Stephanie Logosh

Explain the reason for the laboratory tests listed below. Describe how these lab tests will assist
with a nutritional assessment. Identify which lab tests are affected by a change in hydration
status.
Lab Test and Values:
1. Albumin (normal adult level: 3.5-5 g/dL or 35-50 g/L) blood, urine
Albumin is a laboratory test to determine a measure of hepatic function. Albumin is synthesized in the
liver by hepatocytes; when the liver is compromised by disease, hepatocytes cannot properly produce
albumin thus a patients serum albumin level will be decreased. Because albumin composes
approximately 60% of total protein, it is also a measure of nutritional status. Burn patients,
malnourished patients, and patients with protein malabsorption issues will show low serum albumin
levels. An albumin blood or urine test assists with a nutritional assessment by identifying protein
status. May be elevated or reduced in response to dehydration. 21 day half-life

2. Transferrin (normal adult male level: 215-365 mg/dL or 2.15-3.65 g/L; normal adult female
level: 250-380 mg/dL or 2.50-3.80 g/L) blood
Transferrin is used as a lab test to measure iron. Iron is bound to transferrin and so when iron stores
are low, transferrin levels increase and vice versa. Other proteins are also available to bind mobile
iron however, transferrin represents the most available iron-binding protein. Transferrin, which is
produced by the liver, is a negative acute-phase reactant protein- during acute inflammatory reactions,
transferrin will lower. Transferrin is also low when a patient has a chronic illness such as liver
disease. Hypoproteinemia also may also reduce transferrin levels. Increased transferrin lab findings
may be due to oral contraceptives, iron deficiency anemia, or polycythemia vera. Will be elevated or
reduced in response to dehydration.

3. Pre-Albumin (normal adult level: 15-36 mg/dL or 150-360 mg/L) blood, CSF, 24 hr urine
Pre-albumin is used as a marker of nutritional status since this major plasma protein has a short halflife of 1.9 days. With the short half-life, prealbumin levels can show changes affecting protein
synthesis and catabolism. Thus, it is useful when monitoring patients on TPN. It is also used to
indicate protein-wasting diseases of intestines or kidneys, malnutrition, and inflammation

4. Serum Creatinine (normal adult female level: 0.5-1.1 mg/dL or 44-97 umol/L; normal adult
male level: 0.6-1.2 mg/dL or 53-106 umol/L) blood
Serum creatinine is a marker of renal function. Creatinine is excreted by the kidneys and is produced
in levels dependent upon muscle mass. Serum creatinine level should remain constant and normal in
patients with healthy renal excretory function. Dehydration and renal disorders such as
glomerulonephritis, pyelonephritis, acute tubular necrosis, and urinary obstruction will result in an
increased serum creatinine level. A creatinine test is used as an approximation of glomerular filtration
rate. Generally, double the amount of normal creatinine indicates a 50% reduction in GFR. If serum
creatinine is low, it may help nutritional assessment by reflecting decreased muscle mass. Will be
elevated in response to dehydration.

5. Blood Urea Nitrogen (normal adult level: 10-20 mg/dL or 3.6-7.1 mmol/L) blood
BUN is a measure of metabolic function of the liver and excretory function of the kidney. Together
with serum creatinine, BUN make up the renal function studies. BUN/creatinine ratio 6-25 for healthy
adults; the optimal adult value is 15.5. Specifically, BUN measures the amount of urea nitrogen in the
blood made from ammonia deposited by the liver. Patients with elevated levels of BUN have

azotemia. Generally all renal diseases cause blood concentration of urea to rise above normal. Other
conditions cause elevated BUN as well such as GI bleeding or excessive consumption of protein.
Hydration status affects BUN levels. BUN is elevated in dehydration and reduced in overhydration.
Patients with severe liver disease also decreases BUN status. Patients with both renal and liver
disease may falsely show a normal BUN because poor hepatic functioning has resulted in decreased
formation of urea. Other examples causing reduced BUN may be due to negative nitrogen balance,
pregnancy, and nephrotic syndrome. Examples causing elevated BUN may be due to CHF, GI
bleeding, starvation, and sepsis. Will be elevated in response to dehydration.

6. Serum Uric Acid (normal adult male level: 4.0-8.5 mg/dL or 0.24-0.51 mmol/L; normal adult
female level: 2.7-7.3 mg/dL or 0.16-0.43 mmol/L) blood urine
The product of purine catabolism, uric acid is excreted mostly by the kidney and to some extent by
the intestinal tract. Often when a patient has hyeruricemia, the patient has gout with a serum urate
measurement > 6.8mg/dL (exceeding the physical saturation threshold). With gout, monosodium
urate crystals may form and be deposited in joints and soft tissues. The overproduction or decreased
excretion of uric acid which causes hyperuricemia may be due to kidney failure, alcoholism,
leukemia, metastatic cancer, hyperlipoporoteinemia, DM, stress, lead poisoning, and dehydration.
Elevated uric acid in the urine, uricosuria, depends on uric acid levels in the blood, GFR, and tubular
secretion of uric acid into the urine. As the urine pH rises, more uric acid can exist without
crystallization and stone formation.

7. Leukocytes (normal adult level: 5000-10000/mm3 or 5-10x109 /L) blood

Leukocytes (WBC) are measured in two ways. First with total count of WBCs in 1 mm3 of peripheral
venous blood. Second with differential count of the percentage of each type of leukocyte present in
the same specimen. There are five major types of leukocytes- neutrophils, lymphocytes, monocytes,
eosinophils, and basophils. These are categorized as either granulocytes or nongranuolcytes.
Granulocytes include neutrophils, basophils, and eosinophils. Nongranulocytes (mononuclear cells)
include lymphocytes, monocytes, and histiocytes. The function of WBC is to fight infection and react
against foreign bodies or tissues. Increased total WBC count (>10000) usually indicates infection,
inflammation, tissue necrosis, or leukemic neoplasia. Trauma and emotional or physical stress can
also elevate total WBC. Leukopenia, WBC <4000, is caused by forms of bone marrow failure such as
infections, dietary deficiencies, and autoimmune diseases.
WBC
Neutrophil (G)

% in mm3
55-70

Absolute per mm3

2500-8000

Lymphocyte (NG)

20-40

1000-4000

Monocytes (NG)

2-8

100-750

Basophils aka mast

cells
eosinophils(G)

Eosinophils
1-4
Basophils
0.5-1

50-500
25-100

Function
Produced in 7-14 days, in circulation for 6 hours;
phagocytosis of bacterial microorganisms
T cells: cellular-type immune reactions; B-cells:
humoral immunity (antibody production); fight
chronic bacterial and acute viral infections
Fight bacteria in way similar to that of neutrophils;
produced rapidly, spend longer time in circulation
Involved in allergic reaction; phagocytosis of
antigen-antibody complexes; do not respond to
bacterial or viral infections

8. Cholesterol (normal adult level: <200 mg/dL or <5.20 mmol/L) blood

Cholesterol laboratory tests are part of a patients lipid profile. Specifically, LDL, HDL, and VLDL
lipoproteins are tested, as well as triglycerides, for a lipid profile. Cholesterol testing is done to
identify patients at risk for arteriosclerotic heart disease. While high cholesterol is associated with
patients at increased risk of coronary heart disease, low cholesterol test results is associated with

malnutrition and severe liver diseases. This is because the liver is required to make cholesterol so low
levels indicate a problem. Furthermore, diet is the main source of cholesterol so malnourished
patients will show low levels.

9. Triglycerides (normal adult male level: 40-160 mg/dL or 0.45-1.81 mmol/L; normal adult
female level 35-135 mg/dL or 0.40-1.52 mmol/L) blood
TGs is a form of fat transported in the bloodstream by VLDL or LDL. It is part of the lipid profile
that elevates cholesterol. TGs are produced in the liver. The level of TGs is increased after ingestion
of fatty meals and alcohol, pregnancy, glycogen storage disease, hyperlipidemia, hypothyroidism,
high CHO diet, poorly controlled DM, risk of arteriosclerosis, HTN, MI, and nephrotic syndrome.
The level of TGs is decreased during malnutrition, malabsorption syndrome, and hyperthyroidism.

10. Glucose (normal adult level: 74-106 mg/dL or 4.1-5.9 mmol/L) blood
Levels of glucose in the blood are controlled by hormones insulin and glucagon. In the fasting state,
glucose levels are low so glucagon is excreted to raise glucose. In the fed state, glucose levels are
high so insulin is secreted to drive glucose into cells to be metabolized to glycogen, aa, and FA.
Serum glucose levels fluctuate by the time of day they are taken; for example, levels will be high if
taken right after a meal. True glucose elevations indicate DM but hyperglycemia is also caused by
acute stress response, cushing syndrome, chronic renal failure, acute pancreatitis, and diuretic
therapy. Hypoglycemia, on the other hand, may be caused by insulinoma, hypothyroidism, extensive
liver disease, and starvation.

11. Hemoglobin (normal adult male level: 14-18 g/dL or 8.7-11.2 mmol/L; normal adult female
level: 12-16 g/dL or 7.4-9.9 mmol/L) blood
Hgb in peripheral blood reflects the number of RBCs in blood. Hgb test is part of a complete blood
count. Hgb also serves as a vehicle for oxygen and carbon dioxide transport. Reduced levels of Hgb
indicate anemia, hemorrhage, hemolysis, nutritional deficiency, lymphoma, systemic lupus
erythematosus, kidney disease, splenomegaly, and neoplasia. Elevated levels of Hgb indicate
congenital heart disease, chronic obstructive pulmonary disease, CHF, high altitudes, severe burns,
and dehydration. Will be elevated in response to dehydration.

12. Hematocrit (normal adult male level: 42-52% or 0.42-0.52 volume fraction; normal adult
female level: 37-47% or 0.37-0.47 volume fraction) blood
Hct is the measure of the percentage of total blood volume that is made up by RBCs. The ratio of the
height of the RBC column compared with the original total blood column after centrifugation is
multiplied by 100%-- this is Hct. Hct in percentage points usually is about three times the Hgb
concentration in g/dL when RBCs are of normal size and contain normal amounts of Hgb. Decreased
HCT indicates anemia, cirrhosis, hemorrhage, dietary deficiency, bone marrow failure, pregnancy,
leukemia, renal disease, lymphoma, and Hodgkin disease. Increased HCT indicates congenital heart
disease, polycythemia vera, erythrocytosis, eclampsia, burns, severe dehydration, and COPD.
Hemodilution and dehydration may affect Hct levels. Will be elevated in response to dehydration.

13. Schillings Test: determines whether B12 is absorbed normally

Schillings test evaluates B12 absorption in four different stages to find the cause of a
decreased vitamin B12 level. The test also evaluates pernicious anemia. In stage I, a patient is
given cobalamin by mouth. In stage II, radioactive B12 is given along with intrinsic factor;
this can determine whether absorption problems are happening in the stomach. Stage III tests
whether abnormal bacterial growth has caused the poor absorption; in this stage, a patient is
given antibiotics for two weeks. Stage IV evaluates the pancreas and whether this is the cause

of the problem; the patient is given pancreatic enzymes for three days and then a radioactive
dose of vitamin B12. Considerations: patients cannot eat 8 hours before the test. Urinating 840% of radioactive B12 within 24 hr is normal result
14. Urinary Ketones (normal: negative) urine
Normally no ketones are in the urine. Kteones are the end product of fatty acid catabolism. Ketones
will spill over into the urine if blood levels of ketones in a patient with DM are elevated (as with
glucose). The excess production of ketones in urine is usually associated with poorly controlled DM.
This part of a urinalysis is important to evaluate ketoacidosis associated with alcoholism, fasting,
starvation, high PRO diets, and isopropanol ingestion. Ketonuria may also occur with acute febrile
illnesses, esp. in infants and children, dehydration, anorexia nervosa, prolonged vomiting, and
excessive aspirin ingestion.

15. Urinary Glucose (normal: negative in fresh specimen, 50-300 mg/d or 0.3-1.7 mmol/d in 24
hr specimen) urine
Glucose in the urine tests for DM or other causes of glucose intolerance. Usually glucose is filtered
from the blood by the glomeruli of the kidney and then all of it is resorbed in the proximal renal
tubules. However, when blood glucose exceeds the capability of the renal threshold to resorb glucose
(>180 mg/dL), glycosuria occurs. Glucosuria can be seen in patients with DM, pregnancy, renal
glycosuria, and hereditary defects in metabolism of reducing substances such as galactose, fructose,
and pentose.

16. Urinary Proteins (normal: 0-8 mg/dL, 50-80 mg/24 hr at rest, <250 mg/24 hr exercise) Urine
Part of a urinalysis. Abnormalities detected by urinalysis may reflect either UTI (ex. Infection, loss of
concentrating capacity) or extrarenal disease processes (glucosuria in DM< proteinuria in monoclonal
gammopathies, bilirubinuria in liver disease). Protein is a sensitive indicator of glomerular and
tubular renal function. Normally, <30 mg of PRO/d is in urine. In glomerulonephritis where
glomerular filtration membrane is injured, larger particles can go through so protein seeps out into
filtrate and then into urine. Proteinuria is the major indicator of renal disease. Urinary protein also
tests for complications of DM, glomerulonephritis, amyloidosis, preeclampsia, CHF, malignant HTN,
SLE, bladder tumor, and multiple myeloma.

17. Total Iron Binding Capacity (normal: 250-460 mcg/dL or 45-82 umol/L) blood
TIBC is a measurement of all proteins available for binding mobile iron. Transferrin makes up most
of TIBC. Ferritin is not included in TIBC because it only binds stored iron. TIBC varies minimally
according to iron intake and is more of a reflection of liver function and nutrition than of iron
metabolism. TIBC is increased in 70% of pt with iron deficiency. Chronic illness is characterized by
decreased TIBC as well as hemolytic anemia, pernicious anemia, and sickle cell anemia. It is not
uncommon to find high TIBC in late pregnancy

18. Total Lymphocyte Count

Total/absolute lymphocyte count is part of the white blood cell differential test; reference range
1000 to 3500 (multiply % lymphocytes by total number of WBC). Lymphocytosis (elevated
lymphocytes) occurs due to chronic bacterial infection, viral infection, lymphocytic leukemia,
multiple myeloma, infectious mononucleosis, radiation, and infectious hepatitis. Lymphocytopenia
occurs due to leukemia, sepsis, chemotherapy, radiotherapy, surgery, malnutrition, bone marrow
failure, renal failure, Cushings syndrome, immunodeficiency diseases, SLE, and the later stages of
HIV.

19. C-reactive Protein (normal findings: <1.0 mg/dL or < 10.0mg/L) blood
CRP is protein produced by the liver during an acute inflammatory process and other diseases. It is
used to diagnose bacterial infectious disease and inflammatory disorders as a nonspecific, acute-phase
reactant. The synthesis of CRP is initiated by antigen-immune complexes, bacteria, fungi, and trauma.
Failure of CRP to normalize is associated with heart tissue damage. Increased levels of CRP also
indicate arthritis, acute rheumatic fever, Crohn disease, SLE, MI, UTI, TB, and bacterial meningitis.

20. Nitrogen Balance (reference range: 12-20 grams per 24 hr)

Urine urea nitrogen test: measures amount of urea in urine. 24-hr urine sample is needed to
check patients protein balance and amount of dietary protein needed by severely ill patients.
Results also show kidney function.

List the nutritional interactions of the following medications and their indications for use.
Medications:
1. Prednisone/Solumedrol: corticosteroid taken by mouth
Indication for use: anti-inflammatory, immunosuppressant; treats severe allergies, adrenal problems,
endocrine problems, bone marrow problems, lupus, skin conditions, kidney problems, arthritis,
asthma, stomach or bowel problems, ulcerative colitis, and flare-ups of MS.
Nutritional interactions: lower sodium, increase Ca, increase vit D, increase protein. May need
increased potassium, increased vitamin A, C. Caution with grapefruit, limit caffeine. . Interferes with
DM medicine, diuretics, NSAIDs, blood thinners. May increase appetite.

2. Glucophage/metformin: antihyperglycemic agent, biguanide

Indication for use: Take with meals to lower GI distress, potentiates effect of insulin, and decreases
hepatic glucose production. Treats DM 2. May be affected by diuretics, birth control pills, BP
medicine, nicotinic acid, steroid medicine, and thyroid medicine.
Nutritional interactions: may causes fever or chills, stomach pain, N/V, diarrhea, gas,
lightheadedness, dizziness, weakness, trouble breathing, confusion, shakiness, chest tightness, and
increased hunger

3. Maxzide aka triamterene/hydrocholorthiazide

antihypertensive, diuretic; by mouth

(used

in

combination

or

alone):

Indication for use: treats edema or HTN. Do not use with AC inhibitor or other BP medicine, blood
thinners, DM medicine, laxatives, NSAIDs, or steroids.
Nutritional interactions: may cause kidney problems, high or low levels of Ca, Mg, K, or NA, and
gout. May also cause dizziness, allergic reaction, dry mouth, N/V, fever, sore throat, stomach pain,
fever, and/or problems urinating.

4. Glucotrol/Glucotrol XL glipizide: oral hypoglycemic

Indication for use: treats high blood sugar caused by type 2 DM. May interact with aspirin, niacin,
blood pressure medications, NSAIDs, MAO inhibitor, estrogens, thyroid medications, warfarin,
diuretics, and steroids
Nutritional interactions: may cause low blood sugar and higher risk of heart or blood vessel problems.
Part of extended-release tablet may pass in stool (this is normal). May cause nausea, diarrhea, upset
stomach, increased hunger, dizziness, allergic reaction, or confusion.

5. Lasix/ furosemide: diuretic, antihypertensive (loop diuretic); by mouth or injection

Indication for use: treats fluid retention from CHF, liver disease, kidney disease. Also treats high
blood pressure. May interact with ACTH, laxatives, steroids, NSAIDs, and methotrexate.
Nutritional interactions: may cause hypokalemia, and changes in blood sugar levels. Can cause
dizziness, diarrhea, weakness, dry mouth, loss of appetite, increased thirst, nausea, stomach pain chest
tightness, SOB. It is important to keep sufficiently hydrated.

6. Aldactone/ spironolactone: antihypertensive, potassium-sparing diuretic

Indication for use: high blood pressure and heart failure, hyperaldosteronism, edema in pt with CHF,
nephrotic syndrome, or liver cirrhosis; can treat hypokalemia. Do not use with eplerenone. May
interact with NSAIDs and steroid medicine.

Nutritional interactions: careful with salt substitutes that contain potassium. Do not use if pt has
Addison disease. May cause weakness, drowsiness, dry mouth, increased thirst, N/V, tingling in
hands, lips, blood in stools, allergic reaction.

7. Lactulose: laxative to treat increased ammonia level (soln); by mouth

Indication for use: treats constipation. May also treat problems caused by liver disease. Can be
affected by antacids or antibiotics. Caution with pt with DM
Nutritional interactions: increases absorption of Ca and Mg. Do not use with diets low in lactose or
galactose. May cause severe diarrhea, gas, N/V, stomach pain or cramps.

8. Parnate/tranylcypromine: antidepressant, MAOI

Indication for use: depression. Do not use with MAOIs, cyclobenzaprine, St Johns wort, narcotic
medicine, cough and cold medicine, medication for DM, or medicine that lower BP. Do not use if pt
has high BP, liver disease, heart disease, or history of headaches.
Nutritional interactions: limit caffeine, avoid food and drinks high in tyramine, and do not eat
anything aged or fermented such as most cheese, alcohol, cured meat, and soy sauce. May cause dry
mouth, loss of appetite, dizziness, N/V, and constipation.

9. Coumadin/Warfarin: anticoagulant (by mouth or injection)

Indication for use: blood thinner to prevent/treat blood clots. Do not take with other blood thinners,
NSAIDs, SSRI meds, ginkgo, Echinacea, or St. Johns wort. Caution with pt with kidney, liver, or
heart disease, stomach ulcer, protein C deficiency, high BP, DM, recent surgery, and cancer. Also
caution with pt with history of stroke, anemia, or severe bleeding.
Nutritional interactions: keep levels of vitamin K stable from day to day (monitor foods high in
vitamin K such as asparagus, broccoli, Brussel sprouts, cabbage, green leafy vegetables, plums,
rhubarb, canola oil). Do not drink large quantities of cranberry or grapefruit juice. May cause
bleeding from gums, dizziness, vomiting blood, black stools, and dark brown urine.

10. Phenytoin/Dilantin: antiepileptic (by mouth or parenteral)

Indications for use: controls seizures. Do not use with delavirdine. Caution with aspirin, folic acid,
furosemide, vitamin D, St. Johns wort, birth control, HIV medication, steroids, cholesterol
medications, antidepressants, or anticoagulants. Do not take antacids or Ca, aluminum or magnesium
supplements at same time as phenytoin (take at different time of day, see below)
Nutritional interactions: take consistently with food to lower GI irritation. Need to add 1 mg of folate
daily to increase drug metabolism. May need Ca and Vit D supplements but take separately with
medication. Do not drink alcohol. May cause liver damage, weak bones, high blood sugar levels, and
decreased levels of blood cells. Additionally may cause constipation, N/V, dizziness, headache, and
fever.

11. Isoniazid (INH): antimycobacterium (by mouth or parenteral)

Indications for use: tuberculosis treatment. Caution with melatonin which increased the drug level.
Also caution with blood thinners, birth control pills, and antacids. Caution with decreased hepatic
function and kidney disease.
Nutritional interactions: food decreases absorption. Take one hour before meals. Like with MAOI,
avoid high tyramine or histamine foods. Need 25-50 mg/d pyr supplement to prevent peripheral
neuropathy. May inhibit conversion of tryptophan to niacin. May cause pellagra due to niacin
deficiency. May cause dry mouth, headache, dizziness, N/V, constipation, and diarrhea. Avoid
alcohol

12. Insulin list different types

Type

Class

Intraven
ous

Name

Brand

Maker

Onset

Peak

Duration

Comments

Uman
regular (U100)

Humulin R

Lilly

Immediate

Novolog

<10
min

No differences in rapidacting and regular given

intravenously

Aspart

Apidra

NovoNordis
k

Immedia
te

30-90
min

< 5 hr

< 5 hr

At mealtime; pump
indication/CSII; control
glycemia following
meal/food intake

15-45 minutes prior to meal

Sanofi

Glulisine
Bolus
(subcuta
neous)

Rapid
acting

Lispro

Humalog

Lilly

5-15 min

Aspart

Novolog

novoNordisk

5-15 min

Glulisine

Apidra

Sanofi

5-15 min

30-90
min

< 5 hr

30-90
min

Basal
(subcuta
neous)

Short
acting

Human
regular (U100)

Humulin R

Lilly

30-60 min

2-4 hr

5-8 hr

Novolin R

NovoNordis
k

30-60 min

2-4 hr

5-8 hr

Interme
diate

Human NPH

Humulin N

Lilly

2-4 hr

4-10 hr

Human
regular (U500)

Novolin N

NovoNordis
k

2-4 hr

4-10 hr

10-18
hr

Humulin R
(U-500)

2-4 hr

4-10 hr

Lilly

10-18
hr

Once or twice day

Similar to NPH; use
tuberculin syringe

10-16
hr

Mixed
(subcuta
neous)

Long
acting

Glargine

Lantus

Sanofi

2-4 hr

None

24 hr

Detemir

Levemir

novoNordisk

3-6 hr

None

18-24
hr

Premixed

Human
NPH/regular

Humulin
70/30

Lilly

30-60 min

Dual

NovoNordis
k

30-60 min

Dual

10-18
hr

Lilly

5-15 min

Dual

Lilly

5-15 min

Dual

NovoNordisk

5-15 min

Dual

Novolin
70/30
Lispro
protamine/Li
spro
Lispro
protamine/
Lispro
Aspart
protamine/
Aspart

Humalog
Mix 75/25
Humalog
mix 50/50
Novolog mix
70/30

10-18
hr
10-18
hr
10-18
hr
10-18
hr

Usually once a day

All mixed insulins have dual

peaks reflecting combination
of rapid/short and
intermediate/long-acting
insulins; does not allow
independent manipulation of
insulin components; usually
bid

Indications for use: improper functioning of pancreas, body does not produce enough insulin
as it should
Nutritional interactions: risk of hypoglycemia; caution should be used when consuming
alcohol; general weight gain may occur
13. Heparin: anticoagulant
Indications for use: prevents and treats blood clots. Caution with other blood thinners, aspirin,
nicotine, and some allergy meds and certain antibiotics.
Nutritional interactions: may cause N/V, abdominal pain, GI bleeding, constipation, black tarry
stools. Caution with DM, ESRD, hyperkalemia, and decrease hepatic or renal function. May also
cause bleeding, dizziness, headache, fever, osteoporosis, decrease platelets, increased AST and ALT,
increase potassium, decreased TG, and increased FFA.

14. Digoxin: cardiotonic, antiarrhythmic, CHF treatment, inotropic agent (oral or parentral)
Indications for use: congestive heart failure, heart rhythm problems; often used in combination with
diuretic and ACE inhibitor.
Nutritional interactions: maintain diet with increase potassium, decreased sodium, and adequate Mg
and Ca. Take at least 2 hours before antacids or Mg supplement, otherwise may have decreased
absorption of drug. Caution with Ca or Vit D supplement, some herbal products such as aloe. Avoid
St. Johns Wort and natural licorice. May cause decreased appetite, stomach pain, weight loss, Ca and
Vit D induced hypercalcemia, N/V, diarrhea. May also cause weakness, headache, depression,
drowsiness, and apathy. Monitor electrolytes.

15. Kayexalate/ sodium polystyrene sulfonate: antihyperkalemia, cation exchange resin (oral or
rectal)
Indications for use: Treats hyperkalemia. Caution in pt with high BP, CHF, heart rhythm problems,
severe swelling, kidney disease, low Ca, low Mg, or stomach or bowel problems.
Nutritional interactions: Diets should be low in potassium and pt should avoid potassium
supplementations. Patients should be wary of sodium intake and should adhere to a low sodium diet.
IF patient is taking a calcium or magnesium supplement or antacids, these should be taken several
hours before or after taking kayexalate. Kayexalate should not be taken with salt substitutes or
sorbitol. May cause hypokalemia, N/V, SOB, chest pain, constipation, loss of appetite, stomach pain,
dry mouth, and increased thirst. This drug will lower potassium, Mg, and Ca in the blood while
raising serum sodium concentration. Electrolytes should be monitored.

16. Colchicine: antigout, anti-inflammatory, treatment of familial Mediterranean fever (oral)

Indications for use: Treats and prevents attacks of gout. Caution with decreased hepatic or renal
function, cardiac disease, GI disorder. Caution if pt is taking HIV medication, medication to lower
cholesterol, and medication to treat an infection, as well as digoxin.
Nutritional interactions: diet low in purines. Avoid grapefruit/related citrus. May result in loss of
appetite, weight loss, may decrease absorption of Vitamin B12. May cause sore throat, N/V, stomach
pain, weakness, and diarrhea. May also increase blood pressure and incite renal damage. Avoid
alcohol.

17. Propofol/Diprivan: sedative (injection)

Indications for use: sedative and anesthetic to be used before and during surgery. Caution in pt with
DM, kidney disease, pregnant or breastfeeding, heart problems, pancreas problems, and high
cholesterol.

Nutritional interactions: If pt is allergic to eggs, egg products, soybeans, or soy products, this
anesthetic should not be used. May cause fever, pain or fullness in upper stomach, weakness,
seizures, SOB, irregular heartbeat, swelling in extremities, decreased urination, lightheadedness, and
N/V.

18. Potassium Chloride (KCl): electrolyte, mineral supplement (oral or parenteral)

Indications for use: prevents and treats low potassium levels in the blood. Caution taking KCl while
also taking potassium-sparing diuretics, AC inhibitors, salt substitutes, and digoxin. Caution if pt has
kidney or heart disease.
Nutritional interactions: Do not take KCl with salt substitutes. There is no RDA; the adult minimum
potassium requirement is 1600-2000 mg. KCl may cause GI irritation, N/V, abdominal pain, diarrhea,
flatulence, hyperkalemia, throat pain, bloody or black stools, and in rare cases, ulceration. Potassium
and chloride will increase in pts blood and urine. Serum potassium, chloride, and magnesium levels
should be monitored as well as renal function.

19. Reglan/metoclopramide: antiemetic, antigerd, diabetic gastroparesis treatment (oral or

parenteral)
Indication for use: diabetic gastroparesis treatment. Also relieves symptoms of GERD such as N/V,
heartburn, and loss of appetite. If on insulin for DM, may need to adjust dose of insulin while using
Reglan. Do not use if pt has epilepsy, intestinal bleeding, or a tumor in the adrenal gland.
Nutritional interactions: Take 30 minutes before meals. May cause dry mouth, increased gastric
emptying, nausea, diarrhea, and constipation. Avoid alcohol. May also cause drowsiness, fatigue,
dizziness, dyskinesia, headache, depression, galactorrhea, HTN, transient edema, and acute CHF.
Increases urination. Drug also increases prolactin in blood and transiently increases adolesterone
levels as well.

20. Colace/docusate sodium: stool softener, laxative (oral)

Indication for use: Treatment for constipation by altering the intestinal absorption of water and
electrolytes. Caution if pt has Crohns disease or ulcerative colitis.
Nutritional interactions: Pt taking Colace needs a high fiber diet with 1500-2000 mL fluid/d to
prevent constipation. Drug may cause bitter taste, throat irritation, nausea, cramps, and diarrhea. Pt
should not take drug if experiencing N/V or abdominal pain. Drug increases glucose and potassium in
blood.

21. Ranitidine/ histamine H2 receptor antagonists: antiulcer, antigerd, antisecretory (oral or

parenteral)
Indication for use: Treats and prevents heartburn, stomach ulcers, and conditions which may result in
increased stomach acid. Caution if pt has decreased hepatic or renal function, COPD, or asthma.
Effectiveness of Ranitidine may be altered if pt is taking warfarin.
Nutritional interactions: Pt may have diet of bland foods. If pt taking iron supplement, must take drug
at least 2 hours before or after iron supplement; this is true for magnesium supplements or
aluminum/magnesium antacids as well. Pt should limit caffeine and xanthine. Avoid alcohol. Drug
will lower iron and Vit B12 absorption. Magnesium or Al/Mg antacids will lower absorption of the
drug. Drug may cause decreased gastric acid secretion, increased gastric pH, N/V, diarrhea,
drowsiness, dizziness, headache, and constipation. AST, ALT, and alkaline phosphatase levels will be
increased in the blood while iron and vitamin B12 will be decreased in the blood if drug taken for
long term use. Monitor hepatic function and vitamin B12 if long term use.

22. Antacid/ calcium supplement (oral)

Indication for use: increases calcium, if needed. Also helps to prevent osteoporosis. Caution if pt has
kidney disease or kidney stones, or hypercalcemia.
Nutritional interactions: Supplement should be taken with food. Take other medications 2 hours
before or after supplement. Do not take supplement with high-fiber meals or caffeine. Avoid large
amounts of alcohol. May cause stomach or digestion problems, diarrhea, malabsorption of nutrients,
headache,dry mouth, loss of appetite, constipation, or flatulence.

23. Compazine/prochlorperazine/ phenothiazines: antiemetic, antinauseant, antipsychotic (oral or

parenteral)
Indication for use: Treats N/V. Also can treat anxiety and schizophrenia. Caution in pt with decrease
hepatic or renal function, Parkinsons disease, or seizures. When on drug, pts hepatic function should
be monitored. Caution if pt is taking lithium, blood thinners, diuretics, blood pressure/heart
medication, and medicine to treat seizures.
Nutritional interactions: take with food to reduce GI distress. If pt taking Mg supplement, take
separately from drug by two hours. Limit caffeine. Avoid alcohol. May cause increased appetite,
weight gain, dyskinesia, fever, sore throat, dizziness, N/V, dry mouth, drooling, constipation, and
greater requirements for riboflavin. Drug may also cause decreased absorption of vit B12. Drug
increases risk of dental problems.

24. Synthroid/ levothyroxine: thyroid hormone (T4) (oral or parenteral)

Indication for use: Treats hypothyroidism and can help decrease the size of englarged thyroid glands.
May also be prescribed for pt with thyroid cancer. Caution if pt has DM, CVD, HTN, osteoporosis,
pernicious anemia, and pituitary or adrenal gland problems. Monitor thyroid function and TSH.
Caution if pt taking digoxin, blood thinners, insulin or other DM medications, or antidepressants. Do
not use if pt has had MI recently.
Nutritional interactions: take with water before breakfast to increase drug absorption. If pt taking iron,
Ca, or Mg supplement, take these supplement at least 4 hours before or after taking the drug. Try to
avoid taking drug with soy milk, cottonseed meal, walnuts, and high fiber foods which can decrease
the absorption of the drug. Drug may change appetite and/or cause weight loss. Drug may lower
cholesterol and LDL in the blood. May cause N/V, chest pain, SOB, and headache.

25. Sinemet/ levodopa & carbidopa: antiparkinson

Indication for use: treats symptoms of Parkinsons disease (increases levels of dopamine in brain).
Caution if pt has kidney or liver disease, endocrine problems, lung problems, sleep disorder, or heart
problems. Monitor pts hepatic, renal, and cardiovascular function. Caution if pt taking BP
medications or antidepressants. Do not use if pt taking MAOI
Nutritional interactions: do not take directly with high protein food or amino acids; aromatic aa
compete with drug for absorption at blood brain barrier and during intestinal absorption. Avoid fava
beans which contain a significant amount of levodopa naturally. Diet of 5:1 Pro to 7:1 CHO while
consuming most protein in the evening to stabilize drug effects. May cause loss of appetite, weight
loss or weight gain, dry mouth, taste loss, excessive salivation, dark saliva, bitter taste, dyskinesia,
teeth grinding, dizziness, dysphagia, N/V, epigastric distress, constipation, diarrhea, dark urine and
flatulence. Although rare, drug may cause ulcers and bleeding.

26. Remeron/mirtazapine: antidepressant, NaSSa (noradrenergic agonist, specific serotonin

antagonist) (oral)
Indication for use: Treats depression. Caution in pt with decreased hepatic and renal function. Caution
in pt already taking HIV medication or blood thinners
Nutritional interactions: avoid taking with St. Johns Wort. Drug will increase appetite, incite weight
gain, increase thirst, and may cause anorexia. Drug may cause dry mouth, N/V, abdominal pain,

constipation drowsiness, low sodium levels, and dyspnea. Cholesterol and TG will increase in blood
while WBC and platelets will decrease, possibly causing anemia. Urination will increase in
frequency. Avoid alcohol.

27. Megace/ megestrol: appetite stimulant, antineoplastic, hormone

Indication for use: treats hot flashes and can regulate menstrual cycle. Also treats breast and uterine
cancer. Additionally, drug is prescribed to pt with HIV to increase appetite and prevent weight loss
Caution in pt with DM or decreased renal function. May cause edema, depression, HTN, headache,
drowsiness, and fever. Monitor renal function and glucose levels in pt with DM.
Nutritional interactions: may consider taking with high fat meal and pt may want to take with food to
reduce GI distress. Increases appetite and weight. May cause N/V, dizziness, weakness, SOB, chest
pain, and dyspepsia. May increase thirst and frequency of urination. Drug will cause sodium, LDL,
and glucose to rise in the blood while reducing the levels of HDL.

28. Aricept/ donepezil: antialzheimers, acetylcholinesterase inhibitor (oral)

Indication for use: treats Alzheimers and also used to treat vascular and mixed dementia. Caution in
pt with seizures, asthma, COPD, and peptic ulcer disease and pt taking NSAIDs.
Nutritional interactions: can cause anorexia, weight loss, and dehydration. Drug may also cause N/V,
GI bleeding, bloating, pain, diarrhea, fatigue, headache, dizziness, and increased or decreased BP
with possible hypotension. Increases frequency of urination.

29. Namenda/memantine: NMDA receptor antagonist (oral)

Indication for use: Alzheimers treatment (for moderate to severe cases) and also used to treat
vascular dementia. May cause hallucinations, back pain, and confusion. Caution in pt with reduced
renal function. Caution if pt is taking an antacid or laxative that contains sodium bicarbonate.
Nutritional interactions: take drug without food. Diet/other meds that produce alkaline urine such as
when consuming milk and milk products and citrus fruits increase drug blood levels due to decreased
drug excretion. May cause vomiting, constipation, HTN, cough, drowsiness, dyspnea, and fatigue.

30. Remodulin/Flolan/ treprostinil: vasodilator (oral, injection, inhalation)

Indication for use: treats pulmonary arterial hypertension. Inhaler medication may cause cough, throat
sensitivity, headache, flushing, and dizziness. Caution if pt is taking diuretics, other BP medication,
and blood thinners. Do not use if pt has liver disease.
Nutritional interactions: Avoid ginkgo Ma cause nausea, diarrhea, GI hemorrhage, Caution in pt with
decreased hepatic or renal function or pt with low BP which increases risk of hypotension.

31. Beta Blockers: propranolol, metoprolol, atenolol, bisoprolol

Indication for use: cardiac arrhythmias, protecting against recurrent heart attack; sometimes HTN;
block action of endogenous catecholamines epinephrine and norepinephrine
Nutritional interactions:

32. Ace Inhibitors: angiotensin converting enzyme inhibitors lower blood pressure and
decrease blood volume; perindopril, captopril, lisinopril
Indication for use: HTN, CKD, CHF, HF, stroke, DM
Nutritional interactions: possible hypotension, reduction in GFR, hyperkalemia, loss of appetite, upset
stomach, diarrhea

33. Calcium Channel Blockers: amlodipine, verapamil, diltiazem

Indication for use: HTN, alter heart rate, reduce chest pain, antiarrhythmic drug

Nutritional interactions: constipation, dizziness, pedal edema, GI bleed in elderly

34. Plavix/ clopidogrel: platelet aggregation inhibitor (oral)

Indication for use: treats acute coronary syndrome; prevents repeat MI, CVA, or vascular event. Can
decreased rate of new ischemic stroke, MI, or other event to cause vascular death. May cause UTI.
May be used in combination with aspirin. Caution if pt taking warfarin, antidepressants, or some
stomach medications.
Nutritional interactions: Good significantly raises bioavailability. Take with food if pt experiences GI
discomfort. Avoid grapefruit and related citrus fruits. May cause dyspepsia, N/V, abdominal pain,
HTN, flu-like symptoms, dizziness, headache, fatigue, edema, GI bleeding, hemorrhage, diarrhea, and
constipation. Increases bleeding time, cholesterol, and uric acid; decreases platelets and neutrophils;
can cause anemia.

35. Veletri/ epoprostenol: prostaglandins (injection)

Indication for use: treats pulmonary hypertension. Mix wither sterile water for injection, USP or NaCl
0.9% injection, USP. Caution if pt taking Digoxin, diuretics, BP medication, and blood thinners
Nutritional interactions: May cause chest pain, SOB, cough, fever, sore throat, dizziness, diarrhea,
N/V, loss of appetite, headache and jaw pain

36. Tikosyn/Dofetilide: antiarrhythmic, selective potassium channel blocker (oral)

Indication for use: Corrects irregular heartbeat of pt with atrial fibrillation or atrial flutter. Caution if
pt has reduced renal function. Caution if pt using some diuretics, antidepressants, blood pressure
medication, medicines for infection or medicine for HIV. Do not take with renal or hepatic failure or
have long QT syndrome. Monitor renal function ECG, and electrolytes.
Nutritional interactions: Take without food. Pt must have diet with adequate potassium and
magnesium (K and Mg levels WNL). Caution with grapefruit and other citrus fruits. May cause
nausea, abdominal pain, diarrhea, headache, dizziness, chest pain, flu-like symptoms, and dyspnea

Sources: www.ncbi.nlm.nih.gov/pubmedhealth, Food Medication Interactions, MedlinePlus

NLM

Nutrition Focused Physical Exam/Malnutrition (Lakeside/Lerner Tower)

1. Please read: Nutrition Focused Physical Assessment: Making Clinical Connections. By
Mary Demarest Litchford, PhD, RDN, LDN
Define:
Peripheral edema: site at legs and feet
Pedal edema: site at feet
Pitting edema (edema either pitting or non-pitting): by pressure to swollen area of skinpitting edema is classified if indentation of skin persists after applied pressure is released
Ascites: edema at abdomen
Anasarca: edema of whole body
Dermatitis: (atopic)- chronic dry skin with scaly and itchy rashes eczema, may be due
to lack of certain proteins thus causing skin to be more sensitive
o Sings of blisters, bumpy skin (especially on back of arms and front of thighs), raw
areas of skin, redness
o Seborrheic dermatitis: inflammation of skin that causes flaky, white/yellowish
scales to form on oily areas of scalp, face, or inside ear
o Contact dermatitis: skin becomes red, sore, and inflamed after direct contact with
a certain substance such as detergents, fabric softeners, solvents, other chemicals
Jaundice/ icterus: yellowish appearance of skin and whites of eyes due to excess amounts
of serum bilirubin dissolved in subcutaneous fat; yellowish appearance may extend to
other body tissues and may turn body fluids such as urine a darker yellow color
o Sign of variety of medical conditions
o Ex. when RBC destroyed and excretion of bilirubin disrupted excessive
hemolysis (ability of liver to remove bilirubin reduced)
Glossitis: inflammation of tongue; raw appearance; sore, tender, pale or bright red color,
smooth surface; can cause problems chewing, swallowing, or speaking
o Folate and B12 deficiencies
Mucositis: inflammation and ulceration of mucous membranes lining digestive tract (term
used usually for oral and oropharyngeal cavity); show symptoms including ulcerative
lesions, bleeding, pain, xerostomia
o Usually caused by chemotherapeutic agents or radiation therapy
Thrush: yeast infection of tongue and lining of mouth; signs of whilte sores in mouth and
on tongue, some bleeding, pain when swallowing
o Caused by fungus Candida
o Risk increases when pt is in poor health, very old, has HIV/AIDS, receiving
chemotherapy, taking steroids, has DM and high blood sugar, taking antibiotics,
ill-fitting dentures
Alopecia: totalis- hair loss from scalp; universalis- hair loss from total body)
o Male-pattern baldness/ androgenic alopecia: most common cause of hair loss,
inherited X-linked trait
o Female-pattern baldness (causes hair to thin but total baldness rare): due to
hormone changes after pregnancy, extreme stress from major illness, VLC diets,

rapid weight loss post bariatric surgery (inadequate PRO, Fe, zinc, biotin), thyroid
disease, and polycystic ovary syndrome; telogen effluvium- hair loss in handfuls
o Alopecia areata: autoimmune disorder- immune system attacks hair follicles;
starts as patchy hair loss and can lead to total baldness
o Medications may increase hair loss- warfarin, gemfibrozil, antidepressants, betablockers, NSAIDs, drugs for gout, arthritis, birth control, and high BP
o Telogen effluvium: hair follicles in resting phase and fall out too early; pt shed
100-150 hairs/d
o Anagen effluvium: hair falls out during active phase of growth; matrix cells which
produce new hairs cannot divide normally (common side effect of chemo)
Tenting of skin: elevated skin common in pt with dehydration; pink skin to check for
turgor/elasticity, if skin remains tented for more than 3 seconds then turgor is decreased
o Turgor is naturally slower in older adults and is not a reliable indicator of
dehydration
o Preferred sites to check for tenting: sternum and inner aspect of thigh, also top of
hand
o Sign of severe dehydration
Xerosis: dry skin; deficiency of essential fatty acid

Geriatrics (Lakeside/Lerner Tower)

1. Please list reasons for concern and potential nutrition interventions and/or
recommendations for the following conditions in the geriatric population:
Involuntary weight loss
o Due to living alone, history of lung or heart disease, presence of acute
vomiting, impaired cognition, forgetfulness to eat; low quality diet,
sedentary lifestyle, increased frailty, disability, functional dependency;
medical, pharmaceutical, social, economic, environmental causes
o Reason for concern: underlying disease, association with mortality; poor
health outcomes, marker for deteriorating well-being
o Female caloric needs: sedentary 1600 kcal/d, moderately active 1800
kcal/d, active 2000 kcal/d
o Male caloric needs: sedentary 2000 kcal/d, moderately active 2200 to
2400 kcal/d, active 2400 to 2800 kcal/d
Dementia
o Reason for concern: nerve cell death which may impair mental function to
an extent that interferes with activities of daily living; personality changes,
behavioral problems, agitation, irritability, hallucinations, memory loss;
problems with motor skills or eating, appetite, forgetting to eat, not
physically being able to eat
o Dx: inadequate oral intake, unintended weight loss
o Nutrition intervention/recommendation: consult SLP if having problems
with chewing/swallowing, may need feeding assistance, supplement when
appropriate if not receiving enough PRO + energy
Dysphagia: may involve parts of mouth, pharynx, larynx, esophagus
o Reason for concern: choking; dysphagia may be due to stroke,
Alzheimers, Parkinsons, head/neck cancer, Sjogrens syndrome,
achalasia, DM neuropathy, xerostomia, mucositis; three phases include
oral, pharyngeal, esophageal; look out for drooling, pocketing food,
slurred speech, facial weakness, coughing while eating, poor control of
tongue movements, frequent throat clearing, delayed swallowing, gurgly
voice,
o Nutrition intervention/recommendation: to prevent aspirationeat while
sitting upright, small meals, chin down when drinking; check nutritional
status of fluid and electrolytes, weight changes, dietary intake and
cough/gag reflex; national dysphagia diet; foods eaten in bite-size pieces
o Thin regular liquids
o Nectar thickened liquids: falls slowly from spoon, sipped through straw
o Honey thickened liquids: drops from spoon but too thick to sip through
straw
o Spoon liquids: maintains shapes, needs to be consumed with spoon, too
thick to drink (ex. Pudding)
o Commercial thickeners or can use pureed vegetables/fruits, starches
(tapioca, potato flakes, etc.), powdered skim milk
o Dysphagia level 1 diet: pureed
o Dysphagia level 2 diet: mechanically altered

o Dysphagia level 3 diet: advancednearly regular with exception of very

hard, sticky, or crunchy foods
Aspiration pneumonia: oral/gastric contents in bronchial tree
o Risks: reduced consciousness, lack of cough reflex, intermittent bolus of
TF, supine body position, large bore NG feeding tube, GERD,
gastroparesis, decreased gastric emptying, disorders of upper GI tract or
surgery here, dysphagia, endotracheal intubation, upper endoscopy,
o Reason for concern: inadequate oral intake, inadequate enteral nutrition
infusion, excessive enteral nutrition infusion inadequate mineral intake
o Nutrition intervention/recommendations: prevent weight loss, maintain
LBM, safe nutrient intake, appropriate food and liquid consistencies;
generally will have normal fluid requirements; for TF pthead of bed at
least at 30 to 45 degree angle, change feeding infusion to continuous rate,
place TF into small bowel; PRO 1.0-1.5 g /kg
Parkinsons
o Reason for concern: change in appetite, inability to eat, need for feeding
assistance, changes in smell/taste, issues chewing/swallowing,
constipation, reflux, weight changes, dry mouth (side effect of treatment),
constipation
o Dx: inadequate oral intake, inadequate fluid intake, malnutrition,
swallowing difficulty, biting/chewing difficulty, underweight, food-med
interaction, unintended weight loss, self-feeding difficulty
o Nutrition intervention/recommendations: adequate pro + energy and
micronutrients, esp. D and B12; TF; protein may need to be monitored
carefully if taking Levadopa (aa compete with drug to cross BBB) eat
protein in evening, maintain higher CHO:pro 5:1 to 7:1; avoid
supplements containing more than 100% DV for B6, iron, Mg
Alzheimers
o Reason for concern: memory loss, impaired cognitive function, behavioral
issues, impaired capacity to accomplish activities of daily living; problems
with feeding self (utensil use, forget how to chew or swallow, etc.), taste
fatigue, aspiration pneumonia risk
o Dx: inadequate oral intake, unintended weight loss
o Nutrition intervention/recommendations: consistency modified diets for pt
with chewing/swallowing difficulty (consult SLP); try to liberalize diet to
encourage all PO intake; prevent weight lossfortify favorite foods, add
high kcal/high PRO supplements
Constipation (normal-transit, pelvic floor dysfunction, slow-transit)
o Reason for concern: often due to dehydration, loose stools, sufficient
criteria to diagnose IBS; may be d/t cocktail of medications, low activity
level, concurrent disease
o Dx: inadequate fluid intake, intake of types of CHO inconsistent with
needs (specify), inadequate fiber intake, undesirable food choices, food
and nutrition-related knowledge deficit
o Nutrition intervention/recommendation: 25-38 g fiber (insoluble aka
cellulose, psyllium, inulin, oligosaccharideswhole grains, skins of fruits

and vegetables, bran) add fiber gradually; increase fluid intake to

minimum of 64 oz/d, daily physical activity, consider laxatives,
pro/prebiotics,
Failure to Thrive anorexia of aging, multifactorial
o Reason for concern: malnutrition, decreased physical function, depression,
cognitive impairment, decreased daily energy intake; reduced chance of
improving co-morbidities; protein-energy undernutrition, loss of muscle
mass (sarcopenia), problems with balance and endurance, declined
cognition, depression
o Nutrition intervention/recommendation: 1.0-1.25 g PRO/kg BW, 25-25%
total daily energy from lipids (10% from SF, less than 300 mg chol, no
trans fats) fat recommendations may be flexible if palatability increased
for aging pt not eating, 45-65% total daily energy from CHO; 1200 mg
Ca, 800 IU vit D, B vitamins; 30 ml/kg body weight of minimum of 1.5
L/d (AI 2.7 L females, 3.7 L males)
Depression
o Reason for concern: FTT, altered nutrition status, inadequate/excess intake
of macronutrients or micronutrients, unplanned weight change; may
present with drug/EtOH abuse, assess food insecurity, assess meds for
possible side effects
o Dx: increased energy expenditure, inadequate energy intake, excessive
energy intake, inadequate oral intake, excessive oral intake, excessive
alcohol intake, intake of types of CHO inconsistent with needs (specify),
inadequate fiber intake, food- and nutrition-related knowledge deficits, not
ready for diet/lifestyle changes, self-monitoring deficit, limited adherence
to nutrition-related recommendations, undesirable food choices, physical
inactivity, inability to manage self-care, impaired ability to prepare
foods/meals, limited access to food or water, unintended weight loss,
unintended weight gain; dry mouth, constipation from meds
o Intervention/recommendations: exercise (30 minutes every day break up
to 10 minute sessions); if on MAOI, need tyramine-restricted nutrition
therapy (9-12 mg/d); encourage appropriate fish (6-8 oz/week), PUFA,
fiber, fruit and vegetable consumption, omega-3s (750-1000 mg), folate,
vit D; meal structuring/timing/composition to assure adequate intake and
stability; nutrient-dense foods; plan for bowel regularity
Diabetes Mellitus
o Reason for concern: long term microvascular and macrovascular issues;
constipation, depression, involuntary gain of loss of more than 10% BW in
less than 6 months
o Dx: unintended weight loss, altered nutrition-relate lab values, excessive
energy intake, intake of types of CHO inconsistent with needs (specify),
inconsistent CHO intake, intake of types of fats inconsistent with needs
(specify), excessive fat intake, overweight/obesity, food-and nutritionrelated knowledge deficit, not ready for diet/lifestyle change, disordered
eating pattern, limited adherence to nutrition-related recommendations,

physical inactivity, inability to manage self-care, impaired ability to

prepare foods/meals
o Nutrition intervention/recommendations: MVI, CHO counting, simplified
meal plans (small frequent meals tid with snack); need to reduce
hyperglycemia, HTN and improve dyslipidemias; encourage variety of
nutrient-dense foods; try to liberalize diet as much as possible for
appropriate PO intake (regular menu with consistent amounts and timing
of CHO); adjust meds to achieve target glucose goals rather than
restricting energy
2. What are some clinical conditions in addition to immobility that place a patient at risk for
development of a pressure ulcer? How would you calculate calorie, protein, and fluid
needs in a patient with pressure ulcers?
Clinical conditions: End stage renal disease, DM (especially uncontrolled Type
2), dehydration, thyroid disease, steroid use, impaired blood flow, exposure of
skin to urinary/fecal incontinence, cognitive impairment
Nutrition-related risk factors: significant unintentional weight loss, changes in
appetite or intake of foods and fluids, poor dental health, GI elimination issues,
chewing/swallowing difficulty, ability to self-feed, drug-nutrient interactions,
alcohol and substance abuse
Protein requirements for each stage
o I: 1.25-1.5 g/kg
o II: 1.25-1.5 g/kg
o III: 1.25- 1.5 g/kg
o IV: 1.5-2.0 g/kg
Energy requirements for each stage
o I: greater than or 30-35 kcal/kg lean body eight or ABW if obese
o II: slightly above maintenance of 30-35 kcal/kg
o III: 30-35 kcal/kg
o IV: 35-40 kcal/kg
o General: 30-35 kcal/kg/d
Fluid requirements for each stage
o I and II: greater than or 30 mL/kg with minimum of 1500 mL unless renal
or cardiac disease
o III and IV: greater than or 30-35 mL/kg or minimum of 1500 mL
3. What are some conditions and factors that may increase risk of dehydration or
Fluid/Electrolyte imbalance in an elderly patient? How would you typically calculate
fluid needs in an elderly client?
Physiologic changes and factors decreased fluid intake: kidneys decreased
ability to concentrate urine, blunted thirst sensation, endocrine changes in
functional status, alterations in mental status and cognitive abilities, adverse
effects of medications, mobility disorders; Fear of incontinence and increased
arthritis pain; N/V

Chidester,199;Chernoff, 1994: adult > 65 years needs 25 mL/kg body weight

Total body water (TBW): males >80 yrs 0.5 x wt (kg); females >80 years 0.4 wt (kg)

Wounds (Lakeside/Lerner Tower)

MNT for Pressure Ulcer Stages I-IV
1. Describe pressure ulcers stages I-IV: localized injury to skin and/or underlying tissue
usually over bony prominence as result of pressure
o I: least severe; intact skin with unfading redness (dilation of skin capillaries) of
localized area usually over bony prominence; area may be painful, firm, soft,
warmer or cooler to surrounding area; difficult to detect in pt with dark skin tones
o II: partial thickness loss of dermis presenting as shallow open ulcer with red pink
wound bed. Without slough. Presents as shiny or dry shallow ulcer without slough
or bruising
o III: depth varies based on anatomical locationif area of little subcutaneous
tissue (bridge of nose, ear, malleolus) can have shallow stage III but if in area
with much adipose tissue, can develop very deep stage III; full thickness tissue
loss. Subcutaneous fat may be visible but bone, tendon or muscle not exposed.
Slough, undermining, tunneling may be present
o IV: most severe, infections commonly occur; full thickness tissue loss with
exposed bone, tendon or muscle. Slough or eschar most likely present along with
undermining and tunneling. Can extend into muscle and/or supporting structures
making osteomyelitis possible.
2. What are the protein requirements for each stage? FROM ASPEN
o I: 1.25-1.5 g/kg
o II: 1.25-1.5 g/kg
o III: 1.25- 1.5 g/kg
o IV: 1.5-2.0 g/kg
3. What are the energy requirements for each stage?
o I: greater than or 30-35 kcal/kg lean body eight or ABW if obese
o II: slightly above maintenance of 30-35 kcal/kg
o III: 30-35 kcal/kg
o IV: 35-40 kcal/kg
o General: 30-35 kcal/kg/d
4. What are the fluid requirements for each stage?
o I and II: greater than or 30 mL/kg with minimum of 1500 mL unless renal or
cardiac disease
o III and IV: greater than or 30-35 mL/kg or minimum of 1500 mL
5. Name the nutrition-related risk factors for pressure ulcer development.
o Anemia, need to assess hbg and hct
o Malnutrition
o Low visceral protein status
o Hypocholesterolemia (<160 g/dL) with poor appetite and weight loss: potential
nutritional risk factor stress, severe infection, cytokine-induced inflammatory
states decrease serum cholesterol
o Uncontrolled hyperglycemia
o Unintentional weight loss (significant)
o Changes in appetite or intake of food and fluids
o Poor dental health
o GI and elimination problems

o Alcohol and substance abuse

o Chewing and swallowing difficulties
o Dehydration
o Co-morbidities: ESRD, thyroid disease, DM
o Drug-nutrient interactions: Steroid use which affect wound healing
6. Please list the vitamin/mineral supplementation used for wound healing. Please discuss
the recommended dose and the role each supplement plays in wound healing.
o Support line article: PRO, kcal, vit C, vit A, zinc, vit E, arginine, glutamine but
further research needed for aa
o Vit C: essential for collagen formation for new tissue stabilize collagen b
increasing tensile strength and maintaining elasticity of connective tissue; vit C
also resists infection; recommended dose from 500-1000 mg/d (III and IV: 500
mg bid 2 weeks) toxicity only issue for pt at risk for oxalate stone formation
renal pt should take 100 mg/d
i. I and II: 100-200 mg/d
ii. III and IV: up to 1000-2000 mg/d in divided doses for 10-14 day
o Zinc: immune function, collage synthesis (cofactor in protein synthesis
correlated with albumin, prealbumin, transferrin levels deficiency occurs d/t
excessive wound drainage (delay healing by minimizing would tensile strength
and inhibiting closure) supplementation to improve visceral stores 220 mg
zinc sulfate (50 mg elemental) for two weeks ONLY FOR THOSE PT
DEFICIENT.. dont want to decrease copper absorption
i. I and II: 15 mg elemental per day; if deficient up to 50 mg ad 10-14 days
ii. III and IV: 25-30 mg elemental zinc per day for 10-14 days
o Vit A: cell division, cell differentiation, immune system function by enhancing
lysosomal membrane lability, increasing macrophage influx, stimulating collagen
synthesis deficiency rare but if it is suspected, supplement with 700-3000 IU/d
(higher range for males), sometimes megadoses of 25000 IU/d on steroids for 712 days do not exceed 5000 IU/d for HD pt and 3300 IU/d for pregnant pt
i. I and II: increase up to 25000 IU ad for 10 days if deficiency suspected
ii. III and IV: 5000 IU per 1000 kcal
o Delayed wound healing = reduced visceral protein and reduced blood glucose
control
o Protein: PRO malnutrition impairs collagen synthesis and decreases wound
strength, diminishes immune function wound induces hypermetabolic and
catabolic state as much as 100 g/d PRO may be lost through wound exudate
1.5-2 g/kg needed
o Energy: synthesis of collagen, nitrogen, anabolism, wound healing with II or IV
pressure ulcers: 35-40 kcal/kg/d BW adjusted based on wound severity, pt age,
obesity
Glucocorticoids, immunosuppressive agents, anticoagulants may interfere with wound
healing
Define and state the nutrition intervention if there are any for the following:

 Diabetic Ulcer: foot ulcers; due to arterial insufficiency or neuropathy leading cause of
hospitalization and amputation in pt with DM
Venous Ulcer: most common type of chronic wounds treated; may be caused by valve
incompetence in perforating veins or when history of deep vein thrombophlebitis and/or
thrombosis; associated with edema; found on lower leg or ankle
Arterial Ulcer/ ischemic ulcer: caused by poor perfusion to lower extremities; overlying
skin and tissues deprived of oxygen, killing tissues and causing area to form open wound
Surgical Wound: cut made into skin during operation wound infection
Necrosis:
o may benefit wound by providing stable barrier to infection
o necrotic tissues on heels of feet considered stable eschar and shouldnt be
removed
o as tissue becomes necrotic, turns from light yellow and nonadherent to loosely
adherent yellow slough to finally black eschar
Debridement
o Enzymatic, surgical, mechanical, autolytic
o Remove nonliving necrotic or black eschar tissue to allow living tissue to heal
o Afterwards, wound usually becomes larger
Unstageable Wound
o Wound base covered by slough or necrotic tissue
o Depth and stage difficult to determine until base of wound exposed
o Full thickness tissue loss, base of ulcer covered by slough
Deep Tissue Injury
o Purple/maroon localized area of discolor intact skin or blood-filled blister d/t
damage of underlying soft tissue from pressure and/or shear
o Area may be painful, firm, muhys, warmer or cooler than surrounding tissue
Ecchymosis: discoloration of skin resulting from bleeding underneath usually caused by
bruising
Abrasion: superficial damage to skin no deeper than epidermis
Wound dehiscence
o Increased with infection; infection impairs collagen formation thus delaying
healing process
MRSA: methicillin-resistant Staphylococcus aureus; causes staph infection
Dx: inadequate oral intake, fluid intake, protein intake, vitamin intake (such as vit C),
mineral intake (such as zinc); increased nutrient needs; malnutrition
Sources: Nutrition, Physical Assessment, and Wound Healing. Megan Tempest, Erika
Siesennop, Kristin Howard, Hatherine Hartoin. Support Line. June 2010 22-29

Diabetes (Lakeside)
1. List risk factors for type 2 diabetes.
Age, obesity (fat accumulation. Larger adipocytes dont respond to insulin),
family history, genetic predisposition, history of GDM, impaired glucose
metabolism, physical inactivity, dyslipidemia
2. Describe lab values involved with the diagnosis of type 2 diabetes.
Glycated hbg level of 6.5% or more
Fasting plasma glucose level of 126 mg/dL or more (7.0 mmol/L)
2 hr plasma glucose level of 200 mg/dL or more during OGTT (11.1 mmol/L)
administering 75 g glucose
Classic symptoms of hyperglycemia or hyperglycemic crisis: random plasma
glucose value of greater than 200 mg/dL
Symptoms: polyuria, polydipsia, unexplained weight loss
Category
FPG test
HbA1c
2 Hr Plasma
Glucose test
Normal

< 100 mg/dL (<5.6

mmol/L)

< 140 mg/dL (7.8

mmol/L)

<5.7%

Impaired fasting
glucose and
impaired glucose
tolerance

100-125 mg/dL
(5.6-6.9 mmol/L)

140-199 mg/dL
(7.8-11.0 mmol/L)

Pre-DM 5.7-6.4%

DM

126 mg/dL (7.0

mmol/L)

> 200 mg/dL (11.1

mmol/L)

> 6.5%

3. List symptoms of hypo- (plasma glucose lower than 70 mg/dL or 4.0 mmol/L) and
hyperglycemia (first elevated postprandial glucose conc. Caused by insulin resistance at
cellular level then elevated fasting glucose conc.).
Hyper: glucotoxicity of inulin sensitivity and insulin secretion; caused by
impaired beta cell insulin secretion d/t functional defect in glucose secretion;
moderate decrease in beta cell mass; rates of hepatic glucose production elevated
d/t increased gluconeogenesis; skeletal muscle becomes insulin resistant; any
blood glucose level in excess of 110 mg/dL
o Frequent urination, increased thirst
o High levels of sugar in urine and high blood glucose
Hypo: sweating, trembling, difficulty concentrating, light-headedness, lack of
coordination alleviated by eating CHO foods; severe hypoinability to selftreat because of mental confusion, lethargy, unconsciousness
o Eat or drink 15-20 g glucose to raise glucose levels to 45-50 mg/dL
response to treatment apparent in 10-20 minutes
4. List complications associated with prolonged poor glycemic control.
Microvascular: Retinopathy, cataract, glaucoma blindness

Microvascular: nephropathy: microalbuminuria, gross albuminuria kidney

failure
Microvascular: neuropathy: peripheral, autonomic amputation
Macrovascular issues: CVD
o Thickening of lumen and decreased flexibility of vessels, increased BP,
accelerated atherosclerosis
5. Name 4 types of insulin and provide one example of each.
Type

Class

Intraven
ous

Name

Brand

Maker

Onset

Peak

Duration

Comments

Uman
regular (U100)

Humulin R

Lilly

Immediate

Novolog

<10
min

No differences in rapidacting and regular given

intravenously

Aspart

Apidra

NovoNordis
k

Immedia
te

30-90
min

< 5 hr

< 5 hr

At mealtime; pump
indication/CSII; control
glycemia following
meal/food intake

15-45 minutes prior to meal

Sanofi

Glulisine
Bolus
(subcuta
neous)

Rapid
acting

Lispro

Humalog

Lilly

5-15 min

Aspart

Novolog

novoNordisk

5-15 min

Glulisine

Apidra

Sanofi

5-15 min

30-90
min

< 5 hr

30-90
min

Basal
(subcuta
neous)

Short
acting

Human
regular (U100)

Humulin R

Lilly

30-60 min

2-4 hr

5-8 hr

Novolin R

NovoNordis
k

30-60 min

2-4 hr

5-8 hr

Interme
diate

Human NPH

Humulin N

Lilly

2-4 hr

4-10 hr

Human
regular (U500)

Novolin N

NovoNordis
k

2-4 hr

4-10 hr

10-18
hr

Humulin R
(U-500)

2-4 hr

4-10 hr

Lilly

10-18
hr

Once or twice day

Similar to NPH; use
tuberculin syringe

10-16
hr

Mixed
(subcuta
neous)

Long
acting

Glargine

Lantus

Sanofi

2-4 hr

None

24 hr

Detemir

Levemir

novoNordisk

3-6 hr

None

18-24
hr

Premixed

Human
NPH/regular

Humulin
70/30

Lilly

30-60 min

Dual

NovoNordis
k

30-60 min

Dual

10-18
hr

Novolin
70/30

10-18
hr

Usually once a day

All mixed insulins have dual

peaks reflecting combination
of rapid/short and
intermediate/long-acting
insulins; does not allow

Lispro
protamine/Li
spro
Lispro
protamine/
Lispro

Humalog
Mix 75/25
Humalog
mix 50/50
Novolog mix
70/30

Lilly

5-15 min

Dual

Lilly

5-15 min

Dual

NovoNordisk

5-15 min

Dual

10-18
hr
10-18
hr

independent manipulation of
insulin components; usually
bid

10-18
hr

Aspart
protamine/
Aspart

6. How does metabolic stress affect blood sugars?

Increased flux of metabolic substrates to liver cause increased gluconeogenesis
elevated hepatic glucose output rates
Stress-induced hyperglycemia (hyperglycemia associated with critical illness aka
stress DM)
Increased production of counterregulatory hormones: glucocorticoids,
catecholamines raise blood glucose levels by promoting hepatic
gluconeogenesis and glycogenolysis
Stress triggers systemic inflammatory response which increases production of
cytokines augment gluconeogenesis and worsen insulin resistance
Define:
Hemaglobin A1C: glycosylated hemoglobin ( normal range is 3.9-5.2%) used to monitor
long-term blood glucose control (avg. over 120 days)
Accu-check: SMBG monitoring via test strips; pierce finger with lancing device and get
meter reading

Renal (Lakeside)
1. Briefly define Hemodialysis and Peritoneal Dialysis
a. HD: removes excess toxic by-products of metabolism from blood through
selective membrane with use of artificial kidney dialyzer made out of hollow fiber
or parallel-plate dialyzers; ultrafiltration and diffusion; access site is either
arteriovenous fistula (AVF), arteriovenous graft (AVG), or catheter; treatments
usually 3x/wk for avg. 4 hr/treatment
b. PD: selective membrane is pts peritoneal wall (**be sure pt has adequate protein
due to albumin and aa losses here); dialysate introduced into peritoneum through
peritoneal catheter; three typescontinuous ambulatory peritoneal dialysis
(CAPD- dwell time of 4 to 6 hr followed by draining and replacement with fresh
solutionchange 4x/d), continuous cyclic peritoneal dialysis (CCPD- cycler fills
and empties abdomen 3-5x/night, once exchange during day with daylong dwell
time), and intermittent peritoneal dialysis; range of dextrose concentrations that
alter osmolality and assist in fluid removal (glucose absorption needs to be
considered when calculating energy)
2. Review the Renal Diet Patient Education Materials on Share Drive
a. Diet and Kidney Disease
i. PRO: HBV such as eggs, meat, fish, milk, poultry in proper amounts,
check urea
ii. Kcal: focus on CHO and fats (candies, oils, butters)
iii. Potassium: cant be too high; found in dried fruits, citrus fruits, bananas,
tomatoes, dried beans, green leafy vegetables, potatoes, nuts, milk,
chocolate, salt substitutes
iv. Sodium: low sodium, probably less than 1500 mg/d
v. Ca and Phos: phos binder to lower serum concentration as to not take
calcium from bones; take phos binder with food
vi. Fluid: measured amount in ccs; includes water, milk, cream, juices, pop,
alcohol, koolaid, gelatin, ice cream, soups, ice cubes, popsicle
b. Eating Right for Kidney Health: Tips for People with CKD
i. Grill, broil, bake, roast, stir-fry instead of frying for heart health
c. High Magnesium Diet
i. Important for proper nerve, muscle, heart, bone function
ii. Nuts, beans, unrefined grains, green vegetables, molasses, avocado
d. Kidney Test Results
i. GFR: kidneys filtering blood
ii. Urine albumin-to-creatinine ratio (UACR): checks for kidney damage
(want low number)
iii. Blood pressure: checks possible damage to heart
iv. Serum albumin: checks malnourishment
v. Bicarbonate: acid in blood
vi. BUN: urea in blood
vii. K: checks nerve and muscle function
viii. Ca: checks bone health
ix. Phos: checks bone and heart health
x. PTH: checks control of Ca and Phos in blood

xi. Vit D: checks bone and heart health

xii. A1c: avg. blood sugar for 2-3 months
xiii. Total-chol: could be sign of clogged blood vessels or arteries
xiv. HDL: good cholesterol
xv. LDL: bad cholesterol
xvi. TG: fat in blood
xvii. Hgb: sign of anemia
e. Phosphorus
i. Foods with low amounts: fresh fruit, rice milk, breads, pasta, corn and rice
cereal
ii. Eat smaller portions of foods high in PRO (2-3 oz. of meat, c milk or
yogurt, c nuts)
f. Potassium
i. Foods with low amounts: white rice, white bread and pasta, cooked rice
and wheat cereals, rice milk, apples, berries, rapes, watermelon,
honeydew, broccoli, corn, mushrooms, cucumber, bell pepper,
cauliflower, carrots, lettuce
g. Ways to Increase Calorie Intake While Following Renal Diet
i. 6-8 small meals throughout day (calorically dense)
ii. Drink fluids 1 hr before or after meals to avoid satiety during meal
iii. High kcal, pro supplements
iv. Mild physical activity to stimulate appetite
v. Add butter, margarine, sour cream, cool-whip, hard boiled eggs to meals
vi. Renal friendly snacks: sweetened applesauce, buttered popcorn, cottage
cheese with berries
Define:
CKD (chronic kidney disease) include causes of CKD
o Loss of excretory, endocrine and metabolic functions of kidney, defined as GFR <
60 mL/min/1.73 m3 for > 3 months
o 5 stages defined by GFR
Stage Description
GFR (mL/min per 1.73 m3) Action
1
Kidney damage
>90
Dx and treatment,
w/normal or increased
treatment of
GFR
comorbidities, slow
progression, lower
CVD risk
2
Kidney damage
60-89
Estimate progression
w/mildly decreased
GFR
3
Moderately decreased
30-59
Evaluate and treat
GFR
4
Severely decreased GFR 15-29
Prepare for transplant
5
Kidney failure
<15 or undergoing dialysis Transplant if uremia
present
o Causes: DM (elevate glucose damages kidney vessels) , HTN, glomerulonephritis,
African American ethnicity, family hx (apo1 gene), polycystic kidney disease,

direct/forceful blow to kidneys, prolonged exposure to aspirin and other meds,

Pima Indians
o Evidence that low PRO intake slows decline of GFR (0.6g/kg/d 0.7 g/kg/d for pt
without DM and not yet on dialysis)
AKI (acute kidney injury): abrupt- within 48 hr- reduction in kidney function defined as
absolute increase in serum creatinine of > 0.3 mg/dl, percentage increase of 50%, or
reduction in urine output of < 0.5 ml/kg/hr for more than 6 hrs)
Stage
1

Creatinine criteria
Urine output criteria
>0.3 mg/dl or increase to 150-200% from
<0.5 ml/kg/hr for > 6 hr
baseline
2
Increase to > 200-300% from baseline
<0.5 ml/kg/hr for > 12 hr
3
Increase to > 300% from baseline or 4.0
<0.3 ml/kg/hr x 24 hrs or
mg/dl with acute rise of at least 0.5 mg/dl
anuria x 12 hr
ESRD (end stage renal disease): kidneys can no longer support bodys needs, after last
stage of CKD; treatment involves dialysis or transplant; collective signs and symptoms
called uremia
o Anorexia, N/V, pericarditis, central nervous system abnormalities, peripheral
neuropathy
o GFR < 15
Glomerulonephritis: inflammation of glomeruli that damage function to filter waste and
fluids from blood
o Blood and PRO lost in urine
o Leading cause of nephrotic syndrome in adults
PCKD (polycystic kidney disease): cyst in kidney, strong positive family history, cyst
enlarges kidneys, reducing function and leading to kidney failure
o Cyst damages surrounding tissue, other cysts may form in liver
Nephrotic syndrome: urinary losses of albumin and other plasma proteins (> 3 g/d)
o Hyperlipidemia: increased synthesis of lipids
o Edema
o Causes: DM, lupus, infections, medications, PEC, neoplasms
o Want to avoid proteinuria so lower protein diet recommended
HIV associated nephropathy: failure of kidney cells due to HIV infection
o Usually begins with proteinuria and quickly progresses to kidney failure
o Especially prominent in black pt with HIV

Hepatobiliary (Lakeside/Lerner Tower)

1. What conditions can lead to cirrhosis? Gressner, J Cell Mol Med, 2007
Liver cell injury due to HBV and HCV infections (also bacterial), autoimmune
attacks (primary biliary cirrhosis, primary sclerosing cholangitis, sarcoidosis),
parasites, cholestasis, metabolic disease (Wilson disease, alpha-1-antitrypsin
deficiency), venous obstruction, alcohol ASH, cryptogenic, drugs and toxins
(medications, industrial chemicals like vinyl chloride, aflatoxins, poisonous
mushrooms), obesitas NAFLD (often due to metabolic syndrome or insulin
resistance)
o Triggers inflammation which results in production of fibroblast cells
(EMT and monocytes) in extracellular matrix which interferes with blood
flow through liver
o Activation of hepatic stelliate cells (HSC)
o Expansion of myofibroblasts (MFB) pool
Fibrosis occurs which leads to cirrhosis
2. Describe the nutritional implications of these symptoms associated with cirrhosis: ascites,
edema, anasarca.
Ascites: edema in abdomen consequence of portal HTN, reduced serum
protein synthesis and sodium and water retention by kidneys; causes accumulation
of body fluid leaking out of gut into peritoneal cavity
o Causes abdominal discomfort and reduced appetite; linked to malnutrition
o Feeling of fullness and early satiety
Edema: fluid accumulation, exacerbated by low serum albumin
Anasarca: overall body edema
If pt experiencing any type of fluid accumulation, should be on low sodium diet
less than or equal to 2 g/d
When calculating nutritional needs, must use estimated dry weight
Water restriction
Frequent, small meals including bedtime snack recommended (reduce breakdown
of LBM during night fast)
3. What causes jaundice?
Excessive amounts of serum bilirubin dissolve in subcutaneous fat
Yellowish appearance of skin and whites of eyes
May turn urine a darker color
Reduction of ability of liver to remove and modify bilirubin (deterioration in
hepatic synthetic function)
4. Describe the following types of hepatitis: A, B, C inflammation of liver tissue
Hepatitis A: disease spreads through contact with infected stool; flu-like
symptoms, jaundice
HBV: disease spreads through contact with infected blood, semen, or other body
fluid (can pass from mother to infant during childbirth); same symptoms as HAV;
chronic HBV can lead to cirrhosis, liver failure, or liver cancer
HCV: disease spreads through contact with infected blood, sex, and mother to
infant; pt may be asymptomatic for years; can lead to cirrhosis, liver failure, liver
cancer

5. Define Wilsons disease. How is it diagnosed? What is the nutrition therapy?

Rare heterogeneous inborn disorder of copper metabolism due to mutations in
ATP7B gene
Accumulation of copper leads to hepatic disease because of improper biliary
excretion of copper
Diagnosed by serum ceruloplasm, 24 hr urine copper, slit-lamp eye examination,
and liver biopsy with hepatic copper quantification
Treatment: use of chelating agents to remove tissue copper and allow excretion in
urine
o Usually penicillamine and trientine
Zinc therapy: induces metallothionein and reduces dietary copper absorption
Pt should avoid foods high in copper such as liver, chocolate, shellfish, nuts
6. Explain the difference between an ERCP and MRCP.
ERCP: endoscopic retrograde cholangiopancreatography: upper GI endoscopy
and xrays treat problems in bile and pancreatic ducts; used to diagnose problems;
treatment usually delivered during procedure; used when bile or pancreatic ducts
narrowed/blocked due to tumors, gallstones in gallbladder, infection,
inflammation, closed sphincters, scarring of ducts (sclerosis), pseudocysts
MRCP: magnetic resonance cholangiography (diagnostic): non-invasive unlike
ERCP: evaluates intrahepatic and extrahepatic bile ducts and pancreatic duct;
doesnt allow intervention treatments to be made at same time such as stone
extraction
7. What is the association of the following with cirrhosis: portal hypertension,
esophageal/gastric varices
Portal hypertension: scar tissue on liver impedes blood flow thus this resistance
causes an increase in BP within portal vein (liver perfused by this vein)
Esophageal varices may protrude into lumen and be vulnerable to rupture and
bleeding; may be an issue when placing nasoenteric tube if needed by pt
8. What three lab values make up the MELD score? What is the significance of the MELD
score for a patient who is awaiting a liver transplant?
MELD score: model for end stage liver disease score (prognostic); ranges 6-40
Lab values: serum bilirubin, serum creatinine, and international normalized ratio
(INRclotting of blood)
Indicates risk of death without liver transplant
9. Discuss what the medications lactulose and rifaximin do for a patient with cirrhosis.
Lactulose (synthetic sugar laxative to treat constipation and liver problems): antiencephalopathy agent but may cause malnutrition due to increased occurrence of
diarrhea ; products broken down in colon pull water out from body and into colon
to soften stools; reduces amount of ammonia in blood by drawing into colon for
removal (helps prevent esophageal varices)
Rifaximin (antibiotic): help prevent hepatic encephalopathy by stopping growth
of bacteria that produces toxins which may worsen fibrosis of cirrhosis
10. Explain what the protein requirements are for someone with cirrhosis. What are branched
chain amino acid supplements used for? (See reference)

PRO: 1.0-1.5 g/kg/d, likely to have PEM (this is usually well tolerated, protein
restriction not needed)
Leucine, valine, isoleucine: one study found that high dose of oral BCAA (12 g/d)
given to pt with cirrhosis without history of hepatocellular carcinoma lower
incidence of HCC after 6 months of therapy
Another study: improve quality of life, increased event-free, improved serum
albumin concentrations
Improve intractable encephalopathy
11. Describe how TPN can lead to liver dysfunction.
Infection, metabolic complications
Young pt on TPN especially at risk for liver dysfunction
Theories: nutrients delivered to body first and not intestines/liver; loss of
hormones given to liver after passage through GI tract; increase in bacteria that
reach liver; altered blood flow to liver

Cardiac/Hypertension (LT 5, CICU)

For the following as it applies to the various categories and questions: define, list causes, list
treatments, list medications, list types, pathogenesis, risk factors, and complications.
1. What is the difference between the myocardial infarction and a cardiac arrest?
a. Types :
o non St elevation myocardial infarction (NSTEMI): development of cell death
in heart muscle without ECG change of ST-segment elevation (partial
thickness) d/t acute interruption of blood supply to part of heart; look for
elevated CK or troponin in blood
o St elevation myocardial infarction (STEMI): full thickness injury of heart
muscle, more severe heart attack
o Risk factors: high cholesterol, HTN, DM, smoking, age, male gender, family
hx, physical inactivity, obesity, excess EtOH, excess CHO intake, social
deprivation, competitive and stressful lifestyle, deficient intake of fresh
vegetables/fruit/polyunsaturated fats
b. MI: blood supply to part of heart reduced/interrupted (lack of blood flow: coronary
ischemia)blockage d/t CAD from plaque build up
o Diet treatment: limited intake of saturated fat, cholesterol, trans fatty acids,
balanced intake of fruits, veggies, whole grains, fiber, soluble fiber, lean
protein, omega-3 FA, 2 g sodium, monitor fluids
o Causes: elevated cholesterol and blood lipids arterial plaque, plaque also
may be caused by inflammation, infection, cell damage
o Treatment: medication, lifestyle changes, angioplasty, coronary artery bypass
graft surgery
o Labs: PT, INR to measure rates of blood coagulation (pt may be on
Coumadin); normal PT: 11-13 seconds; therapeutic range of INR twice
normal value: 3.0-4.5
Vit K measure clotting factor
Troponin: protein released within few hours after damage to myocardium,
indicating MI; normal troponin I <0.35 ng/mL and normal troponin T <0.2
ng/mL after MI will peak at 12 hours for troponin I and 12-48 hours for
troponin T (troponin I > 1.5 ng/mL critical)
CK: indicates damage to myocardium; normal for men: 38 to 174 U/L; normal
for women: 26-140 U/L
LDL < 100 mg/dL optimal
Total Chol < 200 mg/dL
HDL >40 mg/dL
TG < 150 mg/dL
FBG: < 100 mg/dL
BUN, creat, alb, electrolytes
o TLC diet: <7% energy from saturated and no trans fat
<200 mg cholesterol/day
25-35% total energy from fat with unsaturated omega-3s emphasized
50-60% total energy from CHO with 25-30 g fiber/d (least half soluble); 2 g/d
plant stanols/sterols
15% total energy from POR

o
o
o

2.

3.

4.

5.

Fluids: 35 mL/kg/d
Complications: heart arrhythmia, acute heart failure, cardiogenic shock, mitral
regurgitation, Dresslers syndrome (fever, pleuritic, pericarditis, caused by
autoimmune rxn to damage), chronic heart failure
Meds: opiate analgegics, anti-platelets, anti-coagulants, beta-blockers (reduce HR,
BP), nitrates (vasodilators, pain relief), statins, ACE inhibitors, coronary angiography

c. Cardiac arrest: heart stops due to arrhythmia

o Causes: ventricular tachycardia/ ventricular fibrillation
o Risk factors: similar to those of CHDsmoking, dyslipidemia, HTN, physical
inactivity, obesity, DM, family hx
o Meds: ICD therapy (implantable cardioverter defibrillator), anti-arrhythmic
drugs
o Treatment: heart healthy diet, heart healthy lifestyle , omega-3s
What is Cardiac Cachexia?
a. Wasting syndrome: loss of body weight and muscle mass sign of malnutrition
b. Bloated abdominal, sodium and fluid abnormalities
c. Skeletal muscle wasting, fatigue, anorexia
What is a Hypothermia Protocol (Arctic Sun Protocol)?
a. Therapeutic protocol to minimize brain injury to improve care of pt after
resuscitation from cardiac arrest (neurologic injury is most common cause of
death after cardiac arrest)
d. When is it used; for how long of a period
o First hours after cardiac arrest, maintained for 12-24 hours with gradual
rewarming
o Lower core body temp to 33-34 degrees Celsius
o Used when pt not following commands after resuscitation such as during
cerebral edema, seizure activity
Define types of heart failuredetermined with echocardiogram
e. Systolic: LVEF (ejection fraction: 50-60%) <50%
o Diet modifications limit sodium and fluid intake to correct
f. Diastolic: heart muscle not completely relaxed when at rest, very rigid heart
cannot fill completely with blood
o Ejection fraction shows as normal
o Managed with medications
What are the major types of arrhythmias?
a. Four main types: premature (extra) beats, supraventricular, ventricular, and
bradyarrhythmias
b. 1. Premature beats: atrial premature beats (APBs, PACs), ventricular premature
beats (VPBs/PVCs)
i. Happen naturally
ii. May be due to too much stress, exercise, caffeine, or nicotine
c. 2. Supraventricular (tachycardias), start in atria or AV node: atrial fibrillation
(AF), atrial flutter, paroxysmal supraventricular tachycardia (PSVT), and WolffParkinson-White (WPW) syndrome
i. AF: most common arrhythmia, signal doesnt begin in SA node and
doesnt travel normally atria doesnt pump blood into ventricles
properly, dangerous if ventricles beat very fast; major complications

stroke and heart failure; may be caused by high blood pressure, CHD,
rheumatic heart disease, inflammation, overactive thyroid, heavy alcohol
use; risk increases with age
ii. Atrial flutter: electrical signals spread through atria in fast and regular
rhythm; similar complications and symptoms as AF but less common
iii. PSVT: very fast heart rate with sudden onset and end; caused by issues
with electrical connection between atria and ventricles; can happen during
intense physical activity
iv. WPW: electrical signals travel along extra pathway from atria to
ventriclesdisrupts timing, causes ventricles to beat very fast (life
threatening)
d. 3. Ventricular arrhythmias: start in lower chambers, very dangerous, require
immediate medical attention
i. Ventricular tachycardia: fast, regular beating of ventricles that lasts for
only a few seconds or for much longer (only a few seconds dont lead to
other problems but if they last long, can turn into more serious
arrhythmias)
ii. Ventricular fibrillation (v-fib): abnormal electrical signals make ventricles
quiver rather than pump (adequate blood flow not supplied to body); can
lead to SCA and death within few minute; condition must be treated
immediately with heart defibrillator; may occur during or after heart attack
or in those with weak hearts
e. 4. Bradyarrhythmias: heart rate slower than normal, may not allow blood to reach
brain if beat is too slow (<60 BPM); may be caused by heart attacks, underactive
thyroid gland, aging, chemical/electrolyte imbalance, medications (beta blockers,
calcium channel blockers, anti-arrhythmics, digoxin)
i. Bradycardias, sinus bradycardia
f. Atrioventricular block
g. Non-sustained ventricular tachycardia
6. What is cardiopulmonary arrest? See above for cardiac arrest
7. Define cardiopulmonary resuscitation (CPR)
a. Chest compressions, cleared airway, rescue breathing
b. Needed seconds after cardiac arrest to prevent brain damage or death
c. Pt who received bystander CPR had better survival than pt who had delayed CPR
from EMS
8. What is angina pectoris? (CP)
a. Chest pain, usually occurs with activities or stress due to impaired blood flow
through blood vessels in heart
b. Associated with myocardial ischemia
i. Oxygen demand exceeds supply
c. Causes: coronary arteries blocked by atherosclerosis or blood clot; most common
causeCAD
d. Risk factors: DM, HTN, high LDL low HDL, smoking, arrhythmias, anemia,
coronary artery spasms, heart failure, heart valve disease, hyperthyroidism, pt
with heart diseasecold weather, exercise, emotional stress, large meals

e. Symptoms: feelings of tightness, pressure, squeezing, crushing in chest which

may spread to arm (usually left), back, jaw, neck, shoulder
f. Treatment: lifestyle modification, medication, coronary angiography with stent
placement, CABG
i. Meds: ACE inhibitors, beta blockers, calcium channel blockers, nitrates,
ranolazine
Heart Disease
1. What are the similarities and differences with the following types of heart disease?
a. Congenital: structural issue with heart presented at birth
o Cyanotic: ebsteins anomaly, hypoplastic left heart, pulmonary atresia,
tetralogy of fallot, total anomalous pulmonary venous return,
transposition of great vessels, tricuspid atresia, truncus arteriosus
o Non-cyanotic: aortic stenosis, atrial septal defect, atrioventricular
canal, coarctation of aorta, patent ductus arteriosus, pulmonic stenosis,
ventricular septal defect
b. Ischemic (CAD): most common type; one or more symptoms, signs, or
complications from inadequate blood supply to heart usually due to obstruction
or coronary arteries such as from atherosclerosis
o Angina pectoris, MI, blood clot
c. Rheumatic: emphasis on developing nations and poverty; usually occurs in
childhood or adolescence; acute rheumatic fever (ARF) from bacterial
infection causes inflammation and lesions from pericarditis, myocarditis,
valvulitis
o Usually affects left heart valves
o Symptoms: SOB, edema, fatigue, rapid heartbeat
d. Valvular: heart valves do not work properlyissues may be present at birth,
caused by infections, heart attacks, or heart damage; main symptom is heart
murmur
o Regurgitation, mitral valve prolapse, stenosis
o Common in elderly
2. Cardiomyopathy (enlarged heart muscle, includes rigidity) and Heart failure
Dilated cardiomyopathy (DCM): dilation and impaired contraction of one or both
ventricles; hypertrophy of heart; impaired systolic function
Hypertrophic cardiomyopathy (HCM): hypertrophy of left ventriclenormal or
reduced volume; diastolic dysfunction
Restrictive cardiomyopathy (RCM): non-dilated ventricles with impaired
ventricular filling; less common
Arrhythmogenic right ventricular cardiomyopathy/dysplasia: ventricular
arrhythmias, fatty tissue causes abnormal right ventricle function
Unclassified cardiomyopathies
Causes: genetics, inflammation, metabolic issues, toxins, other co-morbidities
(ischemic, valvular, hypertensive diseases)
a. When does the Heart Failure result?
o Identified by ECG evaluation
o Assessment of LVEF (systolic dysfunction) <50% (normal: 50-60%)

Stage
A
B

C
D

o Heart cant pump enough blood to meet bodys needs, can affect one
side of heart or both result from cardiac dysfunction
o Blood flow to kidneys diminished problematic hormonal response
vasoconstriction fatigue, edema, SOB, CP
o Causes: CAD, HTN, DM, MI, in elderly: elevated natriuretic peptides
Classification Description
High risk
Pt doesnt have structural heart disease or symptoms. Pt has HTN,
atherosclerosis, DM, obesity, MS
Asymptomatic Pt doesnt experience symptoms although structural damage to
heart such as enlarged left ventricle (LV hypertrophy or previous
MI)
Symptomatic Pt has structural changes in heart, experiences symptoms such as
SOB, fatigue, reduced tolerance to activity
Advanced
Structural changes, experiencing symptoms at rest despite
disease
medications and treatment

New York Heart Association

Functional Classification
NYHA Class I
NYHA Class II
NYHA Class III
NYHA Class IV

Descriptor
Asymptomatic, pt not SOB or fatigued during activity
Pt SOB/ fatigued after moderate activity (climbing two flights
of stairs, carrying load of laundry)
Pt SOB/fatigued after mild exertion (walking around house or
up half flight of stairs)
Pt exhausted, SOB, fatigued at rest

b. What are some of the treatment?

o Goals: manage fluid retention, SOB, fatigue long term goal is to
reduce hearts workload, provide better QOL
o Nutrition treatment: 2 g Na diet, maintain/achieve appropriate weight
o Medications: anti-coagulants, hypertensive meds, K repletion, antiarrhythmics
o Procedures: CABG, heart valve surgery, pacemaker, defibrillator
3. What is Cardiac Tamponade?
Accumulation of pericardial fluid under pressure compression of cardiac
chambers; caused by pericardial effusion
Chambers become smaller and diastolic pressure reduced
Cardiac volume lowers during ejection, cardiac output declines, blood pressure
falls
Low pressure, regional cardiac tamponade
May be associated with aortic aneurysm, end-stage lung cancer, MI, heart
surgery, pericarditis, injury to heart, hypothyroidism, kidney failure, leukemia,
XRT to chest, SLE
Symptoms: anxiety, restlessness, CP to other parts of body, SOB, discomfort,
fainting, pale/gray/blue skin, palpitations, rapid breathing, swelling, dizziness,
fatigue, weak pulse
4. What is and when is a Coronary Artery Bypass Graft needed and for whom?

Recommended for patients with obstructive coronary artery disease whose

survival will be improved compared to medical therapy or PCI (percutaneous
coronary intervention) or those who cannot receive PCI
CABG creates new path for blood to flow to heart via vein from leg or artery from
chest/wrist; attached to coronary artery above/below blockage
5. What is mechanical ventilation and how is nutrition considered in treatment of and used?
Mechanical ventilation/positive pressure ventilation: oxygen and other gases is
forced into central airways to flow into alveoli set by an inspiratory trigger; ends
with termination signal causes ventilator to stop forcing air into lungs and
decreasing intraalveolar pressure
Indicated for acute or chronic respiratory failure
Ventilation can take on some or all increased work of breathing, helping to save
body from working harder and burning more kcal to breath decreasing elevated
risk of malnutrition
Need EN or TPN
6. When is cardiac catherization used? Procedure used diagnosed and treat some heart
conditions
Used to asses cause or severity of cardiac abnormality
Thin, flexible tube put into blood vessel in arm, groin, or neck (femoral or radial
arty) and thread to heart
Can be used for coronary angiography (dye to asses build-up of plaque)
Routine hemodynamic measurements: aorta, left ventricle, right ventricle, right
atrium, pulmonary artery, pulmonary artery wedge position
7. What is cardiomyopathy and heart failure
Cardiomyopathydisease of heart; various structural and functional types (disease of
myocardium associated with mechanical/electrical dysfunction) frequently genetic
a. Dilated (DCM): dilation and impaired contraction of one/both ventricles
followed by increase in total cardiac mass; impaired systolic function
Hypertrophic (HCM): hypertrophy of LV and sometimes RV; LV volume
normal or reduced, diastolic dysfunction present
Restrictive (RCM): non-dilated ventricles with impaired ventricular
filling, there may be increase in LV wall thickness; systolic function
normal for most part; less common than DCM or HCM
Arrhythmogenic right ventricular cardiomyopathy/dysplasia: genetically
determined; ventricular arrhythmias; RV free wall replaced by fibrous
tissue with residual myocardial cells; RV function abnormal
b. Treatments: device therapy (pacemaker, ICD), resynchronization therapy
with biventricular pacing, revascularization
c. Nutrition intervention: Na restriction, fluid restriction
d. Medications: ACE inhibitor, beta blocker, statin, loop diuretic; *avoid
NSAIDs, antiarrhythmic drugs, non-dihydropyridine Ca channel blockers
Heart Failure
a. Heart enlarged with weakened pump inability to pump blood properly
throughout body leaders to fatigue, limited mobility, exercise intolerance,
chest congestion, shortness of breath, edema; LVEF < 40-50% (low LVEF

referred to as systolic HF HFrEF); diastolic HF heart muscle too rigid

and doesnt completely relax at rest (EF preserved HFpEF)
b. Treatments: management of contributing factors and conditions (HTN
primary cause, MI, DM, thyroid dysfunction, infection), lifestyle
modification (restriction of alcohol, cessation of smoking, weight loss;
possible device therapy (Implantable cardioverter-defibrillator-ICD,
cardiac resynchronization therapy- CRT)
c. Nutrition intervention: main concerns include adequate pro and kcal
intake, Na and fluid intake (less than 2-3 g Na restriction and 2 L fluid/d)
with serum Na below 130 mEq/L; thiamine and potassium
supplementation PRN; folate, B12 (200-500 mcg daily), Mg; limit alcohol
to one drink per day for women and two drinks per day for men
d. Medications: beta blocker, ACE inhibitor, angiotensin II receptor blockerARB, mineralocorticoid receptor antagonist-MRA, loop diuretics, nitrates,
vasoselective calcium channel blockers, digoxin, aldosterone antagonist
8. Myocardial Infarction (MI)
What is the most common triggering event leading to an MI? Caused by ischemia
AEB myocardial injury or necrosis
Most MI occur because of CHD (http://www.nhlbi.nih.gov/health/healthtopics/topics/heartattack/causes)
According to Cleveland Clinic, certain triggers have also been identified such as too
much exertion too quickly, cold temperatures, intense emotions, and eating a big
meal (http://health.clevelandclinic.org/2014/01/surprising-heart-attack-triggers)
Define:
Anasarca: Whole body fluid retention
Edema: Fluid retention
Dash Diet: diet to reduce blood pressure, servings below based on 2000 kcal diet
o Low SF
o 7-8 servings whole grains
o 4-5 servings vegetables
o 4-5 servings fruits
o 2-3 servings low-fat or fat-free dairy
o 2 or less servings meats, poultry, fish
o 4-5 servings per week of nuts, seeds, dry beans
o 2-3 servings of unsaturated fats and oils
o Reduced red meat, sweets, sugar-sweetened beverages
o High magnesium, potassium, calcium, protein, fiber
Arrhythmia: Irregular heart beat
o Four main typessee above
Bradycardia: Slow heartbeat, <60 BPM
Myocardial Infarction (MI): Necrosis of myocardial cells due to oxygen deprivation
Ischemia: inadequate blood supply to heart, lack of blood flow
Angina: Chest pain due to deficiency of oxygen to heart
o Stable (during physical activity) and unstable (during rest)
PCI: percutaneous coronary intervention

o Catheter from artery in groin to trouble spot in artery of heart

o Balloon inflated, compressing plaque and dilating coronary artery so blood can
flow better
o Usually followed with placement of stent
Stents: wire-meshed tubes placed in arteries after PCI to keep arteries open and blood
flowing
Homocysteine: intermediary aa formed from methionine to cysteine; metabolized by
either transsulfuration or remethylation (need B6 and B12); high levels associated with
increased risk of CVD
Troponin: protein released into blood after damage to heart muscle occurs (after heart
attack)
o Troponin T/troponin I
Cardiomyopathy: disease of myocardium (see above)
o Cardiac Cachexia: Wasting syndrome: loss of body weight and muscle mass
sign of malnutrition
o Bloated abdominal, sodium and fluid abnormalities
o Skeletal muscle wasting, fatigue, anorexia
Congestive Heart failure (CHF): Condition when ventricles cannot properly eject blood
from heart or to fill with blood
Coronary Artery Bypass Graft (CABG): procedure that generally uses saphenous
vein/internal mammary artery to bypass blocked vessel
Systolic Pressure: Pressure from ejection of ventricles
Diastolic Pressure: Pressure as ventricles relax
CVVH: continuous venovenous hemofiltration, similar to CAVH (continuous
arteriovenous hemofiltration); need use of blood pump; used to remove fluid
ECMO: extracorporeal membrane oxygenationcardiopulmonary support; venoarterial
and venovenous (both respiratory support but only VA provides hemodynamic support as
well)

References: NHLBI, NCM, Up-to-date

Neurology (LT4, NSU)

1. Please describe the difference between a hemorrhagic stroke, ischemic stroke, and a TIA.
Hemorrhagic stroke: less common, occurs when blood vessel breaks and bleeds
into brain; brain cells begin to die
o Causes: bleeding aneurysm, arteriovenous malformation (AVM) or artery
wall breaks open
o May also be caused by elevation in blood pressure or medications that
result in excessive bleeding
Ischemic/embolic/thrombotic stroke: blood clot blocks blood vessel in brain
which keeps blood from flowing properly; may also be caused by stenosis d/t
atherosclerosis
o Inadequate oxygen supply to brain
o Temporary or permanent loss of function
o Blood clot often travels to brain (embolic)
o Plaque within cerebral artery ruptures and platelets aggregate and obstruct
already narrowed artery (thrombotic)
TIA (transient ischemic attack): stroke that comes and goes quickly d/t brief
stoppage of blood supply to brain
o At risk for recurrent stroke
o Symptoms usually disappear within an hour to 24 hours
Symptoms: numbness/weakness of face, arm, or leg (usually on one side of body),
confusion, trouble speaking/understanding speech, trouble walking, dizziness,
loss of balance, severe headache
2. What are some risk factors for stroke? Lifestyle factors? Current dietary interventions and
recommendations?
Risk factors: HTN; DM; dyslipidemia; obesity; high intake of sodium, saturated
and trans fats, cholesterol; low intake of fruits, vegetables, fiber, omega-3 fatty
acids
Criteria to assign risk: Framingham 1-year risk score
Lifestyle risk factors: cocaine use, heavy alcohol intake, smoking
Dietary interventions: control DM, weight management, HTN, and lipid profile
o DASH diet to manage HTN
Intervention for ischemic and TIA: identify and limit sources of saturated fat,
cholesterol, sodium, hydrogenated oils; select unsaturated fat sources including
monounsaturated and omega-3 polyunsaturated fat within total fat intake of 2535% of total energy intake; include vegetables, fruits, whole grains, low-fat dairy
products, dietary fiber, plant sterols and stanols; read food labels; 3.7 L fluids for
men and 2.7 L fluids for women; increase fiber; begin exercise program, manage
weight, manage blood glucose as needed (pt with BMI >25 should lose weight at
rate of 1-2 lbs per week for first 6 months)
Intervention for hemorrhagic stroke: BP <140/90 mmHg or <130/30 mmHg for pt
with DM or CKD; lose weight if over BMI of 25; chose diet low in fat and rick in
vegetables and low-fat dairy products; reduce intake of sodium; be moderately
Revised 7/2015

active for at least 30 min day most days of week; reduce alcohol consumption (2
drinks/d for men and 1 drink/d for women)
Intervention for pt with disorders of lipid metabolism: saturated and trans fat less
than 7% total energy intake (no trans fat) focus on whole grains and
unsaturated fat; total fat limited to 25-35% of total kcal intake; cholesterol <200
mg/d; plant sterols/stanols 2-3xd for total of 2-3g/d; antioxidant rich foods;
omega-3 fatty acids (two or more servings of 4oz fish per week); total fiber intake
21-25 g/d females and 25-38 g/d men with emphasis on soluble fiber (7-13 g/d)
such as whole grains
Intervention for pt with metabolic syndrome: kcal controlled diet, energy
reduction for 7-10% weight reduction from baseline, limited added sugar and fat;
physical activity most days of week for 30 minutes
Intervention for pt with elevated TG: kcal controlled diet, energy reduction,
limited added sugar and fat; use of omega-3 fatty acids
Intervention for pt with HTN: DASH diet1600 to 2300 mg Na/d
Warfarin and vitamin K: need consistency; RDA is 65-80 mcg/d (1 cup of green
leafy vegetables will exceed this); high doses of Vit E contraindicated in pt taking
warfarin
o With ischemic stroke, prothrombin time may need to be increased
o With hemorrhagic stroke, PT may need to be decreased
3. What is dysphagia and explain the pathophysiology of dysphagia following stroke.
Dysphagia: difficulty swallowing caused by issue in swallowing mechanism
Phase one of swallowing: oralbolus propelled into pharynx where swallow
triggered
o voluntary
Phase two of swallowing: pharyngealswallow triggered and bolus moves
through pharynx to cricopharyngeal sphincter (upper esophageal sphincter) which
opens to allow food to enter esophagus
o Voluntaryaffected during stroke
Phase three of swallowing: esophagealbolus propelled from upper esophageal
sphincter to LES by peristalsis
4. Please describe the national dysphagia guidelines incorporating the different diet levels.
Grade of dysphagia:
o 1: middle but can eat regular diet
o 2: pureed, soft, or liquid diet
o 3: need for feeding tube, IV hydration
Liquid consistencies
o Thin: regular liquids, no adjustment needed (ex. Tomato juice, water)
o Nectar: falls slowly from spoon and can be sipped through straw or from
cup
o Honey: drops from spoon but too thick to drink through straw (ex. Tomato
sauce)
o Spoon: maintains shape, needs to be eaten with spoon, too thick to drink
(ex. Pudding)
Food consistencies
o Dysphagia level 1: pureed pudding-like texture; add gravies, sauces,
vegetable broth, milk, cream to puree

o Dysphagia level 2: mechanically altered blend, chop, grin, mash foods;

moisten foods
o Dysphagia level 3: advanced food should be moist and in bite-size
pieces; avoid sticky and crunchy foods
5. Explain the role of Sinemet in symptom control of those who suffer from Parkinsons.
Please describe any food and drug interactions and any dietary recommendations you
would give to a patient taking Sinemet.
Sinemet (Carbidopa and levodopa): oral med for Parkinsons (lack of striatal
dopamine) that works by circulating levodopa in plasma to blood-brain-barrier
where it can be converted by striatal enzymes to dopamine; carbidopa inhibits
peripheral plasma breakdown of levodopa by inhibiting its decarboxylation
o Increases availability of levodopa at blood-brain-barrier
Food-drug interactions: high protein diets have potential to impair levodopa
absorption
o Levodopa competes with certain aa for transport across gut wall or across
BBB
Dietary recommendations: avoid high protein diets
Define:
Aphasia, including expressive aphasia, receptive aphasia, and global aphasia.
o Aphasia: language disorderproblems reading, writing, meaningful speech
o Expressive aphasia: issues saying or writing what is meant; language understood
o Receptive aphasia; cannot understand words when heard or read
o Global aphasia: cant speak, understand speech, read, or write
o Anomic aphasia: issue using correct term for objects, places, or events
Dysarthria: problem with controlling mouth and throat in order to form clear speech
o Slurred speech, speak softly/whisper, speak too quickly/slowly, drool, issues
eating; facial droop
References: Medline Plus NLM, NCM, Up-to-date

Pulmonary (MICU)
Define and answer the following:
1. Pneumonia: infection in one or both of lungs
a. Are there different types of pneumonia? If so, what are they?
Aspiration pneumonia: food/liquid/salvia gets into lungs
Hospital acquired pneumonia/health-care acquired pneumonia (HCAP):
occurs 48 hours or more after admission to hospital that wasnt present at
time of admission
o In pt with IV therapy or chemotherapy or wound care within
previous 30 days
o At risk: residents of nursing homes or LTC, pts in acute care
hospitals for two or more days within previous 90 days or in
hemodialysis clinic within last 30 days
Community-acquired pneumonia (CAP): most common, infectious from
streptococcus pneumoniae, viruses, haemophilus influenzae
b. What is the appropriate medical abbreviation for pneumonia? PNA
c. Nutrition recommendations:
pt are in hypermetabolic/catabolic state
1.0-1.5 g pro/kg
o PNA complicated by sepsis: 1.6-2.0 g pro/kg; watch for urine urea
nitrogen
Small frequent snacks may be better tolerated d/t SOB
Goals are to prevent anorexia, SOB, N/V
2. Pneumonitis: inflammation of alveoli in lungs
a. May be caused by airborne irritants, medications, or cancer treatment
b. Symptoms: difficulty breathing and dry cough
3. Pneumothorax: collapsed lungair gets into space between lungs and chest wall; may be
caused by chest injury
a. What is the appropriate medical abbreviation for pneumothorax? PTX
4. Hemopneumothorax: air and blood in chest cavity
5. Chest tube: hollow, flexible tube in chest that acts as drain for blood, fluid or air from
around lungs to allow full expansion
a. Tube placed between ribs and into space between pleural space
6. Asthma: walls of airways sore, swollen, sensitive react strongly to allergies and
irritants; airways contract under irritation making it more difficult to take in air
7. COPDumbrella term for chronic bronchitis, emphysema, and other lung disorders;
lungs elastic recoil reduced and airway resistance increased
a. What does it stand for? Chronic obstructive pulmonary disease
b. How is it staged? Global Initiative for Chronic Obstructive Lung Disease (GOLD)
use forced expiratory volume in one second but FEV only captures one
component of COPD; symptom severity assessed using mMRC or CAT (number
of exacerbations in previous year used to predict future risk)
Group A: low risk, less symptoms, GOLD 1 or GOLD 2 (mild or
moderate airflow limitation) and/or 0-1 exacerbation per year
Group B: low risk, more symptoms, GOLD 1 or 2 and/or 0-1 exacerbation
per year
Group C: high risk, less symptoms, GOLD 3 or 4 (severe or very severe
airflow limitation), and/or 2 exacerbations per year

 Group D: high risk, more symptoms, GOLD 3 or 4, and/or 2 exacerbations

per year
c. What are the energy and protein needs of a patient with COPD?
Energy and protein needs increase with increased work of breathing,
chronic infection, chest PT, pulmonary rehab exercise programs, altered
metabolism (hypermetabolism)
d. What are some physical signs that a patient COPD may exhibit?
Dyspnea, wheezing
Persistent cough
Increased breathing rate
Barrel chest: lungs chronically overinflated with air
Crackles heard with breathing
Cyanosis: deoxygenated hemoglobin in blood vessels near skin surface
Digital clubbing (thickening of skin under fingernails and toenails), nails
curve downward
e. What are some barriers to adequate nutrition that a COPD patient may encounter?
Unintential weight loss
Diminished appetite and lack of interest in eating
Inability to shop and prepare meals
Exhaustion
SOB
8. Emphysema: damage to alveoliabnormal and permanent enlargement of airspaces
distal to terminal bronchioles
a. Moderate to severe obstruction
9. Interstitial Lung Disease
a. What is the appropriate medical abbreviation for interstitial lung disease? ILD
b. Group of disorders that inflame or scar lungspulmonary fibrosis
c. May be caused by breathing in dust or other irritating particles (coal, farm dust,
asbestos fibers, iron, silica dust)
10. Pulmonary Hypertension: high blood pressure in arteries of lungs
11. Be familiar with the different methods of oxygenating a patient on a med-surg floor:
nasal cannula: lightweight and flexible tube fitted into nostrils; used to deliver
supplementation oxygen; delivers inspiratory oxygen fraction of 24-40% at
flows from 1-5 L per min (influenced by breath rate, tidal volume,
pathophysiology)
Bipap: bilevel positive airway pressure: high pressure when pt breathes in and
lower pressure when pt breathes out; used for airways that collapse while
sleeping, decreased air exchange in lung, muscle weakness
CPAP: continuous positive airway pressure; prevents episodes of airway
collapse that block breathing in people with OSA pt with respiratory failure,
COPD, HF

Venturimask: mask mixes oxygen with room air to create high-flow enriched oxygen; used
when CO2 retention is a concernprovides accurate and constant inspiratory oxygen fraction
12. Hypercapnia or hypercarbia: abnormally high carbon dioxide levels in blood
13. Identify the following abbreviations:
a. SOB: shortness of breath
b. WOB: work of breathing
c. DOE: dyspnea on exertion
References: NCM, Up-to-date, MedlinePlus NLM

Medical GI

(LT 9, SICU)

1. Gastroesophageal reflux cause, effect and treatment

a. Cause: gastric contents come back up into esophagus when LES is not functioning
properly due to physical and lifestyle factors such as smoking; obesity; increased
secretion
of
gastrin/estrogen/progesterone;
hernia;
meds
including
dopamine/morphine/theophylline; foods like spearmint, peppermint, high in fat,
sometimes spicy
b. Effect: complicationsdysphagia, aspiration, pneumonia/asthma, ulcer,
perforation/stricture of esophagus, Barretts esophagus; nutrition issueschanges
in appetite, ab pain, food intolerances, electrolyte imbalances 2/2 vomiting, iron
deficiency, weight loss, impaired nutrient absorption d/t med use
c. Treatment: meds such as antacids or buffering agents, histamine blocking agents,
PPIs, prokinetic agents, mucosal protectants; may need Nissen fundoplication
procedure performed
i. Nissen fundoplication: LES tightened by wrapping top of stomach around
outside of esophagus
ii. Stretta procedure: radio frequency waves strengthen LES (endoscopic)
d. Nutrition intervention and prescription: briefly eliminate black and red pepper,
coffee, alcohol, chocolate, mint, high fats; smaller frequent meals; stop smoking;
weight loss if needed; remain upright after eating; avoid eating 3 hours before
bedtime; loose-fitting clothes; raise head of bed for sleeping
2. Lactose intolerance discuss lactase
a. Lactose in milk, milk products, food additive, in medications
b. Lactase: enzyme that breaks down lactose for digestion and absorption
i. Born with ability to produce lactase but in some racial and ethnic groups,
decrease in production of lactase after weaning
ii. Racial and ethnic groups: Latinos, Africans, Native Americans, Asians,
Ashkenazi Jews
iii. Secondary lactase deficiency: disease/infection, injury to small intestine,
surgery, malnutrition
c. Lactose intolerance: onset of GI symptoms following blinded, single dose
challenge of ingested lactose by individual with lactose malabsorption
d. Without lactase, lactose will go to large intestine undigested and unabsorbed
causing lactose to ferment, increasing gas and cramping can also pull water into
large intestine causing bloating, distention, gas, diarrhea]
e. Most adults can tolerate up to 12 g lactose without symptoms
f. Milk and milk products have a lot of vitamin D, calcium, and riboflavin so look
for deficiencies in these nutrients if pt is avoiding milk
3. Gastric:
a. What are parietal cells? Cells in stomach that help to make up gastric glands
(along with mucous, endocrine, and chief cells)
b. What is dumping syndrome? Common complication after gastric surgery; may be
caused by changes in gastric empty8ing, innervation to stomach; altered GI
hormones
i. Increased osmolar load enters small intestine too quickly and too large in
volume fluid drawn into small intestine which may cause cramping, ab
pain, diarrhea, weakness, tachycardia (early dumping, within 10-20
minutes after eating)

ii. Intermediate dumping: 20-30 min after eating gas, ab pain, cramping,
diarrhea
iii. Late dumping: 1-3 hours after eating, common when consuming simple
CHO insulin release but no substrate for insulin to act on
hypoglycemia shakiness, sweating, confusion, weakness
iv. Meds to treat: acarbose, octreotide, etc.
v. How to avoid: no simple sugars; no clear liquids beside broth for first
meal; no sucrose, fructose, sugar alcohols; chew thoroughly; meals should
contain protein, fat, complex CHO but only 1-2 food items at time; 5-6
small meals per day; liquids 30-60 min after solids; lie down after eating;
functional fibers to delay gastric emptying and assist with diarrhea; may
need liquid MVM
c. What is gastroparesis? Delayed gastric emptying from stomach into small
intestine
i. Caused by issue relating to vagus nerve which controls involuntary
movement of food through digestion track
ii. DM most common cause (diabetic gastropathy)
iii. Symptoms: N/V of undigested food, early satiety, bloating, ab pain,
fluctuations in blood glucose levels, hyperglycemia, electrolyte
imbalances
iv. Treatment: manage glucose; small frequent meals; low-fat and low-fiber
options, soft foods, liquid meals; Reglan; jejeunostomy EN; exercise;
chew foods well; may need supplements for Mg, Fe, B12, D
4. Explain how absorption of medium chain triglycerides is different than long-chain
triglycerides.
a. Easily to absorb than long-chain: passively diffuse from GI tract and do not need
bile salts for digestions (no energy needed for absorption, use, or storage)
b. Used often for pt with malnutrition, malabsorption, or fatty-acid metabolism
disorders
c. Examples: coconut oil, palm oil, dairy fat
5. What is diverticulitis and diverticulosis?
a. Diverticulosis: presence of sac-like pouches or herniations in mucosal layer of
colon (esp. descending)
i. Advanced age or Meckels diverticulum (usually present at birth)
ii. Usually asymptomatic
iii. May be developed through history of constipation, high red meat intake,
obesity, decreased physical activity, low fiber intake
iv. Signs and symptoms: fever, ab pain in left lower quadrant, GI bleeding,
elevated white blood cell count
v. Complications: bleeding abscess, obstruction, fistula, perforation
vi. Treatment: fiber intake and pro/prebiotics
vii. Nutrition therapy: 6-10 g beyond 25-35 g fiber per day; probiotic foods
such as yogurt, miso, kefir; proper fluid intake
b. Diverticulitis: inflammation of diverticulum
i. Treatment: NPO until bleeding and diarrhea absolve clear liquid diet
ii. Nutrition therapy: possible need for folic acid, B12, Fe; flow-fiber diet;
high probiotic foods
6. Define Crohns disease and Ulcerative colitis: environmental trigger causes abnormal
inflammatory autoimmune response within GI tract

a. Crohns disease: can affect any portion of GI tract but most commonly affects
ileum and colon
i. Development of fistulas which results in fibrotic tissue strictures and
bowel obstructions
ii. Symptoms: ab pain, fever, diarrhea, oral aphthous ulcerations, pyroderma
gangrenosa
iii. Complications: abscesses, anal fissures, bowel obstruction, bowel
perforation, bowel resection, colon cancer, fistulas, hyperoxaluria,
malnutrition, steatorrhea, strictures, ulcers
b. UC: usually affects lower bowel (colon and rectum), no areas of normal mucosa
i. Symptoms: pain, cramping, bloody diarrhea, N/V, fever
c. Treatments: aminosalicylates, immunomodulators, antibiotics, biological
modifiers, corticosteroids, surgical intervention
d. Comparative standards: 25-35 kcal/kg, 1.0-1.5 g pro/kg/d; may need
supplementation of B12, folate, thiamin, riboflavin, niacin, vit C, vit E, vit D, vit
K, Fe, zinc, Mg, Se, K; omega-3 fatty acids, glutamine, prebiotics, probiotics
(fructooligosaccharides)
e. Nutrition prescription for exacerbation: EN, TPN if needed; low-fat, low-fiber
(during acute exacerbations), high kcal; small frequent meals; supplementation of
Vit D, Zn, Ca, Mg, folate, B12, Fe if needed
f. Nutrition for remission: avoid foods high in oxalate (beer, beans, beets, berries,
chocolate, coffee, cranberries, nuts, dark green veggies, oranges, dark pop, soy,
wheat bran); increase antioxidant intake; supplementation with omega-3s and
glutamine; pre/probiotics
g. Common problems: anorexia, malnutrition, increased protein needs, ab pain,
diarrhea, catabolism, short bowel syndrome, blood loss, long-term steroid use,
surgical resections of stomach
7. Define IBS. What is the FODMAP diet?
a. IBS: irritable bowel syndrome IBS-C, IBS-D, IBS-M (mixed), IBS-U
(unspecified)
b. Rome III criteria: recurrent ab pain/discomfort 3 days per month in last 3 months
and two or more change in frequency/onset/form of stool
c. ACG: ab pain or discomfort that occurs in association with altered bowel habits
over period of at least 3 months
d. Symptoms: lower ab pain, constipation, diarrhea, bloating, mucus in stools,
incomplete evacuation, chest discomfort, excessive gas, fatigue, headache, urinary
incontinence
e. Medications: antidiarrheal agents, antispasmodics, clonidine, tricyclic
antidepressants
f. FODMAPs: fermentable oligosaccharides, disaccharides, monosaccharides,
polyols such as fruits, dried fruits, fruit juice, fructose as sweetener, HFCS,
honey, coconuts, onion, leek , asparagus, artichokes, cabbage, brussel sprouts,
beans, legumes, sorbitol, mannitol, isomalt, xylitol
i. These foods enter distal small bowel and colon where they ferment
increased intestinal permeability and possibly inflammation
g. Treatment: probiotics; reduce lactose; may need MVM; avoid foods that increase
gas
8. Celiac disease: autoimmune disordersensitivity to aa in prolamin of wheat, barley, rye
(gliadin, hordein, secalin, respectively)

a. Diagnostic tests: serologic tests such as IgA, biopsy of small intestine (look for
increased density of intraepithelial lymphocytes, partial/total villous atrophy,
crypt hyperplasia); genetic markers such as DQ2, DQ8
b. Treatment: lifelong adherence to gluten-free diet; may need supplementation of
Ca, Vit D, Fe, folate if deficient
c. Symptoms: gas, constipation, bloating, indigestion, steatorrhea, ab pain, anemia,
bone disease, dental enamel defects, joint pain, anxiety, depression, infertility,
miscarriage, delayed puberty, short stature
d. May have secondary form of lactose intolerance
e. Grains and plant foods to include in diet: rice, corn, amaranth, quinoa, teff, millet,
soy, arrowroot, buckwheat, flax, sago, potato, wild rice, tapioca, mesquite,
legumes, cassava, yucca, nuts, seeds, potential oats
f. To avoid when shopping: flour, white flour, plain flour, bromated flour, enriched
flour, phosphate flour, self-rising flour, durum flour, farina, semolina, graham
flour, beer, malt
g. Careful of bouillon cubes, brown rice syrup, candy, cold cuts/processed meat,
communion wafers, French fries, gravy, imitation fish, licorice, matzo, rice mixes,
sauces, seasoned snack foods, soups, soy sauce, vegetables in sauce
9. Discuss the following and how they affect stool output:
a. Psyllium: bulk-forming laxative to treat constipation
i. Absorbs liquid in intestines to form bulky stool easy to pass
b. Docusate: stool softener to treat constipation
i. Absorbs liquid in intestines to form bulky stool easy to pass
c. Miralax: stool softener/ osmotic laxative to treat constipation
i. Absorbs liquid in intestines to form bulky stool easy to pass
d. Senna: stimulant laxative to empty bowels and treat constipation
i. Increases activity of intestines to cause bowel movement
e. Bisacodyl: stimulant laxative to empty bowels and treat constipation
i. Increases activity of intestines to cause bowel movement
ii. Normally causes BM within 6-12 hours
f. Lactulose (synthetic sugar): stool softener to treat constipation
i. Breaks down in colon then pulls water from body into colon
g. Magnesium citrate: osmotic laxatives
i. often used to empty colon before colonoscopy
ii. soften stools
10. Discuss the 4 general types of diarrhea
a. Osmotic: poorly absorbed, osmotically active solutes in gut lumen, disrupting
osmotic forces, substrates drawn across intestinal epithelium; stools large and
water and resolve with elimination of osmotically active agent; may be caused by
sorbitol, Mg-based antacids, lactulose, hyperosmolar EN feedings
b. Malabsorption: alteration in luminal/mucosal integrity of gut (ex. Enzyme
deficiency); may be seen with lactose intolerance, pancreatic insufficiency, blind
loop syndrome after bowel resection or short-bowel syndrome
c. Resulting from defective ion absorption: small intestine and colon brush border
membranes have gradients for ion absorption need more than two ion brush
border
exchangers,
otherwise
congenital
diarrhea
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC152597/)
d. Secretory: large volume of stool output >1000 mL/d despite little food intake
intestinal oversecretion of fluid and electrolytes exceeding absorptive capacity of

bowel; may be caused by GVHD, gut wall damage, bacterial endotoxins,

endocrine tumors
e. Motor/ dysmotility-associated: intestinal motility becomes abnormal d/t
alterations in mechanical stretch receptors; may be caused by impaction or
obstruction that distends bowel; characterized by small amounts of liquidsemiliquid stools
11. C-Difficile cause, effect and treatment and 2 research articles about treatment of CDiff.
a. Definition: spore-forming, toxin-producing, gram-positive anaerobic bacterium
that causes antibiotic-associated colitis; one of most common healthcareassociated infections
b. Cause: colonizes in intestinal tract after normal gut flora altered by antibiotic
therapy
c. Effect: range of manifestationsdiarrhea, toxic megacolon, lower ab pain,
cramping, low-grade fever, nausea, anorexia, leukocytosis
d. Treatment: stopping inciting antibiotic therapy; antibiotic therapy
(fluoroquinolones, clindamycin, cephalosporins, penicillins); infection control
policies (hand hygiene with soap and water); anti-motility agents
e. Knight-Connoi V, Mascio C, Chesnel L, Silverman J. Discovery and development
of surotomycin for treatment of Clostridium difficile. J Ind Microbiol Biotechnol.
2015; DOI 10.1007/s10295-015-1714-6
i. Forms environmental- and gastric acid-resistant spores contamination of
surfaces with spores helps transmission
ii. Typically oral-fecal route via contact with contaminated environmental
surface
iii. CDI: mild to severe diarrhea or infection
iv. Diagnosis of CDI: positive toxin test performed on fecal samples or
isolated pathogen
v. Initial treatment determined by severity of diarrhea: for mild to moderate
diarrhea, use metronidaxole; for severe cases, use vancomycin
vi. After first recurrence, rates of subsequent recurrences increase 25-65%
vii. Potential therapeutic options: fecal microbiota transplant, toxin binders,
vaccines, monoclonal antibodies, alternative antimicrobials
viii. Surotomycin development: orally dosed, non-absorbed cyclic lipopeptide
analog of daptomycin acyl group targets Cdiff (improved potency) and
designed to minimize potential for resistance selection
ix. Derived from and tested in hamster models at doses of 0.5 mg/kg fro 5
days
x. Phase 1 study: 30 healthy volunteers on either 250. 500, or 1000 mg BID
surotomycin for 14 days; only small amount absorbed in lower GI tract;
mild-moderate adverse events unlikely r/t surotomycin
xi. Phase II study: randomized, double-blind, multi-center trial comparing
125 or 250 mg BID with vancomycin (125 mg 4x d) for 10 days; pt had
acute CDI symptoms and positive stool test; primary endpointclinical
response at end of treatment and secondary endpointrecurrence of CDI;
response rate with either dose of surotomycin similar to that of
vancomycin; recrurrence rates lower for both doses of surotomycin
compared with vancomycin and sig. lower for 250 mg dose; both doses
well tolerated

f. Rikstrup LT, Aarup M, Hagemann-Madsen R, Dagnaes-Hansen F, Kristensen B,

Olsen KEP, Fuursted K. Treatment of Clostridium difficile infection in mice with
vancomycin alone is as effective as treatment with vancomycin and metronidazole
in combination. BMJ Open Gastro. 2015; 2
i. Treatment depends on disease severity aka diarrhea
ii. Combination of vancomycin and metronidazole recommended for severe
cases
iii. Aim: examine in murine model of CDI if mice treated with combo of
vancomycin and metronidazole had better clinical outcome than mice
treated with vancomycin or metronidazole alone
iv. Mice treated with placebo, vancomycin, metronidazole, or combo for 10
days
v. Mice monitored for 20 days and stool samples collected
vi. None of mice in vancomycin-treated group died during treatment phase
compared to mortality rate of 17%, 33%, and 55% in combo,
metronidazole, and infected control group, respectively
vii. Mice treated with vancomycin alone and in combo recovered from CDI
faster than mice treated with metronidazole alone
viii. After treatment, vancomycin-treated and combo-treated mice succumbed
to clinical and bacteriological relapse
Define:
Achalasia: LES doesnt relax causing abnormal motility of food in esophagus to stomach
Peristalsis: involuntary muscle movements of digestive tract
Steatorrhea: fat in stool
Define toxic megacolon: widening of large intestine within a few days; occurs as
complication of IBD (UC/Crohns) and infections of colon

Surgical GI (LT 9, SICU)

1. Define enterocutaneous fistula and mucus fistula. Describe how an EC fistula can affect
nutrient absorption?
Fistula: abnormal opening/ connection between two tissues, often in
stomach/intestines that allows content to leak
EC fistula: leak goes through skin; consequences depend on composition of
fistula drainage and volume
o Low output: drains less than 200 mL/d
o Moderate output: 200-500 mL/d
o High output: more than 500 mL/d
o Often in postop pt who fails to recover normally from ab surgery
o May experience ab discomfort, distension, tenderness, low grade fever, ab
sepsis
o Fistula usually recognized 7-10 days after surgery
o Nutrient malabsorption: ongoing fluid losses lead to electrolyte
abnormality; vitamin deficiencies; NPO and will need nutrition support if
fluid output high; 0.8-2.5 g/kg protein per day; omega-3 fatty acid
supplementation improves immune function
Mucus fistula: small stoma that puts out mucus
2. Short Bowel Syndrome (also a medical GI diagnosis): malabsorptive state that may
follow massive resection of small intestine (for Crohns disease, malignancy, radiation,
vascular insufficiency)
Low QOL: GI issues and chronic fatigue
Nutrient effects: EN feeding continuous or small bolus feedings enhance
absorption
CHO in diet major cause of diarrhea in SBS because of high osmotic load (esp.
simple CHO)
Protein in diet usually well-tolerated as kcal source and contributes little to
osmotic load; fats have low osmotic load as well and are good kcal source
Likelihood of resuming oral diet based on length of remaining small bowel (need
>200 cm jejunal length), remaining segments of small bowel, presence of colon
and intact ileocecal valve, intestinal adaptation
Start EN slowly once pt stabilizescomplex diets enhance adaptation but
elemental diets are better during exacerbation
Continuous tube feedings in post-op period shown to sig. increase net absorption
of lipids, proteins, and energy
Protein hydrolysate diets better with fiber supplementation rather than EN
formula high in CHO
3. Anastomosis: surgical connection between two structures (usually between tubular
structures such as blood vessels or loops of intestine)
AV fistula: opening between artery and vein for dialysis
Colostomy: open between bowel and abdomen
Intestinal: two ends of intestine sewn together
Connection between graft and blood vessel to create bypass
4. Review When Chyle Leaks and also the 2011 Update located in your Articles for
Assignment file
Parrish CR, McCray S. When Chyle Leaks: Nutrition Management Options. Practical
Gastroenterology. 2004.

Chyle: alkaline, milky, odorless fluid ~200 kcal/L

o >30 g/L pro, 4-40 g/L lipid (mostly TG) and lymphocytes
Leak can occur after injury to intra-ab lymphatics, chylous effusion (thoracic
cavity), chylous ascites (peritoneal cavity), chylopericardium (cardiac cavity) or
external draining fistula
o 60% d/t lymphoma, 25% d/t trauma, cirrhosis, TB, etc.
Diagnosis subjective but lipid content should be greater than that of plasma and
protein should be more than half
o Restrict fat intake and see if drainage becomes clear and/or decreases
Most dietary fat in form of long chain fats need gastric lipase, pancreatic lipase,
enzymes, pH of 7, bile salts
Lymph: from interstitial fluid, only means for protein that has left vascular
compartment to return to blood
Chylomicrons returned to blood stream via thoracic duct common pathway for
all lymphatic flow
o 2-4 L of chyle transported thrugh thoracic duct each day
Increased interstitial fluid pressure will increase lymph flow
o Water intake can increase flow of chyle by 20%
Absorption of fat takes places primarily in proximal jejunum
Bile salts reabsorbed and returned to liver via enterohepatic circulation in ileum
Once absorbed across intestinal mucosa, fatty acids and monoglycerides reesterified into TG combining with cholesterol and protein to form chylomicrons
o Then enter lymphatic system as chyle via lacteals
o Fat-soluble vitamins also absorbed this way
Short and medium chain TG more easily absorbed than long chain
o MCT absorbed directly across intestinal mucosa and delivered to portal
vein
Goals of nutrition management of chyle leaks: 1 decrease production of chyle
fluid to avoid aggravating effusion, ascites or chest tube drainage; 2 replace fluid
and electrolytes; 3 maintain or replete nutritional status and prevent malnutrition
Options for treatment: fat free diet, fat free diet supplements with MCT, EN
feeding (either fat free, MCT based, or very low fat) or TPN
o If on fat free diet: need fat-soluble and essential fatty acid supplementation
o MCT oil or specialized oral/enteral supplements 8.3 kcal per g; doses of
60-70 g per day (4-5 tablespoons, ~500-600 kcal) tolerated
o Resource combined with MCM and protein
o Small amount of safflower oil to meet EFA
When Chyle Leaks: 2011 Update
Lymph systems: lymph vessels, capillaries, thoracic duct, lymph nodes, spleen,
thymus, bone marrow, gust associated lymphoid tissue (GALT)
o Immunological role, absorbs excess interstitial fluid and returns it to blood
stream, transports LCT and fat-soluble vitamins; also transports chyle
from GI tract throughout body
Chyloptysis (chyle in sputum), chyluria (chyle in urine)
Pharmacological treatment: primarily Octreotide (inhibitor of growth hormone,
glucagon, insulin)
o Suppresses gastrin, motilin, secretin, pancreatic polypeptide and
splanchnic blood flow

Lymphangioleiomyomatsosis (LAM): secondary cause chyle leaks rare lung

disease (women of childbearing age at risk, associated with hormones)
Indications for surgical repair: > 1 L of chyle output per day, failure of leak to
close after 2-3 weeks of conservative therapy, signs of nutritional/metabolic
complications from leak, possibility of further damage from leak (lung damage)
Chyle reinfusion into enteral access port during times off EN may prevent need
for IV fluids
5. Define the different types of ostomies (colostomy, ileostomy, jejunostomy). Name
nutrients which a patient would be at risk of developing deficiency with an ileostomy or
jejunostomy. Review the article about ostomates.
Ostomy: surgery to create opening (stoma) from area inside body to outside
new way for waste leave body to treat certain disease of digestive and urinary
systems
Colostomy: colon attached to stoma to bypass rectum and anus
Ileostomy: ileum attached to stoma to bypass colon, rectum, anus
Jejunostomy: jejunum attached to stoma to bypass stomach, colon, rectum, anus
Urostomy: bladder bypassed
Nutrient issues: development of dehydration, electrolyte imbalances
B12, water soluble vitamins, bile salts, fats, water soluble vitamins absorbed in
ileum
CHO, pro absorbed by duodenum and jejunum
Willcutts K, Touger-Decker R. Nutritional Management for Ostomates. Top Clin Nutr.
2013; 28 (4): 373-383.
Majority of ostomies and stomas for fecal diversions
Review of lit from Ovid, PubMed, CINAHL, Cochrane, Nutritional Guidelines
Clearinghouse
Inclusion criteria: 1997-2012, English, human participants > 18 y/o
Need to know length of healthy, contiguous bowel proximal to ostomy to develop
treatment plan
Colostomy: openings from colon to skin; usually for colon/rectal CA pt, those
with
diverticulitis,
or
after
trauma;
can
originate
from
ascending/transverse/descending; typically start functioning 2-5 days after
surgery; output ranges from 200-600 mL/d
o No evidence for benefit of specialized diet
o Some pt avoid certain foods to prevent increased gas and stoma output
such as garlic, eggs, carbonated beverages, cabbage
o Post-op: hold food until bowel ready to function; evidence that oral diet
or tube feeding can start early after surgery; United Ostomy Association of
Americalow fiber diet for approx. 6 weeks after surgery
Ileostomy: openings between ileum and skin; indicated for fecal diversion, rectal
CA, IBD, familial adenomatous polyposis, rectal trauma
o Diverting ileostomy: anastomotic leakage, EC fistula, distal obstruction,
extensive local malignancy
o Standard type, Brooke type, end ileostomy/loop ileostomy (loop used most
for temporary)
o Will start function within 24 hrs after surgery; effluent increases over first
week to about 1200 mL of liquid output per 24 hr; thickens and output
drops to less than L per day over 2-3 months

o Adaptation: increasing mucosal surface area by increasing cell

hyperplasia, bowel circumference, villous height, depth of crypts
o Normal output: 800-1000 mL/d
o Goal: semiliquid to pastelike output may contain parts of undigested
foods
o Empty ostomy bag 4-8 times per day
o Increased oral fluid intake 500-750 mL/d above pts typical fluid intake
o Sodium liberalized due to 50-100 mmol/d losses
o Issues with nighttime emptying
o Blockage foods: dried fruit, corn, nuts, popcorn, celery, coconut, etc.
o Thickening foods: potatoes, rice, PB, bananas, bread, crackers,
marshmallows
o Evidence lacking for soluble fiber in form of psyllium but often prescribed
o FODMAPs... on high FODMAP diet, water output increased by 95 mL/d
(significant); on low FODMAP diet, effluent thicker (sig)
o High FODMAP: artichokes, asparagus, beets, brussels sprouts, broccoli,
cabbage, fennel, garlic, leeks, okra, onions, peas, shallots, wheat, rye,
barley, legumes, lentils, chickpeas, apples, peaches, persimmon,
watermelon, pistachios, apples, apricots, cherries , nectarines, peaches,
plums, prunes, avocado, cauliflower, mushrooms, snow peas, sorbitol,
mannitol, maltitol, xylitol, mangoes, pears, honey, HFCS
More proximal ostomies have less bowel available for absorption
Small bowel measured from Ligament of Treitz (junction between duodenum and
jejunum)
If have less than 200 cm of healthy, small bowel proximal to stoma, pt at
increased risk for malabsorption of fluids and electrolytes
No set definition for High-Output Stomy
o Usually associated with IBD, C.Diff, intra-abdominal sepsis,
partial/intermittent obstruction, metoclopramide, suddenly ending steroid
use
Primary problem: dehydration; always record I/Os, esp. urine output upon
discharge
o Pt should contact MD if urine output drops below 800-1000 mL per 24 hr
Risk of hyponatremia; urinary sodium of less than 20 mmol/L sign of Na
depletion
Hypomagnesemia: reduced absorption, binding with fat, hyperaldosteronism
hypokalemia
6. Review the 2 handouts about the sites of nutrient absorption. These are to be placed in the
interns binder for future reference.
Define:
Bezoars
o Gastric bezoar: foreign body resulting from accumulation of ingested material,
most commonly found as hard mass or concretion in stomach
o Phytobezoars: composed of vegetable, most common, persimmon fruit
o Trichobezoars: hair
o Pharmacobezoars: ingested medications
o Usually result from ingestion of indigestible material in pt with impairment in
grinding mechanism of stomach and interdigestive migrating motor complex

Ischemic bowel (damage to bowel)

o Causes: hernia, adhesions, embolus, arterial thrombosis, venous thrombosis. Low
blood pressure
o Symptoms: diarrhea, fever, vomiting, severe ab pain
o Treatment: surgery, ostomy often needed
o Mesenteric ischemia: small intestine affected
o Colonic ischemia: large intestine affected
o Splanchnic/visceral ischemia: more general term for ischemia affecting intestine
or other ab organs like liver, spleen, or kidneys
Blind loop: digested food slows/stops moving through part of intestines, causing
overgrowth of bacteria in intestines and leads to suboptimal nutrient absorption
o blind loop because part of intestine bypassed blockage doesnt allow digested
food to flow normally through intestinal tract
o Bile salts malfunctioning, preventing fat and fat-soluble vitamins from being
absorbed into body and can lead to steatorrhea
o B12 deficiency
o DM and scleroderma slow down movement in segment of intestine which can
cause syndrome
o Can happen as complication of IBD
o Symptoms: diarrhea, steatorrhea, fullness after meal, loss of appetite, nausea,
unintentional weight loss

References: MedlinePlus NLM, Up-to-date, NCM