SNH5419 Clinical Nutrition Module Summary PDF

SNH5419 Clinical Nutrition Module Summary 2024/25 Semester 1 Dr Kent Yeung L1 Nutritional Care Plan SOAP Documentation Subjective Objective Assessment Plan S – Subjective Info provided by patient, family, or others (e.g. diet history, reported physical activity, stated beliefs an...

SNH5419 Clinical Nutrition Module Summary 2024/25 Semester 1 Dr Kent Yeung L1 Nutritional Care Plan SOAP Documentation Subjective Objective Assessment Plan S – Subjective Info provided by patient, family, or others (e.g. diet history, reported physical activity, stated beliefs and attitudes, reported prior dietitian contact or nutrition education) Complaints from patients (e.g. nausea, vomiting, decreased appetite) Previous dietetic input or other nutrition support O – Objective (data with physical evidence) Factual observations and findings Diagnosis Current diet/ nutritional support/ special diet Ht, Wt, BMI, desirable wt range, wt history (% loss or gain) Biochemical data Temperature Activity factor and physical activity Bowel motions Infection Medications (those related to dietary intake and nutritional needs) Relevant social history Nutrition-focused physical examination findings (e.g. SGA, PG-SGA) A – Assessment Overall nutrition status/nutrition problem. Requirements: energy, protein, fluids (including calculation) Assessment of dietary intake with respect to adequacy PESS statement: Problem…related to…Etiology…as evidenced by…Signs or symptoms Assessment of nutrition knowledge, motivation, stage of change The Stages of Change Theory The theory suggests that making behavioral change is a process Individuals go through different stages before they actually change their behaviour For this stage-based process, 5 different stages have been most commonly identified The Stages of Change Theory Enter Pre-contemplation Maintenance Contemplation Action Preparation Exit and re-enter at any stage P – Plan Nutritional interventions Hospital diet (energy, protein, fluids, etc) Discharge plan Education for patients and/or caregivers Items for monitoring Review plans including timeframe SOAP Example S Patient works night shift, eats two meals a day, before and after his shift; fried foods, burgers, ice cream, beers in restaurants. Does not add salt to foods. Activity: Plays golf 1x month O 34 y.o. male with history of HTN, T2DM, hyperlipidemia. Ht: 178cm; wt: 113kg; BMI 35.7, Obesity II A Excessive food intake relating to consumption of high fat and high sugar takeaways as evidenced by the rapid increase in body weight. Pt could benefit from increased physical activity and gradual weight loss. P Provided basic education on balanced diet with appropriate intake of fat and carbohydrates. Guidelines on dining out and takeaways. Patient will return to outpatient nutrition clinic for lifestyle intervention and counseling within 1 month after discharge. L2 Hypertension Hypertension Persistently high arterial blood pressure, the force exerted per unit area on the walls of arteries Two types of hypertension: Primary/ 90-95% patients Essential Complex interaction between poor lifestyle hypertension choices and gene expression (e.g. high Na, low 原發性高血壓 F&V intake, physical inactivity) Secondary Hypertension arises as the result of another hypertension disease, usually endocrine (e.g. thyroid problems, 繼發性高血壓 renal failure) Hypertension Diagnostic Criteria Systolic blood pressure(SBP) ≥ 140 (mmHg) OR Diastolic blood pressure (DBP) ≥ 90 mmHg Pre-hypertension: SBP between 120-139mmHg or DBP between 80-89mmHg Management of hypertension Eat less salt (no matter added salt, or high sodium food) ↑ potassium intake Reduce any excess weight Appropriate physical activity Reduce alcohol intake Stress management Medications What else? DASH diet (得舒飲食) Dietary Approaches to Stop Hypertension (DASH) diet A diet to control hypertension promoted by the U.S.- based National Heart, Lung, and Blood Institute, part of the National Institutes of Health (NIH). The DASH diet is rich in fruits, vegetables, whole grains, and low- fat dairy foods. Include meat, fish, poultry, nuts, and beans. Limited in sugar-sweetened foods and beverages, red meat, and added fats. DASH diet (得舒飲食) Rich in vegetables, fruits & low fat dairy Aim to ↑ magnesium & potassium intake (by ↑ fruit & vegetable consumption) Aim to ↑ calcium intake (via consumption of low fat dairy) Will reduce BP in both hypertensive & normotensive people (more profound effect when combined with low sodium intake) L3 Malnutrition Sources of protein Complete sources of protein: these contain all the essential amino acids and are high-quality sources of protein. Complete sources are predominantly animal-based Incomplete sources of protein: these lack at least one essential amino acid and are a lower-quality source of protein. Incomplete sources are plant-based. Complete sources Incomplete sources Animal-based Plant-based Meat, chicken, fish, eggs Nuts, nut pastes and seeds Dairy products (e.g. milk, yoghurt, Legumes, beans and lentils cheese) Wholegrains (e.g. wheat, rice, oats Plant-based and buckwheat) Soy products (e.g. tofu, soymilk) Quinoa, Amaranth Screening of Malnutrition Different screening tools are used to identify potential malnutrition cases: Subjective Global Assessment (SGA) Patient-Generated Subjective Global Assessment (PG-SGA) Mini Nutritional Assessment (MNA) Malnutrition Universal Screen Tool (MUST)  L4 Oncology Top 10 Cancers in Hong Kong (Incidence – 2021) Link: https://www3.ha.org.hk/cancereg/topten.html Nutritional Management – Dry mouth Increase fluid intake (rule-of-thumb: 1ml water per kcal intake) Use of artificial saliva or mouthwashes Add sauces/ gravy to moist the food Encourage sipping of liquids throughout the day https://www.onofre.com.br Nutritional Management – Change of smell and taste Use herbs and seasonings to enhance flavor and appetite Question: What type(s) of herbs and seasonings should NOT be used? Use of colour to make the food appealing Serve food in glass or porcelain rather than metal pans or dishes http://inhabitat.com Nutritional Management – N&V Small frequent meals Give liquids only between meals Do not lie down right after meals Avoid foods which are too hot, sweet, greasy or spicy Avoid foods with strong odor Use of antiemetics if necessary Nutritional Management – Diarrhea Small frequent meals Avoid fatty, deep-fried, or high-fibre foods Increase fluid intake to prevent dehydration Avoid intake of large amount of fruit juices (worsen diarrhea) Avoid lactose-containing drink and foods L5 Musculoskeletal Disorder Osteoarthritis (OA) Most common form of arthritis, sometimes called degenerative joint disease Caused by damage or breakdown of joint cartilage between bones (usually develop slowly and get worse over time) Frequently occurs in the hands, hips, and knees Signs & Symptoms: Pain Stiffness Decreased range of motion Swelling of joints  Osteoarthritis (OA) Risk factors: Joint injury or overuse Aging Gender Being obese Genetics Race Source: US Centers for Disease Control and Prevention. (2017). Osteoarthritis Fact Sheet. Retrieved June 07, 2017, from: https://www.cdc.gov/arthritis/basics/osteoarthritis.htm Medical Management of OA Doctors usually treat OA with a combination of therapies, which may include the following: Physical activity Medications, including prescription drugs and over-the-counter pain relievers Physiotherapy with muscle strengthening exercises Weight loss Supportive devices such as crutches or canes Surgery (if other treatment options have not been effective) Nutritional Management – Weight Control Excessive weight puts extra burden to the weight-bearing joints Being overweight – high risk of knee OA & increase risk of hand and hip OA A well-balanced diet can promote the attainment and maintenance of desirable body weight Moderate weight reduction is effective in reliving the symptoms of OA Nutritional Management – Anti- inflammatory Diet The diet aims for variety, the inclusion of fresh foods, least amount of processed and fast foods, with an abundance of fresh F&V Effect in OA management – still controversial Yet anti-inflammatory diet usually contains adequate F&V and good fats, which can in turn help weight management No diet has been proven to cure osteoarthritis L6 Pulmonary Disorder Chronic Obstructive Pulmonary Disease (COPD) Slow, progressive obstruction of the airways Characterized by airflow limitation that is not fully reversible Symptoms: dyspnea on exertion呼吸困難, chronic cough, increased sputumproduction 痰, tiredness Other clinical features: wheezing喘息, chest tiredness, weight loss, respiratory infections Risk Factors for COPD 1. Cigarette smoking (account for 80-90% of COPD cases) 2. Passive smoking 3. Occupational exposure (occupational dust, chemicals, fumes or smoke from cooking or heating fuels) 4. Air pollution 5. Genetic abnormalities (Alpha-1 deficiency) Objectives for Nutrition Management of COPD ✓Facilitate nutritional well being ✓Maintain an appropriate ratio of lean body mass to adipose tissue ✓Maintain healthy body weight ✓Correct fluid imbalance ✓Manage drug nutrient interactions ✓Prevent osteoporosis Importance of maintaining healthy body weight Being overweight Increases workload on the heart and lungs Excess abdominal fat makes it difficult to fully expand The lungs making breathing harder Increases the risk of other cardiovascular diseases Being underweight Contributes to respiratory muscle weakness making breathing more difficult Associated with poor exercise performance Increases the risk of infection L7 GI Disorder Gastroesophageal Reflux Disease (GERD) Esophageal protective mechanism: ↓ pressure in lower esophageal sphincter and ↑ intra-abdominal pressure Episodes of reflux overwhelm esophageal protective mechanism Symptoms: reflux of gastric secretions, heartburn, substernal pain, belching, esophageal spasm High risk groups: Pregnant women, being overweight, patients with COPD or Hiatal hernia橫膈裂孔疝氣, people on certain medications such as muscle relaxants and NSAIDs, smoking https://oldedelmarsurgical.com/general-surgery/hernia-surgery/ Gastroesophageal Reflux Disease (GERD) Prolonged acid exposure at esophagus can lead to esophagitis, esophageal erosions, stricture 食道狹窄 and in some cases dysphagia Patients may be unable to consume an adequate diet → interfere with sleep, work, social events and overall quality of life Nutritional Management – Food Choices Avoid: Large, high-fat meals Alcoholic beverages Coffee Carbonated drinks Excess spices (chili, Excess citrus fruits peppermint) A low-fat, liquid diet can minimize esophageal distention, passes more easily through strictured areas (yet not for long term) Upgrading of diet depending on recovery Lose weight if overweight Nutritional Management – Feeding Strategies After eating, wait at least 3-4 hours before lying down Stay upright and avoid vigorous activity soon after eating Avoid tight clothes after a meal Crohn’s Disease & Ulcerative Colitis Crohn’s disease: chronic inflammatory process affecting the full thickness of the GI tract. It can occurs at any point from mouth to anus Ulcerative colitis: chronic inflammatory process affecting the mucus membrane or superficial lining of all or part of the colon Medical management: steroids, antibiotics, pain-relief, surgery Small Bowel Resection Ileostomy Colostomy 小腸切除術 迴腸造口 結腸造口 Removal of part or all of Opening of the ileum at Opening of the colon at small bowel (duodenum, the abdominal wall, with the abdominal wall, with jejunum and ileum) the entire colon, rectum the entire rectum and and anus removed anus removed Source: uvahealth.com Source: www.saintlukeshealthsystem.org/ Source: wannawearone.blogspot.hk/ Nutritional Implications – Small Bowel Resection Most digestion and absorption happen in duodenum and jejunum If jejunum is removed → ileum typically adapts to perform the functions of jejunum CHO and protein malabsorption Malabsorption of fat → steatorrhea Ileum resection → vitamin B12 and fat malabsorption Short bowel syndrome – symptoms such as weight loss, muscle wasting, diarrhea, dehydration and hypokalemia Nutritional Management – Small Bowel Resection After surgery, gradual change from parenteral to enteral nutrition May take months or up to 2 years to adapt A normal balanced diet of protein, fat and CHO should be introduced Six small feedings with avoidance of lactose, large amount of concentrated sweets and caffeine Supplementation may be required: fat-soluble vitamins, Ca, Mg, Zn MCT may be used for patients with fat malabsorption Nutritional Implications – Ileostomy & Colostomy Colon is responsible for reabsorbing electrolyte fluid (esp. sodium and chloride) Removal of colon leads to lower risk malnutrition than removal of small bowel Patients with ileostomy or colostomy usually do not become nutritionally depleted Another issue of greater concern is management of having stoma Small Intestine Major division Position and Length Functions Duodenum First section: 9-10 secretes digestive enzymes and bile for most inches chemical digestion to take place Jejunum Middle section: 8 feet has a lining which is designed to absorb carbohydrates and proteins villi in the jejunum are much longer than in the duodenum or ileum Ileum Final section: 12 feet absorb vitamin B12, bile salts, and any products of digestion that were not absorbed by the jejunum Gastroesophageal Reflux Disease (GERD) Prolonged acid exposure at esophagus can lead to esophagitis, esophageal erosions, stricture 食道狹窄 and in some cases dysphagia Patients may be unable to consume an adequate diet → interfere with sleep, work, social events and overall quality of life L8 Metabolic Disorder Genetic Metabolic Disorders – Examples Category Disorders Affected Enzymes Disorder of amino acid Phenylketonuria (PKU) Phenylalanine metabolism 苯丙酮尿症 hydroxylase Fumarylacetoacetate Tyrosinemia, Type 1 hydrolase Disorder of Galactosemia Galactose-1-phosphate carbohydrate uridyltransferase metabolism Glycogen storage disease Glucose-6-phosphatase Disorder of fatty acid Medium-chain acyl-CoA Medium-chain acyl-CoA oxidation dehydrogenase deficiency dehydrogenase (MCAD) Long-chain 3-hydroxyacyl- Long-chain 3- CoA dehydrogenase hydroxyacyl-CoA deficiency (LCHAD) dehydrogenase Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Deficiency)葡萄糖六磷酸去氫酵素缺乏症 G6PD is an enzyme → protects the red blood cells and prevents them from being damaged People with G6PD deficiency usually have normal health But once suffer from severe infection or are exposed to certain drugs or chemical agents, →RBCs damaged and broken down (acute hemolysis) →Jaundice (when bilirubin builds up) →Brain damage, mental retardation, cerebral palsy, hearing deficit Source: HKSAR Department of Health. (2016). Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency. Retrieved June 06, 2017, from: http://www.dh.gov.hk/english/main/main_cgs/files/DH2289E%20G6PD%20English.pdf Common symptoms of hemolytic crisis Sudden rise of body temperature and yellow coloring of skin and mucous membrane Dark yellow-orange urine Pale, fatigue, general deterioration of physical conditions Heavy & fast breathing Weak & rapid pulse. Source: G6PD Deficiency Favism Association. (2018). What is G6PD Deficiency. Retrieved 18 July 2018 from: https://www.g6pd.org/en/G6PDDeficiency.aspx. Living with G6PD Avoid Chinese herbal medicines such as: Rhizoma Coptidis (Huang Lien); Flos Lonicerae (Kam Ngan Fa); Flos Chimonanthi Praecocis (Leh Mei Hua); Kam Ngan Fa Mothballs Calculus Bovis (Niu Huang); and Margaritas (pearl powder) Avoid some western medicines such as: certain antibiotics and antipyretics Avoid close contact with mothballs Nutritional Management Avoid eating fava or broad beans and their products Mother who are breastfeeding the babies with G6PD Deficiency should consult doctor before taking any Chinese or Western medicines Fava Beans L9 Metabolic Stress Enteral Nutrition Main types of Enteral Feeding: Nasogastric tube (NGT) starts in the nose and ends in the stomach. Orogastric tube (OGT) starts in the mouth and ends in the stomach. Nasoenteric tube starts in the nose and ends in the intestines (subtypes include nasojejunal and nasoduodenal tubes). ◦ Oroenteric tube starts in the mouth and ends in the intestines. ◦ Gastrostomy tube is placed through the skin of the abdomen straight to the stomach (subtypes include PEG, PRG, and button tubes). ◦ Jejunostomy tube is placed through the skin of the abdomen straight into the intestines (subtypes include PEJ and PRJ tubes). Parenteral Nutrition Parenteral nutrition is the provision of nutrients intravenously Used when GI tract is not functioning or if normal feeding is not sufficient for patient’s needs Can be used alone or as part of a dietary plan together with oral or tube feeding ◦ Total parental nutrition (TPN)/hyperalimentation: supplies all daily nutritional requirements bypassing the GI tract ◦ Nutrient solutions can be administered through central vein or peripheral vein ◦ Catheter is surgically inserted by a physician or an IV nurse under sterile condition Why is enteral feeding preferred? Problems about central parenteral nutrition: Mucosal atrophy胃粘膜萎縮 Decline in tight junctions in the epithelium Loss of epithelial barrier function (infectious complications) PN: Expensive, invasive, does not reduce catabolism in critical illness Enteral feeding help to restore gut function and the structural integrity完整性 of gut Nutritional Management – Energy Daily energy expenditure = BMR x AF x IF (MJ) Activity factor (AF) usually bed-bound → 1.2 Injury factor (IF) Surgery – uncomplicated → 1.1-1.2 Surgery – complicated → 1.2-1.4 Sepsis → 1.3-1.4 Nutritional Management – Protein After serious injury, body protein is moved to the injury sites for healing Adequate protein intake (via enteral nutrition) can ↓protein loss Requirement: 1.5-2.0g/kg body wt Yet excessive protein (>2.0g/kg) may result in: Uraemia, hypertonic dehydration, metabolic acidosis Major Burns Major burns results in severe trauma Energy requirement increases depending on the extent and depth of the injury ↑Protein catabolism & ↑ urinary nitrogen excretion Burns patients are particularly susceptible to infection Wallace Rule of Nines Wallace Rule of Nines is a tool used by trauma and emergency medicine providers to estimate the body surface area (BSA) involved in burn patients. https://medical-dictionary.thefreedictionary.com/rule+of+nines Galactosemia 半乳糖血症 Caused by mutations in particular gene and affect different enzymes involved in galactose catabolism. A small amount of galactose is present in many foods. It is primarily part of a larger sugar called lactose, which is found in all dairy products and many baby formulas. The signs and symptoms of galactosemia result from an inability to use galactose to produce energy.  Low-Galactose Dietary Pattern Food Groups Allowable Foods Remarks Milk and Milk Ca-fortified soy milk/almond milk/ Lactose-free milk is Substitutes rice milk still NOT safe Mindful of the sauce Breads and Cereals Cooked and dry cereals, and gravy used macaroni, spaghetti, noodles, rice, Unsafe ingredients: tortillas, bread or crackers without milk, buttermilk, milk or unsafe ingredients cream, lactose, Meat, Poultry, Fish, Plain beef, lamb, pork, fish, galactose, dry milk Eggs, Nuts chicken, turkey, eggs, nuts solids, curds More dietary guidelines for people with Galactosemia can be found in the website of Galactosemia Foundation http://www.galactosemia.org/. L10 HBD Functions of Liver, Gallbladder and Pancreas Liver Metabolism of CHO, protein and fat Storage and activation of vitamins and minerals Conversion of ammonia to urea (detoxification) Metabolism of steroids Action as a filter and flood chamber (maintain homeostasis) Gallbladder膽囊 Concentrate, store and excrete bile, which is produced by liver Pancreas 胰臟 Exocrine外分泌 Secretes enzymes to intestinal lumen for digesting proteins, fats and CHO Endocrine內分泌 Secretes the hormones (insulin胰島素& glucagon胰高血糖素) to control blood sugar levels Synthesizes somatostatin生長抑素to inhibit secretion of insulin & glucagon Liver diseases Hepatitis Acute Viral Hepatitis Chronic Hepatitis Liver Cirrhosis Fatty Liver Alcoholic Fatty Liver Disease Nonalcoholic Fatty Liver Disease (NAFLD) Cirrhosis – Clinical Symptoms (Internal) Portal hypertension Hepatic encephalopathy 肝性腦病 Esophageal varices 食道靜脈曲張 Hepatorenal syndrome 肝腎症候群 *portal vein drains the blood from GI tract, gallbladder, pancreas, and spleen to the liver. Prevention of NAFLD Maintain optimal body wt and waistline (gradual wt loss is preferred) Eat a balanced diet Be physically active Avoid alcohol Do not smoke Good control of blood glucose, blood lipids and blood pressure Nutritional Management of Hepatitis – Protein & CHO Protein: 1.5-2.0g/kg High biologic value (HBV) protein to promote liver tissue repair CHO: at least 50-55% of total caloric intake To restore liver glycogen肝糖 reserve To spare protein for tissue regeneration * Fat intake should not be high since secretion of bile increases the workload of liver Pancreatic surgery The food will bypass pancreas and duodenum and enter small intestine directly The most common reasons for the surgery: pancreatitis & pancreatic cancer Whipple procedure – a surgical procedure used for pancreatic carcinoma (pancreaticoduodenectomy) Removal of portion of stomach, head and neck of pancreas, duodenum, gallbladder and bile duct L11 Renal Disease Chronic Kidney Disease (CKD) The definition of CKD: individuals with markers of kidney damage (e.g. albuminuria, haematuria, structural abnormalities detected by imaging, etc); OR those with an eGFR of less than 60 ml/min/1.73m2 on at least 2 occasions 90 days apart (with or without markers of kidney damage). Diabetes is the leading risk factor for CKD, followed by hypertension Other causative factors: chronic glomerulonephritis, infection, toxic agents (e.g. heavy metals, certain drugs), renal vascular or tubular diseases, genetic disorders (e.g. polycystic kidney disease), systemic autoimmnue diseases (e.g. lupus)  Chronic Kidney Disease – Five Stages Stages 1-2: Early stages with markers like proteinuria and hematuria Stages 3-4: Advanced stages Stage 5: Fatal, unless dialysis or kidney transplantation Stage eGFR Description (ml/min/1.73m2) 1 >90 Normal kidney function 2 60-89 Mildly reduction in kidney function 3A 45-59 Moderate reduction in kidney function 3B 30-44 4 15-29 Severe reduction in kidney function 5