Medical Nutrition Therapy Flashcards
(115 cards)
1
Q
Nutrition diagnosis
A
A nutritional problem that dietitian is responsible for treating independently; changes as patients response changes
-I.e. undesirable overweight status
2
Q
Medical Diagnosis
A
A disease or pathology that canb e treated or prevented; does not change as long as the condition exists
-Ex: T1DM
3
Q
Clinical Diagnostic domain (NC)
A
Nutritional findings that relate to medical/physical condition
- Functional –> difficulty swallowing
- Biochemical –> change in metabolsim
- Weight –> involuntary weight loss
4
Q
Intake Diagnostic domain (NI)
A
- Intake diagnosis is PRIORITY!
- actual nutrition problem related to intake
- Ex: inadequate oral intake; hypermetabolism; excessive CHO intake
5
Q
Behavioral-Environmental Diagnostic domain (NB)
A
- problems related to knowledge, access to food, and food safety
- Ex: undesireable food choices
6
Q
PES Statements
A
- One problem, One etiology, Assessment of signs and symptoms
- Intake diagnosis takes priority for PES statement
- select most important and urgent problem to be addressed
- Need to be able to document signs and symptoms and monitor them
7
Q
Altered GI Function (NC1.4)
A
problems INSIDE the GI tract; changes in digestion, absorption, and/or elimination
-Indicators: IBS, constipation, FFS, diarrhea, abd dist
8
Q
Impaired NUTRIENT utilization (NC 2.1)
A
Problems with METABOLISM of nutrients once they enter the circulatory system; endocrine functions
-Indicators: abnormal LFTs, hyperglycemia, renal/liver failure
9
Q
Evidence Based Dietetics Practice
A
Systematically reviewed evidence used in making food and nutrition practice decisions
10
Q
Health Information Portability and Accountability Act (HIPPA)
A
Medical record documentation guidelines: black pen or typed; complete, clear, legible, accurate; sign, date all entries; when diet orders are not chosen correctly, contact the person who wrote the order
11
Q
When do discharge plans begin?
A
Day ONE of hospital stay
12
Q
GI Disorders
A
- ulcers
- diarrhea
- short bowel syndrome
- hiatal hernia
- dumping syndrome
- gastroparesis
- tropical sprue
- celiac disease
- constipation
- diverticular disease
- gastritis
- IBD
- IBS
- Lactose intolerance
13
Q
Ulcer
A
- eroded mucosal lesion
- caused by H.Pylori bacteria and requires antibiotics
-Diet: as tolerated w/o exacerbating symptoms; avoid late night snacks,chili powder, excess caffeine and alcohol
14
Q
Hiatal Hernia
A
- Protrusion of stomach above diaphragm
- Main symptom= heart burn
-Diet: small, bland feedings, avoid late night snacks
15
Q
Dumping Syndrome
A
-After a gastrectomy: billroth I (gastroduodenostomy) or billroth II (gastrojejunosotmy)
- Eating too many CHO at once –> dumped into sm. intestine –> H2O drawn out of intestine for osmotic balance –> BP increases –> signs of cardiac insuff
- 2 Hrs later – CHO is absorbed rapidly –> increase BG –> overproduction of insulin –> decrease in BG below fasting –> Reactive alimentary hypoglycemia
- Sx: cramps, rapid pulse, dizziness, sweating
- Anemia is common: Fe, B12, Folate deficiencies common but can be prevented with diet
-Diet: sm dry feedings; fluid before and after meals; minimal concentrated sweets; 50-60% complex CHO; protein at each meal; moderate fat; B12 injections
16
Q
Gastroparesis
A
- delayed gastric emptying
- prokinetics given to increase stomach contractility
17
Q
Tropical Sprue
A
- Bacterial, fungal, parasitic infection
- chronic intestinal lesions that may also affect the stomach
- deficiencies in folate and B12 due to decreased IF and HCl
- Tx: antibiotics (tetracycline)
- Diet: high kcal, high pro with IM B12 and folate supp
18
Q
Non-Tropical Sprue aka Celiac disease
A
- Allergic reaction to gliadin in gluten
- affects only the intestinal tract –> malabsorption and macrocytic anemia (B12)
-Diet: gluten free; NO wheat rye, barly; rice and corn are okay
19
Q
Constipation
A
Treated with high fluid, high fiber, and exercise
20
Q
Diverticular Disease
A
- Diverticulosis: presence of sm. mucosal sacs called diverticula on intestinal wall
- ->Diet: high fiber diet; rapid transit
- Diverticulitis: inflammation of diverticuli
- ->Diet: clears + Low resider –> gradual return back to high fiber diet
21
Q
Fiber: oat bran + soluble fiber _____ serum cholesterol by binding _______ causing more cholesterol to be converted into bile
A
- decreases serum cholesterol
- bile acids
22
Q
Gastritis
A
- Inflammation of stomach
- Diet: clears –> advance as tolerated
23
Q
Inflammatory bowel disease: CROHNS
A
- when body’s immune system attacks and destroys healthy tissue
- chronic inflammation of gi Tract
- can affect mouth all through gi tract to anus
- most likely to be involved= terminal ileum –> leads to B12 deficiency –> megaloblastic anemia
Sx: anorexia, diarrhea, weight loss
Tx: acute flare ups –> bowel rest, PN
Non flare ups: high kcal, high pro, moderate fat; only limit fat with steattorrhea
24
Q
IBD: Chronic Ulcerative Colitis
A
- Ulcer disease of the colon
- Fx of colon is to reabsorb water and electrolytes
-Major symptom = chronic bloody diarrhea
- Tx: elemental diet to decrease fecal volume
- High fiber diet in remission to increase perstalsis
25
IBS
chronic abdominal discomfort
-Diet: tailored to specific GI issues
26
Lactose intolerance
- lactase deficiency
- Sx: bloating, distention, diarrhea because lactose not broken down
- Lactose Tolerance Test:
- -> intolerance= BG rise < 25mg/dL above fasting called the "flat curve"
- -> Tolerance = BG rise > 25 mg/dL --> normal glucose curve
-Diet: no animal milk or milk product; yogurt and small amount of aged cheese might be tolerated
27
Diarrhea
- Infants and Children:
- ->Acute: aggressive and immediate rehydration of fluids and electrolytes
- ->Chronic: insignificant malabsorption; give 40% kcal as fat balanced with limited fluids; restrict/dilute juices with high osmolar loads (i.e. apple juice)
-Adults: bowel rest ; replace lost fluids and electrolytes
28
Steattorrhea
- Consequence of malabsorption
- normal stool fat = 2/5 gm
- Malabsorption of fat = > 7 gm
-Diet: high protein, high complex CHO, fat as tolerated; fat soluble VIT, MCT
29
Short Bowel Syndrome
- Consequences related to significant resections of SB
- Major concern: loss of distal 1/3 of ileum, loss of ileocecal valve, loss of colon
- Loss of Distal ileum: where B12, IF, and bile salts are absorbed and a major portion of fluid; not able to recycle bile salts if no ileum --> malabsorption of fat and fat-soluble vitamins
- Loss of Jejunum: normal balance of nutrients
- Loss of ileum: limit fat, use MCT oil; supplement fat soluble vitamins, Ca, Mg, and Zn; parenteral B12, likely require PN initially
30
Liver, Biliary Tract, and Pancreatic Disorders
- Acute viral hepatitis
- Cirrhosis
- Alcoholic Liver Disease
- Hepatic failure
- gallbladder disease
- pancreatitis
- Cystic fibrosis
31
Liver Enzymes (LFTs
- elevated LFTs = damage to liver tissues
- ALP, LDH, AST (SGOT), ALT (SGPT)
- In liver disease: ALL FOUR ELEVATED
-In uncontrolled diabetes, AST (SGOT) is LOW
32
Acute Viral Hepatitis
- Major symptom = anorexia
- Hep A= fecal-oral transmission
- Heb B= sexually transmitted
- Hep C= blood to blood
Diet: high protein needs to help prevent fatty liver; small frequent feedings due to anorexia
33
Cirrhosis
- Damaged liver tissue --> scar tissue --> disrupts blood flow through liver
* Protein deficiencies --> ascites, fatty liver, impaired blood clotting
- Diet: high calorie, high protein, mod-low fat; low fiber if varices; low Na if ascites or fluid restriction
34
Complications of cirrhosis
- Ascites: when blood can't LEAVE liver due to connective tissue overgrowth --> accum of excess fluid and Na it carries in peritoneal cavity
- Esophageal Varices: blood cant ENTER the liver due to connective tissue overgrowth; blood backs up in portal vain increasing pressure --> increased BP (*PORTAL HTN); varices are fragile and can break open with roughage
35
Alcoholic Liver Disease
- Hepatic steatosis --> alcoholic hepatitis --> cirrhosis
- alcohol converted into acetaldehyde + H2 --> H2 replaces fat as fuel in TCA cycle --> fat builds up in liver --> fatty liver and in blood --> increased TG
- Alcohol = decreased absorption of thiamin, B12, folate, and Vit C
- LT Thiamin deficiency: Wernicke-Korsakoff Sx
36
Hepatic Failure (ESLD)
- Liver fx decreased to 25% or less
- Liver can't convert NH3 --> urea = Increased NH3
- Diet: Very high calorie, very high protein
- Hepatic encephalopathy = decreased BCAA and increased AAA because liver can't clear them --> last resort tx option = add BCAA to correct imbalance
37
Gallbladder Disease
- usually caused by infection
- Cholecystitis: inflammation of the gallbladder
- Cholycystectomy: surgical removal of gall bladder --> *bile now secreted by LIVER directly into intestine
38
Pancreatitis
Common characteristic = premature activation of enzymes in pancrease --> autodigestion of pancreas
- Diet for acute: NPO --> low fat as tolerated
- Diet for Chronic: PERT= pancreatic enzymes with meals and snacks to minimize fat malabsorption; avoid large meals with fat and alcohol to avoid pain
39
Cystic Fibrosis
- PERT: pancreatic enzymes at all meals and snacks
- Diet: very high protein, very high calorie, very high fat and high salt
- Increased protein needs due to malabsorption related to pancreatic enzyme deficiency
- Supp: H2O soluble vitamins and minerals;
- Supplement with water soluble form of fat soluble vitamins --> esp vit A because still poorly absorbed with enzymes
40
CVD, Coronary Artery Disease, and Ischemic Heart Diseases
- hypertension
- atherosclerosis
- heart failure
41
Hypertension
Systolic > 140 (contraction)
Diastolic > 90 (relaxed)
- Management:
- -> Thiazide diuretics -- may cause K wasting
- -> DASH diet: dietary approaches to stop HTN; F,V, whole grains, mod salt, fish, poultry
- Mediterranean diet: rich in omega 3 and MUFA
- Obesity = major factor in cause and treatment
42
Atherosclerosis
- Dysipidemia: high TG and low HDL
| - Metabolic Syndrome
43
Metabolic syndrome
-3 or more risk factors linked to insulin resistance and increased risk for coronary evens
-Risk factors:
high BP, high TG, fasting glu > 110 mg/dL, low HDL, waist >40 for men >35 for women
44
Heart Failure
Weakened heart = poor output and decreased blood flow
-Fluid is held in tissues --> edema
- Tx: diuretics are common
- Diet: Low Na, DASH diet, Fluid Restriction if needed
45
National Cholesterol Education Program (NCEP)
1. diet therapy:
TLC: therapeutic lifestyle change: up to 35% kcal from total fat, < 7 % from sat fat, <200 mg chol; fiber, stanols/sterols; exercise
2. Medications
46
Normal Lipid Panel
```
TG = < 150mg/dL
LDL = < 100
Chol = < 200
HDL = < 40 for men, < 50 for women
```
47
High homocysteine level is an independent risk factor for _______________
Coronary Heart Disease
48
Renal Disease
```
Renal calculi
Acute renal failure
nephrosis
chronic kidney disease
end stage renal disease
chronic renal failure
```
49
Nephrone
Contains the:
- glomerulus
- proximal convoluted tubule (where major nutrient absorption takes place)
- loop of henle
- distal tubule
50
Kidney filters everything EXCEPT ______ and ______
Red blood cells and protein
51
Hormones involved in renal function
- Vasopressin: (ADH) elevates BP (secreted by pituitary)
- Renin: vasoconstrictor and increases BP; secreted when blood volume decreases (secreted by the kidney)
- Erythropoietin: stimulates bone marrow to produce RBCs (secreted by the kidney)
52
Renal Biochemical Markers in renal disease
URINE TESTS
- Decreased GFR
- Low creat clearance
BLOOD TESTS
- elevated serum creatinine
- elevated BUN
53
What does renal solute load measure
mainly nitrogen and Na
54
Renal Calculi
- Kidney stones
- 1.5-2L fluid/day to dilute urine and prevent further stone formation
- Most common stone = calcium stone
55
Acute Renal Failure
- Sudden kidney sut down likely due to trauma
- Sx: oliguria (urine output < 500 ml) and azotemia (increased urea N2 in the blood)
Diet: restrict protein initially then increase intake as able
56
Nephrosis (Nephrotic Syndrome)
- Defect causes protein to enter filtrate moving thru the tubules
- Sx: albuminuria and hyperlipidemia, hypercholesterolemia, edema, malnutrition
- Diet: RESTRICT Fat AND protein; restrict protein to 0.8-1.0 gm/kg
57
Chronic Kidney Disease
-Protein restricted when the GFR FALLS!
58
Protein restriction based on GFR
CKD 1, 2, 3: GFR < 60 = 0.8 gm pro/kg
CKD 4, 5: GFR < 25 = 0.6 gm pro/kg
59
End Stage Renal Disease (ESRD)
-few functioning nephrons remain
Diet: VERY LOW protein
-Giovanetti Diet: 20 grams HBV protein and increased kcal intake
60
Chronic Renal Failure
- Diet can be liberalized with dialysis
| - Hemodialysis and peritoneal dialysis
61
Hemodialysis calorie/protein needs
30-35 kcal/day
| 1.2 gm pro/kg (>/= 50% HBV)
62
Peritoneal dialysis calorie/protein needs
< 60 y.o. = 35kcal/kg including dialysate
> 60 y.o. = 30-35 kcal/kg
1.2-1.3 gm pro/kg BW or adj BW (> 50% HBV)
63
Endocrine Disorders
```
diabetes
Gestational diabetes
postprandial/reactive hypoglycemia
Addison's disease
Thyroid disorders
Goiter
Gout
```
64
T1DM
- T1DM: insulin deficient
- Management strategies: consistency of CHO recommended with fixed daily doses of insulin; planned exercise, reduce insulin dosage
65
Normal BG levels
70-110 mg/dL
< 140 mg/dL 2hours post prandial
66
Diabetic BG levels
- Fasting plasma glucose: >/= 126 mg/dL
- GTT >/= 200 mg/dL
- HbA1c >/= 6.5%
67
Glycosylated Hgb A1c
- Measures % of Hgb that has glucose attached
- goal for diabetics = < 7%
- At risk for developing DM = 5.7-6.4%
- Measures LT control of BG --> over the last 60-90 days
68
Gestational Diabetes
- Risk factors: BMI > 30, history of GDM
| - Increased risk for fetal macrosomia (LGA) and fetal hypoglycemia at birth
69
Types of insulin
Rapid Acting: take 15 min before meal
-ex: novalog, humalog
Short acting: take before meal; one unit covers 10-15gm CHO; burst of insuline
-ex: Regular
Intermediate Acting: lasts 10-18 hours
-Ex: NPH
Long Acting: Lasts 18-24 hours
-Ex: Lantus, levemir
70
Oral glucose lowering medications
- Insulin Secretagogues: promote insulin secretion; ex=sulfonylureas; glycotrol
- Biguanides: enhance insulin action; ex=metformin and glucophage
71
Dawn Phenomenon
- Increase in morning BF and insulin needs due to increase glucose production in liver
- Increased need for insulin at dawn
72
Acute ketoacidosis
- complication of uncontrolled diabetes
- hyperglycemia, dehydration
- Tx: insulin and rehydration
73
Acute hypoglycemia
due to excess insulin or lasck of eating
- Tx: glucose
1) 15 gm CHO from juice, sugar, or tablets
2) Wait 15 min, if still < 70 take another 15gm CHO until BG is normalized
74
Postprandial/Reactive Hypoglycemia
- Increased insulin sensitivity
- BG falls <50 mg/dL 2-5 hrs after eating
- Goal: prevent major rise in glucose that would stimulate more insulin
- Diet: Avoid simple sugars, 5-6 small meals, spread CHO intake throughout the day
75
Addison's Disease
- Adrenal cortex insufficiency
- Absence of adrenal hormones and adrenal cortex atrophies
- Decreased cortisol: glycogen depletion, hypogly
- Decreased aldosterone: Na loss, K retention
- Decreased androgenic: tissue wasting
-Diet: High protein, high salt, frequent feedings
76
Hyperthyroidism
- Excess thyroid hormone secretion
- Increased T3 AND T4
- Increased BMR = weight loss
77
Hypothyroidism
- thyroid hormone deficiency
- Normal or LOW T3 and LOW T4
- Decreased BMR = weight gain
78
Goiter
-Enlargement of thyroid gland due to insufficient thyroid hormone
79
Gout
- Disorder of purine metabolism
- increased serum uric acid levels may lead to gout
-Diet: Low purine may not be effective; Avoid high purine foods --> i.e. anchovies, broth, and sardines
80
Inborn Errors of Metabolism
```
Galactosemia
Urea Cycle Defects
Phenylketonuira
Homocysteinurias
Maple Syrup Urine disease
```
81
Galactosemia
- Due to missing enzyme that converts galactose into glucose
- Tx by DIET ONLY! NO Galactose or lactose!!!
82
Urea Cycle Defects
- Unable to synthesis urea from ammonia = increase ammonia in the blood
- Diet: protein restriction (based on tolerance) to lower blood NH3 levels
83
Phenylketonuria (PKU)
- Missing enzyme phenylalanine hydroxylase --> converts phenylalanine into tyrosine
- Accum of phylalanin can result in poor brain function
- Need for PHE decreases with age and infection
- Children with PKU have higher incidence of dental caries due to high CHO and LOW protein diet
-Diet: restrict PHE -- but still need some to promote growth
84
Homocysteinurias
- Disorder of AA metabolism
- Increase in methionine and homocysteine in blood
- Increased homocysteine in urine
- Associated with LOW levels of FOLATE, B6, B12
-Tx: Provide folate, B6, B12 at high doses
85
Maple Syrup Urine Disease
Error of metabolism of BCAA (leucine, isoleucine, and valine)
-Diet: Restrict BCAA
86
Arthritis
inflammation of peripheral joints
- Diet: wel balanced with vitamin intake to meet min of DRI
- Anemia is common -- NOT due to diet --> duet to inflammation of joints preventing reuse of iron, supp does not Tx this
87
Systemic Lupus Erythematosus (SLE)
- Anemia r/t disease, not diet
| - May have symptoms of celiac disease
88
Osteoporosis
- Loss of bone tisue
- Lower incidence in black than white wmn
- Highest risk: old, frail, white women
- Causes: protein malnutrition, lack of exercise, decline in estrogen
-Tx: hormone replacement therapy and weight bearing exercise; vit D 400-800 mg and Ca >1200mg supp
89
Osteomalacia
- Adult rickets
- Decreased bone density due to vit D deficiency
- Vit D and Ca supp
90
Neurological Disorders
```
Epilepsy
Cerebral palsy
paralysis
hyperkinesis/hyperactivity
alzheimers disease
```
91
Epilepsy (seizures)
- Anticonvulsants: phenobarbital and phenytoin interfere with Ca absorption
- -> may need Ca and Vit D supp
- ->EN decreases bioavailability of phenytoin -- hold TF >2 hours after administration of med
- Ketogenic Diet: HIGH fat, LOW carb (4:1)
- ->ketone bodies as as inhibitory neurotransmitters and may stop seizures
- Supp: Ca, D, folate, B6, B12
92
Cerebral Palsy
- Spastic Form: rigid, limited acitivty -- obese
- Non-spastic form (athetoid): constant, spastic, irregular motions -- weight loss
- Diet: high kcal, high protein; likely need finger foods
93
Paralysis
Can result in pressure ulcers:
- High kcal and high protein (1.2-2gm/kg)
- Normal intake of Ca
- Adequate fluids
- May supp: vit c, Zn, Vit A
94
Microcytic Hypochromic Anemia
SMALL (low MCV) and PALE (low MCH) cells
- Due to iron deficiency
- R/t chronic infections, malignancies, renal disease
95
Macrocytic Megaloblastic Anemia
FEW LARGE (high MCV) and RED (high MCH) cells
- Due to folate OR B12 deficiency
96
Schilling Test
-Tests for B12 deficiency -- pernicious anemia
97
MCV = mean corpuscular volume
```
Normal = 80-95
Low = small cells
High = large cells
```
98
MCH= mean corpuscular hemoglobin
```
Normal = 27-32 pg
Low = pale
High = bright red
```
99
Foods high in iron
Liver, kidney, beef, dried fruit, leafy greens, fortified whole grains
100
Allergies
- Immunoglobumin E = food allegy
- Most common food allergens: wheat, soy, shellfish, peanuts, tree nuts, milk, eggs
- Cows milk = most common allergen for infants
- Introduce eggs at 24 mo of age
- Introduce nuts/fish at 36 mo of age
- Rice: least likely food to cause allergy
-RAST: mixes serum and allergen on a paper disk and measures specific IgE antibodies
101
Fever/Infection
- Excessive fluid loss --> dehydration
- Tx: IV fluids of dextrose and water; progress towards high calorie high protein diet
- BMR INCREASES 7% for each degree increase in temp above 98.6
102
Burns
- Immediate shock period = catabolism, BMR 50-100x normal
| - First goal = replace fluids and electrolytes lost and then increase kcal and protein intake
103
Body's Response to Trauma
-Hypermetabolic and catabolic response following trauma
Release of catabolic hormones:
- catecholamines, epinephrine, norepinephrine
- ACTH
- Aldosterone
- ADH
104
Marasmus
- Protein AND calorie starvation
- diagnosed with anthropometric data
- pt. appears starved
105
Kwashiorkor
- Protein deficiency only
- Diagnosed with lab values
- Increased mortality rate
106
iatrogenic Malnutrition
-Protein-calorie malnutrition due to treatments, hospital stay, and medications
107
Bariatric Surgery
- Class III obesity with BMI >/= 40 or >/= 35 with comorbidities
- Roux-en-y: small gastric pouch connected directly to the jejunum; dumping syndrome, supplementation is needed
- Sleeve (gastroplasty) -> staples to the stomach to make it smaller
- Gastric Band: band tigthened aroudn stomach; B12, folate, and Fe supp not needed
108
Prader Willi Syndrome
- congential disorder
- elevated grehlin levels = increased growth hormone, appetite, intake, and fat mass depletion
- they don't sense satiety
- Obesity at 2-3 years + FTT
Best Tx: control access to food
109
Dental Caries
- Enzymes ferment CHO deposits on plaque -> increases acid that demineralizes surface
- pH in mouth is 5.5 --> enough acid to damage enamel
- Low cariogenic foods: high protein, moderate fat, min fermentable CHO --> cheddar cheese, nuts, meat
- Potato chips and peanut butter = cariogenic
110
Stomatitis
- inflammation of the mouth
- associated with riboflavin deficiencies
- avoid hot, cold, spicy, sour
111
Esophagitis
- Decreased gastric acidity/reflux
- Achalasia: lower esophageal sphincter doesn't relax or open upon swallowing --> dysphagia
-NDD= National Dysphagis Diet: begins with smooth pureed and moist, thick foods
112
Pregnancy Induced Hypertension
- Pre-Eclampsia --> Eclampsia
- HTN, edema, proteinuria, wt. gain
-Diet: Na restriction NOT recommended; increased Na needed due to expansion of tissue and fluid during pregnancy
113
AIDS
- Diarrhea, weight loss
- Preserve lean body mass
- Diet: high kcal, high protein, high fluids upon Dx to help boost immunity
- Peds HIV: high protein, high calorie, supplement for weight gain
- Neutropenic diet for some patients to protect against infection
114
COPD
- Persistent obstruction of airflow through lungs
- Emphysema and chronic bornchitis
Tx: maintain stable weight; increased energy to breath; replete but DON"T overfeed
115
ARDS
-Meet basic nutritional requirements and maintain weight to facilitate weaning from vent
