![\"Step](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_1-assess-1024x132.png\")
\r\n- \r\n \t
- Clinical Data<\/strong>: past medical history, history of presenting illness (HPI), imaging, investigations, pathology, scheduled procedures, consultations, medical orders (medications, infusions), clinical documentation (fluids in and out, bowel movements, drains and tubes, vitals, and documentation of symptoms), medical plan, disposition plan<\/li>\r\n \t
- Anthropometric Data<\/strong>: weight, height, BMI, weight change, % weight change, % usual body weight, physical assessment, subjective global assessment.<\/li>\r\n \t
- Nutritional Requirements<\/strong>: energy, protein, and fluid<\/li>\r\n \t
- Biochemical Data<\/strong>: laboratory values (blood, urine, feces, sputum, tissue, wounds, drains etc.).<\/li>\r\n \t
- Dietary Data<\/strong>: current\/ recent hospital diet order(s), current intake\/ recent intake\/ baseline intake, dietary restrictions, allergies\/ intolerances, eating behaviours and patterns, calorie counts, supplements, previous nutrition\/dietitian interventions.<\/li>\r\n<\/ol>\r\nThe components reviewed in each section are common considerations but you may need to consider other factors depending on your patient.\r\n
Subjective Global Assessment<\/h2>\r\nAccording to the Canadian Malnutrition Task Force<\/a>:\r\n
Subjective global assessment (SGA) is the gold standard for diagnosing malnutrition. SGA is a simple bedside method used to diagnose malnutrition and identify those who would benefit from nutrition care. The assessment includes taking a history of recent intake, weight change, gastrointestinal symptoms and a clinical evaluation.<\/blockquote>\r\nUse of the SGA varies among institutions. If you do not use the SGA, you can still follow the procedures for assessment by taking the history described above.\r\n\r\n \r\n
\r\n Case Study: Meet Carson<\/h2>\r\n<\/header>\r\n
\r\n<\/div>\r\n\r\n\r\n[caption id=\"attachment_1147\" align=\"aligncenter\" width=\"640\"]![\"Carson](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/EnternalNutrition_Actor.jpg\")
Carson Deluca, your patient[\/caption]\r\n\r\n<\/div>\r\nThroughout this section's case study, you are a Registered Dietitian in General Surgery. The patient you are assessing is a 50 year old male named Carson.\r\n\r\n<\/div>\r\n<\/div>\r\nClinical Data<\/h1>\r\nClinical data can include, but is not limited to:\r\n
- \r\n \t
- Reason for visit<\/strong>: hospital visit or RD consult.<\/span><\/li>\r\n \t
- Past medical history<\/strong> (PMHx): health history to date.<\/li>\r\n \t
- History and presenting illness<\/strong> (HPI): symptoms, surgeries, prognosis, tests (i.e. CT scan, ultrasound).<\/li>\r\n \t
- Current medical orders<\/strong>: IV infusions, medications, consultations.<\/li>\r\n \t
- Clinical documentation<\/strong>: Fluids intake (i.e. oral, IV, TPN\/EN) and output (i.e. urine, vomit, bowel movements, drains (i.e. catheter, chest tube, surgical site drain) and suctioning (i.e. oral secretions, OGT to straight drain), documentation of tubes (i.e. G-tube vs. NGT) and lines (i.e. PICC), vitals.<\/li>\r\n \t
- Medical care plan and disposition<\/strong>: chemotherapy, radiation therapy, scheduled surgery, transfer to different floor, rehab facility, treatment facility, long term care, home.<\/li>\r\n<\/ul>\r\n
\r\n Carson's Clinical Data<\/h2>\r\n<\/header>\r\n
\r\n\r\nReview Carson\u2019s clinical data. If you come across something you are not familiar with, such as a diagnosis or medication, pause and take the time to research it. Understanding all of the components of Carson\u2019s assessment is critical in understanding the case study and is good practice for your practicum. Take note of components that you think may be important for your enteral nutrition plan.\r\n- \r\n \t
- Age<\/strong>: 50-year-old male<\/li>\r\n \t
- HPI<\/strong>: 6- month history of progressive dysphagia, loss of appetite, and 25 pounds weight loss<\/li>\r\n \t
- Admission<\/strong>: 2 weeks ago for worsening dysphagia, poor PO intake, and weakness<\/li>\r\n \t
- Investigations<\/strong>: CT of neck\/abdomen, OGD scope with biopsy<\/li>\r\n \t
- Pathology<\/strong>: Esophageal cancer (squamous cell carcinoma)<\/li>\r\n \t
- Operations\/ Procedures<\/strong>: partial esophagectomy with primary anastomosis and tumor removal. Gastrostomy tube placed intraoperatively \u2013 suspected poor swallowing function post operatively and during the course of chemotherapy and radiation therapy treatment.<\/li>\r\n \t
- Consultations<\/strong>: Speech Language Pathology (SLP) for videofluoroscopic swallowing study, RD for initiation of EN via G-tube, medical oncology for assessment of chemotherapy and radiation therapy<\/li>\r\n \t
- Medications via G-tube<\/strong>: Levothyroxine 0.25 mcg @ [pb_glossary id=\"1660\"]0600h[\/pb_glossary], Sodium Phosphate 9 mmol \u00d7 1 dose, Hydromorphone controlled release 3 mg [pb_glossary id=\"1661\"]q[\/pb_glossary] 8 hours, Docusate sodium 100 mg BID, Sennosides 17.2 mg @ [pb_glossary id=\"1624\"]HS[\/pb_glossary], Magnesium Hydroxide 30 ml @ HS, Potassium Chloride Liquid 40 mmoL BID \u00d7 2 days, PRN dimenhydrinate 25-50 mg q4hrs<\/li>\r\n \t
- Infusions<\/strong>: IV \u2154 + \u2153 @ 75mL\/hr = 1800 mL per day (while [pb_glossary id=\"1662\"]NPO[\/pb_glossary])<\/li>\r\n \t
- Medical plan<\/strong>: chemotherapy + radiation therapy (outpatient)<\/li>\r\n \t
- Disposition plan<\/strong>: home with home care supports once stable on enteral feeds<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n
Assessments of Swallowing<\/h2>\r\n[caption id=\"attachment_328\" align=\"alignright\" width=\"158\"]
![\"Fluoroscopic](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2021\/09\/EN-3-158x300.png\")
Fluoroscopic image of a barium swallow
Source: Dr. Ian Bickle<\/a> via Radiopaedia<\/a>[\/caption]\r\n\r\nSpeech-language pathologists (SLP) are concerned with the identification, assessment, treatment, rehabilitation and prevention of communication and\/or swallowing disorders.\r\n\r\nVideofluoroscopic Swallowing Study (VFSS) is a radiographic procedure that provides a direct, dynamic view of oral, pharyngeal, and upper esophageal function during swallowing. During this procedure, the SLP presents various food and liquid consistencies mixed with barium. The barium is necessary to view structures via videofluoroscopy during the swallow.\r\n\r\nThe VFSS allows the SLP to assess if food goes into the airway instead of the stomach (aspiration), which part of the swallow is affected, which food and liquid consistencies are safest to swallow, and if certain positions or strategies improve the swallow.\r\n\r\n \r\n\r\n \r\n\r\n Carson's VFSS Results<\/h3>\r\n<\/header>\r\n
\r\n\r\nCarson has progressive dysphagia. The VFSS revealed overt aspiration and an inability to clear residue from his oral cavity.\r\n\r\nThe SLP recommends that Carson remain [pb_glossary id=\"1662\"]NPO[\/pb_glossary] with an alternate form of nutrition (i.e. EN).\r\n\r\n<\/div>\r\n<\/div>\r\nNutrition in Dysphagia Management<\/h2>\r\nDysphagia is the medical term for swallowing difficulties. For more information about dysphagia and its causes, read this \"Dysphagia 101\" resource from Nestle Health Science<\/a>.\r\n\r\nThe epiglottis muscle is responsible for making sure food or drinks go down your esophagus into the stomach (avoiding the airway). Normally, the airway should close as foods or liquids enter the throat to make sure a swallow is successful. Often, for people with dysphagia, this function can be impaired, leading to food or liquid going into the airway; this is a safety concern for aspiration.\r\n\r\nTo manage dysphagia, an SLP will complete an assessment and determine the safest dysphagia diet (liquid consistency, food texture, or NPO). Thickened beverages and texture-modified foods may help with swallowing safety by improving control and slowing down the movement of boluses in the mouth and throat. This gives more time to close off the airway so the liquids can travel down the esophagus to the stomach.\r\n\r\nThe tables below provide an overview of food and drink consistencies for those with ranging degrees of dysphagia, and are based on information from the International Dysphagia Diet Standardisation Initiative (IDDSI).\r\n
- HPI<\/strong>: 6- month history of progressive dysphagia, loss of appetite, and 25 pounds weight loss<\/li>\r\n \t
- Past medical history<\/strong> (PMHx): health history to date.<\/li>\r\n \t
- Anthropometric Data<\/strong>: weight, height, BMI, weight change, % weight change, % usual body weight, physical assessment, subjective global assessment.<\/li>\r\n \t
![\"The](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/IDDSI_Framework_whitebackground_Headline_small_July2020-1-e1643735577411.png\")
The IDDSI Framework provides a common terminology for describing food textures and drink thicknesses to improve safety for individuals with swallowing difficulties. Full text description is below.![\"The](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2021\/08\/OAJNN.MS_.ID_.555552.G016-300x196.jpg\")
The interosseous muscle is depressed in a patient with muscle wasting. ![\"Hollow,](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2021\/08\/Periorbital_darkness-254x300.jpeg\")
Hollow, dark circles under the eyes. ![Photo by Serdar G.<\/a>,](\"https:\/\/commons.wikimedia.org\/wiki\/File:Periorbital_darkness.jpg\"){kind=link}