National Nutrition Month Campaign

March is National Nutrition Month and it has been a process in the making at developing a campaign for such an important month to the professional of dietetics! As an intern, I have worked with the entire staff at the facility that I am rotating at currently at, and there are a number of events, activities, and education that we have planned for this month.

MyPlate March Madness:
– Employees register for a month-long MyPlate cornhole tournament and particpate during their lunch hour in the multipurpose room within the facility. The winner at the end of the month will receive a healthy cookbook and cooking tips as well!

West Virginia Ramps:
– Nutritional information, cultural background, cooking use, and growth information will be provided to clients, patients, and employees at the facility. I collaborated with another staff member at developing the content.

NNM 2014 Table Tents:
– I developed these table tents with the NNM 2014 logo as well as “Nutrition 101” questions and answers at the bottom of each side of the table tents. Then I put these on display in the facility’s public eating area for everyone to see! This gives this specific population a boost of nutrition knowledge all throughout the month!

March Mediterranean Lunch ‘n Learn:
– This event will incorporate cooking skills, food culture, and nutritional benefits-like heart health. I assisted in the development and implementation of the event and this will take place at the end of the month, as a 1-hour event in a multipurpose room within the facility as well. Participants will learn how to create easy, affordable, and creative appetizers, dips, and spreads. I’ll even give you a hint- kale chips will have a BIG role in this delicious event as well!

NNM VAMC 2014

Intradialytic Parenteral Nutrition (IDPN)

Intradialytic parenteral nutrition is the infusion of an intravenous nutritional formula of hyperalimentation (artificial supplements of nutrients), like amino acids, glucose, and lipids, during dialysis to treat protein calorie malnutrition in an effort to decrease the associated morbidity and mortality experienced in patients with renal failure or end-stage renal disease (ESRD). The term “parenteral” refers to administration of medication or fluid other than through the digestive tract (intravenous or intramuscular).

Protein calorie malnutrition, typically assessed by measurements of serum albumin, occurs in an estimated 25–40% of those undergoing dialysis and is associated with increased morbidity and mortality. For example, the risk of death is increased more than 10-fold in those whose serum albumin levels are less than 2.5 g/dL, and those with a serum albumin near the normal range have a mortality rate twice as high as those with albumin greater than 4.0 g/dL.

In patients receiving chronic dialysis, the National Kidney Foundation currently recommends a daily protein intake of equal to or greater than 1.2 g/kg in patients undergoing hemodialysis and equal to or greater than 1.3 g/kg in patients undergoing peritoneal dialysis. In hemodialysis, the intradialytic IDPN infusion is administered through the venous port of the dialysis tubing, typically, 30 minutes after dialysis has begun, and continued throughout the remainder of a dialysis session. In peritoneal dialysis, sometimes referred to as intraperitoneal parenteral nutrition (IPPN) or intraperitoneal nutrition (IP), parenteral nutrition is infused into the peritoneal cavity during peritoneal dialysis.

Patients with ESRD on chronic hemodialysis have a high incidence of protein-energy malnutrition (PEM). The reasons for this are multi-factorial and include: inadequate food intake, a catabolic response to systemic illness or chronic inflammation, loss of nutrients through the dialysis procedure, as well as systemic effects of the uremic milieu. IDPN has been supported for the management of malnutrition in hemodialysis patients. The rationale for its use is that patients are unable to increase oral intake to meet their nutritional needs or that the oral or enteral route is not effective in managing malnutrition in this group of patients. Nevertheless, numerous studies using IDPN have failed to demonstrate efficacy conclusively with this very costly mode of treatment.

So, this being said… Today I had the opportunity to witness and assist in the methodology regarding how the Clinical Manager at my rotation site approves or possibly denies a patient request for IDPN. Currently, the cost for this request would approximately be $7,000 per month for a patient to receive IDPN, which is three times per week. So, my job today was to determine if this patient is eligible for the hospital to provide IDPN and how to justify the approval/deny request to hospital administrators as well.

Below are the criteria that I researched which is currently being used for the approval/denial of IDPN:

Patient must demonstrate the following:
– Failed attempt to increase nutritional status with oral nutritional supplements
– Is not a candidate for tubefeeding (where nasogastric or gastronomy feeding is unsafe or impractical)
– Is able to meet greater than or equal to 50% of needs orally

Criteria for Initiation: Patient must meet any three of the following:
– Three month average serum albumin 10% of UBW –or- <90% of IBW
– SGA: score B or C indicating moderate to severe malnutrition
– Diet history showing decrease in:
o Protein <1.0g/kg/d
o Calories <25kcal/kg/d (≤30kcal/kg/d for those with higher kcal requirements)
– Documented diagnosis of a GI disorder (like gastroparesis, malabsorption syndromes, etc.)

Sample IDPN prescription
Initiated after 30 minutes into the dialysis session, through the venous port of the dialysis tubing and given for the duration of the hemodialysis procedure (3.5 hours) at a rate of 150 ml/hour.

Solution:
1. Amino acids: 300 mL of a 15% solution of amino acids (15% Clinisol®; Baxter Healthcare Corp., Deerfield, Illinois, USA) consisted of nine essential AAs (lysine, 1.18 g; leucine, 1.04 g; phenylalanine, 1.04 g; valine, 960 mg; histidine, 894 mg; isoleucine, 749 mg; methionine, 749 mg; threonine, 749 mg; thryptophan, 250 mg) and eight nonessential AAs (alanine, 2.17 g; arginine, 1.47 g; glycine, 1.04 g; proline, 894 mg; glutamate, 749 mg; serine, 592 mg; aspartate, 434 mg; tyrosine, 39 mg).
2. Dextrose: 150 mL of dextrose at a concentration of 50%
3. Lipids: 150 mL of lipids at a concentration of 20% This solution provides 188 kcal/hour or 3.5 kcal/kg fat-free mass per hour for a total of: 45 g of protein and 735 total kcal in 600 mL.

Medicare Intermediary Criteria (2009) for Initiating IDPN in the Presence of a Functional Gastrointestinal Tract
1. Evidence of protein or energy malnutrition and inadequate dietary protein and/or energy intake (for instance: dietary history of decreased intake: protein <0.8 g/kg and/or calories <25 kcal/kg and subjective global assessment (SGA): “C” rating [severe malnutrition])
2. Weight loss greater than 10% of ideal body weight or 20% of usual body weight (no time constraints)
3. Serum albumin <3.4 g/dL (3 month rolling average)
4. Evidence of a comprehensive nutritional assessment and dietary counseling
5. Inability to administer or tolerate adequate oral nutrition, including food supplements or tube feeding
6. Evidence that patient was intolerant of enteral nutrition, or could not meet the individual’s nutritional needs or is not feasible (3 month trial)
7. Evidence that the individual has had the following conditions ruled out or previously addressed:
– Anorexia caused by the uremic state
– Altered taste sensation
– Intercurrent (limited) illness
– Emotional distress or illness
– Impaired ability to procure, prepare or mechanically ingest foods
– Unpalatable prescribed diets
– Catabolic response to a superimposed (limited) illness
– Inadequate dialysis/uremic state
– Gastroparesis
– Constipation

ESRD_Costs_Billions

idpn

esrd

Amyotrophic Lateral Sclerosis (ALS)

Amyotrophic lateral sclerosis (ALS), also known as “Lou Gehrig’s Disease,” is a progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord. Motor neurons reach from the brain to the spinal cord and from the spinal cord to the muscles throughout the body. The progressive degeneration of the motor neurons in ALS eventually leads to their death. When the motor neurons die, the ability of the brain to initiate and control muscle movement is lost. With voluntary muscle action progressively affected, patients in the later stages of the disease may become totally paralyzed.

There is early evidence from a small study that people with ALS who are fed a high-kcal, high-carb diet, could potentially see the progression of their disease slowed.
Patients with ALS, who have difficulty swallowing, as did the 24 people in this study, often end up requiring a feeding tube into the stomach in order to receive the adequate amount of nutrition. These patients are usually fed a standard commercially available formula. ALS patient lose weight because they are not able to take in enough calories because of their difficulty in swallowing. As patients lose weight, they are actually burning their own muscle.

Researchers found that a high-kcal, high-carb tube-fed diet was safe and tolerated- better than one designed to main weight or a diet high in fat. Patients on the high-kcal, high-carb diet gained some of the weight they had lost. At the very least, patients should avoid losing weight.

There needs to be larger trials to see if patients should be trying to gain weight. But, until this happens, all patients with ALS should be actively avoiding losing weight.
This study was published in February 2014 and experts report that the results are far from definitive. This study is also much too small to really show a survival benefit from the diets described. A larger trial would be needed to really highlight any problems. Overall, the study, and future studies, would be beneficial if it included more patients.

als

Coronary Artery Disease (CAD)

CAD is the most common type of heart disease. In the United States, it is the #1 cause of death for both men and women. Lifestyle changes, medicines, and medical procedures can help prevent or treat CAD. These treatments may reduce the risk of related health problems. CAD happens when the arteries that supply blood to heart muscle become hardened and narrowed. This is due to the buildup of cholesterol and plaque, on the inner walls. This buildup is called atherosclerosis. As it grows, less blood can flow through the arteries. As a result, the heart muscle can’t get the blood or oxygen it needs. This can lead to chest pain (angina) or worse. Most heart attacks happen when a blood clot suddenly cuts off the hearts’ blood supply, causing permanent heart damage.

A patient seen today was admitted in the intesive care unit (ICU) and was referred to the nutrition staff for support in cardiac care.

Background:
The patient experienced a myocardial infarction (MI) and had coronary artery disease (CAD). He was a male, 85 y/o, and admitted for an MI protocol. He was currently on a cardiac diet with no gastric irritants (NGI). NGIs are foods like juices, chili, and black pepper. He was not experiencing shortness of breathe (SOB), nausea, fever, chills, or vomiting.

Anthropometrics:
Ht: 69 in.
CBW: 195# (88.5kg)
BMI: 28.86 (overweight)
IBW: 160# (72.73kg)

Past Medical History (PMH):
• CAD/Cornoary Artery Bypass graft (CABG)
• Deep Veing Thrombosis (DVT)
• Chronic Kidney Disease (CKD)
• Carotid Stenosis
• Hypertension (HTN)
• Peripheral Vascular Disease (PVD)
• Gallbladder Disease
• Microvascular Decompression (MVD)
• Aortic Atherosclerosis
• Renal Neoplasm
• Cholecystitis
• Stable Angina
• Asbestos Exposure
• B-12 Deficiency

Labs:
Glucose: 132 mg/dl (70-109: normal)
Cholesterol: 144 mg/dl (160-200: normal)
TGs: 205 mg/dl (35-160: normal)
HDL: 36.3 mg/dl (40-60: normal)

Assessment:
TLC Diet
• Limit saturated and trans fats
• Limit cholesterol: less than 200 mg/d
• Limit total fats: 25%
• Consume dietary fiber
• Consume more omega-3 fats
• Consume more plant-based meals

Blausen_0259_CoronaryArteryDisease_02

Familial Hypertriglyceridemia

Familial hypertriglyceridemia is a common disorder passed down through families in which the levels of triglycerides in a person’s blood are higher than normal. This condition is not associated with a significant increase in cholesterol levels. Recently I had the opportunity to assist in the treatment of a patient who suffered from familial hypertriglyceridemia. I’m glad I had the opportunity to take part in this case because I really learned a lot from this patient, his conditions, and how all of the components in life can affect the rest of your life and health.

The patient was a male, 39 years of age, and was suffering from hypertriglyceridemia. His condition was also exacerbated by his weight, insulin resistance, and alcohol consumption. The patient’s peripheral vascular disease raised suspicion for familial dysbetalipoproteinema. The gentleman was a non-traditional student at a nearby college, majoring in mechanical engineering. He was also married with two daughters. The patient was the main food preparer in the household and was open and willing to learn new ways of cooking (low-fat) for his family.

Here were the patient’s labs values:
Cholesterol: 254 mg/dl (160-200: normal)
TGs: 1029 mg/dl (35-160: normal)
Glucose: 127 mg/dl (70-109: normal)
HDL: 36.3 mg/dl (40-60: normal)

I’ve noticed it’s always important to put the normal range for each lab value because different facilities/healthcare agencies could have different normal ranges, depending on their measuring tools.

The patient’s typical diet consisted of:
Breakfast:
– Once a week
– Breakfast sandwich
– Danish (sometimes)
– Coffee
Lunch:
– 12p-1pm
– Leftovers- dinner
– Salad- chicken, shredded cheese, Ranch/Italian dressing)
– Sandwich- turkey/ham, wheat/rye bread –or- Chicken hoagie with mustard
Dinner:
– Lean chicken breast (grilled/baked)
– Olive oil
– Bread crumbs
– Vegetables (variety)
– Shredded cheese (Mozzarella or cheddar)
Bedtime Snack:
– Pretzels

So after speaking with the patient, learning his diet habits, and hearing about his lifestyle factors, as well as other miscellaneous habits, we developed a few goals for him to strive for.
Goal 1: The patient mentioned that he drinks 2-3 cans of soda a week. So, we asked if he can cut that out of his diet. And he said he could.
Goal 2: The patient mentioned that he’s very tech savvy so we asked if he could keep a food log on through a Smart phone application. And he said he could.

We also gave the patient education materials on:
– Dean Ornish program
– Nutrition Therapy for high TG levels
– High TG Meal Tips
– Fat-Restricted Diet

It was clear to me that the patient was at risk for developing pancreatitis from the amount of pressure that his pancreas was experiencing from the fat in his diet. So, to avoid this, we recommended that the patient restrict his fat intake to 15% of his daily energy intake. This is a good starting point for this patient. This way we can work together to get his fat (and protein) levels down and take those important baby steps towards decreasing his fat intake even more, hopefully, in the future.
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Pro-Stat Supplement

Pro-Stat is a nutritional supplement that I recently became familiar with at my MNT rotations. This supplement is used for patients who are having difficulties gaining weight or consuming energy, in general. This supplement delivers the highest concentration of protein and calories in the smallest serving size. It is ideal for patients with an increased need for protein, have a poor appetite, suffer from pressure ulcers, or who could be experiencing protein-energy malnutrition. Pro-Stat is a complete protein and contains all the essential amino acids while being easy to administer. There is no mixing required and I witnessed the supplement being used with a patient who was on a tube feeding. The patient didn’t seem to mind the supplement, which is rare. A large number of patients who are on tube feedings seem to be very particular about what supplements or formula they are consuming. So, it was to my surprise that the patient who we introduced this supplement to, actually seemed like he enjoyed the protein supplement. Plus, I think it helped that I explained to the patient why we were giving him the supplement and how it would help his health status too.

ProStat

Nasogastric Tube Feedings

A nasogastric (NG) tube is a special tube that carries food and medicine to the stomach through the nose. It can be used for all feedings or for giving your patient/client extra calories. It’s important to take good care of the feeding bag and tubing so that they work properly, as well as the skin around the nostrils so that it does not get irritated.NG tube feedings incorporate a procedure where a thin, plastic tube is inserted through the nostril, down the esophagus, and into the stomach. Once the NG tube is in place, healthcare providers can deliver food and medicine directly to the stomach or remove substances from it.

NG tube feeding has four distinct advantages:

·         Short-term (<4 weeks)

·         Most commonly used

·         Easiest to place (with a prior patient assessment)

·         Least expensive to administer

Nasogastric tubes are used mainly for short-term support in patients who do not have problems like vomiting, GERD, poor gastric emptying, ileus or intestinal obstruction. Nasogastric tubes can be used for longer term support where other enteral access is not possible or could potentially carry a risk. NG tubes are potentially dangerous in patients who cannot swallow correctly and those who need to be nursed. A patient assessment should always be carried out prior to placement of an NG tube. NG tubes are placed by appropriately trained staff like nurses or doctors.

There is a small risk that NG tubes can be misplaced on insertion or move out of position at a later stage. Position of NG tubes should be verified on initial placement and before each use. It is recommended that a pH <5.5 is consistent with gastric placement. If aspirate cannot be obtained or the pH is >5.5 feeding should not begin. The NG tube should be left in place, the patient’s position changed and the aspirate re-tested in 1 hour. The feed itself can increase the pH in the stomach, so aspiration should take place at least 1 hour after the feed has been stopped.

NG tube

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

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.

Swallowing_Phases.95151037_std

barium-swallow

What is a SOAP Note?

A SOAP note is a form of documentation used by healthcare professionals to record a patient’s visit or consultation. It is an ongoing system to support the steps of the Nutrition Care Process (NCP) in the capacity of a hospital, long-term care facility, and other similar agencies. Standardized language is part of NCP, which improves both written and oral communication among members of the health care team as well as communication with the patient. A Registered Dietitian at my rotations said to me the first week I was there, “Ninety percent of life is communication.” And when the RD said this to me, it really stuck with me. Life really is based on communication- every aspect of it. So, if healthcare professionals all use the same words, or standardized language, when documenting the progress of a patient, it prevents a barrier of communication or confusion. These SOAP notes are designed to be relevant, accurate, and timely. Yes, there are several other forms of documentation but, the SOAP note seems to be the most commonly used. Here is a brief outline of how a SOAP note should be constructed:

Subjective (S):

This is where the healthcare provider enters all patient information or data collected from the patient or caregiver. This information would also include a diet recall and any food allergies that the patient reports.

Objective (O):

This section is based more on physical evidence about the patient. Information in this section would include height, weight, BMI, weight change over a period of time, labs, PMH, medications currently using, or any other trending values (i.e.: TG levels over the past 6 months).

Assessment (A):

This is where the Nutrition Diagnosis is made. This diagnosis is referred to by healthcare professionals with a nutrition background, as a PES statement. PES stands for problem, etiology, and signs and symptoms. The PES statement is phrased as follows:

Problem related to etiology as evidenced by signs and symptoms

Examples:

·         Altered GI function related to Partial Bowel Obstruction/ileus as evidenced by hypoalbuminemia, parenteral nutrition.

·         Excessive intake of simple sugars related to consumption of regular sodas and juices as evidenced by food and blood glucose logs.

·         Inadequate oral food/beverage intake related to decreased appetite due to cancer and treatment as evidenced by dietary recall and unintentional weight loss.

Plan (P):

This is the section where an outline of interventions is made necessary to treat the nutrition problems(s). Goals are made, short-term and long-term, using the SMART format.

S: Specific

M: Measurable

A: Attainable

R: Realistic/Relevant

T: Timely Manner

This section also includes information as to how the patient plans on monitoring their progress, when their follow-up consultation should take place, and if any multivitamins are being suggested.

oldSOAPnote

soapnote_example