1. Nutrition Teresa V. Hurley. MSN, RN

2. Factors Affecting Food Habits Physical — –geographic location, –food technology, –income Physiologic — –health, – hunger – stage of development Psychosocial — –culture, –religion, –tradition, –education

3. Psycho/Social

4. Developmental

5. Human Growth and Development Infants through School-Age -rapid growth with high protein, vitamin, mineral and energy demand; infant doubles birth weight in 4-5months; triples weight at 1 year Breast Feeding encouraged -reduces allergy risks What other factors?

6. Infants Formula Cow’s milk causes GI bleeding Kidney’s unable to handle Research: milk in 1st and the development of Type I Diabetes later in life Honey and corn syrup maybe be source of botulism

7. Introduction of Solid Food 4 to 6 months of age Introduce one at a time 4 to 7 days apart to identify allergies

8. Toddlers Picky eaters around 18 months of age 3 meals and 3 snacks Calcium and phosphorous for bone growth Hot dogs, candy, nuts, grapes, raw veggies, popcorn frequently lead to choking deaths

9. School Age Growth slower and steadier Check for protein, vitamins A and C High fat, sugar and salt intake lead to childhood obesity compounded by sedentary lifestyle

10. Adolescents Energy needs increase to meet the increase metabolic demands of growth protein., calcium, iron (females) and muscle growth (males) Fad dieting, oral contraceptive use, fast foods, skipping meals Eating disorders anorexia nervosa and bulimia nervosa

11. Young and Middle-Age Energy demands less Fetal development affected by mother’s nutritional status and weight at time of conception; protein, calcium, iron, folic acid Lactation: protein, calcium, Vitamins A, C, B; avoid caffeine, alcohol and drugs

12. Older Adults Lifestyle Income Lack of teeth, dentures, thirst sensation less with resultant dehydration (confusion, weakness, hot dry skin, rapid pulse Nutrient dense foods: peanut butter, cheese, eggs, cream and meat-based soups

14. Cultural

15. Alternative Food Patterns Vegetarian –Ovolactovegetarian (no meat, fish and poultry but will have milk and eggs) –Lactovegetarians (drink milk but no eggs) –Vegans (plant foods) -A Zen vegan eats brown rice, grains, herb teas -Fruitarians eat only fruits, nuts, honey and olive oil

16. Religious Dietary Restrictions Islam (no pork, caffeine, ritual slaughter of animals; Ramadan fasting sunrise to sunset for a month) 7 th day Adventists (no pork, shellfish, alcohol, vegetarianism encouraged) Hinduism (no meats) Latter Day Saints (no alcohol, tobacco, caffeine)

17. Risk Factors for Poor Nutritional Status Developmental factors State of health Alcohol abuse Medications Megadoses of nutrient supplements

18. Anorexia -poor appetite related to ketosis an appetite suppressant Surgical Procedures with resultant pain Diagnostic testing (NPO, bowel evacuations)

19. Promoting Appetite Keep environment free of odors Oral hygiene Insulin, glucosteriods, thyroid hormones affect metabolism Antifungals alter taste Psychotropics affect appetite, nausea, alter taste

20. Nursing Interventions Risk for Aspiration –Assess LOC –Decrease or absent gag or cough reflex –Surgical procedures –Neuromuscular impairments –Sensory impairments

21. Nursing Interventions Upright position Food placed stronger side of mouth Thickening agents Rate of eating slower to provide for chewing and swallowing Use clock as guide to identify food location for visually impaired Use assistive devices (padded forks, spoons etc)

22. Nursing Interventions Client to direct order and preferences of food items to eat

23. Therapeutic Diets NPO nothing by mouth Clear Liquid: broth, bouillon cubes, tea, carbonated beverages, clear fruit juices, popsicles Full Liquid: add to clear liquid diet smooth textured dairy products as custard, refined cooked cereals, pureed veggies, all fruit juices

24. Diets Continued Pureed ( continue to add to the previous) scrambled eggs, pureed meats, veggies, fruits, mashed potatoes and gravy Mechanical Soft (add to the previous) ground or diced meats, flaked fish, cottage cheese, cheese, rice, potaotes, pancakes, light breads, cooked vegetables and fruits, canned fruits, bananas, soups, peanut butter

25. Diets Continued Soft Low Residue: add pastas, casseroles, moist tender meats, canned cooked fruits and vegetables, desserts, cakes, cookies without nuts or coconut High Fiber: add fresh uncooked fruits, steamed veggies, bran, oatmeal, dried fruits Low Sodium: 4g (no added salt) 2gm to 500mg Na diets require selective choices

26. Medications Stimulate appetite –Periactin –Megace –Marinol’

27. Diets Continued Low Cholesterol 300mg/day in accordance with AHA guidelines for serum lipid reduction Diabetic: Food exchanges with balanced intake of protein, CHO and fats and vary according to energy demands as exercise, pregnancy, illness Regular NO restrictions

28. Enteral Nutrition Short-term nutritional support –Nasogastric –nasointestinal route Long-term nutritional support –Enterostomal tube created into stomach (gastrostomy) –Percutaneous endoscopic gastrostomy (PEG) jejunum (jejunostomy)

29. Enteral Nutrition (EN) Nutrients given via the GI tract Formula given via NGT,PEG, PEJ Initial tube placement verified by x-ray which is the most accurate indicator Traditional Method for placement –Measure distance from tip of nose to earlobe to xiphoid process of sternum –Water soluble lubricant –Insert through naris toward posterior nasopharynx –Flex head toward chest after passage through posterior nasopharynx –Have client mouth breathe and swallow small sips of water –Stop advancing if client choking, coughing, cyanotic

30. Types of Tubes Naso-Gastric Salem Sump

31. Types of Tubes Gastrostomy TubeJejunostomy Tube

32. Tube Placement

33. Evidence Based Research X-ray verification most accurate X-ray method not feasible, the next best method is pH testing of gastric aspirate with readings between 0-4. pH of 6 or more placement in lung, intestine Ausculatory method should not be used but in some agencies still in use

34. Gastrostomy or Jejunostomy Tube HOB elevated 45 degrees Auscultate for bowel sounds Verify placement by testing pH of gastric aspirate Check gastric residual –If over 100 ml notify MD –Would you replace the gastric contents? –Would you stop the feeding?

35. Some Complications of Feeding Aspiration Tube displacement Cramping from using cold formula Diarrhea Impaired skin integrity Nosocomial infections

36. Parenteral Nutrition Total parenteral nutrition (TPN) Partial parenteral nutrition (PPN)

37. Total Parenteral Nutrition TPN- Total Parenteral Nutrition complete form of nutrition – protein –CHO – fat – vitamin –minerals =

38. Indications for TPN Inability to eat –Ventilator dependency –Additional surgery –Altered mental status affecting ability to eat Diminished nutrient intake –Anorexia –Dyspepsia from medications –Gastrointestinal problems including nausea, vomiting, diarrhea, and distention Increased nutrient requirements –Hyper metabolism –Nitrogen loss caused by surgery and corticosteroid administration –Malabsorption

39. TPN ACCESS DEVICES

40. Complications of Parenteral Nutrition Insertion problems Infection Metabolic alterations Fluid, electrolyte, and acid-base imbalances Phlebitis

41. PN Complications Electrolyte and Mineral imbalances: refeeding syndrome -high concentrations of glucose leads to endogeneous insulin production which leads to -cations moving from inter to intracellular (potassium, magnesium and phosphorus) which leads to cardiac dysarrthymias, CHF. Respiratory distress, convulsions, coma, death

42. Complications of PN Rapid administration of hypertonic dextrose leads to osmotic diuresis and dehydration –DO NOT SPEED UP IF BEHIND –DO NOT STOP LEADS TO HYPOGLYCEMIA

43. Glucose Testing Diabetes is a metabolic disorder –Inadequate insulin production by pancreatic beta cells or –Insulin resistance whereby glucose unable to cross sell membrane Cellular starvation Fluid and electrolyte imbalances

44. Diabetes Hypoglycemia: pancreas secretes glucagon Hyperglycemia: pancreas secretes insulin –Polyuria –Polydyspia –Polyphagia –Glycosuria –Ketones

45. Hypoglycemia Rapid onset with BS 80 or below Cool, pale, diaphoretic skin Disorientation---coma Shaky, dizzy, agitated Pulse maybe tachy B/P maybe high Seizures common Treat with PO or IV Glucose

46. Hyperglycemia Gradual onset with BS 200 or above Skin warm, dry, flush Awake, lethargic Hungry, blurred vision Deep, rapid respirations Pulse, weak, rapid B/P maybe low Breath: fruity odor Dehydrated Polyuria Polydyspia Treatment: IV, insulin and K

47. Glucose Monitoring ac and at hs Range 70-110 mg Insulin Coverage –Regular Insulin (Rapid Acting) 3-4 hr –NPH/reg (Fast Acting) 30 min---24hr –Lente, NPH (Intermediate Acting) 1-3 hr---18- 28 hr –Ultra-lente(Long Acting) 4-6 hr---36 hr