Nutrition Case Study Presentation

It is crazy to think that my rotation is already wrapping up!  I have learned so much information and practical information that will help me to succeed as a dietitian and a health professional.  As a final evaluation of my performance as a dietetic intern I was responsible for identifying a patient to follow for a case study.  After conducting multiple nutrition assessments on my patient for the past few weeks I complied the information I learned into a presentation that I presented to all of the registered dietitians – about 10 of them.

<div style=”margin-bottom:5px”> <strong> <a href=”https://www.slideshare.net/wmthompson/nutrition-case-study&#8221; title=”Nutrition case study” target=”_blank”>Nutrition case study</a> </strong> from <strong><a href=”http://www.slideshare.net/wmthompson&#8221; target=”_blank”>Wendy Thompson</a></strong> </div>

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Nutrition Topic of the Week: Parenteral Nutrition

What is Parenteral Nutrition (or TPN)?

As you all know – everyone needs food/nourishment to live!  So… what happens when a person is unable to eat normally or tolerate a tube feeding or cannot get enough intake? That is were parenteral nutrition comes in.  Parenteral nutrition refers to feeding through the vein, or intravenous nutrition.  This is very different from enteral nutrition because it does not enter the digestion pathway.  Parenteral nutrition (PN) bypasses the normal digestion process (ingested food is broken down in the stomach and the intestines, absorbed in the bowel, and carried by the blood throughout the body).  PN in inserted directly into the blood stream via an IV catheter to the vein bypassing the digestive tract.  This is a sterile formula that is mixed in the pharmacy that contains water, amino acids, glucose, *lipids, vitamins and minerals and requires very close monitoring.  Note: it is very common for their to be a lipid (fat) shortage (or a different drug shortage) so at many facilities lipids are only give lipids on Monday, Wednesday, and Friday and in limited quantities.  Since parenteral nutrition may be someone’s only source of intake it is important that all essential nutrients are provided if PN will be used for a long duration. In addition to macronutrients, PN may also include electrolytes (sodium, potassium, chloride, phosphate, calcium, and magnesium) and trace elements (since, copper, manganese, and chromium).  There is currently a shortage on trace elements so they are typically not included unless the patients has been on PN for over 30 days.

Who May Need Parenteral Nutrition?

People of all ages may receive parenteral nutrition and the time may be relatively short or for as long as needed.  Patients may require PN for conditions or diseases that impair food intake, nutrition digestion or absorption. Common examples include: short bowel syndrome, GI fistulas, bowel obstruction, critically ill patients, severe acute pancreatitis, ulcerative colitis, or severe Crohn’s Disease.

How is Parenteral Nutrition Supplied?

An IV catheter (needle) is placed a large vein in either the arm, chest or neck. Common names for these catheters include: PICC, triple lumen, double lumen, single lumen catheter, and ports.  Parenteral nutrition can be supplied continuously over 24 hours or cyclically down to about 12 hours a day.  An infusion pump will control the rate at which the solution is supplied.  Total parenteral nutrition (TPN) will need to be administered through a central access vein such as the chest or the neck and can be supplied in higher concentration to meet the needs of a patient who is relying solely on TPN for nutrition.  Peripheral parenteral nutrition (PPN) is administered in lower concentrations and can be given through a peripheral vein such as through the arm and is mostly used for patients who are also consuming food through another source.  TPN lines will go through a major vein and end at the superior vena cava.

What are the Potential Complications of Parenteral Nutrition?

  • Infection – can be a common complication because of the chronic IV access point. If the infection is severe enough septic shock and death could ultimately occur.
  • Blood Clots – if a blood clot forms in the IV lines but breaks off and enters the lung then death can result from a pulmonary embolism. Patients on long term tube feeds typically receive a Heparin flush periodically to dissolve clots.
  • Liver Damage and Liver Failure – may appear as jaundice
  • Cholecystitis – inflammation of the gallbladder
  • Osteoporosis – bone disease
  • Refeeding Syndrome – characterized by hypokalemia, hypophosphatemia and hypomagnesemia (or low serum potassium, phosphate, and magnesium levels)
  • Hyperglycemia – high glucose levels, can be controlled with insulin

How is Parenteral Nutrition Monitored?

Depending on the facility, TPN will usually be monitored by a nutrition support care team that may include a physician, dietitian, pharmacist, and nursing staff. It is crucial to the patient’s safety that labs be monitored frequently in addition to monitoring weight status. The following labs should be closely monitored so that the order can change as needed:

  • CBC – Complete Blood Count
  • Electrolytes (Sodium, Potassium, Calcium, Phosphorus, Magnesium, Chloride, Bicarbonate)
  • BUN – Blood Urea Nitrogen
  • Glucose Levels
  • Albumin/Pre-Albumin
  • Triglycerides

 

TPN Formula - No Lipids

TPN Formula – No Lipids

TPN Formula with Lipids

TPN Formula with Lipids

PN Routes

PN Routes

References:

http://www.nutritioncare.org/wcontent.aspx?id=270

http://transplants.ucla.edu/body.cfm?id=70

http://www.merckmanuals.com/professional/nutritional_disorders/nutritional_support/total_parenteral_nutrition_tpn.html

Weight Loss Surgery and Lifestyle Changes

This past week I had the opportunity to spend time at a weight loss center, wound clinic, and also in medical telemetry and ICU. I am sure you all have heard of weight loss surgeries (more appropriately called bariatric surgeries) by now and while it may seem like a quick and easy fix… it is far from that.  Even though the majority of these surgeries are preformed laparoscopically, no surgery comes without some risk.  At this particular center the surgeons performed three different bariatric surgeries: Laparoscopic Adjustable Gastric Banding (LABG), Laparoscopic Sleeve Gastrectomy, and Roux-en-Y Gastric Bypass (RYGB).

Bariatric Infograph

 

What is the role of an RD when it comes to bariatric surgeries?

Bariatric surgeries all require a dramatic lifestyle change. Dietitians are responsible for conducting an initial nutritional screening to ensure that the client is suitable for surgery. If the patient is not willing to change their diet then they will not be allowed to undergo surgery due to the danger it could  cause. Dietitians are also used to explain and educate the patient on the bariatric diet prior to surgery and participate in follow-up appointments with patients as needed. Here is just a brief overview of some of the dietary changes one must undergo after surgery.

  • Advance diet as tolerated from clear liquids to puree/soft foods to solids post surgery – this typically takes at least one month.
  • Eat slowly – it should take 20-30 minutes to finish a meal!
  • Always sip liquids, NEVER chug! You should drink about 1 oz. every 15 minutes.
  • Chew slowly and thoroughly before swallowing
  • Avoid sugary foods to prevent “Dumping Syndrome”
  • Limit fat intake – fats slow the digestion process which can lead to nausea
  • REMEMBER the stomach can only hold a few tablespoons immediately after surgery and will eventually hold up to 0.5-1 cup so you will need to eat less
  • Drink at least 64 oz. fluid to prevent dehydration
  • Do not drink fluid with meals – stop drinking 30 minutes before eating and wait until 30 minutes after to drink again
  • Always eat your protein food first to make sure your protein intake is adequate
  • Tolerance of dairy (lactose) may be altered so substitute a lactose-free dairy if needed

What does a typical menu look like for the first month after surgery once you are discharged?

Breakfast – 8:00AM:

  • ¼ cup unsweetened applesauce
  • ¼ – ½ cup non fat cottage cheese

Supplement – 10:00AM:

  • ½ cup skim plus with 1 scoop of protein powder

Lunch – 12:00PM:

  • ¼ – ½ cup blended soup
  • ¼ cup tuna fish with low fat mayo

Snack – 2:00PM:

  • ½ cup sugar free yogurt
  • 1 sugar free popsicle

Dinner – 6:00PM:

  • 1-2 oz. flaked fish
  • ¼ cup puree vegetable

 

References:

http://www.nordbariatric.com/en/articles/infographics/different-wls-compared

http://www.mayoclinic.com/health/gastric-bypass-diet/my00827

Nutrition Topic of the Week: Enteral Nutrition

What is Enteral Nutrition?

As we all know, everyone needs food to survive.  In some cases, individuals are not able to intake any or enough food on their own.  One way to provide nourishment for these individuals is with “enteral nutrition” or more commonly known as “tube feedings.”  Another way to provide nourishment to individuals who cannot orally ingest food is through “parenteral nutrition,” which is providing nutrients through a vein directly into the blood stream.  These two methods are very different and as the saying goes, “use it – or lose it.” In this instance I am referring to the gut and digestive system – if the gut works, then use it!

Tube feeding formulas are in a liquid form that contains protein, carbohydrates, fats, vitamins and minerals.  They are many varieties of formulas to meet different needs and the dietitian performs a variety of calculations to determine which formula will be best for the patient. This formula is given through a tube and then normal digestion can occur in the stomach and intestines.

What Conditions Require Enteral Nutrition?

Any condition that alters a patients’ ability to swallow can lead to the implementation of enteral nutrition as long as the gastrointestinal (GI) system is still working.  Also, if a patient cannot take in adequate nutrition due to impaired nutrient ingestion, digestion, absorption, or metabolism then enteral nutrition can be used.  Common conditions include:

  • Neurological disorders
  • Facial/oral/esophageal trauma
  • Respiratory failure (the need for a ventilator)
  • Traumatic brain injuries
  • Cystic fibrosis
  • Dysphasia (common after a stroke)
  • Major burns, trauma, or wounds

What are the Considerations when Choosing a Formula?

  • Digestibility/availability of nutrients
  • Nutrition adequacy to meet needs
  • Osmolality (fluid needs)
  • Ease of use
  • Cost

What are the Different Formula Categories?

  • Standard – these contain nutrients that are intact (most often used)
  • Elemental – partially or completely hydrolyzed (broken down) nutrients
  • Disease specific – designed for a wide variety of disease states (renal, diabetes, etc.)
  • Modular – allows for the addition of nutrient content

How is the Tube Feeding Supplied?

There are multiple different placements options when considering a tube feed depending on the specific needs of each patient. The greater use of the GI system that can be tolerated by the patient is the route that is used in most cases.  Estimated length of time the feeding tube will be required helps to determine the route.  Another important factor is the risk of aspiration. If there is a high risk for aspiration then the patient will need the tube to continue past the pyloric sphincter.

Short Term (<3 weeks):

  • Orogastric – tube enters through the mouth and goes into the stomach
  • Nasogastric – tube enters through the nose and goes into the stomach
  • Nasoduodenal – tube enters through the nose and goes into the duodenum (first part of the small intestine)
  • Nasojejunal  – tube enters through the nose and goes into the jejunum (second part of the small intestine)

Long Term (>4-8 weeks):

  • Gastrostomy – tube enters directly through the skin into the stomach
  • Jejunostomy – tube enters directly through the skin into the jejunum (second part of the small intestine)

 Enteral Nutrition

What are the Delivery Methods of Enteral Nutrition?

Continuous:

  • Delivered at a continuous/steady rate that is controlled via a feeding pump
  • Most often used when feeding into the small bowel (intestine)
  • Preferred for critically ill patients and those unable to tolerate bolus or intermittent feedings

Bolus or Intermittent:

  • Bolus – last from a few minutes to 20 minutes and given via a syringe
  • Intermittent – last 20-60 minutes and given via a gravity drip
  • Preferred type of feeding for gastric routes (into the stomach) but not well tolerated in the intestine
  • Used for ambulatory patients and patients in their home
  • Fluid ranges between 240-480 mL

Cyclic or Nocturnal:

  • Used as a transition from enteral feedings to an oral (normal) diet
  • Rate can reach up to 150 mL/hour
  • Commonly used for patients in their home
  • They are infused continuously for 10-12 hours (typically overnight) to allow for greater oral intake during the day

What are the Complications of Enteral Nutrition?

While tube feeding is a generally safe option, there are potential risks associate with it.  For example, patients may experience abdominal discomfort, nausea, vomiting, abdominal distention, constipation, diarrhea, or aspiration.  There are ways to reduce this risk that health providers should always abide by.

References:

http://www.nutritioncare.org/wcontent.aspx?id=266

http://patients.gi.org/topics/enteral-and-parenteral-nutrition/

New Rotation – What Does a Clinical Dietitian Do?

This past week I started a new rotation.  This rotation will include the majority of my objectives from Medical Nutrition Therapy II and the Clinical Concentration.  I will be here for about six weeks and am excited to take on a new challenge and get more experience in the clinical setting.

There are a variety of hospitals in the area and many dietitians that I will get to work with over the next few months so that I can experience the greatest diversity in patients and conditions. This first week I primarily spent my time with surgical and neuro patients on the floors and in the intensive care unit (ICU).  Due to the severity of these patients’ conditions, many of these patients required tube feedings, which is also known as enteral nutrition – stay tuned for a post specifically about enteral nutrition! In the weeks to come I will have a chance to work with trauma, pediatrics, rehab, cardiac, behavioral medicine, weight loss, cystic fibrosis, diabetes, transplant, and even the wound clinic!

So before I get too far into this rotation I wanted to provide a little background so you can start to understand what exactly it is that a clinical dietitian does!  A clinical registered dietitian (RD) will typically have following responsibilities:

  • Identify patients at nutritional risk
  • Provide nutrition care using the Nutrition Care Process (see below)
  • Determines the nutritional needs and diet restrictions for patients
  • Plans therapeutic diets and implements preparation and service of meals for patients, which includes tube feedings, parenteral nutrition, and modified texture diets.
  • Instructs patients and their families on healthy eating and/or special diets
  • Participates in interdisciplinary discussions and meetings with other health care providers

What is the Nutrition Care Process?

The NCP is a systematic approach to providing quality nutrition-related care.  It is divided into four separated, but interrelated steps: assessment, diagnosis, intervention, monitoring/evaluation.

  • Nutrition Assessments – obtain, verify, and interpret data to identify nutrition-related problems, their causes, and their significance. Five main domains:
    • Food/Nutrition Related History:
      • Examples include:
        • Allergies, intolerance, special diets
        • How has the patient been eating?
        • Access to food
      • Anthropometric Measurements:
        • Examples include:
          • Height and Weight
          • Calculate BMI, Ideal Body Weight, Adjusted/Feeding Body Weight
          • Any weight changes?
          • NOTE: use this information to calculate calorie, protein, and fluid needs
      • Biochemical Data, Medical Tests, and Procedures:
        • Examples include:
          • Lab values, test results, surgeries
      • Nutrition-Focused Physical Findings:
        • Examples include:
          • Edema, skin breakdown, hair loss
      • Client History:
        • Examples include:
          • Previous health conditions
  • Nutrition Diagnosis – describe nutrition related problem using standardized language
    • Commonly referred to as a PES statements
      • Problem, Etiology, Signs and Symptoms
  • Nutrition Intervention – actions used to remedy a nutrition diagnosis/problem
    • Calculate tube feeding prescriptions
    • Calculate parenteral nutrition prescriptions
    • Recommend nutrition supplements to meet calorie/protein needs
    • Modify diet consistency or texture
    • Provide nutrition education or counseling
  • Nutrition Monitoring and Evaluation:
    • Follow the progress of nutrition goals by monitoring weight, labs, intake and/or diet tolerance.

 

Nutrition Care Process

Nutrition Care Process

 

What patients are seen by the dietitian?

Patients of nutrition risk are seen by the RD – This can be determined by:

  • Admitting diagnosis, condition, or chief complaints.  Common examples include:
    • Bowel Obstruction/Ileus
    • Burns
    • Cancer
    • Celiac Disease
    • Cirrhosis
    • Chronic Kidney Disease
    • Cystic Fibrosis
    • Diabetes, new onset
    • Dysphasia
    • Hepatic Encephalopathy
    • Malnutrition
    • Pancreatitis
    • Renal Failure
    • Renal Transplant
    • Spinal Cord or Traumatic Brain Injury
    • And many more…
  • NPO/Clear Liquid greater than 3 consecutive days
  • New tube feeding (enteral nutrition) orders
  • New parenteral nutrition orders
  • Specific lab values:
    • Low albumin (<2.5 mg/dL)
    • Low prealbumin (<16 mg/dL)
    • High blood glucose (≥200 mg/dL X 3 consecutive results)
    • NICU: Phosphorus (>600 U/L)
    • NICU: Bilirubin (<4.5 mg/dL)
    • NICU: Alkaline phosphatase (> 2 mg/dL)
  • Consults made by MD, RN, Pharm D, ancillary or patient’s family.
    • May include a request for: an assessment, visit, calorie count, tube feeing, parenteral nutrition, or education.

 

References:

http://www.eatright.org/HealthProfessionals/content.aspx?id=7077

http://andevidencelibrary.com/ncp/inc/circle.gif

West Virginia Diabetes Symposium – 2013

These past three days I have my time at the West Virginia Diabetes Symposium that was held in Morgantown, WV at the Waterfront Place Hotel.  This is an annual event that has been in existence for the past 13 years.  This year the conference was entitled “Bridging the Gap with Education.” This conference is attended by physicians, physician assistants, dietitians, nurses, and various other health professionals alike.

On the first day of the conference I attended two sessions:

  • “Diabetes Prevention in the Real World: The Group Lifestyle Balance Program” – Kaye Kramer, RN, DrPH, CCRC
  • “Role of Physical Activity in Diabetes” – Andrea Kriska, PhD

West Virginia has a fairly poor standing when it comes to national health measures. Below are a few statistics to give you a mental representation of the issues this state is facing:

  • 32.4% of the WV adults are obese = 3rd highest in the nation
  • 35.1% of WV adults participate in no leisure-time physical activity or exercise
  • 12% of WV adults have diabetes = 4th highest in the nation
  • 12.3% of WV adults have cardiovascular (heart) disease = 1st highest in the nation

As you can see, West Virginia has a multitude of issues that stem from the high obesity rates in the state.

Are familiar with diabetes? If not, here are few things you should know about diabetes:

  • There are a two main types of diabetes; Type 1 and Type 2.
  • Type 1 Diabetes only accounts for about 5% of all diabetes cases. It is typically diagnosed in childhood or early adulthood.  With Type 1, your body does not produce any insulin.
  • Type 2 Diabetes accounts for the remaining 95% of all diabetes cases.  It can be diagnosed at any time in life. With Type 2, your body produces insulin but your body does not respond to it like it should – this is called insulin resistance.

The lab criteria is the same for any type of diabetes in order to be diagnosed you must meet one of the following criteria:

  • Symptoms of diabetes AND casual plasma glucose of 200mg/dl or above
  • Fasting plasma glucose of 126mg/dl or above
  • 2-hr plasma glucose of 200mg/dl or above during an oral glucose tolerance test
  • Hemoglobin A1c greater than or equal to 6.5%

Exercise can be a huge contributor to overall health!  Remember exercise can be any form of physical activity that gets your body moving.  Exercise has been proven to have a positive impact on:

  • Coronary heart disease (CVD)
  • Cancer (certain types…e.g. colon and breast cancer)
  • Gallbladder disease
  • Bone health
  • Mental health
  • Osteoarthritis
  • Quality of Life/Independence
  • Weight management
  • DIABETES!

While diet will contribute more directly and quicker to one’s weight – it has been stated that one of the greatest predictors of who will keep the weight they lost from coming back is… EXERCISE!

One the second and third day of the conference, I attended the following sessions:

Thursday:

  • “Diabetic Retinopathy” – Muge Kesen, MD
  • “Type 2 Diabetes: A Cardiovascular Disease” – Joel Zonszein, MD, CDE, FACE, FACP
  • “Roles and Strategies of Diabetes Support Group Facilitators” – Joanne Costello, PhD, MPH, RN

Friday:

  • “How to Identify Type 1 versus Type 2 Diabetes, and is There Such a Thing as Type 1.5?” – Brian Ely, MD
  • “Pharmacological Management of Type 2 Diabetes Mellitus: Highlighting the Benefits and Limitations of Each Treatment” – Angel Kimble, PharmD, BCPS
  • “Developing Cultural Competence in Health Care Providers” – Pedro (Joe) Greer, Jr., MD, FACP, FACG

Diabetes wordcloud

References:

– American Diabetes Association, http://www.diabetes.org

– West Virginia Diabetes Symposium & Workshop, http://dsw.ext.wvu.edu/

Final Reflections on WVU Dining Services Rotation

After spending 5 weeks rotating with WVU dining services, working with the dietitian and food service staff, I have a much more complete view of the role of a food service dietitian and a greater appreciation for the work they do.  Over the past five weeks I have been able to: work with food service administration to design staff in-services, wellness programs, and plan employee schedules; work with production staff in multiple dining facilities to learn about cash operations, assist with food preparation, design production schedules, and assist with catering events; conduct temperature, quality, and waste studies; assist with the farmer’s market and hold a student forum to promote local foods; design new meals and put together week-long menus, conduct recipe and cost analysis; and design and conduct a process improvement project on portion control.  In addition to food service activities, I have managed to attend and conduct nutrition counseling sessions, assess body composition, create meal plans, lead and assist with grocery store and dining hall tours, speak with athletic teams, and observe the interactions between the strength and condition staff, athletic coaches and the sports dietitian.  These past five weeks have been busy with a wide variety of activities to ensure that I walk away from this experience fully prepared to tackle the food service industry as a registered dietitian.

My favorite part of the rotation was the week I spent with the sports dietitian.  I had never imagined that I would end up liking sports nutrition as much as I did.  I found it fascinating and very enjoyable to work closely with student athletes.  This was also my first experience with outpatient nutrition counseling and I enjoyed that very much and was surprised how naturally it flowed.  I learned a great deal from the dietitian and listening to her converse with athletes and from her feedback on my counseling skills. (See my previous blog post about this section here!)

I learned so much from each of these activities and how the entire process works together to seamlessly serve thousands of students each day.  I learned the importance of knowing job descriptions in order to be able to contact the correct individual with concerns or consultations. In such a large institution it can seem overwhelming to determine who does what but after my time spent here I realize that that aspect just takes time.  I feel confident in my abilities and my understanding of the role of a dietitian in a food service organization and I can see the need to refill the open position with WVU Dining Services as soon as possible.

I find it very interesting when you think about how many different allergies and diets the staff must accommodate here at Café Evansdale.  This is definitely a skill I need to refine prior to working in a food service establishment.  It is difficult to know exactly which items contain some of the not-so-common allergens.  Part of learning this would come with time and dealing with this on a regular basis and becoming familiar with the food that is served.  I am thankful for having this opportunity to complete this rotation and have learned a tremendous amount of information that has helped me understand food service on a larger scale.