Topic C: Planning and Intervention Flashcards
Health and wellness promotion and risk reduction programs
Community intervention programs are divided up into three categories
- Primary Prevention Programs
- Secondary Prevention
- Tertiary Prevention
Health Promotion
Which prevention program reduces exposure to a promoter of disease
early risk screening for diabetes
Primary prevention programs
Bringing fruits and vegetables to schools
Fixing problem before it starts
Risk Reduction
Which risk reduction level includes recruiting those with elevated risk factors into treatment program
Slow progress to restore health
Reduce impact of a condition that has already occurred
Secondary Prevention
setting up an employee’s gym
specifically for those at risk
Rehabilitation efforts
Which prevention level?
as disease progresses, intervention to reduce severity, manage complications
(cardiac / stroke programs)
Tertiary prevention
those with disease and helping manage
Discharge plan begins on
Day 1 of a hospital stay
Gastrointestinal disorders
Ulcer/Peptic Ulcer tx/medications
1. ____
2. ____ to eradicate Helicobacter pylori bacteria
eroded mucosal lesion
Follow a CAP free
antacids, antibiotics to eradicate Helicobacter pylori bacteria
H. pylori is the cause of most ulcers
diet: as tolerated, well-balanced) avoid late night snacks
What to omit when ulcers presnet:
* ____and _____
* large amounts of ____
* avoid excess ____,____ and_____
cayenne and black pepper, large amounts of chili powder, avoid excess caffeine and alcohol, cocoa
gatric irritants
Gastrointestinal disorders
Hiatal hernia diet order includes small, bland feedings and avoiding what 4 things
protrusion of portion of the stomach above the diaphragm into the chest
- late night snacks
- caffeine
- chili powder
- black pepper
heart burn is the main symptom
occurs after a gastrectomy (Billiroth I, II)
Dumping syndrome symptoms (5)
not able to handle dissacharides (lactose)
cramps, rapid pulse, weakness, perspiration, dizziness
patient will feel these symptoms along with the feeling of fullness
Diet order for Billiroth I (gastroduodenostomy) and Billiroth II (gastrojejunostomy)
- frequent small, ______, ____ before or after meals (to slow passage)
- restrict _____ concentrated sweets
- give _____ complex CHO
- _____ at each meal
- moderate fat
- ____ injections may be needed
- _____ may be poorly tolerated due to rapid transport
- dry feedings, fluids before or after meals (to slow passage)
- restrict hypertonic concentrated sweets
- give 50-60% complex CHO
- protein at each meal
- moderate fat
- B12 injections may be needed
- Lactose may be poorly tolerated due to rapid transport
dissaccharide may decrease
whey still may be OK
Dumping Syndrome
Following a complete gastrectomy, which deficiencies can occur
* 7 nutrients:
* decreased pancreatic secretion =
-iron, B12, folate, calcium, vitamin D, B1 and copper
- steatorrhea
B12 deficiency= anemia (folate deficiency will follow)
B12 deficency d/t loss of intrinsic factor
Gastroparesis is
food sits in stomach too long; stomach muscles can’t move down food
delayed gastric emptying due to surgery, diabetes, viral infections, obstructions
moderate to severe hyperglycemia causes detrimental effects on gastric nerves and is the symtom for
Gastroparesis
may slow gastric emptying w/ long term effects on motility
Gastroparesis Tx.
a. prokinetics (_____, metoclopramide) which increase stomach contractility and slows ______
b. small, frequent meals
c. _____ foods
d. avoid high fiber, avoid ____
e. avoid (5)____
a. (erythromycin) slow gatric emptying time
b. small, frequent meals
c. pureed foods
d. high fat (liquid fat may be better tolerated)
e. avoid caffeine, mint, alcohol (acidic), carbonation
Foods high in fat delay gastric emptying (ex: corned beef)
Rice OK to eat
Treatment for Diverticular disease
Fiber includes (3 things)
provides indigestible bulk, promotes intestinal function
M: 38 g F: 28 g
- dietary fiber
- oat bran
- soluble fiber
oat bran and soluble fiber decrease serum cholesterol by binding bile acids = converting more cholesterol into bile
Dietary fiber functions
increases water absorption from the intestine
nondigestible CHOs and lignin
binds water, increases fecal bulk
low fiber diet may cause constipation
high fiber diert may decrease the need for Ca, Mg, P, Cu, Zn, Fe
Dietary fiber sources
(4 food sources)
includes oats, beans, and bran cereals
a. legumes (cellulose, hemicellulose)
b. wheat bran (cereal grains- cellulose, hemicellulose)
c. fruits, vegetables (cellulose, hemicellulose, pectin)
d. whole grains
Soluble fibers functions
* delay gastric emptying
* absorb ___
* form ____ in small intestine
* slows passage and delays or inhibits
absorption of _______
pectins, gums
Fruits, vegetables, legumes, oats, barley, carrots, apples, citrus fruits, strawberries, bananas, corned beef
- delay gastric emptying
- absorb water
- form soft gel in small intestine
- slows passage and delays or inhibits
absorption of glucose and cholesterol
Type of Inflammatory bowel disease (IBD)
which disease:
* affects terminal ileum
* leads to weight loss, anorexia, diarrhea
* has B12 deficiency which leads to megaloblastic anemia
* and iron deficiency anemia due to blood loss, decreased absorption
Regional enteritis (Crohn’s disease)
For acute Crohn’s flare-ups - bowel rest, parenteral nutrition or minimal residue
For which disease to you provide the following treatmetn for?
- maintain fluid and electrolyte balance; ____ agent (sulfasalazine)
- energy needs according to current BMI, limiting fat only if ____ present
- supplement water-soluble and fat-soluble vitamins; ___ and ____ and assess ___, ___, ___
- watch _____, frequent feedings. High fat may improve energy balance.
For acute Ulercative cholitis, elemental diet may be needed to minimize fecal volume
IBD
- maintain fluid and electrolyte balance; antidiarrheal agent (sulfasalazine)
- energy needs according to current BMI, limit fat only if steatorrhea
- supplement water-soluble and fat-soluble vitamins; iron, folate, assess Ca, Mg, Zn
- watch lactose, frequent feedings. High fat may improve energy balance.
High fat intake may improve energy balance
ex. of vitamins needed C and B12
Which disease is this diet order for??
- _____: an easy to oxidize source of energy and may improve bowel damage.
- _____ at each meal, chewable MV
when this patient is in remission or has sytmptoms under control, what do you recommend?
IBD
- Coconut oil derived MCT
- protien
high fiber to stimulate peristalsis
With treatment for acute Diarrhea in children you want to provide
* agressive and immedaite ____
* replace ____ and ____ lost in stool
-aggresive and immediate rehydration
-replace fluids and electrolytes lost in stool
rehydrate within 4-6 hours
WHO recommends glucose and electrolyte solution
consequence of malabsorption
steatorrhea tx. includes high protein, high complex CHO, fat as tolerated, (3)_____
normal stool fat range:
amount of stool of fat that shows malabsorptions:
first determine cause and then treat
- vitamins, minerals, MCT (they are rapidly hydrolyzed in GI tract)
- normal stool fat 2 - 5 g
- > 7 g is indicative of malabsorption
*especially fat soluble vitamins
Part of Short Bowel Syndrome (SBS)
Complications with ileal resection:
- if distal - absorption of B12, intrinsic factor, and _____ compromised
- will need above average needs of ____to compensate for excessive losses in the stool.
- ileum may not be able to recylce ____
Diet order: ___, increase ____ and protein
ileum normally absorbs major portion of fluid in GI tract
- B12, intrinsic factor, bile salts
- water
- recycle bile salts
Diet order: parenteral B12, increase fluids, increase protein
Drink at least 1 liter more than their ostomy output daily.
Too much illeum
What happens if a pt has redundant illeum
B12 def. may develop
If the ____ can not recycle bile salts what happens?
- malabsorption of ____
- malabsorbed fats combine with ______ leading to “_____”
- colonic absorption of oxaloacetates increases leading to _____
- increased _____and electrolyte secretion
- increased _____ motility
- the ____ can not produce new bile salts to adequately emulsify lipids
Illeum
- malabsorption of fat-soluble vitamins
- malabsorbed fats combine with Ca, Zn, Mg, leading to “soaps”
- colonic absorption of oxalate increases leading to renal oxalate stones
- increased fluid
- increased colonic
- the liver can not produce new bile salts to adequately emulsify lipids
lipids are not emulsified
renal oxalate stones = kidney stones
Nutrition care for SBS
what are the 4 things involved in ileal care
- limit fat
- use MCT (does not require bile salts, needs less intestinal surface area)
- supplement fat-soluble vitamins (ADEK) and **Ca, Mg, Zn **
- Parenteral B12 (followed by monthly injections if more than 100 cm of terminal ileum is removed)
MCT= coconut oil
stores and releases blood, filters toxic elements, metabolizes and stores nutrients, regulates fluid and electrolyte balance are functions of the
liver
When the liver is diseased all metabollic funcitons are distrupted
Liver enzyme profile
* ALP alkaline phosphatase:
* LDH ____
* AST, SGOT aspartate amino transferase hepatitis:
* ALT, SGPT alanine aminotransferase liver disease:
major enzymes found in organs and tissues;
enzyme levels in blood are elevated when tissue damage causes them to leak into the circulation
- 30-120 U/L
- lactic acid dehydrogenase
- 0-35 U/L
- 4-36 U/L
In liver disease, enzymes levels are elevated
elevated liver enzymes = tissue damage
liver fucntion test
ALP alkaline phosphatase
30-120 U/L
* elevated
* decreased
- liver disease, bone disease
- scurvy, malnutrition
liver fucntion test
LDH lactic acid dehydrogenase
* elevated (3)
- hepatitis
- myocardial infarction
- muscle malignancies
liver funtion test
AST, SGOT aspartate amino transferase : 0-35 U/L
* elevated
hepatitis
ALT, SGPT alanine aminotransferase liver disease: 4-36 U/L
* elevated
liver dz
When a diet order is high protein and low CHO
increase fluids
Acute viral hepatitis- inflammation and necrosis of the liver
prescription/diet therapy of acute viral hepatits involves:
* increase fluids to prevent ____
* ____CHO to replenish _____ and spare protein (high cal)
* moderate to liberal ___ intake if tolerated
* small, frequent feedings (___) because of the anorexia
* encourage coffee (antioxidant)
* multivitamin with (4) ____
* if fluid retention restrict to ___ gmNa
care varies according to sympt. and nut. status, anorexia major sympt
With liver dz adjust Na, Pro, fluid
- dehydration
- 50-55% CHO to replenish liver glycogen and spare protein (high cal)
- moderate to liberal fat intake if tolerated
- small, frequent feedings (4-6) because of the anorexia
- encourage coffee (antioxidant)
- multivitamin with** B complex, Vit C, K, zinc**
- if fluid retention restrict to 2 gmNa
if steatorrhea present limit fat to <30% cals
a pt with liver dz will likely be deficient in these B complex, C, K, zinc
1.0-1.2 g pro/kg
Purpose of high protein intake for acute hepatitis is two things:
* cell regeneration
* provide lipotropic agents to
convert fat into lipoproteins so they can be removed from liver
a high protien intake will help with cell regeneration and prevent fatty liver
Cirrhosis
When a pateint has ascites
* Connective tissue overgrowth blocks blood flow out of the ___
* * They may have low serum albumin due to ___
occurs when blood cannot leave the liver
liver into vena cava
* dilution factor
ascities can cause faulse albumin values
Causatiion from connective tissue overgrowth *main problem
What is this explaining:
* The liver expands until it exceeds storage capacity
* pressure caused by increased blood volume forces fluid to sweat through the liver into the peritoneal cavity
* fluid is turned into almost pure plasma with a high osmolar load, pulling more fluid in to dilute the load
* leading to sodium and water retention.
the liver can store a liter of extra blood
The liver when ascities is present
ascites - sodium and water retention
peritoneal cavity = interstial space
Cirrhosis
what is this describing?
- Connective tissue overgrowth causes resistance to blood entering from portal vein.
- The increased pressure forces blood back into collateral veins that offer less resistance.
- Esophageal, abdominal, collateral veins enlarge
occurs when blood can’t enter the liver: portal hypertension
very fragile, can be torn easily
esophageal varices
The enlargement of veins will cause out pouching of vessel wall = varicies
diet for cirrhosis
- adequate to high protein ___g/kg; in stress at least ___ g/kg
- high calorie ____ cals/kg estimated dry weight or BEE + ____
- moderate to low fat ____ of calories, MCT if needed
- <30 grams ___ if malabsorption.
- low fiber if ____ are present
- low sodium (<2gm) if edema or ascites
with severe cirrhosis restrict Na
- 8 - 1.2 g/kg; in stress at least 1.5 g/kg
- 25 - 35 cals/kg estimated dry weight or BEE + 20%
- 25 - 40% of calories, MCT if needed
- fat if malabsorption.
- varices are present
Fat is preferred fuel in cirrhosis.
Include omega 3 and decrease LCT if steatorrhea develops
diet for cirrhosis
* Na: with hyponatremia- what restrction and amount per day
* vitamins (4):
- fluid restriction of 1 - 1.5L/day (depending on severity, and moderate sodium intake)
- B complex vitamins, C, Zn, Mg (monitor need for A and D)
zinc involved in conversion of ammonia to urea, increased loss in urine
Ammonia accumulation (no conversion of ammonia to urea)
Hepatic Failure (ESLD) treatment:
* If not comatose: moderate to high levels of ___, increase up to 1-1.5 gram _____/KG as tolerated.
* to minmize muscle catabolism = provide extra energy from ____
* ___ calories/kg; 30-35% calories as fat with MCT if needed
* low sodium if ascites; vitamin/mineral supplementation
increase BCAA and decrease AAA (aromatic AA)
- protein (modest protein intake if protein-sensitive hepatic encephalopathy)
- CHO and Fat
- 30-35 calories/kg;
1 oz roast beef OK to give (low Na, high B12, high pro)
we want to maintain high albumin
ESLD Tx
altered neurotransmitter theory
* _____are decreased since they are used by muscles for energy)
* ____are high because damaged liver is unable to clear them
* adding ____ - adds calories and protein; may not reduce symptoms
use when standard therapy does not work and patient does not tolerate standard protein
- BCAA are decreased since they are used by muscles for energy)
- AẠA are high because damaged liver is unable to clear them
- adding BCAA - adds calories and protein; may not reduce symptoms
Standard Tx for ESLD
* ____ (hyperosmotic laxative that removes nitrogen)
* _____ (antibiotic that destroys bacterial flora that produce ammonia)
- lactulose (hyperosmotic laxative that removes nitrogen)
- neomycin (antibiotic that destroys bacterial flora that produce ammonia)
choleocystits- inflammation of the gallbladder
Gallbladder disease Tx.
* low ___diet: acute 30-45 grams; chronic ____% of calories
* No gallbladder: Limit ___intake for several months to allow liver to compensate. Slowly increase ____ to help normalize bowel movements.
- low fat diet: acute 30-45 grams; chronic 25 - 30% of calories
- No gallbladder: Limit fat intake for several months to allow liver to compensate. Slowly increase fiber to help normalize bowel movements.
After removal B vitamin absorption is the top concern
cholecystectomy - surgical removal of gallbladder; bile now secreted from liver directly into intestine.
disease of exocrine glands
Name of specific disease:
- secretion of thick mucus that obstructs glands and ducts; chronic pulmonary disease, pancreatic enzyme deficiency, high perspiration electrolyte levels, malabsorption.
- Affects transport of chloride across the cell membrane.
May lead to: pulmonary disease, pancreatic enzyme deficiency, and malapsorption
Cystic fibrosis
Tx. of Cystic Fibrosis
* PERT: __________with meals and snacks
* high protein 15 - 20% calories - malabsorption due to ______
* carbohydrate 45-55% total _____ high
* liberal ____ to compensate for high energy needs - 35-40% of calories
* additional 2-4 grams ____/day in hot weather, with heavy perspiration
* age-appropriate doses of water-soluble vitamins and minerals
* supplement ____, water-soluble forms of fat-soluble vitamins (A and E)
use age-appropriate BMI to assess height and weight
- PERT: pancreatic enzyme replacement therapy with meals and snacks
- high protein 15 - 20% calories - malabsorption due to pancreatic deficiency
- carbohydrate 45-55% total calories high
- liberal fat to compensate for high energy needs - 35-40% of calories
- additional 2-4 grams salt/day in hot weather, with heavy perspiration
- age-appropriate doses of water-soluble vitamins and minerals
- supplement zinc, water-soluble forms of fat-soluble vitamins (A and E)
we want to meal plan
noncomplaince with salt recommendation- lab values will show hyponatremia
Cystic Fibrosis
What will happen if a patient in non compliant with PERT
daily, large foul smelling stool
CVD, CAD, IHD
HTN
* systolic -
* diastolic -
may be primary (essential) or secondary due to another disease
- systolic - contraction, greatest pressure;
- diastolic - relaxation, least pressure
HTN classes
* Normal:
* Elevated Systolic:
* Stage 1 Systolic:
* Stage 2 Systolic:
classified in stages based on risk of developing coronary heart disease
- Normal <120/80 mm Hg
- Elevated Systolic between 120-129 and diastolic less than 80
- Stage 1 Systolic between 130-139 or diastolic between 80-89
- Stage 2 Systolic at least 140 or diastolic at least 90 mm Hg
optiaml BP in regards to CVD risk is 120/80
Managing HTN (4)
four modifiable factors in primary prevention and treatment: overweight, high salt intake, alcohol consumption, physical inactivity
- thiazide diuretics may induce hypokalemia (low potassium)
- salt restriction < 2300 mg sodium/day
- decrease weight if needed
- DASH diet
thiazides reduce fluid retention
When a pateint is obese and HTN first recommendation should be to
Obesity is a major factor in the cause and tx. of CVD
decrease Na
HTN
DASH Diet
* emphasizes: whole grains, fruits, vegetables, low fat dairy, ____, ____
* moderate consumption of:
* limit:
* decrease:
* what DRI do we need to meet:
Dietary Approaches to Stop Hypertension; whole grains, fruits, vegetables, low fat dairy, poultry, fish, moderate sodium, limit alcohol, decrease sweets, calcium to meet DRI (not supplements)
Atherosclerosis- fat deposits in brain, heart, and legs
Classification of lipoprotiens
* ____- synthesized in intestine from dietary fat, transports dietary triglycerides from gut to adipose, lowest density: smallest amount of protein
* -____ (pre-beta) - transports endogenous triglyceride from liver to adipose
* ____(beta) - transports cholesterol from diet and liver to all cells
* ____- cholesterol to liver for excretion
* ____- LDL precursor
how fat is transported in the blood bound to protien
Dyslipidemia- includes high triglycerides and low HDL
- Chylomicron - synthesized in intestine from dietary fat, transports dietary triglycerides from gut to adipose, lowest density: smallest amount of protein
- VLDL (pre-beta) - transports endogenous triglyceride from liver to adipose
- LDL(beta) - transports cholesterol from diet and liver to all cells
- HDL- cholesterol to liver for excretion
- IDL- LDL precursor
Difference between small dense LDL-C and Large buoyant LDL
- small dense LDL-C associated with increased risk, responsive to diet trerapy
- larger buoyant LDL not associated with increased risk
AHA recommended
Heart Healthy diet for prevention and treatment of cardiovascular disease
(1) Saturated fat ___ of total calories, ___ mg cholesterol, 2g sodium, no trans fat
(2) Promotes whole grains, fruits and vegetables, ____, ___fats
(3) Includes _ to _g fiber per day and __ to __g soluble fiber
(1) Saturated fat <7% of total calories, <200 mg cholesterol, 2g sodium, no trans fat
(2) Promote whole grains, fruits, vegetables, low fat or fat-free dairy, unsaturated fats
(3) Includes 20 - 30g fiber per day and 5-10g soluble fiber
HF may lead to
Cardiac Cachexia Tx
* _____and ______ may help.
* Low saturated fat, low cholesterol, low ____, <2 grams sodium, high ____
unintended weight loss, blood backs up into liver and intestines causing nausea and decreased appetite.
- Arginine and glutamine may help.
- Low saturated fat, low cholesterol, low trans fat, <2 grams sodium, high calorie
HF protein needs (for normally nourished and malnourished)
Folate, Mg, B12, and MV also needed
1.1 - 1.4g protein /kg ABW
Thiamin needs to be assesed, may decrease d/t loop diuretics
lab tests in renal disease:
a. _____glomerular filtration rate and creatinine clearance
b. ____ serum creatinine, BUN
c. BUN: creatinine ratio of (more than)> ___ indicates a “____ state”
d. BUN: creatinine ratio of (less than)< ____ suggests reduced ___ reabsorption
e. Normal BUN:Cr -
decrease GFR, Increase Creatinine, and Increase BUN
a. decreased glomerular filtration rate, creatinine clearance
b. increased serum creatinine, BUN
c. BUN: creatinine ratio of > 20:1 indicates a “pre-renal state”
d. BUN: creatinine ratio of < 10:1 suggests reduced BUN reabsorption
e. Normal BUN:Cr - 10-20
BUN: creatinine ratio of > 20:1 indicates a “pre-renal state” in which BUN reabsorption is
increased due to acute kidney damage (may be reversible and may not require dialysis)
BUN: creatinine ratio of < 10:1 suggests reduced
BUN reabsorption due to renal damage (may need dialysis).
renal disorders
acute kidney injury, acute renal failure diet order
* low sodium (___grams), replace losses in diuretic phase when in renal failure
* ____ mg/kg phosphorus. May need phosphate binders.
* ____ grams potassium based on output, serum potassium, dialysis
* replace fluid output from previous day plus ___ ml
- low sodium (2-3 grams), replace losses in diuretic phase when in renal failure
- 8 - 15 mg/kg phosphorus. May need phosphate binders.
- 2 - 3 grams potassium based on output, serum potassium, dialysis
- replace fluid output from previous day plus 500 ml
when potassium is low pt will have N/V
When in renal failure potassium and phosphorus will
increase in attempts to to balance out e-
bicarbonate will be low, acid high from build up
When hyperkalemic give
bicarbonate so it can exchange hydorgen for potassium
which disease is being described
- defect in capillary basement membrane of glomerulus which permits escape of large amounts of protein into the filtrate moving through the tubules
- albuminuria, edema, malnutrition, hyperlipidemia/hypercholesterolemia
- decrease synthesis and clearance of VLDL
large amount of pro moving through tubules
nephrosis
nephrotic syndrome
albuminuria: decrease albumin through urine and loss of protien thriugh urine
CKD protein needs
* CKD stage 3-5: ____g protein/kg
* or 0.28 - 0.43 g/kg with _________ to meet ____g protein/kg
- CKD 3-5: 0.55 - 0.60 g protein/kg
- or 0.28 - 0.43 g/kg with keto acid analogs to meet 0.55 - 0.60 g protein/kg
anemia will be present due to deficient production of hormone erythropoietin
Chronic renal failure- long term goal is to prevent malnutrition
Hemodyalisis supplementation
* (3) to correct deficiencies based on symptoms
* ____and ____supplements if deficient
* ____and ____ supplements NOT recommended
- Vitamins B6, folate, B12 to correct deficiencies based on symptoms
- vitamin D and C supplements if deficient
- vitamin A and E supplements NOT recommended
B6= pyridoxine
recommendations same for peritoneal dialysis
Which of the following would be appropriate for a hemodialysis patient on a 60 gram protein diet, with 75% from HBV protein?
a. 2 eggs, 2 ounces chicken, 3 ounces beef, ½ cup milk
b. 1 egg, 2 ounces chicken, 3 slices bread, 3 ounces beef
c. 2 eggs, 3 ounces chicken, 3 ounces beef, 1 cup milk
d. 1 egg, 3 ounces chicken, 2 cups milk, 5 slices bread
steps: multiply g of protein x HBV
the correct answer will add up to g of pro x HBV
HBV % only animal pro
chicken/beef per oz= 7g pro
1 egg = 7 g pro
1/2 cup milk = 8 g pro
1 slice of bread = 3 g pro
Endocrine and metabolic disorders
Diabetes mellitus- Type 1
insulin deficient, depend on exogenous insulin
Type 2 DM
insulin-resistance with relative insulin deficiency (may need insulin)
Risk factors for DM
- acanthosis nigricans: gray-brown skin pigmentations in skin folds from insulin resistance =
- GADA:
- high blood insulin levels since cells are not taking them up
- glutamic acid decarboxylase antibodies.
Peritoneal dialysis protein and kcal needs
- 1 - 1.2 g protein/kg SBW or adjusted BW
- 25 - 35 calories/kg
CHO may be absorbed during this and continous renal therapy
What is this strategy used for
- With fixed daily doses of insulin, consistency of CHO is recommended
- Integrate insulin therapy with usual eating habits
- Monitor blood glucose and adjust insulin doses for amount of food eaten
Type 1DM
With intensive insulin therapy, adjust pre-meal insulin dosages based on
total CHO content of each meal, using an insulin-to-CHO ratio
For planned exercise how do you adjust insulin? insulin rec for endurance athletes
- For planned exercise, reduction in insulin dosage may be best choice
- Endurance athletes: 120-180mg/d is guideline during activity
legumes, milk, whole grains, fruits, vegetables, nuts, pasta, ice cream, yogurt are examples of foods with
low gylcemic index
glucose from these foods are absorbed slowly
gestational diabetes testing:
At how many weeks do you test?
How do you screen?
What is the glucose level that indicates further testing?
at 24-28 weeks of gestation, screen with 50g oral glucose load; glucose ≥140mg/d| indicates need for further testing
glycemic load
weighted average of the glycemic indexes of all foods eaten
gestational diabetes increases risk of
fetal macrosomia (LGA large for gestational age, 4000-4500 grams) or **fetal hypoglycemia **at birth
Consistent Carbohydrate Diet - provides a range of:
* ___CHO a serving at each meal and ___ servings for snacks
* One choice from the starch, fruit or milk list = ___ grams CHO and each is a CHO choice
* Foods with 6-10 g CHO provide ___CHO serving.
- **3-5 **CHO a serving at each meal and 0-4 servings for snacks
- One choice from the starch, fruit or milk list = 15 grams CHO and each is a CHO choice
- Foods with 6-10 g CHO provide **0.5 **CHO serving.
One starch choice has
__grams of carbohydrate, __ grams of protein,__ gram of fat, and 80 calories
15 grams of carbohydrate, 3 grams of protein, 1 gram of fat, and 80 calories
ex of one starch choice
* pasta =
* slice of toast=
* cup of brown rice=
* oatmeal =
- pasta 1/3 cup
- 1 slice of toast
- 1/3 cup of brown rice
*oatmeal 1/2 cup
One fruit choice has
15 grams of carbohydrate and ___ calories.
15 grams of carbohydrate and 60 calories.
ex of 1 fruit choice
- 1/2 cup of orange juice
- raspberries 1 cup
- grapes 3 oz
- grape juice 1/3 cup
- One milk choice has ___ grams of carbohydrate and __ grams of protein (all milk)
- One fat-free (skim) or low-fat (1%) milk choice has 0 to _ grams of fat and 100 calories per serving
- One **reduced fat **(2%) milk choice has 5 grams of fat and ___ calories per serving.
- One whole milk choice has __ grams of fat and 160 calories per serving.
- 12 grams of carbohydrate and 8 grams of protein (all milk)
- 0 to 3 grams of fat and 100 calories per serving
- 5 grams of fat and 120 calories per serving.
- 8 grams of fat and 160 calories per serving.
ex of 1 milk choice
* fat free milk=
* yogurt=
* evaporated milk=
- 1 cup fat free milk
- 2/3 cup yogurt
- 1/2 cup evaporated milk
One nonstarchy vegetable choice (½ cup cooked or 1 cup raw) has __ grams of carbohydrate, __ grams of protein, __ grams of fat, and 25 calories.
5 grams of carbohydrate, 2 grams of protein, 0 grams of fat, and 25 calories.
- beets
- carrots
- cucumber
- tomato
- spinach
are examples of
nonstarchy vegetables
Sweets, Desserts, and Other Carbohydrates
- One carbohydrate choice has 15 grams of carbohydrate and about __ calories
- One fat choice has __grams of fat and 45 calories.
- 15 grams of carbohydrate and about 70 calories
- 5 grams of fat and 45 calories.
ex of 1 dessert choice
- choclate chip cookies- 2 cookies= 1 cho and 2 fat
- ice cream 1/2 cup= 1 CHO and 2 fats
One lean protein choice has
0 grams of carbohydrate, __ grams of protein, __ grams of fat, and __ calories.
examples: ground beef, salmon, cottage cheese, canadian bacon, shellfish (lobster)
0 grams of carbohydrate, 7 grams of protein, 2 grams of fat, and 45 calories.
These are examples of one-
* canadian bacon 1 oz
* cottage cheese 1/4 cup
* turkey 1 oz
* beef 1 oz
* shellfish 1 oz
lean protein choice
1 ounce is usually the serving size for meat, fish, poultry, or hard cheese.
One medium-fat protein choice has
__ grams of carbohydrate, 7 grams of protein, __ grams of fat, and 75 calories.
0 grams of carbohydrate, 7 grams of protein, 5 grams of fat, and 75 calories.
These are examples of:
* 1egg
* fired fish 1 oz
* pork 1 oz
* mozerella 1 oz
1 med fat protein choice
One high-fat protein choice has 0 grams of carbohydrate, __ grams of protein, __ grams of fat and 100 calories.
0 grams of carbohydrate, 7 grams of protein, 8 grams of fat and 100 calories.
These are examples of:
* bacon 2 slices
* turkey bacon 3 slices
* american cheese 1 oz
* 1 hot dog
one high-fat protein choice
Plant-Based Protein
One carbohydrate choice has how many CHO and Calories
15 grams of carbohydrate and about 70 calories.
ex of one plant based protein option:
* 1/2 cup of beans=
* tofu 1/2 cup=
* peanut butter 1 tablespoon =
- 1/2 cup of beans= 1 starch + 1 lean protein
- tofu 1/2 cup= 1 medium fat protein
- peanut butter 1 tablespoon = 1 high fat protein
One fat choice has how many grams of fat and calories
5 grams of fat and 45 calories.
ex of one fat choice
* almond milk =
* olive oil =
* margarine =
* salad dresssing =
* cream cheese =
- almond milk 1 cup
- olive oil 1 tsp
- margarine 1 tsp
- salad dresssing 1 tbsp
- cream cheese 1 tbsp
free foods are ___ calories and ___ grams CHO per serving
< 20 calories and < 5 grams CHO per serving
ex of free foods
- coffee creamers 1 1/2 tsp
- mayonnaise fat free 1 tbsp
ex of combinaiton foods
* plain hamburger (235 kcals)
* Fried fish sandwich (417kcals)
* main salad with dressing (305 kcals)
- plain hamburger: 2 CHO, 1 med fat prot= 235Kcals
- Fried fish sandwich = 2 1/2 CHO, 2 med fat prot, 1 1/2 fat =417kcals
- main salad with dressing= 1 CHO, 4 lean prot, 1 fat
Type 2 Diabetes
Non-Insulin medications (6)
* _____= low risk of hypoglycemia and increases uptake in muscles, taken with food and check B12 levels
* DPP-4 inhibitors
* ______= used for CKD with T2DM
* ______ (GLP-1) receptor agonist= promotes fullness and leads to weight loss
* TZD Thiazolidinediones
* _______: hypoglycemia
- biguanides= low risk of hypoglycemia and increases uptake in muscles, taken with food and check B12 levels
- DPP-4 inhibitors
- SGLT-2 inhibitors= used for CKD with T2DM
- glucagon-like peptide-1 (GLP-1) receptor agonist= promotes fullness and leads to weight loss
- TZD Thiazolidinediones
- Sulfonylureas: hypoglycemia
- Metformin (Glucophage)
- suppress hepatic glucose production.
- First line therapy for most with T2D.
- Take with food. Check B12 levels.
- Deficiency can lead to anemia or peripheral neuropathy.
- Weight neutral. Low risk of hypoglycemia.
biguanides
- saxagliptin (Onglyza), sitagliptin (Januvia),
- often used with Metformin.
- Allows endogenous GLP-1 to stay active longer, reduces glucose released by liver overnight and between meals.
- Weight neutral.
DPP-4 inhibitors
- canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance)
- target blood glucose-lowering action in kidneys, by blocking a protein that returns glucose to the blood after it is filtered through the kidney.
- More glucose is excreted in urine and less reabsorbed.
- Monitor kidney function.
- Weight loss.
- Considered for patients with T2D and CKD
SGLT-2 inhibitors
- Exenatide (Byetta), dulaglutide (Trulicity), semaglutide (Ozempic)
- slows gastric emptying
- enhances insulin secretion when glucose is high after eating
- suppresses postprandial glucagon secretion
- promotes fullness and leads to weight loss.
glucagon-like peptide-1 (GLP-1) receptor agonist
- increase insulin sensitivity in muscle.
- Weight gain
TZD Thiazolidinediones: (Actos)
- glimepiride (Amaryl)
- secretagogue stimulates pancreas to release more insulin.
- May lead to hypoglycemia.
- Weight gain.
Sulfonylureas
Thyroid disorders
*excess secretion of thyroid hormone
* elevated T3 and T4
* BMR leading to weight loss
* increase calories
hyperthyroidism
- deficiency of thyroid hormone
- T4 low and T3 low or normal
- decreased BMR leading to weight gain
- need weight reduction
hypothyroidism
Phenylketonuria (PKU) diet:
* restrict the substrate phenylalanine (PHE), and supplement ____
* Tyrosine becomes a conditional amino acid.
* avoid ____
* ___ protein, ___ CHO intakes may lead to increased ___
no conversion of phenyalinine to tyrosine
- restrict the substrate phenylalanine (PHE), and supplement tyrosine
- Tyrosine becomes a conditional amino acid.
sweetners - avoid aspartame
- low protein, high CHO intakes may lead to increased dental caries
purpose of Phenex-1,2, Phenyl-Free 1,2 (low phenylalanine formulas)
low in phenylalanine, but provide enough to promote normal growth
the need for phenylalanine decreases with
age and infection
what happens to phenyalanine when you have an infection
infection causes tissue catabolism releasing phenyalanine into the blood (increases)
these are sources of
* eggs
* chicken
* liver
* bread
* milk
* soybeans
* artificial sweetners
phenyalanine
need folate, B6 (pyridoxine), B12 (cyanocobalamin)
- treatable inherited disorder of amino acid metabolism
- characterized by severe elevations of methionine and homocysteine in plasma, and excessive excretion of homocystine in urine
- associated with low levels of folate, B6, B12
protein is the main nutrition concern
homocystinuria
if a newly diagnosed pt doesnt respone to folate, B6, B12 give
low protein, low methionine diet
What is the main concern in Maple Syrup Urine Dz (MSUD)
protein
diet for normocytic anemia may develop with long term arthritis-
* if it is **not **diet-related, inflammation of arthritis prevents reuse of ___
* not treated with ____ supplement
* “anti-inflammatory diet” may help ____: fresh fruits and vegetables, resembles Mediterranean diet
- It is not diet-related, inflammation of arthritis prevents reuse of iron
- not treated with iron supplement
- “anti-inflammatory diet” may help osteoarthritis: fresh fruits and vegetables, resembles Mediterranean diet
Skeletal and connective tissue disorders
Arthritis
inflammation of peripheral joints
Which disease is associated with:
* diet modification of sucrose, starch and maltose
* If on Sacrosidase (oral enzyme replacement for sucrase), they do not need to restrict sucrose in their diet (just starch and maltose). Enzyme is taken before and during meals and snacks.
* Diabetics on Sacrosidase need to check blood glucose levels. It converts sucrose into fructose and glucose.
congenital sucrase isomaltase disease (CSID)
non-hereditary, brain damage; inadequate control over voluntary muscles leading to spasms
cerebral palsy
Which form of cerebral palsy exhibits:
* difficult, stiff movement; limited activity; obese
* diet: low calorie, high fluid, high fiber diet
spastic form of cerebral palsy
spastic= stiff or rigid
Which form of cerebral palsy is associated with
- involuntary wormlike movement, constant irregular motions leading to weight loss
- give high calorie, high protein diet; finger foods
finger foods becasue of constant motiosn of the limbs
non-spastic (athetoid) form
with atraumatic brain injury
the systemic inflammatory response includes: hypermetabolism, hyperglycemia, insulin resistance and-
aggresive nutrition support is an important part of the care
protein wasting
traumatic brain injury needs if indirect calorimetry is unavailable
energy at 140% of estimated REE
enteral feeding into small bowel is often best option
Alzheimers disease nutrient needs
* low sat fat, ___(3)
* not ___, since that is associated with memory loss
- low sat fat, neede fotate, B6, BI2
- not B1 (thiamin - is associated with memory loss)
Alzheimers
anomia, form of aphasia
lost words, unable to recall names of common items
Anemia (decrease red cell mass)
What type of anemia is:
* small, pale cells; due to iron deficiency
* associated with chronic infections, malignancies, renal disease
microcytic, hypochromic anemia
- FEW large cells, filled with hemoglobin
- due to deficiency of folate or vitamin B12:
Schilling test for pernicious anemia (B12)
macrocytic, megaloblastic anemia
macrocytic lab values
* MCV and MCH are ___
* RBC below ___ M and __ F
* Hgb and Hct ___
large and filled with hemoglobin
- MCV and MCH are high
- RBC below 4.7 M and 4.2 F
- Hgb and Hct low
MCH indicates color amount
microcytic hypochromic lab values
* all values other than RBC are ___
* Hgb below __ M and __ F
* Hct below 42% M and 35% F
* MCV below __ (means small cell size)
- all values other than RBC are low
- Hgb below 14 M and 12 F
- Hct below 42% M and 35% F
- MCV below 80 (means small cell size)
Fever and Infection
Fluid needs
* the higher the fever = the more ___ and kcal needs
* excessive fluid loss may lead to ____ (hyperglycemia, dry, loose inelastic skin)
* IV feedings of __ and water first, and then diet high in calories and fluids
- the higher the fever = the more fluids and kcal needs
- excessive fluid loss may lead to dehydration (hyperglycemia, dry, loose inelastic skin)
- IV feedings of dextrose and water, then diet high in calories and fluids
Fever and BMR
* BMR increases __ for each degree rise in F temp
* normal temp 98.6 F
* ex: pt with 102F°
- BMR increases 7% for each degree rise in F temp
- normal temp 98.6 F
- ex: pt with 102F° → 102-98.6=3.4×7% = 24% increase in BMR needs
Energy needs for burn pt in immediate shock
* BMR rises _ to _ %
* the first goal is to?
- BMR rises 50-100%
- replace fluids and electrolytes lost (first goal)
Energy needs for burn pt in recovery period:
* increase____ (based on burn size estimated by Rule of Nines)
* 20-25% calories as protein (1.5 - 2 grams protein/kg, ___g/kg if burn <10%BSA)
* vitamin __ 500 mg X 2, water soluble vitamins, vitamin __ if on antibiotics
* zinc for wound healing if zinc deficient, ___ mg zinc sulfate
- increase calories (based on burn size estimated by Rule of Nines)
- 20-25% calories as protein (1.5 - 2 grams protein/kg, 1.2g/kg if burn <10%BSA)
- vitamin C 500 mg X 2, water soluble vitamins, vitamin K if on antibiotics
- zinc for wound healing if zinc deficient, 220 mg zinc sulfate
Burns
Rule of Nines
* divides the body surface area into percentages
* Arm including hand, head and neck, genitalia- __ % each
* Anterior trunk, posterior trunk, legs including feet- __% each
- divides the body surface area into percentages
- Arm including hand, head and neck, genitalia- 9 % each
- Anterior trunk, posterior trunk, legs including feet- 18% each
the bodies physiological response to trauma
* injury activates ___ that produce and mobalize proteins to meet needs
* accelerated ____ of lean body mass leads to negative nitrogen balance
* protein is then catabolized to release ___ for energy post stress to meet need
hypermetabolic, flight or fight response
- injury activates hormones that produce and mobalize proteins to meet needs
- accelerated cataboism of lean body mass leads to negative nitrogen balance
- protein is then catabolized to release glucose for energy
post stress to meet need
Results of physiologic trauma:
* hyperglycemia, _____, little or no ketosis
* increase ____ to increase glucose production from amino acids (release FFA)
- hyperglycemia, hyperinsulinemia, little or no ketosis
- increase glucagon to increase glucose production from amino acids (release FFA)
Results of pysiological trauma
catecholamines epinephrine, norepinephrine hormones cause
- hepatic glycogenolysis (glycogen to glucose)
- increases energy availability
Results of pysiological trauma
ACTH
* releases ____ which mobilizes amino acids from muscle
* cortisol increases _____ = mobilizing FFA and decreasing _____ synthesis
* increase protein catabolism from skeletal muscle
* glucagon increases _____
- releases cortisol which mobilizes amino acids from muscle
- cortisol increases gluconeogenesis = mobilizing FFA and decreasing proetin synthesis
- increase protein catabolism from skeletal muscle
- glucagon increases gluconeogenesis
Results of pysiological trauma
Aldosterone causes
renal sodium retention, gluconeogenesis
Results of pysiological trauma
ADH causes
renal water reabsorption
symptoms of physiological trauma
* ___- vomitting, diarrhea, excessive bleeding
* ____ cardiac output
* drop in body temperature
* fluid and sodium ____
* potassium ____
* loss of nitrogen, sulfur, ____, ____
- hypovolemia- vomitting, diarrhea, excessive bleeding
- decreased cardiac output
- drop in body temperature
- fluid and sodium retention
- potassium excretion
- loss of nitrogen, sulfur, zinc, phosphorus
two forms of malnutrition
- marasmus
- iatrogenic malnutrition
*when calculating the needs of someone severly under wt use ABW
marasmus:
* protein and ___ starvation
* low anthropometric diagnosis/measurements, serum albumin ____, no edema
* severe fat and muscle wasting, starved appearance
* weight loss
* triceps skinfold, arm muscle circumference ____
- protein and calorie starvation
- low anthropometric diagnosis/measurements, serum albumin normal, no edema
- severe fat and muscle wasting, starved appearance
- weight loss
- triceps skinfold, arm muscle circumference decreased
iatrogenic malnutrition
- protein-calorie malnutrition
- harm brought on by treatment, hospital, medications
In community surveys, frequent symptom of malnutrition
decreased serum albumin
- 1lb body = ____calories
- to lose 1 lb. fat /week, reduce
- Early rapid weight loss during diet is ____ - as liver glycogen is utilized.
- 3500 calories
- 500 calories / day
- water
epidemiologic data/research on cancer
- interrelationship between ___,____,and____ in causing disease
- some evidence that fruits and vegetables are beneficial in overall cancer (____(Vit A),_____(absorbic acid))
- Some evidence that exercise in ______ women decreases risk of breast disease
- host, agent, environment
- cartenoids (vit A), vitamin C (absorbic acid)
- post menopausal
calorie reduction strategies:
* ___-_____ cal/day for women, ___-1800 cal/day for men
* energy deficit of approximately 500 to ____calories/day
* restricting high fat foods, high carbohydrate foods to create an ____ (evidence based)
- 1200-1500 cal/day for women, 1500-1800 cal/day for men
- energy deficit of approximately 500 to 750 calories/day
- restricting high fat foods, high carbohydrate foods to create an energy deficit *evidence based
esophagitis diet order:
* ____ meals, __ fat, bland, ___fiber
* start with ____moist thick foods and progress to thick ____
decreases gastric acidity, reflux
- small meals, low fat, bland, low fiber
- start with pureed moist thick foods and progress to thick liquids
espophagitis
odynophagia
- painful swallowing; globus is a lump in the throat
esophagitis
what is the diagnosis:
- disorder of lower esophageal sphincter motility, does not relax and open upon swallowing
- causes dysphagia - difficulty in swallowing
achalasia
Before a swallow test a patient may recieve
thick liquids
What do you give to a paitent who holds food in his mouth and coughs
smooth pudding
International Dysphagia Diet Standardization Initiative -
* Consistency is measured along _ levels from 0 to 7
* Inconsistency increases risk of____
* Beverages are classified from levels _ to _, thin to extremely thick
* Foods are classified from levels _ to _, liquidized to regular
- Consistency is measured along 8 levels from 0 to 7
- Inconsistency increases risk of aspiration ammonia
- Beverages are classified from levels 0 to 4, thin to extremely thick
- Foods are classified from levels 3 to 7, liquidized to regular
IDDSI
- Level 0 White
- Level 1 Grey
- Level 2 Pink
- Level 3 Yellow
- Level 4 Green
- 0= thin, water flow through straw
- 1=slightly thick, thicker than water, can flow through straw
- 2= mildly thick, sippable
- 3= liquidized, spoon or cup, no lumps OR moderately thick, spoon or drunk from cup, no lumps, effort with wide straw
- 4= extremely thick, spoon, not from cup or straw, not sticky, chewing not required OR pureed, spoon, not sticky
- Level 5 Orange
- Level 6 Blue
- Level 7 Black
- 5= minced and moist, minimal chewing, biting not required, lumps mashed with tongue, avoid hard, dried, tough foods
- 6= soft, bite-sized able to chew bite-sized pieces, knife not required
- 7 = **easy to chew **can bite off and chew soft, tender pieces
diet order for pediatric HIV/AIDS”
___ and ___ with supplements needed for weight gain
high protein, high calorie with supplements needed for weight gain
Acquired immunedeficiency syndrome (HIVAIDS) - symptoms (5)
diarrhea, malabsorption, nausea, vomiting, weight loss
HIV/AIDS nutrition goals:
* ___ lean body mass, prevent weight loss, prevent HIV ___
* healthy BW and body composition
* prevent nutrition deficiency and nutrtion related complications- __, decreased B12, zinc, copper, and ___
* ___ fiber to prevent CVD, DM
No Vit C
- preserve lean body mass, prevent weight loss, prevent HIV wasting
- healthy BW and body composition
- prevent nutrition deficiency and nutrtion related complications- anemia, decreased 12, zinc, copper, and carnotene
- increase fiber to prevent CVD, DM
Drugs for HIV/AIDS
Classification of drugs:
* Retrovir, Zidovudine
* can lead to anemia (microcytic anemia), loss of appetite, nausea, dysphagia
NRTI drugs (Nucleoside reverse transcriptase inhibitors)
HIV pt’s may be prone to foodborne illnesses and would benefit from what kind of diet? and what kind of foods does it eliminate?
- Notropenic diet: decrease bacteria in food
- elimate raw foods: raw eggs, unpasteurized cheese, raw seafood, and rare/undercooked meats
Which conditon mathces the nutrition goal and diet order below:
* goal: maintain stable weight and preserve lean body mass
* provide adequate but not excessive calories; avoid excess non-protein calories
* provide enteral formula containing EPA and GLA (gamma-linoleic acid), and enhanced levels of antioxidant vitamins
* __ - __ g protein/kg BW
adding fat emulsion to replace some of the CHO = decreases RQ
(ARDS) acute respiratory distress syndrome, respiratory failure
* 1.5 - 2 g protein/kg BW
COPD may follow
Nutrition intervention for drug addiction
increase CHO, pro, fiber
decrease fat
Nutrition intervention for drug addiction
- Moderate or discontinued ___ and morderate and discontinued sugar
- sugar releases ___, substituting for the ____ release previously from drugs.
- ___ glucose levels are shown to decreased drug cravings and reduce relapse potential
- caffeine
- sugar releases dopamine, substituting for the dopamine release previously from drugs.
- stable glucose levels are shown to decreased drug cravings and reduce relapse potential
Which formula is
* pre-digested protein or amino acids, glucose or sucrose, LCT and MCT, vitamins, minerals, electrolytes
* hypertonic formula, not absorbed as readily as isotonic formula
* may cause diarrhea in illeal resection pt
* only used on pt’s that are unable to digest and absorb normally (ex. Short Bowel Syndrome)
elemental, chemically defined formula
where is elemental formula absorbed?
* in the ___ with low to no residue,
* doesn’t need___ enzymes, ___ osmolality (hypertonic), poor taste
- in the proximal intestine with low to no residue,
- don’t need pancreatic enzymes, high osmolality (hypertonic), poor ttaste
____ formula names
* Alitraq, Peptamen, Vivonex
* Nepro (_____)
* HepaticAid II (____)
* Glucerna (_____)
elemental
* Nepro (renal)
* HepaticAid II (liver)
* Glucerna (diabetes)
the more specialized the formula, the greater its cost
Which formula do you use when a patient has
* normal GI fungtion
* Patient unable to consume an adequate amount of calories on their own
* NG tube can be used
how many cal/cc do most of these formula provide?
Standard polymeric
most provide 1-1.5 calories / cc
Standard polymeric formula is the least expensive and is made up of ____. How is it initiated and is it istonic or hypertonic?
- intact protein (NOT pre-digested), initiated full strength
*isotonic (osmolality is close to that of blood)
How should you initiate standard polymeric formula
full strength at first
How do you find the rate for 1200 cals given between 8pm - 9 am
- count hours of initiation
- divide 1200 cals/1 cal per cc/13 hrs
- units of answer: ml/hr
answer: 92.31 ml/hr
enteral access feedings are
* Short term access _ to _ weeks
and can be given:
* ____ drip (pump or gravity)
* ___ method
* continuous drip
* nasogastric tube, pt has normal Gl function
- Short term access 3-4 weeks
- intermittent drip (pump or gravity)
- bolus method
- continyous drip
When do you use bolus feeding vs intermittent drip
bolus pt needs to clinically stable
intermittent pt has more mobility
When do you use continuous drip:
* when neededa at a constant, steady rate over __ to __ hours
* usually with a feeding pump (for those with compromised Gl function or who do not tolerate ___ volume infusion)
- when neededa at a constant, steady rate over 16-24 hours
- usually with a feeding pump (for those with compromised Gl function or who do not tolerate large volume infusion)
cyclic feeding is delivered
* by ____drip at an increased rate over - hours, often overnight, by ___
* for under-nourished, especially ___, ambulatory, malnourished patients
- by continuous drip at an increased rate over 8-16 hours, often overnight, by pump
- for under-nourished, especially older, ambulatory, malnourished patients
EN water/calories:
* 1 cal/cc formulas are __-__% water
* 1.5 cals/cc are __-__% water
* 2 cals/cc formulas are __-___% water
Find the formula in ml from 1.5 L of feeding that has 1.5 cal/cc
also used when asking how much free water in a feeding
- 1 cal/cc formulas are 80-86% water
- 1.5 cals/cc are 76-78% water
- 2 cals/cc formulas are 69-71% water
now much.
- convert L to ml by multiplying by 1000
- multiply ml by 76%-78% water
- units of answer ml
normal GRV (gastric residual volume) ≤ ____. Enteral nutrition should not be held for GRVs < ___ml in absence of other signs of intolerance.
a GRV of less than 500 ml alone is not a sufficient reason to stop enteral feeding, unless there are other symptoms of intolerance.
- 250 ml
- 500 ml
enteral access feedings
Actual intake may be ____ than prescribed because of medical procedures and ADL (activities of daily life) interruptions.
lower
what can cause an influx of water into gut when recieiving EN
adverse effects: lactose intolerance, formula hyperosmolality, and rapid infusion
Steps in EN formula calculation:
1. Select formula and determine ____ needed.
2. ____ = ml of formula needed a day
3. Determine protein by _____ by g of protein per L
4. Determine daily fluid need: ____= formula water in ml
5. ____= water flushes
6. To find rate: _________ =unit of answer ml/hr
- Select formula and determine calories needed.
- Divide calorie needs by cal/ml given by formula = ml of formula needed a day
- Determine protein by multiply mls of formula needed a day by g of protein per L
- Determine daily fluid need (ml): Multiply % water in formula x daily formula needs in ml
- Subtract given water from formula from total fluid requirements= water flushes
- To find rate: Divide total mls of formula/day by 24 hours =unit of answer ml/hr
Patient needs 2000 calories per day and is restricted to 1500 ml fluid per day. The enteral formula selected has 1.5 cal/ml, 55g protein/L and is 77% water.
How much formula is required?
When asking only for formula amount you only need calorie needs of the patient and the cal/ml provided by the formula.
calories/1.5 cal/ml= 1333ml
’
**Peripheral PN **is administered to what parts of the body and on and for how long can it be used?
- small surface veins
- only 5-7 days
short term therapy with minimum effect on nutritional status
PPN solutions are
* IV dexrose= ___ cal/g
* protein __-__%
* fat 10% = ___ cal/cc or 20%= __ cal/cc
* solutions generally limited to __-__ mOsm
- IV dexrose= 3.4 cal/g
- protein 3-15%
- fat 10% = 1.1 cal/cc or 20%= 2.0 cal/cc
- solutions generally limited to 800-900 mOsm
PN solution
protein: ratio for anabolism is
- 1 gram nitrogen /150 calories
- 1-1.5 grams protein / kg / day
% = number of grams of protein in 100 mls of solution
A 3% solution has
3 grams of amino acids / 100 ml.
850ml of 5.5% AA is equal to how many kcals
- 850*.055=46.75
- 47.75*4 (pro value)= 187 kcals
A 60kg pt recieves 2700 kcals PN. How do you calculate the gram of N in the PN solution
divide kcals by 150 kcals (from protein ratio)
= 18 g of N in the PN solution
PN
Find total kcals: 65g Pro, 200 g dextrose, 20% fat @ 7ml in 24 hrs
- 65 g pro x 4
- 200 g dextrose x 3.4
- 7ml x 24= ml/hr x 2.0
add up all totals for kcals= 1276 kcals
How do you transition a pt off of PN
give a minimal amount of full-strength enteral feeding at a low rate of 30-40 ml/hour to establish GI tolerance
this will prevent hypoglycemia
What is refeeding syndrome and who is at risk for it?
* at risk diagnosis: anorexia nervosa, chronic ___, prolonged fasting, unfed 7-10 days, significant weight loss, ____-deficient PN
- aggressive administration of nutrition to malnourished
- at risk diagnosis: anorexia nervosa, chronic alcoholism, prolonged fasting, unfed 7-10 days, significant weight loss, phosphorus-deficient PN
What happens as a result of refeeding syndrome:
* starved cells take up nutrients, ____ and ____ shift into intracellular compartments
* results in:
- starved cells take up nutrients, potassium and phosphorus shift into intracellular compartments
- results in: hypokalemia, hypophosphatemia, and hypomagnesemia
symptoms of refeeding syndrome:
* ____: cardiac, renal, carbohydrate metabolism, muscle weakness
* _____: cardiac abnormalities, respiratory failure, seizures
* ____: intracellular metabolism, cardiac arrhythmias hypocalcemia
- hypokalemia: cardiac, renal, carbohydrate metabolism, muscle weakness
- hypophosphatemia: cardiac abnormalities, respiratory failure, seizures
- hypomagnesemia: intracellular metabolism, cardiac arrhythmias hypocalcemia
where should blood glucose be for a patient at risk for feeding syndrome
tightly control blood glucose 140-180 mg/dI
Overfeding PN and dextrose 25mg/Kg/min may lead to
hyperglycemia
DRI
goals for healthy individuals to prevent nutritional deficiency diseases, includes gender, age, life phases
RDA: Recommeded Dietary Allowance
meets the needs for 50% of population, used in planning meals for healthy people, assesses group nutritional adequacy
EAR: estimated average requirement
used when insufficient evidence exists for EAR, RDA
AI: adequate intake
the amount not associated with adverse side effects in most individuals of a healthy population
tolerable upper level
DHHS
identifies broad goals and specific objectives for improving the public health
Healthy People 2030
Healthy People 2030
Focus on ____, such as risk factors and behaviors, rather than disease outcomes, address issues of _____, address ____that have a major impact on public health outcomes, are modifiable in the short term (through _____ and ____ to motivate action at the national, state, local, and community level), address _____, ____, and ____, have new data available periodically, preferably annually
- upstream measures
- national importance
- high-priority public health issues
- evidence-based interventions
- strategies
- social determinants of health, health disparities, and health equity
Development of programs and services
Goals should be
set in broad direction, general purpose
ex: increase quality and years of life
ex: Increase the awareness of CHD risk factors.
Development of programs and services
Objectives should be
thinks SMART objectives
- specific measurable (tangible) actions within a time frame
ex: Increase the number of women who can identify two risk
ex: improve cardio health in adults and decrease infection caused by Listeria
Implemenation of a community based program requires what and in what order
- administrative support
- realsistic budget
- staff commitment
- support of target population
funding for public health programs usually comes from
- general revenues (taxes)
- federal, local or foundation grants
