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  <head>
    <title>050-02 Nutritional diagnosis, refeeding physiology, artificial support, and metabolic treatment</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Nutritional diagnosis, refeeding, artificial support, and metabolism">
      <outline text="Nutritional diagnosis">
        <outline text="Distinguish intake, absorption, catabolism, composition"/>
        <outline text="Weight mixes fat, muscle, bone, organs, water">
          <outline text="Oedema, ascites, obesity conceal muscle loss"/>
        </outline>
        <outline text="Combine weight rate, intake, disease, examination"/>
        <outline text="Examine muscle at temples, clavicles, interossei"/>
        <outline text="Grip, chair rise, gait, cough show function"/>
      </outline>
      <outline text="Fasting and critical illness">
        <outline text="Fasting: falling insulin mobilises stored fuel">
          <outline text="Ketone adaptation lowers amino-acid demand"/>
          <outline text="Red cells still need glucose"/>
        </outline>
        <outline text="Critical illness: stress hormones and cytokines">
          <outline text="Proteolysis and hepatic glucose despite feeding"/>
        </outline>
        <outline text="Treat disease, give protein, load muscle safely"/>
      </outline>
      <outline text="Energy and protein targets">
        <outline text="Requirement is estimated, not assumed"/>
        <outline text="Predictive equations fail in obesity, fever, burns"/>
        <outline text="Indirect calorimetry measures gas exchange"/>
        <outline text="Overfeeding: carbon dioxide, glucose, liver fat">
          <outline text="Adds ventilatory burden"/>
        </outline>
        <outline text="Underfeeding prolongs negative balance"/>
        <outline text="Protein target follows organs, losses, catabolism"/>
        <outline text="Measure actual delivery, not the prescription"/>
      </outline>
      <outline text="Biochemical markers">
        <outline text="Albumin is not a nutritional scoreboard">
          <outline text="Inflammation, leak, dilution, loss, liver failure"/>
          <outline text="Low value predicts severity, not intake"/>
          <outline text="Infused albumin does not rebuild muscle"/>
        </outline>
        <outline text="Nitrogen balance is only approximate"/>
      </outline>
      <outline text="Micronutrients">
        <outline text="Iron deficiency may precede microcytosis">
          <outline text="Ferritin rises with inflammation"/>
        </outline>
        <outline text="B twelve: nerve damage with or without anaemia">
          <outline text="Folate can mask progressing B twelve injury"/>
        </outline>
        <outline text="Thiamine deficiency">
          <outline text="Wernicke, neuropathy, lactic acidosis, heart failure"/>
          <outline text="Classic triad often incomplete"/>
          <outline text="Treat parenterally without waiting for results"/>
        </outline>
        <outline text="Fat malabsorption: vitamins A, D, E, K"/>
        <outline text="Zinc, copper, vitamin C, selenium by mechanism">
          <outline text="Excess zinc can cause copper deficiency"/>
        </outline>
        <outline text="Empirical replacement can itself be toxic"/>
      </outline>
      <outline text="Refeeding syndrome">
        <outline text="Intracellular redistribution emergency"/>
        <outline text="Total-body depletion despite normal serum values"/>
        <outline text="Carbohydrate raises insulin">
          <outline text="Electrolytes shift into cells"/>
          <outline text="Phosphorylation and ATP demand rise"/>
          <outline text="Sodium and water retained"/>
        </outline>
        <outline text="Arrhythmia, respiratory failure, seizure, death"/>
        <outline text="Identify risk before feeding"/>
        <outline text="Thiamine, electrolytes, cautious start, stepwise rise"/>
        <outline text="Do not stop feeding reflexively for every fall"/>
      </outline>
      <outline text="Oral and enteral support">
        <outline text="Oral preferred when swallowing is safe">
          <outline text="Treat symptoms, remove unnecessary fasting"/>
          <outline text="Texture change may reduce intake"/>
          <outline text="Mealtime assistance may beat a prescription"/>
        </outline>
        <outline text="Enteral when gut works but oral is insufficient">
          <outline text="Nasogastric short term, post-pyloric selected"/>
          <outline text="Confirm position, air auscultation unreliable"/>
        </outline>
        <outline text="Tube does not stop aspiration of saliva or reflux"/>
        <outline text="Residual volumes cause avoidable interruption"/>
        <outline text="Diarrhoea: antibiotics, infection, sorbitol, rate"/>
      </outline>
      <outline text="Parenteral nutrition">
        <outline text="When the gut cannot absorb enough safely"/>
        <outline text="Not automatically superior in critical illness"/>
        <outline text="Central access: infection, thrombosis, occlusion">
          <outline text="Dedicated aseptic lumen, daily necessity review"/>
        </outline>
        <outline text="Excess glucose: hyperglycaemia, lipogenesis, CO2"/>
        <outline text="Long term: cholestasis, steatosis, trace elements"/>
        <outline text="Abrupt stop with insulin risks hypoglycaemia"/>
        <outline text="Transition while confirming oral delivery"/>
      </outline>
      <outline text="Obesity and metabolic treatment">
        <outline text="Chronic relapsing biological condition">
          <outline text="Stigma delays care, ask permission"/>
        </outline>
        <outline text="Sarcopenic obesity missed by body mass index">
          <outline text="Goal becomes function, not weight alone"/>
        </outline>
        <outline text="Weight loss triggers hunger and lower expenditure"/>
        <outline text="Drugs need long-term use and class-based review"/>
        <outline text="Metabolic surgery: durable loss, many benefits">
          <outline text="Leak, dumping, gallstones, deficiencies"/>
          <outline text="Vomiting or neurology may signal thiamine lack"/>
        </outline>
      </outline>
      <outline text="Goals, discharge, and follow-up">
        <outline text="Goals follow prognosis and values">
          <outline text="Feeding may not help irreversible disease"/>
        </outline>
        <outline text="Discharge states route, intake, line care, tests"/>
        <outline text="Follow delivery, strength, wounds, not weight alone"/>
        <outline text="Plan is updated as illness and life change"/>
      </outline>
    </outline>
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