fundamentals nutrition and documentation terms

24-hour recall

assessment tool used to help a client recall what they have eaten over the last 24 hours

added sugars

sugars added to food that are not naturally occurring

antioxidants

substances, commonly found in plant-based foods, that protect the cells against free radicals

anus

external opening of the rectum where feces is removed from the body

aspiration

when solids or liquids enter the lungs during inhalation

assistive devices

equipment or tools that help a client perform daily tasks easier

blood glucose

provides energy to the cells in the body, primary sugar in the body that is made from foods eaten

calorie density

the number of calories a food contains related to its volume or weight

calories

the energy that is stored in food and used for processes of the body such as walking, breathing and running

carbohydrates

macronutrient that provides the body’s cells, organs and tissues with the energy they need to function

clear liquid diet

diet consisting of only liquids that are clear and offers little daily calories and nutrients

digestion

when the body breaks down food into simple substances that can be used as nutrients or excreted as waste

dysphagia

difficulty swallowing

enteral nutrition

nutritional intake through the GI tract, including mouth or a GI tube

esophagus

organ responsible for moving food from the mouth to the stomach

fasting blood glucose

blood sugar level taken after a person has not eaten or drank anything for at least 8 hours

fat-soluble vitamins

vitamins that do not dissolve in water but instead are dissolved in fats

fats

essential nutrient that help the body absorb vitamins while providing energy

food frequency questionaire

tool used to determine a client’s typical food consumption based on a list of foods

full liquid diet

diet of liquids, foods that are considered liquids and foods that turn into liquids at room temperature

gallbladder

stores bile and then releases it when the body needs it

gastrostomy tube (G-tube)

delivers nutrition to a client via a tube in the stomach

glycemic index

a carbohydrate-containing food’s ability to increase the body’s blood glucose level

heart healthy diet

promotes cardiovascular health through controlling portion, eating a varied diet, and watching sodium intake

hypoglycemia

a blood glucose level below the expected reference range

laparoscopic technique

procedure where small incisions are made on the abdomen and a tiny telescope is used to place a g-tube

large intestine

removes electrolytes and water from food while turning it into waste

liver

removes toxins from the blood and produces bile, which breaks down carbohydrates, proteins and fats

macronutrients

vitamins and minerals which are consumed in small amounts and required for optimal growth, development and body function

minerals

noncarbon, inorganic nutrients that promote health and support optimal functioning of the body

nasogastric tube (NG tube)

thin plastic tube placed via the nostril with the tip located in the jejunum

net carbs

the amount of carbs counted toward consumption after taking away the amount of fiber and sugar alcohols in a food

NPO

abbreviation meaning nothing by mouth

omega-3 fatty acids

found in a number of foods, mainly fish. fish oil supplements are the most common nonvitamin-nonmineral natural product taken by adults and children

open surgery technique

technique used to place a G-tube when laparoscopic is not an option; open surgery allowing the surgeon to complete other procedures if indicated

overt aspiration

aspiration causing symptoms such as coughing or trouble breathing

pancreas

aides in the metabolism of sugar by producing insulin

parenteral nutrition

nutritional intake through the veins, given when a client’s GI system does not function

partial parenteral nutrition

supplies client with part of their nutritional requirements allowing for supplemental oral intake

percent daily value (%DV)

the percentage of the recommended daily value for each individual nutrient in a single serving of food

peristalsis

involuntary muscle contractions that occur throughout the digestive system that move food along the pathway to be digested

protein

building blocks of the body that provide amino acids that the body needs to build and repair muscles

pureed diet

diet of foods that do not require chewing

rectum

storage area for feces at the end of large intestine

regular diet

a healthy, varied diet with foods from all food groups

renal diet

diet for individuals with kidney diseases that limits intake of sodium, potassium and phosporus

serving size

the number of servings in a package of food

silent aspiration

aspiration with no obvious symptoms

small intestine

where food is broken down and the majority of the nutrients are obsorbed

soft diet

diet containing foods that are soft, easy to digest, low in fiber, and easy to swallow without difficulty

stomach

organ that holds food and uses acids and enzymes to digest food

thickened liquids

liquids that are thickened using powder or gel to help prevent aspiration for those with dysphagia

total perenteral nutrition

intravenous liquid nutrition that makes up all of client’s nutritional intake

total sugars

sugars that occur naturally in foods

trace minerals

needed in small amounts to help with different body functions

vitamins

carbon-based organic micronutrients that promote health and support optimal functioning of the body

warfarin

medicine that thins the blood to prevent blood clots

water

an essential nutrient that makes up more than half of the body weight and is required by systems in the body to function properly

water-soluble vitamins

vitamins that are carried to the tissues of the body but are not stored in the body

charting by exception (CBE)

documenting only unexpected or unusual findings

computerized provider order entry (CPOE)

allow providers to enter and transmit prescription electronically

electronic health records (EHRs)

systemic, digitized documentation system used to improve medical records. a computerized, real-time form of a client’s paper chart that can be shared between members of the interprofessional team; includes information such as the medical history, diagnosis, allergies and diagnostic testing results

FACT

acronym used to help nurses with proper documentation practices. FACT stands for factual, accurate, complete and timely

focus charting

centers on specific health care problems and the change in condition, client events and concerns. three items must be documented which are data, action and response (DAR)

health insurance portability and accountability act (HIPAA)

established by the federal government with the goal of making healthcare more efficient

health record

a collection of health information and data about an individual client’s health

HIPPA privacy rules

part of HIPAA. established in 2003, it created regulations that govern EHR records to protect the privacy of healthcare consumers

PIE model

type of documentation that omits the plan of care and utilizes flow sheets and progress notes

problem-orientated medical record (POMR)

used to create a comprehensive and organized approach among all members of the interdisciplinary team

source-oriented medical record

traditional form of documentation, divided in specific sections within the medical record

telephone prescription

a prescription received over the telephone from a provider when the provider is not physically present

verbal prescriptions

prescriptions received from a provider directly, transcribed by licensed personnel, and later cosigned by the provider