Reference Manual Part 3

Reference
Mary Bonack
DIETETIC STUDENT
Mary Bonack
FN 455 Medical Nutritional 4/27/2016
Therapy FN 455
Mary Bonack
4/27/2016
FN 455
Bowel Resection
Description
A bowel resection is a surgical procedure in which a part of the large or small intestine is removed.
Bowel
resection may be performed to treat various disorders of the intestine, including cancer, obstruction, in
flammatorybowel disease, ruptured diverticulum, ischemia (compromised blood supply), or traumatic i
njury.
Food & Nutrition-Related History
A careful diet history may reveal low intake of specific nutrient or foods that may result in a nutrient
deficiency. Diet history data are needed for nutrition diagnosis and intervention. A detailed past
surgical history should be obtained to determine the location and extent of the current bowel
resection, previous resections/surgeries, tolerance to food, history of gastrointestinal disorder
complications (eg, obstructions, fistulas, etc), and underlying disease processes. Questions related to
normal bowel pattern for the client should be presented, along with medications that may affect
gastrointestinal function (eg, antibiotics, steroids, antimotility and promotility agents, antacids,
probiotics, etc), and use of dietary supplements/herbs.
Anthropometrics
Skinfold thickness or bioimpedence may be valuable in some patients. Body mass index should be
calculated and monitored over time. For critically ill patients, indirect calorimetry should be used when
available to calculate RMR.
Biochemical Tests
Laboratory Tests Normal Range Adult Laboratory Tests Normal Range Adult
Values Values
Hemoglobin 12-16 g/dL (women); CO2 24-30 mmol/L
13.5-17.5 g/dL (men)
Hematocrit 37% to 47% (women); Glucose 70-110 mg/dL
40% to 54% (men)
Mean corpuscular 84-96 dL Blood urea nitrogen 8-26 mg/dL
volume
Mean corpuscular 31.5% to 36% Creatinine 0.6-1.3 mg/dL
hemoglobin
Mean corposcular 27-34 pg Sodium 135-155 mmol/L
hemoglobin
concentration
Red cell distribution 11.6% to 16.5% Potassium 3.5-5.5 mmol/L
width
Total iron-binding 250-460 mcg/dl Phosphorous 2.5-4.5 mmol/L
capacity
Ferritin 12-300 ng/ml Chloride 98-108 mmol/L
(women); 12-400
ng/ml (men)
Transferrin 200-400 mg/dL Magnesium 1.6-2.6 mEq/L
Vitamin B-12 100-700 ng/mL Calcium 8.7-10.2 mg/dL
Folate 187-645 ng/ml Osmolality 275-295 mOsm/kg H20

Fecal fat Less than 7 g per 24
hours
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4/27/2016
FN 455
Medical Procedures
Surgery
Endoscopy (Looking at Ducts)
Ileostomy or Colostomy
Nutrition-Focused Physical Related Findings
After surgery the patient must be assessed for malnutrition, micronutrient deficiencies, and
dehydration. Typically the abdomen is assessed by inspection (color, wound, feeding device, muscle
development), auscultation (bowel sounds), percussion (tympany, dullness, density), palpation
(texture, temperature, location of organs). Micronutrient deficiencies are screened for physically
through inspection (color, hair texture, eyes, nails, skin). Hydration assessment includes inspection
(skin turgor, temperature, oral cavity for color, texture, and moisture), and vital signs (blood pressure,
respiration, pulse, capillary refill).
Common Medications
Medications that may affect gastrointestinal function (eg, antibiotics, steroids, antimotility and
promotility agents, antacids, probiotics, etc). Gut slowing medications - loperamide, and if needed
narcotics. Slow motility and secretions - Somatostatins (and analogs), glucagon-like polypeptide 2,
growth hormone and other hormones.
Estimated Energy and Fluid Requirements
Estimated energy: Mifflin St. Jeor is they are able to eat and Penn State if they are NPO > 7days and
need to be on enteral or parenteral nutrition.
Fluid Requirements: Fluid intake and output should be monitored closely, especially as patients may
have diarrhea postoperatively: 30kg/mL
Nutrition Diagnosis
Increased nutrient needs, (specify), (NI-5.1), Altered GI function, (NC-1.4),
Nutrition Interventions
Modify distribution, type, or amount of food and nutrients within meals or at specified time
Formula/ solution (for enteral/ parenteral nutrition)
Nutrition relationship to health/ disease
Recommended modifications
Collaboration/ referral to other providers
Monitor and Evaluate
Total energy intake
Amount of food
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Weight/weight change
Electrolyte and renal profile
Oral fluid amounts
Area and level of knowledge
Gastric Bypass Surgery
Description
Gastric Bypass Surgery is a surgical procedure in which the stomach is divided into a small upper
pouch and a much larger lower "remnant" pouch and then the small intestine is rearranged to connect
to both.
Common procedures for gastric surgery include the following:
Vagotomy, Gastric resection, and Pyloroplasty
Procedures for reconstruction after pyloroplasty or gastric resection will generally use one of the
following three procedures:
Gastroduodenostomy (Billroth I), Gastrojejunostomy (Billroth II), and Roux-en-Y
A complete nutrition assessment should address the following:
Dietary history
Anthropometrics and physical assessment
Biochemical and clinical parameters
Nutrition assessment should identify the following:
Eating pattern assessment: Association of symptoms with food, fluids with meals, and the use
of simple carbohydrates.
Ability to chew; use and fit of dentures
Problems swallowing
Nausea
Vomiting
Constipation
Diarrhea
Heartburn
Any other symptoms interfering with ability to ingest normal meal plan
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Ability to feed self
Ability to cook and prepare meals
Food allergies, preferences, or intolerances
o High-fat foods
o Lactose
o Caffeine
o Sorbitol
Previous food restrictions
Ethnic, cultural, and religious influences
Use of alcohol and vitamin, mineral, herbal, or other type of supplements
Previous nutrition education or nutrition therapy
Eating pattern:
o 24-hour recall
o Food history
o Food frequency
Anthropometrics
Weight
BMI
Waist/Hip ratio
Body fat % measurement
Biochemical Tests
Laboratory Normal Range Adult Laboratory Normal Range Adult

Values Values
Albumin 3.5 -5.0 g/dL Folate 5-25 ng/dL
Prealbumin 16-35 mg/dL Thiamin 0.50-9.4 ng/mL
Hemoglobin 14-18 g/dL male; 12-16 Vitamin A 360-1200 ug/L
g/dL female
Hematocrit 42% to 52% male; Vitamin D 25-80 ng/mL
37% to 47% female
Red blood cell count 4.7-6.1 male; 4.2-5.4 Copper 0.751.45 ug/mL
female
Mean corpuscular 80-95 mcm3 Glucose
70-110 mg/dL
volume
Mean corpuscular 27-31 pg Blood urea nitrogen 10-20 mg/dL
hemoglobin
Mean corpuscular 32-36 g/dL Creatinine 0.5-1.2 mg/dL
hemoglobin
concentration
Red cell distribution 11-14.5% Sodium 136-145 mEq/dL
width
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Total iron-binding 250-460 mcg/dL Potassium

3.5-5.5 mEq/dL
capacity
Ferritin 12-300 ng/mL male; Phosphorous 2.3-4.7 mEq/dL
10-150 ng/mL female
Transferrin 80-180 mcg/dL male; Chloride 95-105 mEq/dL
60-160 mcg/dL female
Vitamin B-12 160-950 pg/dL Calcium 9-11 mg/dL
Carbon dioxide Osmolality 285-295 mmol/kg/H2O
23-30 mEq/dL
Medical Procedures
Surgery
Vagotomy: Eliminates innervations from the vagus nerve to the parietal cells, resulting in
decreased acid production and a decreased response to gastrin.
Pyloroplasty: The innervations to the parietal cells are severed and the portion of the vagus
nerve controlling gastric emptying is also eliminated. The pyloric sphincter is enlarged.
Billroth I: A partial gastrectomy or pyloroplasty is performed with a reconstruction with
anastamosis of the proximal end of the duodenum to the distal end of the stomach.
Billroth II: Partial gastrectomy with anastamosis of the proximal end of the jejunum to the distal
end of the stomach
Roux-en-Y: Partial gastrectomy with creation of small pouch with anastomosis of jejunum to the
upper portion of the stomach (Society for Surgery of the Alimentary Tract, 2007; Jamieson
2000).
Intended/unintended Weight Loss

Hair loss or thinning
Nausea/vomiting, which is often a consequence of inadequate chewing, eating too quickly, or
inadequate preparation of the specific protein (choice of meat, poultry, and fish with proper
tenderizing; cooking and reheating methods).
Dumping syndrome with Roux-en-Y gastric bypass (RYGB) (a consequence of consuming high-
sugar foods or highly processed foods and/or drinking fluids while eating after the first
postoperative year).
The necessity for lifelong, daily intake of vitamin and mineral supplements after RYGB and
sleeve gastrectomy.
Possible risks associated with alcohol intake, especially after RYGB.
Common Medications
Acarbose, octreotide, prokinetic
Estimated Energy Needs: at least 1000kcal/day, <30g CHO/meal, >130g CHO/day, 60-80g/day
protein
Fluid Requirements: >40mL/kg fluid, Men should consume at least 30 fl oz and Women should
consume at least 40 fl oz.
Nutrition Diagnosis
Inadequate oral intake (NI-2.1)
Intake of types of carbohydrate inconsistent with needs (specify) (NI5.8.3)

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Inadequate vitamin intake (specify) (NI-5.9.1)
Food- and nutrition-related knowledge deficit (NB-1.1)
Promote optimal healing postoperatively.
o Ensure adequate energy and protein intake.
o Recommend appropriate nutrition support if progression to solid food does not proceed
easily.
Prevent onset of early and late dumping syndromes.
o Initially avoid all simple sugars. Avoid clear liquids (except for broth) as first oral
feeding.
o The first meals should consist of protein, fat, and complex carbohydrate, but with
only one to two food items at a time. Patients may be initially lactose intolerant. Slowly
progress to five to six small meals each day.
o Consume liquids 30 minutes to 1 hour after consuming solid food.
o Lie down after eating.
o Consider addition of functional fibers to delay gastric emptying and assist with
treatment of diarrhea.
Prevent development of nutrient deficiencies.
o Liquid multivitamin and mineral supplements should be initiated to meet minimally the
Dietary Reference Intakes for all established nutrients. Vitamin B-12 injections are
initiated.
o Additional supplementation may be required to correct suboptimal levels of

micronutrients.(ODonnell 2008)
Provide nutrition education that will promote optimal nutritional intake and minimize
symptoms of malabsorption and/or maldigestion.
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Nutrition support should be considered when progression to an oral eating pattern is delayed
as a result of complications and/or when preexisting malnutrition warrants.
Promote optimal healing postoperatively.
Prevent onset of early and late dumping syndromes.
Prevent development of nutrient deficiencies.
Provide nutrition education that will promote optimal nutritional intake and minimize
symptoms of malabsorption and/or maldigestion.
Total energy intake
Amount of food
Weight/weight change
Crohns/Ulcerative Colitis
Description
Inflammatory bowel disease (IBD) is an autoimmune, chronic inflammatory condition of the

gastrointestinal tract. IBD is actually the term designating a syndrome consisting of the disease
categories ulcerative colitis, Crohns disease, and indeterminate colitis. These diseases are very similar
but can be distinguished from one another by the following:
Symptoms, Gastrointestinal involvement, Biopsy, and Antibody testing
Food and Nutrient Intake
o Food intake (FH-1.2.2)
o Fluid and Beverage Intake (FH-1.2.1)
o Bioactive substance intake (FH-1.4)
o Alcohol intake (FH-1.4.1)
o Caffeine intake (FH-1.4.3)
o Macronutrient intake (FH-1.5)
o Protein intake (FH-1.5.2)
o Fiber intake (FH-1.5.4)
o Micronutrient intake (FH-1.6)
Meal-snack pattern (FH-1.2.2.3): 24-hour recall, food history, food frequency

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Physical ability to complete tasks for meal preparation (cook and prepare meals) (FH-7.2.1)
Physical ability to feed self (FH-7.2.2)
Food allergies (FH-2.1.2.5), preferences including ethnic, cultural, and religious influences (FH-
2.1.2.3; FH-4.2.12), or intolerances (FH-2.1.2.6)
Prescription medication use (FH-3.1.1)
OTC medication use (FH-3.1.2)
Nutrition-related complementary/alternative medicine use (herbal or other type of

supplements) (FH-3.2.1)
Meal-time behavior (FH-5.4)
Avoidance behavior (FH-5.2.1)
Restrictive eating (FH-5.2.2) and Cause of restrictive behavior (FH-5.2.3)
Food/Nutrition Related supplies availability (FH-6.4)
Previously prescribed diets (previous food restrictions) (FH-2.1.2.1)
Previous nutrition education or nutrition therapy (FH-2.1.2.2)
Adherence (FH-5.1)
Food and nutrition knowledge skill Area(s) and level of knowledge (FH-4.1.1)
Readiness to change nutrition-related behaviors (FH-4.2.7)
Anthropometrics
Height (actual measurement should be taken, not verbal) (AD-1.1.1)
Current weight (AD-1.1.2)
Weight change (history) (AD-1.1.4):
o Highest/lowest adult weight

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o Usual body weight
Body mass index (AD-1.1.5)
Biochemical Tests

Values Values
Albumin 3.6 -5.0 g/dL Folate 100-700 ng/mL
Prealbumin 19-43 mg/dL Vitamin C 0.50-1.40 mg/dL
(plasma)
Hemoglobin women: 12-16 Vitamin A 30-80 mg/dL
g/dL; men: 13.5-17.5
g/dL
Hematocrit women: 37%-47%; Magnesium 0.70-1.15 mmol/L
men: 40%-54%
Red cell distribution 11.6%-16.5% Zinc 11-23 mmol/L
width
Mean corpuscular 84-96 fL Glucose 70-110 mg/dL
volume
Mean corpuscular 31.5%-36% Blood urea nitrogen 8-26 mg/dL
hemoglobin
Mean corpuscular 27-34 pg Creatinine 0.6-1.3 mg/dL
hemoglobin
concentration
Sodium 135-155 mmol/L
Total iron-binding 250-460 mcg/dL Potassium
3.5-5.5 mmol/L
capacity
Ferritin 12-300 ng/mL male; Phosphorous 2.5-4.5 mmol/L
10-150 ng/mL female
Transferrin 200-400 mg/dL Chloride 98-108 mmol/L
Vitamin B-12 100-700 ng/mL Calcium 8.7-10.2 mg/dL
Carbon dioxide Osmolality 275-295 mOsm/kg H20
24-30 mmol/L
C-reactive protein Antineutrophil Negative
< 1 mg/L
cytoplasmic antibodies
Erythrocyte 25 hydroxy-Vitamin D 16-74 ng/mL
women: < 17 mm/h;
sedimentation rate (Vit D 25OHT)
(ESR men: < 15 mm/h
Lactoferrin (stool Vitamin K 10.4-12.8 slc
Negative
specimen) Use also prothrombin
levels
Antisacchromyces Plasma zinc > 70 g/dL
Negative
antibodies
Medical Procedures
Surgical intervention is required in both ulcerative colitis and Crohns disease in more than 60% of
patients to resect segments of bowel that have significantly inflammation (Lashner, 2004); a total
colectomy is the most common procedure for ulcerative colitis
Physical assessment for the individual with inflammatory bowel disease will include steps to assess
overall nutritional status and growth, malnutrition, micronutrient deficiency, and dehydration.
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Abdominal physical assessment may include the following:
Inspection: color, contour, muscle development (PD-1.1.4), wounds, feeding devices, and
ostomies* (PD-1.1.5)
Auscultation: bowel sounds (PD-1.1.5)
Percussion: tympany, dullness, density of abdominal contents (PD-1.1.5)
Palpation: texture, temperature, identification/location of organs (PD-1.1.5)
Physical assessment for micronutrient deficiency and overall assessment may include the
following:
Inspection: skincolor and appearance; haircolor, texture, excessive loss of hair and nails
(PD-1.1.8)
Eyes (PD-1.1.6)
Color of oral mucosa (PD-1.1.5)
Physical assessment for hydration status may include the following:
Inspection: skin turgor (PD-1.1.8), temperature (PD-1.1.9); oral cavity for color, texture,
moisture/dryness (PD-1.1.5)
Vital signs: blood pressure, respirations, pulse, capillary refill (PD-1.1.9)
Physical changes caused by dehydration include the following:
Weight change (AD-1.1.4)

Dry conjunctiva without tears (PD-1.1.6)
Dry, cracked lips (PD-1.1.5)
Small, multifurrowed tongue (PD-1.1.5)
Decreased skin turgor (PD-1.1.8)
Orthostatic blood pressure (PD-1.1.9)
Tachycardia (PD-1.1.3)
Flattened neck veins (PD-1.1.3)
Prolonged filling of hand veins (PD-1.1.3)
Digestive System (PD-1.1.5):
Ability to chew; missing or misaligned teeth; use and fit of dentures (inability to chew foods thoroughly
increases the risk of food obstruction) and Problems swallowing.
Common Medications
Aminosalicylates (act locally in the GI tract to reduce inflammation): sulfasalazine,

mesalamine, balsalazide
Immunomodulators (these medicines prevent inflammation by suppressing the immune

system): azathioprine,cyclosporine, methotrexate
Antibiotics (reduce intestinal bacteria and treat infections related to abscesses, fistulas, and
medications that cause immunosuppresion): ciprofloxacin, flagyl
Biological modifiers (these medications help reduce the inflammation in the colon through
targeting specific TNF proteins involved in the inflammatory response): infliximab,
adalimumab, certolizumabantitumor necrosis factor medication (clinical trials have shown
improvement in more than 80% of patients treated) (Hanauer, 2003)
Corticosteroids (rapidly produce immunosuppression): prednisone, methylprednisolone,

hydrocortisone

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Estimated Energy: Crohns & UC BMI <15, 35-45kcal/kg

BMI 15-19, 30-35kcal/kg
BMI 20-29, 25-30kcal/kg
BMI >30, 15-25kcal/kg
1-1.5g/kg protein
Fluid Requirements:
Average healthy adult 30-35 mL/kg body weight
Adult 55-65 30 mL/kg body weight
Adult > 65 years 25 mL/kg body weight
Nutrition Diagnosis
Inadequate oral intake (NI-2.1)
Malnutrition (NI-5.2)
Inadequate fluid intake (NI-3.1)
Underweight (NC-3.1)
Inadequate mineral intake (specify) (NI-5.10.1)
Excessive bioactive substance intakecaffeine intake (NI-4.2) (Note: patients may increase
caffeine intake to high levels to manage their fatigue levels.)
Food/nutrition-related knowledge deficit (NB-1.1)
Disordered eating pattern (NB-1.5)
Altered GI function (NC-1.4)
Weight
o Underweight (NC-3.1)
o Unintended weight loss (NC-3.2)
o Overweight/obesity (NC-3.3)
Vitamin/Mineral Intake
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o Inadequate vitamin intake (NI-5.9.1)
o Excessive vitamin intake (NI-5.9.2)
o Inadequate mineral intake (NI-5.10.1)
o Excessive mineral intake (NI-5.10.2)
Energy Balance
o Inadequate energy intake (NI-1.2)
Protein
o Inadequate protein intake (NI-5.7.1)
o Excessive protein intake (NI-5.7.2)
Fiber
o Inadequate fiber intake (NI-5.8.5)
o Excessive fiber intake (NI-5.8.6)
Fluid Intake
o Inadequate fluid intake (NI-3.1)
o Excessive fiber intake (NI-3.2)
Meals and Snacks
o Composition of meals/snacks - Fiber modified diet (ND-1.2.6)
o Specific foods/beverages or groups (ND-1.4)
Vitamin and Mineral Supplements
o Multivitamin/mineral (ND-3.2.1)
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o Mineral: Calcium (ND-3.2.4.1)
Initiate EN (ND-2.1) or PN (ND-2.2)
Nutrition Education
o Purpose of the nutrition education (E-1.1)
o Priority modifications (E-1.2)
o Recommended modifications (E-1.5)
Nutrition Counseling
o Motivational interviewing (C-2.1)
o Goal Setting (C-2.2)
o Problem solving (C-2.4)
o Social support (C-2.5)
o Stress management (C-2.6)
Coordination of Care
o Team meeting (RC-1.1)
o Collaboration with other providers (RC-1.4)
Referral to community agency or program (RC-1.6)
Food and nutrient intake
o Food intake (FH-1.2.2)
o Fluid and beverage Intake (FH-1.2.1)
o Bioactive substance intake (FH-1.4)

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o Alcohol intake (FH-1.4.1)
o Caffeine intake (FH-1.4.3)
o Macronutrient intake (FH-1.5)
o Protein intake (FH-1.5.2)
o Fiber intake (FH-1.5.4)
o Micronutrient intake (FH-1.6)
Meal-time behavior (FH-5.4)
Avoidance behavior (FH-5.2.1)
Restrictive eating (FH-5.2.2) and cause of restrictive behavior (FH-5.2.3)
Adherence (FH-5.1)
Food and nutrition knowledge skillarea(s) and level of knowledge (FH-4.1.1)
Current weight (AD-1.1.2)
Weight change (history) (AD-1.1.4)
Nutrition physical exam findingsgastrointestinal (PD-1.1.5)
Adherence (FH-5.1)
Laboratory testsvitamin profile; mineral profilesee Nutrition Assessment section
Pancreatitis
Description
Pancreatitis is a complex condition involving an inflammation of the pancreas. The condition can be
both acute and chronic; can range from mild to severe; and, in the case of chronic pancreatitis, can
take several years to evolve.
Acute pancreatitis is most often associated with alcoholism and biliary tract obstruction. Pancreatitis
may evolve from other medical conditions such as cystic fibrosis, hypertriglyceridemia, hypercalcemia,
or renal failure, or from infectious causes such as hepatitis or mumps. Some medications such as
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diuretics (furosemide) or antibiotics (tetracycline), trauma, or surgery can lead to acute pancreatitis.
Despite these other potential causes, alcohol abuse accounts for 70% to 80% of all cases.
Assist in confirmation of nutritional status
Determine if there are food intolerances
Gather evidence of nutrient deficiency
Establish nutritional intake before admission
Anthropometrics
Height (AD-1.1.1)
Weight (AD-1.1.2)
Usual body weight (in last year)
Biochemical Tests

Values Values
Amylase 25-125 U/L Carbon dioxide 23-30 mEq/L
Lipase 0-417 U/L Glucose 70-110 mg/dL
Hemoglobin Women: 12-15 g/dL Blood urea nitrogen 8-18 mg/dL
Men: 14-17 g/dL
Hematocrit Women: 37% to 47% Creatinine 0.6-1.2 g/dL
Men: 40% to 54%
Lactate 208-378 U/L Sodium 135-145 mEq/L
dehydrogenase
Alanine Potassium
4-36 U/L 3.5-5.5 mEq/L
aminotransferase
C-reactive protein 0 Phosphorous 2.3-4.7 mg/dL
Osmolality 285-295 mmol/kg/H2O Chloride 95-105 mEq/dL
Calcium 9-11 mg/dL
Medical Procedures
Surgery
ERPC
Endoscopic sphincterotomy
Cholecystectomy
No aspects of outward physical appearance are unique to nutritional status and pancreatitis,
but physical assessment should include steps to assess overall nutritional status, malnutrition,
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and micronutrient deficiency. This assessment is especially pertinent for individuals with
chronic pancreatitis.
Abdominal physical assessment may include the following:
Inspection: Color, contour, muscle development, wounds, feeding devices, and ostomies
Auscultation: Bowel sounds
Percussion: Tympany, dullness, density of abdominal contents
Palpation: Texture, temperature, identification/location of organs
Physical assessment for micronutrient deficiency may include the following:
Inspection: Color, texture of hair, eyes, nails, skin, oral mucosa
Common Medications
Med to decrease gastric acid secretion d/t decreased HCO3- secretion

Cholecystokinin (CCK), Acetaminophen (Acephen, Cefotan, Mapap, Tylenol, FeverAll, Aspirin
Free Anacin) for pain, Insulin and Pancrelipase (Creon, Pancreaze, Ultresa, Viokace, Zenpep)
pancreatic enzyme supplements.
Estimated Energy: 35kcal/kg, 1-1.5g/kg protein, parenteral and enteral nutrition if npo>7 days
Estimation of Fluid Requirements:
Method 1 (based on energy intake): 1 mL fluid per kcal
Method 2 (based on body weight):
Age Amount of Fluid
Young adult, 16-30 years 35-40 mL/kg
Average adult 30-35 mL/kg
Adult 55-65 years 30 mL/kg
Adult >65 years 25 mL/kg
Keep in mind that fluids should be provided intravenously when a patient is ordered nothing by mouth
(nil per os, or NPO). Appropriate fluids may be given via total parenteral nutrition or within enteral
feedings.
Nutrition Diagnosis
Increased energy expenditure (NI-1.1)
Malnutrition (NI-5.2)
Altered GI Function (NC-1.4)

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Impaired nutrient utilization (NC-2.1)
Predicted suboptimal nutrient intake (NI-5.11.1)
Nutrition intervention is determined by severity and duration of disease. Historically, ordering the
patient to be NPO (nil per os, or nothing by mouth) would allow for complete pancreatic rest and
reduce the inflammatory process in pancreatitis (Petrov, 2008). More recent research has
demonstrated the benefit of enteral nutrition support over both continued NPO and parenteral nutrition
support for those patients with severe pancreatitis.
Current standards of care indicate that patients with mild to moderate pancreatitis should initially be
prescribed NPO and then, as symptoms subside, progress to an oral diet (Anand, 2012; Mirtallo, 2012;
McClave, 2009). A recent prospective, randomized, controlled, double-blind clinical trial showed no
difference between symptom relapse in patients with mild pancreatitis who progressed to a solid food
diet as opposed to clear liquids or a reduced-energy solid food diet (Moraes, 2010). Historically,
patients were progressed from a clear liquid diet to a low-fat solid diet (<50 g fat) with the rationale of
reducing the stimulation of the pancreas and, thus, the symptoms that patient would experience. The
level of fat restriction, once the patient has progressed to solid food, is dependent on the degree of
steatorrhea and abdominal pain the patient experiences. Pancreatic enzyme replacement may be
required for those patients with chronic pancreatitis. As indicated in this discussion, as more research
is conducted, the progression of oral diets may be liberalized.
Nutrition support is not required for patients with mild to moderate pancreatitis. Nutrition support
should be initiated, after fluid resuscitation and when patients are hemodynamically stable, for those
individuals with severe pancreatitis, those who present with significant malnutrition, or those who were
not able to initiate oral feedings within 5 to 7 days (Mirtallo 2012; McClave, 2009; Gianotti, 2009.
Nutrition support
Severity classification
Duration of nutrition therapy
Generally, weight measurements should be obtained at least weekly and adjustments in

nutrition regimen made accordingly to prevent rapid weight loss as well as excessive gain.
Pancreatitis is an inflammatory state causing a reprioritization of hepatic proteins; the

following laboratory values do not reflect the nutritional status of the patient:
o Albumin
o Prealbumin
o Transferrin
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Type 2 Diabetes
Description
Type 2 diabetes, once known as adult-onset or noninsulin-dependent diabetes, is a chronic condition

that affects the way your body metabolizes sugar (glucose), your body's important source of fuel. With
type 2 diabetes, your body either resists the effects of insulin a hormone that regulates the
movement of sugar into your cells or doesn't produce enough insulin to maintain a normal glucose
level.
Energy intake based on 24-hour recall or a typical day's intake
Eating times for meals (and snacks, if applicable)
Typical macronutrient intake
Readiness to change nutrition-related behaviors
Behavioral factors that influence achievement of nutrition-related goals
Usual physical activity
Travel frequency
Usual sleep habits
Appetite/gastrointestinal issues
Food allergies/food intolerances
Current weight, weight history, weight goals
Alcohol use
History of previous nutrition care services/medical nutrition therapy
Anthropometrics
Anthropometric measurements include weight, height (for adults at initial visit and for children at
every visit), and body mass index (BMI). Waist circumference is used to evaluate abdominal fat.
Abdominal fat is associated with greater health riskscardiovascular disease, dyslipidemia, and
hypertensionthan peripheral fat. A high waist circumference is one of the indicators for metabolic
syndrome (insulin resistance). This measurement is particularly useful in clients who are categorized as
normal weight or overweight based on BMI.
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To measure waist circumference, locate the upper hip bone and the top of the right iliac crest. Place a
measuring tape in a horizontal plane around the abdomen at the level of the iliac crest. High-risk waist
circumferences are as follows:
Men: > 40 in (> 102 cm)
Women: > 35 in (> 88 cm)
Biochemical Tests
An A1C test should be performed at least twice a year in patients who are meeting treatment
goals (and who have stable glycemic control) and quarterly in patients whose therapy has
changed or who are not meeting treatment goals.
Fasting or random plasma glucose testing may be done at routine office visits. If the blood is
drawn at the same time the patient performs a blood glucose meter test, the laboratory value
can be used to determine the accuracy of the meter and testing procedures.
In adult patients, a fasting lipid profile, including low-density lipoprotein (LDL) cholesterol, high-
density lipoprotein (HDL) cholesterol, and triglycerides, should be performed annually and
more often if needed to evaluate effectiveness of therapies being adjusted to achieve goals.
In adults with low-risk lipid values (LDL < 100 mg/dL, HDL > 50 mg/dL, triglycerides < 150
mg/dL), lipid assessments may be performed every 2 years.
Blood pressure should be measured at every routine diabetes visit. Patients found to have
systolic blood pressure of 140 mm Hg higher or diastolic of 80 mm Hg or higher should have
blood pressure confirmed on a separate day.
Testing to assess urine albumin excretion rate should be done annually starting at diagnosis in
patients with type 2 diabetes. Serum creatinine should be assessed at least annually in all
adults with diabetes regardless of the degree of urine albumin excretion. Serum creatinine
should be used to estimate glomerular filtration rate and determine the level of chronic kidney
disease, if present.
In youth with type 2 diabetes, blood pressure measurement, a fasting lipid profile, microalbuminuria
assessment, and dilated eye exam should be performed at the time of diagnosis. Thereafter, screening
and treatment recommendations for hypertension, dyslipidemia, microalbuminuria, and retinopathy
are similar to youth with type 1 diabetes.
Medical Procedures
Bariatric Surgery (weight loss)

Cholecystectomy (weight loss)
Most people with type 2 diabetes are obese, and obesity itself causes some degree of insulin
resistance. People with type 2 diabetes who are not obese by traditional weight criteria may have an
increased percentage of body fat distributed predominately in the abdominal region. Upper body or
central/abdominal obesity is a strong risk factor independent of total obesity risk.
Onset of type 2 diabetes occurs predominately after age 40, especially in whites. However, type 2
diabetes is found increasingly in younger adults, children, and adolescents, particularly among African
Americans, Hispanic Americans, Asian Americans, and Native Americans. Although obesity is often
associated with type 2 diabetes, type 2 diabetes is also found in nonobese individuals. Furthermore,
many obese individuals never develop type 2 diabetes. Genetic predisposition is a major determinant
of who develops diabetes.
There is a strong connection between obesity and type 2 diabetes in children and adolescents,
particularly among youth in at-risk ethnic populations. A high percentage of children with type 2
diabetes can be identified by the presence of acanthosis nigricans, a skin condition resembling a rash
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that is velvety, gray-brown skin pigmentation typically occurring on the neck or in skinfolds. They
occur as a result of high levels of circulating insulin in the blood.
Common Medications
The use of newer oral or injectable glucose-lowering medications, alone or in combination, provides
numerous options for achieving glycemic control in persons with type 2 diabetes. Because of their
differing mechanisms of action and sites of action, glucose-lowering medications can be effectively
combined. Metformina is the preferred initial pharmacological agent for type 2 diabetes, either in
addition to MNT and support for weight loss and physical activity or when lifestyle efforts alone have
not achieved or maintained glycemic goals. If A1C target goals are not reached after approximately 3
months, a second oral agent, a glucagon-like peptide 1 (GLP-1) receptor agent, or insulin is added. If
A1C goals are not reached after another 3 months, a three-drug intervention is implemented. If this
combination therapy, which includes a long-acting insulin, does not achieve A1C goals, a more
complex insulin therapy involving multiple daily doses, usually in combination with one or more
noninsulin agents, is implemented.
Site and Mechanism of Adverse Effects/Nutritional

Class Brand Name
Action Considerations
Metformin
Liver Nausea, vomiting, diarrhea, and gas
(Glucophage)
Biguanide
Decrease hepatic glucose May be able to reduce adverse effects by
Metformin
production and may help slowly increasing dose and taking with a
Extended Release
reduce insulin resistance meal
(Glucophage XR)
Glipizide
(Glucotrol)
Sulfonylureas Glipizide
Pancreas
(second- (Glucotrol XL)
Stimulate insulin Hypoglycemia
generation)
Glyburide
secretion from beta cells
(Glynase Prestabs)
Glimepiride
(Amaryl)
Repaglinide
Pancreas
Meglitinides (Prandin)
Stimulate insulin Hypoglycemia
(Glinides) Nateglinide
secretion from beta cells
(Starlix)
Thiazolidinediones Pioglitazone Muscle Weight gain, fluid retention

(Actos)
Improve peripheral insulin
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Class Brand Name
Rosiglitazone
sensitivity
(Avandia)
Pancreas, liver, and

gastrointestinal tract
Exenatide (Byetta)
Nausea, vomiting, and hypoglycemia if taken
Enhance glucose-
Exenatide with a sulfonylurea or insulin
dependent insulin
Glucagon-like Extended
secretion Exenatide can be injected up to 60 minutes
peptide-1 (GLP-1) Release (Bydureo
prior to meal. If nausea and/or vomiting
receptor agonists n) Suppress postprandial
occur, try moving injection closer to meal: 10
glucagon secretion
Liraglutide to 20 minutes or immediately prior to eating.
(Victoza) Slow gastric emptying
Increase satiety
Sitaglipton
(Januvia)
Pancreas and liver
Dipeptidyl Saxagliptin
No major adverse effects
Enhance the effects of
peptidase-4 (DPP- (Onglyza)
GLP-1 and GIP by Possible cold symptoms
4) inhibitors Linagliptin
preventing degradation
(Tradjenta)
Alogliptin (Nesina)
Diarrhea, gas, and nausea (can lessen effects

by slowly increasing dose)
If mild to moderate hypoglycemia occurs in

Acarbose Small intestine
combination with another antidiabetic drug
Alpha glucosidase (Precose)
Delay carbohydrate such as a sulfonylurea or insulin, the
inhibitors
Miglitol (Glyset) absorption hypoglycemia should be treated with oral
glucose (dextrose) instead of sucrose (table
sugar) because the drug blocks the digestion
of sucrose to glucose.
Amylin agonists Pramlintide Liver, gastrointestinal Bladder infections

(Symlin)
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Class Brand Name
tract, brain
Decrease glucagon
production, which
decreases mealtime
hepatic glucose release
and prevents postprandial
hyperglycemia
Kidney
Canagliflozin
Reduce the reabsorption
Sodium-glucose (Invokana)
of glucose in the kidneys Constipation, diarrhea, nausea, urinary
transport protein
Dapagliflozin via sodium glucose frequency, and genitourinary infections
inhibitors (SGLT)
(Farxiga) cotransporter-2 (SGLT2)
inhibition
See section on Supplement endogenous

Insulin Hypoglycemia
insulin insulin
Approximate Energy Meal Carbohydrate Servings Snack Servings per

(kcal) (g carbohydrate) Day (if desired)
1,200-1,500 (for weight

3 (45 g) 1 (15 g)
loss)
1,600-2,000 (for weight

4 (60 g) 2-3 (30-45 g)
control)
2,100-2,400 (for active

5 (75 g) 4-6 (60-90 g)
individuals)
Fluid Requirements:
Average healthy adult 30-35 mL/kg body weight
Adult 55-65 30 mL/kg body weight
Adult > 65 years 25 mL/kg body weight

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Nutrition Diagnosis
Unintended weight loss (NC-3.2)
Altered nutrition-related laboratory values (specify) (NC-2.2)
Excessive energy intake (NI-1.3)
Intake of types of carbohydrate inconsistent with needs (specify) (NI-5.8.3)
Inconsistent carbohydrate intake (NI-5.8.4)
Intake of types of fats inconsistent with needs (specify) (NI-5.6.3)
Excessive fat intake (NI-5.6.2)
Overweight/obesity (NC-3.3)
Food- and nutrition-related knowledge deficit (NB-1.1)
Not ready for diet/lifestyle change (NB-1.3)
Disordered eating pattern (NB-1.5)
Limited adherence to nutrition-related recommendations (NB-1.6)
Physical inactivity (NB-2.1)
Inability to manage self-care (NB-2.3)
Impaired ability to prepare foods/meals (NB-2.4)
Examples of possible nutrition intervention terminology (Academy, 2014):
General/healthful diet (ND-1.1)
Modification of distribution, type, or amount of food and nutrients within meals or at specified time
(ND-1.2)
Specific foods/beverages (ND-1.3)
Initiation of/change to nutrition-related medication (ND-6.1 and ND-6.2)

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Initial/brief nutrition education (E-1.1, E-1.2, E-1.3)
Comprehensive nutrition education (E-2.1, E-2.2, E-2.3)
Nutrition counseling (C-1.2, C-1.3, C-1.4, C-1.5)
Strategies (C-2.1, C-2.2, C-2.3, C-2.4, C-2.5, C-2.6, C-2.7, C-2.8, C-2.9, C-2.10)
Coordination of nutrition care (RC-1.1, RC-1.2, RC-1.3, RC-1.4)
Types of nutrition therapy interventions implemented included reduced energy and fat intake,
carbohydrate counting, simplified meal plans, healthy food choices, physical activity, and behavioral
strategies (Pastors, 2012). A unifying focus of MNT for type 2 diabetes is a reduced energy intake.
Multiple encounters to provide education and counseling initially and on a continued basis are also
essential. Metabolic outcomes are improved in nutrition intervention studies, both when provided as
independent MNT or when nutrition therapy is provided as part of overall diabetes self-management
education.
Sources Cited::
1.) Nutrition Care Manual

2.) Mahan, L. Kathleen., and Janice L. Raymond. Krause's Food & the Nutrition Care
Process. 13th ed. St. Louis: Saunders, 2012. Print.
3.) http://www.gastro.org/guidelines/2014/03/04/acute-pancreatitis
4.) http://emedicine.medscape.com/article/181554-medication
Reference Manual Part 2

Acute Respiratory Distress Syndrome
Description
Acute respiratory distress syndrome (ARDS) is a severe lung disease caused by a variety of direct and
indirect insults; a less severe form is called acute lung injury (ALI). Both ARDS and ALI are
characterized by inflammation of the lung parenchyma and increased pulmonary capillary permeability
leading to impaired gas exchange.
ARDS is defined as arterial partial oxygen tension (PaO2) to the fraction of inspired oxygen
(FiO2) ratio of below 200 mmHg in the presence of bilateral alveolar infiltrates on the chest x-
ray and a normal pulmonary capillary wedge pressure.
A PaO2/FiO2 ratio of 201 to 300 mmHg with bilateral infiltrates and a normal wedge pressure
indicates ALI.
During ARDS and ALI, pulmonary edema increases the thickness of the alveolar and capillary space,
increasing the distance the oxygen must diffuse to reach blood. This impairs gas exchange leading to
hypoxia and increases the work of breathing. Moreover, the entire alveoli may collapse or completely
flood. As the alveoli contain progressively less gas, more blood flows through them without being
oxygenated resulting in massive intrapulmonary shunting. This condition is life threatening, usually
requiring mechanical ventilation and admission to an intensive care unit.
Weight change
Appetite
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Satiety level
Taste changes/aversions
Nausea/vomiting
Bowel habits, including diarrhea, constipation, or steatorrhea
Alcohol or drug use
Chewing or swallowing difficulty
Pain when eating
Surgical resection or disease of gastrointestinal tract
Diet history and usual meal pattern
Dietary restrictions
Food allergies/intolerances
Symptoms and alterations in the ability to consume adequate intake (eg, shortness of breath)
Intake of vitamins and mineral supplements, herbals, or exercise enhancers and protein
supplements
o If possible, ask the patient or family to bring in the supplement bottle to obtain the
most accurate information
Medications
Level of activity and exercise
Ability to secure and prepare food
Anthropometrics
Height
Current weight
Weight history
Usual body weight
Ideal body weight and percentage of ideal body weight
Body mass index
Indirect calorimetry (IC)
o IC will not be possible for spontaneously breathing patients with supplemental oxygen
Biochemical Tests
Parame Norma Critica

Nutritional Significance
ter l Value l Value
pH 7.35- The chloride and acetate ratio of parenteral <7.25

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nutrition can be modified to correct acid-base

disorders. If patients are acidotic, chloride levels or
7.45
should be minimized and for alkalosis, acetate >7.55
should be minimized.
Patients with elevated CO2 levels should not be

35-45 <20
PaCO2 overfed, as excessive energy intake is associated
mm Hg or >60
with increased carbon dioxide production.
The chloride and acetate ratio of parenteral

nutrition can be modified to correct acid-base
21-28 <15
HCO3 disorders. If patients are acidotic, chloride levels
mEq/L or >40
should be minimized and for alkalosis, acetate
should be minimized.
The PaO2/FiO2 level, used to define acute

respiratory distress syndrome is calculated using
80- this value. The PaO2 should be divided by the
PaO2 100 FiO2 that the patient was receiving at the time the <40
mm Hg ABG was drawn. Example: PaO2: 80 and FiO2: 60%
PaO2/FiO2 = 80/.60 or 133
Medical Procedures
Lung transplantation
Arterial blood gas
Blood tests, including CBC and blood chemistries
Blood and urine cultures
Bronchoscopy
Chest x-ray
Sputum cultures and analysis
Tests for possible infections
Impaired oral intake
Poor diet quality (eg, low fruit and vegetable intake)
Nausea
Vomiting
Diarrhea
Abdominal pain
Weight loss
Inadequate growth
Reduced skeletal muscle mass as evidenced by history, physical, and anthropometric

assessment
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Patients admitted with the diagnosis of pulmonary issues and who have had severe or significant
weight loss should be considered at nutritional risk. The following table categorizes the degree of risk
associated with weight loss before hospital admittance.
Significant Percentage Weight Severe Percentage Weight

Time
Loss Loss
1 week 1-2% >2%
1 month 5% >5%
3
7.5% >7.5%
months
6
10% >10%
months
Subjective Global Assessment (SGA) is one clinical technique to assess nutritional status and assign
level of risk.
Patient history. Determine:
o Weight change
o Dietary intake change
o Gastrointestinal symptoms
o Functional capacity
o Disease-related nutritional requirements
Physical examination. Assess:
o Loss of subcutaneous fat
o Muscle wasting
o Ankle and sacral edema
o Ascites
Common Medications
Antibiotics
Anti-inflammatory
Corticosteroids
Diuretics
Anti-anxiety drugs
Blood pressure lowering medications
Estimated Energy: range for adults can generally be met at 25 kcal/kg to 35 kcal/kg, but this is
dependent on weight, coexisting disease process, and nutritional deficits
Fluid Requirements:
-Average healthy adult 30-35 mL/kg body weight
-Adult 55-65 30 mL/kg body weight
-Adult > 65 years 25 mL/kg body weight
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Patients with ALI and ARDS should receive an enteral formula containing dietary fish oil with
eicosapentaenoic acid (EPA) and borage oil with gamma-linolenic acid (GLA) and enhanced
levels of antioxidant vitamins
Patients should receive 1.5 g to 2 g protein per kilogram of body weight
Prevent weight loss even in overweight patients
Maintain lean body mass
Weight change
Energy and protein intake
Review of clinical data
24-hour recall or calorie count to determine caloric intake and determine
macronutrient/micronutrient composition of diet
Medication changes
Pediatric growth charts (for patients with cystic fibrosis)
Tolerance of tube feeding or parenteral nutrition infusion (for patients with ARDS)
Nutrient intake compared to goal and fluid status (for patients with ARDS)
Chronic Obstructive Pulmonary Disease
Description
An incurable condition which results in progressive obstruction and inflammation of the air ways. COPD
is the umbrella term for chronic bronchitis, emphysema, and a range of other lung disorders. COPD
results from airway obstruction and reduced expiratory flow. The lung's elastic recoil is reduced and
airway resistance is increased. As COPD progresses, the work of breathing increases to 10 to 20 times
that of a person with normal lung function.
Increased Energy expenditure

Decreased Intake (Dyspnea, Fatigue, Dyspepsia, and early Satiety)
Inefficient nutrient use
Medications-corticosteroids
Food security
Ability to prepare meals
Ability to feed self
Eating pattern
Anthropometrics
Decrease in LBM may occur even though weight appears to be stable (Muscle Mass and
Temporal Wasting)
Fluid Status
Weight History including UBW
COPD: Assessment of Weight Status
Registered dietitians should use BMI and weight change to assess weight status in individuals with
COPD. Studies report that in individuals with COPD, the prevalence of lower BMI (under 20 kg/m 2) may
be as high as 30% and the risk of COPD-related death doubles with weight loss.
COPD: Measurement of Body Composition

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In individuals with stable COPD, registered dietitians should evaluate body composition. Studies report
that even for those with BMI greater than 20 kg/m2, body composition differs from healthy controls in
that fat-free mass index and bone mineral density are lower in individuals with COPD.
COPD: Determination of Energy Needs
Registered dietitians should assess energy needs of individuals with COPD, based on indirect
calorimetry measurements, since resting energy expenditure (REE) based on measurement is more
accurate than estimation using predictive equations. Studies report that the total daily energy needs of
individuals with COPD are highly variable.
COPD: Energy Needs in Stable COPD
When using predictive equations to assess energy needs of individuals with stable COPD, registered
dietitians should account for the presence of inflammation and level of physical activity. Studies report
that the presence of inflammation increases resting energy expenditure and that the level of physical
activity has varying effects on total daily energy needs.
COPD: Energy Needs During Exacerbation
When using predictive equations to assess energy needs of individuals with COPD during an
exacerbation, registered dietitians should account for the presence of inflammation. Studies report that
the presence of inflammation increases resting energy expenditure.
COPD: Bone Density Screening
Registered dietitians should recommend bone density screening for individuals with COPD. Research
indicates that individuals with COPD are at increased risk for osteoporosis and vertebral fractures.
Biochemical Tests
Hemoglobin and hematocrit
Serum iron
Serum electrolytes
Serum proteins
pH
pO2
PaCO2
Immunologic testing
Creatinine height index
Nitrogen balance
Medical Procedures
Chest x-ray
CT scan
Arterial Blood gas analysis
Chest radiograph
Chest tube
Enteral tracheal intubation
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Ability to chew
Swallowing problems
Muscular strength and coordination
Constipation or diarrhea
Temporal wasting
Edema
Weight loss, diminished appetite
Shortness of breath
Cyanosis
Barrel Chest
Digital clubbing: Thickening of flesh under fingernails
Common Medications
Bronchodilators
Steroids
Antibiotics
Estimated Energy: Mifflin St. Jeor with stress factor of 1.3
Fluid Requirements: 20-25mL/kg
Nutrition intervention for persons with COPD should focus on:
Maintaining, or restoring, optimal nutrition status by food and beverage intake or supplements
Preventing continued weight loss, even in overweight patients
Maintaining, or restoring, lean body mass
Examples of nutrition intervention strategies for persons with COPD include:
Diet order expanded to encourage oral intake, while fulfilling medical priorities
Individualized meal plan to meet specific energy and nutrition needs
Small, frequent, mini-meals and snacks to help compensate for shortness of breath and
possible limited oxygen supply to gastrointestinal tract
Food choices that are easy to chew, swallow, and digest, with nutrients easily absorbed
Variety of easy-to-prepare-and-eat whole grains, fruits, and vegetables to provide adequate

fiber, vitamin, and mineral intakes
Nutrient-dense nourishment and/or medical food supplements to achieve optimal energy and
nutrient intakes
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Vitamin and mineral supplement to compensate for inadequate oral intake
Increased or decreased nutrient intake, based on medication-nutrient interactions
Proper sitting posture along with sequencing of breathing and swallowing for eating, to prevent
aspiration
Oxygen therapy during food procurement, preparation, and eating, if prescribed
Continual client-centered nutrition education by RD, as part of interdisciplinary care
Individuals with COPD should be closely monitored and evaluated, as the pulmonary status may
improve or deteriorate. COPD is a chronic, progressive condition.
At every visit, monitor and evaluate:
Typical day diet, 24-hour recall, or calorie count. Determine energy intake and
macronutrient/micronutrient composition of diet. Include abilities to shop, prepare, and eat in
conjunction with symptoms of, and treatment for, COPD.
Clinical data (e.g., anthropometrics, laboratory values, lung function, and medical and dental
examinations)
Medication changes (e.g., bronchodilators, glucocorticosteroids, mucolytic agents)
Lifestyle influences (e.g., quality of life, exercise, family, work, smoking)
Each follow-up nutrition intervention for individuals with COPD should include adjusting nutrition goals
and treatment plans according to a patient's response to the current treatment.
Cirrhosis of the Liver
Description
Cirrhosis is a chronic disease in which the liver is damaged typically through alcohol abuse and/or
hepatitis. This disease may lead to scarring and liver failure. Cells begin to degenerate and the tissues
of the liver becomes thick and fibrous blocking the flow of blood inhibiting or slowing down the liver
from performing its bodily functions.
Careful assessment of food intake for adequacy of nutrients
Compliance to nutrition prescription
Alterations in eating habits and tolerances
Weight and muscle mass changes
Incidence of abnormal digestion or absorption
Anthropometrics
Although anthropometrics are not always a valid part of the nutrition assessment because of their
inability to correlate with muscle and fat stores, they can be useful in monitoring for changes in these
stores when done serially. In fact, for some patients, handgrip strength, triceps skinfold, and arm
muscle circumference may be the most reliable markers of nutritional status.
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Indirect calorimetry may be useful for energy assessment in those patients for whom it is difficult to
predict energy needs because of significant fluid retention or who are not thriving while being provided
with 100% of their estimated nutrition needs.
Biochemical Tests
Liver function tests
Electrolytes and glucose
Hepatitis markers
Blood counts and clotting factors
Protein levels
Vitamin and mineral levels
Medical Procedures
Ablative therapy (alcohol, cryotherapy, radiofrequency)

Chemoembolization
Conformal radiation
Chemotherapy plus radiation
Clinical trial
Surgery
Computed tomography scan
Magnetic resonance imaging
Abdominal ultrasound
Cholangiogram
Liver biopsy (a helpful tool in assessing the degree of liver disease and its complications)
Fatigue and Weakness

Gastrointestinal bleeding
Confusion
Edema
Telangiectasias (spider veins)
Ascites
Hyperglycemia
Excessive gas
Bruising
Bleeding
Weight loss/gain
Jaundice
Pain in the abdomen
Bloody dark stool
Common Medications
Spironolactone
Propranolol
Vasopressin
Lactulose
Neomycin
Ferrous Sulfate
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Bisacodyl
Docusate
Diphenhydramine
Estimated Energy: Mifflin St. Jeor

Fluid Requirements: For stable, easily managed patients, fluid restrictions are not necessary
and they should tolerate a normal fluid intake. Patients with difficult-to-manage ascites or
edema may benefit from a modest fluid restriction.
The primary goal is to keep patients in a mildly negative fluid balance between their intake and
the amount of urine produced. The medical situation that may require fluid restriction is
hyponatremia. When the serum sodium level decreases below 128 mEq/L, patients should be
advised to limit their total fluid intake to 1,200 mL to 1,500 mL per day. In more severe cases,
when the sodium level is below 125 mEq/L, a restriction of 1,000 mL to 1,200 mL per day is
usually ordered.
The type of fluids consumed should also be considered with these patients. Obviously, they
should avoid fluids with a high sodium content. Intake of fluids with high nutritional content
should be encouraged, especially for those with a restricted intake or those who are
malnourished.
Provision of adequate nutrients in the meal plan
Enteral and/or parenteral support
Limitation of nutrients to assist in the management of cirrhotic complications
Education to ensure ongoing compliance with the nutrition and medical prescription
Weight changes
Energy and protein counts and assessment of intake for adequacy
Laboratory values
Control of symptoms
Evaluation of the nutrition intervention plan includes monitoring the adequacy of intake (oral, enteral,
and/or parenteral) and the success of controlling the liver disease symptoms.
Acute Renal Failure/AKI
Description
Acute renal failure is common in hospitalized patients and occurs in approximately 20% of
patients admitted to the intensive care unit. Acute renal failure is often a complication of the
following:
-Sepsis
-Trauma
-Multiple organ failure
The prognosis of acute renal failure remains poor and mortality ranges from 40% to 80%. The
choice of dialytic method depends on the clinical situation.
Nutrition history
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o Usual food intake
o Special diet instructions
o Chewing/swallowing ability
o Assessment of GI issues
Medical history
o Disease or condition leading to acute renal failure
o Treatment modality
o Concurrent medical conditions
o Medical conditions with potential nutritional implications
o Medications with food/drug interactions
Anthropometrics
Height
Weight at admission, estimated dry weight
Body mass index
Weight history, recent weight changes, and weight goals
Standard body weight (SBW) and/or usual body weight (UBW) adjusted for amputation or
obesity and % SBW and/or % UBW
Indirect Calorimetry
Estimated Dry Weight
-Weight (kg) Excess body fluid (kg)= Estimated Dry Weight
Biochemical Tests
Albumin (BD-1.11.1): 3.5-5.0 g/dL
Prealbumin (BD-1.11.2): 19-43 mg/dL
Sodium (BD-1.2.5): 135-145 mEq/L
Potassium (BD-1.2.7): 3.5-5-5 mEq/L
Phosphorus (BD-1.2.11): 2.5-6.0 mg/dL
Calcium: 8.5-10.5 mg/dL
Magnesium (BD-1.2.8): 1.5-2.0 mEq/L
Serum glucose: 80-200 mg/dL (enteral), 150-250 mg/dL (parenteral)
Triglycerides (BD-1.7.7): <250 mg/dL 4 hours after lipids stopped, <400 mg/dL during
continuous infusion
Chloride (BD-1.2.6): 100-106 mEq/L

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CO2 (carbon dioxide): 24-30 mEq/L
Hematocrit (BD-1.10.2): 36% to 45% (women), 38% to 50% (men)
Hemoglobin (BD-1.10.1): 12-16 g/dL (women), 14-18 g/dL (men)
Ferritin: 100-800 ng/ml
Transferrin: saturation 20% to 50%
Blood Urea Nitrogen BUN (BD-1.2.1)
Creatinine (BD-1.2.2)
Glomerular filtration rate (BD-1.2.4)
Medical Procedures
Dialysis
Transplantation
Immunosuppressant therapy
History of weight loss
Nutrition intake
Gastrointestinal (GI) derangements
Functional capacity
Subcutaneous tissue loss
Muscle wasting
Presence of edema
Note the degree of edema, if present, as marked muscle wasting may be masked by the edema.
Physical signs of nutrient deficiencies, excesses, or increased needs (Wiggins, 2001) include the
following:
Decubiti
Poor wound healing
Thinning hair
Pale conjuctiva
Cheilosis
Common Medications
Phosphate Binders
Increased need for water-soluble vitamins
Fat-soluble vitamins A and K not supplemented
EPO
Activated vitamin D
Bisphosphonates
Reduce bone turnover
Contraindicated in stage 4 & 5 CKD, and ESRD
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Iron
Estimated Energy: 25-35kcal/kg dry weight

-Consider dialysate
Fluid Requirements: Balance as able-replace day before output + 500cc
-Dialysis/CRRT
Early Dialysis and Nutrition Support

Eliminate cause of Kidney failure and promote recovery; prevent further damage
Provide adequate calories and protein
Preserve muscle mass
Manage anemia
Reassess use of nephrotoxic drugs
Supplementation of H2O-soluble vitamins to prevent deficiency caused by dialysis losses,
inadequate intake, drug-nutrient interaction, or increased needs
Vitamin C should be limited to the DRIs for age and sex to prevent oxalosis
Vitamin D supplementation to prevent secondary hyperparathyroidism
Vitamin K deficiency is of concern if on TPN and receiving antibiotics (should be supplemented)
Fluid: Balance as able-replace day before output +500cc
Sodium restriction: 2-3g/day based on BP, edema, replace loss in diuretic phase
Potassium restriction: 2-3 g/day, replace loss in diuretic phase
Phosphorous: 8-15 mg/kg or limit if necessary
Calcium: maintain serum value within normal limits
Vitamins/Minerals: Dietary Reference Intakes, adjust to level of catabolism
Based on Medical Nutrition Therapy Guidelines
Hospitalized patients should be monitored by a registered dietitian daily or as indicated. The follow-up
includes review of clinical data and eating plan evaluation. Acute renal failure patients are in a state of
constant metabolic change. They need close monitoring of their fluid and electrolyte balance, nutrition
support, and medical treatments to alter the nutrition care plan. Assessment of functional ability and
behavioral outcomes is also necessary.
Based on Medical Nutrition Therapy Guidelines
Follow-up nutrition intervention includes evaluation of medical progress, metabolic status, nutrition
support, and review of nutrition prescription and tolerance of nutrition therapy. Appropriate
communication regarding this nutrition intervention, including documentation and recommendations,
is required.
Coronary Artery Bypass Graft
Description
CABG is a major surgery in which an alternate blood vessel is surgically placed to bypass one or more
occluded coronary arteries. It usually requires a large, sternal incision. CABG is one treatment for CHD.
During CABG, a healthy artery or vein from the body is connected, or grafted, to the blocked coronary
artery. The grafted artery or vein bypasses (that is, goes around) the blocked portion of the coronary
artery. This creates a new path for oxygen-rich blood to flow to the heart muscle.

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Age
Gender
Weight Hx
Medical Hx and comorbidities :HTN, Coronary artery disease, DM
Food intake Hx
Nutrition Education Hx/Nutrition Therapy tolerance
Medication and Supplement use
Lab data: Lipid profile, blood glucose, BUN, creatinine, potassium, and albumin
Family Hx: Who does food preparation and shopping
Social Hx: Job, Stress level, financial/cultural factors
Alcohol, tobacco, and drug use Hx
Past and current physical activity, recommendations or restrictions for physical activity from
physician
Ethnicity BP Hx: If patient has HTN
GI symptoms/digestive issues, dysphagia, chewing/swallowing issues: if patient has
cerebrovascular disease
Anthropometrics
Weight (if edema or ascites is present, try to estimate dry weight by getting a weight history)
Height
Abdominal obesity waist circumference measured in a horizontal plane around the abdomen at
the level of the iliac crest:
>40" in males
>35" in females
Body mass index >25 or <18.5
Skin fold measurements
Biochemical Tests
Low-density lipoprotein cholesterol
Total cholesterol
High-density lipoprotein cholesterol
Triglyceride
Other laboratory values to consider include the following:
Fasting glucose
Blood urea nitrogen, creatinine
Albumin
Sodium and other electrolytes
Medical Procedures
PCI (Percutaneous Coronary Intervention) aka Angioplasty

Stents
EKG (Electrocardiogram)
Stress Test
Coronary Angiography and Cardiac Catheterization
Echocardiography
Chest X-ray and/or cardiac CT
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Oxygen Therapy and/or cardia rehabilitation (post op.)

Temporary pacemaker placement (post op.)
Cardiac CT (post op.)
Overweight/Obesity
Loss of weight and Muscle wasting
Edema
Head and eyes (specify) arcus corners
Skin (specify) Xanthomas, Xanthelsama
Vital signs (specify) blood pressure
Common Medications
Bile Acid Sequestrates (Cholestyramine)

Nicotinic Acid
Statins or 3-hydroxy-3-methylglutaryl-coenzyme A
Fibric Acid derivatives
Probucol
Estimated Energy: Use Mifflin St. Jeor
(10 x weight in kg) + (6.25 x height in cm) (5 x age

Men
in years) + 5
Wom (10 x weight in kg) + (6.25 x height in cm) (5 x age

en in years) 161
-Multiply the RMR by an activity factor of 1.3 for sedentary individuals. If needed, use a higher
activity factor to correct for active individuals engaging in exercise or purposeful activity.
-For weight loss: Subtract 500 kcal per day for a goal of 1 lb loss per week.
-For weight gain: Add 500 kcal per day for a goal of 1 lb gain per week.
Fluid Requirements: Fluid needs of a patient who has experienced myocardial infarction are
usually approximately 35 mL per kg body weight per day, but fluid intake levels may need to
be individualized if there are fluid retention issues.
Therapeutic Lifestyle Changes
<7% saturated and trans fat (8-10% LDL decrease)
<200 mg cholesterol (3-5% LDL decrease)
25-35% of total energy from fat
<10% PUFA; <20% MUFA
Include omega-3 fatty acids
Add 2 grams plant sterols/stanols a day
5-15% decrease in LDL
50 to 60% CHO
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Add 5-10 grams soluble fiber/day (3-5% LDL decrease)
15% protein
If overweight, lose 10 pounds (5-8% LDL decrease)
Low-density lipoprotein cholesterol
Total cholesterol
High-density lipoprotein cholesterol
Triglyceride
Other laboratory values to consider include the following:
Fasting glucose
Blood urea nitrogen, creatinine
Albumin
Sodium and other electrolytes
Current medical condition and medical treatment plans

Current laboratory values
Current dietary intake
Evaluation of ability to chew, swallow, and consume adequate nutrients
Weight and weight changes
Physical activity patterns
Assessment of readiness for education
Compliance to previous education
Adjust nutrition goals and tx plan as needed in response to current tx
Sources Cited
http://www.nhlbi.nih.gov/health/health-topics/topics/cabg/after
Nutrition Care Manual
Acute Renal Failure/AKI power point lecture slides on D2L
Cirrhosis of the Liver power point lecture slides from D2L
Cirrhosis of the Liver power point slides from group case study
Mahan, L. Kathleen., and Janice L. Raymond. Krause's Food & the Nutrition Care Process. 13th ed. St.
Louis: Saunders, 2012. Print
http://www.nhlbi.nih.gov/health/health-topics/topics/cabg/whoneeds
Reference Manual Part 3

Critical Illness
Description
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Critical Illness means an illness, sickness or a disease or a corrective measure like Cancer, Kidney
failure, Coronary Artery (Bypass) Surgery, Heart Attack (Myocardial Infarction), Heart Valve Surgery,
Major Organ Transplantation, Multiple Sclerosis, Primary Pulmonary Arterial Hypertension , Aorta graft
surgery, Paralysis, Coma, Total Blindness and Stroke. A person can become critically ill for many
reasons, including traumatic, surgical, or inflammatory injury; infection; or acute exacerbations of
chronic illness. Critically ill patients are at nutritional risk because hyper metabolism and the catabolic
state often produced by the inflammatory response to illness can rapidly deplete protein stores and
delay initiation of nutrient intake. Compromised nutritional status can contribute to longer hospital
stays, poor wound healing, compromised immune function, and organ dysfunction
Diet history (FH-2.1) is often unavailable from the critically ill patient. The decision to start nutrition
support depends on the presence and severity of inflammatory response, estimated time until
adequate oral diet, and risk for complications related to malnutrition.
However, this does not discount the importance of diet history (FH-2.1), typically provided by a family
member, and screening for preexisting malnutrition (NI-5.2) prior to admission. The diet history should
focus on:
Recent changes in the amount of food consumed
Meal patterns/meal frequency (for instance, does the patient skip meals?)
Avoidance of food groups
Noticeable weight changes
Use of supplements
Disease severity
Presence of altered gastrointestinal function
Anthropometrics
Standard anthropometric measurements such as:
Height (AD-1.1.1),
Weight (AD-1.1.2), and
Weight changes (AD-1.1.4) need to be evaluated carefully.
Body weight of intensive care unit (ICU) patients often reflects fluid resuscitation or fluid
retention. It is important to pay attention to fluid balance, since 1 liter of fluid is equivalent to 1
kg of body weight. Evaluation of weight changes prior to admission or prior to ICU stay is often
more meaningful. Actual weight may be estimated utilizing information from the family.
Biochemical Tests
Monitoring electrolytes,
Renal profiles (BD 1.2),
Blood glucose (BD 1.5.2), and
Acid-base balance (BD-1.1), in combination with clinical findings and patient history, is
necessary to assess fluid status, renal function, adequacy of glucose control, and need for
supplementation or restriction of electrolytes.
Serum albumin, pre-albumin, retinol-binding protein, and transferrin are negative acute-phase
proteins that often appear low during critical illness due to hepatic reprioritization and fluid
shifts. C-reactive protein, a positive acute-phase protein, becomes elevated during critical
illness due to stress and inflammation. These proteins may be prognostic indicators but are not
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indicators of nutritional status in the critically ill and should not be used to monitor or
determine the patients protein requirements
Medical Procedures
Indirect Calorimetry
Physical observations are divided into two time frames.
1. Observations of the patient's nutritional status before admission, which are performed as early
as possible
2. Observations of the effects of critical illness on body composition after admission, made
continually after the initial assessment
Obesity is a commonly seen in the critically ill. Body mass index (BMI, AD-1.1.5) is an indirect method
of calculating body fat, and a threshold BMI of 30 almost always equates with obesity (excessive fat
stores) in patients not in the intensive care unit. However, this calculation should be accompanied by
direct observation of the patient, because some patients with high BMI do not have excess body fat,
and some patients are obese despite a BMI of less than 30. Furthermore, reported heights (AD-1.1.1)
should be confirmed by direct observation/measurement, because the reported values could be
estimates from family members or staff and therefore could be inaccurate (this is also true for weight,
but it can be difficult to confirm a reported weight because the observation can be influenced by water
retention, even early in the admission). The registered dietitian nutritionist should either measure or
develop the skill of accurately estimating heights and weights rather than relying on the estimates of
others.
Common Medications
Insulin protocols,
Steroid use,
Sedation and analgesia,
Gastrointestinal medications,
Anticonvulsants (especially enteral phenytoin),
Inotropes and vasopressors, and
Electrolyte supplements should be noted and considered in the assessment.
Energy Requirements:
Predictive Equations for the Critically Ill
Condition Equation Recommended by
PSU 2003b
Nonobese, mechanically ventilated RMR = Mifflin (0.96) + VE (31) + Tmax (167) Academy EAL
6,212
PSU 2003b
Obese, mechanically ventilated,
RMR = Mifflin (0.96) + VE (31) + Tmax (167) Academy EAL
younger than 60 years
6,212
PSU 2010
Obese, mechanically ventilated older
RMR = Mifflin (0.71) + VE (64) + Tmax (85) Academy EAL
than 60 years
3,085
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Predictive Equations for the Critically Ill
Condition Equation Recommended by
RMR males = 10 weight (kg) + 6.25 height

(cm) 5 age (y) + 5
Mifflin equationused in PSU Used in PSU
RMR females = 10 weight (kg) + 6.25 height
(cm) - 5 age (y) - 161
11-14 kcal/kg actual weight

Obese ASPEN/SCCM
22-25 kcal/kg ideal body weight
Fluid Requirements: Fluid requirements in the critically ill patient will often be influenced by the
physiologic state. This includes need for volume resuscitation; extent of endothelial injury and
capillary leak; and acute and preexisting disorders of cardiac and renal function. (30 mL/kg)
Nutrition Intervention
Nutrition interventions are divided into four domains:
Food and/or nutrient delivery
Nutrition education
Nutrition counseling
Coordination of care
Within the first domain, food and/or nutrient delivery (ND), there are sections for enteral and
parenteral nutrition (ND-2), supplements (ND-3), and nutrition-related medication management (ND-6).
The nutrition intervention terms for enteral and parenteral nutrition include composition,
concentration, rate, volume, feeding schedule, feeding route, and site care. Nearly all nutrition support
activities in the critically ill patient can be described using the standardized terminology of the eNCPT
reference manual.
A primary nutrition intervention in the critically ill is early (24- to 48-hour) initiation of enteral feeding
to attenuate the stress response rather than focusing on correction of protein-energy malnutrition.
With the optimal timing, formula, and route, nutrition support has the potential to influence outcomes.
The presence or absence of bowel sounds and/or flatus should not preclude the use of enteral
nutrition.
Food and Nutrition-Related History (FH)
Energy intake (FH-1.1)
Enteral and parenteral nutrition intake (FH-1.3)
Macronutrient intake (FH-1.5)
Micronutrient intake (FH-1.6)
Diet order (FH-2.1.1)
Enteral and parenteral nutrition administration (FH-2.1.4)
Medications (FH-3.1)
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Anthropometric Measurements (AD)
Weight (AD-1.1.2)
Biochemical Data, Medical Tests, and Procedures (BD)
Acid-Base balance (BD-1.1)
Electrolyte and renal profile (BD-1.2)
Gastrointestinal profile (BD-1.4)
Glucose/endocrine profile (BD-1.5)
Inflammatory Profile (BD-1.6)
Metabolic rate profile ( BD-1.8)
Protein profile (BD-1.11)
Urine volume ( BD-1.12.5)
Nutrition-Focused Physical Findings (PD)
Overall appearance (PD 1.1.1)
Digestive system (mouth to rectum) (PD-1.1.5)
Vital signs (PD-1.1.9)
Heart Failure
Description
Heart failure (HF) is a syndrome caused by cardiac dysfunction. The heart has become enlarged and
has a weakened pump. The hearts inability to pump blood efficiently to the rest of the body leads to
symptoms of fatigue, limited activities, exercise intolerance, chest congestion, shortness of breath, and
edema.
Sodium (FH-1.6.2.7) and fluid intake (FH-1.2.1)
Energy (FH-1.1.1) and protein intake (FH-1.5.2)
Fat (FH-1.5.1) and carbohydrate (FH-1.5.3) intake
Micronutrient (FH-1.6) intake (magnesium [FH-1.6.2.4], thiamine [FH-1.6.1.6], vitamin B-12

[FH-1.6.1.11], vitamin B-6 [FH-1.6.1.10], folate [FH-1.6.1.9], and Potassium [FH-1.6.2.5])
Caffeine (FH-1.4.3) and alcohol (FH-1.4.1) intake
Anthropometrics
Height/length (AD-1.1.1)
Weight, weight history (AD-1.1.2)

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Biochemical Tests
The registered dietitian nutritionist should review relevant laboratory data, such as lipid profile, high
sensitivity C-reactive protein (hs-CRP), vitamin D, lipoprotein (a), and blood glucose, hemoglobin (Hb)
A1c, blood urea nitrogen, creatinine, potassium, phosphorus, and albumin.
Serum lipid panel (fasting 12 hours), measuring the following:
o Total cholesterol level (BD-1.7.1)
o High-density lipoprotein (HDL) cholesterol level (BD-1.7.2)
o Low-density lipoprotein (LDL) cholesterol level (BD-1.7.3)
o Non-HDL-cholesterol (BD-1.7.4)
o Triglyceride level (BD-1.7.7)
Vitamin D (BD-1.13.3)
Fasting blood glucose (BD-1.5.1)
HbA1c in patients with known diabetes (BD-1.5.3)
Liver function tests (BD-1.4.1)
Coagulation profile: prothrombin time (BD-1.4.9) and International Normalized Ratio (BD-
1.4.11)
Other blood chemistries
o Blood urea nitrogen (BD-1.2.1)
o Creatinine (BD-1.2.2)
o Sodium (BD-1.2.5), potassium (BD-1.2.7) and other electrolytes (BD-1.2)
In some settings, newer tests may include:
Lipoprotein (a)
LDL-particles
Apo A1 and B
Lipoprotein-Associated Phospholipase A2 (Lp-PLA2)
hs-CRP (BD-1.6.1)
Insulin sensitivity measures
Medical Procedures
Pacemaker
Defibrillator
Mechanical heart pump
Heart transplant
Edema (pedal and abdominal)

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Vital signs (blood pressure) (PD-1.1.9)
Abdominal girth
Muscle and subcutaneous fat wasting
Common Medications
Heart failure (HF) medications include an angiotensin converting enzyme inhibitor or

angiotensin receptor blocker, beta-blocker, and diuretic
Medications and/or supplements that may contribute to fluid retention (nonsteroidal anti-
inflammatory drugs, Actos, Avandia). Other medications may include statins,
antihypertensives, or diabetes, renal, and thyroid medications.
Misuse of medication (FH-3.1.3)
Prescription Medication Use (FH-3.1.1)
o Anticoagulants (coumadin, heparin, warfarin)
Nutrition-related complementary/alternative medicine use (FH-3.2.1)
o Wine
o Hawthorn berry
o Coenzyme Q10
o Arginine
Estimated Energy: The Evidence Analysis Library (EAL) evidence-based practice guideline for
heart failure (HF) states: The use of indirect calorimetry best determines energy needs in the
patient with HF. When indirect calorimetry is not available, start with the usual predictive
equations (Mifflin St. Jeor) and adjust for increased catabolic state.
Fluid Requirements: The EAL evidence based practiced guideline for HF states: For patients
with HF, fluid intake should be between 1.4 and 1.9 L (48-64 oz.) per day, depending on clinical
symptoms (i.e. edema, fatigue, shortness of breath). Fluid restriction will improve clinical
symptoms and quality of life. The Heart Failure Society of America indicates fluid restriction of
less than 2 L/day is recommended in patients with severe hyponatremia (serum sodium < 130
mEq/L). Such fluid restriction should be considered for any patient with fluid retention that is
difficult to control despite high doses of diuretics and sodium restriction.
Meals and Snacks (ND-1)
Modify composition of meals/snacks (ND-1.2)
o Fluid-modified diet (ND-1.2.8)
o Mineral-modified diet (ND-1.2.11)
Modify schedule of food/fluids (ND-1.3)
o Small frequent meals, for patients experiencing early satiety
Additional Food and Feeding Considerations
Early satiety may cause loss of appetite.

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Shortness of breath may cause anxiety or interfere with adequate food intake.
People consuming high-sodium foods or foods prepared with salt may need to gradually
decrease the sodium in their diet. Patients may seek out high-fluid-content foods to
compensate for fluid restriction.
Nutrition EducationContent (E-1)
Purpose of the nutrition education (E-1.1)
Priority modifications (issue of most concern to patients health and well-being) (E-1.2)
Food preparers often need to learn how to use other seasonings to flavor foods.
Patients without family support at home need guidance in choosing lower-sodium convenience
foods and in quick, easy meal preparation.
Patients may need guidance on menu modifications while dining out.
Nutrition Counseling (C-1, C-2)
Cognitive-behavioral theory (C-1.1)
Transtheoretical model/stages of change (C-1.4)
Motivational interviewing (C-2.1)
Goal setting (C-2.2)
Self-monitoring (C-2.3)
Weigh daily to monitor fluid retention
Problem solving (C-2.4)
Social support (C-2.5)
Stimulus control (C-2.7)
Coordination of Nutrition Care (RC-1)
Team meeting (RC-1.1)
Collaboration with other providers (RC-1.4)
Referral to community agencies/programs (RC-1.6)
Energy (FH-1.1.1) and protein (FH-1.5.2) intake
Sodium (FH-1.6.2.7) and fluid intake (FH-1.2.1)
Adherence to the DASH diet pattern
Current laboratory values (serum sodium (BD-1.2.5), BUN (BD-1.2.1), and creatinine (BD-1.2.2)
levels) - used to assess adherence to sodium and fluid restrictions
Current weight
Daily weight record/weight changes (self monitoring)

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Fluid intake, method of monitoring fluid intake and response to thirst
Bioactive substances (FH-1.4) alcohol intake (FH-1.4.1), caffeine (FH-1.4.3), herbal

supplements
Physical activity (FH-7.3) patterns
AIDS/HIV
Description
The Human immunodeficiency virus which is contracted through bodily fluids. Transmission may occur
during unprotected sex, needle sharing, or exposure to HIV-infected blood or from mother to child
during pregnancy, delivery, or breastfeeding. HIV carries and injects ribonucleic acid (RNA) into the
targeted host cell, especially activated CD4 immune cells. The incorporation of RNA and subsequent
dysfunction of the cell, as well as ultimate cell destruction as new viruses emerge from the host cell,
cause immune dysfunction. In addition, other cells, such as macrophages, can be rendered
dysfunctional by HIV infection. The disease process itself contributes to the development of
malnutrition and wasting. Infection leads to an inflammatory response and challenges the
maintenance of lean tissue stores.
Food and nutrient intake (FH-1)
o Enteral nutrition intake (FH-1.3.1)
o Parenteral nutrition intake (FH-1.3.2)
o Liquid meal replacement or supplement (FH-1.2.1.3 )
o Vitamin intake (FH-1.6.1)
o Mineral/element intake (FH-1.6.2)
o Pattern of alcohol consumption (FH-1.4.1.3)
o Meal/snack pattern (FH-1.2.2.3)
Diet history (FH-2.1)
o Diet experience (FH-2.1.2)
o Eating environment (FH-2.1.3)
Food and nutrition knowledge/skill (FH-4.1)
Beliefs and attitudes (FH-4.2)
Adherence (FH-5.1)
Avoidance behavior (FH-5.2)
Mealtime behavior (FH-5.4)
Social network (FH-5.5)
Food/nutrition program participation (FH-6.1)
o Eligibility for government programs (FH-6.1.1)

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o Participation in government programs (FH-6.1.2)
o Eligibility for community programs (FH-6.1.3)
o Participation in community programs (FH-6.1.4)
Safe food/meal availability (FH-6.2)
Safe water availability (FH-6.3)
Food and nutrition-related supplies availability (FH-6.4)
Nutrition-related activities of daily living (ADLS) and instrumental ADLs (FH-7.2)
Physical activity (FH-7.3)
Factors affecting access to physical activity (FH-7.4)
Nutrition quality of life (FH-8.1)
Anthropometrics
o Body composition/growth/weight history (AD-1.1)
o Height/length (AD-1.1.1)
o Weight (AD-1.1.2)
o Frame size (AD-1.1.3)
o Body mass index (AD-1.1.5) (20 to 24.9 is optimal)
o For children, growth pattern indices (AD-1.1.6)
Biochemical Tests
Laboratory values include the following:
Albumin
Prealbumin
Triglycerides
Cholesterol
High-density lipoprotein (HDL) cholesterol
Low-density lipoprotein (LDL) cholesterol
Glucose
Insulin
C-reactive protein
Transferrin
Total iron-binding capacity
Hydration indicators
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Kidney function tests
Liver function tests
Pancreatic function tests
Anemia indicators
Human immunodeficiency virus (HIV) viral load
CD4 cell count
Nutrient levels
Testosterone levels
Medical Procedures
Test blood and saliva for antibodies

CD4 count
Viral load
Drug resistance
Physical examination includes an overview of the body's general appearance and shape,
anthropometry, other body composition measures, fat deposition patterns, and clinical signs of
nutrient deficiency or toxicity. There are several ways to evaluate nutritional status and body
composition, which should take into consideration the existence of weight loss, wasting, and altered
body fat patterns (Kotler 1994, Paton 1997, Niyongabo 1999, Salomon 2002, Knox 2003).
Compare actual measures with estimates of optimal levels for body cell mass and fat; identify
alterations from baseline or expected patterns of body fat deposition; identify client profile (eg,
wasting, optimal, obesity); and identify potential nutrient deficiencies or toxicities. The table below
shows a variety of physical examination criteria.
Examination
Criteria for Evaluation
Item
Body mass 18.5-24.9

index (BMI)
<18.5 suggests high risk for morbidity, mortality, and the development or
presence of wasting or lipoatrophy
>24.9 suggests potential for obesity related diseases and central fat
accumulation
Body cell 100% of ideal

mass (BCM)
<95% of ideal suggests wasting and associated complications of reduced body
functions
As BCM declines, additional body functions are compromised according to the

severity of BCM loss, including hormonal stasis, ability to sit, ability to swallow,
and ability to breathe
<55% is associated with the timing of death

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Weight Weight gains and losses >5% should be evaluated for causes and
change consequences
>5% unintentional loss is associated with increased risk of morbidity and

mortality
>5% unintentional gain is associated with increased risk for central fat
accumulation
Other Evaluate appearance of skin, hair, eyes, fingernails, teeth, and oral cavity for
physical potential deficiency or excess of nutrients or involvement in disease process if
exam nutritional evaluation shows deficient or excessive nutrient intake; particular
criteria notes should be made on findings that may affect food intake
Serial anthropometric measures of neck, back, chest, breast, waist, hip, mid-
upper arm, thigh, and calf circumferencesalong with facial, triceps, biceps,
subscapular, suprailiac, abdominal, thigh, and calf skinfoldscan identify
trends to provide an early diagnosis of altered fat patterns and potential muscle
wasting
Body composition/growth/weight history (AD-1.1)

Height/length (AD-1.1.1)
Weight (AD-1.1.2)
Frame size (AD-1.1.3)
Body mass index (AD-1.1.5) (20 to 24.9 is optimal)
For children, growth pattern indices (AD-1.1.6)
Common Medications
Generic Name Food, Drink, and Other Potential Side Effects

(commercial name); Interactions
Class of Drug
(manufacturer);
Forms (tablets, capsules,
oral solutions, or
injections)
Abacavir (Ziagen); Take with or without food; Nausea and vomiting, loss of appetite,
NRTI (Glaxo SmithKline); caution with alcohol abdominal pain, diarrhea, anemia,
Tablets, oral solution (increases amount of time a pancreatitis, lactic acidosis (rare)
(strawberry-banana) drug is active in your body)
Abacavir/Lamivudine/Zidovud Take with or without food See side effects on drug labels for
ine (Trizivir); Abacavir, Lamivudine, Zidovudine
NRTI1 combination (Glaxo
SmithKline);
Tablets
Amprenavir (Agenerase); Take with or without food; do Diarrhea, nausea and vomiting, taste
Protease inhibitor (Glaxo not take with high-fat meal; changes, stomach upset, diabetes,
SmithKline); do not take with a vitamin E fatigue, increased cholesterol levels,
Capsules (contains sorbitol, supplement; if taking increased triglyceride levels, fat
vitamin E), oral solution antacids, take Amprenavir 1 maldistribution, anemia. Do not take if
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(grape, bubble gum, hour before or after; avoid you have kidney or liver failure.
peppermint) contains grapefruit juice; increase fluid
acesulfame potassium, intake.
saccharin, vitamin E
Tipranavir (Aptivus); Protease

inhibitor ( Boehringer Hypertriglyceridemia, hyperglycemia,
Take with a high-fat meal.
Ingelheim Pharmaceuticals); fat maldistribution
Capsules
Atazanavir (Reyataz) Take with food Nausea, increased indirect bilirubin,

Protease inhibitor (Bristol- lactic acidosis (rare)
Myers Squibb) Be careful if you have liver problems,
capsules (contain lactose) may require dose change
Darunavir (Prezista)
Nausea, diarrhea, headache, cold-like
Protease inhibitor (Tibotec Take with or without food
symptoms (runny nose and sore throat)
Therapeutics) capsules
Delavirdine (Rescriptor); Take with or without food; do Increased thirst, loss of appetite, dry
NNRTI2 (Agouron); not take with antacids or mouth, nausea and vomiting, inflamed
Tablets (contain lactose); magnesium-containing stomach, diarrhea, constipation, passing
supplements; may take with gas;
acidic drinks (such as be careful using this drug if you have
cranberry juice); avoid liver problems
drinking alcohol
Didanosine, ddI (Videx, Videx Take without food on an Loss of appetite, diarrhea, nausea and
EC); empty stomach 1/2 hour vomiting, abdominal pain, constipation,
NRTI (Bristol-Myers Squibb); before or 2 hours after a meal; dry mouth, taste changes, pancreas
Videx: chewable tablets do not take with acidic drinks infection, (increased risk if you drink
(orange, contains sorbitol, or foods, aluminum-containing alcohol), lactic acidosis (rare), problems
aspartame); powder; antacids, or magnesium- with feeling in your arms and legs;
Videx EC: capsules containing supplements; be careful if you have kidney problems
avoid drinking alcohol
Efavirenz (Sustiva); Take on an empty stomach; a Loss of appetite, nausea and vomiting,
NNRTI (Bristol-Myers Squibb); high-fat meal increases the diarrhea, taste changes, increased good
Capsules, tablets (both risk for side-effects; avoid and bad cholesterol levels, increased
contain lactose) drinking alcohol triglyceride levels
Emtricitabine (Emtriva); Take with or without food; Nausea and vomiting, diarrhea, lactic
NRTI (Gilead); Eating a high-fat meal lowers acidosis (rare);
Capsules the highest drug levels Be careful if you have kidney problems;
may require a dose change
Enfuvirtide (Fuzeon); Fusion No diet restrictions Diarrhea, nausea, fatigue, loss of

inhibitor (Hoffman-LaRoche); appetite, constipation, inflamed
Powder for injection pancreas, increased triglyceride levels,
increased lipase, increased amylase;
Low weight decreases clearance of drug
from your blood, but no dose adjustment
is recommended
Fosamprenavir (Lexiva); Take with or without food; Nausea, vomiting, diarrhea, increased
Mary Bonack
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Protease inhibitor (Glaxo avoid vitamin E triglyceride levels, fat maldistribution

SmithKline); supplementation
Tablets
Indinavir (Crixivan); Take on an empty stomach or Nausea, vomiting, acid reflux, increased
Protease inhibitor (Merck); with very-low-calorie/low- or decreased appetite, abdominal pain,
Capsules (contain lactose) protein snack (Note: no food taste changes, diarrhea, kidney stones,
restriction when taken with diabetes (rare), increased blood liver
ritonavir); take with plenty of enzyme levels or pancreas enzymes,
fluids (at least 1.5 liters per increased muscle damage, red blood
day); avoid grapefruit juice cells are destroyed faster than your
body can make them, impaired liver
functioning;
Dose is changed in cirrhosis liver
disease; hyperlipidemia; fat
maldistribution
Lamivudine, 3TC (Epivir); Take with or without food Nausea-and vomiting, abdominal
NRTI (Glaxo SmithKline); cramps, diarrhea, pancreatitis, lactic
Tablets; oral solution acidosis (rare);
(strawberry-banana flavor) Dose is changed for kidney problems;
Note: also used for hepatitis B in lower
doses as Epivir HBV
Lamivudine/Zidovudine, Take with or without food See side effects on drug labels for
3TC/ZDV, 3TC/AZT Lamivudine, Zidovudine
(Combivir); NRTI combination
(Glaxo SmithKline);
Tablets
Lopinavir/Ritonavir (Kaletra); Take with food Abdominal pain, diarrhea, nausea,

Protease inhibitor (Abbott); increased triglyceride levels; increased
Soft gel capsules (contain cholesterol levels, fat maldistribution;
sorbitol), oral solution (cotton inflamed pancreas; hyperglycemia;
candy or vanilla; contains Be careful if you have liver problems; if
alcohol and saccharin) taken with Didanosine, must be taken 2
hours apart
Nelfinavir (Viracept); Take with fatty food; may Diarrhea, gas passing, nausea,
Protease inhibitor (Agouron); crush tablets, mix with water, abdominal pain, hyperlipidemia; fat
Tablets; powder (contains and take immediately after maldistribution; diabetes (rare),
aspartame) mixing; mixing powder with increased liver enzymes;
acidic food or drink results in Be careful in you have liver problems
bitter taste
Nevirapine (Viramune); Take with or without food Nausea and vomiting, abdominal pain,
NNRTI (Roxane); fatigue, toxic to the liver
Tblets; oral suspension
(contains sorbitol)
Ritonavir (Norvir); Take with food Nausea and vomiting, diarrhea, taste
Protease inhibitor (Abbott); changes, loss of appetite, upset
Soft gel capsule; oral solution stomach, diabetes, inflamed pancreas,
(contains saccharin, alcohol; increased triglyceride levels, increased
peppermint, caramel) liver enzymes, increased muscle
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damage, increased uric acid
Saquinavir (Invirase, Take within 2 hours of a high- Nausea, abdominal discomfort, gas,
Fortovase); calorie, high-fat meal diarrhea, low blood sugar,
Protease inhibitor (Roche); mouth/esophageal ulcers; Be careful if
Invirase: capsules; Fortovase: you have liver disease, check
soft gel capsules triglyceride levels
Stavudine, d4T (Zerit, Zerit Take with or without food; Nausea and vomiting, diarrhea, loss of
XR); avoid drinking alcohol appetite, mouth/esophageal ulcers,
NRTI (Bristol-Myers Squibb); lipoatrophy, hyperlipidemia, problems
Zerit: capsules or powder with feeling in your arms and legs,
(fruit); Zerit XR: capsules increased liver enzymes, increased
pancreas enzymes;
May change dose for kidney problems
Tenofovir (Viread); Take with food; avoid St John's Nausea, vomiting, diarrhea, passing gas,
NRTI (Gilead); Wort, garlic supplements, and abdominal pain, lactic acidosis (rare),
Tablets (contain lactose) milk thistle increased muscle damage, increased
triglyceride levels;
Do not take if you have kidney problems
Zalcitabine, ddC (Hivid); Take on an empty stomach; Loss of appetite, mouth sores, nausea
NRTI (Roche); avoid drinking alcohol and vomiting, diarrhea, constipation,
Tablets (contain lactose) problems with feeling in your arms and
legs lactic acidosis (rare), inflamed
pancreas (rare), increased triglyceride
levels, anemia
Dose may be changed for kidney
problems
Zidovudine, AZT, Compound Take with or without food; do Loss of appetite, nausea and vomiting,
S, Azidothymidine (Retrovir); not take with a high-fat meal upset stomach, constipation, taste
NRTI (Glaxo SmithKline); changes, anemia, muscle disease in
Tablets, capsules, syrup long-term use;
(strawberry), injections Dose may be changed in liver or kidney
impaired functioning
Mifflin St. Jeor plus 10-50% increase added on REE (Resting Energy Expenditure)
Fluid Requirements: 30 mL/kg
Food is the primary basis for nutrition-related intervention. However, food insecurity (including food
availability and access) can be issues for many underserved people infected with human
immunodeficiency virus (HIV). Children who are HIV-infected may experience challenges in feeding
because of developmental delays. Food access, education, and individualization of interventions to
meet the client's priority needs are essential to health maintenance with chronic HIV infection.
Food and water safety education is of special importance to those experiencing immune dysfunction,
especially for those with low CD4 cell counts. Each patient should be provided with information that fits
his or her own lifestyle for shopping, cooking, storing food, and dining out.
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Limitations that compromise food consumptionsuch as economic resources, symptoms that interfere
with food intake, cultural beliefs or habits, and othersshould be considered in developing
individualized nutrition counseling and meal plans. Barriers to adequate and appropriate food intake
should be considered in determining any need for alternate sources of nutrients, such as enteral (oral
or tube) or parenteral feeding.
Nutrition reassessments should be conducted every 3 to 6 months in people living with human
immunodeficiency virus/acquired immune deficiency syndrome, based on initial assessments. This is
an important time to monitor food intake, body composition, laboratory results, and medications and
supplements.
Oncology
Description
Cancer is a general term used when abnormal cells exhibit uncontrolled growth; normal cells have a
definite life span and ultimately undergo apoptosis (programmed cell death). Although commonly
thought of as one disease, cancer is actually many diseases caused by a multitude of cell types that
require different treatment modalities. Cancer is known by other names, including malignancy or
neoplasm. Malignant cancers are defined as masses of abnormal cells that may invade surrounding
tissues or spread (metastasize) via the blood or lymphatics or by direct extension to distant areas of
the body from the original or primary location. Some cancers are classified as benign because they do
not penetrate or destroy surrounding tissues. These cancers can occur in any part of the body.
Cancers are classified in two ways: by the histology, or type of tissue in which the cancer originates,
and by primary site, or the location in the body where the cancer first developed. From a histological
standpoint, there are hundreds of different cancers that are grouped into five major categories:
carcinoma, sarcoma, myeloma, leukemia, and lymphoma:
Carcinomas: The most common type of cancer that comprises 80% to 90% of all cancers
occurring in adults; these cancers arise in the epithelial tissue of organs. There are two major
subtypes of carcinoma, adenocarcinoma in organs or glands, and squamous cell carcinomas in
squamous epithelium.
Sarcomas: Malignancy arising from the mesenchymal tissue of muscle or bone.
Lymphomas: Hematological malignancy of the lymphocytes.
Leukemias: Hematological malignancy of the bone marrow resulting in overproduction

of immature blood cells.
Myelomas: Malignancy of the hematopoietic portion of the bone marrow resulting in

inadequate production of antibodies
Food and beverage/alcohol intake; current requirement of nutrition support (enteral or

parenteral nutrition)
Dietary supplement use (eg, vitamins, minerals, botanicals, protein powders, etc)
Input and output
Assess intake for adequacy (eg, energy, protein, micronutrients, fluids, etc)
Assess availability of food and ability to prepare

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Assess client's knowledge level, motivation, and readiness for change
Prioritize goals based on clinical status and prognosis
Evaluate nutrition history for presence of nutritional impact symptoms including, but not
limited to, the following:
o Anorexia
o Nausea
o Vomiting
o Diarrhea/malabsorption
o Dysphagia
o Mucositis/stomatitis
o Dysgeusia
o Taste aversions
o Constipation
o Pain
o Infection
o Fatigue
o Xerostomia
o Use of complementary and alternative medicine (CAM) therapies
o Use of these therapies has increased in the cancer patient population. Whereas
the majority of therapies are harmless, some CAM practices may have serious
contraindications for individuals undergoing cancer therapy and recovery.
Anthropometrics
Height
Weight
Body mass index
Weight history
Body composition
Weight distribution
Biochemical Tests
Neutrophil count
Iron studies
Electrolytes
Kidney function
Liver function
Glucose
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Medical Procedures
Biopsy: A surgical procedure that involves removing all or part of tissue suspected of being
cancerous
Imaging studies: Diagnostic tests that display the structure and function of internal organs;
examples of imaging used for cancer diagnosis include the following:
o Computed tomography scans
o X-rays
o Radioisotope scans
o Ultrasonography
o Magnetic resonance imaging
o Positron emission tomography scans
Pathologic and cytologic studies: The analysis of tissue samples for the presence of cancer
cells; the cells are obtained via biopsy: Pap test, fine-needle aspiration, surgical incision
(removal of a small portion), or excisional biopsy (removal of the entire lesion)
The term anthropometric refers to comparative measurements of the human body. Body
parameters such as weight and height and body mass index (BMI) are commonly used to
assess nutritional status. Other anthropometric measurements less commonly used in routine
practice include waist and hip circumference and skinfold measurements. Each of these
measures provides valuable information about the individuals body composition, but they also
have limitations. For example, skinfold measurements are associated with a high degree of
error and can cause significant burden to the patient, so they are rarely used in clinical
practice.
Weight should be obtained from a calibrated scale at each patient visit, or as determined by
the facility. Weight information should be gathered in several ways. Usual body weight (UBW)
refers to the patients last stable weight. Data regarding the timeline for last stable weight
should also be collected. Ideal body weight (IBW) describes the reference weight considered to
be optimal for the patient; this can be obtained from reference tables. Actual body weight
(ABW) is a measure of the current weight of the patient. ABW should be compared with UBW
and IBW. The change in a patients weight over time is an inexpensive and relatively accurate
method of predicting nutritional status.
BMI defines weight in relation to height. It is commonly used to describe the degree of
adiposity and disease risk in populations. BMI alone is not a perfect predictor of overweight or
obesity. Its use is limited in older adults because it underestimates body fat in those who have
lost muscle mass.When evaluating muscular individuals such as body builders or patients with
large amounts of edema or ascites, clinical judgment must be utilized because these
physiological states may lead to false overestimation of the degree of fatness.
Common Medications
Altretamine
Asparaginase
Bleomycin
Capecitabine
Carboplatin
Carmustine
Cladribine
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Cisplatin
Cyclophosphamide Cytoxan
Cytarabine
Dactinomycin
Docetaxel
Doxorubicin
Imatinib Gleevec
Doxorubicin Liposomal
Etoposide, VP-16
Fludarabine
Fluorouracil, 5-FU
Gemcitabine
Hydroxyurea
Idarubicin
Ifosfamide
Irinotecan, CPT-11
Methotrexate
Mitotane Lysodren
Mitoxantrone
Paclitaxel Taxol
Topotecan
Vinblastine
Vincristine
Vinorelbine
Estimated Energy:
- 5 to 30 kcal/kg body weight for non-ambulatory or sedentary adults
-30 to 35 kcal/kg body weight for slightly hypermetabolic patients, for weight gain, during the
first month after allogeneic hematopoietic stem cell transplant, or for an anabolic patient
-35 body weight for hypermetabolic or severely stressed patients, patients with acute graft-
versus-host disease, for patients receiving more than 75% of their total energy intake via
parenteral nutrition, or those with malabsorption
Fluid Requirements: 30-35 mL/kg fluid
Preventing weight loss even in overweight patients
Maintenance of lean body mass
Preventing unintentional weight gain, particularly in certain groups of cancer patients (eg,
those with hormonal cancers such as prostate or breast cancer, and those on high-dose
steroids for long periods of time)
Identification and management of treatment-related adverse effects
Interventions must be individualized to the therapy and nutritional impact symptoms of the patient. A
one-size-fits-all approach to medical nutrition therapy is not efficacious in cancer patients. The
nutrition intervention in cancer patients commonly focuses on symptom management. Some general
principles to help patients manage nutritional impact symptoms include the following:
Alter food choices and eating patterns to accommodate the patient's changing needs.
Small, frequent snacks may be easier to tolerate than 3 large daily meals.
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Food choices should be easy to chew, swallow, digest, and absorb even if high in fat.
Supplements and nutrient-dense nourishments should be prescribed to maintain adequate

nutrient intake.
Encourage light physical activity such as walking.
Counseling by a qualified nutrition health care provider such as a registered dietitian can be
helpful in creating an individualized meal plan to meet specific nutrition needs.
If patients desire to take vitamin supplements or one is necessary because of inadequate

intake, patients should be advised not to exceed the Upper Intake Levels (UL) of the Dietary
Reference Intakes for nutritional supplements containing antioxidant nutrients.
Weight
Tolerance to nutrition interventions
Treatment side effects and nutrition implications.
Dysphagia
Description
Dysphagia, or difficulty in swallowing, can be a medical and feeding issue at any age; however, it is
particularly prevalent in older individuals. Identification of dysphagia is done using medical history,
clinical observation, and physical examination. Some treatments for dysphagia include H-2 blockers,
Proton Pump Inhibitor, and GI stimulants:
Dysphagia is not a disease, but a disruption of a normal swallowing process. Without effective
treatment it can lead to:
Inadequate oral intake, unintended weight loss, underweight and eventually malnutrition
resulting in death
Aspiration pneumonia
Dehydration
Depression
Pneumonia (pulmonary complications)
Decreased rehabilitation potential
Decreased quality of life
Increased length of hospital stay
Increased costs
Total energy intake

Food and fluid/alcohol intake Nutrition support
Dietary supplement use
Experiences with weight loss diet
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Anthropometrics
Height
Weight
Body Mass Index (BMI) and waist-hip ratio
Weight Changes
Swallowing problems (current, history, duration)
Pocketing of food under tongue or in cheek
Spitting food out
Facial weakness
Slow oral transition time
Choking
Coughing
Poor tongue control or excessive movement
Hoarseness or breathy voice
Evaluations of any swallowing tests
Biochemical Tests
Hemoglobin and hematocrit (Hct and Hgb)
Blood urea nitrogen (BUN)
Na+ (sodium)
K+ (potassium)
Cl- (chloride)
Ca++ (calcium)
Mg++ (magnesium)
Prothrombin time (PT)
International normalized ratio (INR)
Total lymphocyte count (TLC)
Medical Procedures
Clinical bedside evaluation
Bedside swallow assessment
Simple standardized bedside swallowing assessment (SSA)
Simple water swallow test
Burke water swallow test
Barium swallow
Video fluoroscopy
Double contrast esophagoscopy
Radio nucleotide studies

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Manometry
Endoscopy
Pressure or discomfort in the chest
Lump or fullness in the throat
Chronic heartburn
Because dysphagia is seen with a broad range of disorders at different stages of the lifecycle, nutrition
assessment should be done in a manner that is appropriate for the age of the patient and the
medical/physical problem(s) of that patient. Ability to swallow should be assessed in all patients seen
by the healthcare team, but particularly monitored in the most typical diseases.
Initial screening for dysphagia can be done using:
Patients history and physical
Bedside screening protocol
Observation of the patient while eating
Bedside tests are important for early dysphagia screening, but they have limitations in accuracy of the
specific swallowing problem especially in recognition of silent aspiration. In screening patients by
questioning and/or mealtime observation, a speech-language pathologist and a registered dietitian
could agree on identification of dysphagia patients effectively. However, a collaborative effort of
speech-language therapists and dietitians strengthens insights into the diagnosis of dysphagia.
Based on guidelines in Nutrition Care of the Older Adult, warning signs for swallowing problems
include:
Excessive mouth movement during chewing and swallowing
The need to swallow two and three times with each bolus
Food remaining on the tongue after swallowing
Coughing or choking before, during, or after swallowing food, liquids, or medication
Nasal regurgitation, excessive drooling
Wet vocal quality; hoarse, breathy voice or gargly breathing
Frequent throat clearing
Feeling of something caught or sticking in throat
Pocketing of food in mouth
Repetitive rocking of tongue from front to back
Weight loss
Dehydration
Fever
Common Medications
Mary Bonack
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H2 blockers
Proton pump inhibitors
Calcium channel blockers
Botox
Isosrobide dinitrate
Estimated Energy:
Fluid Requirements: Weight (kg) x 30 mL = normal daily fluid requirement
Fluid requirements may differ for those clients with cardiac problems, renal failure,
dehydration, those that are obese, or for those requiring fluid restrictions.
One intervention is not usually adequate for optimizing swallowing. A combination of interventions is
usually needed to provide the best swallowing outcomes for any single individual (eg, chin tuck, head
turned toward paretic side, jaw extension, Mendelsohn maneuver exercises, positioning, thickened
fluids, texture changes, not eating or drinking 2 hours before bed or reclining).
Nutrition therapy for dysphagia have been standardized by the National Dysphagia Diet Task Force, a
group of RDs, speech-language pathologists, and researchers who developed through consensus the
National Dysphagia Diet (American Dietetic Association, 2002). Four levels of liquid and solid
consistency have been identified. Thickening agents may be necessary for patients requiring thickened
liquids. Commercially available products as well as readily available foods from the grocery store can
be used as thickeners.
Nutritional monitoring should be an ongoing process for all patients. At the very least, weight for
height should be monitored. For patients who have poor nutritional assessment measurements in the
beginning of care, frequent blood work may be necessary. With improvement, monitoring will become
less involved and less frequent.
Particularly in the outpatient setting, ongoing monitoring and evaluation of food intake by the patient
with dysphagia by the health care team is important. Whether 24-hour recall, food diary, or food
frequency questionnaire is used, monitoring for acceptance and nutritional adequacy of the meal plan,
as well as hydration status of the patient, should be done. If a variety of appropriate foods are not
consumed, nutrient deficiencies can result. Alternative ways of approaching the food plan may need to
be tried. Adequate hydration can be particularly challenging for the patient who must use thickened
liquids.
Wound Care
Description
A wound is a disruption of the normal structure and function of the skin and underlying soft
tissue. Healing occurs as a cellular response and involves activation of keratinocytes, fibroblasts,
endothelial cells, macrophages, and platelets. Acute wounds in previously healthy individuals heal
through a sequence of physiological events characterized by overlapping phases that include
inflammatory, proliferative, and maturation.
Total energy intake (FH-1.1.1.1)
Fluid/beverage intake (FH-1.2.1)
Food intake (FH-1.2.2)

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Alcohol intake (FH-1.4.1)
Macronutrient intake (FH-1.5)
Diet history (FH-2.1)
Beliefs and attitudes (FH-4.2)
Nutrition-related activities of daily living and instrumental activities of daily living (FH-7.2)
Physical activity (FH-7.3)
Anthropometrics
Height (AD-1.1.1)
Weight (AD-1.1.2)
Biochemical Tests
Glucose/endocrine profile (including hemoglobin A1c, if patient has diabetes) (BD-1.5)
Inflammatory profile (BD-1.6)
Metabolic rate profile (indirect calorimetry) (BD-1.8)
Medical Procedures
Glucose/endocrine profile (including hemoglobin A1c, if patient has diabetes) (BD-1.5)
Inflammatory profile (BD-1.6)
Metabolic rate profile (indirect calorimetry) (BD-1.8)
Overall appearance (PD-1.1.1)
Digestive system (abnormalities of the tongue and/or lips and ability to chew and swallow
foods) (PD-1.1.5)
Extremities, muscles and bones (alternations in subcutaneous tissue, presence of dehydration,

edema and/or muscle wasting) (PD-1.1.4)
Skin (presence and/or severity of wound) (PD-1.1.8)
Vital signs (PD-1.1.9)

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Common Medications
Pentoxifylline, a methylxanthine that improves perfusion of peripheral vascular beds, is useful

in patients with ulcers secondary to peripheral vascular disease.
Iloprost, a prostacyclin analogue, is an established treatment for intermittent claudication,
severe limb ischaemia, and prevention of imminent gangrene, and to reduce the pain and
clinical symptoms associated with Raynaud's disease.
Antimicrobials including iodine based preparations and silver releasing agents are used to treat
infected wounds.
Glyceryl trinitrate, a nitric oxide donor, is effective in the management of chronic anal fissures
when applied topically as 0.2% ointment.
Calcium antagonists such as diltiazem and nifedipine are useful in treating vasculitic ulcers
secondary to Raynaud's disease and connective tissue diseases.
Systemic corticosteroids are useful in treating ulcers secondary to connective tissue diseases,
including rheumatoid arthritis, scleroderma, and other vasculitic disorders.
Zinc
Phenytoin
Retinoids
Analgesics
Estimated Energy: The recommended energy level for optimal wound healing, according to the
American Society for Parenteral and Enteral Nutrition and the Wound Healing Society, is
estimated at approximately 30 kcal/kg/day to 35 kcal/kg/day
Fluid Requirements: Recommendations for daily fluid intakes are 30 mL/kg or 1 mL/kcal to 1.5
mL/kcal. Increased fluid is required for patients with high-protein intakes and/or high exudate
or other fluid losses.
Inadequate nutrition, dehydration, and/or weight loss must be corrected through nutrition
interventions for a wound to heal.
Meals and snacks (ND-1)
Enteral and parenteral nutrition (ND-2)
Medical food supplements (ND-3.1) (offering nutritional supplements between meals,

enhanced foods [with modified recipes] and/or protein-dense foods)
Vitamins and minerals (ND-3.2)
Feeding assistance and set-up with meals (ND-4)
Oral nutritional supplements can be used to help meet patients nutrition needs, combat weight loss
and undernutrition, and enhance wound healing. Supplement acceptance and tolerance should be
documented in the medical record. In the event of poor supplement acceptance, alternatives should be
offered and/or high-kilocalorie, high-protein food choices should be provided.
For the patient with chronic or post-surgical wounds, nutrition monitoring and evaluation should be
individualized to the nutrition diagnoses, working toward improving the signs/symptoms and
determining if the nutrition prescription has been implemented. Indicators that are most relevant to
delayed healing risk or treatment include the following:
Energy intake (FH-1.1)

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Food and beverage intake (FH-1.2)
Protein intake (FH-1.5.2)
Carbohydrate intake (FH-1.5.3)
Micronutrient intake (FH-1.6): from all sources, for example, food, beverages, supplements,
and via enteral and parenteral routes.
Vitamin intake (FH-1.6.1), specifically vitamins C and A
Mineral intake (FH-1.6.2), especially zinc, iron, and copper
Diet order (FH-2.1.1)
Food and nutrition knowledge/skill (FH-4.1)
Weight (AD-1.1.2) and weight changes (AD-1.1.4)
Glucose/endocrine profile (BD-1.5) and hemoglobin A1c (BD-1.5.3)
The amount and type of food, fluid, and/or nutrition support (when indicated) intake or infusion should
be monitored closely to ensure that the patient is meeting nutritional requirements. Without
appropriate monitoring by the registered dietitian, patients may experience reduced food and nutrient
intake or receive nutrition misinformationboth of which can inhibit wound healing and increase cost
to patients, third-party payers, and health care facilities.
Cited Sources
Nutrition Care Manual

Cancer slides
https://www.irda.gov.in/ADMINCMS/cms/Uploadedfiles/Critical%20Illness%20Insurance
%20Policy.pdf (Critical Illness)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1440619/ (Common Medications for Wound Care)
http://www.drugs.com/cancer.html (Common Medications for Oncology)

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Reference

Food & Nutrition-Related History

Folate 187-645 ng/ml Osmolality 275-295 mOsm/kg H20

Nutrition-Focused Physical Related Findings

Estimated Energy and Fluid Requirements

Increased nutrient needs, (specify), (NI-5.1), Altered GI function, (NC-1.4),

Formula/ solution (for enteral/ parenteral nutrition)

Nutrition relationship to health/ disease

Collaboration/ referral to other providers

Monitor and Evaluate

Total energy intake

Electrolyte and renal profile

Oral fluid amounts

Area and level of knowledge

Gastric Bypass Surgery

Common procedures for gastric surgery include the following:

Vagotomy, Gastric resection, and Pyloroplasty

Gastroduodenostomy (Billroth I), Gastrojejunostomy (Billroth II), and Roux-en-Y

Food & Nutrition-Related History

A complete nutrition assessment should address the following:

Anthropometrics and physical assessment

Biochemical and clinical parameters

Nutrition assessment should identify the following:

Ability to chew; use and fit of dentures

Ability to feed self

Ability to cook and prepare meals

Food allergies, preferences, or intolerances

Previous food restrictions

Ethnic, cultural, and religious influences

Use of alcohol and vitamin, mineral, herbal, or other type of supplements

Previous nutrition education or nutrition therapy

Laboratory Normal Range Adult Laboratory Normal Range Adult

Total iron-binding 250-460 mcg/dL Potassium

Nutrition-Focused Physical Related Findings

Intended/unintended Weight Loss

Acarbose, octreotide, prokinetic

Estimated Energy and Fluid Requirements

Inadequate oral intake (NI-2.1)

Intake of types of carbohydrate inconsistent with needs (specify) (NI5.8.3)

Inadequate vitamin intake (specify) (NI-5.9.1)

Food- and nutrition-related knowledge deficit (NB-1.1)

Promote optimal healing postoperatively.

o Ensure adequate energy and protein intake.

Prevent onset of early and late dumping syndromes.

o Consume liquids 30 minutes to 1 hour after consuming solid food.

o Lie down after eating.

Prevent development of nutrient deficiencies.

o Additional supplementation may be required to correct suboptimal levels of

Monitor and Evaluate

Inflammatory bowel disease (IBD) is an autoimmune, chronic inflammatory condition of the

Symptoms, Gastrointestinal involvement, Biopsy, and Antibody testing

Food & Nutrition-Related History

Food and Nutrient Intake

o Food intake (FH-1.2.2)

o Fluid and Beverage Intake (FH-1.2.1)

o Bioactive substance intake (FH-1.4)

o Alcohol intake (FH-1.4.1)

o Caffeine intake (FH-1.4.3)

o Macronutrient intake (FH-1.5)

o Protein intake (FH-1.5.2)

o Fiber intake (FH-1.5.4)

o Micronutrient intake (FH-1.6)

Meal-snack pattern (FH-1.2.2.3): 24-hour recall, food history, food frequency