1. NFSC 470 Seminar MNT Review of Clinical Nutrition

2. What are some signs/symptoms of dysphagia? What labs might be affected?

3. If dysphagia doesn’t resolve and you must recommend a tube feeding, where would you recommend it be placed and why?

5. What are your diet and lifestyle recommendations for someone who has GERD?

6. So… for GERD:

7. What are the nutrition implications of chronic gastritis? In other words, the absorption of what vitamin might be affected, and this would lead to what condition?

8. What are the most common causes of gastric ulcers? What recommendations would you give to your patients with ulcers?

9. The post-gastrectomy diet is designed to decrease risk for dumping syndrome. What are the primary tenets of this diet?

10. What are the signs of fat malabsorption? What are the nutritional implications? What are your dietary recommendations for someone with fat malabsorption, in general??

11. What are your recommendations for someone with lactose intolerance?

12. What is IBD? Name two forms.

13. What are the nutritional recommendations for IBD?

14. What are the dietary recommendations for diverticulosis? Diverticulitis?

15. Describe the nutrition recommendations for someone with a colostomy or ileostomy.

16. What are some causes of hepatic steatosis? What are your nutrition recommendations?

17. What are the biochemical indicators for hepatic steatosis?

18. Ascites is associated with what disease state? What are the nutritional recommendations?

19. Cirrhosis may cause steatorrhea. Why? What’s the MNT?

20. Would you expect a change in lab values for someone with cirrhosis?

21. What are the hallmark lab indicators of acute pancreatitis? Hallmark symptoms?

22. Why would pancreatitis cause steatorrhea?

23. What’s the MNT for acute pancreatitis?

24. For someone with acute pancreatitis who requires a tube feeding, where should it be placed and why?

25. Tell me what could cause elevated blood glucose levels.

26. What’s albumin and why do we look at it when assessing nutritional status?

27. What pair of lab values may indicate dehydration? (Tell me which way they’d be off, either elevated or depressed).

28. What might cause low electrolyte values?

29. What does it mean, in general, if someone has a low Hgb and Hct?

30. What does a high MCV mean, and what dietary factors could cause it?

31. What are the two labs that (in general) together indicate kidney disease?

32. In renal failure, how would you expect the following labs to change? (Indicate up, down, or n/c for no change) ___BUN___creatinine ___uric acid ___K+ (potassium) ___ PO4 (Phosphorus) ___ Hgb/Hct __albumin

33. What is Hgb A1c and what does it indicate?

34. What are the LDL goals for people with diabetes, and why?

35. What does GFR indicate?

36. What are the dietary restrictions associated with kidney failure? (pre-dialysis)

37. Which one of these changes once dialysis is initiated?

38. List the “desirable” or “optimal” values: a.Total cholesterol (for people age 30+) ____________ b.LDL cholesterol __________ c.HDL cholesterol __________ d.TG (triglycerides) __________ e.Blood pressure ______________ f.Fasting blood glucose (range) ____________ g.Serum albumin ___________

39. What type of dietary fiber helps reduce serum cholesterol? How does it do it? What are some good food sources?

40. What is the DASH diet? For whom is it appropriate? What are the main tenets of this diet?

41. What are the main tenets for the TLC diet? (Therapeutic Lifestyle Changes) Nutrient Saturated fat Polyunsaturated fat Monounsaturated fat Total fat Carbohydrate Fiber Protein Cholesterol Recommended Intake

42. Enteral Nutrition Indications –Patient must have a functioning GI tract –Malnourished patient expected to be unable to eat > –Normally nourished patient expected to be unable to eat > –(anorexia, comotose, head/neck surgery, hypermetabolic, adaptive phase of SBS, upper GI obstruction if TF can be placed beyond it)

43. Contraindications –Intractable vomiting and/or diarrhea –Intestinal obstruction, ileus, or bleed –Early SBS –Fistula –Early short-bowel syndrome –Pt. intolerance –No enteral access/pt. refusal –Pt. expected to eat within reasonable timeframe –Aggressive therapy not warranted

44. Types of formulas –Intact (Standard) –Hydrolyzed (Elemental) –Modular Kcals: –Standard –Concentrated Osmolality

45. Routes of Administration –NG –ND –NJ –PEG –PEJ

47. Enteral Calculations Volume: rate (ml/hr) x 24 hours = ml total volume/day Kcals: volume x kcal/ml = kcals Protein: g_ x volume (L) = g prot/day L Water: volume x %free water (plus flushes) = ml/day (Review Homework Problems)

48. Parenteral Nutrition TPN = Total Parenteral Nutrition Provision of nutrients intravenously –Central –Peripheral (PPN) For patients who are already malnourished or have the potential for developing malnutrition and who are not candidates for enteral nutrition

49. Indications for TPN 1.NPO for extended period (>10 days) 2.Enteral nutrition support projected to be inadequate for >14 days 3.Extensive small bowel resections 4.Radiation enteritis 5.Intractable diarrhea/vomiting 6.GI tract obstruction 7.Severe acute pancreatitis 8.Fistula

50. B. Contraindications 1. Patients for whom EN would meet requirements 2. Terminally ill patients.

51. Routes for Parenteral Nutrition Central Venous Access

52. PICC Line –Peripherally inserted central catheter Easier to insert than central line

54. Peripheral Parenteral Nutrition (PPN) Utilization of peripheral veins for the administration of nutrients Indications for use: 1.Short term PN 2.No access to central vein 3.Malnourished pts with frequent NPO for procedures/tests

55. Contraindications: 1.Weak peripheral veins 2.Fluid restrictions (i.e. kidney disease, congestive heart failure, etc.) Limitations Peripheral site more prone to inflammation/infection Fewer kcals administered Remember: PPN solution needs to have: <10% [dextrose] to avoid phlebitis lipids q day to protect the vein

56. Review of PN Solutions and Calculations

57. Intravenous Solutions Abbreviations: D: dextrose W: water NS: normal saline (0.9% sodium chloride solution) D 5 W: D 10 W: D 50 W: D 70 W:

58. Calculations Dextrose = AA = Lipid –10% lipid provides –20% lipid provides –Lipid can be infused separately or with dextrose and amino acid (admixture)

59. TPN Orders – Several ways they can be written. Examples: –Per liter Example: 500 ml 70% dextrose, 500 ml 15% AA @ 50 ml per hour, plus 250 ml 20% lipid/d –Final concentration Example: 20% dextrose, 6% AA at 85 ml/hr plus 500 ml 10% lipid/d –Per Day: 960ml 8.5% Aas, 960ml D 50 W at 80ml/hr, plus 250 ml 20% lipids q day

60. Example1: Figure out total kcalories and protein grams per day from this per liter order: 500 ml 8.5% AA/L 500 ml D 50 W/L to be run@75ml/hr. plus 500ml 10% lipid = 1 liter ‘admixture’ In this example, lipids are hung separately

61. Protein Grams (per 500 mL): Kcalories (per L):

63. Example 2: Calculate total kcals and protein grams provided in this per-day formula 960ml 8.5% AAs 960ml D 50 W to run @ 80ml/hr (X 24h = 1920ml) plus 250 ml 20% lipids q day

64. D 50 W: 8.5% AAs: Lipids:

65. TPN Administration A.Rate 1.Start slowly, especially w/dextrose. Allows blood to adapt to increased glucose/osmolality 2.Infusion pump is used to ensure proper rate. 3.Example: Start at 40ml/hr x 24hr. Then progress to 80ml/hr x 24h (equivalent to increasing TPN by 1 liter per day), etc. until goal rate has been reached or patient intolerance is noted.

66. a. If rate is increased too quickly, hyperglycemia may result b. Monitor tolerance: electrolytes, blood glucose, triglycerides, ammonia, etc. 4. Introduce lipids gradually to avoid adverse reactions (fever, chills, backache, chest pain, allergic reactions, palpitations, rapid breathing, wheezing, cyanosis, nausea, and unpleasant taste in the mouth) 5. When pt. is taken off TPN, rate must be tapered off gradually to prevent hypoglycemia. 6. (  TPN by ½ X 2 hrs, then DC – usually sufficient to prevent hypoglycemia) 7. PPN doesn’t need to be tapered off (uses more dilute solution w/less dextrose)

67. B.Cyclic Infusion 1.TPN infused at a constant rate for only <24 hours/day (e.g. 12-14hr overnight) 2. Allows more freedom/normal daytime activity 3.Can be used to reverse fatty liver resulting from continuous infusion (Chronically high insulin levels may inhibit fat mobilization  fatty liver) 4.Fewer kcals may be necessary to maintain N balance (body fat better mobilized for energy) 5.Requires higher infusion rate: not all patients can tolerate it.

68. Potential TPN Complications A.Catheter or Care-Related Complications: Fluid in the chest (hydrothorax) Air or gas in the chest (pneumothorax) Blood in the chest (hemothorax) Sepsis Blood clot (thrombosis) Infusion pump malfunctions Myocardial or arterial puncture

69. B. Metabolic or Nutrition-related Complications –Hyperglycemia/Hypoglycemia –Dehydration/Fluid overload –Electrolyte imbalances –Hyperammonemia –Acid-base imbalance –Fatty liver –Bone demineralization

70. Transitional Feedings -- moving from parenteral to enteral nutrition A.Begin oral diet while tapering off TPN 1. 2.

71. B. Tube feeding while tapering off TPN 1.Rate of TF gradually increases as TPN rate decreases 2.Remember that long term TPN without enteral nutrients  atrophy of intestinal villi C. Discontinue TPN when oral/enteral intake provides 1.Consider possible apprehension to begin oral intake 2.Poor appetite possible at first 3.Team members should provide support and reassurance