MNT 2 - Exam #1 Flashcards
What is the Nutrition Prescription?
Concise statement of plan to best meet patient/client’s nutrition needs (developed by the RD)
What is the Nutrition Prescription NOT?
the admit/current diet order (MD orders)
What is the PURPOSE of the Nutrition RX?
To communicate RD’s nutrition/ diet recommendations (based on complete assessment)
What is found within the Nutrition RX?
- Content should be related to the PES statement;
- EX: if problem= inadequate energy intake, then nutrition RX should address meeting energy needs;
- Enmount of desired weight gain/specific time period (ie:wk)
What should the RX include?
- Energy level;
- Amount of desired weight gain/specific time period (i.e.:wk);
- May include specifications of:
- meals & snacks
- supplemental feedings;
- enteral feedings;
- Environmental changes to promote intake;
- % energy from specific macronutrients
Items from the IDNT that might be in the RX:
- Number, size, frequency of meals;
- Macronutrient rec’s (specify gm/day or %kcal);
- Micronutrient rec’s ;
- Bioactive substances;
- Texture/ consistency of solid or liquids;
- Liquid diet (ie: clear/ full);
- Food groups/ exchanges/ servings;
- Enteral/ parenteral feedings (specify formula/solution, rate, access, schedule)
What are the 4 categories of Intervention Strategies?
- Food and/or Nutrient Delivery
- Nutrition Education
- Nutrition Counseling
- Coordination of Nutrition Care
* *Use IDNT terminology
What are some CLINICAL goals for Monitoring/Eval?
- Weight gain/loss (specify amt/time frame);
- Protein status: biochemical indicators, physical findings, body composition;
- Biochemical Assessment(LDL C, serum glu,Hgb A1C);
- Hydration status indicators: biochemical, physical findings, anthropometrics, cognitive function
What are some BEHAVIORAL goals for Monitoring/Eval?
- Change in eating behavior (e.g. increasing fruit and vegetable intake);
- Change in nutrition knowledge/ awareness ;
- Change in environment/continuum of care?;
- Provision of nutrient intake (ie: energy intake, enteral/parenteral feedings)
What is Enteral Nutrition?
- Feeding through the GI tract via a tube, catheter, or stoma that delivers nutrients distal (after) the oral cavity → Nutrient intake that is NOT consumed orally;
- “Enteral or Tube Feeding”;
- NO “volitional” intake
What are the indications for the need of Enteral Nutrition?
**FUNCTIONAL GI tract, but cannot adequately feed (orally) themselves;
Recommended for patients:
-Altered mental status;
-Swallowing dysfunction;
-Upper GI disorders → Bypass by insertion of tube past dysfunction
What Nutrition Diagnoses could indicate Enteral Nutrition?
- Malnutrition;
- Increased energy expenditure;
- Involuntary weight loss;
- Inadequate oral food/beverage intake ;
- Inadequate fluid intake ;
- Increased nutrient needs;
- Biting/chewing difficulties;
- Impaired swallowing;
- Impaired nutrient utilization
What are the CONTRAINDICATIONS to Enteral Nutrition?
**DO NOT utilize enteral tube feeds;
Serious medical conditions of GI tract =
-Diffuse peritonitis (inflammation/infection of the peritoneal lining of abdominal cavity);
-GI bleeding;
-Obstruction or ileus that prevent passing of intestinal contents;
-Intractable vomiting or diarrhea not responsive to medical treatment
ADAVANTAGE of Enteral Nutrition
- Cost-effective;
- Reduced hospital stay;
- Reduced surgical interventions;
- Reduce rate of infectious complications in critical care patients;
- Improved wound healing;
- Maintenance of GI function
When might Enteral be used along with Parenteral Nutrition?
- Even when pt. cannot meet all nutritional needs through EN, trophic or “trickle” may be prescribed with parenteral to minimize villous atrophy and prevent bacterial translocation → Keeps protective villi alive and maintains immunity ;
- “Use It or lose it”
DISADVANTAGES of Enteral Nutrition
-Potential difficulty of administration;
-Poor tolerance;
-Difficulty meeting nutritional requirements
→ Minimize disadvantages by careful patient selections through nutrition physical and standard protocols
What decisions need to be made about implementing Enteral Nutrition?
- GI Access;
- Formula;
- Delivery schedule;
- Duration
What is a Nasogastric tube feed?
Nose → stomach;
- Normal GI function;
- Stimulates normal digestion;
- Meds can be placed in tube;
- Bedside insertion;
- Can potentially cause aspiration, discomfort, nasal irritation and tube displacement
What is a Nasoduodenal tube feed?
Nose → duodenum (intestine);
- Normal SI function, but need to bypass stomach;
- Tube insertion bedside;
- Can lead to discomfort and tube displacement
What is a Nasojejunal tube feed?
Nose → ileum (intestine);
- Normal SI function, but need to bypass stomach;
- Tube insertion bedside;
- Can lead to discomfort and tube displacement
What is a Gastrostomy tube feed?
Directly into stomach (surgically through skin);
- Normal GI function but need to bypass upper GI;
- Long-term feeding access;
- Reduced risk of tube displacement;
- Allows bolus feedings;
- Surgical procedure accompanied with possible irritation or infection
What is a PEG (percutaneous endoscopic gastrostomy)?
Directly into stomach (laparoscopic through skin);
- Normal GI function but need to bypass upper GI;
- Long-term feeding access;
- Outpatient procedure w/o anesthesia;
- Less expensive and lower risk of displacement;
- Allows bolus feedings;
- Risk of irritation and infection
What is Jejunostomy tube feed?
Directly into jejunum (through skin);
- Normal GI function but need to bypass part of GI;
- Long-term feeding access;
- Surgical procedure with risk of irritation and infection;
- Small lumen of tube, so risk of clogging increased
What needs to be assessed to determine the appropriate formula for Enteral feeding?
- Medical diagnosis;
- Nutrition diagnosis;
- Labs;
- Skin breakdown;
- Weight (weight loss/gain);
- Tolerance of previous tube feedings;
- Risk of aspiration;
- Vomiting/diarrhea;
- PO or NPO;
- Activity
What are the most common formulas used for Enteral Feedings?
- Jevity
- Jevity 1.2
- Jevity 1.5
Other formulas
- Glucerna 1.0, 1.2, 1.5;
- Suplena;
- Nepro;
- Hi-Cal;
- Optimental
What the 3 different type of delivery schedules for Enteral Feeding?
- Enteral nutrition delivery is usually regulated by a small, programmable feeding pump;
1. Bolus;
2. Intermittent;
3. Continuous
- Enteral nutrition delivery is usually regulated by a small, programmable feeding pump;
What are Bolus Feedings?
- Rapid administration of formulas of 240-480 ml of formula several times a day;
- Calculate amount needed in number of cans per feeding and how many times per day
- Example: 2 cans three times/day and 1 can HS = Mimics 3 meals and a bedtime snack
- Note: 1 can = 240 ml
When might bolus feeding be appropriate?
–
What are Intermittent Feedings?
- Administered several times a day;
- Administered a little slower than bolus;
- Usually over 20-30 minutes;
- Uses a pump to administer formula;
- If a pump is not available then can use gravity drip
What are Continuous Feedings?
- Administered over 8-24 hours daily;
- Uses a pump to control the feeding rate;
- Preferred in acute care settings;
- GI tolerance is best with continuous feedings;
- Disadvantage: limited mobility
- -How to overcome- adjust feeding schedule to feed over 8-12 hours rather than 24 hours
When should Continuous Feedings be chosen?
- Pt often has residuals;
- Cannot tolerate large amounts of volume at a time;
- Bedbound;
- Not active;
- NPO;
- Not attending rehab therapy
How should a Continuous Tube Feed be INITIATED?
If a NEW TF patient =
Start at 45-50 ml/hr and progress by 10-20 ml/hr every 8 hours until goal rate is obtained
How should a Bolus Tube Feed be INITIATED?
If a NEW TF patient =
- Initiate 120 ml (1/2 can) every 3 hours for 2 feedings;
- Then increase by 120 ml every 2 feedings to final goal volume per feeding
How are water needs determined with CONTINUOS Tube Feeds?
*Need to determine if the pump AUTO FLUSHES
If the pump auto flushes…
- If so, the pump will automatically provide 25 ml of water/hour;
- This will provide an additional 600 ml of water/24 hours;
- Make sure this provides enough fluid for patient
How would you check to see if provision of fluid is adequate?
–
What is the pump does NOT auto flush for a Continuous Tube Feed?
- Determine the amount of water provided by the formula;
- Subtract amount of water provided by formula from fluid needs you have calculated for the patient
Example of Water Calc (NO auto flush)
- Fluid needs calculated = 1800 ml/day;
- Water in formula provides 1150ml/day;
- Difference is 650ml;
- Divide 650 by 3 = 217ml/flush;
- Round to nearest 25ml = 225 ml/flush;
- 225ml/flush X 3 = 675 ml water provided by flushes + 1150 water provided by formula = 1825 ml total water
What is the most a Water Flush should ever be?
Water flushes should not exceed 275-300 ml/flush → Typically 150-175 ml/flush 3-4 times a day (TID or QID)
How should water flush recommendations be written?
- Flush 225 ml water 3 times/day to provide a total of 1825 ml/day
- OR - Could be 175 ml 4 times/day to provide a total of 1850 ml/day
How are water flushes determined for BOLUS Feedings?
- Calculate the amount of water provided from total number of cans given per day;
- Subtract the amount of water in formula from estimated fluid needs;
- Write the recommendation the same as continuous feeding
* *All water flushes should be rounded up to the nearest 25, 50, 75, or 100 ml
What is monitored for tolerance of Tube Feeds?
1. Residuals; 2 Intake/Output; 3. Nausea/Vomiting; 4. Diarrhea/Constipation; 5. Weight; 6. Labs; 7. Aspiration
What are Residuals?
-Undigested feeding solution remaining from previous feeding;
-May result from =
•High volume
•High rate
•Not tolerating a specific formula
How often are Residuals checked?
- ~every 4-6 hours;
- MDs write order to stop feeding if =
1. residuals are > 1.0-1.5 times the hourly rate or
2. > 150 ml before the next bolus or intermittent TF - *Controversial topic
- You need to monitor nurses notes;
- If residuals are too high, TF may be held
How is Intake/Output used to monitor tolerance?
- If intake > output, could be dehydrated;
- → increase flushes or change formula (that is less concentrated so lower kcal/ml)
How is Nausea/Vomiting used to monitor tolerance?
- Decrease volume by increasing kcal/ml ;
- Change formula to a higher kcal concentration;
- Example: Change Jevity 1.2 to Jevity 1.5;
- Spread out the flushes;
- Spread out the bolus feedings
How is Diarrhea/Constipation used to monitor tolerance?
- Change formula with more fiber;
- Check medications;
- Consider possible bacterial etiology (diarrhea)
What labs are check for tolerance of Tube Feed?
- Glucose, BUN, Cr, K, Na…;
- May need to change formula;
- Increase flushes or even decrease flushes if over hydrated;
- Medications may need to be adjusted;
- Monitor for dehydration or even over-hydration
How is aspiration monitored for tolerance of tube feed?
- Look in nurses notes;
- Xray results, formula coming out of mouth or out of tube;
- HOB at or > 30 degrees;
- Continuous feeding may help improve aspiration or decrease risk of aspiration
What are the characteristics of a successful nutrition counselor?
- Respect all clients;
- Be genuine = real person;
- Consider client’s feelings, experiences, beliefs;
- Be flexible, non judgmental, optimistic;
- Consider client’s role in family, culture;
- Provide structure – explain what you will do/ why/ how
How do you establish rapport?
- Use open ended questions (Begin with “what”, “why”, “how”; “Can you tell me more about….?”);
- Share control;
- Demonstrate sincere concern;
- Utilize active listening → Clients often need to talk/ express feelings;
- Watch for non verbal responses
What are the component of effective communication?
- Listening sensitivity vs. information expert;
- Body language shows client is important ( Eye contact, Posture, gestures);
- Terminology client can understand → Use handouts! ;
- Don’t argue or insist / roll with resistance;
- Be open;
- Encourage discussion/ explore why patient is resistant
What is the traditional model of RD counseling?
- Used same intervention technique for everyone;
- Used change process matched to action and maintenance stages;
- PROBLEM: many clients in pre-action stage/ not ready to change;
- RESULT: POOR success!
What are the current counseling guidelines?
- Assess readiness to change;
- Raise awareness of disease, diet concerns (discuss how nutrition “can help with” …);
- Address client concerns;
- Correct misinformation (be non judgmental);
- Provide education
What are the stages of change/
- Pre contemplation (client not aware of problem/ needs info)
- Contemplation (ambivalence/ discrepancy/ to change or not to change)
- Preparation (identify options/set short term goals/ action plan)
- Action (client engages in actions of change)
- Maintenance (provide support, additional education/ revise goals, action plan)
- Relapse (normal / anticipate/ restart change process)
What else can help the patient?
- Help client visualize self in healthy lifestyle → Privilege vs punishment;
- Identify unhealthy behaviors and healthier alternatives;
- Identify unhealthy thoughts/ attitudes and strategies for change (CBT);
- Realistic goal setting (1-2 behavioral goals)
How do you identify unhealthy behaviors and strategies?
- How to change environment (Stimulus control);
- Strategies for healthier food and exercise choices
What is realistic goal setting?
- Acceptable, Achievable , Appropriate;
- Using guidelines presented, emphasize client choices re: action plan;
- Ask what client is willing to change (remember, most people don’t want to change; can negotiate such as reducing # soft drinks). ;
- Discuss options for goals (present to client in writing if possible);
- Example: If you have identified need to increase F/V, decrease sodium, increase dairy, patient can identify a category they would prefer to start with.
What are tools that can be used in counseling?
- Self monitoring tools = Offer possibilities: what they are, how they work;Client participates in choice of tools, frequency used;
- Support sense of self efficacy → Help client identify small successes in past and present;
- Follow up plan- develop with client;
- Relapse Management;
- On going support
What should a counselor DO?
- Choose/develop handouts carefully (quality vs quantity);
- Be creative with handouts: think color, interest, easy to read;
- Utilize form/contract to document goals with client;
- Place educational information in front of client
What should a counselor AVOID?
- saying “on a diet”;
- reading your PES statement to the client;
- using “ words” like “intaking”;
- referring client to internet source for basic information you should be providing;
- using .coms as additional resources
What should/not be in a sample menu?
- Do not include deli turkey or fruited yogurt;
- Foods should be healthy, yet accessible;
- Consider client schedule, time, use of restaurant food, budget, familiar foods, family meals; - Look over menu with client and allow for questions and requests for changes;
- Though you will not have time to go through each menu item, you should focus on a few specific areas of the menu and be willing to adjust according to patient preferences or schedule.; - Leave room on menu to make adjustments with client during session
How common is CVD in the US?
- *CVD remains the leading cause of death in U.S=
- estimated 1 in 3 adults in U.S. have one or more types of CVD;
- even though relative rate of death from CVD declined by 32% from 1999-2009, 1 in every 3 deaths still attributed to CVDl;
- “The total direct and indirect cost of CVD and stroke in the United States for 2009 is estimated to be $312.6 billion”
What causes a large portion of death from CHD?
- More than ½ of the deaths from CHD are related to ISCHEMIA (impaired blood flow) → From constriction or obstruction;
- Most CVD deaths seen with older persons (>65yrs), 1/3 of deaths occur prematurely (in persons <75yrs per above reference);
- Almost 50% of decrease due to identification of risk factors;
- Remainder due to treatment (includes Increased detection/mgt of HTN)
What is the Specialized Conduction System of the Heart?
- Electrical activity initiated in the heart at the SA node.;
- The change in electrical energy potential (depolarization) in SA node causes atria to contract.;
- Depolarization carried from atria to ventricles by AV node.;
- Depolarization of AV node is carried into the ventricles by bundle of His which splits into rt.;
- And L branches.;
- Depolarization is spread through ventricles by Purkinje fibers
What is the Cardiac Cycle?
-Repeating contraction/relaxation of the heart:
1. Systole (contraction )
2. Diastole (relaxation)
= Force exerted on the walls of blood vessels during contraction and relaxation of the VENTRICLES: “systolic blood pressure” and “diastolic blood pressure” respectively
What is Stroke Volume?
volume of blood ejected with each contraction of LV
What regulates Stroke Volume?
-End-diastolic volume (EDV) ;
-Mean arterial blood pressure (MAP);
- Strength of ventricular contraction
→ All additively contribute to the volume of blood ejected!!
What is End Diastolic Volume (EDV)?
How much blood is in the left ventricle at the END of relaxation period (prior to next contraction)
What is Mean Arterial Pressure?
- average force of the blood against the wall during the cardiac cycle;
- regulated by cardiac output and total peripheral resistance
What is the Ejection Fraction?
- Percentage of the blood within the left ventricle that is ACTUALLY ejected during contraction → used to determine the functioning of the heart;
- A small ejection fraction can lead to enlargement of the heart, due to the attempt to pump more blood; Largely due to increased resistance of circulation
What is involved in the regulation of Mean Arterial Pressure?
- Sympathetic/ parasympathetic nervous system
— Parasympathetic – decreases heart rate
— Sympathetic – increases heart rate - Renin-angiotensin system
- Renal function — Renin is secreted by the kidneys!
What hormones are involved in the regulation of MAP?
- Epinephrine
- Vasopressin
- Angiotensin II
How does Epinephrine affect MAP?
–
How does Angiotensin II affect MAP?
–
How does Vasopressin affect MAP?
–
What are the purposes or differences in the JNC 7 and JNC 8?
- Publication of many new studies.;
- JNC 7 were NOT all randomized control trials, but JNC 8 are ALL randomized control trials;
- Need for a new, clear, and concise guideline useful for clinicians.
- Need to simplify the classification of BP.
What were the changes between the JNC6 and the JNC7?
-JNC 7 Normal BP 120/160/>100 (no more stage 3)