clinical worksheet #1 cancer and...

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1 Name: Danielle Reschke BRIGHAM YOUNG UNIVERSITY NDFS 466 Clinical Worksheet #1 CLINICAL WORKSHEET #1 Cancer and Trauma Purpose(s) 1. To complete nutrition assessment, diagnosis, and intervention for a case patient. 2. To practice the application of clinical judgment. Note: When using “Clinical Judgment” there may be no oneright answer to most of the questions asked, therefore it is important to explain or justify your answers. General Guidelines 1. Complete both case studies in the worksheet 2. Worksheets must be completed electronically 3. Upload the cases in Learning Suite in the assignment section. a. The worksheets must be uploaded as a Word document (.doc or .docx an .rtf file is also acceptable) b. Name file LastName_FirstName_Worksheet_1 For example if my name was John Doe the file would be names Doe_John_Worksheet_1 4. Graded assignments will be returned, with comments, via Learning Suite Sources for completing worksheet. Assume these are the sources available: Nutrition Care Manual -- Adult and Pediatric (online). This should be your first source; use other sources only if needed. IDNT Manual Any textbooks from NDFS courses ADA Evidence Analysis Library (online) and noted journal articles Class Lecture Notes from any NDFS course ASPEN nutrition support guidelines Websites for formula companies (e.g. Nestle, Mead Johnson, Abbot) Citations. List sources used at the end of the case and cite sources as appropriate throughout worksheet. Cite works as indicated in the student handbook. Points Each case is worth 12.5 points a total of 25 points for the full worksheet.

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Name: Danielle Reschke BRIGHAM YOUNG UNIVERSITY

NDFS 466

Clinical Worksheet #1

CLINICAL WORKSHEET #1 Cancer and Trauma

Purpose(s) 1. To complete nutrition assessment, diagnosis, and intervention for a case patient.

2. To practice the application of clinical judgment. Note: When using “Clinical Judgment”

there may be no “one” right answer to most of the questions asked, therefore it is

important to explain or justify your answers.

General Guidelines

1. Complete both case studies in the worksheet

2. Worksheets must be completed electronically

3. Upload the cases in Learning Suite in the assignment section.

a. The worksheets must be uploaded as a Word document (.doc or .docx an .rtf file

is also acceptable)

b. Name file LastName_FirstName_Worksheet_1 For example if my name was John

Doe the file would be names Doe_John_Worksheet_1

4. Graded assignments will be returned, with comments, via Learning Suite

Sources for completing worksheet.

Assume these are the sources available:

Nutrition Care Manual -- Adult and Pediatric (online). This should be your first source;

use other sources only if needed.

IDNT Manual

Any textbooks from NDFS courses

ADA Evidence Analysis Library (online) and noted journal articles

Class Lecture Notes from any NDFS course

ASPEN nutrition support guidelines

Websites for formula companies (e.g. Nestle, Mead Johnson, Abbot)

Citations. List sources used at the end of the case and cite sources as appropriate throughout worksheet.

Cite works as indicated in the student handbook.

Points Each case is worth 12.5 points a total of 25 points for the full worksheet.

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Case #1: Esophageal Cancer and Enteral Feedings

Doctor’s Office Workup JQ is a 69-year old retired military officer. He sought medical attention after several months of

increased difficulty swallowing, lethargy, paleness, and unintentional weight loss. JQ’s physician

ordered blood lab work and did an upper GI series. The upper GI revealed an esophageal lesion

which when biopsied, was positive for squamous cell carcinoma. A chest x-ray was negative.

Available lab results from the doctor’s office visit follow:

Glucose 98 mg/dl Albumin 3.0 g/dl

Hospital Admission JQ was admitted to the hospital for further work up and surgery. Information from his Doctor’s

Office workup was available in the hospital chart. His admitting diagnoses were:

1. Esophageal squamous cell CA

2. Dysphagia 2° to #1

3. Anemia

4. Malnutrition

Labs from the hospital after surgery include

Hgb 11 g/dl Prealbumin 20 mg/dl

Hct 32% Glucose 105 mg/dl

Albumin 2.7 g/dl Calcium 7.6 mg/dl

JQ has never had any previous medical problems; however, he has a long standing history of

smoking (1 pack per day) and moderate social drinking. He is happily married with three grown

children. He has adequate medical insurance and a substantial retirement pension.

Additional radiographic studies indicated the carcinoma was quite extensive and radical surgery

was necessary. JQ was NPO for surgery. He tolerated the surgery fairly well, but would not be

able to take an oral po for several weeks. The physician ordered a diet consult for nutrition

support.

As JQ had difficulty speaking, the dietitian spoke with his wife regarding his diet history. Mrs. Q

stated that JQ’s height was 5'10" and he weighed 170 lbs three months ago, which was his usual

weight. He ate three meals a day and enjoyed a dish of ice cream in the evenings. Although he

followed no special diet, lately he preferred soft, moist foods such as casseroles or meat loaf with

lots of gravy and seemed to be eating smaller portions. The last two weeks he had barely eaten

anything. He drank water with his meals as large amounts of milk gave him gas and cramping.

He had no food allergies.

The nurse weighed JQ using the bed scale and recorded his hospital admit weight at 151 lbs.

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Section 1: Nutrition Assessment Complete a Nutrition Assessment by working through the following

Food/Nutrition Related History (AKA Dietary)

1. Are JQ’s nutritional needs being met? Explain. (Type text in box below)

No, because he has not been eating for around 2 weeks and he has been NPO for the surgery.

This shows that he is losing weight because he does not have enough calories. Also, if he has

been eating, he’s most likely not getting enough protein, which is important for him especially as

he is recovering from surgery.

Anthropometric Measurements 1. List JQ’s

Ht (in & cm) 70 inches; 177.8 cm

Wt (lb & kg) 151 lbs; 68.6 kg

Usual Wt (lb

& kg)

170 lbs; 77.3 kg

%IBW IBW=5 ft=106 #

10 in x 6 lbs per in= 60

106 + 60= 166 lbs

151/166= 91% IBW

BMI 68.6 kg/(1.778)2= 21.7

2. Evaluate JQ’s current wt and any significant wt changes. (Type text box below)

JQ has a healthy current weight, he is within 10% of his IBW and his BMI is 21.7, which is

in a healthy range

[(170-151=19)/170= 0.11 x 100= 11.2% weight loss in 3 months, which is classified severe

weight loss for that amount of time.

(1)

Biochemical Data, Medical Tests and Procedures

1. List abnormal lab values and explain possible causes for each. The causes should be related

to the case, not just any cause. e.g. what is causing JQs abnormal levels.

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Lab and Value Possible Causes

Albumin 2.7 Malnutrition—JQ has seems to have acute malnutrition caused by

squamous cell carcinoma and 2o

dysphagia that have caused him to

be unable to eat and have affected his nutrition. (2)

Hgb 11 Anemia—One of JQ’s diagnoses was anemia. Anemia can decrease

hemoglobin levels. (2)

Hct 32% Anemia— One of JQ’s diagnoses was anemia. Anemia can decrease

hematocrit levels. (2)

Ca2+ 7.6 Hypoalbumineamia—JQ has low albumin blood levels. Low albumin

levels in the blood can decrease calcium levels in the blood. (2)

Nutrition-Focused Physical Findings (AKA Clinical)

1. List and explain any pertinent nutrition-related physical characteristics found in the nutrition-

focused physical exam, interview, or medical record. (Type text in box below.)

Difficulty swallowing—indicative of dysphagia

Paleness and lethargy—indicative of anemia

Unintentional weight loss—indicative of malnutrition

Milk intolerance—his cramping and bloating after drinking milk may indicate lactose

intolerance.

Client History

1. List and explain any pertinent nutrition-related concerns found in the client history

Smoking—can affect vitamin and mineral absorption; cause weight loss; can cause lung, throat,

and mouth cancer.

Comparative Standards

1. Determine JQ’s needs for energy, protein, and fluid. (Type needs in chart below.) Indicate wt

used for calculations, formula used (e.g. HBE, Penn, Kcal/Kg, etc.) write out name of

formula and equation as appropriate, and any activity/stress factors.

Needs Equation Used Activity/Stress

Factors

Energy (Kcals) 2600 kcal Unintended Weight Loss in

Healthy Older Adults (3)

1.25

Protein (g/d) 103 g/day 1.5 g/kg/day (3)

Fluid (ml/d) 2100 mL/day 30 mL/kg for average adults (3)

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Weight Used (lb

and Kg)

151 lbs

68.6 kg

Use the box below to show your calculations

Weight: 68.6 kg x 30 kcal/kg= 2058 kcal x 1.25 activity factor= 2573 (I rounded up to 2600

kcal)

Protein: 68.6 x 1.5 g/kg=102.9 (I rounded up to 103 g/day)

Fluid: 68.6 kg x 30 mL/kg=2058 mL (I rounded up to 2100 mL)

2. Justify the following:

Equation used for energy needs and any activity/stress factors used.

Protein need calculation

Weight used

Remember to cite sources used for justification; sources should be listed at end of case. (Type

text in box below.)

Weight: I used the Unintentional Weight loss for Healthy Older Adults, because JQ had severe

unintentional weight loss in the past 3 months. He had a healthy body weight before his

admission to the hospital and his UBW is close to his IBW. He also currently has a healthy BMI

with his current weight, so I thought that using the unintentional weight loss equation for healthy

adults made sense. (3)

I used JQ’s admit weight, because he has been losing weight for several months, so his admit

weight is going to be more indicative of his current nutritional status as compared to his usual

body weight.

Protein: I used the guidelines for underweight individuals in the “weight management” category

of the NCM. These guidelines said that 1-2 g/kg/day of protein was needed for weight regain. I

chose 1.5 g/kg. (3)

Fluid: I used the 30 mL/kg, because that was what the needs were stated as for average adults,

and I thought that because JQ was healthy before his admission, it made sense for him to have

the average amount of fluids that adults need. (3)

IDNT Nutrition Assessment Terms and Statements

Using the case and assessment information you discussed above, complete the following table.

Enter a one or more assessment terms for each assessment category along with

terminology number. The term used should be at least in the second level, but can be

third or fourth level as appropriate for the case. For example

o First level Food and Nutrient Intake (1)

Second level Energy Intake (1.1.)

Third level Food intake (1.2.2)

o Fourth level Amount of food (FH-1.2.2.1).

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o See pages 77-81 of IDNT 4th

edition for a quick look. In-depth pages 83-221.

Write a brief assessment statement for each term chosen. You can combine terms into

one state if it seems logical. For example anthropometrics would logically go together in

one statement. Others may as well.

o Example: Ht: XX (in/cm); wt: XX (lbs/kg); BMI XX, usual wt XX. Weight loss

XX% mild loss.

Note: only enter information if it applies to this case. Add additional rows as needed.

Assessment Category

Assessment term and number (4)

Assessment Statement

Food/Nutrition-Related History

Energy Intake: FH-

1.1.1

Unintentional weight loss % of 11.2% in 3

months; states that he has been eating smaller

portions,

Diet Experience: FH-

2.1.2.6

Has gas and cramping when drinks milk. This

indicates that he may have a dairy intolerance

Anthropometric Measurements

Weight Change: AD-

1.1.4

11.2% weight loss in 3 months.

Height/length: AD-

1.1.1

70 inches, 177.8 cm

Weight: AD-1.1.2 158 lbs, 68.6 kg

Biochemical Data, Medical Tests, and Procedures

Calcium, serum: BD-

1.2.9

Serum calcium levels are low at 7.6 mg/dL

Swallow study: BS-

1.4.23

JQ reported having a hard time swallowing and

has dysphagia 2o at 1#

Hemoglobin: BS-

1.10.1

Hemoglobin value is low at 11 g/dL

Hematocrit: BS-1.10.2 Hematocrit value is low at 32%

Albumin: BD-1.11.1 Albumin levels are low at 2.7 g/dL

Nutrition-Focused Physical Findings

Overall Appearance:

PD-1.1.1

Overall Appearance of JQ shows muscle wasting

and paleness

Extremities, muscles

and bones: PD-1.1.4

Muscle wasting due to malnutrition and weight

loss.

Client History

Personal Data: 1.1 Age: 67, Gender: Male, Tobacco Use: Positive

Patient chief nutrition

complaint: CH: 2.1.1

JQ’s chief complaint was unintentional weight

loss, difficulty swallowing, lethargy, and

paleness.

Gastrointestinal: CH-

2.1.5

Mrs. Q reports that JQ has gas and cramping

when he drinks milk which indicates possible

lactose intolerance.

Hematology/Oncology:

CH 2.1.7

Esophageal squamous cell carcinoma

Surgical Treatment:

CH-2.2.2

Upper GI surgery to remove squamous cell

carcinoma.

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Section 2. Nutrition Diagnosis

Determine Nutrition Diagnosis/Problem (4)

1. Use the IDNT book to list problems (nutrition diagnosis) JQ has. Add rows if necessary.

Diagnosis term

number Diagnosis Term

Domain (Intake, Clinical,

Behavioral/Environmental) NI-1.1 Inadequate Energy Intake Intake

NI-2.1 Inadequate Oral Intake Intake

NI-5.2 Malnutrition Intake

NC-1.1 Swallowing difficulty Clinical

NC-3.2 Unintended weight loss Clinical

Write a Nutrition Diagnosis PES Statement (4) Write a Diagnosis Statement using PES format for two of JQ’s problems:

Diagnosis Term/ Problem

Etiology Signs and/or

Symptoms

Unintended Weight

Loss

Related

to Decreased ability to

consume sufficient

energy

As

evidenced by Weight loss of >7.5% in

90 days

Swallowing Difficulty Related

to An esophageal tumor As

evidenced by An abnormal swallow

study

Section 3. Nutrition Intervention

Analyze Potential Nutrition Interventions

1. Is TPN appropriate for JQ? Explain. (Type text in box below.)

No, because JQ’s GI tract is working properly and it is important to use the digestive system if

it’s working. TPN is also invasive and JQ is not in a situation where TPN is necessary to receive

all needed nutrients. (5)

2. Is PPN appropriate? Explain. (Type text in box below.)

No, because JQ’s GI tract is working and it is best to use the digestive system if it’s working.

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Also even though PPN is not as invasive as TPN, it is still invasive and shouldn’t be used if it’s

not necessary. In this case, he can receive all the nutrients he needs from enteral feeding, so PPN

is not appropriate. (5)

3. Is enteral feeding appropriate? Explain. (Type text in box below.)

Yes, because he has trouble swallowing, so enteral feeding will help him to be able to get all of

the nutrients that he needs to heal. Also, enteral feeding will allow him to use his GI tract, which

is indicative of better mortality and morbidity outcomes when assisting patients with feeding. (5)

4. List two enteral formulas which would be appropriate for JQ. Justify why the formula is

appropriate.

Formula Name Justification for Use

Jevity 1.0 (6) I used Jevity because a standard solution is better to use in situations

where there is not a specific disease state, such as this situation,

where the main problem is unintentional weight loss. Jevity has the

kcal, the protein, and the fluid that JQ needs to gain weight and

recover. Jevity is also less expensive than formulas for specific

disease states.

Osmolite 1.0 (6) I used osmolite for the same reasons as I used Jevity.

5. Calculate the following information to meet JQ’s current nutritional needs which you

determined in the comparative standards section above. TF must closely meet JQ’s

estimated energy and protein needs for credit.

List energy, pro, fluid needs from above: 2600 kcal, 103 g protein, 2100 mL/day

Formula #1 (6) Formula #2 (6)

Formula Name Jevity 1.0 Osmolite 1.0 (1.64)

Goal rate ml/hr 102.5 mL/hr 102.5 mL/hr

Total ml/day 2460 ml 2460 mL

Total Kcals 2460 kcal 2608 kcal

Non-Pro Kcal 2049 kcal 2172 kcal

Pro g and Kcals 109 g; 411 kcal 109 g; 436 kcal

CHO g and Kcals 380 g; 1336 kcal 354 g; 1416 kcal

Fat g and Kcals 109 g; 713 kcal 85 g; 756 kcal

Osmolality 492 mOsm/kg H2O 492 mOsm/kg H2O

Total Fluid 2040 mL 2066 mL

Free fluid (ml) 1703 mL 1740 mL

Additional fluid need (ml) 397 mL 360 mL

Comment on adequacy of your formula recommendation(s) in meeting estimated nutrient

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needs: These formulas meet the recommendations for JQ in calorie needs, protein needs, and fluid needs. Both of these would be good for enteral nutrition for him.

6. Where the tube should be placed? Why? (Type text in box below.)

The tube should be placed nasogastrically, because the enteral feeding will not be long term, fust

for the amount of time for JQ to meet recover from his surgery and gain back the weight he lost.

A jejunostomy or a gastronomy will be too invasive for a short term enteral feeding.

(5).

7. What tube lumen is appropriate? (Type text in box below.)

8-12 French (5)

8. What are the general guidelines regarding the use of the feeding tube for medications.

(Type text in box below.)

Using feeding tubes for medications can result in metabolic complications, due to nutrient

interactions. They can also cause osmolality abnormalities and crystal or gel formations.

If medications need to be put down the tube, the tube can be flushed with water, then crushed

medications can be put down the tube, and then the tube needs to be flushed with water after

the medication has been given.

Also liquid forms of medications can be given down the feeding tube.

No enteric coated or sublingual medications can be given with a feeding tube.

(5)

9. How can you increase the fiber in a tube feeding? Evaluate the practice of adding

Metamucil to a feeding tube. (Type text in box below.)

You can increase fiber during a tube feeding by using a formula that has fiber added into it

already.

Adding Metamucil into a feeding tube is not recommended, because it will cause gel formation

(5)

10. Complete the following table regarding common nutrition-related problems in the tube-

fed patient. Fill in 3-4 causes and corrective measures for each problem area (Type text in

box below.)

Problem Possible Causes Suggested Corrective Measures

Nausea Surgery (5) Keep the patient comfortable

Pain Medications (5) Ask the doctor about different pain

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Vomiting medications or give tube feeding at

times when he has not had pain meds.

Rapid infusion (5) Infuse the solution slower

Infusing cold formula (5) Let the formula warm up before

infusing

Diarrhea Bacterial overgrowth (5) Treat infection

Contaminated tube feed (5) Flush the tube with water and stop

contamination

Fat malabsorption (5) Infuse the solution slower or try a

different solution that has lower

amounts of fat.

Constipation Milk based formula (5) Find a dairy free formula

Decreased fiber (5) Give patient more fiber

Decreased fluid (5) Give patient more fluid.

Determine Appropriate Nutrition Interventions

1. Complete the following table

a. Fill in the nutrition prescription

b. Fill in one or two interventions. Make sure the interventions are different from

each other. Formula solution (ND 2.1.1.) and Insert enteral feeding tube (ND

2.1.2) are the same ultimate intervention – starting a TF.

i. The intervention should be at least a second level term. Example:

1. First level “Food and/or nutrient delivery” (ND)

a. Second level “ Meal and Snacks (ND 1)

i. Third level Specific foods/beverages or groups (ND

1.3)

c. Use the IDNT manual nutrition intervention terminology. Be sure that the

interventions match your PES statements. That means the interventions should be

directed at fixing the nutrition problem/diagnosis.

d. Remember these interventions should be things done at the initial overall nutrition

assessment, not interventions that will come later at f/u encounters or future

outpatient visit.

Nutrition Prescription:

It is important to consume more calories than are expended for unintentional

weight loss and underweight individuals. A high calorie diet with adequate

NPC is important to help with weight loss.

Intervention Goal(s)/Expected Outcome

Intervention # 1

ND-2.1: begin enteral feeding of

Jevity 1.0 through a NG tube at

102.5 mL/hr.

Weight regain back to 170 # or 77

kg.

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(4)

Intervention # 2

RC-1.4: collaboration with speech

pathologist to prevent dysphagia

(4)

Prevention of dysphagia and

increased ability to eat comfortably

with a decreased risk of aspiration.

Section 4. Nutrition Monitoring and Evaluation

1. What signs and symptoms should the dietitian look for when monitoring JQ’s tolerance

to the tube feeding. (Type text in box below.)

Abdominal distention and discomfort

Fluid intake and ouput

Edema and dehydration

Wegiht

Stool output and consistency

Serum electrolytes, BUN, creatinine, glucose, calcium, magnesium, phosphorous.

(1)

2. What tools can the dietitian use to monitor the nutritional adequacy of the enteral

feeding? Include recommended lab tests. (Type text in box below.)

Tube position

Weight trends

Fluid intake output—urinalysis

Lab data: glucose levels, albumin and prealbumin, electrolyte levels.

Medications

Changes in GI function

(3)

3. Is JQ at risk for refeeding syndrome? Explain. (Type text in box below.)

Yes, because he has not eaten in an extended period of time

(3)

4. What indicators of refeeding syndrome will you watch for? (Type text in box below.)

Electrolyte abnormalities, edema, heart arrhythmias.

(3)

5. How can refeeding syndrome be avoided? (Type text in box below.)

Through monitoring JQ’s serum potassium, magnesium, and phosphorous levels and normalized

through replacement therapy prior to starting enteral nutrition. Also through starting enteral

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nutrition slowly.

(3)

6. Complete the following table for the two interventions and goals you indicated above.

Define the following

a. The indicators you will use to measure change. The indicators should measure

progress towards goal. Example: If your goal is weight gain, possible indicators

would be weight, BMI, skin-folds, calorie count.

b. The criteria for evaluation (be specific.) What criteria will you use to assess if

the indicators show you are meeting goals? In the above example criteria would

be weight increase, BMI between 18.5 and 24.9 Kg/m2, skin-folds within normal

range, calorie intake XXXX/day.

c. Note: the IDNT manual has listed indicators and criteria in the Assessment,

Monitoring, and Evaluation, and Diagnosis section. Remember your interventions

are aimed at resolving a nutrition problem/diagnosis.

Intervention (Copy from above)

Goal/Expected Outcome (Copy form above)

Indicator(s)

Criteria for evaluation

ND-2.1: begin

enteral feeding

of Jevity 1.0

through a NG

tube at 102.5

mL/hr.

(4)

Weight regain back to 170

# or 77 kg

Weight, calorie count. 2600 kcal/day

given to JQ.

Weight regain of

2 lbs per week

until weight is

regained.

RC-1.4:

collaboration

with speech

pathologist to

prevent

dysphagia

(4)

Prevention of dysphagia

and increased ability to eat

comfortably with a

decreased risk of

aspiration.

Swallow studies. Ability to

eat/drink all

thicknesses of

foods and liquids

in a barium

swallow study

without

aspirating.

Section 5. Complete your initial chart note

1. Write your Initial Assessment chart note in the box below. The note should contain all

steps of the nutrition care process, assessment (include all areas), diagnosis,

intervention (include nutrition prescription), monitoring and evaluation (include

goals and indicators). Use the information you’ve written about above to create your

note.

A: 69 year old male

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Height: 70”; 177.8 cm

Weight: 151 lbs; 68.6 kg

IBW: 166 lbs

% IBW: 91%

BMI: 21.7

Pertinent Labs: Albumin: 2.7

Hgb: 11

Hct: 32%

Ca2+: 7.6

D: Unintended weight loss related to decreased ability to consume sufficient energy as evidenced

by weight loss of >7.5% in 90 days.

I: Begin enteral feeding of Jevity 1.0 through a NG tube at 102.5 mL/hr to help JQ regain weight

back. Enteral feeding will give 2600 kcal/day to JQ. A goal of regaining 2 lbs per week.

M/E: Follow up daily to see how the tube feed is being tolerated. Follow up weekly to evaluate

weight gain in JQ compared to the goal of 2 lbs/week.

Section 6. Hospital Follow-Up

The physician ordered the TF protocol you recommended and JQ is tolerating the tube feed well.

He has been on the TF for several weeks and has been progressing and recovering from his

medical illness. A new swallow study indicated JQ could start trying po.

1. Outline your plans for advancement from TF to oral feedings. How will you progress

from TF to oral feeds? Include how you would advance the oral feedings, and what kind

of diet you would want him on orally. How will you know when to d/c the TF? (Type

text in box below.)

I will start JQ on spoon-thickened and pureed foods and start with him eating 1 meal/day orally

and receiving the rest of his kcal from enteral nutrition. After a week of this, if he is tolerating

the oral diet well, I will transition him from eating 1 meal/day orally to having 2 meal/day orally.

If he tolerates this diet well for a week, then I will take him off of the tube feed entirely and let

him eat 3 meals orally per day. After he can eat 3 meals orally, I will introduce some

mechanically altered foods and honey-thickened liquids into his diet. As I introduce less-soft

foods into his diet, I will continue to check for aspiration and monitor his tolerance for these

foods. As he can eat less-soft foods and thinner liquids, I will continue to introduce more foods

into his diet gradually. The hope is that he will be able to eat all thickness of foods eventually.

2. During the transition period, what information would you monitor and why? (Type text in

box below.)

Information Monitored Why Weight To see if he is receiving nutrients from the food that is being

given to him and if he is tolerating an oral diet.

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Swallowing Abilities To ensure that he is not aspirating.

3. List at least one potential nutrition related problem JQ might encounter during this

transition phase and provide a realistic solution. (Type text in boxes below.)

Problem: Constipation (1)

.

Solution: Providing more fluid and fiber with meals. (1)

Section 7. Outpatient Follow-Up

JQ has advanced to full oral feedings and has been discharged. He has scheduled a follow up

with you in one month in the outpatient clinic.

1. During JQ’s outpatient visit, identify which parameters would you monitor to assess his

current nutritional status and indicate why. (Hint – use assessment, monitoring, and

evaluation terms from IDNT.) (Type text in box below.)

I would evaluate his weight, because the primary goal that I set for JQ was weight gain back to

170 lbs. I would also give him a 24 hour recall or a food diary to evaluate and to monitor his

caloric intake. A 24 hour recall or a food diary would also give me an idea of his dysphagia,

because I will be able to see what kinds of foods he is eating (i.e. soft casseroles that may be

more indicative of dysphagia or a regular diet).

References for Case Study #1 (Use the format indicated in the Student Handbook)

1. Mahan KL, Escott-Stump S, Raymond JL. Krause’s Food & the Nutrition Care Process.

13th

ed. St. Louis, MS: Elsevier Saunders; 2012

2. Pagana KD, Pagana TJ. Mosby’s Maunal of Diagnostic and Laboratory Tests.4th

ed. St.

Louis, MS: Mosby Inc; 2010.

3. Academy of Nutrition and Dietetics. Nutrition Care Manual. Available at:

https://www.nutritioncaremanual.org/index.cfm. Accessed February 10, 2015.

4. Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology

(IDNT) Reference Manual. 4th

ed. Chicago, IL; 2013

5. Willams P. Lecture notes. Advanced Dietetics Practice. Brigahm Young University, Feb.

10, 2015

6. Abbott Nutrition. Our Products. Available at: http://abbottnutrition.com/brands/abbott-

brands. Accessed February 9, 2015.

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Case #2 Trauma TPN and the Metabolic Effects of Injury

Hospital Admission JJ is a 23-year old male admitted to the hospital unconscious after being trampled by a bull in a

local rodeo contest. In addition to multiple fractures, an exploratory laparoscopy identified

massive internal injuries to the GI system.

Physician’s Orders Dietitian to consult for TPN and make recommendations

The dietitian was able to obtain the following information from the medical record and

observation.

Previous medical history unremarkable with minor injuries in the past resulting from

other rodeo accidents.

Large framed, approximately 6'1" tall and weighed 210# on the bed scale.

Family members live out of state and have not been able to visit JJ yet.

Admit labs

Alb 2.1 g/dl Hct 31% Prealbumin 7.0 mg/dl

Trigs 170 mg/dl Hgb 10 g/dl CRP 21.4 mg/dl

Gluc 200 mg/dl Na 133 mmol/L

.

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Section 1. Nutrition Assessment

Food/Nutrition Related History (AKA Dietary)

1. Do you need a diet history on this patient? Why or why not? No, because JJ is in acute response phase, so what he has been eating previously is not as

important and making sure that he has enough kcal and protein to support his metabolic

processes.

Anthropometric Measurements 1. List JQ’s

Ht (in & cm) 73”; 185 cm

Wt (lb and Kg) 210 #; 95.5 kg

IBW (lb and Kg) 184 #; 83.6 kg

%IBW 114%

BMI (kg/m2) 28

2. How accurate are JJ’s current anthropometrics?

I would say that they are probably pretty accurate. JJ was not malnourished before coming into

the hospital, so his weight and BMI are most likely accurate.

Biochemical Data, Medical Tests and Procedures

1. List abnormal lab values explain possible causes for each. (pagana)

Lab and Value Possible Causes

Albumin; 2.1 g/dl

Inflammation—because albumin is a negative phase reactant, during

inflammation albumin levels decrease. (2)

Triglyercides; 170

mg/dl

Because JJ’s triglycerides are a little bit over the normal ranges, I

think that it could be because of the acute stress response causing

lipolysis. (2)

Glucose; 200 g/dl Acute stress response—Severe stress stimulates catabolism which

secretes glucagon secretion. Glucagon secretion causes

hyperglycemia. (2)

Hct; 31% Hemorrhage—because JJ has broken bones, bruises, and undergone

internal injuries with his GI tract, there may be some internal

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bleeding which could cause a low hematocrit (2)

Hgb; 10 g/dl Hemorrhage—because JJ has broken bones, bruises, and undergone

internal injuries with his GI tract, there may be some internal

bleeding which could cause a low hemoglobin (2)

Na 133 mEq/L JJ’s sodium is just under the normal values, so I think that it could be

because of his injuries, but there is nothing drastic that is causing the

low sodium values. (2)

Prealbumin: 7 mg/dl Inflammation—because prealbumin is a negative phase reactant,

during inflammation prealbumin levels decrease. (2)

CRP; 21 mg/dl Inflammation—because CRP is a positive phase reactant, during

inflammation CRP levels increase. (2)

2. Are these lab values accurate tools to use to determine JJ’s nutritional status? Explain

No because due to the acute response phase and inflammation, these lab values do not show

JJ’s actual biochemical values or his biochemical nutrition status.

Nutrition-Focused Physical Findings (AKA Clinical)

1. What clinical signs would you look for to help complete your nutritional assessment?

Edema and muscle wasting.

(1)

2. What clinical signs are typical in trauma patients?

Edema, muscle wasting, confusion.

(1)

Comparative Standards

1. Determine JJ’s needs for energy, protein, and fluid. (Type needs in chart below.) Indicate

wt used for calculations, formula used (e.e. HBE, Penn, Kcal/Kg, etc.) write out name of

formula and equation as appropriate, and any activity/stress factors.

Needs Equation Used Stress Factors

Energy (Kcals) 2600 25-30 kcal/g (1) None

Protein (g/d) 115 g 1.2-2.0 g/kg (3)

Fluid (ml/d) 2400 mL per day 25-30 ml/kg (3)

Weight Used (lb

& kg)

210 lbs

95.5 kg

Use the box below to show your calculations

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Kcal: 25 kcal x 95.5= 2400 kcal; 30 kcal x 95.5= 2900 kcal

Protein: 1.2 g/kg x 95.5= 115 g/day; 2.0 g/kg x 95.5= 191 g/day

Fluid: 25 ml/kg x 95.5= 2400 ml/day; 30 kcal x 95.5= 2900 mL/day

2. Justify the following:

Equation used for energy needs and any activity/stress factors used.

Protein need calculation

Weight used

Remember to cite sources used for justification; sources should be listed at end of case. (Type

text in box below.)

Energy: Krause said that a range of 25-30 kcal/kg could be used in critical care. I calculated this

range and then chose a number in the middle, which was 2600 kcal. (1)

Protein: The nutrition care manual said to use 1.2-2.0 g/kg of protein for critical care patients, I

chose 1.2, because I didn’t want to give him too much protein, as giving too much protein can

cause hyperglycemia in the acute response phase. (3)

Weight: I used his admit weight, because no other weight was given and it is unlikely that he has

lost much weight in the short amount of time between getting injured and arriving at the hospital.

IDNT Nutrition Assessment Terms and Statements

Using the case and assessment information you discussed above, complete the following table.

Enter a one or more assessment terms for each assessment category along with

terminology number. The term used should be at least in the second level, but can be

third or fourth level as appropriate for the case. For example

o First level Food and Nutrient Intake (1)

Second level Energy Intake (1.1.)

Third level Food intake (1.2.2)

o Fourth level Amount of food (FH-1.2.2.1).

o See pages 77-81 of IDNT 4th

edition for a quick look. In-depth pages 83-221.

Write a brief assessment statement for each term chosen. You can combine terms into

one state if it seems logical. For example anthropometrics would logically go together in

one statement. Others may as well.

o Example: Ht: XX (in/cm); wt: XX (lbs/kg); BMI XX, usual wt XX. Weight loss

XX% mild loss.

Note: only enter information if it applies to this case. Add additional rows as needed.

Assessment Category

Assessment term and number

Assessment Statement

Food/Nutrition-Related History

N/A N/A

N/A N/A

N/A N/A

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Anthropometric Measurements

Body

composition/growth/weight

history AD-1.1

(4)

Height: 73”, 185 cm

Weight: 210 lbs; 95.5 kg

IBW: 184 lbs; 83.6 kg

% IBW: 114%

BMI: 28.0

Biochemical Data, Medical Tests, and Procedures

Sodium BD-1.2.5

(4)

Sodium levels are low at 133

Glucose, casual- BD-1.5.2

(4)

Glucose levels are high at 200

C-reactive protein BD-

1.6.1

(4)

CRP is high at 21

Triglycerides, serum BD-

1.7.7

(4)

Triglycerides are high at 170

Nutritional Anemia Profile

BD-1.10

(4)

Hgb is low at 10

Hct is low at 31%

Protein Profile BD-1.11

(4)

Albumin is low at 2.1

Prealbumin is low at 7

Nutrition-Focused Physical Findings

Overall Appearance PD-

1.1.1

(4)

Unconscious,

Extremities muscles and

bones PD-1.1.4

(4)

Bruises and broken bones

Digestive System PD-1.1.5

(4)

Internal damage of GI tract

Client History Personal Data CH-1.1

(4)

23 years old, male.

Section 2. Nutrition Diagnosis

Determine Nutrition Diagnosis/Problem

1. Use the IDNT book to list problems (nutrition diagnosis) JQ has. Add rows if necessary.

Diagnosis term

number Diagnosis Term

Domain (Intake, Clinical,

Behavioral/Environmental) NI-1.1 (4) Increased energy expenditure Intake

NC-1.4 (4) Altered GI function Clinical

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Write a Nutrition Diagnosis PES Statement (4) Write a Diagnosis Statement using PES format for two of JJ’s problems:

Diagnosis Term/ Problem

Etiology Signs and/or

Symptoms

Increased energy

expenditure

Related

to Acute phase stress

response

As

evidenced by Fractures and internal

injuries

Altered GI Function Related

to Internal injuries to

the GI tract

As

evidenced by Exploratory laporascopy

results.

Section 3. Nutrition Intervention

Analyze Potential Nutrition Interventions

1. From your nutrition assessment do you think JJ is at nutrition risk? Explain.

Yes, because he is in the acute response phase of metabolic stress, his body is most likely

catabolic. This means that his protein, calorie, and fluid needs will increase. If these increased

needs are not met, he could become malnourished and his risk of mortality will increase.

2. What will be the main challenges in providing sufficient nutrition?

Giving JJ increased calories and protein but not over feeding him. Over feeding a patient in

critical care increases mortality and morbidity risks. I think another challenge will be assessing

his nutrient absorption to JJ, because he has internal injuries to his GI tract. (3)

3. Is enteral feeding appropriate? Explain.

No, because we are not sure if he will aspirate or if he can swallow. Also, because he has many

internal injuries to his GI tract, his GI tract may not work. In addition, we want to start feeding

him within 24 hours, and we will not be able to receive the information we need to evaluate if he

is at risk for aspiration or if his GI tract will be efficient at absorbing nutrients, so it will be best

to start him on TPN. (3)

Complete the physician’s order to consult for TPN.

The hospital has a standard TPN formula of 500 cc D50 and 500cc 8.5% AA (per 1000 cc) and

the availability of both 10% and 20% lipids.

4. Calculate a TPN solution to meet JJ’s current nutrition needs as calculated above. Fill in

the following table with the TPN calculations. If you cannot determine a TPN that will

adequately meet both energy and pro needs, discuss that in the last part of #5 below.

List energy, pro, fluid needs from above: Energy: 2600 kcal; Protein: 116 g; Fluid: 2400 mL

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Total volume of standard solution (ml/24 hr)

2400 mL

Rate of standard solution (ml/hr) 100 mL/hr

Type of lipids used and frequency

10% 2x per week

Carbohydrate grams and Kcals 600 g; 2040 kcal

Protein grams and Kcals 102 g; 408 kcal

Fat grams and Kcals 14 g/day; 157 kcal per day

Total Kcals 2605

Non-pro Kcals 2197

Non-pro Kcals (NPC):N ratio (Goal ~150:1)

137:1

% NPC Calories from lipid (Goal <30%)

7%

% NPC from CHO (goal 70-80%) 93%

Fat Load (goal ≤ 1 gm/kg) 0.15

CHO Load (mg/kg/min) 4.36

Show calculations below.

1200 mL protein: 1200 x .085= 102 g x 4= 408 kcal

1200 mL CHO: 1200 x .5= 600 g x 3.4= 2040 kcal

Fat: 1000 mL x 1.1 kcal/ml= 1100 kcal/7= 157 kcal/day

1100 kcal/11 kcal per g= 100 g/7= 14 g/day

5. Assess the above TPN recommendation for JJ’s needs. Current TPN provides:

% Protein needs 88%

% NPC needs 103%

% total Kcal needs

100%

% free fluid needs 100%

Appropriate NPC:N ratio? Explain.

Yes, because it is around 150:1, which was the guideline for this ratio.

Having a NPC:N ratio around 150:1 will help promote muscle

building instead of muscle catabolism while still giving the patient the

energy that he/she needs.

Appropriate fat load? Explain.

I think that this fat load is a little bit low, but the fat low is within the

guideline of <1.0, so this fat load is appropriate.

Appropriate CHO load? Explain.

This carb load is lower than the guideline of 5-7, so I do not think that

it is appropriate.

Is there I could add in modules, such as extra carbohydrate or extra protein.

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something you can do to more closely meet pt needs when only standard TPN is available?

(5)

6. List the advantages and disadvantages of using standard TPN solutions.

Advantages Disadvantages -Already made

-less expensive

-Reduce the risk of infection

-less waste

(5)

-Doesn’t cater to special needs

-Is difficult to customize

-Can be harder to calculate

(5)

7. List the advantages and disadvantages of using individualized TPN (3-in-one solutions).

Advantages Disadvantages -You can get the exact grams and calorie

amounts that you need

-Easier to meet the special needs of patients

-Fat goes in at a slower rate so fat clearance

improves

-Saves time for the nurses

(5)

-Takes more time

-Can be harder to calculate

-More expensive

-Increased risk of contamination

-There can be solution issues with mixing

things in the custom solution

-Risk of occluding the TPN catheter.

(5)

8. List the general complications of TPN.

Some complications of TPN include hyperglycemia, hypoglycemia, EFA deficiencies,

hypertriglyceridemia, azotemia, high BUN and high creatinine. It can also cause fatty liver

and biliary obstructions. Also hemothoraxes, infections, and blood clots are important to

watch out for. (5)

9. List the indications for use of TPN. (e.g. when is TPN appropriate)

Peripheral: If they will have TPN for <2 weeks and don’t need full nutrition.

Central: If TPN is a long-term solution (>1 week), if a feeding tube isn’t working or the

patient can’t eat, and if the client is clinically stable and hemodynamically stable.

(5)

Determine Appropriate Nutrition Interventions

10. Complete the following table

a. Fill in the nutrition prescription

b. Fill in one or two interventions. Make sure the interventions are different from

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each other. Formula solution (ND 2.1.1.) and Insert enteral feeding tube (ND

2.1.2) are the same ultimate intervention – starting a TF.

i. The intervention should be at least a second level term. Example:

1. First level “Food and/or nutrient delivery” (ND)

a. Second level “ Meal and Snacks )(ND 1)

i. Third level Specific foods/beverages or groups (ND

1.3)

c. Use the IDNT manual nutrition intervention terminology. Be sure that the

interventions match your PES statements. That means the interventions should be

directed at fixing the nutrition problem/diagnosis.

d. Remember these interventions should be things done at the initial overall nutrition

assessment, not interventions that will come later at f/u encounters or future

outpatient visit. Note: you may have one goals that the two interventions will

address or you may have two separate goals.

Nutrition Prescription:

During critical care and the acute stress response, it is important to support

the metabolic system through giving patients adequate calories, protein, and

fluid.

Intervention Goal(s)/Expected Outcome

Intervention # 1

ND-2.2:

Begin 2400 mL of parenteral

nutrition each day with 2 bags of

10% lipids twice a week.

(4)

That the calorie and protein amounts

will provide JJ nutrition that he needs

while his body goes through the

acute stress response.

Intervention # 2

RC-1.3:

Work with medical team to ensure

that JJ’s GI tract can heal and that he

can transition to an oral diet as soon

as possible.

(4)

That JJ’s gut will heal and that with

time and counseling with other

health professionals, he will be able

to transition from TPN to an oral

diet.

Section 4. Nutrition Monitoring and Evaluation

1. What should you use to monitor TPN effectiveness and recommendation?

-Blood glucose levels to watch for hyperglycemia and to adjust protein and carbohydrate recommendations -BUN so that protein breakdown and kidney function can be assessed and accounted for. -Serum osmolality to ensure that he is getting enough free fluid and that there aren’t too many aspects to the TPN that is changing the osmolality. -Electrolytes to watch for hyponatremia and hypernatremia. (3)

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2. What complications could result if excessive carbohydrate is given in TPN?

Hyperglycemia (5)

3. What are your best monitors to check CHO tolerance?

Blood glucose levels and insulin levels (5)

4. What complications could result if excessive fat is given in TPN?

Hyperlipidemia, fatty liver and spleen, impaired liver, anemia, and clotting insufficiencies. (5)

5. What are your best monitors to check for lipid tolerance?

Blood lipid levels

6. Complete the following table for the two interventions and goals you indicated above.

Define the following

a. The indicators you will use to measure change. The indicators should measure

progress towards goal. Example: If your goal is weight gain, possible indicators

would be weight, BMI, skin-folds, calorie count.

b. The criteria for evaluation (be specific.) What criteria will you use to assess if

the indicators show you are meeting goals? In the above example criteria would

be weight increase, BMI between 18.5 and 24.9 Kg/m2, skin-folds within normal

range, calories at XXXX kcal/day.

c. Note: the IDNT manual has listed indicators and criteria in the Assessment,

Monitoring, and Evaluation, and Diagnosis section. Remember your interventions

are aimed at resolving a nutrition problem/diagnosis.

Intervention (Copy from above)

Goal/Expected Outcome (Copy form above)

Indicator(s)

Criteria for evaluation

ND-2.2:

Begin 2400 mL

of parenteral

nutrition each

day with 2 bags

of 10% lipids

twice a week.

That the calorie and protein

amounts will provide JJ

nutrition that he needs

while his body goes

through the acute stress

response.

Weight fluctuations, hyper-

or hypo- glycemia, blood

lipid levels outside of the

normal ranges, and muscle

anabolism.

Weight stability,

blood glucose

levels within

normal ranges,

blood lipid levels

within normal

ranges, and

nitrogen

excretion

through the stool.

RC-1.3:

Work with

medical team to

ensure that JJ’s

That JJ’s gut will heal and

that with time and

counseling with other

health professionals, he

Fewer visible internal GI

tract injuries, normal

swallow studies.

Ability to eat

without

aspirating, and

tolerance of a

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GI tract can heal

and that he can

transition to an

oral diet as soon

as possible.

will be able to transition

from TPN to an oral diet.

tube feed.

Section 5. Complete your initial chart note

1. Write your Initial Assessment chart note in the box below. The note should contain all

steps of the nutrition care process, assessment (include all areas), diagnosis,

intervention (include nutrition prescription), monitoring and evaluation (include

goals and indicators). Use the information you’ve written about above to create your

note.

A: 23 year old male

Height: 73”; 185 cm

Weight: 210 lbs; 95.5 kg

IBW: 184 lbs; 83.6 kg

% IBW: 114%

BMI: 28

Pertinent Labs: Albumin: 2.1

Triglycerides: 170

Glucose: 200

Hgb: 10

Hct: 31%

Na: 133

Prealbumin: 7

CRP: 21

D: Increased energy expenditure related to acute phase stress response as evidenced by

fractures and internal injuries.

I: Begin 2400 mL of parenteral nutrition each day with 2 bags of 10% lipids twice a week.

M/E: Follow up daily to see if TPN is being tolerated and to adjust TPN order. Follow up

once a week to check for weight fluctuations and protein excretion.

Section 6. Hospital Follow-Up The physician ordered the TPN you recommended. You are assessing JJ 3-days later and want to

determine if the TPN is meeting JJ’s needs. A UUN was ordered.

1. If the UUN was 32 gm/24 hr, how many grams of protein are being lost in one day? (hint

1 gm N= 6.25 g pro OR protein is 16% N)? Show work

32 g N/.16 N= 200 g protein (5)

2. Using the UUN above calculate the N balance. Show work

(32 g lost each day + 4= 36 g N) (5)

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(102 g ingesting x .16= 16 g N)

16-32= -16

(5)

3. How would you modify your nutrition support (in general) based on the N balance

calculated above?

I would give JJ 100 more grams of protein in the TPN.

4. Would indirect calorimetry be of benefit in assessing this patient?

Yes, indirect calorimetry would be beneficial (3)

5. What can indirect calorimetry tell you?

It can tell us how many calories he is burning, which can help us adjust the TPN order. It will

also tell us the RQ, which can tell us if he is burning more CHO, protein, or fat.

(3)

After a week, you met as part of the interprofessional team in rounds to discuss JJ’s case. The

team decided JJ was ready to try po feeds.

6. How would you (the dietitian) modify the TPN as JJ is advanced to po feedings?

I would taper him off of TPN so that he is receiving 33%-50% of his nutrient needs from a tube

feed or from an oral diet. I would then watch and see when JJ is meeting 50% of his needs from a

tube feed or an oral diet, and then take him off of TPN completely.

(5)

7. How would you monitor tolerance to his oral feedings?

I would look for diarrhea, distention, and his biochemical lab values.

(3)

References for Case Study #2 (Use the format indicated in the Student Handbook)

1. Mahan KL, Escott-Stump S, Raymond JL. Krause’s Food & the Nutrition Care Process.

13th

ed. St. Louis, MS: Elsevier Saunders; 2012

2. Pagana KD, Pagana TJ. Mosby’s Maunal of Diagnostic and Laboratory Tests.4th

ed. St.

Louis, MS: Mosby Inc; 2010.

3. Academy of Nutrition and Dietetics. Nutrition Care Manual. Available at:

https://www.nutritioncaremanual.org/index.cfm. Accessed February 10, 2015.

4. Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology

(IDNT) Reference Manual. 4th

ed. Chicago, IL; 2013

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5. Willams P. Lecture notes. Advanced Dietetics Practice. Brigahm Young University, Feb.

10, 2015