Download Level 1 Clinical Rotation Worksheet

USU CLINICAL ROTATION WORKSHEET
Clinical Rotation Worksheet
This worksheet is intended to prepare you for your clinical rotation and is not a comprehensive
review of clinical dietetics. If there are areas or sections on this worksheet that you struggled
with or feel the need for further review, refer to your DPD notes, texts, or any of the references
listed below to strengthen your understanding and ability to practice in the clinical setting.
DO NOT SHARE YOUR ANSWERS with any current or future interns. Doing so would be in direct
violation of USU’s academic integrity policy, and will not help anyone. Going through the
process of reviewing notes, texts, and other reliable sources is an important part of preparing
for rotations and the RD exam.
The following references were used in compiling this information, and may be useful to you:
 Krause’s Food, Nutrition and Diet Therapy, 14th edition, 2017
 Nutrition Care Manual, https://www.nutritioncaremanual.org/
 AND Evidence Analysis Library, https://www.andeal.org/
 eNCPT, https://ncpt.webauthor.com/
MEDICAL TERMINOLOGY:
For additional practice with medical terminology we recommend you complete a free online
medical terminology course. The course is free unless you want the certificate, which you don’t
need. To access the review course go to: http://www.dmu.edu/medterms/.
CALCULATIONS:
Refer to handouts from Orientation. You should be comfortable with more than two methods
and predictive equations to calculate energy, protein, and fluid needs. You should also be
comfortable with calculating BMI and IBW. You will need to know how to convert height from
inches to centimeters, weight from pounds to kilograms, minerals from milligrams to
milliequivalents, and common conversions from milliliters to ounces to name just a few.
MEDICATIONS:
Refer to reference texts from your DPD program or a reliable online library. Your preceptor(s)
will expect you to have a working knowledge of a variety of medications. Review common
medications, and their nutrient interactions, for diabetes, cardiovascular disease,
gastrointestinal disorders, renal disorders, oncology, and critical care. Some sections of this
worksheet discuss common medications for the disease states listed.
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GENERAL NUTRITION
1. What information should be included in the NCP categories?
A:
I:
D:
M/E:
-
-
2. Give normal values for the following labs (Reference ranges differ between laboratories so
your answers may not match the answer key and that’s okay! This is to give you a general idea
of what normal values are):
albumin
BUN
sodium
cholesterol
HDL
MCV
HGB
SGOT (AST)
SGPT (ALT
glucose
creatinine
potassium
triglycerides
LDL
RDW
HCT
amylase
lipase
3. Various laboratory tests are used for assessing the visceral protein status of a patient. Use
the table below to record your answers.
Lab Test
Norm.
Level
HalfLife
What
exactly
does the
lab mean?
What does it
mean when it
is elevated?
What does it mean
when it is
decreased?
When do you use
each lab to assess
changes?
Serum
Albumin
Serum
Transferrin
Pre-Albumin
RetinolBinding
Protein
(RBP)
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4. There are five labs that assess red blood cells and the iron status in patients. Fill in the table
below answering each of the questions at the top of the columns for each value.
Lab Test
Normal Level
(men,
women)
What exactly does
the lab mean?
(cell size, color)
What does it mean
when it is elevated?
What does it mean when
it is decreased?
When is each test linked
to Anemia? (What type
of Anemia?)
HCT
HGB
MCV
TIBC
RDW
5. What effect does dehydration have on albumin, sodium, BUN and creatinine? Why?
6. What percentage is considered a significant weight loss at one week, one month, and six
months? What percentage is considered severe?
7. What does the nitrogen balance in a patient tell you? How is it measured?
a. Define:
b. Positive Nitrogen Balance:
c. Negative Nitrogen Balance:
d. How is it measured?
8. The usual goal for nitrogen balance is:
a.
0 to +1
b.
+2 to +4
c.
+3 to +6
d.
+5 to +8
9. List the weight loss percentages used to determine significant and severe weight loss:
Significant
Severe
1 week
1 month
6 months
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10. Define the following:
a. Passive transport/diffusion:
b. Facilitated diffusion:
c. Active transport:
11. In the simplified diagram of the gastrointestinal tract on the next page, identify the organs,
the location where enzymes and digestive fluids are secreted, and where nutrients are
absorbed. As you complete the diagram, consider the implications of a surgical resection of any
part of the GI tract. What nutrients would need to be supplemented if a specific section is
resected? Items listed in red are already identified and listed to help you complete the diagram.
Alcohol
Amino Acids
Bicarbonate
Bile
Bile Salt
Biotin
Brush Border Enzymes
Calcium
Chromium
Chlorine
Colon
Copper
Folate
Fructose
Galactose
Gallbladder
Glucose
HClIleum
Intrinsic Factor
Iron
Jejunum
Lipids
Magnesium
Duodenum
Manganese
Molybdenum
Niacin (B3)
Pancreas
Pancreatic Enzymes
Pantothenate (B5)
Pepsin
Phosphorus
Potassium (K+)
Pyridoxine (B6)
Riboflavin (B2)
Selenium
Small peptides (di- and
tri-peptides)
Short-chain fatty acids
Sodium (Na+)
Stomach
Sulfate (SO4)
Thiamin (B1)
Vitamin A
Vitamin B12
Vitamin D
Vitamin E
Vitamin K
Water
Zinc
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_______________________.
_______ functions to
emulsify lipids and facilitate
digestion of lipids.
________________________.
The common bile duct (or bile
pancreatic duct) empties
________________________.
____________ phosphorus,
_________________________
_________________________
_________________________
_______________________.
_________________
are secreted along the
entire length of the
small bowel.
_____________________.
Nutrients absorbed in ___________:
______________________,
pantothenate (B5), ___________,
_______________________,
magnesium, __________, chromium,
___________________ amino acids,
_______________________________
_______________________________
____________________________.
The stomach secretes
_______________.
_________________ are
absorbed in the stomach.
____________________
____________________
____________________
____________________
The ileum.
Nutrients absorbed in the
ileum: _____________,
____________________,
vitamin D, vitamin K,
______________.
_______________________
_______________________
_______________________
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12. A small amount of fat digestion occurs in the mouth due to lingual lipase and the stomach
due to gastric lipase. The majority of fat digestion occurs in the small bowel. After pancreatic
lipase and bile salts break the fats down into tiny globules of lipids, how are the resulting free
fatty acids and monoglycerides absorbed across the brush border membrane of the small
bowel? In 1-2 paragraphs describe the process of absorption of dietary fat.
DIABETES
1. Describe the characteristics of Type 1 Diabetes and Type 2 Diabetes, Latent Autoimmune
Diabetes in Adulthood and Gestational Diabetes?
a. Type 1 Diabetes
b. Type 2 Diabetes
c. Latent Autoimmune Diabetes in Adulthood (LADA)
d. Gestational Diabetes
2. Discuss possible ways dietitians can impact or provide solutions to two different points
addressed on this infographic by the American Diabetes Association: 1-2 paragraphs.
3. Describe the primary criteria used to confirm a diagnosis of diabetes.
4. What are the American Diabetes Association’s recommendations for hemoglobin A1c and
fasting and post prandial blood glucose levels for adults?
i. A1c:
ii. fasting (preprandial plasma glucose):
iii. 1-2 hours postprandial plasma glucose:
5. What are the medical nutrition therapy recommendations (as of 2015) for persons with
diabetes? Refer to the Evidence Analysis Library.
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6. Alternative sweeteners are frequently used by with diabetes. What are the major types of
artificial sweeteners available for consumption in the US? What does the Evidence Analysis
Library say about artificial sweeteners?
a. The artificial sweeteners that have been tested and approved by the U.S. Food
and Drug Administration (FDA) for additions into food products:
b. Evidence Analysis Library:
7.
What are the signs/symptoms of hypoglycemia? What is the treatment protocol for
hypoglycemia in diabetes?
a. Symptoms:
b. Pathophysiology:
c. Treatment:
i.
ii.
iii.
iv.
8. List the grams of carbohydrate, protein and fat and calories in each of the diabetes
exchange categories. Note: some categories may have multiple amounts; please list all of
them.
Food Item
Carbohydrates (g)
Protein (g)
Fat (g)
Calories
Starch
Fruit
Milk
Fat-free- 1%
2%
Whole
Non-starchy Vegetables
Meat:
Lean
Medium-Fat
High-Fat
Fat:
* You will need to memorize the grams of CHO, protein, and fat for the different
exchanges for the RD exam.
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WEIGHT MANAGEMENT
1. For overweight or obese persons, losing 5-10% of body weight can have beneficial effects.
List three potential benefits of 5-10% weight loss.
a.
b.
c.
2. List the ranges BMI values of <18.5 to >40 based on their classification of corresponding
weight.
Classification
Body Mass Index
3. What are some of the strengths and limitations of using the BMI calculations to determine
risk for disease?
a. Strengths:
i.
ii.
iii.
b. Limitations:
i.
ii.
iii.
4. How are waist circumference and waist to hip ratios measured? Why are the two
measurements used? At what measurement of waist circumference and waist to hip ratio
does the risk of disease increase?
5. What are some of the medical complications associated with obesity?
6. Describe the characteristics and function of the regulatory factor below and how they
impact weight management.
Regulatory Factor
Describe the characteristics, function and how they impact weight management.
Serotonin and
neuropeptide Y
Incretins
Insulin and Glucagon
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Leptin
Ghrelin
Vagus nerve
7. What is weight cycling?
8. According to the American College of Sports Medicine, what are the exercise
recommendations for weight loss versus weight maintenance?
Weight Loss
Weight Maintenance
RENAL NUTRITION
1. Define and discuss nutritional intervention for the following:
a. Urolithiasis/nephrolithiasis vary in the type of kidney stones:
b. Chronic kidney disease is divided into 5 stages related to the eGFR of patients:
c. End stage renal disease (ESRD):
2. What are phosphorus/phosphate binders and when are they used?
3. What factors may contribute to anemia in chronic hemodialysis patients?
4. What is the ingredient in salt substitute that should be limited by renal patients? Why?
5. What are the symptoms of hypokalemia? How do you treat it?
a. Symptoms:
b. Treatment:
6. List 5 foods high in potassium.
CARDIOVASCULAR DISEASE
1. Name at least 5 modifiable factors that are correlated with higher risk for cardiovascular
disease:
a.
d.
b.
e.
c.
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2. A patient comes to see you for specific recommendations on addressing her
hypertension through dietary measures. What recommendations would you give for
lowering blood pressure?
3. Briefly describe the goals and recommendations for the following diets:
a. National Cholesterol Education Program (NCEP) (Therapeutic Lifestyle Changes
diet):
b. National Institutes of Health (NIH) DASH Diet:
c. American Heart Association (AHA):
4. Provide a brief description and a nutrition prescription for the situations listed below:
a. Post-CABG or valve repair:
b. Congestive Heart Failure (CHF):
c. Left Ventricular Assist Device (LVAD):
5. For each medication listed below, list the action, indications, and nutrition concerns
associated with them. Also provide the generic name of at least one medication that
falls in that category:
Medication
Category
Action
Indication
Anticoagulant
Possible Nutrition Concerns
Generic Name (Brand names
included in parentheses)
Maintain consistent intake of
vitamin K containing foods or
supplements (warfarin)
Avoid alcohol intake
St. John’s Wort can decrease
effectiveness (dabigatran,
apixaban, rivaroxaban)
Diuretic
Heart failure;
hypertension
Antihypertensive
Antiarrhythmia
Cholesterol
lowering
 Amiodarone (Pacerone)
Decrease
serum
cholesterol
levels
6. You are working with three clients who want to make improvements to their blood lipid
profile. What general recommendations would you give to improve lipid levels from
what is listed below?
a. Increase HDL from 29 mg/dl:
b. Decrease LDL from 165 mg/dl:
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c. Decrease triglycerides from 250 mg/dl:
ONCOLOGY
1. Name at least 3 nutrition and dietary factors that are correlated with higher cancer risk:
a.
b.
c.
2. A patient undergoing cancer treatment is struggling to meet her nutrition goals due to
experiencing several unpleasant side-effects. List some recommendations you would
make for the following possible side-effects of cancer treatment:
a. Poor appetite:
b. Nausea and vomiting:
c. Sore mouth or throat:
d. Diarrhea:
e. Constipation:
f. Altered taste or smell:
3. Define Cancer Cachexia. List possible signs and symptoms. Explain the role of cytokines.
List some dietary management strategies
a. Define:
b. Signs/Symptoms:
c. Cytokines:
d. Management:
4. Upon completing an assessment and identifying a diagnosis for an oncology patient, you
determine that the appropriate intervention will include a neutropenic diet. Briefly
describe what a neutropenic diet is, and some nutrition recommendations and goals for
patients with neutropenia:
5. At what point in cancer treatment would palliative care be recommended and what
does it involve?
CRITICAL CARE NUTRITION
1. After trauma or serious medical event, patients will move through the stress response
to injury often referred to as the “Ebb” (immediate) and “Flow” (occurring days to
weeks after the incident) phases. What are the specific metabolic changes that occur in
each phase? (Hint: there are at least 5 more changes in each phase)
Ebb Phase
Flow Phase
2. A patient is admitted to the ICU after being electrocuted and the RDN is consulted
within 12 hours of the event. The patient has not undergone any surgeries but is being
medically stabilized.
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a. What phase of the metabolic response is this patient in? (Ebb/Stress,
Flow/Catabolic).
b. What are the nutrition concerns you have for this patient based on the
metabolic response to injury? What might your nutrition intervention focus on?
3. A patient is admitted to the ICU due to respiratory failure caused by complications from
influenza. The patient is intubated and sedated and thus unable to provide any
information about his medical/nutrition history.
a. What should you do?
b. You were able to interview the patient’s family and determined that he meets
the criteria for severe malnutrition outlined by AND/ASPEN. The attending
physician anticipates that this patient will need to be ventilated for more than 5
days. What are the criteria for a severe malnutrition diagnosis? What is your
nutrition intervention?
i. Severe malnutrition symptoms:
ii. What is your nutrition intervention?
4. A 53 yr old patient with a BMI of 48.7 kg/m2 is admitted to the ICU after a coronary
artery bypass graft surgery. At 48 hours post-op the patient has not been weaned from
the ventilator due to poor respiratory response and decreased renal output. He will
need nutrition support while he receives supportive therapy.
a. What weight will you use to determine the patient’s energy needs?
b. What are the consequences of over- and under-feeding?
5. List the diagnostic criteria for Systemic Inflammatory Response Syndrome (SIRS):
a.
b.
c.
d.
e.
f.
6. List three (3) challenges to providing nutrition support for the critically ill patient:
a.
b.
c.
7. The following terms and abbreviations are used commonly in the critical care setting.
You should be familiar with them before starting your inpatient clinical rotation. You do
not need to list the definitions here, but if you don’t know what they are look them up
in your textbooks or DPD materials.
a. Refeeding syndrome
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b.
c.
d.
e.
f.
g.
Acute Respiratory Distress Syndrome (ARDS)
Closed head injury (CHI)
Disseminated intravascular coagulopathy (DIC)
Abdominal aortic aneurysm (AAA)
Abdominal compartment syndrome
Continuous renal replacement therapy (CRRT) or continuous veno-venous
hemodialysis (CVVH)
h. Extracorporeal membrane oxygenation (ECMO)
8. Review common ICU medications. You do not need to list anything about those
medications here, but if you don’t know what they are look them up in a reference text
or reliable online library.
a. Propofol (diprivan)
b. Keppra
c. Dilantin (phyenytoin)
d. Narcotics
e. Vasopressors (norepinephrine, epinephrine, vasopressin, dopamine,
phenylephrine, dobuatmine)
GASTROINTESTINAL DISORDERS (UPPER AND LOWER GI,
HEPATOBILIARY AND PANCREATIC DISORDERS):
1. List three changes to digestion and absorption after a small bowel resection of the
jejunum:
2. A patient with ulcerative colitis undergoes a total colectomy and requires an ileostomy.
a. What foods are not recommended in order to prevent blockages?
b. What foods should they add to help thicken stool and manage diarrhea?
c. What foods should be avoided to prevent and manage gas and odors? What
foods may help relieve gas and odor?
3. What is the recommended nutrition management for patients with acute and/or
chronic pancreatitis?
a. Acute pancreatitis:
b. Chronic pancreatitis:
4. Define Wernicke’s-Korsakoff syndrome. List the symptoms and treatment.
a. Define:
b. Symptoms:
c. Treatment:
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5. While reviewing a patient’s medical record you see the medication Lactulose. Why is
this medication prescribed (what conditions or diseases)?
6. What is the nutrition prescription for a patient with cirrhosis?
7. Distinguish between Crohn’s disease and ulcerative colitis.
a. Briefly define the pathophysiology of both diseases and what area of the
digestive system is affected.
b. What potential nutrient deficiencies could a patient develop with either of these
diseases?
8. A patient is referred to you in clinic for nutrition counseling for gastroesophageal reflux
disease. List 5 diet and behavior modifications that you will discuss with this patient to
help manage their symptoms:
a.
b.
c.
d.
e.
9. What is the pathophysiology of a gastric ulcer?
10. The MD has asked you to provide nutrition education to a patient with a history of
gastric ulcers. As you walk away, he reminds you to tell the patient about eating a low
acid diet and drinking milk or cream to help coat the stomach. Is this advice supported
by evidence-based research? Yes or no. Why?
11. What is the rationale for using branched chain amino acids (BCAA) in patients with
encephalopathy? What are the pros and cons of BCAA treatment in patients with
encephalopathy?
12. The following or procedures or diseases that you should be familiar with during your
clinical rotations. You do not need to list the definitions or any answers here; this is just
for you, but if you don’t know what they are look them up in your textbooks or DPD
materials.
Atrophic gastritis
Dumping syndrome
Dyspepsia
Esophageal varices
Esophagectomy
Upper/lower endoscopy
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Gastroparesis
Celiac disease
Nissen fundoplication
GERIATRIC NUTRITION AND WOUND HEALING
1. Define sarcopenia:
a.
2. Define dysgeusia and xerostomia, list potential causes, and its potential effect on
nutrition:
a. Dysgeusia:
b. Xerostomia:
c. Causes:
d. Potential effects on nutrition:
3. A 73 yr old female is admitted to the hospital with confusion, loss of balance and
numbness and tingling in her hands and feet. What vitamin deficiency is most likely to
blame? If the vitamin deficiency treated, are these symptoms reversible?
4. List the four syndromes that can predict failure to thrive in the elderly:
a.
b.
c.
d.
5. What are the symptoms of failure to thrive?
6. List three potential social causes of under- or malnutrition in the elderly:
7. List five nutrition services specifically targeted at the elderly community
a.
b.
c.
d.
e.
8. The Minimum Data Set (MDS) is required by CMS to monitor the care provided to
residents at skilled nursing facilities. When does the MDS need to be completed?
9. Pressure ulcers, previously referred to as bedsores or decubitus ulcers, develop from
continuous pressure that diminishes capillary blood flow to skin and the underlying
tissue. List four factors or conditions that may contribute to development of pressure
ulcers:
a.
b.
c.
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d.
10. List the nationally recognized pressure ulcer stages:
11. Describe the nutrition prescription for a patient with a pressure ulcer:
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