NSC 325 Examination 1 Study Guide

NSC 325 Examination 1 Study Guide

Nutrition Care Process

  • Screening

    • Screening precedes the nutrition care process; it is not part of the process.

  • ADIME Framework

    1. Nutrition Assessment:

    • Comprises four domains: A (Anthropometric), B (Biochemical), C (Clinical), D (Dietary).

    1. Diagnosis:

    • Uses the P-E-S format: Problem, Etiology, Symptoms.

    • Common problem: Intake issues.

    1. Intervention:

    • Establishes plan and outcomes.

    1. Monitoring:

    • Evaluates success of intervention.

    1. Evaluation:

    • Determines if adjustments to the intervention are necessary.

Anthropometric Data

  • Measurements

    • Includes Height/Weight, Ideal Body Weight (IBW), IBW range, % Usual Body Weight (% UBW), % weight change.

    • For calculations:

    • Generally use current/actual weight, but:

      • If weight is impacted by fluid status, use "dry weight".

      • Use current weight when it is less than IBW range or when computing using Mifflin or Basal Energy Expenditure (BEE) equations.

    • Obesity Considerations:

    • Consider using Mifflin equation (with actual weight) and IBW to estimate protein and fluid needs.

Biochemical Data

  • Sensitivity & Specificity

    1. Sodium:

    • Reflects fluid status but not sodium intake necessity.

    1. Potassium:

    • Affected by dietary intake; kidney function influences levels; some diuretics increase losses.

    1. Chloride:

    • Minimal dietary influence; indicates acid/base status; can rise with dehydration.

    1. Bicarbonate:

    • Influenced by acid/base status but not diet.

    1. Blood Urea Nitrogen (BUN):

    • Relevant for renal disease; decreases with malnutrition.

    1. Creatinine:

    • Increases in renal disease and with protein catabolism; decreases with malnutrition.

    1. Glucose Levels:

    • Fasting glucose > 125 mg/dL indicates diabetes mellitus (DM); must assess impacts of inflammation and stress.

Biochemical Data: Metabolic Panel

  • Liver Function Tests (LFTs):

    • Includes alanine aminotransferase, alkaline phosphatase, aspartate aminotransferase.

  • Phosphorus:

    • Influenced by dietary intake and renal function; at risk in refeeding syndrome.

  • Albumin/Prealbumin:

    • Negative acute phase proteins; decrease in response to blood loss, liver dysfunction, inflammatory response/stress; variable with hydration.

Serum Albumin

  • Impact of Inflammation:

    • Decreases with inflammation and overhydration.

    • Increases with dehydration.

  • Functions:

    • Maintains fluid balance through oncotic pressure; transports micronutrients and drugs; serves as a significant prognostic indicator.

    • Not recommended as a sole nutrition marker.

Role of Inflammation

  • Impact on Laboratory Values:

    • Increases glucose and C-reactive protein (CRP) levels; decreases albumin.

  • Common Inflammatory Conditions:

    • Obesity, Inflammatory Bowel Disease (IBD), infections, surgeries, rheumatoid arthritis, respiratory failure, renal disease, trauma, and sepsis.

Refeeding Syndrome

  • Common Scenarios:

    • Occurs with initiation of nutrition support.

  • Monitoring Levels:

    • Check phosphorus, potassium, and magnesium levels before starting nutrition support, especially in high-risk groups:

    • Chronic diseases associated with undernutrition.

    • Unfed for 7-10 days.

    • Alcohol abuse.

    • Gastric bypass surgery.

    • Thiamine concerns due to initial low baseline levels.

    • Supplement 100 mg thiamine for 5 days.

Nutritional Anemias

  • Causes:

    • Primary cause: Poor nutrition.

  • Types of Anemia:

    1. Microcytic:

    • Due to iron deficiency; characterized by low hemoglobin and hematocrit; decreased Mean Corpuscular Volume (MCV) and Mean Corpuscular Hemoglobin Concentration (MCHC).

    1. Macrocytic:

    • Due to folate and/or Vitamin B12 deficiency; increased MCV/MCHC.

    • Assess specific lab values to distinguish between folate deficiency and B12 deficiency (check Vitamin B12, Methylmalonic Acid (MMA) - high in B12 deficiency, and RBC folate levels).

Clinical Status

  • Influences Nutritional Needs:

    • Inflammation increases protein needs.

    • Medications and medical procedures impact needs:

    • Prednisone: Increased protein and calcium needs.

    • Long-term use of Nexium: Increased iron and B12 needs.

    • Surgery increases caloric (kcal) and energy needs.

    • Critical illness significantly increases protein needs.

    • Pressure ulcers also heighten fluid, energy, and protein requirements.

Calculating Needs

Protein Needs

  • Recommendations:

    • Healthy: Minimum of 0.8 gm/kg/day (e.g., healthy adult).

    • Mild stress: 1-1.1 gm/kg (e.g., low-stress surgery).

    • Moderate stress: 1.2-1.4 gm/kg (e.g., pneumonia, ICU respiratory failure).

    • High stress: >1.4 gm/kg (e.g., trauma, major gastrointestinal surgery, severe acute pancreatitis, sepsis).

    • Special cases:

    • Intermittent Hemodialysis: 1.2-1.4 gm/kg.

    • Liver failure/cirrhosis: 1.2-1.5 gm/kg.

    • Critical illness: 1.2-2.0 gm/kg (minimum 1.2 gm/kg in ICU setting).

    • Pressure ulcers: 1.25-1.5 gm/kg.

    • For patients with BMI >30 in ICU settings, aim for 2-2.5 gm/kg.

  • Using Percentage:

    • For healthy adults, protein contribution may also be calculated as 10%-25% of total kcal.

    • Actual weight should be used for these calculations unless otherwise noted.

    • If edema or anasarca is present, consider using dry weight or usual body weight (UBW).

Energy Needs

  • Commonly Used Approach:

    • Kcal/kg for inpatient adults where Indirect Calorimetry (IC) is unavailable.

  • Recommend kcal/kg method endorsed by ASPEN; prevalent in practice.

  • Short Method for Estimating Kcals per Kg:

    Stress Level

    Loss

    Maintain

    Gain


    Low

    20

    25

    30


    Moderate

    25

    25-30

    35


    High

    25

    25-35

    40

    • Guidelines:

    • Kcals should be based on actual weight; however, adjustments are made for obesity protocols (BMI >30).

    • Age, weight, and severity of illness will also impact kcal requirements.

Fluid Needs

  • Recommendations Based on Age:

    • Ages 18-55: 35 mL/kg.

    • Ages 56-75: 30 mL/kg.

    • Ages 75+: 25 mL/kg.

  • Minimum fluid intake should generally not fall below 1500 mL/day.

  • Use actual weight for calculations, and for BMI >30, consider using IBW or 1 mL per kcal based on fluid requirements.

Diet (Nutrition) History

  • Assessment Objectives:

    • Evaluate adequacy/inadequacy of nutritional intake versus needs.

    • Compare captured data to established nutritional standards (My Plate, American Heart Association, American Diabetes Association, etc.).

    • Refer to Institute of Medicine (IOM) standards, Dietary Reference Intakes (DRIs) / Recommended Dietary Allowances (RDAs), and clinical practice guidelines.

Nutrition History Assessment Considerations

  • Aspects to Evaluate:

    • Appetite, chewing/swallowing issues, bowel problems (nausea/vomiting/diarrhea), taste changes, attitudes towards food, any irrational ideas about food, cooking/shopping responsibility, and cooking methods.

Nutrition Assessment Summary

  • Process Overview:

    • Collect and summarize assessment data based on the ABCDs framework, presented as a narrative.

    • Example: "Mr. Smith is a 45 y.o. male with a current weight at 125% of IBW; he appears adequately nourished with stable weight and good appetite. Laboratory data is not available. He has an increased obesity risk due to reported overconsumption of calories and inadequate dietary fiber intake. He is motivated to undertake lifestyle changes to mitigate his chronic disease risk."

Diet Assessment & Recommendations


  • Food Group Intake Recommendations:

    Food Group

    Servings/Day

    % of Calories

    Comments


    Carbohydrates

    45%-65%

    -

    IOM minimum = 130 grams minimum/day


    Starches

    Minimum 4

    -

    Whole grains are preferred


    Fruits

    Minimum 2-3

    -

    Aim for colorful varieties


    Vegetables

    Minimum 2-3

    -

    Aim for colorful varieties


    Fiber

    >25 g/day (women), >38 g/day (men <51), >30 g/day (men >51)

    -

    Prioritize legumes, fruits, vegetables, whole grains


    Protein

    Minimum 7

    10%-35%

    RDA: 0.8/kg; elderly may need 1 g/kg


    Dairy/Dairy Alternatives

    Minimum 2-3

    -

    Important for Ca++ and D intake


    Fat

    Minimum 5

    20%-35%

    SFA <6% of total kcals; <30% total kcals


    Fun Calories

    100-200/day

    -

    Limit empty/nutrient-devoid calories

    Nutritional Recommendations for Key Nutrients


    • Recommended Dietary Allowances (RDAs):

      Nutrient

      RDA: Men

      RDA: Women

      Upper Tolerable Limit

      Rich Food Sources

      Special Considerations


      Potassium

      4700 mg/d

      4700 mg/d

      N/A

      Dairy, potatoes, bananas, tomatoes, orange juice

      Renal function, medications, etc.


      Iron

      8 mg/d

      19-50 y.o.: 18 mg/d; >51: 8 mg/d

      45 mg/d

      Liver, fortified cereals, clams, legumes

      Anemia risk for postmenopausal, pregnant/lactating women


      Calcium

      1000 mg/d (19-70 y.o); 1200 mg/d (>70 y.o)

      Same

      2000 mg/d

      Dairy & fortified foods

      Bone density (peaks at ages 25-30)


      Vitamin D

      15 ug/d (19-70 y.o); 20 ug/d (>70 y.o)

      Same

      100 ug/d

      Cod liver oil; cooked salmon; fortified OJ

      Skin color, sun exposure, medical status


      Folic Acid

      400 mcg/d

      400 mcg/d

      1000 mcg/d

      Spinach, fortified cereals

      Pregnancy concerns & alcohol use


      Vitamin C

      90 mg/d (men); 75 mg/d (women)

      Same

      2000 mg/d

      Citrus fruits, peppers, broccoli

      Additional 35 mg/d for tobacco users

      Dietary Reference Intakes (DRIs) for Micronutrients

      • Common Deficiencies and Food Sources:

        • Calcium: 1000 mg/d; over 51 years (F) 1200 mg/d; >70 years (M) 1200 mg/d.

        • Vitamin D: 600 IU/d (18-70 y.o.); 800 mg/d (>70 years).

        • Folate: 400 mcg/d (critical for women of child-bearing age).

        • Iron: 8 mg/d for males; 18 mg/d for females.

        • Vitamin C: 75 mg/d for females; 90 mg/d for males; add 35 mg/d for smokers.

        • Magnesium: 320 mg/d for females and 420 mg/d for males.

        • Common Excess: Sodium.

      Diet Orders in Hospital Settings

      • Common Diet Orders:

        • NPO (nothing by mouth).

        • Clear liquid diet: broth, tea, clear juices, gelatin.

        • Full liquid diet: includes milk; hot cereals like oatmeal; yogurt or pudding.

        • Regular diet and various specialty diets available (e.g., carb consistent, heart healthy).

      • Consistency Modifications:

        • Liquids (soft diet, mechanical soft diet, pureed diet).

      • Enteral & Parenteral Support:

        • Tube feeding and IV feeding.

      • Nutritional Supplements:

        • Ensure/Boost, disease-specific drinks, protein powders, vitamin-mineral supplements.

      Specific Populations – Nutritional Needs

      • Adolescents (11-18 y.o.):

        • Males: Excessive sodium, processed foods, soda; insufficient fruits/vegetables and fiber; inadequate calcium/Vitamin D.

        • Females: Inadequate iron, calcium, folate, protein; reliance on processed foods.

      • Young Adults (19-39 y.o.):

        • Focus on building bone density until age 25-30.

      • Middle Age (40-64 y.o.):

        • Attention required for iron needs after 51 y.o.; prior deficiencies common.

      • Older Adults (>64 y.o.):

        • Nutritional needs heavily dependent on individual health status.

      Dietary Recommendations for Healthy Eating

      • Best Practices:

        • Recommend an anti-inflammatory or Mediterranean diet as a healthy eating intervention.

        • Specific dietary guidance on moderation of wine and encouraging water intake.

      Nutrition Assessment Example

      • Example Case:

        • Nicole, 33 y.o. female, hospitalized for dehydration after chemotherapy. Current weight: 130 lbs, usual weight 140 lbs, sodium/BUN levels indicate mild dehydration. Nutritional assessment should include clinical data related to her eating patterns and how treatment (e.g., hydration and nutrition) will support recovery.

      Nutrition Diagnosis

      • ADIME Framework

        • Following the assessment comes the diagnosis, which bridges assessments and interventions.

        • Prioritize the top two Problems (P). Usually, malnutrition is ranked as the most critical problem.

      • Nutrition Diagnosis Components:

        1. Problem (P): A nutrition issue the dietitian can affect.

        2. Etiology (E): The root cause of the identified problem.

        3. Signs/Symptoms (S): Evidence supporting the existence of the problem and its extent.

      Malnutrition Criteria

      • Criteria for Diagnosis:

        • Must meet at least two indicators related to energy, weight, fat, or muscle loss.

      • Contextual Elements:

        • Chronic (low to moderate inflammation, lasting >3 months) vs. Acute (extreme inflammation and abrupt onset).

      • Severity Assessment:

        • Gage based on weight changes, inflammation levels, and context of malnutrition.

      Nutrition Interventions in Medical Nutrition Therapy (MNT)

      • Goal Setting:

        • Must have at least one intervention addressing each component of the PES.

        • Interventions can be framed as SMART goals or outcomes aimed at addressing nutritional problems.

        • Categories of intervention include food delivery, education, counseling, and coordination of care.

      Monitoring & Evaluation

      • Purpose of Monitoring:

        • Evaluates whether the nutrition problems defined in the PES are being resolved.

      • Follow-up Frequency:

        • Varies by the setting and nature of the problem; outpatient or inpatient considerations dictate follow-up intervals.

      Summary of Key Points

      • Components of the Nutrition Care Process

        • ADIME: A for assessment, D for diagnosis, I for intervention, M for monitoring, E for evaluation.

      • Intervention's Importance

        • If interventions do not resolve the identified problem, adjustments must be made.