Cycle Menus and Food Cost Management in Foodservice Operations, Exams of Nutrition

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The 5 management functions are: - planning, organization, staffing, directing, and controlling. The 3skills you need to be a successful manager are - 1.Technical-knowledge and capabilities to perform specific tasks 2.Human/Interpersonal-soft skills that should be nurtured, such as communication and attention to relationships (in contrast tohard skills that can be learned) 3.Conceptual-ability to integrate activities and interests of an organization →the most important skill to have at higher levels of managemen define Management Functions planning - Planning -usingproblem solving and decision making to ensure proper utilization of all resources define Management Functions organization - Organization -assigning duties; delegating authority; creating responsibility define Management Functions staffing - Staffing-recruiting and screening potentialemployees; hiring, orienting, and training newemployees; supervising and evaluating employees define Management Functions directing - Directing -usingleadership and management styles; using motivation and communication define Management Functions controlling - Controlling -establishing standards forperformance; evaluating actual performance; implementing corrective action

How should a manager decide on an in-service training topic?a.Choose from the job specifications b.Observe staff and their work area c.Ask a manager in another department d.Find ideas online - Controlling has 5 characteristics. - An end function-comes into play when performances are made with plans •Pervasive-includes all managers, all levels, all types of concerns •Forwardlooking-look to the past for effective control in the future •Dynamic-continuous review, making changes wherever possible •Related to planning-without planning, controlling is meaningless and without controlling, planning is useless What are the4steps in controlling? - 1)Establish standards (targets to achieve) 2)Measureperformance 3)Compareactual and standard performance -identify causes and extent of deviation 4)Takeremedial actions -takecorrective measures for deviations and possibly revising targets. A manager can only exercise control by taking corrective measures Interpersonal Roles - provide information and includethe roles of afigurehead, leader, and liaison.4Figureheads have social, ceremonial, and legal responsibilities; they serve as an authority figureand a source ofinspiration.Leaders serve as a leader, and manage performance and responsibilities. Liaisonscommunicate with internal and external contacts and network effectively Informational roles - process information and includethe roles of amonitor, disseminator, and spokesperson.4Monitorsseek informationrelated to their industry, look for changes in the industry environment, and monitorthe team on productivity and well-being. Disseminators communicate useful information to teamsand colleagues.Spokespersonsrepresent and speak for their organization,andtransmit information about their organization and goals to people outside of it

Decisional roles - use information and includethe roles ofentrepreneur, disturbance handler, resource allocator, and negotiator.4Entrepreneurscreate and control change (including problem solving), generate new ideas, and implement them. Disturbance handlers take charge when the team hits an unexpected roadblock and mediate disputes within the team. Resource allocators determine where organizational resources should be applied, allocate funding, and assign staff and other resources. Negotiators take part in and directimportant negotiationswithin the team, department, and even organization. Transactional Leadership - focus is on supervision, organization, performance•Goalis to maintain the status quo•Obtains employee followers through rewards and punishments, which typically only lasts for the short term•Effective in a crisis; effective when projects have very specific parameters Transformational Leadership - Connects with employees' sense of identity and dedication to the mission and organization. In doing so,enhances motivation, morale,and performance •Aligns followers with appropriate tasks in order to improve performance•Goalis to change the future•Acts as a positive role model•Effectivein smaller businesses due to hands-on outreach to employees, rather than in complex or large organizations Contingency / Situational leadership - Changes leadership approach depending on the situation•Used when tasks and environment vary, and/or when organizations are open systems requiring careful management HBL leadership style telling - Instruction, direction, autocratic Leader gives precise and firm instructions and deadlines while closely monitoring progress HBL leadership style selling - Persuasion, encouragement, incentive Leader explains goals, tasks, methods and reasons, and remains available to followers to provide support

HBL leadership style participating - Involvement, consultation, teamwork Leader works with followers, involving the group, seeking input, and encouraging efforts HBL leadership style delegating - Trust, empowerment, responsibility Leader gives responsibility to followers to set goals, plan, and execute the plan. Game theory: - introduces a competitive componentinto decision making by bringing the actions of an opponent into the situation. The goal is to obtain the highest gains with smallest amount of losses,regardless of what a competitor does queuing theory - balancing the cost of waiting in lines against the cost of expanding facilities to prevent them. For example, balancing the number of cashiers working in the hospital cafeteria with the number of customers waiting in line task behavior - How knowledgeable is the employee? Do they have the necessary skills?How much help will they need from the leader?You can think of task behavior as the degree of directive behaviorrequired by the leader.When "task behavior"or "directive behavior"is HIGH, the employeeneeds to be instructed on every aspectof the task they are being asked to do. When "task behavior" or "directive behavior" is LOW, the employee is knowledgeableabout the task at hand and have the necessary skills to get it done Relationship behavior - How excited is the employee about the task? How willing are they to engage in the task? How much motivation will the leader need to provide?You can think of relationship behavior as the degree of supportive behaviorrequired by the leader.When "relationship behavior" or "supportive behavior"is LOW, the employee is self-motivated and does not require a large amount of support from the leader. When "relationship behavior" or "supportive behavior" is HIGH,the employee requires a large amount of support fromthe leader as they may not be confident or excited about the task

HBL maturity levels M1: - M1 are the least experienced workers and are described by some texts as "unable and unwilling", corresponding to R1 in the diagram following.The employee may be inexperienced or simply lack the skillsnecessary for the task. The employee will require a high level of direction from the leader at every step and because the leader is guiding them in the tasks themselves, there is a low amount of supportive behavior required. M1 maturity corresponds to R1 readiness and S1 - telling HBL maturity levels M2: - M2 are inexperiencedlike M1, but are interested in learning. The leader should adapt their style to provide more supportivebehavior to match the employee's excitementabout increasing their skill set. The leader needs to provide both direction and support.M2 maturity corresponds to R readiness and S2 -selling HBL maturity levels M3: - M3 are employees who have most of the skills and knowledge necessary to get the job done correctly, thus requiring little guidance on the task from the leader. They benefit from supportive behavior to enhance their confidence and build the employee-leader relationship.M3 maturity corresponds to R3 readiness and S3 -participating HBL maturity levels M4: - M4 are employees who are confidentin their ability to complete at ask and can do so independently, without direction or support from the leader. M4 maturity corresponds to R r4e3adiness and S4 -delegating management 4 E's - Efficient: getting the most output from the least amount of input •Effective: doing things well, producing intended results •Economical: havinggood value with respect to the money/time/effort spent1-aka your total inputs for the "budget"; an economical approach -aka a "thrifty"approach •Expedient: suitable for a purpose,given the circumstanc

theft - taking property without force1-"taking" means removingwithout permission or right, and is often premeditated pilfering - stealing minor items in small amounts, petty theft robbery - taking property that may involve forceandperson-to-person interaction embezzling - steal or misappropriate (money placed in one's trust or belonging to the organization for which one works). burglary - entering a building/residence with intention of theft.1Burglary does not require that property is actually stolen, and there may or may not be person-to-person interaction The Management ProcessThe management process begins with establishing objectives and then identifies functions required to achieve the objectives. Then,the manager determines responsibilities -describes them and assigns them as appropriate. Finally, the manager delegates by assessing whichemployees have the skills and/or resources to achieve the tasks -

1. establish objectives- managment objectives begins with establishing objectives
2. identify fucntions- the function to be included to acheive objective
3. determine responsibilities- task or responsibilites must be described and assigned as appropriate
4. delegate- assess what employees have the skills/resources to acheive task deficiency needsor D-needs - basic needs include physiological needs(food, warmth, water, rest) and safety needs(security and safety). These are also known as deficiency needsor D-needsalong with psychological needs. Motivations decrease as needs are met, and motivations increase as the duration of deficiency continue

psychological needs(also D- needs) - Next are belonginess and love needs (intimate relationships, friends),and esteem needs(prestige, feeling of accomplishment)-the psychological needs,referenced above, are the human needsfor interpersonal relationships that motivate behavior at this level. Esteem includes esteem for yourself (dignity, independence), desire for reputation (status, prestige) and desire for respect from others. Esteem needs are higher among children and adolescents than certain adults. B-needs (being needs) - The highest level of Maslow's Hierarchyof Needs is self-actualization(achieving your full potential) also called the self-fulfillment needs.In contrast to D-needs, self-actualizationincludesB- needs(being needs). These motivationsare increasedas lower needs are met Maslow's Hierarchy of Needs 1st need -

1. Physiological needs - these are biological requirements for human survival, e.g. air, food, drink, shelter, clothing, warmth, sex, sleep. If these needs are not satisfied the human body cannot function optimally. Maslow considered physiological needs the most important as all the other needs become secondary until these needs are met. Maslow's Hierarchy of Needs 2nd need -
2. Safety needs - once an individual's physiological needs are satisfied, the needs for security and safety become salient. People want to experience order, predictability and control in their lives. These needs can be fulfilled by the family and society (e.g. police, schools, business and medical care). For example, emotional security, financial security (e.g. employment, social welfare), law and order, freedom from fear, social stability, property, health and wellbeing (e.g. safety against accidents and injury). Maslow's Hierarchy of Needs 3rd need -
3. Love and belongingness needs - after physiological and safety needs have been fulfilled, the third level of human needs is social and involves feelings of belongingness. Belongingness, refers to a human emotional need for interpersonal relationships, affiliating, connectedness, and being part of a group. Examples of belongingness needs include friendship, intimacy, trust, and acceptance, receiving and giving affection, and love. Maslow's Hierarchy of Needs 4th need -

4. Esteem needs are the fourth level in Maslow's hierarchy and include self-worth, accomplishement and respect. Maslow classified esteem needs into two categories: (i) esteem for oneself (dignity, achievement, mastery, independence) and (ii) the desire for reputation or respect from others (e.g., status, prestige). Maslow indicated that the need for respect or reputation is most important for children and adolescents and precedes real self-esteem or dignity. Maslow's Hierarchy of Needs 5th need -
5. Self-actualization needs are the highest level in Maslow's hierarchy, and refer to the realization of a person's potential, self-fulfillment, seeking personal growth and peak experiences. Maslow (1943) describes this level as the desire to accomplish everything that one can, to become the most that one can be. maslows hierarchy of needs states that Motivation increases as ______________ needs are met and motivation decreases as _______________ needs are me - B-needs are met , D-needs McGregor's Theory X - assumes that employees must be controlled, directed, and coerced.14Other assumptions are that employees have little ambition, they dislike work, are irresponsible, and will avoid work,if possible. Managers believing in Theory X think that the primary employee motivation is first monetary and then,security. Managers may use hard or soft management approaches. Hard management approaches includecoercion, implicit threats, micromanagement, and tight controls andmay result in hostility, employees producing poor work on purpose, and extreme demands from labor unions. Soft management approachesare permissive in the hopes employees will cooperate but may result in workers wanting greater reward if they can do less work. McGregor's Theory Y - Yassumes that most people not only accept but seek responsibilityand that exerting physical and mental effort at work is as natural as play or rest.14Managers believing in Theory Y believe that most people will exercise self-control to achieve an organizational objective. Theory Y builds on the esteem and self-actualization needsfrom Maslow's Hierarchyof Needs.Note that managing via Theory Y does not mean a manager must use a "soft approach". Key tools for managers using Theory Y include: decentralization and delegation, broadening the scope of an employee's job description, consulting employees in decision making (participative management), and having employees set goals and conduct self-evaluations Theory Z (Ouchi) -

is a "Japanese Management" style that boomed in the 1980's. Japanese employees were empowered and productive,leading to high quality products at low prices. Managerial assumptions about employees were that employees desired affiliation and expected support from their company, and that family culture and traditions are important,both at work and at home. Extensive training is a tool in Theory Z management to develop a sense of order and moral obligation to work hard and produce quality work. Managersbelieving in Theory Z focus on improving employee loyalty to the organization by improving their well-being,both in and outside of work. Benefits of this managerial style include stable employment (low turnover), high productivity, high morale, and high employee satisfaction.15Companies using this form of management typically have slow promotions, group decision-making, and life-time employment opportunities Unity of Command - Unity of Command: each employee is accountable to only one superior. Considered to be a traditional or classical management approach Scalar Principle - Scalar Principle:a management rule where each employee reports directly to their higher up and no one else. Authority and responsibility flow via delegation in a direct line, vertically from highest to lowest levels. This principle is alsoknown as the chain of command Line Authority - Line Authority: when multiple employees report to a single administrator, such as 20 clinical RDs reporting to one nutrition manager. There is still a chain of commandbut it is via line authority (multiple employees to one supervisor) versus the one-to-one in Unity of Command Synergy - Synergy: when the outcome of multiple employees working together is greater thanthe sum of themworking alone; you can replace the word "employees" with functional units; it's a practical approach for getting results.1Managers can foster synergy by creatingteams of people who complement each other, facilitate collaboration through open work spaces, and set common objectives that let team members overcome individual differences. centralized organization - A structure in which top-level managers delegate little authority to lower levels Good for :•Established & detailed processes

•Close control of operations •Uniformity of policies, practices, and procedures •Better use of centralized and/or specialized experts decentralized organization - An organization in which lower-level managers make important decisions Good for: •Adaptability and innovation •Quick decision-making •Good training experience for future promotions to higher level management •Diverse businesses•Geographically dispersed companies span of control - the optimal number of subordinates a manager supervises or should supervise Span of control is at the individual manager level, not the organizational level.17A manager's span of control is their ability to efficiently and effectively supervise all work sites and workers. What reduces a manager's span of control? - Complicated work, geographical or departmental dispersion of workers, and vague policies. A company produces infant formula and has offices across the United States. They would likely benefit from a (decentralized / centralized) organizational structure because - (decentralized) because it is a geographically dispersed company A nonprofit health organization interacts with government officials, healthcare professionals, and education representatives. Their market span is (diverse / not diverse) and would likely benefit from a (decentralized / centralized) organizational structure. - Diverse, decentralized A hospital's foodservice department has a Director, Nutrition Manager, Foodservice Manager, and HR Manager. The clinical RDs report to the Nutrition Manager; foodservice staff report to the Foodservice Manager; and support staff report to the HR Manager. Each week, all managers meet with the Director to get project approvals. All employees are required to follow the same policies and

procedures. This department is an example of a (decentralized / centralized) organizational structure.

• centralized A large research organization has several highly qualified expert scientists and maintains several lab locations across the world, with an expert at each location. They advertise that the advantage of using their lab services is the high quality and standardized lab procedures. It would be best for them to use a (decentralized / centralized) organizational structure because - decentralized because of the geographically diverse location, despite having standardization and experts. the processes required to change inputs into outputs - transformation key to an efficient and effective system. Allows for continual relationships and interaction between the subunitswithin an organization - interdependency information on how operations worked or failed, or how they should be changed or modified to restore equilibrium(can be internal or external) - Feedback outputs may be achieved in a variety of ways, such as producing quality meals (outputs) from both raw ingredients in-house and/or quality pre-prepared products (inputs - Equifinality: used by managers to unify a system. Include communication and decision making - Linkingprocesses: Example: Cold Food and Feedback-The dietetic technicians and dietitians hear from the patients andcafeteria customers that the food is cold. The DTRs and RDNs relay this information to the food service manager, who discusses recipe changes with the chef,trickling down to the line cooks. Using a systems approach,evaluating theeffectiveness of a new policy should consider both the internal and the external environments via feedback(See next page for a diagram). are these feed backs internal or external? -

In thisexample, internalfeedbackcomes from the patients and customers about food temperature to the diet tech or the dietitian. Internal feedback occurs within a department, so the communication between the DTR/RDNs, foodservice manager, chef, and line cooks is also internal feedback. Externalfeedback, such as thatfrom The Joint Commissionor the health inspector,is external feedback. In this example, there is no external feedback. Don't be fooled by thinking the feedback from the patients and customers isexternal feedback. Systems Thinking - a way of monitoring the entire system by viewing multiple inputs being processed or transformed to produce outputs while continuously gathering feedback on each part Systems Theory - theory that describes the interconnected elements of a system in which a change in one element affects all of the other elements systems analysis - a method of problem solving or decision making that applies sytem thinking to management organizations "the continuous and systematic management process to determine long-term goals, the best approach to accomplish them, and how success will be measured."1Itis used to inform policies and operational decisions. Itis notused in evaluation - Strategic Planning Strategic planning may also be called strategic management. It is a form of organizational and environmental analysis used to establish goals and success criteria by implementing strategies to move towards those goals.1A key part of strategic planningis evaluating progress towards the goal. marketing is concerned with - Customerwants-focus on producingthegoods customers want•Profit-maximize net profit rather than focusing on total sales•Futuregrowth-forecasting future growth

4 P's of Marketing - 1.Price: pricing affects how a product is sold; linked to perceived value of product; must understand how a consumer sees the product because a price too high OR too low will hinder sales. 2.Promotion: marketing communication strategies and techniques,including advertising, sales promotions, special offers, and public relations. Must be suitable for product, price, and end user. Promotion is the communication part of the entire marketing function. 3.Place: how is the product provided to the customer? Placement strategy assessesthe most suitable channel and must complement the rest of the product strategy. 4.Product: atangible good or intangible service; developed to meet a specific consumer need and demand. Need to understand the problem the product is trying to solve and then convey the benefits tothe consumer. The LEARN Mode - The LEARN model was designed to overcome communication barriers in health care encounters. The model stands for: Listen, Explain, Acknowledge, Recommend treatment, Negotiate agreement The dominant force in how a patient views healthcare is ________________.21__________________ are secondary drivers - individual experience, (Social hierarchy, race, and ethnicity) The ETHNIC Model of culturally competent care - Explanation, Treatment, Healers, Negotiation,Intervention,Collaboration. How does a patient'sunderstanding of their illness and treatment fit with what is expected and accepted in their culture? How can we determine treatment options in a collaborative (not imposed) process? This model focuses on questions and conversations providers should have with patients to achieve theirgoals The BATHE Mode - This model helps create a culturally competent environment,focusing on the psychosocial context for the patient's visit rather than medical details. The model stands for: Background, Affect, Trouble, Handling, Empathy.

The GREET Mode - This model is useful when working with immigrant populations and helps providers understand the context of the patient and how they understand information related to their illness. Generation, Reason, Extended family, Ethnic behavior, Time living in the United States Campinha-Bacote Model - Cultural awareness- involves challenging assumptions and asking client questions about their values, beliefs, and practices, resulting in acquisition of cultural knowledge Cultural knowledge-the provider familiarizes themselves with variations in cultural impact and expands their Cultural skills- to collect key information in order to conduct effective assessments and decide on an intervention that takes into account preferred language, foods consumed or avoided (especially when feeling ill), and foods consumed or avoided for religious reasons Cultural encounters Cultural desire- where the practitioners want to engage in cross-cultural care. the purnell model - This model is derived from multiple theories and includes16 assumptions about culture. "A culturally competent health care provider develops an awareness of his or her existence, sensations, thoughts, and environment without letting these factors have an undue effect on those for whom care is provided." explanatory model - a patient's views about health and illness and its treatment FOCUS -PDSA Model - Total Quality Management (TQM) -

a management philosophy that focuses on satisfying customers through empowering employees to be an active part of continuous quality improvement These 8 aspects are key to TQM: •Customer-focused •Strategic approaches •Total employee involvement •Continuous improvement •Process-centered •Fact-based •Integrated system•Communication The key tenants of CQI are: - •Customer satisfaction •Data collection via the scientific method •Team involvement Customer satisfaction directs the CQI process towards what should be examined. Data collection, via the scientific method, provides high quality data to guide the improvement process. Team involvement encompasses the system level and includes people from all areas that the improved program or process might touch RUMBA - The RUMBA model stands for reasonable, understandable, measurable, believable, and achievable.27It's an individualized model that you can use as a manager to engage your team with change. An effective leader accepts change as a part of life and works with their team to embrace it. Pareto Chart - In the FOCUS model section, the diagram mentions Pareto Charts and cause and effect Charts in "F" for "Find the problem". Pareto charts have 2 components: a bar graph that representsthe descending frequency of occurrence (or cost), and a line graph representing the cumulative percentage of total occurrences(or cost).

Why do we use Pareto charts? By ordering the occurrence of a complaint in descending order, we can identify the complaintthat has the largest effect on satisfaction.14We can also determinethe number of factors we need to address in order to reduce complaint frequency by a certain percent. If the chart represents cost rather than occurrence, thenyou can imagine that addressing the most expensive problem, or knowing how many problems you need to address to cut costs to meet your budget, would be helpful PERT chart - ChartPERTchartstands for "Program Evaluation Review Technique" and is a project management evaluation toolused for effective planning at the management level. We use it to schedule, organize, and coordinate tasks within a project. To construct a PERT chart: 1)Each task necessary to complete a project is written in nodes (blank boxes in this example) .2)Directional arrows represent sequential tasks -one must be completed before another. Not all tasks are sequential;some can be performed at the same time. 3)The amount of time needed to complete each activity is written along each line -it could be days, weeks, hours, or months. 4)Critical path analysis is a bolded line that shows the longest path by duration to completethe project as described in the chart. cause and effect diagram (fishbone diagram) - Ishikawa" diagrams, named after their developer, Kaoru Ishikawa, These diagrams can be used to identify problems for continuous quality improvement programs, like the F step of the FOCUSmodel.28It can also be used in less formal processes to discover bottlenecks and root causes of problems. To construct a cause and effect diagram: 1)Write down the problem to one side as the fish head 2)Brainstorm major factors that might affect the situation by drawing lines off the center spine 3)Write down causes (horizontal lines) that contribute to each major factor 4)Add further sub-causes with more branches off of the cause lines(vertical) and their factors (horizontal)5)Analyze the diagram Delphi Method - Delphi method: a group of experts are contacted individually and anonymously with questionnaires.29Their responses are statistically tallied and summarized in a report which is sent

back to the experts with another questionnaire. The goal of the Delphi method is to reduce the range of responses from experts and arrive at what might be called a consensus. Delbecq Nominal group technique - .Delbecq's nominal group technique: using structured,small-group discussion to reach a consensus.30The moderator presents the question of interest. Each group member writes down their ideas separately. Then each person shares their idea and the moderator writes them on a group board. The group then discusses each idea, revising them, and then voteson the best one. Charrette - Charrette: collaborative planning process harnessing the talents of all interested parties.31Results in a master plan that represents transformative community change. In the resting state,sodium (Na+), calcium (Ca2+), and chloride (Cl-)reside primarily in the ECF or ICF?

• ECF In contrast, potassium (K+) and phosphate (PO43-)reside in the ECF or ICF in the resting state? - ICF the ability of a solution on one side of the cell membrane to attract water from solution on the other side of the cell membrane. In clinical scenarios, tonicity refers to osmolality of a solution relative to human plasma. The tonicity of a fluid depends on the amount of osmotically activesolutesand tonicity of ECF is determined primarily by sodium levels - tonicity the amount of osmotically active substances in a solution expressed as milliosmoles per liter of water (mOsm/L).Osmotically active substances increase the tonicity of solutions and cause osmosis. The main osmotically active substance in ECF is sodium. - Osmolality the movement of water from a lower tonicity solution to a higher tonicity solution through a semipermeable or permeable membrane.Osmosis maintains homeostasis,or equilibrium,because it evens out the ratio of fluid and solute between the intracellular and extracellular compartments. - Osmosis

Describe tonicity in 2 different ways. - The ability of a solution to attract water across a membrane. •The concentration of solutes on one side of a membrane relative to the other side Higher calorie enteral formulas are hypertonic. What does hypertonic mean in this situation? - Hypertonic enteral formulas have osmolarity higher than plasma (> 300 mOsm/L) Hypertonic enteral formulas can lead to GI symptoms and distress. Describe these symptoms and why they occur. - Hypertonic enteral formulas can cause water to enter the intestinal lumen because the higher concentration of solutes results in water diffusing in. This leads to watery diarrhea, cramping, and other abdominal symptoms Describe the 3 types of dehydration. Connect the name with the loss of electrolytes versus the loss of water. - •Isotonic dehydration occurs with equal loss of fluid and electrolytes. Serum sodium and BUN will be WNL. •Hypotonic dehydration occurs with loss of electrolytes, leading to hypotonic plasma. Serum sodium will be low (<130 mmol/L). •Hypertonic dehydration occurs with loss of fluids, leading to hypertonic plasma. Serum sodium will be high (>150 mmol/L) and serum BUN will be high (>20 mmol/L To estimate fluid needs - 30-35 ml/kg 100 mL/kg for the first 10 kg body weight, 50 mL/kg for the next 10 kg, and 20 mL/kg for the remaining body weight 1ml/kcal

Isotonic / Isonatremic / Hypovolemic Dehydration - Loss of water and electrolytes in proportion to plasma levels •Excessive sweating •Repeated vomiting •Diarrhea •Severe bleedingMost common type of dehydration Sodium: WNL 130-150 mmol/LBUN: WNL 7-20 mg/dL hypotonic (hyponatremic) dehydration - Na< sodium losses exceed water losses seen when -patient consumes diluted fluids or free water during dehydration -adrenal insufficiency can be rehydrated over 24 hours -too rapid correction -> central pontine myelinosis Primarily loss of electrolytes, especially sodium •Intravascular water shifts to ECF •Results in hypotonic plasma, water shifts from ECF to ICF leading to swelling Treating dehydration with electrolyte-poor fluids •Diarrhea •GI obstruction, fistula, or ileus •Heat exhaustion•Pancreatitis •Burns •Trauma •Ketonuria •Chronic malnutrition

•Cystic fibrosis with excessive salt loss in sweat •Renal tubular acidosis •Diuretics (thiazides, furosemide, mannitol) hypertonic (hypernatremic) dehydration - Na> BUN> 20mg/dl water losses exceed sodium losses associated with highest mortality causes -breastfeeding failure -inappropriate use of rehydration solutions (boiled milk) -diabetes insipidus -DKA can be rehydrated over 48 hours -too rapid correction -> cerebral edema Water deprivation•Diarrhea (esp. in peds) •Excessive sweating •Hyperventilation •Unmanaged diabetes with ketoacidosis and polyuria •Heat stroke •End-stage renal failure •Infusion of hypertonic solutions •Some diuretics The kidneys have 4 key functions: - volume and osmolarity regulation, ion concentration and pH regulation, waste and toxin excretion, and hormone production.

what happen in the body and kidneys When extracellular fluid (ECF) volume is low? - plasma solute concentrationincreases,which increases osmolarity. In responsetoanincreased solute concentration, the kidneysreabsorb water in order toincrease the ECFvolume, which decreasesthe plasmasolute concentration and restores normal osmolarity. The resultof the kidneys reabsorbing water is concentrated urine. what happen in the body and kidneys When extracellular fluid (ECF) volume is low? - plasma solute concentration decreases,which decreases osmolarity.In responseto decreased solute concentration, the kidney excretes excess water,which reduces ECF volume, restores solute concentration and osmolarity to normal, and results in dilutedurine as water is excreted into the collecting duct. how do the kidneys regulate ion concentration? - The kidneys primarily regulate ion concentration by reabsorbing or excreting sodium, potassium, and calcium to maintain relatively constant levels of electrolytes. When electrolyte plasma levels are too high, the kidneys will remove them from circulation and excrete them in the urine. If electrolyte plasma levels are too low, the kidneys will retain them from the circulating blood instead of excreting them how do the kidneys regulatem pH balence? - Both the kidneys and the lungs play a role in maintaining blood acid-base balance.Therespiratory system compensates for short term disruption of acid-base balance by changing ventilation patterns.The kidneys are slower to respond to acid-base imbalance but have a larger effect by excreting excess acid (H+) in the urine or reabsorbing bicarbonate (HCO3-) to keep in the blood.Bicarbonate does not have a transporter so reabsorption and excretion occur © 2021 V1MAY2021Kidney Function, Electrolytes, and Dehydration9via reactions controlled by renal epithelial cells.Buffers, like NH3, absorb the excess H+ and OH-to maintain pH Acid-Base BalanceNormal blood gas values can be reported for arterial blood (ABGs) or mixed venous blood - Normal ABG valuep H 7.35 -7.45 PCO2 35 -45 HCO3- 22 -26 Acidemiais when blood pH is - less than 7.35

alkalemia is when pH - is greater than 7.45. Acidemia and alkalemia refer to abnormal pH while - acidosis and alkalosis refer to the metabolic or respiratory process whose compensatory response led to the abnormalpH values. Respiratoryacidosiscan occur - from pulmonaryissues, such as COPD exacerbation, asthma, pneumonia, pulmonary edema, respiratory muscle weakness (e.g. ALS), or from CNS depression (e.g. head trauma, drug toxicity, post-ictal state). The pH will be low and PCO2 will be high. As the body compensates, we will see elevated HCO3-and H2CO3 levels because the lungs are hypoventilatingin order to retain CO2 Respiratory alkalosis can occur - due to pain, anxiety, panic attacks, pregnancy, hypoxemia, drug toxicity, hyperventilation, or pulmonary disease. The pH will be high and PCO2 will be low. As the body compensates, we see decreased HCO3-and H2CO3 because the body is increasing the respiratory rate (hyperventilation) to wash out excess CO2. Metabolic acidosis can be - "high anion gap" or "normal anion gap". High anion gap metabolic acidosis can occur due to lactic acidosis (e.g.metformin use, liver failure, infection, ischemia), ketoacidosis, salicylate use, renal insufficiency, excess iron intake, accumulation of exogenous organic acids (e.g. methanol or paraldehyde poisoning), uremia (e.g. rhabdomyolysis). Normal anion gap metabolic acidosis can occur due to renal tubular acidosis, GI loss of HCO3-from diarrhea, fistulas or intestinal stomas, hyperchloremia (e.g. from excess salineor PN), Addison's disease(e.g. aldosterone deficiency), or from use of some drugs like spironolactone. In both cases of metabolic acidosis, we will see low pH and low HCO3-levels. The body compensates by lowering PCO2 production. © 2021 V1MAY2021Kidney Function, Electrolytes, and Dehydration10Anion gap is calculated from the differencebetween the major positive and negative ions in the blood (sodium, potassium, chloride, and bicarbonate). You don't need toknow how to calculate anion gap. Metabolicalkalosiscan be " - chloride-responsive" with normal urinary chloride levels or "chloride-resistant" with urinary chloride in excess of 40 mmol/L.They are also called saline-responsive and saline-resistant (saline contains chloride). Chloride-responsive metabolicalkalosis can occur from vomiting,excessive nasogastric suctioning, hypovolemia, or types of diuretics (loop, thiazide). Chloride-

resistantmetabolic alkalosis can occur in several syndromesincluding hyperaldosteronism, Cushing's, Bartter(excess mineralocorticoids), very low serum potassium, or excess alkali intake. In both cases of metabolicalkalosis, HCO3-will be high and the body compensates byincreasingPCO2. For a straightforwardquestion on acid-base balance, evaluate first the pH (is it low or high), then look at PCO2 (high or low?), and then finally look at HCO3 (high or low?). For simple acid-base disorders, either PCO2 or HCO3 will be abnormal and can point you to respiratoryversus metabolic as the primary etiology of pH imbalance. In real life, acid-base disorders can be a mix,which is trickierto ascertain. When the blood is too acidic (low pH) the kidneys will: - increase bicarbonate reabsorption •increase hydrogen ion secretion from renal epithelial cells •increase ammonia secretion to increase the NH3buffer When the blood is too basic (high pH) the kidneys will: - decrease hydrogen ion secretion from renal epithelial cells •decrease rates of glutamine metabolism •decrease rates of ammonium excretion (NH4) Renin controls - salt and water balance, and thus blood pressure. In response to low mean arterial blood pressure (MAP), the kidneys release renin,which cleaves angiotensinogen (from the liver) to angiotensin I. Angiotensin converting enzyme (ACE) converts angiotensin I to angiotensin II, which constricts blood vessels and stimulates increased blood pressure via other mechanisms Calcitriol - (1,25-D3) circulates as a hormone regulating calcium and phosphate metabolism, and is the active form of vitamin D. Vitamin D can be generated from cholecalciferol (sun) which goes to the liver and then travels to the kidney as calcidiol (25-hydroxy D3).

Vitamin D can also be generated from cholecalciferol (D3;from food) or ergocalciferol (D2;from supplements) which then go to the liver and the kidney. Observational Studies - in observational studies, the researcher doesn't intervene or manipulate the conditions,they just gather information. Thus, the results are measures of association or correlation, not causation. prospective studies - studies planned by the researcher for collection of primary data for the specific study and implemented in the future (ex. all participants attend clinic visits in the same way, answer the same surveys, and have the same tests done. However,the researchers do not manipulate anything,they just collect dataand assess their observations.) in a large cohort study constructed in 1980, a group of 20,000 adults aged 30 -80 were recruited and attended regular clinic visits every 5 years. Between clinic visits, study staff contacted participantsvia telephone. At every 5-year clinic visit, participantscompleted a food frequency questionnaire. Using this data, study investigators studied the association betweentheHealthy Eating Indexfrom the dietary data and the risk of hospitalization from ischemic stroke,beginning with a baseline in1980 andfollowing participantsthrough 2010. what kind of study is this - prospective retrospective studies - Studies conducted using data that have already been collected about events that have already happened. Such secondary data were originally collected for a purpose other than the current research. cross-sectional studies - a research method that compares participants in different groups at the same time you measure the exposure and outcome at the same time, like a snapshot in time. Surveys are often cross-sectional, such as NHANES and BRFSS case-control studies - assess outcome status and then assess for exposure history

ex: you measure the outcome at the start of the study and go backwards to measure the exposure. For example, if you are interested in looking at prenatal exposures in mothers with premature born children, you could identify all the mother-child dyads in the NICU at your hospital, and then interview the mothers about their behaviors during pregnancy cohort studies - record exposures throughout time and then assess the rate of a certain outcome the exposure is measured before the outcome develops. Cohort studies can be prospective, where you recruit participants and follow them over time, or retrospective, using existing data where the exposure was still measured prior to the outcome Investigators want to study the predictors of ICU readmission during a single hospital stay following cardiac surgery. They identify patientswho underwent cardiac surgery from January to December of 2010 and were admitted to the ICU at least once. Cases are those that were readmitted to the ICUfollowing the initial ICU stay. Controls were those not readmitted to the ICU (one ICU stay during the cardiac surgery-related hospitalization). what type of study is this? - retrospective independent variable - The experimental factor that is manipulated; the variable whose effect is being studied. I.e smoking is the independent varible to lung cancer dependent variable - The outcome factor; the variable that may change in response to manipulations of the independent variable. i.e lung cancer is the dependent varible to smoking experimental studies - studies in which the independent variables are directly manipulated and the effects on the dependent variable are examined