ClinicalNutritionWorksheet_Youngman

Name: Yoko Youngman Clinical Nutrition Worksheet Instructions: Please complete this entire worksheet. For each question, you are expected to provide a reference for your answer unless otherwise noted. Reference should be cited in American Medical Association (AMA) format with the following options:  Full citation after each answer  Numbered list of references at the end of the worksheet. Provide the number to the specific reference on that list after each answer Medical Abbreviations and Terminology : In general, we consider it best practice to avoid using abbreviations in documentation. However, there are common abbreviations you will see regularly in medical charts. 1. What do the following common abbreviations mean? NKA No known allergies SOB Shortness of Breath p.o. By mouth dx Diagnosis BP Blood pressure DNR Do not resuscitate b.i.d., BID Twice a day t.i.d., TID Three times a day H.S., HS “Hora Somni” At bedtime p.r.n. As needed (“Pro renata”) CHF Congestive heart failure WNL Within normal limit COPD Chronic obstructive pulmonary diseas HTN Hypertension CRF Chronic renal failure CVA Cerebrovascular accident CAD Coronary artery disease MI Myocardial infarction CABG Coronary artery bypass grafting Hx History The Joint Commission has released an official “Do Not Use” list of abbreviations. We have included that list below. Do not use this Use this instead U, u unit IU International Unit Q.D., QD, q.d, qd daily Q.O.D., QOD, q.o.d, qod every other day Trailing zero 100.0mg or Lack of leading zero .1mg 100mg or 0.1mg MS, MSO 4 , MgSO 4 morphine sulfate or magnesium sulfate Reference for 1 : Merriam-Webster medical terms and abbreviations Page 1 of 15 Revised 9 June 2023

2. RECOMMENDED : Many of our graduates have recommended knowing medical terminology for clinical rotations and the RD exam. If you would like practice with medical terminology, we recommend you complete a free online medical terminology course. The course is free unless you want the certificate, which you don’t need. To access the course, go to: http://ww w .dmu.edu/medt e rms/ Please let us know if you took the free medical terminology course or not. You will not be scored on this course. We are colleting this information to see if there is a noticeable difference in clinical readiness between those that take the course and those who do not. _____ Yes, I took the medical terminology course __X__ No, I did not take the medical terminology course. (I took medical terminology in undergrad) Reference for 2 : No reference required for this question. Nutrition Assessment (Adults): 3. There are six characteristics typically used to determine adult malnutrition. List at least three of them below for full credit: i. Unintended weight loss ii. Low BMI iii. Reduced muscle mass Optional iv. Lack of subcutaneous fat Optional v. Fluid accumulation Optional vi. Diminished functional status Reference for 3 : ASPEN Clinical Guidelines: Nutrition screening, assessment, and interventions in adults Nutrition Focused Physical Exam A nutrition focused physical exam on a 73-year-old-female recently admitted to the hospital for weakness finds: Patient is alert but appears pale and tired. Her hair is thin, dry, and easily falls out when handled. Her face is notable for dark circles under both eyes, narrow facial appearance, and temporal muscle depression. Her eyes appear normal. Patient’s oral exam is notable for dry oral mucosa and angular stomatitis. She has good dentition with no missing teeth and normal tongue. She has evident clavicular muscle wasting. Her biceps reveal muscle wasting and triceps demonstrate subcutaneous fat loss with loose and slightly hanging arm skin. Rib fat loss is evident. Patient’s skin is dry with poor skin turgor. No wounds are evident. Abdominal exam is unremarkable. No lower extremity or pedal edema is evident. Nails are thin with slow capillary refill. Interosseous muscle is mildly wasted. 4. Based on the findings, what are your nutrition concerns for the patient?  Malnutrition and Weight Loss: The patient's overall appearance of weakness, muscle wasting, and subcutaneous fat loss in various areas of the body indicate that she may be experiencing malnutrition and significant weight loss. The muscle wasting and fat loss suggest a possible deficiency in essential nutrients, such as protein and calories.  Vitamin and Mineral Deficiencies: The presence of angular stomatitis (inflammation and cracking Page 2 of 15 Revised 9 June 2023

Creatinine 0.2 (0.4-1.3 mg/dL) 6. Is the patient at risk for refeeding syndrome? Explain why or why not. Yes, the patient is at risk for refeeding syndrome. Several factors contribute to the patient's risk for refeeding syndrome: 1. History of significant weight loss: The patient has experienced weight loss and reduced oral intake for a month prior to admission. This period of undernutrition puts him at risk for refeeding syndrome. 2. Limited oral intake prior to admission : The patient had minimal intake for 4 days prior to admission. This period of fasting can deplete the body's stores of essential nutrients, including electrolytes and minerals. 3. Low serum electrolyte levels : The patient's biochemical data show low levels of potassium, phosphorus, and magnesium. These electrolytes are essential for various physiological processes and can become depleted during prolonged periods of undernutrition. 4. NPO status: The patient has been kept NPO (nothing by mouth) since admission until hospital day 3. This sudden reintroduction of nutrition after a period of fasting increases the risk of electrolyte shifts and imbalances. Reference for 6 : Kane K, Prelack K. Advanced Medical Nutrition Therapy . Burlington, MA: Jones & Bartlett Learning; 2019:360-363. 7. What biochemical indices should be monitored with refeeding syndrome?  Electrolytes: o Potassium: Refeeding can lead to shifts in potassium levels, which is critical for proper heart and muscle function. o Phosphorus: Low phosphorus levels are associated with refeeding syndrome and can lead to muscle weakness, respiratory failure, and cardiac complications. o Magnesium: Magnesium plays a role in many enzymatic reactions, and its levels can be affected during refeeding.  Glucose: Monitoring blood glucose levels is important, as insulin release in response to carbohydrate intake can lead to hypoglycemia (low blood sugar) in individuals with depleted glycogen stores.  Thiamine (Vitamin B1): Thiamine deficiency can result from rapid carbohydrate refeeding, especially in individuals with malnutrition. Thiamine is essential for energy metabolism and neurological function.  Other vitamins and minerals: Monitoring levels of vitamins and minerals such as vitamin B12, folate, and vitamin D is important to address potential deficiencies and support overall health.  Fluid balance: Monitoring fluid intake and output is crucial to prevent fluid overload, especially in individuals with compromised kidney function  Renal function: Monitoring serum creatinine and blood urea nitrogen (BUN) levels helps assess renal function, as refeeding can increase the workload on the kidneys.  Cardiac Markers: Electrolyte imbalances can impact cardiac function. Monitoring cardiac markers such as troponin levels helps detect potential cardiac complications. Reference for 7 : Kane K, Prelack K. Advanced Medical Nutrition Therapy . Burlington, MA: Jones & Bartlett Learning; 2019:360-363. Page 4 of 15 Revised 9 June 2023

Using the Pocket Guide for Clinical Nutrition: 8. Please list the appendix (letter, name, and starting page number) in the clinical nutrition pocket guide that you can use to help with biochemical assessment. Appendix A: Laboratory Assessment. Starts page 387. Reference for 8 : No reference required for this question. 9. According to this appendix, what is the reference range for Sodium (Na)? 136-145 mEq/L or 136-145 mmol/L. (Critical values: <120 or >160 mEq/L) Reference for 9 : No reference required for this question. 10. Please list the appendix (letter, name, and starting page number) in the clinical nutrition pocket guide that you can use to help with assessment of potential side effects and nutrition implications of various prescribed drugs your patients could be taking. Appendix B: Food-drug Interactions. Starts page 407. Reference for 10 : No reference required for this question. 11. According to this appendix, what is a dietary recommendation you could make to a patient on Lisinopril for hypertension? Caution with foods high in potassium or potassium supplements. Avoid salt substitutes. Maintain adequate hydration. Reference for 11 : No reference required for this question. 12. Please list the appendix (letter, name, and starting page number) in the clinical nutrition pocket guide that you can use to learn more about the supplements your patient may be taking and possible adverse effects or drug interactions with those supplements. Appendix C: Vitamins, Minerals, and Dietary Supplements Facts. Starts page 455. Reference for 12 : No reference required for this question. 13. Turmeric is a supplement commonly taken to reduce inflammation. According to this appendix, what are the potential drug interactions associated with turmeric? Anticoagulants, antacids, diabetic medications. Reference for 13 : No reference required for this question. Nutrition Support: 14. Please list at least three indications for enteral nutrition. i. Malnourished patient expected to be unable to eat for >5 to 7 days ii. Functional or partially functional gut iii. Following severe trauma or burns Page 5 of 15 Revised 9 June 2023

Disease States: Diabetes Mellitus 20. What are the differences in pathophysiology between Type 1, Type 2, and Gestational Diabetes? Type 1 results from autoimmune destruction of pancreatic beta cells leading to absolute insulin deficiency. Type 2 results from progressive insulin secretory defect on the background of insulin resistance GDM is diagnosed in 2 nd of 3 rd trimester of pregnancy and no DM present prior to gestation. Reference for 20 : Page 248 Table 9.1 in Pocket Guide. 21. According to the American Diabetes Association and your MNT text, what are the four diagnostic criteria for diagnosing diabetes: i. Fasting plasma glucose >= 126 mEq/dL ii. A1C >= 6.5% iii. 2 hour plasma glucose in the OGTT >= 200 mg/dL iv. Classic symptoms of diabetes (polyuria, polydipsia, unexplained weight loss) and a random plasma glucose >= 200 mEq/dL Reference for 21 : Pocket Guide page 251 Box 9.4 The best meal plan for a particular person is the one that they are willing to use. The meal plan should be adjusted to fit the individual's preferences and lifestyle and not the other way around. A variety of meal planning methods exists for patients with diabetes. Please describe each of the following meal plans and explain the type of patient you would suggest each plan for. 22. Exchange method: System that separates food, with an emphasis on the source of CHO, into six categories based on their macronutrient content. Depending on the energy level, an exchange pattern consists of a set number of exchanges from each group. Within each list, foods can be exchanged, but the serving size may vary. This method is good for patients who self manage blood glucose to help keep their DM under control. Fine for Type 1 or Type 2. The exchange method is also particularly useful for those planning weight loss. Reference for 22 : Pocket Guide page 254. 23. Basic carbohydrate counting: A meal planning approach for people with type 1 or type 2 diabetes that focuses on balancing CHO food choices throughout the day. Emphasizes total amount of CHO consumed, rather than the source. Promotes consistency in the timing and amount of CHO intake. This is the preferred monitoring method for practitioners/dietitians, and it is good for patients who self-manage their blood glucose to learn about the relationship among foods, physical activity, DM medications, and blood glucose levels. Reference for 23 : Pocket Guide, page 254. Page 7 of 15 Revised 9 June 2023

24. What are the medical nutrition therapy recommendations for persons with diabetes according to the Evidence Analysis Library (https://www.andeal.org/)? Individualized Nutrition Prescription, healthful eating plan and goal of weight maintenance and prevention of weight gain, wt loss for overweight or obese adults, individualized macronutrient consumption, carbohydrate management, insulin dosage education, nutrition education, glucose monitoring education, and glycemia index and glycemic load education. Reduced sodium intake recommended and physical activity encouraged. Reference for 24 : EAL DM: Executive Summary of Recommendations (2015) 25. The American Diabetes Association recognizes blood glucose levels below what level as consistent with hypoglycemia in those with diabetes? a. 50 mg/dL b. 70 mg/dL c. 126 mg/dl d. 200 mg/dl Reference for 25 : 26. The use of the "15/15" rule is recommended in clinical practice as management of hypoglycemia. Please describe what the "15/15" rule is. 1. Check blood glucose. If BG is 50-69 mg/dL, give 15 grams of CHO. If BG is <50, give 30 g CHO. 2. Wait 15 minutes and recheck BG. If BG <70, repeat step 1. Reference for 26 : Page 270 Box 9.8 in Pocket Guide. Guideline to manage mild hypoglycemia. 27. Fill out the following information related to insulin action times: Category Insulin Names Start Time Peak Time Duration Rapid Humalog, Novolog, Apidra 5-15 min 30-90 min 3-5 hr Short-acting Humulin R, Novolin R 30-60 min 2-4 hr 5-8 hr Intermediate acting Humulin N, Novolin N 1-3 hr 6-10 hr 12-16 hr Long acting Lantus, Basaglar, Levemir 1 hr No peak Up to 24 hr. Reference for 27 : Pocket Guide pg 262 Table 9.5 28. Long-term metformin use can lead to a deficiency of which micronutrient? Vitamin B12 Reference for 28 : Drugs.com Nutrient Interactions. Cardiovascular disease Page 8 of 15 Revised 9 June 2023

i. Fluid recommendations for HF: 500-1000 cc depending on severity of HF ii. Sodium recommendations for HF: Sodium restriction <1,000 mg/day if severe or 2,000-3,000 mg if less severe. Reference for 32 : Pocket Guide, page 235. Gastrointestinal Disease 33. Define the following signs of maldigestion/malabsorption: i. steatorrhea: Greasy, foul-smelling diarrhea which indicates undigested fat excretion in the stool. ii. glossitis: Beefy red tongue, magenta color. May indicate folate, niacin, riboflavin, iron, vitamin B6 and or/vitamin B12 deficiencies and/or may be associated with protein-calorie malnutrition. iii. cheilosis: Dry, swollen, or ulcerated lips. May indicate riboflavin, vitamin B6, niacin, or severe iron deficiency. iv. stomatitis: General inflammation of oral mucosa. May indicate B-complex, iron, or vitamin C deficiency. v. ascites: Abnormal accumulation of fluid in the abdominal cavity. vi. cachexia: A severe condition characterized by significant weight loss, muscle atrophy, and overall weakness. vii. edema: Abnormal accumulation of fluid within the body's tissues, resulting in swelling Reference for 33 : Kane K, Prelack K. Advanced Medical Nutrition Therapy . Burlington, MA: Jones & Bartlett Learning; 2019:360-363. 34. Dumping syndrome is one of the most common complications post gastric surgery and is also one of the most intrusive. Describe the differences between early and late dumping syndrome and provide nutrition recommendations often used to manage this symptom. i. Early dumping syndrome: Occurs 30-60 minutes after consumption and is caused by rapid food movement from the stomach, followed by a surplus of fluid from the bloodstream into the small intestine. Symptoms of early dumping syndrome include abdominal cramping, severe diarrhea, nausea or vomiting, and a rapid heartbeat. ii. Late dumping syndrome: occurs 1 to 3 hours after ingestion and is caused by rapid movement of sugar into the small intestine, raising the body’s blood glucose levels and increasing the release of insulin from the pancreas. The rapid release of insulin levels causes blood glucose levels to drop, resulting in hypoglycemia. Symptoms of the late dumping syndrome include fatigue, sweating, dizziness, shakiness, fainting, and rapid heartbeat. iii. Nutrition management of dumping syndrome: The dietary measures recommended for patients with dumping syndrome include delaying the intake of any liquids until 30 minutes after the meal, consuming six small meals per day, and eliminating rapidly absorbed carbohydrates from the diet. Patients are also advised to lie down for 30 minutes after the meal to delay gastric emptying and symptoms of dumping syndrome.54 The patient should follow these dietary recommendations for 3 to 4 weeks, and weekly monitoring should be made by a PCP or registered dietitian (RD). If dumping syndrome symptoms do not improve, various surgical procedures or alternate forms of therapy should be considered. Page 10 of 15 Revised 9 June 2023

Reference for 34 : Kane K, Prelack K. Advanced Medical Nutrition Therapy . Burlington, MA: Jones & Bartlett Learning; 2019:360-363. 35. The two major forms of Inflammatory Bowel Disease (IBD) are ulcerative colitis (UC) and Crohn's disease. Which of the two conditions generally has more drastic nutrition implications and why? Hint: consider the location of each disease. Crohn’s disease has more drastic nutrition implications because unlike UC which only the mucosa and submucosa are affected and is limited to the colon and never involves the small intestine, CD can strike anywhere in the GI tract and all intestinal tissue layers may be affected. Because the small intestine is involved, there are more nutrients that may be malabsorbed. Reference for 35 : Pocket Guide, page 292. 36. List three changes to digestion and absorption after an ileostomy. The removal of a portion of the small intestine means that the digestive process is expedited. The remaining small intestine has less surface area for digestion and absorption. As a result, the transit time of food through the digestive system is significantly reduced. This can lead to decreased absorption of nutrients, water, and electrolytes from the ingested food. An ileostomy produces a watery stool, making postsurgical adjustment more of a challenge. It often causes fat malabsorption because bile is not reabsorbed, resulting in malabsorption of fat-soluble vitamins, which necessitates supplementation. Impaired nutrient utilization. Deficiency of vitamin B12 is also common, as absorption of vitamin occurs in the terminal ileum. It also causes excessive fluid losses along with electrolytes, making dehydration a concern as well as electrolyte imbalance. Obstruction is a possible complication, so thorough mastication of foods is important. Reference for 36 : Pocket Guide page 301. Renal Disease 37. A patient you have been working with has worsening Chronic Kidney Disease (CKD). His most recent labs show an eGFR of 20 mL/min/1.73m2. What stage of CKD is your patient in? How would you describe his kidney function? He is in stage 4 CKD (eGFR 15-29). He has severely reduced kidney function, about 15-29%. Reference for 37 : Kane K, Prelack K. Advanced Medical Nutrition Therapy . Burlington, MA: Jones & Bartlett Learning; 2019:360-363. 38. According to the National Kidney Foundations national guidelines, KDOQI, what are protein requirements for adults with Stage 1-4 CKD and adults with Stage 5 CKD on hemodialysis?  Stage 1: 0.8-1.0 g/kg/day  Stage 2: 0.8-1.0 g/kg/day Page 11 of 15 Revised 9 June 2023

the time that ammonia spends in the colon. This limits the opportunity for ammonia to be reabsorbed into the bloodstream. Reference for 41 : Kane K, Prelack K. Advanced Medical Nutrition Therapy . Burlington, MA: Jones & Bartlett Learning; 2019:360-363. Pg 474. Lung Disease 42. List two common causes of respiratory acidosis and explain what the kidneys do to compensate. Respiratory acidosis is a disorder characterized by low pH, high PaCO2, and a variable increase in plasma HCO3- concentration. This disorder is most commonly caused by decreased effective alveolar ventilation and not an increase in carbon dioxide production. When there is interference in the ventilation at any step, hypoventilation can occur. The most common causes include central nervous system depression, neuromuscular disorders, chronic obstructive pulmonary disease, and interstitial pulmonary disease. Hypoventilation is a common cause of respiratory acidosis. It occurs when an individual breathes too slowly or shallowly, leading to inadequate elimination of CO2 from the lungs. --Kidney compensation: The kidneys respond to respiratory acidosis by increasing the excretion of bicarbonate (HCO3-) in the urine. This helps to reduce the amount of bicarbonate in the blood, acting as a buffer to counteract the acidic shift caused by elevated CO2 levels. This compensatory mechanism assists in stabilizing blood pH and mitigating the effects of respiratory acidosis. Chronic Obstructive Pulmonary Disease (COPD): COPD is a common respiratory condition characterized by obstructed airflow in the lungs. In COPD, the ability to exhale air is compromised, leading to the retention of CO2 and respiratory acidosis. --Kidney Compensation: The kidneys respond by increasing the excretion of HCO3- in the urine, similar to the previous scenario. By doing so, the kidneys help to lower the bicarbonate concentration in the blood, counteracting the acidic state resulting from the elevated CO2 levels. Reference for 42 : Kane K, Prelack K. Advanced Medical Nutrition Therapy . Burlington, MA: Jones & Bartlett Learning; 2019:360-363. 43. List two common causes of respiratory alkalosis and explain what the kidneys do to compensate. Respiratory alkalosis is a condition characterized by a decrease in the level of carbon dioxide (CO2) in the bloodstream, leading to an increase in blood pH and a shift towards alkalinity. This can occur when the body exhales more CO2 than it produces, often due to hyperventilation. Hyperventilation is a common cause of respiratory alkalosis. It occurs when an individual breathes rapidly and shallowly, leading to excessive elimination of CO2 from the lungs. Kidney Compensation: The kidneys respond to respiratory alkalosis by excreting less bicarbonate (HCO3-) in the urine. This helps to retain bicarbonate in the blood, which can act as a buffer to counteract the alkaline shift caused by reduced CO2 levels. This compensatory mechanism helps to stabilize blood pH and mitigate the effects of respiratory alkalosis. Page 13 of 15 Revised 9 June 2023

Anxiety and panic disorders: Emotional stress, anxiety, and panic disorders can trigger rapid and shallow breathing, leading to hyperventilation and respiratory alkalosis. Kidney Compensation: Similar to the previous scenario, the kidneys respond by conserving bicarbonate. By reducing the excretion of bicarbonate in the urine, the kidneys help maintain a more balanced blood pH despite the respiratory alkalosis. Reference for 43 : Kane K, Prelack K. Advanced Medical Nutrition Therapy . Burlington, MA: Jones & Bartlett Learning; 2019:360-363. Cancer 44. Provide at least one nutrition or related recommendation for each of the following side-effects of cancer treatment that a patient could use to better meet their nutrition goals: i. xerostomia (dry mount): Sip water throughout the day to keep the mouth moist. Use sugar-free gum or candies to stimulate saliva production. Avoid spicy, salty, and acidic foods that can further irritate the mouth. Opt for moist and soft foods, soups, and stews that are easier to swallow. ii. mucositis: Choose soft and easy-to-swallow foods that don't require much chewing. Avoid spicy, acidic, and rough-textured foods that can irritate the mouth. Rinse the mouth with a gentle saltwater solution after meals to help alleviate discomfort. Opt for nutrient-rich smoothies, yogurt, and pureed foods to maintain calorie and nutrient intake. iii. dysgeusia (taste changes): Experiment with different flavors and seasonings to find what is more appealing. Choose foods with stronger flavors, such as herbs, spices, and marinades, to enhance taste. Opt for cold or room temperature foods, as they might be more palatable. Focus on foods that are enjoyable and comforting, even if they are different from your usual preferences. iv. nausea: Eat small, frequent meals throughout the day to avoid an empty stomach. Choose bland and easily digestible foods like crackers, plain rice, or bananas. Avoid strong odors and cooking smells that can trigger nausea. Stay hydrated by sipping clear fluids such as water, herbal tea, or clear broth. v. diarrhea: Consume foods that are easy on the stomach, such as plain rice, applesauce, and toast (BRAT diet). Stay hydrated by drinking clear fluids like water, herbal tea, and diluted fruit juices. Limit high-fiber foods, fatty foods, caffeine, and dairy products, which can exacerbate diarrhea. vi. constipation: Include high-fiber foods in your diet, such as whole grains, fruits, vegetables, and legumes. Stay well-hydrated by drinking plenty of water throughout the day. Reference for 44 : Kane K, Prelack K. Advanced Medical Nutrition Therapy . Burlington, MA: Jones & Bartlett Learning; 2019:360-363. 45. Which group of cancer patients have the highest risk for malnutrition compared to other types of cancer? a. Breast cancer b. Lung cancer c. Head and neck cancer d. Hematologic cancer Patients with head and neck cancer typically have the highest risk for malnutrition compared to other Page 14 of 15 Revised 9 June 2023