Nutrition Screening FIGURE 2.3 Sample Admission Nutrition Screening Tool Diagnosis | Ifthe patient has at least ONE of the following diagnosis(es), circle and proceed to Section | E to consider the patient AT NUTRITIONAL RISK and stop here. Anorexia nervosa/bulimia nervosa Malabsorption (celiac sprue, ulcerative coliis, Crohns disease, short bowel syn- rome) Mutiple trauma (closed-nead injury, penetrating trauma, mutiple fractures) Decubitus ulcers Major gastrointestinal surgery within the past year Cachexia (temporal wasting, muscle wasting, cancer, cardiac) Coma Diabetes End-stage liver dieease End-stage renal disease | Nonhealing wounds B. Nutrition intake history lithe patient has at least ONE of the following diagnasis(es). circle and proceed to Section E to consider the patient AT NUTRITIONAL RISK and stop here Diarrhea (> 500 mL x 2 days) Vomiting (> 5 days) Reduced intake (< 1/2 normal intake for > 5 days) ©. Ideal body weight standards if at < 80% of ideal body weight, proceed to Section E to consider the pationt AT NUTRI- TIONAL RISK and stop here. D. Weight history ‘Any recent unplanned weight loss? No_Yes __ Amount (Ibs or kg) IFyes, within the past _ weeks or _months Current weight (Ibs or kg) __ Usual weight (Ibs or kg) Height (tt, in or om) Find percentage of weight lost Usual wt-current wy 499.9% wloss usual wt 240 1998 TDA Manual for Medical Nutrition TherapyMnccecenas FIGURE 2.3 Sample Admission Nutrition Screening Tool (Continued) D. Weight history (Continued from previous page) Compare the percent weight loss with the chart values and circle the appropriate value i week 1-2 >2 2-Sweeks 2-3 >3 month 4-5 28 3months 7-8 >8 5+ months 10 >10 If the patient has experienced a significant or severe weight loss, proceed to Section © and consider the patient AT NUTRITIONAL RISK , Nurse assessment Using the above criteria, what is this patient's nutritional risk? (circle one) LOW NUTRITIONAL RISK AT NUTRITIONAL RISK ‘Adapted with permission from Kovacevich OS, Boney AR, Braunschweign CL et.al Nuttion Risk Classification: A reproducible and valid oo! fr NurBes. Nutr CUn Pract. Vol. 12, No, 1, 20-25, February 1997 FIGURE 2.4 Texas Children’s Hospital - Admission/Transfer Form: Nutrition Status NUTRITION STATUS ACTION PLAN ___tomcanpaue yalcesetpaiesion’ | NEONATES No | ‘yes | NEONATES IN SPECIAL CARE NURSERIES <1 MONTH OF AGE CONSIDERED AT NUTRITION RISK. AND ADMITTED TO SPECIAL a NUTRITION MONITORED PER ‘CARE NURSERIES INTERDISCIPLINARY PLAN OF CARE LESS THAN 10 YEARS OF AGE ANY YES INDICATES POTENTIAL < TOILE WT/HT aja NUTRITION RISK < TOILE HT/AGE ala ORDER, 10 YEARS OF AGE AND OLDER << TORSILE WI/AGE a | a | @ NuTRTION screeNiNe ReauEst << NO%ILE HT/AGE jaja Avie OTHER ala Reprinted with permission from Texas Chidron's Hospital, Houston, TX 1998 TDA Manual for Medical Nutrition Therapy 2TABLE 2.1 Nutrition Acuity Ranking for Dietitian Services By Disease/Condition Level 4 — Extensive ADS ana HW inte Renal failure, acute ‘Anorexe nervosa Renal failure, chronic Bone marrow transplantation Renal transplantation | Bulimia Short bowel syndrome | Burns and major thermal injury Transplantation, heart-lung Cardiac transp'antation Transplantation, lung | Celiac disease (gluten-enteropathy) Tyrosinemia Crohn's disease (regional enteritis) Ulcerative colitis Cystic fibrosis Esophageal cancer Failure to thrive, pediatric Hemodialysis Hepatic carcinoma Hepatic encephalopathy, failure or coma Hirschsprung’s disease (Megacolon) Home total parenterat nutrition Home tube feeding Homocystinuria Hypersmolar hyperglycemic nonketotic coma Inbor errors of CHO metabolism Intestinal fistula Intestinal Lipodystrophy (Whipple's disease) Liver transplantation Maple syrup urine disease Multiole organ dysfunction Multiole organ systems failure Necrotizing enterocolitis Pancreatic carcinoma Peritoneal renal dialysis Phenylketonuria Protein-calorie malnutrition: kwashiorkor Proteir-calorie malnutrition: marasmus ‘Adapted with permission from Escot-Stump S. Nutition Acuity Renking Study by DiagnosisiConditon, Future Dimensions in Cinieal Management. Volume XVI, No, 2, Spring 1987, 212 1998 TDA Manual for Medical Nutrition Therapyx1 TABLE 2.1 Nutrition Acuity Ranking for Dietitian Services By Disease/Condition (Continues) i Acute respiratory failure ‘Adrenocortical ineuficiency, chronic Alcoholic iver disease Amyotrophic lateral sclerosis, Ascites ‘Atherescierosis, coronary heart disease Bacterial endocarits Bilary cinhosis Bowel surgery Brain tumor Bronchial carcinoma (lung cancer) | Burns and minor thermal injury Cancer (general or unisted types) Cardiac cachexia Cerabxal palsy Cerebrovascular accident (stroke) Childhood obesity counseling Cholestatc iver cisease Chorioearcinom Chylothorex Cleft palate Colostomy | Coma Cystinosis (Fanconi’s Syndrome) | Diabetic gastroparesis Diabetic keioacidas's or comma Esophageal stricture or spasm Esophageal rauma Esophageal varices Fai malabsorption syndrome Food allergy, multiple Gastrectomy andior Vagotory | Gastric bypass or staping Gastric carcinoma Gastric retention Gestational diabetes Glorreruionepivitis, acute Glomeruioneptvits, chronic Gulien-Barre syndrome Hartnup disease | Hepatic cirthosis Huntington's chorea Hyperinsulinism Hypetipiceria Hyperrophic gastritis (Menetriers disease) 1998 TDA Manual for Medical Nutrition Therapy Level 3— High Hypoglycemia lleostomy Inborn errors—Vitamin D resistant rickets Insulin-dependent Diabetes Mellitus Intestinal lymohangiectasia Jejuncileal bypass surgery Leukemia, acute Leukemia, chronic Low birtnweight infant Lymphoma, Hodgkin's disease Lymphorna, non-Hodgkin's Myasthenia gravis, Myeloma (simple or multiple) Neprtis, Bright's disease Nephrosclerosis Nephrotic syndrome Neurological trauma, spinal cord ‘Nor-insulin-dependent Diabetes Melitus ‘Open heart surgery Oral cancer Osteosarcoma Pancreatic insufficiency Pancreatic surgery Pancreatitis, acute Pancreaiitis, chronic Paratniyroid disorders (altered calcium) Pernicious vomiting, one week or longer Porta-caval shunt for portal hypertension Prader-Willi syndrome Pregnancy with complications Pregnancy-induced hypertension Pressure ulcers, stage 3 or 4 Pyelonephritis Radiation colts or enteritis Rickets, nutrition Scleroderma (Systemic sclerosis) Sepsis or septicemia Spina bifida Syndrome of inappropriate ADH (SIADH) Systemic lupus erythematous Trauma \Wilm’s tumor (embryoma of kidney) Wilson's disease Zollinger-Elison syndrome 213ion Scret 9 TABLE 2.1 Nutrition Acuity Ranking for Dietitian Services By Disease/Condition (Continued) Level 2— Moderate Achalasia Acromegaly Addison's disease Azheimer’s disease or other dementias ‘Amputation, 1 or more limbs ‘Anemia rom parasitic infestation ‘Anemia, iron deficiency ‘Avemia, nutrtion (folic acid, copper. etc.) Avemia, pericious or vitamin B12 Avermia, sideroblastic Angina pectoris, Aplastic anemia ‘Athlete, spor nutrition advisement Breast cancer Bronchial pneumonia, Candiciass Carcinoid syndrome Cerebral aneurysm Chinese Restaurant Syndrome Chronic fatigue syndrome Congenital heart disease Congestive heart failure Cor puimonale Cultural food pattern, adaptation) adviserrent Cushing’ syndrome Dental dificuties Depression with numerous medications Diarrhea (acute enteritis) Divericular diseases Down's syndrome Dyseniery or Travelers Diarthea Dyspepsia or indigestion Encephalitis or Reye's syndrome Fever, greater than 102 degrees Food aleray, simple Food poisoning, corrective therapy Fracture, long bone Galbiadder disease, surgical or non- surgical Gastritis or gastroenteritis Heart valve diseases 214 Heartburn, hiatal hernia or esophagitis Hemochromatosis (iron overoading} Hemorthage, acute or chronic Hepatitis Hyperaldosteronism Hypercalcemia Hyperkalemia Hypermagnesemia Hypematremia Hypertension Hyperthyroidism Hypocalcemia Hypokalemia. Hypomagnesemia Hyponatremia Hypopituitarism Hypothyroiaism Immobifization, extended lnritabe colon/spastic colitis Kosher dietary patterns, advisement Lactase malabsorption or maldigestion Large-for-gestational-age infant Megacolon, acquired Meningitis Migraine headache Multiple sclerosis Muscular dystrophy Myelomeningocele Myocardial infarction, acute Obesity, non-surgical counseling Oral cisorders (periodontal disease, etc.) Osteoarthritis (degenerative joint disease) Osteomalacia Osteomyelitis, acute Osteoporosis Paget's disease (osteitis deformans) Parkinson's disease Peptic ulcer Pericarditis Perigheral vascular disease Peritonitis Pheochrornocytoma 1998 TDA Manual for Medical Nutrition TherapyDeitel meters) TABLE 2.1 Nutrition Acuity Ranking for Dietitian Services By Disease/Condition (Continued) Level 2 — Moderate (Continued from previous page) Phosphate imbalances Polyarteritis nodosa Pressure ulcers, stage 1 or 2 Prostate cancer Psychosis Pulmonary embolus Pulmonary tuberculos's Respiratory distress syndrome, any age Rheumatoid arthritis Sarcoidosis Sickle cell anemia Spinal surgery Adolescent, normal admission Ankylosing spondylitis Appendectory Ascariasis Bronchial astima Bronchitis, acute Cardiac tamponade Cataract surgery Ceasarean delivery Child, normal admission 1 -6 years Child, normal admission 7 -12 years Constipation Depression, mitd Epliepsy or seizure disorders Food poisoning, preventive counseling Gout Hemorrhoids andjor hemorthoidectomy Herpes simplex | and ti Herpes zoster (shingles) Hysterectorny, abdominal Infant, normal admission 0 -6 months 1998 TDA Manual for Medical Nutrition Therapy Substance abuse and withdrawal! rehabilitation Surgery, general Thalasserias (Cooley's anemia} Thoracic empyema Total hip arthroplasty Trichinosis ‘Typhoid fever Underweight or general debility Urolithiasis (renal stones) Vagetarian, advisement on planning Vitamin deficiency counseling Level 1 — Minimal Infant, normal admission 6 - 12 months Infectious mononucleosis, influenza (flu, respiratory) Meniere's disease Meninaitis Perathytoidectomy Pelvic exenteration Pebic inflammatory disease Poliomyelitis Poiycythemia vera (Osler’s disease) Pregnancy, uncomplicated Rheumatic fever Ruptured intervertebral disc ‘Skin disorders, such as acne or allergies Tardive dyskinesia Temgoromandiular joint dysfunction Thromiboctyopenic purpura Thrombophiebitis Tonsillectomy and adenoidectomy Toxic shock syndrome Trigeminal neuralgia 2sTABLE B-1 Sample Hospital Nutrition Department “STAFF CREDENTIALS AND REQUIREMENTS Dietitians ae eistred through the Commrssion on Dietetic Registration; ‘ech inst alatain thee agitation though cortinung edueaton the education requirement is 75 nous Curing each 5-year etad. Competency Standards are developed, update, and reviewed regeliy by the clinical rutin manager to mee the speci, changing needs ofthe fact. ASSIGNMENTS Full-time equivalents af ina dictitans ae assigned to patient ave ad ‘anbubtay dines, One ful-tine equivalent of a cnical mutton manager ead te ctiiea/outpatien st. Sta are assigned to community e6ues- tion programs upon request and scheduling allows. Based on the diy Census and ect, clinical and ostatient dietitians may ads te daly Stafing patton to meet neds according t changes in patient acuity. Prionty for Nutrition Services igh Priority Defritiene/Inicatins Nutrition interventions that warent Trequent comprehensive patent reassersment to document the Iinpact othe intervention on etc ‘ution outcomes, medical status {Ge labs, OT tolerance, etc}, and/or nical progres Examples: Now or ested EN/P or ‘se of meal food supplements. Conpechensive nusiton education cor couneatig tan of care rviow Update POC wien reassessing patient Standard ‘Scope of Services (continued) Moderate Priority Nuttin iterertions that warrant arly evalition, which can be sut- feienty traced vi bref /u notes. ‘ess Frequent comprehensive patient reassessment is needes Framples: Stable or PH. Brief rusitien education for survival Skis, Corination of care |Win 5 ays, based ona brie chart review, communication other STANDARDS OF CARE Clincal éetitians apply the hospital-approved standards of nutrition ‘ate and the evidence-based guidelines of tho American Dietetic Association, SCREENING [inpatients ave screened by the nursing department within 24 hours of “admission to determine the need fr Further nubition assessment. Cin- ical dietitians develop the sreerig triges, which are approved by ‘he medical staf. Ptionts receive nition intervention based on the preity/acuty levels assigned by the dietitians. The clinical dietitians perfom subsequent re-screning accoréing to policy and regulatory ‘guidlines. Low PHrity ‘Nutrition interventions that bring ‘closure and/or ornately eslve 2 patent’ nutrition diagnosis problem Of wnen no nutrton intervention is needed. F/U's expected in the form of resccening with easessment 35 incited by 2 change in satus. Examples ref nutrition education. No ‘bition diagnos, Plitive care ont Per rescreeing standards patent care provides as appropriate and patient contact. State the nt Won ciagesis, response tireen: ‘Son, andthe new or odie pla, Reastessment standard Within 3 days ASSESSMANT AND NUPRETON DIAGNOSES ‘The lncal ita assess patients using the quietne in the standards ‘of care approved by the medical Sta. Following to professions nut ‘bon care process, 2 nutrition diagnosis is established as needed. The lebology of the diagnosis selected determines the type and extet of intervention that wil be provided. The mest common nutrition dagnoses in hi felt areas Follows Inadequate ral ood/beveroe intake (N-2.2) Tracecute proteln-enegy intake (N-S.3) Ineesied nutrient needs (N-.1) Evident malnattion (NS.2) Tradequate eesay intake (NI-1.4) Salling salty (-1.2) Involuntary weight Loss (NE.2) Inadequate itake fom enteral/parenteratcutron(NI-23) Foo and nutition-related knowledge deficit (NB.2) Undereight (NC-3.2) verweight/obesty(NC-3.3) cessive energy intake (NLS) iti T days Pe esieening standards _TERENTIONS: FOOD AND NUTRIENT DELIVERY According tothe patient’ abit to take in suciet ener. poten, arbohyerate. fat vitamins, minerals and wate, the incl dtitian wilt {Spprove or recommend alterations in the ution prescription, the adé- tion or discontinuation of enteral/prenterl nutrition, andthe use of ‘pec supplements or bioactive substances (2g, sho Iycopen Lutein, ginger, and muliitamin-vineral supplements), ost common feod-nutrient deliver Interventions in ths fay are as follows: Genera/relehtul det (ND= 1.2) ommeril beverages (NO-3.1.2) Initiate EN or PN (ND-2.2) Modify ate, concentration, composition or schedule (NO-2.2) edit stron, type, ot amount of food and nents within nals ora specified times (ND-1.2) Moies beverages (N0-3.1.3) odie fod (ND-3.1.4) Mattivamins/inerats (ND-2.2.3) Nutriionelated macication management (NO-6:1) (comtinved)auozeyisou ‘auozen01d sauojpaurpoxe | aseuna ‘seuos>40 2% onean “vuewe ‘asauigep apuneA( ‘sorci 2puidow opuredoxdong seasnAuogins| aeycoone sever sypeus| ‘sapwuenai] Joved pra sup ‘xe -1v4l 5419 ory ate or espkup soe Ona “2s081d “ous ‘esoquey ig wopuey sisoyey yo anuesge| anu x05 - OH 0919 24s 24| na ¢/04'se/se‘05/0s #oreue pidew wig 2 2e)0891 + Het 209 4 anay3uanag| 4 onenusniodhy smueyauBiee| sen) e1Beudhiod vuny/Ha| souoi| erciphiod ‘exnhjoa sypeus| pute pu ‘os Aun sor 103] ower stsopioy| ‘x02 - Ow ip wopuew uum uy +444 s9u0%9y 0s -0h9| 33 if wes pu SA sinaven| vvaw/iaa %001 annssy| ating| es 5018499 yaa ‘yn umaid 0 shen Sunea yaun sso) ym pr0%y| wnpos| areudosddeusaurooy| sepmme pue soneyag Bunea am ureruiew 2 338 inssei0d unea aug wausmay ROOTES "FevauT pue A 75) ened 2ouous pues59558 pInous Oy vvau/tuc %00t assy a ‘Aaysuaa avg Uap ‘oy rsdeso.n‘aWN| Shep m2} D 0NL-COT 1 4 seo wripos ‘Aueuiensip nus 99 pInoys m4 erx a vosawey unsseiog| es0naN e020uy| -auBwUIED| vn roa sae] 25060]Waid NNW ‘sv SOUT HN soujonpap| wi sojven| ou 389] sonsexey na 229] vcrstarddoounn 1 a wer! aw ‘ay'02"DWA'aa na] vzpue ayn wens ma dyir2-st- old val avenue rao J rae 200d pve zo4l repyoqeowochH tu pe AT seuszva son] sewer Aydasge apsnus} ,ue> 499 asne00q ype bsiou g9 sow pes io] Ioy> uly) sors uasoan@ ua sal Anysul 295219007] qq000'09:1] _ as0on8 /m sero) wu ‘ary are aun 8 mol] 20 8035 va0>A5 Tear SFO wr jonevaogiezep wwe 014/9 2un0 caw oovose:t rewerey = ruoy 98 Mol ansi| van os aaqosoud sae sesAjosply use hos saree ‘sw ou sueou veo ou som sonpord mwpau ou] + 2509018 4 2 o's asonee ou eussonees Aap Payog eusouvt sop aunerfuoud 4} + auveayuagay sin ooo‘ e424 nd speus vay antsy on ‘xorse-Ivd -sx02nj9 ope 02 -O8d pasn ou Ayesouo8 vio sai exnsoaks| asd Buunp on 45009 -0F0| yes iso] et wan pide woo) SaRNIDD TW sug 061 Saswape] reayvana vz 23 10 2yaueg few swwepronuy| ‘TORRGOIRURA Te Saw — 55} Aooroyas tz a se104 uz ‘Dau JU aio ‘aM ‘449 ‘209 2024 Aeppoypernoe-oe "Hla BW 9) ior ‘ava av sea ‘yous ‘unjades8 pony| se ‘nny 18009 ‘nna 2am duces sproms usyoqere> ued) ‘eunen "Lon2ayut hep 2d But | soyaiuu dund vorord/io201 2H HH Bee sso paesae=3e}/p ueneuueyu Su verosd 1)'Nne 18 souessasuinsul| —eu3}Deq UNOUA Aeon 08 Se ‘zo4‘zo0d| enuaah ody] fav yiue] dx ‘ave em AV wsyoqenauodhy Tea ST Y AHUTATIAG ea Apts ay usioud ‘susoco Saye ez Pe ax] stsosodoais) yen az ea smreuoydsoudsi 53 suanyaaunssai sa. sposais aoaeun| aoverea uanedasvon| ba ogerswodhy- poruaes| 20d ‘200d ni9 2801) ‘aseud noe u 0qee) n'y eN ‘eve aw ue agonerausrdhy] __ewnen eves | ~~ eusen nn oF saaoaa jo RUTGE oveWuE—aurweInE ‘ujeau punom/von2ury aunwnut ~ auUIBIE suowoy yams] ‘suuseyn pue aur as ea romog 210425 52,0} [810 J0 52-02 = URIO| rs 200] {60S 51987 03 YSEL 96 XE sonomue ‘Asn Bun {pouing vse 9 04a) + ane By x 809 42) = 3 spoewe one wureyer anes speeu 2u0;e9 soseseue| wsyoqawsody| 2 enusiog oun 250 spores ai0eue ustioqee surg sole TRAIT] Inn] sini TasvApE| 358954]TURTON HG ssausnoj2su02 pave} je uum svoyany jenegouodd reuquegovaud sairaas Tv ie 98 -BaNOTERTT AoW) wonaydas oj 82-1 epppue soueuaiew 05 9/8 ET eouueg uuaiaud swseydoou wed wlan 304 51338 suoneydusoa a80y0snau soueuswew e133 201g worsomn es] ‘Aovapyapounun} ss:0%) p00} pje>/iay /sp004 1pPe/SPoo} Aas Prony Ne LWAE MO} nseydoaunue “sougiyu 95693074 ja asexd.osuen assano1aptso3!n] 04 youd LeU Te “a ‘Hin sv ‘ava ‘su '300] “oip saree 380] suon22yu1 asuraocdo| 2p jeuoanansuon/awospuks SunserA| Woe HOLS TT Aawnnpe wo1shye 1yBiom Auaieay wrenurew eeu psn sures8 joy sep /ronysuny soulppin® soy| suogneseug suado.inen| ‘Aep/tamav/ig est avesuen ipo was ‘Aep/tryney/0°79°r suede voptnon Acpriymav/as7S'r sss9ns2:0n05 Aep/mav/ig'T-2T tusjoqereszdhH ep/Bamay/82T-r 39 passonsuont Aeprymev/ar-e wee sion STx 338 ss, ST 336 swsyogene> /m 3304 4 “STL 339 vodayded fa > SpE xa3a9 Asia] syoxjes suporeye svoqie2oupty anewore 2 eyse> s22u00| wou ‘ueueno ‘suvain siaaueyua| ‘Adesoypounuus “yoje2 ‘Bun 5919 sjeauaypoxtyd sonawanu oy'eN awe aww 2a swuade Bune ayy "3 “84D ‘HH TID euouepus “ppeia stueonoauy aerenoneu vsa *aojo3 Bury ‘aresoud svovai aoetou| va} van Tae] Nn snug 3a} ST)3a ORE ssa] live wo pase fuwey: sreayuerpave suesseuddnsou lconioa ‘susp jeseiva'son04 uu "za ‘soueteq W ‘avd N/M “au '¥S3 ‘Jem qunow wos, 30019 UL squawa ay aseasia ,u400| "UE RD WA HAH [IDA BSH HU — Ta IN ynul ‘9035 95080] sje2u 2UIs 9 “oc jeurou — yeuniat~ LNW | suoneR ‘soucns Aap Sasne> You uoEdosge ae|eKo 35201001 Os p.zeaue “veld #9 “sh 9}Qn}05 Ye yynosano eunseg| royuoyears‘eoynere oD yas 36) Mor = on9asa ea] ‘sauwkzva: 1ueeq N ‘nip "203 204 oxdosqeeu} 1p Jouopzosas won euntal] ‘yy ‘e> "usa ‘44 ‘H/H ‘une 19 sas] ‘uaa aaa uoy/en4s's 's50],u8laM mop Bus ‘ow qyy‘ni9] IN “wsipevoBochy “LL4“HO¥s| wo/leorTor Am UU auowoyyyo,8| st 2uesomoiya| ny way an on itm sapere “AaB UaTIS Supies SOULE WADI AION sol.) HOL3 ON) suyypo9 oun “quo{ ur susodap pe un ual 5] ‘Soy Bom Buse oF Uwoxexphyap “una. x 550) spr0v02000/8 Bun3Su9} ed yum swoon 3104 4B ‘OH HE pow ‘OH wy jauuoy}oy ‘dan0“e> en 78 20 u0880V sue nuedoow 2 a] soauna extoudsho I — p00; Fay 28 ey ove UB poy une arenbape uonow Aeron wasLE? ;pEreW| saqy/PrU HH {BQ pue yas sapsnun nse| ouaueyuew Stn 0 0HU0R1 335 09 anseés|vesmaucanue ‘sonnexe|‘udavopy‘H/n N29 ‘AY |x %0W onHo> Ary OANA «| tiv Ea SismDEeD] IG Haas TNAsee) ~ 2049 804 sosaaieue eoppunef yos emo} ~AaworDarsKo9}OY9 31g] IAOIAHUE VeasHO ‘eax ‘oIpeHIN easneu ‘song ured ony saqy uBi Puc (5900) 3uju04 5€8 moH) os oO a ure eoyuorears ‘vonsuosqeieuy o'z1a yg aygesun| siuawaidars| ejpueakuze| say agri 357 ‘areal ‘ysasoyderp ‘souye00 wears 291 91 plony| 24g 24 wni9s n oyp) ‘asneu ‘séues sye0W uaaMiag spinon a/v IV “BA "29 9 mwopay| SeBins aduis tony] suoqearpous sow doys veo Aensn 'eN ‘gud oT ai NID ‘auiorpuAs uyduing) —_o4nse5 aAN2UN=9H| — wiped wou apysesed so eu jeuarseq ‘Agpasnes ing 28189 ayn] __ anus reaxdou THSUIOS-g SUNURIN ZG HAG 9 w'a'v 9qpsW so1em ‘7m wawaydns yao nyasn a9 Aeus 99} eausoeais Puniw0n| oe} 01101] top ‘ahs eau prony| By8 127 9ep 0294 a4] Agedoroua ae uand or ‘ve ‘ay ‘B 'x‘eN 9] atu yous euros me Bye ose “4 "Sua aqni0s 8 jouoweuweyu) ansds je2ydon-u0N ‘Aas2u3| el apiosp aunwunorne| ——_aseasia 26490) ByuB st may 77 -ST 044 stuepxonue yo us /m LUaWI;EdS ‘anp94 mo} ‘soq4) mo] ~ aseyd B4NDe Uy 22500} wa vo pase ‘ann ‘390 208 H/H 's2 BuHTADS| 8,003 fo ‘jonuweweu sonomnve ‘12€2104| “lL, BN '2> “da “anv bseD9pUR SOUS: UNS 29005 spiny 2seaisu fo “sprovaysoonuoo ‘saxeyoyesouwe na 1) %X'eN "S348 sanyjop annesa94n URN] NA snag] sae 88515‘wg wor ave xt (HD ASious x03-05| ssn woH ABiaue w5e-<2| Aep ous Bw 02> ej sue pue ws wou, AU3 x >| poe 2uquy ‘pe auncoi| nig] seworpuer sedseyp anisayn ounadeveu. -7uu| _‘Swensanbes pe ag Sunes) oxn/ate| ‘3589 avian pue Ajep~wwI80 35n ‘soupap EHN Se BUR STS ous v4 ‘aiv ‘au ‘Bw 89} ‘ayes se 9/0 A ‘250)n>8|| °N Bu eM “avd Augedojeydanu3| ‘48,903 ~ sonneveuakwoau ~ saaoiqnue| ary ‘151 719 EHN “H/i edn ‘OnE OLS BEA) TROT EN MOT INGOT pareoiiduoa} ayos art aw ’e9| “sapien eaBeydos3| Bylo SE-08 “2npunp ‘sia9p0(9 x89) "eh “BuL DOM ‘aval NAH [eu0g “euopa ‘sayosy| patendwooun foaeuweyuinuy ‘eunguy ‘2no!qnuy| any "131 ‘NID "EHN 5801 ya VN “e900 soup] Byatt ong amy Bye Se-08 ss sway ‘sis243] uorapatu‘a V0} 2u2ea| sanedr.| 013 on| (2 avenbape ‘ya mo} ‘5501 14810M asagarue| a0 av Bul oneworsuhsy| saan snes Trvbar aq Rew A steow jews ey mor ured ~peap| HOLEON pous ‘oBeyuowou| oqo. endo ‘vossvarodt| NaL2ONA = auonp CO} uBuy Ye} mo 1 sszs8018 Ue OJN ane 23024 snazanueg asus] TN SISDSpERD| eerhuooor + andino aun pins aoveyeq- pany ‘ep fw oOOT-008 Aep/a ve» Aep/ vz ON Seon se-08 ABsoua soavo9] ‘ep/bus 0907-008 4 Aepphe-zx heft et ON Aep/8 ect en HH yin se08 AO ye se-08 ABs2UR 22/0 "BW'e "8D ON NID stsos0doarso| | ByyB et < 044 Bytud sc-s'o1g | svepurey ‘sopuig aveydsoyd —y49"980.9 ‘NN “dA ‘ysago “ewoaAyBrodhu| | Hs 3865 overs] equave ‘NLM ‘eunumioi| oo eaquepp anBN2y GOs (0x9 s5970" 31H java av 'u soedoyy ouuen| _ni5 io BL You9| 451'Ha1 102.9 Nn By4'e9 ‘9 ‘su2p0iq et2q ‘94 en 'H/H UL "01 0H Ll usuoRuy 208200 ‘Na ‘d49) San | aa] aude dooys ‘Bupous Hua ua Bin 'eD | “vos pasiedus ‘vl s0yso001 ‘one mnip 512920 ‘simpoiaes ‘ava ya “Hf 34 uw zt < aos] re ng FepHEROOT way ‘hos “03 ‘unok 3) 0} ‘ouveBieu! ~ 50101 say 219108 ‘oud wo1,ABsaua st] (08D 421242 x09-05| YISN Woy ABaUD xSE-<2| Aepjjous us 002 > n pue vis WOH ABD 96 > a x aworputs| seuey9 aytysay aonadeseu mu auospuls ay0qeoy Ta Saspaneew| ‘5129 wer af ‘sisauazedAy| ‘Buyyyeaig 2ap s8un)| £7 <-£09H| SISOIENIY 321] pre aso ssa) | Hd ‘Tz02‘T +H] Tay a onewueyr yuanediy| —— Bunasoe@ Aa seu se>z00¢] __ssorenty dsou oneyquan | sdumy} J Hat 4"t 209] ODIO MOR BL GY 2g EUdY “WAC, Sunpeasg au! Bum) 81> -£09H| awe S1SOP1De 22/4 poe asow aanposd saa] ft Hd “| 209 ‘L+4| ([oaos eunpse eureshyes| —— qa¥21a S005 Aa SAGUB Bre c059 sop BY Bay] wonejaven Fs8uny] THAT HT ZOD] Sojdusexy Aq paresuadwoy “E0DH 72034 woRIpuOD, Won ‘3528 - PPV “E0H + +H > £002H > OZH+ ZOD Sioa uzaoy ‘soni 205} vv “auc Sumoyens/Buwaye| sanpuosa 9U0A1 (042 0136 4 ue ‘swesoisadxa sposais|_ nip 'D1L ‘eve ‘ay Aypayyp enasoue] —— ewashudg wavs pesea) _“ssuoqauy sioiaypoynuesg] 2098 200 Hs eo] onvare pny 338 ‘o4o>| rr Sapo sed sseue en onsiosqeleu y U0:49 ziva x sun tars raupnu‘sonoaay] —aseiaeans sana suona.205eN ‘i TepPoW ‘en W018 4 12 | Jovepowsorg sowAIa2neDDUe| —_-cLw UNds>91 soon __eet 20S Bad y9aq “SIN “SUIT a]OyW esq reoym ‘ej Samsequedts ‘Ypeuds ecm ep 0s-a9> = aejx0 prea aco uns His e819 Nn ‘ao Ino en "ey ‘69 Aver Yn wwe SHIenIPUT ‘ByfBuzt > d| papunssiun y Aeppust 7-4 on po | ye se A003 sopevnp ‘suneis] 460:9-Nn8 HV '29 aglow) BGT ond) —_usaomuy SouaUL:3D¥| ‘EN “sD "eve aN 2uopuls onydon auawnies] TNA ral ar] Eo)Criteria to determine maramus/kwashiorkor or both [Disease [Mararmus [Kwashiorkor [Mixed [case [resto wake [reverent nee prtenvea ate hime Fame Int to years [weeks Icotaboc sess on preeaing maramas cine estar ‘Appenronce lzmameed [enacted iow leaos. [eax Swi oe bios woghtion pros waits Treen nf Tricep sinfola-< Se FricepScnfola< Samm MAME [MAN < 35 em ante <25 em leas [e200/i kaz00/en? [eae laze ala [e150 mera [e150 maya lea mg Kcampot e200 meal [200 mew Reactive sun omgens Candida [sam PPD. [ese tela Imm ty ir Physiologie Characters Catecholamines fr ‘Sueagon Ir Ir Ir Tate IP ‘luconeogenes f ‘res excretion Ir Fat Cosbotsm Ir Adation to Stanton laprormar Eos [es ‘ver erargereet es anergy res infection ver Poor wound Reaing DecubtuePractice Form for DM Pattern Calculations Carbohydrates 0% Teal 74 gmlked = __ gm CHO Protein 20% ‘eal 7 gm/heal = gm PRO Fot [Celorie Level 30% eal 79 gn/keal gm FAT (gn CHO / 15 gm cho/exchange = exchanges [Food Exchange Far [car Imi 2% Frat Vegetable “Total Corbos so Far [Starch [Total Pro ze for "heat Medion "Total Foto far rar ‘Tora [Food Exchonge [Breakfast [Lunch (mi Fruit (Wegetable {starch Mest For ‘MENU Write « deys menu following the pattern outlined cbove. Be sure to give you exect amounts Breokfast Lane ‘Supper ShackName Diet: Practice Form [eal= (Serving amt CHO. PRO FAT Milk, Fruit Vegetable Istarch Meat Fat [Breakfast [Lunch [Supper [snack milk Fruit [Vegetable ‘Starch Meat Fat Breakfast Lunch Dinner ‘Snack‘A40 y/o male with bowel obstruction ft to mass in ascending colon. He i 20” and weighs 170 Ibs. Labs include WBC 14.2; Alb 3.0 Customized TPN ew: 166-410% BMI: 28.4 Calculate BEE: 66 + (13.7 * 77.27) +(5* 177.8)~(6.8* 40) BEE = 66 + 1058.5 + 889-272 EE = 17415 calculate for addtional needs: BEE x AF {in bed) xIF (major surgery/infection) Total Caloric needs = 1741.5 «1.2% 1.2 ‘Total Caloric needs = 2507-76 0r~ 2500 cal Protein needs: 77.27kg x 1.0-1.2gm/kg = 77-92.7 em of protein Fluid needs: 77.27kgx 35miL/kg = 2708.4 mL or™ 2700 mt, Factor: 2700m1/1000mL = 2.7 92.7grmx 4 calfgm = 3708/2500 CALORIES. Dextrose An lipids 2500¢al x 30% = 750 cal/day Total must= 100% ‘GRAMS PER DAY Dextrose 1375 cal/3.4 cag AR 375 cal/4 (or 4.3) call Lipids 750.ca/éay x iml/2 cal = 375 ml/day x.2gr/m. = 75 gm/day (using 20% liposyn) (GRAMS PER LITER Dextrose 404 gr/day/2.71 = 149.6 er AN 93.75 g/day /2.7L= 34.7 gmm/t lipids 75 grm/day /2.71 = 27.7em/ mOsmo/t Dextrose 149.6 g/L x5 = 748 a 34.7 em/tx10347 Lipids 277 gmx 71=196 Total 1114.6 mOsmol/ GIR oF DIR sgm/day x 1000/kg x minutes ina day ir 404gm x 1000/77.27 x 1460 aR 3.63mq/kg/minute NPCIN Ratio _(Cal of Dextrose/day + Cal of Lipids dayl/Lem of pro/day * 16) Nec 1375 cal/day + 750 cal/day = 2125 npc N 93.75gm pro/dy *.16gm of Nitrogen/1 gm pro = 15 gm of Nitrogen/day_ Ratio 2425/25 = 161.6:1 (healthy range is 125 to 175 to 1 for non renal/citthosis patients)Figuring out what the TPN contains. 1050 600 mi. RAB. 500 mL {posyn 20 300 mL @ 80 mine 80% 24 = 3920 mL Factor: 1920 mi/1400mL = 1.37 or 14 Basic Caleulations Dex: 600 mL x50% = 300 g/bag x 1.4 = 420 g/day x3.4 cal/g= 1428 caV/day AA: 500 mi x8.596= 42.Se/bag x 14 = 59.5 g/day 4cal/e= 238 cal/day Lip: 300 mt. x2 cal/mt = 600 cal/bag x 1.4» 840 cal/day wa Dex: 420 ¢/192L=218e/L x5= 1093.75 AA: 59:5g/182L= 30.9g/Lx10= 309 Lip: 840 cal xtmL/2eal= 420 mLx.2¢/m Total mOsin/L = 1433 Bg /192L= 43.75 g/L x7 NPC:N Ratio _(Cal of Dextrose/day + Cal of Lipids dayi/lgm of pro/day * 16) Nec 1428 cal/day + 840 caV/éay = 2268 npe N 59.5 gm pro/day * .16gm of Nitrogen/1 gm pro= 9.52 gm of Nitrogen/day Ratio 2268/9.52 = 238.2:1 (healthy range i 125 to 175 to 1 for non renal/eihosts patients)Malnutrition Clients with Protein-Energy Malnutrition (PEM), also called Protein-Calorie Malnutrition (PCM), can have varied symptoms, depending on the classification of the malnutrition. > Marasmus ‘© Malnourished state where there is wasting of somatic fat and muscle stores and preservation of visceral proteins. Caused by protein and calorie deprivation. > Kwashiorkor ‘© Malnourished state where there is wasting of visceral proteins and preservation of somatic fat stores. Caused by protein deprivation Comparison of Characteristics of Marasmus & Kwashiorkor Characteristic Marasmus Kwashiorkor Siena ‘Absent Present Muscle/fat wasting Severe Mild Dyspigmentation of skin/hair | Rare Common Growth stunting Severe ("Infants) Moderate Enlarged liver Common Very common Biochemical Body potassium Mild depletion Severe depletion Visceral proteins Slightly low Very low Serum albumin Mild depletion Severe depletion Extracellular water Moderate High ‘Sources: Rrause’s Food, Nutrition, and Diet Therapy, 12” ed. D.S McLaren, Nutrition and its Disorders, p. 110-111, 1981 MNT-21© Total Iron Binding Capacity (TiC) Normal range: 270 - 400 mg/dl. = Increased with: * Iron deficiency * Decreased with: ‘* Megaloblastic anemias * Hemolytic anemia * Acute and chronic inflammatory disease = Comments © TIBC depends on the number of free binding sites on the plasma iron-transport protein, transferrin * Intracellular iron availability regulates the synthesis & secretion of transferrin ANEMIAS — Comparison of Values Iron Deficiency |" "Bg orFolate ‘Anemia of (microcytic) (maérotytic) ‘Chronic Disease {nermocytic) - | RBC May be normal_ Decreased Decreased Hemoglobin _Low Low Low Hematocrit Low Low Low MCV Low High Normal CH. Low High Normal MCHC Low Slightly decreased Normal - or normal . TIBC High Low Low. NUTRITIONAL FACTORS FOR ANEMIAS ANEMIA TYPE NUTRITIONAL FACTOR Megaloblastic Macrocytic Folic acid or Bz Pemicious* Macrooytic By lon Deficiency Microcytic Iron Chronic Disease Normocytic Protein *Pemnicious anemia is the most common magaloblastic anemia, All pernicious anemias are ‘megaloblastic, but not all mogaloblastic anemias are pernicious. Pemicious anemia is a chronic Condition due to failure of the stomach to secrete enough intrinsic factor. Itis also associated with the absence of hydrochloric acid. MNT-6,Drug/Medication — Nutrient Interactions (Furosemide, Lasix) Medication Nutrient Affected Recommended Action MAO Inhibitors Tyramine Restrict intake (Nardil, Marplan) Antituberoular Vitamin Be Tnorease intake or (INH, Isoniazid) supplement Diuretics (K* wasting) K*, Mg, Ca**) Zn increase intake or supplement Anticonvulsants Folate, Vilamin D Increase intake or (Phenytoin, supplement Phenobarbitol) ‘Anticoaguiants| Vitamin K Maintain steady intake or (Coumadin, Warfarin) possibly restrict intake Immunosuppressants | Potassium Restrict intake (specifically Cyclosporin) | ___ _ Corticosteroids Glucose, Calcium Glucose: possibly restrict (Prednisone, Cortisone) Calcium: supplement Antidepressants Sodium Maintain steady intake (specifically Lithium) ‘Anfi-Parkinson’s Protein Protein: redistribute to (Levadopa) Vitamin Be, aspartame —_| evening meal Vitamin Bs, aspartame’ avoid excess Methotrexate (bc oF Folic acid ‘Supplement rheumatoid arthritis, leukemia) Colchicine (tx of gout) _ | Vitamin Biz Increase intake or supplement ‘Antacids Ca™, Fe, Mg, Zn Increase intake or L supplement Some drugs that increase appetite: ‘Amitriptyline (Elavil) Diazepam (Valium) Chlorpromaxine (Thoraxine) Cyproheptadine (Periactin) Megestrol acetate (Megace) Chlordiazepoxide (Librium) Grapefruit Juice — Drug Inter Grapefruit juice interacts with certain drugs and increases their bioavailability, possibly due to the flavonoid naringen. Grapefruit juice should be avoided when taking calcium channel blockers and some cholesterol lowering drugs (Mevacaor, Zocor, Lipitor). Corticosteroids (Prednisone) ‘MNT-49