Term
| Why was there a need to develop a Consensus statement on malnutrition identification and diagnosis? |
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Definition
To make it more standard because currently....
• Multiple definitions
• Lack of screening and assessment
• Variations in screening tools
• No universal approach to documentation |
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Term
| Know the 6 characteristic markers for diagnosing malnutrition as recommended by the Academy/ASPEN criteria. |
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Definition
1. insufficient energy intake
2. weight loss
3. loss of muscle mass
4.loss of subcutaneous fat
5. edema
6. diminished functional status |
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Term
| How does acute disease/injury-related malnutrition differ from chronic-and starvation-related malnutrition (refer to Figure 1in White et al (2012) articleand the corresponding slides in the lecture notes) |
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Definition
disease/injury (acute): marked levels of edema (crp levels and c-reactive protein increase.
Chronic: low levels of edema. minor CRP levels
starvation: no edema (self or conditionally induced) |
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Term
| How does inflammation affect malnutrition? Know the biochemical markers of inflammation. |
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Definition
• Increases and/or Worsens malnutrition
• Decreases response to nutrition
intervention, increases mortality |
|
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Term
Chronic Disease‐related malnutrition
(mild to moderate inflammation) |
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Definition
• Organ failure
• Cancer
• Rheumatoid arthritis • CVD
• CHF
• DM |
|
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Term
| Acute illness‐related malnutrition (severe inflammation) |
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Definition
• Major infection
• Burns, trauma
• Closed head injury
• Major surgery involving a major organ |
|
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Term
| Biochemical markers of inflammation |
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Definition
Decrease in negative acute phase reactants (APRs) such as?
– Elevated CRP
– Hyperglycemia
– White blood cell count
– Nitrogen balance? (increase neg nit balance) |
|
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Term
| Other signs of inflammation (vital and visual) |
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Definition
• Vital signs
– Fever (≥ 99.9 F) or hypothermia (< 95 F) – Tachycardia (> 100 bpm)
• Visual inspection – Skin?
– Eyes: swelling
• Other: Chills, night sweat, etc.. |
|
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Term
| Why is it important to conduct a NFPE? |
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Definition
•Nutrition‐focused physical exam is one part of a complete nutrition assessment.
•Physicians, NPs, or PAs may not address signs/symptoms of micro‐ or macro-nutrient deficiencies in their exam.
•This skill can improve patient/client care and RDs should own it! |
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Term
| indicators of Micronutrient deficient status (NFPE) |
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Definition
| Skin, hair, nails, oral cavity, eyes, face |
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Term
| 3 types of indicators of Macronutrient deficient status (NFPE) |
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Definition
|
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Term
NFPE skin evals
Xerosis
Follicular hyperkeratosis
Petechia |
|
Definition
Vitamin A/ essential fatty acid: Xerosis (abnormally dry skin)
follicular hyperkeratosis: Vit A and C, fatty acid
Petechia: Vita K and C |
|
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Term
NFPE Skin evals
generalized dermatitis
Pellagra dermatitis
poor turgor |
|
Definition
generalized dermatitis: Zinc and essential fatty acids
Pellagra dermatitis: Niacin and Tryptophan
turgor: fluid, hydration |
|
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Term
NFPE hair eval
easily plucked hair
corkscrew hair |
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Definition
easily plucked hair: Protein, biotin, zinc, iron
corkscrew hair: Vitamin C |
|
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Term
NFPE eye eval
night blindness
bitot spots
corneal xerosis |
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Definition
night blindness: vita A
bitot spots: (shiny grey spots) Vita A
corneal xerosis: (abnormal dryness) Vita A |
|
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Term
NFPE nail eval
Koilonychia
dull
transverse ridging
Periungual hemorrhage |
|
Definition
koilnychina: (Thin concave nails) Iron (with or without anemia)
dull or traverse ridging: protein
Periungual hemorrhage:Vitamin C |
|
|
Term
NFPE mouth eval
Cheilosis:
Glossitis
Bleeding, spongy gums |
|
Definition
Cheilosis: (dry swollen or ulcerated lips)Vitamins B‐6, B‐2, niacin, iron (severe deficiency)
Glossitis: (inflammation of the tongue, magenta color) VitaminsB‐2,B‐6,B‐12, niacin, folate, iron (severe deficiency)
Bleeding, spongy gums: Vitamin C |
|
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Term
NFPE mouth eval
Angular stomatitis
atrophic glottis
dysguesia |
|
Definition
Angular stomatitis: fissures/lesions corner of mouth, bilateral
Vitamin B‐2, B‐6, niacin, iron
atrophic glottis: slick tongue
Niacin, folate, vitamin B‐2, B‐12, iron
dysguesia: distorted tast
zinc |
|
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Term
NFPE teeth eval
dental carries
tooth discoloration |
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Definition
dental carries: vitamin C
discoloration: excessive fluoride |
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Term
Key Signs of Overt Deficiency
Vitamin A |
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Definition
| VitaminA: Eye disorders (e.g. xerophthalmia, night blindness, etc.,) |
|
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Term
Key Signs of Overt Deficiency
Thiamin |
|
Definition
Thiamin:
•Disorientation, confabulation, Wernicke’s Encephalopathy in an alcoholic
•BERI BERI is “classic” deficiency syndrome in non‐alcoholic |
|
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Term
Key Signs of Overt Deficiency
Vitamin C |
|
Definition
VitaminC:
•Swollen gums, corkscrew hair, petechiae, purpura on legs
•SCURVY is the “classic” deficiency syndrome |
|
|
Term
Key Signs of Overt Deficiency
Riboflavin |
|
Definition
|
|
Term
Key Signs of Overt Deficiency
Zinc |
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Definition
| •Zinc: Diminished taste acuity (dysgeusia) |
|
|
Term
Key Signs o fOvert Deficiency
Vitamin D |
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Definition
|
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Term
Key Signs of Overt Deficiency
Iron |
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Definition
| spoon shaped nails, pale conjunctiva, anemia |
|
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Term
Key Signs of Overt Deficiency
Niacin |
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Definition
| •Niacin The 4‘ D’s: Diarrhea, Dermatitis, Dementia, Death. PELLAGRA is the “classic” deficiency syndrome |
|
|
Term
|
Definition
between bicep/tricep
thoracic fat loss: Ribs, lower back, mid‐axillary line
orbital region |
|
|
Term
|
Definition
temporal
clavicle (chest)
acromium region
scapula
dorsal hand
boney knees
quads
calf region
pitting edema in lower extremities |
|
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Term
| Malone Hamilton physical assessment for malnutrition (sings for severe malnutrition) |
|
Definition
orbital (suppressed eyes)
tricep skin fold: little to no space between fingers
thoracic/ lumbar: depression between ribs, can see iliac |
|
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Term
| Why is it important to assess edema in the context of malnutrition?What is the difference between 1+ versus 4+ edema? |
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Definition
pitting edema may be a sign of hypoproteinemia.
must consider coexisting disease
may obscure weight loss
2+15 seconds to rebound
3+ 30 seconds to rebound
4+ 30+ seconds to rebound |
|
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Term
| What medication class is associated with C. difficile-induced diarrhea? Why does this type of medication make it possible for this to happen? Why do we call C. difficile an ‘opportunistic’ bacteria (or bug)? |
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Definition
Antibiotics can cause C-diff via broad or longterm use of antibiotics: decreases intestinal flora and vita K synthesis.
Become very infectious once established |
|
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Term
| What foods are high in tyramine, and which medication requires a tyramine-restricted diet in order to avoid complications? Why is this necessary? |
|
Definition
Monoamine oxidaze inhibitors: Anti depressants
MOA's breakdown neurotransmitters (serotonin, epinephrin etc) and well as Tyramine.
Causes amine (tyramine) to build up in blood.
foods: aged cheese, fish, red wine, fermented soy, aged meat
causes increase B, headache and palpations. |
|
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Term
Drug Nutrient Interactions
Calcium- Channel Blockers
and grape fruit |
|
Definition
Calcium-channel blockers are used for HPTN
Grapefruits has a flavonoid (naringenin) inhibits
intestinal enzyme that breaks down/ oxidizes the drug |
|
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Term
Drug Nutrient interaction
Corticosteroid |
|
Definition
Prednisone, hydrocortisone:
Primary side effects:
• Hyperglycemia, negative N balance, sodium/fluid retention, absorption of Ca++ & K+, and risk of osteoporosis over long-term |
|
|
Term
Drug nutrient interaction
Diuretics |
|
Definition
causes loss of
urinary wasting of Na+, K+, Mg++, and Zn++ |
|
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Term
Mrs. T is a 79 year old woman with pneumonia. She is on her second course of broad spectrum antibiotics. Two days ago, she was placed on a ventilator due to respiratory failure, and a tube feeding was initiated. This morning she has diarrhea.
–What is the most likely cause of her diarrhea? |
|
Definition
| C-diff from her antibiotics |
|
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Term
Mr. K, a 75 year old man with a history of CVD has recently been placed on Coumadin therapy.
–What should he be told about his diet and this medication? |
|
Definition
Coumadin in an anticoagulant that regulated vitamin K (coagulant)
he needs to stay consistent with the amount of vitamin K he is consuming since the meds he is on is meant to manage the K he has, too much or too little could render the medication less useful. |
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Term
Your grandfather has been on Lasix now for several months. He has been complaining of foot cramps at night.
–What is the most likely nutrient-medication
problem at play that could be causing his foot cramps? |
|
Definition
Long term use of lasix can cause wasting of Na, K, Mg, Zn
but dehydration can cause muscle cramps. |
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Term
| Why is enteral nutrition support the preferred route of feeding? |
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Definition
•Better nutrient utilization
•Less cost (considered part of room and board)
•Fewer risks (of infection) |
|
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Term
| When is enteral NS indicated? |
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Definition
–Hyper metabolism
–Neurologic or psychiatric injury/disease
–GI disease
–Oncologic disease
–Organ failure
**** when the gut works |
|
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Term
| contraindications for Enteral NS |
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Definition
*** if the gut doesn't work
–Insufficient absorptive capacity of GIT(SBS)
–Mechanical obstruction of GIT
–Prolonged ileus
–Severe GI hemorrhage
–Intractable vomiting o rdiarrhea
–High output fistula(>500ml/d)
–Need for complete bowel rest (e.g. severe acute necrotizing pancreatitis)
–Ethical contraindications? |
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Term
| Early enteral feeding: Know the definition and major benefits. |
|
Definition
24 to 48 hours after admission
• Benefits
– Reduces the response to stress
– Reduces weight loss
– Minimizes GI mucosal atrophy
– Reduces bacterial translocation
– Decreases sepsis
– Enhances immune response
– Cost‐effective |
|
|
Term
|
Definition
greater than four weeks
–Gastric: Gastrostomy
–Post-pyloric: Jejunostomy |
|
|
Term
Nasogastric feeding tube
indication |
|
Definition
Indications:
• Short term (<4 weeks) feedings
• Intact gag reflex
• Gastric function not compromised
• Low risk for aspiration |
|
|
Term
|
Definition
for ICU or infants
tube placed through the mouth to the stomach
not for people with teeth |
|
|
Term
|
Definition
Small bowel feedings
High risk of aspiration
Gastric function compromised (example?)
Persistent nausea and vomiting
MUST verify placement with x‐ray (See Box 5.3 in Nelms text) |
|
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Term
| What is the normal range for the body osmolarity? |
|
Definition
280-300 mOsm/kg
most meds are higher than 1,000 mOsm/kg |
|
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Term
|
Definition
Intact nutrients
•Protein: Typically from casein and soy isolates
•Carbohydrate: Typically polysaccharides and
glucose polymers
•Fat: Typically a mix of LCT and MCT
– ~ 1.2 ‐ 1.5 kcal/ml; 78
–85% free water – Available with fiber and/or FOS |
|
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Term
|
Definition
| elemental, amino acids, medium chain triglycerides |
|
|
Term
disease related formulas
Pulmonary
Renal
hepatic |
|
Definition
– Pulmonary
•Ex: Pulmocare,Respalor
• Higher fat, lower CHO to reduce CO2
retention??
– Renal
•Ex: Nepro,Suplena,NovasourceRenal • Modified in protein (e.g. EAA, EAA +
His), and electrolytes
– Hepatic
• Ex: Nutrihep • High BCAA |
|
|
Term
|
Definition
– Administered rapidly (<15 minutes), 4 – 6 X/day (250 – 400 ml/feeding)
– Into stomach; gastric complaints common
– Noncritically ill patients; home TF; rehab pts
– Not recommended for initiation of TFs
– Allows more normal lifestyle |
|
|
Term
| What contributes most to osmolality? |
|
Definition
| (mono‐ and disaccharides and amino acids) |
|
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Term
| which formula has a higher level of fat and lower amount of CHO |
|
Definition
| pulmonaryformula contains a higher percentage of kcals as fat (40 -55%) and a lower percentage of kcals as CHO to reduce CO2production. |
|
|
Term
| For what types of patients would intermittent feeding be a good choice? |
|
Definition
non-critically ill patients
rehab patients
– Administered over 30 – 60 minute period 4 – 6x/day (< 400 ml/feeding)
– Into stomach; requires normal GI function
– Noncritically ill patients; home TF; rehab pts
– Allows more normal lifestyle |
|
|
Term
| When would a cyclic feeding be useful? |
|
Definition
useful for transition to oral diet
– Administered by infusion pump over 8 – 16 hours, usually at night
– Requires high infusion rate and/or more concentrated formulas
– Potential GI intolerance
– Useful for transition TF to oral diet |
|
|
Term
| What kinds of problems place a patient at high risk for (pulmonary) aspiration? |
|
Definition
intubation
low gastric emptying
neurologic issues |
|
|
Term
| What actions can be taken to optimally reduce the risk for pulmonary aspiration? |
|
Definition
below pyloric feeding
HOB above 30-35*
postion tube distal
Pro-kinetic agents |
|
|
Term
what should feeding tubes be flushed with
how much
how often |
|
Definition
| Know that feeding tubes should be flushed at a minimum with 30 -50 ml water 6 times/day (that’s every 4 hours), before and after medications are administered through the tube, and when stopping and restarting the feeding. |
|
|
Term
|
Definition
Dehydration; hyperglycemia; electrolyte imbalance
decreases phosphorus, magnesium, potassium
metabolic disturbance from reinstitution of oral nutrition. |
|
|
Term
| Review the indications and contraindications for parenteral NS. |
|
Definition
• Nonfunctioning GIT
– Severe malabsorption, SBS, intractable V or D
• Bowel rest
– Severe acute necrotizing pancreatitis, high output
fistulas
• Severe malnutrition or increased nutrient needs (e.g. burns, trauma, sepsis) |
|
|
Term
In what form is carbohydrate provided in parenteral solutions, and how many kcal/g does it provide?
what happens if it is exceeded? |
|
Definition
5mg/kg/min
hyperglycemia, fatty-liver, excess carbon dioxide production |
|
|
Term
| What concentrations are used for typical dextrose stocksolutions? |
|
Definition
Dextrose monohydrate: 3.4 kcal/g
– Dextrose stock solutions: D50 or D70
– Means50%(50g/100mL)or70%dextrose(70g/100mL) |
|
|
Term
| In what form is protein provided in parenteral solutions? |
|
Definition
AMINO ACIDS
– Crystalline amino acids (EAA + NEAA) |
|
|
Term
| Know that fat is provided in the form of lipid emulsions in parenteral solutions. How many kcal/g does a lipid emulsion provide? |
|
Definition
Safflower, soybean, or combo + glycerol & egg phospholipid (lecithin) = lipid emulsion
Lipid emulsion stock solutions: 10 or 20% • 10 kcal/g (glycerol adds 1 kcal/g)
• 10% lipid emulsions: 1.1 kcal/ml
• 20% lipid emulsions: 2.0 kcal/ml |
|
|
Term
| What is the recommended maximum for lipid administration? What adverse effects could result from exceeding this maximum? |
|
Definition
abnormal fatty liver, immunity can be impacted (low immunity), abnormal liver function tests
max: 1g/kg/min |
|
|
Term
|
Definition
| Electrolytes: Na+, K+, Mg++, Ca++, Cl-, Phos |
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