ClinicalNutritionWorksheet_Youngman

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

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

at the corners of the mouth) and thin, dry hair that easily falls out could be indicative of deficiencies in vitamins and minerals, including B vitamins (such as B12 and riboflavin) and iron.  Dehydration: The patient's dry oral mucosa, poor skin turgor, and dry skin suggest dehydration, which could impact her overall health and well-being. Adequate hydration is important for proper organ function and overall nutrition.  Potential Protein-Calorie Malnutrition: The muscle wasting, clavicular muscle wasting, and interosseous muscle wasting suggest a potential deficiency in both protein and calories. Protein is essential for maintaining muscle mass and overall body function.  Micronutrient Deficiencies: The presence of dark circles under the eyes and nail abnormalities, along with other symptoms, could indicate possible deficiencies in micronutrients such as iron, vitamin C, and other antioxidants.  Potential Inadequate Oral Intake: The dry oral mucosa, angular stomatitis, and thin nails may suggest difficulties with oral intake, possibly due to discomfort or other issues related to eating and drinking.  Skin and Tissue Integrity: The patient's poor skin turgor, dry skin, and thin nails could indicate compromised skin and tissue integrity, which may impact wound healing and overall health.  Potential Underlying Health Issues: These findings may also be related to underlying health conditions that need to be further investigated. Reference for 4 : Nutrition Focused Physical Exam Pocket Guide third edition. 5. What specific micronutrients are of concern for the patient?  Hair loss: Essential fatty acid deficiency, riboflavin, malnutrition, or toxicity: selenium and vitamin A  Pale: anemia/iron, b12, folate  Angular stomatitis: deficiency: riboflavin, vitamin b6, niacin, biotin, folate. Or vitamin A toxicity  Thin nails: anemia  Dark circles under eyes: vitamin C  Pallor: copper deficiency, anemia, b12, folate Reference for 5 : Nutrition Focused Physical Exam Pocket Guide third edition. Nutrition Related Labs Patient is a 68-year-old-male admitted to the hospital with a 1-month history of nausea, vomiting, and diarrhea resulting in weight loss and fatigue. Patient typically has a good appetite and eats well but had minimal intake for 4 days prior to admission. On hospital day 3, you learn that the patient has been NPO since admission. Patient's GI symptoms have resolved, and the medical team has just advanced him to a regular diet. Patient reports an "excellent" appetite and is looking forward to eating. Anthropometric Data: Weight: 73 kg (161 lbs) Last weight: 75 kg (165 lbs) at admission Biochemical Data: (HD 3) Sodium 134 (135-145 mEq/L) Glucose 95 (70-139 mg/dL) Potassium 3.3 (3.6-5.0 mEq/L) Phosphorus 2.9 (2.7 - 4.5 mg/dL) Blood Urea Nitrogen 22 (6-24 mg/dL) Magnesium 1.4 (1.3 - 2.1 mEq/L) Page 3 of 15 Revised 9 June 2023

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

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