunum and ileum (proximal intestine).

Tx: Need (gliadin-free) gluten-restricted diet. (corn and rice okay)

Dietary recommendations for Diverticulosis:

High fiber diet- increases volume and wt residues, provides rapid transit.

Diverticulosis: the presence of diverticula- small mucosal sacs that protrude through the intestinal wall d/t structural weakness. R/t constipation and lifelong intra-colonic pressures.

How does oat bran and soluble fibers decrease serum cholesterol?

By binding bile acids, converting more cholesterol into bile.

Examples of soluble fiber:

f/v, legumes, oats, barley, carrots, apples, citrus fruits, strawberries, bananas.

(soluble fiber attracts water and turns into gel in intestine)

Regional enteritis or Crohn's disease (an IBD) affects this part of the intestine leading to ______ deficiency.

Affects terminal ileium leading to B12 deficiency.

What are the major symptoms of Chronic Ulcerative Colitis (UC an IBD)?

Chronic bloody diarrhea, electrolyte (Na, K) disturbance.

Describe the lactose tolerance test:

Oral dose of lactose after a fast. If intolerant of lactose, blood glucose will rise

Diet recommendations for lactose intolerance:

Lactose-free; no animal milk or milk products, no whey.

Yogurt and small amounts of aged cheese may be tolerated.

Kids 6 and younger should have juice restricted to ____oz/day

4 oz

Diet recommendations for chronic nonspecific infantile diarrhea:

restrict or dilute fruit juices with high osmolar loads, such as apple or grape.

Dietary recommendations for adult diarrhea:

Foods/supplements that contain prebiotic components (pectin, fructose, oats, banana flakes), which favor friendly bacteria.

Probiotics- sources of bacteria used to reestablish bacterial gut flora.

Ileal resection affects the absorption of:

Most distal part of the small bowel.

Affects absorption of B12, intrinsic factor, and bile salts.

Nutritional care for ileal resection:

Limit fat (since bile salts are not available to emulsify fat), Use Medium Chain Triglycerides MCT (does not require bile salts, needs less intestinal surface area). Supplement parenteral B12, followed by monthly injections.

______ enzyme levels indicate tissue damage.

Elevated

In liver disease, enzymes levels are _______.

Elevated

________ is a major symptom of Acute Viral Hepatitis and influences the following dietary recommendations for hepatitis:

Anorexia.

Recommend small, frequent feedings.

(The difficulty in providing much nutritional support is that hepatitis pt's are often anorexic)

________ occurs when blood cannot leave the liver.

Ascites

Connective tissue overgrowth blocks blood flow out of liver into vena cava. The liver expands (can store a liter of extra blood). When storage capacity has been exceeded, pressure caused by increased blood volume forces fluid to sweat through the liver into the peritoneal cavity. This fluid is almost pure plasma with a high osmolar load, pulling more fluid in to dilute the load, leading to sodium and water retention (Ascites).

This leads to Portal Hypertension:

Connective tissue overgrowth in liver causes resistance to blood entering from portal vein.

(Blood can't enter liver-this eventually leads to esophageal varices)

Dietary recommendations for Cirrhosis:

High protein (.8-1.0 g/kg; in stress at least 1.5 g/kg)

High kcal (25-35 kcal/kg estimated dry wt or 1.2 to 1.5 X BEE)

Moderate to low fat (25-40% of calories, MCT if needed;

Long term thiamin deficiency can lead to this syndrome:

Wernicke-Korsakoff Syndrome

Dietary treatment for Hepatic Failure (ESLD)

1. If not comatose: moderate to high levels of protein (increase up to 1-1.5 g/kg as tolerate).

2. 30-35 kcal/kg; 30-35% kcal as fat with MCT if needed.

3. Low sodium if ascites; vitamin/mineral supplementation.

4. With encephalopathy: altered neurotransmitter theory: BCAA decrease (used by muscles for energy); AAA (aromatic AA's) increase because damaged liver is unable to clear them. ONE THERAPEUTIC APPROACH is to add BCAA (which adds calories and protein) and decrease AAA as an attempt to correct imbalance (also provides additional nitrogen to pt).

Gallbladder surgical tx and effect on bile:

Cholecystectomy (removal of gallbladder); bile now secreted from liver directly into intestine.

What is a common characteristic that leads to pancreatitis?

Premature activation of enzymes within pancreas leads to autodigestion (enzymes in pancreas digest the pancreas)

This type of nutrition therapy delivered to the ______may be tolerated with acute pancreatitis:

Elemental (pre-digested) enteral nutrition into the jejunum.

Recommended therapy for chronic pancreatitis:

PERT (Pancreatic Enzyme Replacement Therapy): Take pancreatic enzymes orally with meals and snacks to minimize fat malabsorption from lack of pancreatic lipase.

Recommended sodium restriction for HTN:

Recommended diet for HTN:

DASH (Dietary Approaches to Stop Hypertension)

WG's, f/v's, low fat dairy, poultry, fish moderate sodium, limit ETOH, decrease sweets, calcium to meet DRI (not through supplements)

Recommended diet for high cholesterol/ Atherosclerosis:

TLC (Therapeutic Lifestyle Change)

-- Up to 35% kcal from total fat (

Hormones involved in renal fxn:

Vasopressin (ADH)

--From hypothalamus (stored in pituitary)

--exerts pressor effect; elevates BP

--increases water reabsorption from distal and

collecting tubules.

--SIADH- syndrom of inappropriate antidiuretic

hormone (hyponatremia caused by

hemodilution, treated with fluid restriction)

Renin (Vasoconstrictor)

--Secreted by glomerulus when blood volume

decreases.

--Stimulates aldosterone to increase sodium

absoprtion and return blood pressure to normal.

Erythropoietin (EPO)

--Produced by kidney; stimulates bone marrow to

produce RBC

Urine tests and their results for renal disease:

Decreased glomerular filtration rate and creatinine clearance

BUN:creatinine ratio for kidney damage (for both reversible and dialysis)

"Pre-renal state":

BUN:Creatinine ratio of >20:1

BUN reabsorption is increased d/t acute kidney damage (may be reversible and may not require dialysis)

May need dialysis:

BUN:Creatinine ratio of

What does the Renal Solute Load measure?

Solutes excreted in 1 L urine. Mainly measures nitrogen (60%) and electrolytes (sodium).

Fluid recommendations for renal calculi (calcium stones)

1.5-2 L fluid/day needed to dilute urine (high fluid amount)

Symptoms of nephrosis/nephrotic syndrome

Albuminuria, edema, malnutrition, hyperlipidemia

Nutrition therapy for nephrosis/nephrotic syndrome

--Modest protein restriction: .8-1.0 g/kg; 50% from

HBV (high biological value). Excess protein will

be catabolized to urea and excreted.

--

Protein restrictions according to GFR/kidney disease stage

CKD Stage GFR Protein Restriction

1 >/=90 0.8-1.4 g pro/kg

2 60-89 0.8-1.4 g pro/kg

3 30-59 0.6-0.8 g pro/kg

4 ESRD 15-29 0.6-0.8 g pro/kg

Protein and kcal recommendations on hemodialysis:

1.2 g pro/kg standard body wt (SBW), at least 50% HBV

Protein and kcal recommendations on peritoneal dialysis

1.2-1.3 g pro/kg SBW or adjusted BW; >/= 50% HBV

Normal blood glucose levels:

70-100 mg/dL

2 hrs PG (post-prandial)

Diagnostic criteria for DM (Fasting plasma glucose (FPG), Glucose tolerance test (GTT), and HGA1c)

FPG: >/= 126 or

GTT: >/= 200 or

Symptoms of DM plus casual plasma glucose >/=200 mg/dL

HgA1c: >/= 6.5%

Glucose tolerance test curve shape for normal results:

Curve shape for diabetes:

Normal: sloped curve

DM: rounded

*See diagram on page II MNT 15 in Inman for details

What does glycosylated hemoglobin (HgA1c) measure and what is the goal% for those with DM?

% of hemoglobin that has glucose attached.

What is the goal for ALL diabetics?

Maintain normal blood glucose

(Average pre-prandial goal 70-130; peak post-prandial average

Risk factors for gestational DM

BMI >30, Hx of GDM

KNOW EXCHANGES (May be asked to calculate the grams of CHO, pro, and fat in a given meal)

CHO PRO Fat Kcal

CHO's (g)

Starch/bread 15 3 1 80

Fruit 15 60

Milk

-Fat free, low fat (1%) 12 8 0-3 100

-Reduced fat (2%) 12 8 5 120

-Whole 12 8 8 160

Sweets/other CHO 15 Varies Varies Varies

Non-starchy veg's 5 2 - 25

Proteins (g)

Lean - 7 2 45

Medium-fat - 7 5 75

High-fat - 7 8 100

Plant-based pro's Varies 7 Varies Varies

Fats (g) - - 5 45

ETOH (1 equivalent) Varies 100

Free foods:

Types of insulin, when to take it, and duration:

Rapid Acting: Aspart (Novolog), Lispro (Humalog)

-Take 5-15 min before eating

-Usual duration 4 hrs

Short Acting (regular):

-take 30-45 min before meal (burst of insulin to

cover the meal just about to be eaten).

-One unit covers 10-15 g CHO

-Duration 3-6 hrs

Intermediate-acting: NPH (Humulin, Novolin)

-Onset 2-4 hrs

-Duration 10-16 hrs

Long-acting: Glargine (Lantus), Determir (Levemir)

-onset 2-4 hrs

-Duration 20-24 hours

What is the Dawn Phenomenon (r/t BG)

Natural increase in early morning BG and insulin requirements d/t increased glucose production in liver after overnight fast.

What are two symptoms of acute ketoacidosis?

Dehydration d/t polyuria, increased pulse

What is the treatment for acute ketoacidosis?

Insulin, re-hydration

What is the treatment goal for postprandial or reactive hypoglycemia?

To prevent marked rise in BG that would stimulate more insulin

Dietary recommendations for Postprandial or reactive hypoglycemia:

Avoid simple sugars, 5-6 small meals/day, spread intake of CHO throughout the day, protein at RDA levels.

What's the difference b/t hyperthyroidism and hypothyroidism?

Hyperthyroidism:

-Excess secretion of thyroid hormone

-Elevated T3 and T4

-Increased BMR leading to wt loss

-Diet: increase kcals

Hypothyroidism:

-Deficiency of thyroid hormone

-T4 low; T3 low to normal

-Decreased BMR leading to wt gain

-Diet: Wt reduction

What causes galactosemia and what is the treatment?

D/t missing enzyme that would have converted Galactose-1-PO4 into Glucose-1-PO4

Treated solely by diet- Galactose and lactose free

Protein and Ammonia recommendations for Urea Cycle Defects:

Protein restriction (1.0, 1.5, 2.0 g/kg based on tolerance)

Lower ammonia

Dietary recommendation for phenylketonuria (PKU)

Low in phenylalanine (but provide enough to promote normal growth)

Relationship b/t PKU and Dental Carries in kids and why:

Kids w/ PKU may have increased incidence of dental carries d/t intake high in CHO and low in protein

What is glycogen storage disease?

Deficiency of glucose-6-phosphatase in liver; impairs gluconeogenesis and glycogenolysis.

Liver can't convert glycogen into glucose, leading to hypoglycemia

Pt's newly diagnosed with homocystinurias should receive increased doses of these three vitamins:

Folate, Pyridoxine (B6), B12

Dietary recommendations for Arthritis:

Regular, well balanced diet

What population is most at risk for osteoporosis?

Elderly, white, females

When should you provide phenytoin for epilepsy treatment?

Provide separat from meals and other supplements.

Enteral feedings decrease bioavailability of phenytoin so hold tube feedings >/= 2 hours

What is the ketogenic diet?

High fat, very low CHO

4 g fat: 1 g non-fat (CHO and protein)

Need supplements of Ca, D, folate, B6, and B12

What are the two types of cerebral palsy?

Spastic Form:

-difficult, stiff movement; limited activity; obese

-low kcal, high fluid, high fiber diet

Non-spastic (athetoid) form:

-Involuntary wormlike movement, constant

irregular motions leading to wt loss.

-High kcal, high protein diet; finger foods

Dietary recommendations for pressure ulcers (Decubitis ulcer)

30-40 kcal/kg

1.2-1.5 g protein/kg in Stage I and II; 1.5-2 g in III, IV

Normal intake of calcium, adequate fluids

(may need vit C or zinc supplementation)

What's the difference b/t microcytic and macrocytic anemia?

Microcytic (Hypochromic):

Small pale cells; d/t iron deficiency.

Associated w/ chronic infections, malignancies, renal disease.

Macrocytic (Megaloblastic):

FEW large cells, filled with hemoglobin.

D/t deficiency of folate or vit B12, schilling test for pernicious anemia.

Normal range for MCV (mean corpuscular volume)

80-95 fL

Normal range for MCH (mean corpuscular hemoglobin)

27-32 pg

What are the most common allergies?

Peanuts, eggs, milk, soy, wheat, shellfish

BMR increases ____% for each degree rise in F temp. What is normal body temp?

7%

98.6 degrees F

What is the initial then secondary dietary treatment for burns?

First replace fluids and electrolytes lost.

Then (during recovery period) increase kcals (based on burn size) and increase protein 1.5-2 g pro/kg (1.2 if burn

As part of the ebb and flow response to injury, what results from physiologic trauma?

Hyperglycemia, hyperinsulinemia, little or no ketosis, increased glucagon

Dietary recommendations for Thrush from oral infections:

Avoid spicy, acidic, strongly flavored foods. Provide bland liquids, soft foods, chilled or frozen foods.

What is Iatrogenic Malnutrition?

Protein-calorie malnutrition brought on by treatment, hospital, or medications.

What are the BMI ranges for the different classes of obesity?

Class I: 30-34.9

Class II: 35-39.9

Class III: >/= 40

Recommended pediatric overwt intervention:

Wt maintenance

Healthy obese cholesterol

Elevated LDL, normal to low HDL

Bariatric surgery treatment requirements

Class III obesity with a BMI of 40 or greater, or a BMI of 35 or greater with co-morbidities

What is the best treatments for Prader Willi Syndrome?

To control food intake/access to food (as they don't sense satiety)

Sugar alcohols (sorbitol, xylitol, mannitol) do or do not promote tooth decay?

do NOT

Recommendations for fluorine:

Supplement starting at 6 mo of age if level in water supply is < 0.3 ppm (helps to control dental caries)

Why should an infant not sleep with a bottle?

BBTD baby bottle tooth decay, ECC early childhood caries

What is achalasia?

Disorder of lower esophageal sphincter motility, does not relax and open upon swallowing. Leads to dysphagia.

Dietary recommendations for achalaisa?

(aka dysphagia)

start with pureed moist thick foods, progress to thick liquids.

What is the recommendation for sodium for pregnancy-induced HTN (PIH)?

Sodium restriction is NOT recommended for prevention or treatment; sodium needed to maintain normal levels of sodium in plasma during large prenatal expansion of tissues and fluid.

Describe Elemental Formula:

Predigested, chemically defined.

Used with malnutrition.

Predigested protein or amino acids, glucose or sucrose, small fat, vitamins, minerals, electrolytes.

When to use transpyloric enteral access:

Passed by pyloric valve in stomach; used in comatose pt's or ones with no gag reflex.

fluid recommendations for enteral nutrition:

Give 1 cc water per kcal ingested.

1 kcal/cc formulas are 80-86% water

1.5 kcal/ cc are 76-78% water

2 kcal/cc formulas are 69-71% water

How to figure out kcals provided by IV dextrose:

(ml provided) x (% dextrose) x (3.4)

Provides 3.4 kcals/gram

kcals provided by 10% and 20% intravenous fat emulsion-IVFE (intralipid):

10%: 1.1 kcal/cc

20%: 2.0 kcal/cc

When to use parenteral nutrition (PN)

Typical nutr dx: NC- 1.4 altered GI fxn; NC-2.1 impaired nutr utilization.

-Moderately to severely malnourished expected to

have prolonged periods of GI dysfunction.

-Critically ill hemodynamically stable with paralytic

ileus, acute GI bleeds, bowel obstruction.

-Only malnourished cancer pt's on therapy who

are anticipated to be unable to ingest and absorb

adequate nutrients for a period of 7-14 days.

-Peritonitis, fistulas

-Critical care pt's if enteral nutr is not possible and

hypermetabolism is expect to last more than 5

days.

What are some major concerns regarding PN:

Translocation of bacteria; not feeding through gut allows wall to break down, bacteria move out causing sepsis.