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Department of Nutrition School of Public Health University of North Carolina at Chapel Hill NUTRITION 642: Medical Nutrition Therapy: Acute Care FALL 2010 I. Course Description A lecture and skills course where students practice skills (such as calculating caloric intake and modifying intake, calculating enteral and parenteral nutrition, calculating needs for pediatrics and transplant patients, etc.) under the supervision of a registered dietitian. Nutrition 600, 610, 630, 640 and 650 or equivalents required as a prerequisite or as a co-requisite. Instructor Amanda S. Holliday MS, RD, LDN Office: 241 Rosenau Office Hours: By Appointment Telephone: 966-7214 Email: [email protected] Textbooks Required: th · Mahan, K. and Escott-Stump, S. Krause's Food, Nutrition and Diet Therapy, 12 Edition th · Pronsky, Zaneta M. Food-Medication Interactions. 15 Edition, 2008. nd · IDNT Manual, 2 Edition: · Course pack at bookstore Other resources: · ADA web site: for Position Papers link (along left side of home page) and other menu items of interest (explore and learn more about the profession) · Blackboard for many of the readings, case studies, assignments and study guides · Course Website for lecture recordings and to subscribe to course podcast l username: nutr640, nutr64010 · Nutrition Care Manual (, username: [email protected], password: nutr64009) · 2nd floor study room - A physiology text and a medical dictionary IV. Foundation Knowledge covered in this course: 1. the pathophysiology related to nutrition care; 2. the macronutrient, fluid and electrolyte needs of individuals with a variety of disease states; 3. laboratory parameters relating to various disease states; 4. translate nutrition needs for common conditions into menus for individuals; 5. document nutrition needs and suggested therapies in appropriate medical format; 7. complementary and alternative nutrition and herbal therapies; 6. some of the ethical issues related to nutrition care 7. evolving methods of assessing health status 8. assessment and treatment of nutritional health risks 9. medical nutrition therapy 10. strategies to assess need for adaptive feeding techniques and equipment By the end of this course students will have demonstrated the ability to: 1. screen individuals for nutritional risk 2. collect pertinent information for comprehensive nutrition assessments 3. interpret medical terminology 4. interpret laboratory parameters relating to nutrition 5. calculate and interpret nutrient composition of foods




6. 7. 8. 9. V.

calculate and/or define diets for health conditions calculate enteral and parenteral nutrition formulations translate nutrition needs into food choices and menus counsel individuals on nutrition

Learning Experiences 1. Students will independently complete assignments covering varying aspects of the disorders under discussion. 2. Study Guides are provided that will help the student organize information around various disease states. Completion of the study guides is optional for Nutrition 642 but will be required for the MPH students during Nutrition 710. 3. In the assigned groups, students will work on the case study and lead a discussion of about 20 minutes on the case. 4. Each student who plans to become a registered dietitian in the near future would benefit from developing a Pocket Brain/Cheat Book to be used during supervised practice experiences. This is a collection of material you feel will help you get through your day. Throughout the semester suggestions will be made about what to put in your pocket brain but it is really up to the individual. Pocket brains can be used during the completion of the open book portions of exams in this class. Grading Evaluation of student performance in this course will be based on the following: Learning experiences 30% Exams (3) 70% Exams in this class are both closed book and open book. The open book exams will be practical work similar to homework assignments. Any reference that you have can be used. Grading Scale: Undergraduates: 97-100 93-96 90-92 87-89 83-86 80-82 77-79 73-76 70-72 Below 70 Below 60 Graduates: 748-805(>93%) 603-747 (75-92%) 563-602 (70-74%) <563 (Below 70%)




Honor System: The Honor Code is in effect in this class and all others at the University. I am committed to treating Honor Code violations seriously and urge all students to become familiar with its terms set out at If you have questions, it is your responsibility to ask me about the Code's application. All exams and assignments must be submitted with the following signed statement: On my honor, no unauthorized assistance has been received or given in the completion of this work. Signature: ___________________________________ NOTE: THOSE STUDENTS PLANNING TO TAKE NUTRITION 710: CLINICAL NUTRITION PRACTICE DURING SUMMER, MUST RECEIVE A GRADE OF P OR BETTER IN NUTR 642 IN ORDER TO ENROLL.



Course Schedule 8/24 Introduction to the course Fluids and Electrolytes Text: Krause, Chapter 4 Web Resources: 1. Acid-Base Tutorial: 2. The Merck Manual of Diagnosis and Therapy (review disorders of fluid volume): On Blackboard/Reserves: 1. Simmons and Assell Acid-Base Basics, Support Line, 23(1), pg. 6-11, 2001 2. Whitmire SJ: Fluid, electrolytes, and acid-base balance. In Matarese LE, Gottschlich MM. Contemporary nutrition support practice: a clinical guide. Ed. 2, Philadelphia, 2002. Study Guide: Acid Base Balance



Pulmonary Disease Text: Krause, Chapter 35 ­ skip Cystic Fibrosis; Blackboard: 1. Malone, A.M. Acute Respiratory Distress Syndrome: Pathophysiology, Treatment and Nutrition Intervention, Support Line 20(6): 8-15, December 1998. 2. Hummell, AC. Omega-3 Fatty Acids and Acute Respiratory Distress Syndrome, Support Line 29(6): 3-6, December 2007. 3. Malone, A.M. Specialized Enteral Formulas in Acute and Chronic Pulmonary Disease, Nutrition in Clinical Practice 24: 666, 2009. Study Guide: Pulmonary Disease Enteral Nutrition Text: Krause, Chapter 20, pp. 506-516 Blackboard: 1. Hearing, S.D. Refeeding syndrome is underdiagnosed and undertreated, but treatable. British Medical Journal 328: 908-909, April 17, 2004. 2. Seder, C and Janczyk R. The Routine Bridling of Nasojejunal Tubes is a Safe and Effective Method of Reducing Dislodgement in the Intensive Care Unit. Nutrition in Clinical Practice 2008; 23; 651-654. 3. Enteral Feeding Misconnections: An Update. Nutrition in Clinical Practice 2009; 24; 325. Enteral Practical work: Calculating Tube Feeding Requirements Blackboard: 1. American Gastroenterological Association Medical Position Statement: Guidelines for the Use of Enteral Nutrition. (Note: this is old but still comes up as one of the best articles on the topic) 2. Duncan, H.D. and Silk, D.B.A. Tube Feeding Associated Diarrhea. The Oley Foundation 3. Parrish, Enteral Nutrition: The Art and Science. Nutrition in Clinical Practice 2003 18:76-85. Study Guide: Surgery/GI





Neurological Disorders and Nutrition in Rehabilitation Settings Group 1: Alzheimer's disease Case #19 Text: Krause, Chapter 41 Blackboard: 1. Sherpard, E. Feeding the Trauma Patient: Case In Point. SupportLine, August 2009. 2. Cook, A et al. Nutrition Considerations in Traumatic Brain Injury. Nutrition in Clinical Practice 23(6): 608-620, December 2008 3. Berry, A. Neurocritical Care 101: Learning the Lingo for Effective Nutrition Management, SupportLine, Volume 31, No. 6, page 3. Study Guide: Neurology/Rehabilitation Pressure Ulcers and Wound Healing (Critical Care) Group 2: Traumatic Brain Injury: Metabolic Stress with Nutrition Support Case #28




Text: Krause, Chapter 10, pgs. 294-295 (pressure ulcers) Blackboard: 1. Stechmiller, J. Understanding the Role of Nutrition and Wound Healing. Nutrition in Clinical Practice 25; 61, 2010 2. Doley, J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice, 25: 50; 2010. 3. ADA Position Paper: Liberalization of the diet prescription improves quality of life for older adults in long term care. Assignment #1 Due Th 9/9 Parenteral Nutrition and Parenteral Nutrition Practice Text: Krause, Chapter 20, pp. 516-530 Review assessment materials from Nutrition 630 or Krause, Chapters 14-15; Appendix 29. Blackboard: 1.Jeejeebhoy, KN, Enteral and Parenteral Nutrition: evidence-based approach. Proceedings of the Nutrition Society, 60: 399; 2001. 2. Krzywda EA et al: Parenteral nutrition access and infusion equipment, In Merritt R editor: The ASPEN nutrition support practice manual, ed 2, Silver Spring MD, 2005, ASPEN 3. Kumpf VJ et al: Parenteral Nutrition Formulations: Preparation and ordering. In Merritt R editor: The ASPEN nutrition support practice manual, ed 2, Silver Spring MD, 2005, ASPEN Study Guide: Nutrition Support: Critical Care Liver and Gallbladder Disease Group #3: Cirrhosis of the Liver with Resulting Hepatic Encephalopathy Case #17 Text: Krause, Chapter 28, pp. 707-731 Blackboard: 1. Lieber, C.S. Relationships between nutrition, alcohol use and liver disease. Alcohol Research and Health 27(3): 220-231, September 29, 2004. 2. Ariyan, W. Nutrition Management of Liver Disease. Support Line 26(6): 3-9, 2004. 3. Gurk-Turner, C. Management of the Metabolic Complications of Liver Disease: An Overview of Commonly Used Pharmacological Agents. Support Line 19(4): 1719, 1997. Study Guide: Liver and Gallbladder Disease Catch Up as Needed or More Practical Work Assignment #2 Due: Parenteral Nutrition







Exam 1 (closed book) Exam 1 (open book) Transplants: Heart/Lung, Kidney and Liver Group #4: Renal Transplant Case #27 Text: Krause, Heart: pgs 895-896, kidney: pgs. 929-931, liver: pgs. 716-717 Blackboard: 1. Hasse, The Benefits of Nutrition Therapy in the Liver Transplant Patient National Kidney Foundation, Nutrition and (kidney) transplantation

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9/23 9/28




Transplants: Bone Marrow Guest Speaker: Jennifer Spring Blackboard: 1. Herrmann, V and Petruska, P. Nutrition Support in Bone Marrow Transplant Recipients. Nutrition in Clinical Practice, Feb 1993; vol. 8, pgs. 19-27 2. Ringwald-Smith, K, et al. Determination of Energy Expenditure in the Bone Marrow Transplant Patient. Nutrition in Clinical Practice, Oct 1998; vol 13, pgs. 215-218. Metabolic Stress: Sepsis and Trauma Guest Speaker: Kristen Bryda Text: Krause, Chapter 39 Blackboard: 1. Forrette, T.L. Indirect Calorimetry: Principles and Applications for Managing Critically Ill Patients. Medscape General Medicine 7(4): 1-12, November 2005. 2. Pontes-Arruda, et. Al. Effects of enteral feeding with eicosapentaenoic acid, y-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock. Critical Care Medicine 2006, Vol. 34, No. 9 3. Halasa Esper, et al. Permissive Underfeeding in Critical Illness: What are the Facts? SupportLine February 2007 Volume 29, 1.





Metabolic Stress: Burns Guest Speaker: Yih Chang Text: Krause, pgs 1033-1037 Group #5: Metabolic Stress and Trauma Case #30 Blackboard: 1. Berger, M. Antioxidant Micronutrients in Major Trauma and Burns: Evidence and Practice. Nutrition in Clinical Practice 2006; 21; 438. 2. Peck and Chang. Nutritional support for burn injuries. Journal of Nutritional Biochemistry. 10: 380-396. 1999. Assignment #3 Due No Class: University Day Exam 2 (closed book) Exam 2 (open book) No Class: Fall Break

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10/12 10/14 10/19 10/21




Oncology: Acute Therapy (Chemotherapy and Radiation) Guest Speaker: Aimee Morin MPH, RD, LDN Text: Krause, Chapter 37 Group #6: Esophageal Cancer Treated with Surgery and Radiation Case #32 Blackboard: 1. Comeau, T. Taste and smell dysfunction in patients receiving chemotherapy: a review of current knowledge. Support Care Cancer 2001: 9; 575-580. 2. Review all sections (~47 pages) National Cancer Institute: Nutrition in Cancer Care (Health Professionals Version) ges/print 3. Thomas R, Davies N. Lifestyle During and After Cancer Treatment. Clin Oncol. 2007 Oct; 19(8):616-627. 4. Huhmann M, August D. Review of ASPEN Clinical Guidelines for Nutrition Support in Cancer Patients: Nutrition Screening and Assessment. Nutr Clin Pract 2008; 23; 182188. 5. Evidence based practice guidelines for the nutritional management of patients receiving radiation therapy. Nutrition & Dietetics. 2008; 65 (Suppl.1): S1-S20. 6. Integrating Nutrition into Your Cancer Program. A Supplement to Oncology Issues. Volume 17, No.2. March/April 2002. Study Guide: Oncology and HIV/AIDS



Gynecology: PCOS, Fibrocystic Breast and Infertility Text: Krause, pg. 542 (Focus On) Group #7: Polycystic Ovarian Syndrome, Case #25 Blackboard: 1. Liepa, George, et al. PCOS and Other Androgen Excess Related Conditions: Can Changes in Dietary Intake Make a Difference? Nutrition in Clinical Practice 2008;23; 63. 2. Marsh, et al. Effect of low glycemic index compared with a conventional healthy diet of PCOS. Am J Clin Nutr 2010; 29; 261. Pediatrics: Part I (Normal Growth and Nutrition) Guest Speaker: Sarah Nowak and Kristy Paley Text: Chapter 6 Blackboard: 1. Mehta, N. et al. ASPEN Clinical Guidelines: Nutrition Support of the Critically Ill Child. JPEN 2009 33: 260.





Pediatrics: Developmental Disabilities Text: Krause, Chapter 45 Blackboard: 1. Position of the ADA: Providing Services for People with Developmental Disabilities and Special Health Care Needs 2. Cermak, S, et al, Food Selectivity and Sensory Sensitivity in Children with Autism Spectrum Disorders. JADA, 2010; 110: 238-246. 3. Schwartz, Kate. Patience, Persistence and Progress: Working with People with Disabilities, ADA Times, pgs 12-14 May/June 2007. Pediatrics: Part II (Pediatric Inpatient Nutrition: GI Surgery and Specialty Formulas) Text: Guest Speaker: Abby Weiland




*Mrs. Holliday at FNCE* Blackboard: Study Guide: Pediatrics Th 11/11 Pediatrics: Part III (Neonatal Nutrition and Pediatric TPN) Text: Krause, Chapter 43 Guest Speaker: Pat Becker Blackboard: 1. Groh-Wargo, S. Enteral Nutrition Support of the Preterm Infant in the NICU. Nutrition in Clinical Practice. 2009, Jun-Jul; 24 (3) 363-376. 2. Slicker, J. Pediatric parenteral nutrition. Putting the microscope on macronutrients and micronutrients. 2009, Aug-Sept: 24 (4) 481-486. 3. Walker, A. Breast milk as the gold standard for protective nutrients. Journal of Pediatrics, Feb 2010 (156) no. 2, supplement 1. 4. Vlaardingerbroek, H, et al. Initial nutrition management of the preterm infant. Early Human Development, 2009 (85), pgs 691-695.



Pediatrics: Cardiology and Pediatric Case Studies/Practical Work Text: Krause, Chapter 43 Guest Speaker: Johanna Ballard




Pediatric Neurology and the Ketogenic Diet Text: Krause, Chapter 41 Guest Speaker: Jennifer Gallagher Blackboard: 1. Hartman and Vining. Clinical Aspects of the Ketogenic Diet. Epilepsia, 48 (1): 31-42, 2007 2. Kossoff et al, Optiomal clinical management of children receiving the ketogenic diet: Recommendations of the International Ketogenic Diet Study Group. Epilepsia, 1-14, 2008. Catch Up as Needed or More Practical Work Assignment # 4 Due



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11/25 11/30

No Class: Thanksgiving Break Pediatrics: Genetic Disorders Text: Krause, Chapter 44 Guest Speaker: Surekha Pendyal Med, RD, LDN Rheumatic Disorders Group #8: Rheumatoid Arthritis Case #2 Text: Krause, Chapter 40 Blackboard: 1. Cunningham, E. What nutritional factors affect the risk of gout? JADA 104 (11): 1737, November 2004. 2. Nutrition Care Manual: Purine Restricted Diet 3. Smedslund, Geir, et al. Effectiveness and Safety of Dietary Interventions for Rheumatoid Arthritis: A Systematic Review of Randomized Controlled Trials, JADA 2010; 110: 727-735. 4. Marcason, W. What is the Latest Research Regarding Cherries and the Treatment of Rheumatoid Arthritis? JADA, 2007, pg 1686. End of Life Nutrition Text: Krause, Chapter 17 Assignment #5 Due Blackboard: 1. Monturo, C. The Artificial Nutrition Debate: Still and Issue...After All These Years. Nutrition in Clinical Practice. 2009 (24) 206. 2. Lamers, W. Nutrition and Hydration, Hospice Foundation of America. 3. Gavin, Donna ,Nutrition in Palliative Care: A Hospice Dietitians Story. 2007 Final Exam @ 12 Noon Closed Book (10/26-12/7) Open Book (Cumulative)








Department of Nutrition School of Public Health University of North Carolina at Chapel Hill NUTRITION 642: Medical Nutrition Therapy: Acute Diseases FALL 2010

Case Studies: There is a lot of material covered in the case studies so I will work with each group to identify which questions in the case study to focus on. Some of it will be didactic and some of it will be practical hands on. Please have your Case Study to me 1-2 days prior to your presentation so I can review it and make changes if necessary. Please let me know your thoughts and concerns as the semester goes on and don't wait until the course is finished. Wyler Cantwell-Wood Kitchens Group 1: Alzheimer's disease Case #19 Material due: August 31, 2010 Presentation: September 2, 2010 Group 2: Traumatic Brain Injury: Metabolic Stress with Nutrition Support Case #28 Material due: September 3, 2010 Presentation: September 7, 2010 Group 3: Cirrhosis of the Liver with Resulting Hepatic Encephalopathy Case #17 Material due: September 10, 2010 Presentation: September 14, 2010 Group 4: Renal Transplant Case #27 Material due: September 24, 2010 Presentation: September 28, 2010 Group 5: Metabolic Stress and Trauma Case #30 Material due: October 5, 2010 Presentation: October 7, 2010 Group 6: Esophageal Cancer Treated with Surgery and Radiation Case #32 Material Due: October 22, 2010 Presentation: October 26, 2010 Group 7: Polycystic Ovarian Syndrome, Case #25 Material Due: October 26, 2010 Presentation: October 28, 2010 Group 8: Rheumatoid Arthritis Case #2 Material Due: November 19, 2010 Presentation: November 23, 2010

Tkachuk Daugherty McGee Thebner Davis Mack

Franz Simmons Molinatto Shafer Geralnick Lai Pilweski Hite Kelly Mosher Hubbard Joseph Mickens



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