What is a level 1 national dysphagia diet?

A level 1 national dysphagia diet includes only pureed foods. Pureed foods should have the same texture as pudding. They should be smooth and free of lumps. Pureed foods require very little chewing. Thin liquids need to be thickened because they are hard to swallow and more likely to enter the lungs. The level of thickness you need depends on your swallowing issues. Your doctor will tell you how long you need to follow this diet.

What do I need to know about thickened liquids? 

Thin liquids can be thickened with special thickeners, flour, cornstarch, or potato flakes. Thin liquids include milk, juice, coffee, tea, soda, and nutritional supplements. Foods that are liquid at room temperature should also be thickened. These include frozen malts, yogurt, milk shakes, eggnog, ice cream, and gelatin. Your doctor or dietitian will tell you which of the following types of thickened liquids you need:

• Nectar-like liquids have the same thickness as nectars, vegetable juices, and milkshakes

• Honey-like liquids are thicker than nectar-like liquids. The thickness is similar to honey at room temperature

• Spoon-thick liquids are the thickest. The thickness is similar to that of pudding. These liquids need to be eaten with a spoon

How do I prepare pureed foods? 

• Add small amounts of gravy, sauce, vegetable or fruit juice, milk, or half and half to the food. Use only a small amount of liquid at first. Puree the food and add water as needed to get the same texture as pudding

• Potato flakes can be used to thicken your food if you thinned it too much with liquid

• Add dry milk powder to foods for extra protein and calories, if needed

• Pureed foods can be frozen in small portions and reheated at a later time. When you reheat foods, do not allow a tough outer crust to form on the pureed food. This can make it hard to swallow

What foods can I eat?

All foods listed below should be pureed to the same texture as pudding.

• Grains: 

  o Smooth cooked cereals such as cream of wheat 

  o Breads, rolls, and crackers

  o Pancakes, sweet rolls, Danish pastries, French toast, and muffins

  o Well-cooked pasta

• Vegetables and fruits: 

  o Any pureed cooked vegetable

  o Tomato sauce or tomato paste without seeds

  o Mashed or pureed potatoes without skins 

  o Any pureed fruit

  o Well-mashed bananas 

  o Well-mashed avocados

• Dairy products: 

  o Smooth puddings or custards

  o Yogurt

• Meat and other protein foods: 

  o Pureed cooked meats

  o Pureed casseroles

  o Egg soufflés

• Fats and oils: 

  o Butter and margarine

  o Mayonnaise, sour cream, and cream cheese

  o Whipped topping

  o Smooth sauces such as white sauce, cheese sauce, or hollandaise sauce

What foods should I avoid? 

• Any food that has not been pureed 

• Foods with a tough texture such as raw fruits or vegetables, or nuts

• Pureed foods that still contain pulp, seeds, or chunks

• Fruited yogurts

• Any food with lumps, including soups and oatmeal 

• Peanut butter (unless it is part of a recipe for a pureed food)

CARE AGREEMENT:

You have the right to help plan your care. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment.

© 2017 Truven Health Analytics LLC All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or Truven Health Analytics.

What do I need to know about an ileostomy diet? 

You will need to make changes to the foods you eat for about 6 weeks after surgery. These changes will help your intestines heal and prevent problems that can occur when you have an ostomy. These problems include odor, gas, diarrhea, or obstruction (blockage in your intestines). After you heal, you can eat the foods you regularly ate before surgery. 

What foods can I eat after surgery?

You will be given clear liquids right after surgery. Examples include clear juices, coffee or tea (with no cream or milk), gelatin, and broth. Next, you will be allowed to eat low-fiber foods. At first, you will need to limit fiber to less than 8 grams each day. As you heal and your symptoms decrease, you will limit fiber to less than 13 grams each day. 

 •    Grains: Choose grains that have less than 2 grams of fiber in each serving. Examples include the following: 

   ○   Cream of wheat and finely ground grits

   ○   Dry cereal made from rice 

   ○   White bread, white pasta, and white rice

   ○   Crackers, bagels, and rolls made from white or refined flour

 •    Fruits and vegetables: 

   ○   Canned and well-cooked fruit without skins or seeds, and juice without pulp

   ○   Ripe bananas and soft melon

   ○   Canned and well-cooked vegetables without skins or seeds, and strained vegetable juice

   ○   Potatoes without skin 

   ○   Shredded lettuce on a sandwich

 •    Dairy:

   ○   Cow's milk, lactose-free milk, soy milk, and rice milk

   ○   Cottage cheese and yogurt without nuts, fruit, or granola

 •    Protein:

   ○   Eggs, fish, and tender, well-cooked poultry (such as chicken and turkey) and beef 

   ○   Tofu and smooth peanut butter

What foods should I avoid after surgery? 

Do not eat high-fiber foods right after surgery because they are harder to digest. Avoid foods that cause gas, odors, and diarrhea. Do not eat foods that may cause a blockage. 

•    Foods that are high in fiber: 

   ○   Whole-grain foods such as whole-wheat breads, brown rice, or oats

   ○   Raw fruits and vegetables

   ○   Dried fruit

   ○   Dried beans

 •    Foods that may cause blockage: 

   ○   Vegetable and fruit skins

   ○   Apples, dried fruit, grapes, coconut, and pineapple

   ○   Celery, corn, cucumber, green peppers, peas, and bean sprouts

   ○   Salad greens, cabbage, coleslaw, and spinach

   ○   Casing on sausage and tough, fibrous meats such as steaks

   ○   Nuts (such as almonds and pecans) and peanuts

 •    Foods that may cause gas or odor: 

   ○   Apples, bananas, grapes, prunes, and melons

   ○   Asparagus, broccoli, brussels sprouts, cabbage, cauliflower, and corn

   ○   Onions, garlic, or leeks

   ○   Cucumber, green pepper, onions, radishes, and turnips

   ○   Alcohol

   ○   Cheese, peanuts, dried beans and peas, eggs, and fish

   ○   Carbonated drinks such as sodas

 •    Foods that may cause diarrhea: 

   ○   Alcohol

   ○   Apricots, plums, peaches, prunes, and fresh or dried fruit

   ○   Fruit juice

   ○   Beans, fried meats, fish, poultry (chicken or turkey), nuts, or seeds

   ○   Broccoli, brussels sprouts, cabbage, corn peas, tomatoes, turnip greens, and green leafy vegetables

   ○   Bran, wheat, and other whole grains

   ○   Licorice and sugar-free substitutes 

   ○   Spicy foods

   ○   Drinks with caffeine

   ○   Foods high in fat and sugar

What are some nutrition guidelines I should follow after surgery? 

•    Drink plenty of liquids as directed. Your dietitian or doctor may recommend that you have at least 8 to 10 eight-ounce cups of liquid each day. You may need more liquid if you sweat more than normal, such as after exercise. You may also need to drink more if there is a large amount of liquid coming out of your stoma (opening). Ask which liquids are best for you. You may need to drink an oral rehydration solution (ORS). An ORS has the right amounts of sugar, salt, and minerals in water to replace body fluids. Drink liquids 30 minutes after you eat instead of with meals. This will help your body to absorb more nutrients from food

•    Take small bites of food and chew them well. This will allow your body to better digest and absorb nutrients. This will also help to prevent a blockage and decrease gas

•    Eat small amounts of food every 2 to 4 hours. Your appetite may be lower than normal right after surgery. Eat regularly throughout the day to get enough nutrients. Regular meals and snacks will also help decrease gas. Do not lie down within 1 hour after you eat

•    Eat your full meals in the middle of the day. This will decrease the amount of bowel movement that comes from your stoma at night

•    Avoid acidic, spicy, high-sugar, and high-fat foods. These foods can cause diarrhea. Acidic foods include citrus fruits such as oranges

•    Avoid chewing gum, drinking with straws, smoking, and chewing tobacco. This will help to decrease gas

•    Take vitamin or mineral supplements as directed. Chewable or liquid forms are the best types. You will need vitamin B12 supplements in the form of a nasal spray or injection. Your body will absorb vitamin B12 better if it is given as a nasal spray or injection

When should I contact my doctor? 

•    You are urinating less than usual or your urine is dark

•    You feel dizzy when you stand

•    You feel extremely tired

•    You have nausea, and you are vomiting

•    You have not had any bowel movement come out of your stoma for 4 to 6 hours

•    You have abdominal cramps that last more than 2 or 3 hours

•    You see pills or whole foods in your ostomy bag

•    You have questions or concerns about your condition or care

CARE AGREEMENT:

You have the right to help plan your care. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment. 

© 2017 Truven Health Analytics LLC All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or Truven Health Analytics. 

What's involved in quitting tobacco?

Make a plan, get the tools you need, be aware of your triggers, practice coping skills, and remember that it's okay if you slip up.

Get Ready to Quit

Write down your reasons for quitting. These will help keep you on track and focused on the benefits. Your reasons might include:

•    Protecting the health of your family or pets

•    Saving money

•    Improving your health

•    Pregnancy

•    Bad-smelling clothes or breath

Create your "quit plan." The important parts of a quit plan are:

•    Step 1: Medications

•    Step 2: Support and counseling

•    Step 3: Identify your triggers

•    Step 4: Set your quit date 

•    Step 5: Take action

Step 1: Medications

Nicotine is an addictive drug found in tobacco products. While you're quitting, using various forms of "nicotine replacement" can help you stay away from tobacco. Other medications can help cut down your cravings and withdrawal symptoms.

 Ask your doctor or nurse about medications that are right for you:

•    Non-nicotine medications (prescription required)

  o   Varenicline (Chantix)

  o   Bupropion (Wellbutrin, Zyban)

•    Nicotine replacement

  o   Over-the-counter options: patch, gum, lozenge, mini-lozenge

  o   Prescription options: inhaler, nasal spray

You may get the results from using a combination of medications: 

•    Use non-nicotine medications with nicotine replacements. This is the most effective way to quit

•    Use two forms of nicotine replacement; for example, a long-acting patch to get a stable dose of nicotine and a quick-acting gum or inhaler to relieve cravings

Step 2: Support and counseling

People who use medications plus counseling to quit tobacco are most successful.

•    Please refer to the Jiahui Wellness Center Quit Smoking Program

Contact number: 400-868-3000

Tell your family, friends, and coworkers that you're quitting tobacco. They can be part of your support network and help cheer you on. Try to find a "quit buddy" who will quit at the same time as you.

Step 3: Identify your triggers

Figure out the triggers that make you want to use tobacco, such as coffee, alcohol, stress, driving, eating, or hanging out with friends.

Start thinking about a plan to manage those triggers. You may want to change your routines, especially if they are linked to using tobacco. For example, travel a different way to work if your normal route passes a shop that sells tobacco.

Step 4: Set your quit date

Pick the day you're going to quit using tobacco. Leading up to that day, start preparing:

•    Buy or get a prescription for any medications you plan to use

•    Gather tools that will help you quit, such as:

  o   Gum, toothpicks, sugar-free candy

  o   A calendar for crossing off days

  o   New sneakers for exercising

  o   Something to keep your hands busy (a squeezable stress ball, knitting, games on your phone)

•    A few days before your quit date, make your home and car tobacco-free. Remove ashtrays, lighters, and anything else that could make it easy for you to start up again

Step 5: Take action

On your quit date, start your plan!

•    Take your medications as prescribed (Chantix and Bupropion should be started a week or so before your quit date)

•    Use your support program: attend a group, log onto a website, call a quitline

•    Watch out for danger zones and triggers and use your quit plan to manage them

•    Manage cravings:

  o   Use your quick-acting nicotine replacement (gum, inhaler, lozenge)

  o   Practice the 4 D's (below)

Coping Skills: Practice the 4 "D's"

1.   Deep breathing

Breathe in, hold it for a few seconds, then breathe out. 

2.   Distract

Focus your attention on something else, like going for a walk or watching a movie.

3.   Drink water

This gives you something different to do with your mouth and hands.

4.    Delay

Tell yourself that you'll wait for a few minutes first. Then, see if you still have the urge. Cravings will pass whether you smoke or not, and sometimes they pass pretty quickly.

If You Slip, Get Back on Track

•    If you slip and use tobacco, it's okay! This is a normal part of quitting. It doesn't mean that you have gone back to using it for good. It often takes multiple attempts to quit forever, and you learn from each one

•    Focus on your quit plan. Keep to the plan, and don't beat yourself up

•    Learn from the slip. What caused it? What will you do differently next time?

•    Don't give up! Remember your reasons for quitting. You can do this

This document is intended to provide health related information so that you may be better informed. It is not a substitute for your care team's medical advice and should not be relied upon for treatment for specific medical conditions.

© 2017 The General Hospital Corporation. Primary Care Office InSite

What is hepatitisC?

Hepatitis makes your liver swell and stops it from working right. The liver does many things to keep you alive. The liver fights infections and stops bleeding. It removes drugs and other poisons from your blood. The liver also stores energy for when you need it.

What causes hepatitis C?

Hepatitis C is caused by a virus. A virus is a germ that causes sickness. (For example, the flu is a virus.) People can pass viruses to each other.

How could I get hepatitisC?

Hepatitis C is spread by contact with an infected person's blood. 

You could get hepatitis C by：

•    Sharing drug needles

•    Getting pricked with a needle that has infected blood on it (hospital workers can get hepatitis C this way)

•    Having sex with an infected person

•    Being born to a mother with hepatitis C

•    Getting a tattoo or body piercing with dirty tools 

You can NOT get hepatitis C by:

•    Shaking hands with an infected person

•    Hugging an infected person

•    Kissing an infected person

•    Sitting next to an infected person

Could I get hepatitis C from a blood transfusion?

Before 1992, doctors could not check blood for hepatitis C, and some people received infected blood. If you had a blood transfusion or organ transplant before 1992, ask a doctor to test you for hepatitis C. All blood is tested now so you can no longer get hepatitis C from a blood transfusion.

What are the symptoms of hepatitisC?

Many people with hepatitis C do not have any symptoms. However, some people with hepatitis C feel like they have the flu. 

So, you might:

•    Feel tired

•    Feel sick to your stomach

•    Have a fever

•    Not want to eat

•    Have stomach pain

•    Have diarrhea

Some people have:

•    Dark yellow urine

•    Light-colored stools

•    Yellowish eyes and skin

 If you have symptoms or think you might have hepatitis C, talk with your doctor.

What are the tests for hepatitis C?

To check for hepatitis C, the doctor will test your blood. If this test shows that you have hepatitis C, the doctor will do other blood tests to find out how much of the virus is in your blood stream and what type of hepatitis C virus you are carrying.

How is hepatitis C treated?

Treatments for hepatitis C are getting better. Until recently, the usual treatment was a blend of shots (interferon) and pills that caused unpleasant side effects. Now, there are new treatments options available that will work for most people. With these new treatments, you take one pill once a day for as little time as 8 weeks. There are no shots. Ask your health care provider what treatment will work best for you.

How can I protect myself?

You can protect yourself and others from hepatitis C.

•    If you inject drugs, use your own needles. Do not share needles with anyone

•    Wear gloves if you have to touch anyone’s blood

•    Always use a latex condom when you have sex

•    Don't use an infected person’s toothbrush, razor, or anything else that could have blood on it

•    If you get a tattoo or body piercing, make sure it is done with clean tools

•    If you have hepatitis C, do not donate your blood or plasma. The person who receives it could become infected with the virus

Here are some places to find out more about hepatitis C:

What causes a head injury?

A head injury is most often caused by a blow to the head. This may occur from a fall, bicycle injury, sports injury, being struck in the head, or a motor vehicle accident. 

What are the symptoms of a head injury? 

You may have an open wound, swelling, or bruising on your head. Right after the injury, you may be confused. Symptoms may last anywhere from a few hours to a few weeks. You may have any of the following: 

•    Mild to moderate headache

•    Dizziness or loss of balance

•    Nausea or vomiting

•    Change in mood, such as feeling restless or irritable

•    Trouble thinking, remembering, or concentrating

•    Ringing in the ears or neck pain

•    Drowsiness or decreased amount of energy

•    Trouble sleeping

How is a head injury diagnosed? 

•    Tell your doctor about your injury and symptoms. The doctor will do an exam to check your brain function. He or she will check how your pupils react to light. He will check your memory, hand grasp, and balance

How hard should I exercise?

There are no general rules about how many pounds you should lift or how steep a hill you must climb to reach a moderate or vigorous level of exercise. What is easy for one person will be strenuous for another.

The best advice is to listen to your body. If you are gasping for breath and ready to keel over, you are working too hard! If you feel as calm and comfortable  as you would taking a stroll in the park, you are not working hard enough! When you are exercising at a moderate rate, you will feel that you are challenging yourself, but you will not feel close to your limit.

One way to tell how hard you are working is to use the Borg Exercise Perception Scale, shown here:

The numbers on the left of the scale do not mean how many times or how many minutes you should do an activity. They help you describe how hard you are working.

For endurance(aerobic)activities, such as brisk walking or swimming, you should work your way up to level13 -the feeling that you are working some what hard. Some people might feel that way when they are walking on flat ground. Others will feel that way when they are jogging up a hill. Both are right. Only you know how hard your exercise feels to you.

Strength-building exercises, such as lifting weights, are higher on the Borg scale. Gradually work your way up to level 15 to 17 -hard to very hard - to build muscle effectively. You can tell how hard an effort you are making by comparing it to your maximum effort. How hard does it feel compared to when you are lifting the heaviest weight you can lift？Once you start exerting more than a moderate amount of effort in your muscle - building exercises, your strength is likely to increase quickly. As your body adapts and you become fit, you can make your activities more challenging, a little bit at a time.

What does Target Heart Rate mean?

You may have heard something about a Target Heart Rate. This is another way of measuring how hard you are working when you exercise. Your target heart rate, based on your age and fitness level, is somewhere between 50% and 75% of your maximum heart rate, the hardest your heart can work.

To find out what your maximum heart rate is, subtract your age from 220. You do not want to work your heart to its maximum. So, depending on your fitness level, aim for a target heart rate somewhere between 50% and 75% of your maximum heart rate. So, for instance, the maximum rate for a 55 year old is 165 and the target rate is between 82 (50%) and 123(75%).

To find out whether you are working within your target range, you measure your pulse as you exercise. To measure your pulse, place two fingers on the side of your neck or on the inside of your wrist, wherever it is easier for you to feel a pulse. Using a clock or a watch with a second hand, count your pulse for 10 seconds. Then, multiply the number you get by 6 to come up with your heart rate per minute.

Does the target heart rate work for everyone?

No. Target heart rates are general guidelines for average healthy people. Some 55-year-old individuals will have a higher target heart rate and others will have a lower target heart rate than the one listed above. People with a chronic illness are better off using the Borg scale to measure how hard they work when they exercise. The same goes for people who are stronger and more fit than others their age.

A very simple way to tell how hard you are working when you exercise is something called ''the talk test.'' If you can talk while you exercise, you are working in the moderate range. If you get out of breath when you try to talk, you are working too hard. On the other hand, if you can sing while you exercise, you are not working hard enough.

Should I talk to my doctor about starting a new exercise program?

Men over 40, women over 50 and anyone with a history of heart disease should discuss any new exercise program with the doctor before they start. Some medicines alter heart rate and blood pressure. They can change the way your body responds to exercise. If you are taking any heart medicines or high blood pressure medicines, ask your doctor whether you need to use a lower target heart rate when you exercise.

This document is intended to provide health related information so that you may be better informed. It is not a substitute for your care team's medical advice and should not be relied upon for treatment for specific medical conditions.

© 2017 The General HospitalCorporation.

Primary Care Office lnSite

developed by the MGH Laboratory of Computer Science and Division of General Internal Medicine

What is an epidural steroid injection?

An epidural steroid injection can help relieve pain in the neck, arm, low back and leg (sciatica) caused by swelling and irritation of the spinal nerves. An epidural steroid injection involves bathing the irritated spinal nerves with steroid (anti-inflammatory medication) and a local anesthetic (numbing medication). During this treatment, medication is placed into the epidural space, where the spinal nerves exit the spine. If the pain is significantly improved after the injection, no further injection is usually needed. Pain relief may be very long-lasting. However, it is not unusual to need more than one injection to get pain relief and/or longer benefit.

What is the goal of epidural steroid injection?

The goal is to provide pain relief so that you are able to resume normal activities. In many cases, we will prescribe a course of physical therapy to help you return to a normal level of activity.

What happens before treatment? 

You will be escorted to a room where a nurse will conduct a pre-procedure interview. The physician who will perform the injection will review your medical history, previous imaging studies, physical exam and current medications to help plan the best approach for the injection.

What happens during the treatment? 

The patient remains awake during the entire process. Blood pressure, heart rate and breathing are continually monitored. Lying face down on the procedure table the injection site is cleansed with an antiseptic. This procedure involves inserting a needle through the skin, muscle and soft tissues, so there is some discomfort involved. An injection of local anesthetic (numbing medication) will be administered in the area where you are experiencing pain. The physician then directs a needle with the use of x-ray guidance and deposits the medication. This procedure takes approximately 30minutes.

©2008,MASSACHUSETTS GENERAL HOSPITAL CENTER FOR PAIN MEDICINE

What is Achilles tendinitis? Achilles tendinitis is swelling of the tendon that connects your calf muscle to your heel bone. It may happen suddenly or become a chronic condition. Your risk for Achilles tendinitis increases as you age.

What causes Achilles tendinitis?

•    Overuse of your leg muscles

•    A sudden increase in the amount or intensity of an activity

•    Jumping or running on hard or uneven surfaces

•    Wearing shoes that do not fit or support your foot and ankle

•    Tight calf muscles

•    A bone spur where your Achilles tendon attaches to your heel

•    Medicines such as steroids or antibiotics

What are the signs and symptoms of Achilles tendinitis?

•    Pain in your heel that gets worse with activity

•    Swelling in your heel or calf

•    Stiffness in your heel or calf

How is Achilles tendinitis diagnosed?

Chronic neck pain may start to build slowly over time. Neck pain is chronic if it lasts longer than 3 months. The pain may come and go, or be worse with certain movements. The pain may be only in your neck, or it may move to your arms, back, or shoulders. You may have pain that starts in another body area and moves to your neck. You may have neck pain for years. Some types of neck pain can be permanent.

What causes or increases my risk for chronic neck pain?
Chronic neck pain is often caused by a joint or disc problem in the neck. Any of the following can cause neck pain:

•   Stenosis (narrowing) of your spinal column, or degeneration (breakdown) or inflammation of the discs in your neck