Clinical Flashcards
ISBAR
Identify- self, name, position, location and who you are talking to. Identify patient name, age, sex, location
Situation- state purpose - the reason I am calling is. If urgent- say so
Background - tell the story, current problem, relevant history, relevant examination and test results, management
Assessment- state what you think js going on
Request- state request eg id like your opinion on the most appropriate test
Procedural reasoning
If X is problem then I need to do Y
Draw on knowledge to reason
Is this the reason for referral, the first nutritional priority or in your assessment has something else become a higher priority
Interactive reasoning
Focuses on clients point of view and humanises conditions
I need to do y but the client would prefer Z
Negotiate and consider the interests of different individuals in the decision making process
Pragmatic reasoning
Considers practical issues
A is the best option, but it is too time intensive to be practical so let’s try b
Conditional reasoning
Usually required experience
Integration of procedural and interactive reasoning
Y does not work as well in this situation I know because of my training/ experience which tells me that in the population you need to modify intervention eg:
In elderly should do x
In young should do y
In low ses client on limited budget so lower compliance with commercial oral supplements
When client has limited mobility/ functioning you need to factor this in as it will affect compliance
Narrative reasoning
How we organise our thoughts about the client
Reflection with other health professionals
X is not the greatest priority at this point for the client
Inform all decisions and actions with advanced practice knowledge or seek out experiences opinion. Discuss with them test, what is the natural progression of the disease/ treatment what implications may this have for your proposed intervention?
Static tests
Actual nutrient in biological tissues or fluids or in the htinary excretion rate of the nutrient or its metabolites
Blood
Tissues
Urine
Functional tests
Extent of functional consequences of a nutrient deficiency
Assessment of the activity of a specific enzyme systems for which rejects are essential cofactors
Developmental and physiological aspects of performance eg sexual development as a measure of zinc status during adolescence
Iron status
- first stage
Depleted iron stores
Decreased serum ferritin level (primary storage form of iron in body)
No adverse physiological effect but vulnerability
Common in growing children, menstruating women - second stage
Iron deficiency without anaemia
Increased transferrin saturation (iron transport from the haemoglobin). Increased erthrocyte protoporphyrin (precursor of haeme)
Not optimal haemoglobin synthesis
Haemoglobin within ref range at this stage - third stage
Iron deficiency anaemia
Decreased haemoglobin (oxygen carting molecule)
Decreased mean corpuscular volume (rbc)
Insufficient haemoglobin, reduced oxygen carrying capacity
Calcium status
99% in bones and teeth, 1% everywhere else in plasma and urine
Serum calcium
Serum levels of calcium are so tightly controlled that there is little/ no association between dietary calcium intake and serum levels
Altered serum calcium levels- serious metabolic problems eg. Renal/ parathyroid disease, not low/ high calcium intake
So not very useful when looking for a deficiency in calcium intake
Lipids
- LDLC
Transport cholesterol around body- contain 70% of total serum cholesterol. Most labs measure by LDLC= TC-HDLC - TG/5 - HDLC
picks up from blood and transport cholesterol back to liver and lipoproteins for excretion
Cardiprotective - Triglycerides
Major components of VLDL and chylomicrons, play an important role in metabolism as energy sources and transporters of dietary fat
Glucose
Fasting: 3-6mmol/ L
OGTT: Pt fasted from the night before and is stressed with 75g glucose load of 1.75g/kg of a child
Blood glucose checked at regular intervals to determine tolerance
Diabetes confirmed if fasting glucose >7mmol/L or 2he post prandial >11.1mmol/L
If symptoms absent at least two abnormal results required
Sodium
135-145mmol/L
High or low levels can cause confusion, seizures, coma
- hypernatraemia
Reduced water intake, increased water losses, intravascular depletion, diabetes insipidus, excessive sodium intake
Dehydration and treatment of underlying cause, albumin replacement rehydration, medication, identify and reduce sources of excess sodium (IVT/medications/ diet)
- hyponatraemia
GI salt losses (severe diarrhoea/malabs), excess water/ fluid intake, fluid retention, SIADH, endocrine conditions
Rehydration (oral/IV) and treatment of underlying cause, diuresis, fluid restriction, sodium restriction +/- fluid restriction, medical management
Potassium
High/ low can cause cardiac arrhythmia and muscle spasm/ weakness
Major intracellular cation
Link to glucose transport and insulin levels
- hyperkalaemia
Dehydration/ hadmoconcentration, Renal impairment (acute or chronic), Medications with reduce K excretion, Haemolysis, Over replacement
Rehydration, may utilise dextrose/ insulin, potassium restriction, medical correction if severe- dialysis/ filtration, avoidance of excess dietary K (strict restriction not generally required), cause supplementation, treat medically if severe
- hypokalaemia
Increased GI losses, potassium wasting diuretics, corticosteroids, low total body potassium (severe starvation), refeeding syndrome
TreT cause, replace oral/IV
Urea
Low levels:
Low protein intake
Normal levels do not exclude low protein intake if renal failure of significant catabolism
High levels:
Inability to excrete urea via the kidneys - renal dysfunction, dehydration, levels >39 can cause nausea, itch, confusion and may be indicated of need for dialysis
Creatinine
Low levels
Low muscle mass
Reasonably specific, not sensitive- check by looking at patient
High levels- renal impairment and dehydration
Vit D (25-hydroxyl)
- deficiency
Associated with low bone density and an increased risk of many cancers
- causes Lack of sunlight exposure Lack of adequate vit D in diet Liver and kidney diseases Malabsorption Certain medications including corticosteroids
- treatment
Lifestyle changes
Supplementation
B12 and folate
Folate (red cell) and vit B12
B12 deficiency causes macrocytic anaemia
Full blood examination
Haemoglobin - reduced in iron deficiency, blood loss, haemolysis, infection Red cell count Haematrocrit MCH MCHC MCV (mean corpuscular volume) - high in B12 - low in iron deficiency Platelet count MPV white cell count (marked of infection/ inflammation)
C reactive protein
Produced in liver
Involved in inflammatory response
Acute phase reactant
Sensitive but not specific- high result is general indication of inflammation
Degree of elevation can indicate severity of infection- useful for guiding stress factors
Often precedes increase in WCC
Liver function tests
Total and conjugated bilirubin
Alkaline phosphatase ALP
Gamma-glutamyl transpeptidase
Alanine aminotransferase (ALT)
Aspartate aminotransferase (AST)
Albumin- protein made by liver, serum albumin test measures amount of this protein in clear liquid portion of blood
Albumin is a negative acute phase reactant
Half life of three months
Lower than normal level of albumin may indicate ascites, burns, glomerulonephritis, liver disease, malabsorption syndromes, malnutrition, nephrotic syndrome, inflammation / infection
Total protein
- high
Chronic inflammation or infection including HIV and hep B or C - multiple myeloma
- waldenstroms disease
- low Agammaglobulinemia Bleeding (haemorrhage) Burns Glomerulonephritis Liver disease Malabsorption Nephrotic syndrome Protein losing enteropathy
LFT bilirubin
Precursor to bike and breakdown product of haeme
Is responsible for yellow discolouration in jaundice
Excreted in bike and urine: elevated levels may indicate excess hadmolysis, bike duct obstruction, liver disease
LFT liver enzymes
Aminotransferase (AST and ALT)
- intracellular enzymes
- raised levels indicate damage to hepatocytes
ALP and GGT
- found on cell membrane for bike acid transport
- raised levels indicative of cholestasis
- alcohol can acutely raise GGT level
