Midterm Flashcards
MNT definition
in-depth, individualized nutrition assessment and a duration and frequency of care using NCP to manage disease
scope of practice
- range of roles, activities, regulation in which RDNs perform
- determined by professional licensure (states)
- individual scope: your capabilities
purpose of NCP
- systematic problem solving method used to critically think and make decisions to address nutrition-related problems and provide safe, effective, high-quality nutrition care
- provides consistent structure and framework, systematic and consistent steps
- EBP, scientific principles, protocals
- outcome is improved quality of care and health status
4 steps of NCP
assessment, diagnosis, intervention, monitoring and evaluation
purpose of nutrition screening process
- “on ramp” to the NCP
- quickly identifies those who may benefit from NCP
- identifies level of nutrition risk
- high risk -> complete nutrition assessment by RD
feature of a good nutrition screening tool
- quick, easy to use, valid, and reliable for patient population or setting
- can be carried out by any trained personnel
- no lab measurements
when must nutritional screening be completed on patients admitted to a hospital
JCAHO requires within 24 hours
EBP definition
rigorous systematic methods to:
- define clinical questions
- acquire relevant research literature and evidence
- apply findings as a graded/rated clinical guidelines or recommendation
EBP components
- best available scientific research
- clinical expertise of the practitioner
- patient values and preferences
why EBP
- clinical judgement can be lacking
- research, best practices, and clinical guidelines can change
- scientific evidence isn’t always definitive. critical thinking, clinical judgements, and patient values are needed to guide decisions
- allows for patient focused care
research vs EBP
research: systematic investigation. designed to develop or contribute to generalizable knowledge. findings can contribute to EBP lit review
EBP: synthesize research with clinical expertise and patient preferences to inform a clinical decision. clinical problem can lead to a research question
nutrition assessment purpose
-systematic method for obtaining, verifying, and interpreting data needed to identify nutrition related problems, their cause, and significance
- review, cluster into domains, and compare to reliable standards
nutrition screening vs assessment
screening identifies those who require a complete assessment
5 domains of nutrition assessment
- food/nutrition related history
- anthropometric measurements
- biochemical data, medical tests, and procedures
- physical exam findings
- client history
food and nutrition related history domain
- food and nutrient intake
- energy, protein, and fluid requirements
- medication, supplements
- knowledge, beliefs, behaviors, physical activity
- access of foods/supplies
anthropometric measurements domain
- body size, weight, height, circumferences
- body shape, proportions, rations
- BMI
- body compositions
BMI equation
703 (lb/in^2) or kg/m^2
biochemical data, medical tests, and procedures domain
- measurement of nutrition markers and indicators found in blood, urine, feces, and tissue samples
- protein assessment
- immunocompetence
- hematological
- vitamin and mineral asessment
physical exam domain
- assess for signs and symptoms consistent with malnutrition or specific micronutrient deficiencies
- techniques of inspection, palpation, percussion, and auscultation are used
client history domain
- age, sex, gender, education, food security, socioeconomic data
- previous medical history and testing
- family medical history
sensitivity
- test’s ability to correctly identify people with a disease
- highly sensitive test has few false negatives
specificity
- test’s ability to correctly identify people without a disease
- highly specific test has few false positives
validity
- how well an assessment measures what it’s supposed to measure
reliability
how reliable or consistent are the measures
methods to obtain height on a patient who cannot stand
- half arm span x2
- knee height with equation
calorie count
- best for assessing actual food intake in an inpatient setting
- food weighed before and after intake, or % consumed visually estimated
- 3 day calorie count typically used
1 kg
2.2 lb
1 in
2.54 cm
ABW
actual body weight used in most situation/calculations
UBW
usual body weight used when a person has experienced significant weight fluctuations
IBW
ideal body weight used with certain protein recommendations validated using IBW
%UBW
CBW/UBW
% weight loss
(UBW - CBW)/UBW
adjusted body weight for amputations
subtract prosthetic weight
CBW/(1-%) x 100
somatic protein status indicators
- (muscle stores)
- creatinine height index (CHI)
- nitrogen balance
visceral protein status indicators
- (non skeletal muscle proteins)
- albumin
- transferrin
- prealbumin
- retinol binding protein (RBP)
- C reactive protein (CRP)
- not reliable indicators of nutritional protein status or malnutrition
acute phase protein
- proteins produced by liver in response to inflammation, infection, or damaged tissue
- inflammation markers
negative acute phase proteins
- decrease in response to inflammation, not valid indicators of malnutrition
- albumin
- transferrin
- prealbumin
- RBP
positive acute phase proteins
- C reactive protein
- ferritin
- hepcidin
starvation related malnutrition
pure chronic starvation, anorexia
acute disease or injury related malnutrition
major infection, burns, trauma, closed head injury
chronic disease related malnutrition
organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity
6 AAIM criteria
- insufficient energy intake
- weight loss
- loss of muscle mass
- loss of subcutaneous fat/body fat
- fluid accumulation
- hand grip strength
- need 2/6
muscle loss assessment
- temple
- quads, patellar
- calves
- clavicle, pectoral, deltoid
- scapular
- dorsal hand
fat loss assessment
- orbital
- cheek
- triceps, biceps
- thoracic, lumbar, ribs
how is fluid retention related to malnutrition
- pitting edema may be a sign of hypoproteinemia (low protein)
- edema can mask signs of fat and muscle loss
- legs, arms, ascites
how is metabolism affected by stress
- everything ramps up
- inflammation
- increase in metabolic rate, energy needs, body temp, blood glucose
- catabolism of lean mass
- major fuel source: protein -> gluconeogenesis
how is metabolism affected starvation
- everything slows down
- no inflammation
- decrease in metabolic rate, energy needs, body temp, blood glucose (normal-low)
- preservation of lean mass, protein stores are protected
- major fuel source: fat -> ketones
3 phases of the metabolic stress response
ebb, flow, recovery
ebb phase
- immediately after injury (2-48 hours)
- shock hypovolemia
- tissue hypoxia
- decreased cardiac output, urinary output, oxygen consumption, body temperature
- hemodynamically unstable
flow phase
- 36-48 hours after injury until 7-10 days
- catabolism
- increase positive acute phase proteins, decrease negative
- hormonal and immune responses
- increased cardiac output, oxygen consumption, body temperature, energy expenditure, protein catabolism
- hemodynamically stable
- hypermetabolic
- provide enough energy and protein substrates to protect function and repair tissue damage
recovery phase
- 7-10 days after injury until months
- lost tissue is restored
- body restores to normal function
- anabolism
purpose of MNT during metabolic stress
- important to consider the patient’s primary medical diagnosis along with accommodations for the metabolic changes that have occurred
- establishing hemodynamic stability
glycemic control - balance between prevention of malnutrition and prevention of the possible complications of providing nutrition support
purpose of nutrition diagnosis
- direct link between nutrition assessment and nutrition intervention
- identifies a specific nutrition problem that can be resolved/improved by the RD with nutrition intervention
- not a medical diagnosis
three domains of nutrition diagnosis
intake (preferred), clinical, behavioral-environmental
when would an intake domain diagnosis not be the preferred domain
when the primary nutrition problem is clearly related to a clinical condition or a behavioral factor
three parts of PES statement
problem, etiology, signs and symptoms
problem in PES
- diagnositic eNCPT term that describes an alteration in the client’s nutritional status
- “altered” “excessive” “inadequate”
- RDN must be able to impact this problem
etiology in PES
- factors related to root cause or existence of problem
- intervention is aimed at adressing/resolving or minimizing this underlying cause
- causes the problem
signs and symptoms in PES
- defining characteristic obtained from subjective and objective nutrition assessment data
- data used to determine a problem exists and provides evidence
- intervention is directed at improving this
- provides rationale for ideal goals and outcomes. measuring will indicate if the problem is improved
- specific enough to be measured
PES format
P related to E as evidenced by S
factors that make a strong PES
- clear and concise
- select the most urgent problem
- intake domain preferred
- specific to the patient
purpose of nutrition intervention
- purposeful, planned action intended to improve or resolve a nutrition problem by addressing the underlying cause (etiology)
- if the RDN cannot impact the etiology through nutrition intervention, then the intervention is directed toward improving the signs and symptoms
two stages of the nutrition intervention
planning, implementation
planning stage of nutrition intervention
- prioritize nutrition diagnosis (PES)
- write nutrition prescription
- set goals
- select nutrition intervention
domains of nutrition intervention
- food and/or nutrient delivery
- nutrition education
- nutrition counseling
- coordination of nutrition care
nutrition prescription
- essential first component of the nutrition intervention
- concisely communicates the RD’s diet recommendation based on a nutrition assessment
- includes recommendations for energy, selected nutrients, and/or selected foods
first thing you do in the planning stage of nutrition intervention
prioritize the nutrition diagnosis (PES)
nutrition education
- instruction or training intended to lead to nutrition related knowledge
- group classes, individual instruction, written instruction, or via phone/electronic communication
- outpatient setting is more conducive to education
- in acute-care setting, more content focused
- quickly useable content and straight forward instructions
nutrition counseling
- supportive process, characterized by a collaborative counselor-client relationship
- establishes goal setting and individualized action plans
purpose of monitoring and evaluation
- determine the degree of progress being made and whether the client’s goals or desired outcomes of nutrition care are being achieved
- is the nutrition intervention strategy working to resolve the nutrition diagnosis, its etiology, and/or its signs or symptoms
- involves reassessment
resolved
the nutrition problem no longer exists
improvement shown
nutrition problem still exists but with positive progress toward goal
unresolved
no improvement shown in the nutrition problem
no longer appropriate
change in condition where the nutrition problem and intervention is no longer appropriate/relevant
examples of therapeutic diets found in the hospital setting
texture modified diets, fluid restricted diets, clear liquid diet, full liquid diet, high fiber diet
diet liberalization
- modified therapeutic diet that relaxes restrictions to allow people to eat food they enjoy while still remaining healthy
- potentially leads to improved nutritional intake
some ways a hospital diet could be modified to include more energy
- add butter, margarine, jam, jelly, honey, whole milk, cream, sour cream, yogurt, nut butters, cream cheese
some ways a hospital diet could be modified to include more protein
add powdered milk, liquid egg substitutes, nuts, nut butters, chopped meats, cooked eggs, cheese, yogurt, tofu, soy crumbles
purpose of texture modified diets in the hospital
- for people with chewing and swallowing difficulties
- reduce risk of choking and aspiration
IDDSI framework
- international set of descriptors describing texture modified foods and thickened liquids for people with eating, drinking, and swallowing problems (dysphagia) across the lifespan
clear liquids
- intended to supply fluid and energy in a form that requires minimal digestion and stimulation of the GI tract
- not nutritionally adequate
- should be limited to 24-48 hours unless supplements are added
- research evidence does not support long term use
purpose of fasting prior to surgical operations
minimize risk of aspirations
current best evidence based guideline for feeding post operatively? rationale?
- improved patient recovery with initiation of a general diet post operatively without transitional clear and full liquid diets
- helps maintain gut function, reduce complications, and improve overall recovery by minimizing the stress response to surgery and promoting faster return to normal eating habits
enteral nutrition
- aka tube feeding
- providing nutrition directly into the GI tract
parental nutrition
- intravenous (IV) nutrition
when is EN needed
- inability eat/eat enough
- impaired digestion, absorption, metabolism
- inadequate oral intake 7-14 days
- gut works
benefits of EN
- cost effective
- reduced length of hospital stay
- reduced need for surgical interventions
- reduced incidence of infectious complications in critically ill patients
- improved wound healing
- maintenance of GI function
contraindications of EN
- illeus: lack of movement of the intestines
- complete obstruction of small or large bowel
- severe diarrhea without response to medication
- intractable vomiting
- high output external fistula
- hypovolemic or septic shock
- very poor prognosis
- patient’s wish
why is EN preferred to PN
- safer, more cost effective, easier on the body
- if the gut works, use it
short term vs long term for EN
4 weeks
short term access routes
NG tube through nose, OGT through mouth
long-term access routes
PEG through stomach, jejunostomy through small intestine
prepyloric feeding
- delivering nutrition into stomach
- standard method
- NG tube, PEG
post-pyloric feeding
- delivering nutrition past the pyloric valve, into the small intestine
- used when gastric emptying is impaired, high risk of aspiration, severe gastric reflux, intestinal surgery history
- ND tube, jejunostomy
