Parenteral Nutrition

When a patient cannot eat any or enough food because of an illness or health complication, sometimes other forms of nutrition are required to assist the patient towards better health. The stomach or bowel may not be working normally, or a person may have had surgery to remove part or all of these organs. When this occurs, and a patient or client is unable to eat, nutrition must be supplied in a different way. One method that can be applied is Parenteral Nutrition.

Parenteral Nutrition bypasses the normal digestion in the stomach and bowel. It is a special liquid food mixture given into the blood through an intravenous (IV) catheter (needle in the vein). The mixture contains proteins, carbohydrates, lipids, vitamins and minerals. This special mixture may be called Parenteral Nutrition or Total Parenteral Nutrition (TPN).

A special IV catheter will be placed in a large vein in the chest or arm. It can stay in place for as long as needed. Proper care is required to avoid infection and clotting. Different kinds of catheters may be used. Common types of catheters are Peripherally Inserted Central Catheter (PICC), triple lumen, double lumen, or single lumen catheters, and Ports. Nutrition is given through this large vein. Coordinated care, consisting of doctors, nurses, RDs, and pharmacists, will talk with the patient about the different types of catheters prior to administering anything.

Prior to initiating TPN, a nutrition assessment is necessary to determine nutrient needs and to anticipate any metabolic changes that may occur due to the patient’s underlying condition, medications or concurrent therapies, etc. Important factors to consider when assessing a patient for TPN are:

·         Anthropometric Data: CBW, Wt Hx, IBW

·         Lab Values: Mg levels, Phosphorus levels, TG levels

·         Patient Medical History (PMH): Anatomy resections, ostomies, pre-existing conditions like diabetes or renal failure

·         Diet History: Diet prior to admission, Food/Drug Allergies

·         Medications: Current medications and supplements

TPN_All tube feedings

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Modified Barium Swallowing Test

A Modified Barium Swallow (MBS) test is an X-ray that is taken to check the swallowing skills of a client or patient. I recently observed an MBS in a patient who has been cancer-free for nearly 10 years but, was aspirating when he swallowed certain foods and beverages. The MBS was carried out by a Speech Language Pathologist (SLP) at the facility that I’m rotating at currently. The SLP had previously worked with this patient and mentioned that he had developed fibrous tissue along his esophagus, caused by his radiation treatment several years earlier. This was her initial assessment of the patient’s swallowing problems.

Throughout the test, the mouth, throat, and esophagus are checked to see if there are any visible problems with a patient’s ability to swallow.  Before we began the test, the SLP and I put on protective lead vests and a thyroid collar. This was done to shield ourselves from the radiation used in the actual test.

Barium is actually a dry, white, chalky powder that is mixed with water to make thick, almost like the consistency of a milkshake. It is an X-ray absorber and appears white on X-ray film. When swallowed, a barium drink coats the inside walls of the pharynx and esophagus so that the swallowing motion, inside wall lining, and size and shape of these organs is visible on X-ray. This process shows differences that might not be seen on standard X-rays. Barium is used only for diagnostic studies of the GI tract. The use of barium with X-rays contributes to the visibility of various characteristics of the pharynx and esophagus. Some abnormalities of the pharynx and/or esophagus that may be detected by a barium swallow include tumors, ulcers, hernias, diverticula (pouches), strictures (narrowing), inflammation, and swallowing difficulties.

The SLP noted that if she were to have assessed this patient bedside, she probably would have missed that he has aspirating when he swallowed. The MBS really caught the problem that the patient was actually having. It was interesting to see how everything looked through the MBS and to see how problems can go unnoticed.

The SLP was really hands-on and pointed out every part of the patient’s anatomy including his epiglottis, esophagus, stomach, tongue, etc. I can honestly say that working with patients who suffer from dysphagia or who are experiencing temporary swallowing problems is really becoming an interest of mine. There’s so many elements that an RD has to take into consideration, for example consistencies of beverages and foods or physiological problems from cancer treatments.

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barium-swallow

What is the Braden Scale?

The Braden Scale for Predicting Pressure Sore Risk was developed during a Robert Wood Johnson Teaching Nursing Home project and while writing an NIH proposal to study pressure ulcer risk factors. The scale is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom and the purpose of the scale is to health help professionals assess a patient’s risk of developing a pressure ulcer.

The Braden Scale is a scale made up of six subscales, which measure elements of risk which contribute to both higher intensity and duration of pressure, or lower tissue tolerance for pressure. These subscales are: sensory perception, moisture, activity, mobility, friction, and shear. Each item is scored between 1 and 4, with each score accompanied by a descriptor. The lower the score, the greater the risk for a pressure ulcer a patient is at-risk for.

braden scale1

Braden

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pressure ulcer1

Small Bowel Obstruction in CF Patients

Small bowel obstruction means the small intestine is partially or totally blocked. When this happens, the contents of the intestine cannot properly get out of the body. Stools, fluid, and gas build up inside the intestine. This is a potentially serious condition that requires urgent medical care.

Symptoms

The symptoms for “mechanical” small bowel obstruction include:

          Abdominal fullness and/or excessive gas

          Abdomen feels stretched out more than normal (abdominal distention)

          Pain and cramps in stomach area

          Vomiting

          Constipation (cannot pass gas or stool)

          Diarrhea

          Bad breath

The symptoms of paralytic ileus include:

          Abdominal fullness and/or excessive gas

          Abdominal distention

          Vomiting after eating

          Pain is often less severe than in “mechanical” small bowel obstruction

The diagnosis of a small bowel obstruction is initially performed through a physical exam. The exam will include listening for bowel sounds in your stomach. Very high pitched bowel sounds heard through a stethoscope suggest mechanical bowel obstruction, whereas paralytic ileus often produces no bowel sounds. Your doctor may recommend that you see a gastroenterologist or surgeon depending on the suspected diagnosis. These tests include:

  • CT scan
  • Abdominal ultrasound
  • Abdominal X-ray

For patients with cystic fibrosis, small bowel obstructions are much more common and potentially more dangerous. In cystic fibrosis, the build-up of thick, sticky mucus blocks the ducts leading from your pancreas to your bowel. When this happens, the amount of insulin that your body produces is reduced and digestive enzymes are stopped from aiding your digestion. Without these enzymes, you may not be able to digest enough essential nutrients and you may find it difficult to gain weight. Malnutrition can lead to poor growth, physical weakness and delayed puberty in children. Your feces may contain excess fat making them oily, smelly, large and difficult to flush away.

NYU Langone Medical Center

Bupa Health Center

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Diabetic Ketoacidosis (DKA)

As part of my Medical Nutrition Therapy (MNT) rotation, my preceptor has asked me to create a summary sheet of certain illnesses and complications associated with various disease states. One of which, is diabetic ketoacidosis (DKA).

What is DKA?

DKA is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones.
It develops when your body is unable to produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as an alternate fuel. This process produces a buildup of toxic acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.

What causes DKA?

1. Not enough insulin

2. Not enough food

3. Low blood glucose

When cells don’t get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are acids that build up in the blood and appear in the urine when your body doesn’t have enough insulin. They are a warning sign that your diabetes is out of control or that you are getting sick. High levels of ketones can poison the body. When levels get too high, you can develop DKA. DKA may happen to anyone with diabetes, though it is rare in people with type 2. Treatment for DKA usually takes place in the hospital. But you can help prevent it by learning the warning signs and checking your urine and blood regularly. DKA usually develops slowly. But when vomiting occurs, this is life-threatening and can develop in a few hours.

Sugar is a main source of energy for the cells that make up your muscles and other tissues. Normally, sugar enters your cells with the help of insulin. If you don’t have enough insulin in your body, your body won’t be able to use sugar properly for energy. This prompts the release of hormones that break down fat as an alternate fuel. In turn, this process produces toxic acids known as ketones. Excess ketones accumulate in the blood and eventually “spill over” into the urine.

Early symptoms include:

– Polydypsia (increase of thirst)

– Polyuria (frequent urination)

– Hyperglycemia (high blood glucose levels)

– High level of ketones in the urine

– Fatigue, dry skin, nausea, difficulty breathing, fruity odor on the breath (caused from the presence of ketones)

When diagnosing DKA, a healthcare provider should pay close attention to the following lab values:

Blood Glucose: If there isn’t enough insulin in your body to allow sugar to enter your cells, your blood sugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your blood sugar level will continue to rise.

Ketone level: When your body breaks down fat and protein for energy, toxic acids known as ketones enter your bloodstream.

Blood acidity: If you have excess ketones in your blood, your blood will become acidic (acidosis). This can alter the normal function of various organs throughout your body.

– Blood electrolyte tests, Urinalysis, Chest X-ray, and an Electrocardiogram (ECG)

The treatment for DKA involves a three-pronged approach:

1. Fluid Replacement: receive fluids, orally or intravenously, until rehydrated. These fluids will replace those that have been lost through excessive urination and dilute the excess sugar in the blood.

2. Electrolyte Replacement: Electrolytes are minerals in your blood that carry an electric charge, such as sodium, potassium and chloride. The absence of insulin can lower the level of several electrolytes in your blood. You’ll receive electrolytes through your veins to help keep your heart, muscles and nerve cells functioning normally.

3. Insulin Therapy: Insulin reverses the processes that cause diabetic ketoacidosis. Along with fluids and electrolytes, you’ll receive insulin therapy — usually through a vein. When your blood sugar level falls below 240 mg/dL (13.3 mmol/L) and your blood is no longer acidic, you may be able to stop intravenous insulin therapy and resume your normal subcutaneous insulin therapy.

Diabetic ketoacidosis is usually triggered by an illness or insulin therapy.

An infection or other illness can cause your body to produce higher levels of certain hormones, such as adrenaline or cortisol. Unfortunately, these hormones work against insulin — sometimes triggering an episode of diabetic ketoacidosis. Pneumonia and urinary tract infections are common culprits.

Missed insulin treatments or inadequate insulin therapy can leave you with too little insulin in your system, triggering an episode of diabetic ketoacidosis.

Other possible triggers of DKA could include:

– Stress

– Physical or emotional stress

– High fever

– Surgery

– Heart attack

– Alcohol or drug abuse, specifically cocaine

While DKA is being treated, there are complications that patients and healthcare providers need to be aware of as well. Complications could include:

Hypoglycemia: Insulin allows sugar to enter your cells. This causes your blood sugar level to drop. If your blood sugar level drops too quickly, you may develop low blood sugar.

Hypokalemia: Fluids and insulin used to treat diabetic ketoacidosis may cause your potassium level to drop too low. A low potassium level can impair the activities of your heart, muscles and nerves.

Cerebral Edema: Adjusting your blood sugar level too quickly can produce swelling in your brain. This complication appears to be more common in children, especially those with newly diagnosed diabetes.

American Diabetes Association- DKA

Mayo Clinic- DKA

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WIC Vouchers at the Farmers Market

As a part of my WIC responsibilities for ISPP dietetic rotations, another intern and I went to assist at the Morgantown Farmers market to distribute WIC vouchers to participants. The farmers’ market vouchers were mentioned to clients at WIC when I observed this past week. So, now I that I could actually see how participants come and use the vouchers, it seems much clearer to me as to how the whole process works.

Each WIC participant in each family gets a total of $20 worth of WIC vouchers to spend at vendors at the farmers’ market that accept WIC vouchers. So, for example if you’re a pregnant mother at WIC with 2 children under 5 years of age, then you would receive $60 worth of vouchers to spend. The vouchers have an expiration date of October 31st, 2013 so; this gives parents and families time to spend the vouchers as well. Each voucher packet has two $5 vouchers inside. So, each participant receives two packets.

The vendors that accept the WIC vouchers have orange posted signs that families can look for when shopping at any of the farmers’ markets. The WIC vouchers themselves are only distributed at the Morgantown Farmers’ Market on Spruce Street, the downtown location.

WIC was given $2,500 worth of vouchers this year. The amount of vouchers that they are given each year depends on their redemption rate from the previous year. So, in 2011 the Monongalia County WIC farmers’ market redemption rate was 60%. In 2012, their redemption rate was 70% when the state redemption rate was 65%. So, from the numbers I observed it seems that if a county has a redemption rate higher than the state average, they receive more vouchers than the previous year and vice versa.

When the WIC participants pick-up their vouchers at the downtown farmers’ market, they can use these vouchers at any of the farmers’ market locations in the area. Yes, the vouchers are only distributed at the Spruce Street location. But, the vouchers can be spent at any farmers’ market listed below. The participants are only given the vouchers once per summer.

The vouchers seem to be a hot commodity as well. Last week was the first week that WIC was at the Morgantown Farmers’ Market to distribute the vouchers. Out of the $2,500 that WIC started with, they issued $1,900 last week. So, today we started with $600 worth of vouchers. They weren’t all given out today but, I can definitely see how WIC participants love using these. Not only does it serve as a convenience but, it also supports the local economy. The program, in a whole, is such a great motivator for WIC participants to increase fresh fruits and vegetables into their family’s diet. The only restriction on what the participants can purchase is that the vouchers will only be accepted for fruits, vegetables, and herbs. So, families can’t purchase things like eggs, proteins, or baked goods. But again, this is great because it encourages families to eat more fruits and vegetables and maybe even try a new fruit or vegetable!

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wic fm list

Go Ahead… Pick Your WIC!!

Well, I am currently in full swing of rotations! As of right now, I am rotating in the morning at Taziki’s Mediterranean Café for Institutional Foodservice and at West Virginia’s Monongalia County WIC office in the afternoons.

WIC is available for so many different types of families. The program is available to married and single parents, working or non-working, those receiving other types of aid or not participating in any other programs. Even if you are a grandparent, foster parent, or other legal guardian of a child under the age of 5, you can even apply for WIC.

WIC is available to expecting mothers, up until 6 months after the end of their pregnancy. Infants are categorized in another group and covered from birth – 5 months old. Children are covered from 11 months – 5 years of age. And throughout their childhood, they have appointments every 6 months.

Today marked my “official” first day at the WIC office. Every Monday, Tuesday, and Thursday, the Mon. County WIC schedules their nutrition clinics to see participants for follow-up and new client assessments. This afternoon, I observed a Registered Dietitian at WIC, assess 4 different appointments.

Each participant with a nutrition clinic appointment attends or completes an online nutrition education class 3 months prior to their appointment. The nutrition education classes cover a variety of topics like infant nutrition, nutrition during pregnancy, and shopping on a limited budget. Within the participant’s assessments, WIC RDs ask the parent(s)/proxy, who may also be the primary food preparer, a series of assessment questions. More importantly, these questions should spark a conversation with the participant(s) to try and get the most information about the nutritional status of the client. The suggested assessment questions are broken into three categories: women, infant, and children… How fitting!

Once the participants are seen and finished their clinic appointment, they are given food vouchers which can be used at WIC-approved stores. These vouchers are designated for specific foods through the WIC program. Here are some types of foods that are WIC-approved:

        Milk- Whole milk during infancy, 2% or less during childhood

        Cheese

        Infant Cereal

        Fresh Fruits

        Eggs

        Peanut Butter

        Infant Formula

        Fresh Vegetables

        Juice

        Canned Fish

        Beans

        Whole Grains Breads

        Cereal

        Baby Food

        Soy Milk

Participants receive certain foods based on their individual nutritional needs. If for any reason, mothers are incapable of breastfeeding their infant, WIC provides vouchers for formula. Yes, WIC is major advocate of breastfeeding but, sometimes women are not physically able to do so. Formula that WIC offers is grouped into 3 categories:

1.     Powder: Powder formula that is combined with water, usually cereal formula.

2.     Concentrate: Liquid formula combined with water, usually producing a bubbling effect. This formula may not be best choice for a child with nutritional problems like spitting up or reflux.

3.     Ready-to-Feed: Requires no addition of water.

The WIC is to improve the health of participants by providing the following benefits:

        Nutrition Workshops on a Variety of Topics

        Breastfeeding Support

        Nutritious Foods

        Referrals to Other Health and Social Service Agencies

Overall, I think the first day went really well. I still have a lot to learn and honestly, I’m soaking up the entire experience. I have a list of other projects that I will be completing at WIC so; I’ll have much more to talk about in the upcoming weeks!

A laminated visual that an RD at WIC has on-hand to show clients at appointments.

A laminated visual that an RD at WIC has on-hand to show clients at appointments.

Information that is provided within one of WIC's several pamphlets for participants, based by age of child/infant.

Information that is provided within one of WIC’s several pamphlets for participants, based by age of child/infant.

Food Allergies in Foodservice Rotations

While being in my Institutional Food Service, Production, and Management rotation this summer, a common concern from management has come to my attention. And this concern would be…  Food Allergies!

A food allergy is the body’s immune system reaction to certain foods. Symptoms of an allergic reaction include itching or swelling in or around the mouth, face, and scalp; tightening in the throat; wheezing or shortness of breath; hives; abdominal cramps, vomiting, diarrhea; loss of consciousness; and even death.

Food allergies are a growing public health concern. As many as 15 million people in the U.S. have food allergies. An estimated 9 million, or 4%, of adults have food allergies. Nearly 6 million, or 8%, of children have food allergies with young children affected the most. Although children allergies to milk, egg, wheat, and soy generally resolve in childhood, they appear to be resolving more slowly than in previous decades, with many children still allergic beyond age 5 years. Allergies to peanuts, tree nuts, fish, or shellfish are generally lifelong allergies.

The top food allergens are categorized into eight food groups. These eight food groups account for 90% of all food-allergic reactions. They include: milk, eggs, peanuts, tree nuts, fish, shellfish, soy, and wheat. The estimated prevalence among the American population is:

          Milk and eggs: based on data within and obtained outside the United States, this rate is likely to be 1-2% for young children and 0.2-0.4% in the general population.

          Peanut: 0.6-1.3%

          Tree nuts (e.g., walnuts, almonds, cashews, pistachios, pecans): 0.4%-0.6%

          Fish: 0.4%

          Crustacean shellfish (e.g., crab, lobster, shrimp): 1.2%

          All seafood: 0.6% in children and 2.8% in adults

The Centers for Disease Control and Prevention reported that food allergies result in more than 300,000 ambulatory-care visits a year among children under the age of 18 years. From 2004 to 2006, there were approximately 9,500 hospital discharges per year with a diagnosis related to food allergy among children under age 18 years. Even small amounts of a food allergen can cause a reaction. Most allergic reactions to foods occurred to foods that were thought to be safe. Allergic reactions can be attributed to a form of mislabeling or cross-contact during food preparation. Food allergy is the leading cause of anaphylaxis outside the hospital setting. Every 3 minutes a food allergy reaction sends someone to the emergency department. This is approximately 200,000 emergency department visits per year, and every 6 minutes the reaction is one of anaphylaxis. Teenagers and young adults with food allergies are at the highest risk of fatal food-induced anaphylaxis. Symptoms of anaphylaxis may recur after initially subsisting and experts recommend an observation period of about 4 hours to monitor that the reaction has been resolved. Individuals with food allergies who also have asthma may be at an increased risk for severe or fatal food allergic reactions. Children with food allergy are 3-4 times more likely to have other related conditions such as asthma and other allergies, compared without food allergies. It is possible to have anaphylaxis without any skin symptoms (no rash or hives). Failure to promptly (i.e., within minutes) treat food anaphylaxis with epinephrine is a risk factor for fatalities.

Chemical contamination can occur when high-acid foods are prepared or stored in metal-lined containers. Poisoning may result if brass or copper, galvanized, or gray enamelware containers are used. Fruit juices should never be stored in gray enamelware with lead glaze or tin milk cans. Cases of poisoning have been recorded that have been attributed to use of improper metal utensils. Sauerkraut, tomatoes, fruit gelatins, lemonade, and fruit punches have been implicated in metal poisonings.

Toxin metals also have been implicated in food poisoning cases. Copper may become poisonous when it is in prolonged contact with acid foods or carbonated beverages. The vending industry voluntarily discontinued all point-of-sale carbonation systems that do not completely guard against the possibility of backflow into copper water lines. Also, food such as meat placed directly on cadmium-plated refrigerator shelves may be rendered poisonous.

Mayo Clinic

NIH

FARE

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Quantity Demand: Historical Roots

The desire for an efficient foodservice operation requires that the production manager to know the estimated number of customers or the number of servings of each menu item in time to order prom the procurement unit. Good forecasts are essential for managers in planning smooth transitions from current to future output, regardless of the size or type of the foodservice (i.e., schools, hospitals, or restaurants). Forecasts vary in sophistication from those based on historical records and intuition to complex models requiring large amounts of data and computer time. Choosing a forecasting model that is suitable for a particular situation is essential.

Historical Records

Adequate historical records constitute the basis for most forecasting processes. Often, past customer counts, number of menu items prepared, or sales records re used to determine the number of each menu item to prepare. These records must be accurate and complete, or they cannot be extended into the future with any reliability.

Effective production records should include:

          Date and day of the week

          Meal or hour of service

          Notation of special event , holiday, and weather conditions, if applicable

          Food items prepared

          Quantity of each item prepared

          Quantity of each item served

Although production unite records reveal the vital information on menu items served to customers, production is by no means the only organizational unit that should keep records. Only by cross-referencing records of sales with those of production can a reliable historical basis for forecasting be formalized. Records of sales will yield customer count patterns that can be useful for forecasting. These data can be related to the number of times customers select a given menu item or the daily variations induced by weather or special events.

Historical records in the production unit provide the fundamental base for forecasting quantities when the same meal or menu item is repeated. These records should be correlated with those kept by the purchasing department, which include the name and performance of the supplier and price of the food items.

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Setting Goals with Your Team!

No matter what stage of development your team may be at, they’re most effective when the whole group understands and accepts the goals of their assignment. A way to get your team on-board is to allow members to provide feedback on defining and refining project goals. Managers should also provide feedback on establishing and refining these goals. Synergy between team members and managers in establishing project statements will result in achieving these goals, as well. This conversation should normally happen at the initial project meeting, which should also describe team-building goals and information goals.

Effective teams contribute to the achievement of three types of goals throughout the course of a project.

1.      Team-building goals focus on:

          Getting to know each team member. Teams are most effective when they take time to discover each member’s background, skill, work style, etc.

          Learning to work together. Teams need to identify the strengths of each member and set processes in place to work efficiently together.

          Setting ground rules. Members need a common understanding of how the team will conduct itself and what is acceptable and unacceptable behavior. Some of the topics for discussion are meeting attendance, promptness, conversational courtesy, assignments, and breaks.

          Figuring out decision-making processes. A characteristic of ineffective teams is that decisions just seem to happen. Teams need to discuss how decisions will be made to avoid conflicts in the future.

2.      Information goals include:

          Getting updates from team members on progress! Staying connected with your team and making sure everyone is on the same page is important.

          Learning about the tools used to support the team’s various tasks.

          Communicating with stakeholders.

3.      Project goals focus on:

          Understanding the project and each member’s assignment. Teams should be able to ask questions about their tasks and the stakeholders’ expectations.

          Identifying the business needs supported by the goals.

          Understanding the process that will be used. Not only do team members need to understand the overall process, but they also need to understand which steps are their responsibilities.

          Identifying the resources needed. Team members need to discuss resources that might be needed sooner than later in the process. This discussion ensures that necessary resources will be available at their designated times.

          Developing a project plan or outline of how the team will accomplish their goals. Teams need roadmaps. A team leader should discuss the logistics of the project with team members. Breaking the process into smaller steps and assigning duties will help build team collaboration. Team should continue to review and revise these plans as they move toward reaching their goals.

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