Medical Nutrition Therapy Flashcards
What does a low CBC tell us?
Anemia
What should our albumin levels be?
lower than 3.4
What should our cholesterol levels be?
lower than 160
With a very low LDL
WHat are some instances where we would need to supply nutirtional support to patients?
- Bowel not functioning normally
- Severe prolonged hypercatabolic states (burns, multiple trauma, mechanical ventilation- all change metabolic state significantly-ICU patients)
- Prolonged bowel rest required
- Severe protein-calorie malnutrition who have had a loss of over 25% of body-weight
What is hypercatabolic and what kind of situations would it occur?
- breakdown of molecules in the body to produce energy
- Severe prolonged hypercatabolic states (burns, multiple trauma, mechanical ventilation- all change metabolic state significantly-ICU patients)
Where does IV nutrition (parenteral) from a central line dump into?
dumps right into the right atrium
When determining the need for a enterostomy what perameters would you need?
2
The GI tract works and is it safe to use
Nutritional support needed for longer than 6 weeks
When detemining the need for a nasogastric tube what parameters would you need?
3
The GI tract works and is it safe to use
Nutritional support needed for less than 6 weeks
The patient is not at a high risk of aspiration
When detemining the need for a nasoduodenal tube what parameters would you need?
3
The GI tract works and is it safe to use
Nutritional support needed for less than 6 weeks
The patient is at a high risk of aspiration
When determinging the need for parenteral nutrition what parameters would you need?
The GI tract is does not work and/or not safe to use
If you determined the need to parenteral nutrition what procedure would you do?
Placement of a central venous catheter
When do we start enteral nutrition?
within 48 hours (of whatever condition started the patients problem)
What have studies shown about introducing enteral nurition earlier rather than later?
may decrease the incidence of infection in critically ill patients if provided early in the course of the critical illness.
When do we start parenteral nutrition?
Exact timing when to start parenteral nutrition is unclear but the optimal time is within 1-2 weeks unless otherwise indicate
What have studies shown about introducing parenteral nutrition earlier rather than later?
Early TPN in critically ill pts may increase the incidence of infection and does not reduce mortality.
Indications for eneteral nutrition?
Oral intake insufficient to meet estimated nutritional needs with a functional GI tract
Contraindications for enertal nutrition?
7
- Hemodynamically unstable and have not been fully volume resuscitated (due to risk of bowel ischemia) - not increasing blood pressure because youre thinking they might have a bowel ischemia so you dont want blood flowing to the Intestines. Which it is not doing when you have low blood pressure.
- Bowel obstruction
- major upper GI bleeding
- intractable vomiting (just vomit it back up)
- diarrhea (same with vomiting)
- GI ischemia
- GI fistula
Complications that could arise with enteral feeding
9
- Diarrhea (most common)
- Inadequate gastric emptying, 3. emesis,
- esophagitis,
- occasional GI bleeding
- Aspiration
- Dehydration
- Electrolyte abnormalities
- Mechanical obstruction of the tube
When would you use a nasogastric tube and when would you use a nasoduodenal tube?
Nasogastric tube
-Need to be able to sit up in bed and protect airway
Nasoduodenal tube
-If unable to sit up in bed and/or unable to protect airway
When would you use a Gastroenterostomy and when would you use a Jejunostomy?
Gastroenterostomy
-Bolus feeding, need to be at low risk for aspiration
Jejunostomy
-Distal placement so better for people who are high risks for aspiration
What does a commercially prepared enteral solution include?
7
- Water,
- energy,
- amino acids,
- electrolytes,
- vitamins,
- minerals,
- essential fatty acids
What kind of diseases need specific enteral solutions?
4
- Renal disease
- Malabsorption
- respiratory failure (> 50% of calories from fat)
- hepatic encephalopathy (increased BCA’s)
Why would people with respiratory failure need a diet high in fat?
carb metabolism byproduct is CO2
give them less carbs more fat
What are we monitoring daily with enteral nutrition feeds?
7
Daily 1. electrolytes, 2. glucose, 3. phosphorus, 4. magnesium, 5. calcium, 6. BUN and 7. creatinine until the levels are stable then you can start doing it a few times a week
What should we check monthly with enteral nutrition feeding?
4
RBC,
folate,
copper,
zinc
How do we know an image of the brain is a CT scan or an MRI?
CT scan- big white ring around it
MRI will have a thin white ring
Indications for Parenteral nutrition?
Inability to absorb adequate nutrients via the GI tract!!!!!
What would be some causes that would cause people not to be able to absorb nutrients via the GI tract?
7
- severe diarrhea
- radiation enteritis,
- massive small bowel resection, 4. complete bowel obstruction,
- GI bleeding,
- high output enterocutaneous fistula (fistula b/w small/large bowel and skin)
- hyperemesis gravidarium (severe vommiting during preganancy)
Why cant you use a peripheral vein to deliver TPN?
dont tolerate that osmotic load from TPN.
Contraindcations for parenteral nutrition
2
Functioning GI tract
Lack of Venous access
What veins can be used for TPN?
4
- Subclavian,
- internal jugular,
- femoral or
- PICC line
If long term placement of a tunneled line is indicated what would we use?
3
Groshong, Hickman, subcutaneous port
Whats in TPN feeding?
6
Contains
- dextrose, (in place of carbs)
- amino acids, (in place of proteins)
- electrolytes,
- vitamins,
- minerals and trace elements
- Lipids can be added separately or mixed in(Fats)
When writing a TPN prescirption what needs to be taken into account?
3
Determine weight
Caloric needs
Protein requirements
What weight do we use for TPN ?
Whats the exception?
Use current body weight in all cases unless patient is obese
-Obese patients use the ideal body weight
How many calories per day should we start out critically ill patients on? (TPN)
Whats our goal after a week?
start with 18 kcal/kg per day then increase gradually to a goal of 25-30 kcal/day over the course of a week.
How do we determine what kind of patients need more or less protein in TPN?
Requirements increase as the severity of the illness worsens
For a mild to moderate illness how much protein should be put in TPN?
0.8 to 1.2 g/kg/day
For critically ill patients how much protein should be put in TPN?
1.2 to 1.5 g/kg/day
Severe burns may need as high as ____ a day of protein in TPN?
2 g/kg/day
What do we monitor daily for TPN patients?
6
1. Measurement of fluid intake and output Daily electrolytes including 2. calcium, 3. magnesium, 4. phosphate and 5. renal function Blood Glucose Levels often
What do we monitor weekly for TPN patients?
2
- Liver profile
2. triglycerides
What do we monitor twice weekly for TPN patients?
24 hour urine protein
What should we watching for/what are TPN patients at great risk for?
INfections!!
What do we montitor monthly for TPN patients?
4
RBC, folate, copper, zinc
Complications with TPN?
4
- Catheter site or blood stream infections
- Metabolic derangements
- Refeeding syndrome (previously malnourished)
- Hepatic dysfunction
What are some examples of metabolic derangements?
Hyperglycemia Electrolyte abnormalities (Na, Ca, K, Magnesium, Phosphorus)
What happens in refeeding syndrome?
Abrupt decrease in K, Mg &/or phosphorus from pancreatic stimulation and insulin secretion (already at a decrease and then insulin stimulates electrolyte absorbtion so it continues to decrease)
How do we stop TPN?
NOT abruptly!
Decrease infusion by 50% for 2 hours prior to stopping
Abrupt discontinuation of TPN can cause what?
HYPGLYCEMIA
What can we use if the TPN solution suddenly becomes unavailable for tapering?
10% dextrose solution
What are the nutritional goals for patients with diabetes?
3
ABCs Lower A1C -Maintain as near-normal blood glucose levels by managing food, meds and activity levels Blood pressure control Cholesterol
5 components to the nurtition prescription for diabetes patients?
5
- Caloric intake (balanced with caloric expenditure)
- Weight loss, increased physical activity and weight management
- Consistency in day to day carb intake
- Nutritional content
- Timing of meals and snacks
Most women, sedentary men, and adults over 55 will want what kind of calorie intake for diabetes?
13 kcal/lb (ex: 180 pounds X 13 = 2340)
Sendentary women and obese adults will want what kind of calories intake for diabetes?
10 kcal/lb
What BMI do we want our Type 2 patients to be at?
25 or under
Sustained weight loss of how much can have lasting beneficial effects?
5-10%
How can weight loss help the metabolic derangements that cause DM?
Can help with insulin resistance and impaired insulin secretion
How often do we suggest that patients with DM exercise?
30 min of physical activity 5 days per week
What should our short term weight loss goals be for diabetes?
4-6 week goal lose 3-6 pounds
WHat should our long term weight loss goals be for diabetes?
Long term goal 10-20 pound weight loss
What percentage of our caloric intake should be carbs?
45-55%
900kcal/g divided by 4 = 225 grams per day
One serving of bread/starch, fruit or milk contains how many grams of carbs?
12-15 g of carbohydrate.
What percentage of your caloric intake should be saturated fat?
7%
How much cholesterol should you take in daily?
less than 200mg
What percentage of your diet should be protein?
Who should have a lower amount fo proetin in their diet?
15-20%
Renal patients
How many grams of fiber should you have per 1000 kcal?
14g
What should be your daily sodium limit?
1500mg
Why would keeping our snack and meal times consistant be important for diabetic patients?
keep glucose levels steady
What should we focus on with diet in Type 1 diabetes patients?
4
- physcial activity,
- basic healthy lifestyle,
- focus on weight loss and
- carb counting/adjusting insulin based on carb intake
Hypertension dietary restricitons?
12
- No more than 2 cups of coffee ∙ 2. Less than 2g sodium daily ∙
- 4-5 servings of fruit a day ∙
- 4-5 servings of vegetables a day ∙
- 2-3 servings of low fat dairy a day ∙
- Less than 25% of calories from fat ∙
- FIBER 20-35 g daily ∙
- Eat more fish ∙
- No more then 1 alcoholic drink per day for women/No more then 2 alcoholic drinks per day for men ∙
- Magnesium supplementation 11. Potassium supplementation ∙ 12. Fish oil
How much will our blood pressure lower if we lose 10kg?
5-20 mm/Hg
How much will the dash eating plan lower our blood pressure?
8-14 mmHg
How much will sodium restriction lower our blood pressure?
2-8 mmHg
How much could increased physical activity lower our blood pressure?
4-9 mmHg
How much could limiting our ETOH intake decrease our blood pressure?
2-4 mmHg
What does the DASH diet mean and what does it include? 5
Dietary Approaches to Stop Hypertension
- 4-5 servings of fruit a day,
- 4-5 servings of vegetables a day,
- 2-3 servings of low fat dairy, low fat diet (
What kind of diet changes would we want for hyperlipidemia?
4
- increase fruits and vegetable intake,
- low saturated fat intake,
- increase fiber
- Limit intake of dietary cholesterol to less than 200 mg per day
Mayo Clinic’s “Top 5 Foods to Lower Cholesterol”
5
1) OATmeal, oat bran and high fiber foods.
2) FISH
- Fish and omega-3 fatty acids.
- At least 2 servings of fish a week.
3) Walnuts, almonds and other NUTS.
4) Two tablespoons of OLIVE OIL a day.
5) Foods with added plant sterols or stanols that block absorption of cholesterol. Margarines, fortified orange juice and yogurt drinks. (2 g/day)
What should sodium restrictions be for patients with chronic kidney disease?
1500-2000mg/day
What should protein restrictions be for patients with chronic kidney disease?
0.6-0.8 g/kg/day
What should patients with chronic kidney disease supplement their diet with?
Calcium, vitamin D and iron
What kind of potassium intake should patients with chronic kidney disease have?
Low potassium intake
Avoid foods like: oranges, nectarines, kiwi, raisins, dried fruit, bananas, cantaloupe, honeydew, prunes
What kind of phosphate intake should patients with chronic kidney disease have?
Low phosphate intake
Avoid or limit: asparagus, avocado, potatoes, tomatoes, winter squash, pumpkin, spinach
Why limit sodium for renal disease?
Sodium can build up and contribute to fluid retention and hypertension
Why limit protein for renal disease?
Protein waste products are not processed properly (ammonia, urea, uric acid)
Why limit potassium intake for renal disease?
Potassium levels increase and can lead to arrhythmias
Why limit phosphate levels for renal disease?
Phosphate levels increase and can cause calcium to leach from the bones and lead to osteoporosis and hypercalcemia
