PRE-WORKSHEET FOR CLINICAL WORKSHEET #3

Transcription

1 Name: Danielle Reschke BRIGHAM YOUNG UNIVERSITY NDFS 466 Pre-worksheet for clinical worksheet #3 PRE-WORKSHEET FOR CLINICAL WORKSHEET #3 Purpose(s) 1. To prepare information for use in the nutrition assessment, diagnosis, and intervention, monitoring and evaluation for a case patient. 2. To utilize resources to find evidenced-based information. General Guidelines 1. Complete information in the pre-worksheet 2. Worksheets must be completed electronically 3. Upload the pre-worksheet in Learning Suite in the assignment section. a. The worksheets must be uploaded as a Word document (.doc or.docx) b. Name file LastName_FirstName_PreWorksheet_3 For example if my name was John Doe the file would be names Doe_John_Worksheet_3 4. The pre-worksheet grade will be combined with the case-study grade for a total of 25 points. Sources for completing worksheet. Assume these are the sources available: Nutrition Care Manual -- Adult and Pediatric (online) 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) Course Readings ICD-10 codes may be found at o Eatrightpro.org Practice> Getting Paid> Getting Started with Payment > ICD-10 conversions>icd-10-cm Codes for RDNS o Click on 2015 diagnosis codes. Browse or search for codes. Browsing is probably best to make sure you get a ICD-10, not ICD-9 code Citations List sources used at the end of the case and cite sources as appropriate throughout pre-worksheet. Cite works as indicated in the student handbook. 1

2 You are the dietitian in a hospital with responsibilities to cover the maternity and pediatric floors. You see both inpatients and outpatients in the women s and children specialty areas. To prepare for potential patients you want to create a set of standards with information about pregnancy, pediatrics, infants, etc. This way when you need to assess a patient you have information quickly and easily accessible. To create your standards complete the information for the pre-worksheet below. Billing and Coding 1. List the three CPT codes that can be used to bill MNT? ( CPT Code # Description (1) Medical Nutrition Therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (1) Reassessment and intervention, individual, face-to-face with the patient, each 15 minutes (1) Group (2 or more individuals), each 30 minutes. 2. List ICD-10 codes for the following conditions? Condition ICD-10 Code # Description Gestational Diabetes O Gestational Diabetes mellitus in pregnancy, unspecified control (2) Pre-Eclampsia and/or Eclampsia Pre-eclampisia: O14.0 Pre-eclampsia: Mild to moderate pre-eclampsia Eclampsia: Eclampsia in pregnancy(2) Eclampsia: O15.0 Hyperemesis (vomiting) O21.9 Vomiting of Pregnancy, unspecified (2) during pregnancy Phenylketonuria E70.0 Classical phenylketonuria (2) (PKU) Cystic Fibrosis E84.9 Cystic Fibrosis, unspecified (2) Patent Ductus Arteriosus Q25.0 Patent ductus arteriosus (2) Low birth weight P07.00 Extremely low birth weight newborn, unspecified weight (2) Pregnancy 1. List conditions that can complicate pregnancy? Gaining too much weight 2

3 o Macrosomia o Gestational Diabetes o Preeclampsia Not gaining enough weight o Intrauterine growth restriction (IUGR) o Premature delivery Nausea and vomiting o Shift in hormones Hyperemesis gravidarum o Severe N/V Hypertension o Gestational hypertension after 20 weeks o Stage 1 preeclampsia: abnormal implantation that affects placenta function o Stage 2 preeclampsia: response to abnormal placental function Change in hormones that increase platelet aggression and decrease vasodilation Decrase plasma volume HELLP syndrome o Hemolysis Gestational Diabetes 2. List ways of managing nausea, vomiting, and hyperemesis during pregnancy. N/V Eat when you wake up Medications and supplements Eat small, frequent meals Separate liquids and solids Avoid food odors Hyperemesis gravidarum See if it gets better Medications TPN 3. List possible nutrition factors that may reduce the risk of Pregnancy Induced Hypertension (PIH) Calcium of 1-2 g/day Vit C (1000 mg) and E (400 IU) reduce oxidative damage before week 20 Omega-3 fatty acids may or may not help (mixed studies) Folate of 600 mcg helps a little bit Eat 5+ fruits and vegetables per day No sodium restrictions unless she has chronic HTP 4. When should pregnant women be screened for gestational diabetes? Why does screening 3

4 take place at this time? A pregnant woman who has risk factors for diabetes should be screened at the prenatal visit to test for type II diabetes. They are then rescreened for gestational diabetes between weeks of gestation. Women who are not at risk of diabetes or who do not currently have diabetes will also be screened at weeks of gestation. This is because in the second or third trimester of pregnancy there is an increase in insulinantagonist hormone levels and a resulting insulin resistance. 5. What is the test is used for screening for gestational diabetes? An oral glucose tolerance test (OGTT) 6. How is the test administered? 1 Step test: An Oral Glucose Tolerance Test (OGTT) of 75 g of glucose is given to a woman who is fasting. Her blood glucose levels are taken at fasting, at 1 hour, and at 2 hours. It should be performed after an overnight fast of at least 8 hours. 2 Step test: A nonfasting 50 g glucose load is given and glucose measurements are taken at one hour. If the blood glucose level is 140 mg/dl or higher, a 100 g OGTT is given. The 100 g OGTT is given while fasting. After 3 hours, blood glucose levels are taken. If blood levels exceed 140 mg/dl then gestational diabetes is diagnosed. 7. What are the diagnostic criteria for this test? One step: Fasting: > 94 mg/dl 1 hour: >180 mg/dl 2 hours: >153 mg/dl Two step: 1) >140 mg/dl 1 hour after nonfasting test 2) >140 mg/dl 3 hours after fasting test 8. What are risk factors for developing gestational diabetes? Overweight BMI >25 Gaining too much weight during pregnancy Being physically inactive Having a first degree relative with diabetes Having a previous baby >9 lbs Having PCOS Having high blood pressure Having HDL <35 Being black, Latino, native American, Asian, or Samoan 4

5 9. List at least two ways (equations) to calculate energy needs for a pregnant women Equation #1 Equation #2 Equation No additional calories in the first trimester 340 additional kcal in the second trimester 452 additional kcal in the third trimester 30 kcal/kg if at desirable weight 24 kcal/kg if above desirable weight kcal/kg if below desirable weight Source (e.g. Nutrition care manual, etc.) 10. List one way to calculate protein needs for pregnant women. (Hint look at the DRI) Equation Source (e.g. Nutrition care manual, etc.) Protein needs #1 1.1 g/kg/day 11. List specific recommendations for carbohydrate intake and gestational diabetes. What is the minimum CHO intake? 130 g-175 g per day depending on the trimester What are general guide for CHO at breakfast? g What percent of calories should come from CHO for gestational diabetes? <45% 12. What is the appropriate weight gain for pregnancy according to pre-pregnancy BMI? Fill in the table below to answer. (Hint: check the IOM pregnancy weight gain brief on Learning Suite). Pre-pregnancy BMI kg/m2 Total Weight gain range lbs Average Rates of Weight Gain (lbs per week) in 2nd and 3rd Trimester Underweight < lbs lbs Normal weight lbs lbs Overweight lbs lbs Obese lbs lbs 13. Locate pregnancy weight gain charts; have charts available for case studies in class. (Hint look in NDFS 405 materials or on Learning Suite) 5

6 14. Describe any consequences with excess wt gain during pregnancy. Macrosomia Gestational Diabetes Preeclampsia Less likely to breastfeed 15. What are general recommendations for exercise during pregnancy? 30 min 3 times per week If active prior to pregnancy then you can exercise more If not active prior to pregnancy, start with 5 minutes per day and add 5 minutes per week until you get up to 30 min Don t do high impact or bouncing things as it can hurt joints. Stop if you are dizzy, short of breath, have heart pain, bleeding, loss of movement by the baby, or contractions. 16. Can blood sugars be controlled with oral hypoglycemic agents in gestational diabetes? Explain Yes, there are 3 oral medications that can be used in gestational diabetes: Glyburide: must sign consent forms to take during pregnancy Sufonylureas: Metformin: Class b. Not recommended unless mom was on metformin before pregnancy. 17. Are women with gestational diabetes at risk for developing diabetes later in life? If yes, how can this risk be reduced? Yes they are. This risk can be reduced by breastfeeding, increasing physical activity, and by eating healthy after the baby is born. Pediatrics 1. Locate pediatric weight gain charts for children 2-20; have charts available for case studies in class. Know how to use and interpret charts. (Hint look in Pediatric NCM) 2. Locate the energy needs equations for children. Find both the 2005 DRIs and the 1989 RDA energy equations; have equations available for case studies in class. 3. Locate the protein needs equations for children. Find both the 2005 DRIs and the

7 RDA protein equations; have equations available for case studies in class. 4. What are the equations for calculating fluid needs in children? 1-10 kg: 100 ml/kg/day kg: 1000 ml + 50 ml/kg for each kg above 10 kg >20 kg: 1500 ml + 20 ml/kg for each kg above 20 kg 5. In PKU how much protein should come from medical foods formula? 0-4 years: 90% of protein 5-14 years: 80-90% of protein 15+ years: 75-90% of protein 6. List any adjustments to protein needs for PKU. Protein needs increase by 25-30% 7. What is the blood Phe goal for PKU? What adjustments to Phe intake should be made if Phe blood levels are not within range. Goal Phe is 2-6 mg/dl If Phe is not detected, then add 50 mg of Phe to goal If Phe is <2 mg/dl then add 15 mg of Phe to goal If Phe is >6 but <10 mg/dl then subtract 15 mg from goal If Phe is <10 mg/dl then subtract 30 mg Phe from goal 8. List the name of two formulas appropriate for a child (5-12 years old) with PKU. Nutrient per 100 gm Formula 1 Formula 2 formula Formula Name Phenyl-free 2 Phenex-2 Calories 410 kcal per 100 g powder 410 kcal per 100 g powder Protein 22 g per 100 g powder 30 g per 100 g powder 9. How many mg of Phe in 1 g of protein? 1 g of protein has 50 mg of Phe. 10. A child with PKU comes to the clinic you calculate the following: energy needs 1600 kcals/day, pro needs 40 g/day, amount of protein from formula 32 g. Create one meal than meets ~1/3 of energy, protein needs. These must be food not formulas. Food Amount Calories Protein g Phe mg Insert extra rows 1600 kcal g-32 g in 7

8 as needed. kcal from formula=1190 kcal/3=397 kcal formula=8 g/3=2.7 g Nestea Iced Tea 8 oz 90 kcal 0 g 0 mg Glutinous white ½ c 84 kcal 1.8 g 94 mg rice, cooked Nucoa Buttery 1 TB 100 kcal 0 g 0 mg Spread Cambrooke Foods Veggie Meatballs 2 meatballs 50 kcal 0.6 g 29 mg Canned, spiced ½ c 68 kcal 0.2 g 4 mg apple rings TOTALS 392 kcal 2.6 g 127 mg 11. What are the general nutrition interventions for children with Cystic Fibrosis? 1. A energy-modified diet, protein modified diet, fat-modified diet, or a vitaminmodified diet % of DRI for energy and protein based on growth, lung disease, malabsorption, and other complications Fat intake of 30-40% of energy Increased vitamin intake from a CF specific multivitamin Increased salt intake Calcium and vitamin D intake 2. Modification of diet to include 3 meals and 3 snacks per day 3. Pancreatic enzyme supplementation 4. Nutrition education about the correlation between lung function and nutrition 12. How do you calculate catch-energy needs for a child with Failure to Thrive? Calories for weight for age (kcal) x IBW (kg)/actual weight (kg) 13. What are general nutrition interventions for Failure to Thrive? High calorie diet with 3 scheduled meals and 2-3 scheduled snacks Provide education to caregivers about mealtime and feeding interventions. Monitor weight and length/height once or twice weekly for infants under 3 months; weekly for infants 3-6 months old; and monthly for older children. Follow weight and length/height gain every 3 months until the child follows a growth curve. Initiate enteral feeds if child is unable to meet nutrition needs orally. 14. List 1 or 2 possible interventions for each of the following common problems in pediatric oncology patients. 8

9 Muscositis: 1. Serve bland soft and pureed foods 2. Moisten foods with butter, gravies, or sauces Dry Mouth: 1. Offer lemon-flavored, sugarless candies to help stimulate saliva 2. Offer moist foods and liquids Taste Changes: 1. Enhance food flavors and taste through extra salt, spices, herbs, flavor extracts, and marinades 2. Do not give excessively sweet foods N/V: 1. Avoid high-fat foods 2. Give breads, such as toast and crackers. Infants 1. What causes the initial weight gain in premature infants? Excessive energy and fluid intake 2. What is the expected growth velocity for premature infants? <2500 g: g/kg/day g: 10 g/kg/day >3500 g: 7g/kg/day Overall: g/day 3. Why is the dextrose given initially to premature infants? Often premature infants are hypoglycemic. 4. List access types and typical dextrose concentrations for parenteral nutrition in premature infants. Peripheral Intravenous (IV) line: 12.5 g/dl Peripherally inserted central venous catheter: The PNCM says that peripherally inserted central venous catheter allow for greater concentrations of dextrose, but does not specify how much, so I am assuming that the dextrose concentration can be above 12.5 g/dl, but not greater than 20 g/dl. Central venous catheter: g/dl Umbilical artery catheter (UAC) and umbilical venous catheter (UVC): Solutions greater than 12.5 g/dl can be used, but this increases the risk of glucosuria and dehydration. 9

10 5. List at least one multi-vitamin (MVI) dosing option for an infant weighing < 2500 g. Tri-vitamin drops that contain 1500 IU of vitamin A, 35 mg of vitamin C, 400 IU vitamin D, and up to 10 mg iron 6. List the benefits of using breast milk in premature infants. Improved developmental outcomes Decreased incidence of NEC and late-onset sepsis 7. For a pre-mature infant, are there any nutrients that breast milk may be inadequate in? Protein, calcium, iron, phosphorous, zinc, and fat soluble vitamins. 8. List the calorie and protein content of human milk. Indicate any differences between fullterm and per-term milk. Full term: Energy: 70 kcal/dl Protein: 0.9 kcal/dl Sodium: 18 mg/dl (0.8 meq/dl) Calcium: 28 mg/dl Phosphorous: 15 mg/dl Osmolality: 290 mosm/kg H2O Preterm: Energy: 67 kcal/dl Protein: 1.4 g/dl Sodium: 25 mg/dl (1.1 meq/dl) Calcium: 25 mg/dl Phosphorous: 13 mg/dl Osmolality: 290 mosm/kg H2O 9. List the calorie and protein content of one packet of human milk fortifier. List mixing instructions to make 22 kcal/oz breast milk AND 24 kcal/oz breast milk. Human Milk Fortifier 1 packet, dry: Energy: 3.75 kcal/dl Protein: 0.63 g/dl Instructions for making 22 kcal/oz breast milk: Mix one packet of HMF with 50 ml expressed human milk Instructions for making 24 kcal/oz breast milk: Mix one packet of HMF with 25 ml expressed human milk 10

11 10. List potential complications of enteral feeds in premature infants Infants don t learn how to nipple It may cause oral aversions to nipples Can increase the risk of NEC Can increase risk for aspiration References: 1. Academy of Nutrition and Dietetics. Nuts and Bolts of Getting Paid. Available at: Accessed March 23, ICD10 Diagnosis codes.2015 ICD-10-CM Alpha Index. Available at: Accessed March 25, Willams P. Lecture notes. Advanced Dietetics Practice. Brigham Young University, March 26, Academy of Nutrition and Dietetics. Nutrition Care Manual. Available at: Accessed March 25, Academy of Nutrition and Dietetics. Pediatric Nutrition Care Manual. Available at: Accessed March 25,