1. Bonnie M. Wivell, MS, RN, CNS
Chapter 44: Nutrition
Bonnie M. Wivell, MS, RN, CNS

2. Scientific Knowledge Base: Nutrients
Carbohydrates
Starches and sugars
Fiber
Proteins
Amino acids
Fats
Saturated, monounsaturated, and polyunsaturated
Water
Cells depend on a fluid environment
Vitamins
Essential to metabolism
Water or fat soluble
Minerals
Catalysts for biochemical reactions
The body requires fuel to provide energy
for cellular metabolism and repair,
organ function, growth, and
body movement.
2. The basal rate (BMR) is the energy needed to maintain breathing, circulation, heart rate, and temperature.
3. What is resting metabolic rate (AKA Resting energy expenditure)?
Amount of energy an individual needs to consume over a 24-hour period for the body to function normally while at rest.
Nutrients are the elements needed for body processes and functions.
Fat-soluable vitamins: A, D, E and K
Water-soluable vitamins: C and B complex

3. Anatomy and Physiology of the Digestive System
Digestion
Begins in the mouth and ends in the small and large intestine
Absorption
Intestine is the primary site for absorption
Metabolism and Storage of Nutrients
Anabolic and catabolic reactions
Elimination
Chyme is moved through peristalsis into the large intestines and turned into feces
Functions of Digestive System (above on chart)
MECHANICAL BREAKDOWN
CHEWING, CHURNING, MIXING OF FOOD
CHEMICAL BREAKDOWN
FOOD REDUCED TO SIMPLEST FORM USING ENZYMES
Enzymes
Catalysts to speed up chemical reactions. The food mass in liquefied form is called chyme.
3.Peristalsis - food moves through the GI tract
Absorption uses the processes of
active transport – energy dependent, move from lesser concentration to greater concentration
passive diffusion – greater concentration to lesser concentration
Osmosis – movement through a membrane
pinocytosis – engulfing large molecules of nutrients by the absorbing cell
Approximately 8.5 L of GI secretions and 1.5 L of oral intake is managed daily within the GI tract. The small intestines reabsorbs 9.5 L and the colon absorbs approximately 0.4 L. The remaining 0.1 L is eliminated in the feces
Anabolism is the building of more complex biochemical substances by synthesis of nutrients
Catabolism is the breakdown of biochemical substances into simpler substances and occurs during physiological states of negative nitrogen balance (example: starvation)
Metabolic reactions include
Glycogenolysis – catabolism of glycogen into glucose, carbon dioxide, and water
Glycogenesis – anabolism of glucose into glycogen for storage in liver
Gluconeogenesis- catabolism of amino acids and glycerol into glucose for energy
As feces move toward the rectum, water is absorbed in the mucosa. The longer the material stays in the large intestines, the firmer the feces. Feces contains cellulose, indigestible substances, GI tract cells, digestive secretions, water, and microbes.

4. Dietary Guidelines Food guidelines Daily values
Dietary Reference Intakes
Acceptable range of amounts of vitamins and minerals to avoid deficiencies for age and gender groups
Food guidelines
Food Pyramid Guide, basic guide for meal preparations
Daily values
Needed protein, vitamins, minerals, fats, cholesterol, carbohydrates, fiber, sodium, and potassium
The Food Pyramid appears in print, on food packages, and in TV ads.
The US Department of Agriculture and the US Department of Health and Human Services publish the Dietary Guidelines (see Box 44-3).
3. Students need to be cognizant of the needs of the young, the old, and the culturally diverse to ensure that these populations receive the nutrients necessary to meet their needs.

5. Nutrition During Growth & Development
Infants: as they grow they need protein, vitamins, and minerals; high growth rate
Toddlers: small, frequent meals; picky eaters; need fewer calories, higher protein
School-age: Don’t eat the required nutrients; growth spurts
Adolescents: concerned with body image
Young and middle adults: reduced need for nutrients as their growth periods end
Older adults – decreased need for calories
Each one of these groups has specific needs.
Infants are breast fed or put on formula. Between 4 to 6 months, infants are introduced to solid foods.
Toddlers (1 to 3 years) eat up to 6 times a day, with small frequent meals. They soon become picky eaters.
School-age children (6 to 12 years) often do not eat the required nutrients. They are prone to a diet high in fat, sugar, and salt because of their fondness for fast foods and snacks; GROW AT A SLOW STEADY PACE; DECLINE IN ENERGY REQUIREMENTS; GROWTH SPURTS
Adolescents are concerned with their body image.
Anorexia nervosa and bulimia nervosa.
The main nutritional source for this group is carbohydrates both simple and complex.
MAY HAVE MET GROWTH POTENTIAL (FEMALES)
BASE NEEDS ON PHYSIOLOGICAL AGE RATHER THAN CHRONOGICAL AGE
STILL HAVE HIGH CALORIC NEEDS TO MEET CHANGES IN METABOLISM
EATING DISORDERS MAY ARISE
5. Young and middle adults have a reduced need for nutrients as their growth period ends.
Obesity may become a problem due to decreased physical exercise.
Pregnancy and lactation puts additional demands on women.
6. Older adults have a decreased need for calories as their metabolic rate slows. VITAMIN AND MINERAL REQUIREMENTS DO NOT CHANGE
Avoid grapefruit and grapefruit juice because these will decrease absorption of many drugs
S/S of dehydration: confusion, weakness, hot dry skin, furrowed tongue, rapid pulse, and high urinary sodium

6. Factors Affecting Nutritional Status
Age-related GI changes
Changes in teeth and gums
Reduced saliva production
Atrophy of oral mucosal epithelial cells
Increased taste threshold
Decreased thirst sensation
Reduced gag reflex
Decreased esophageal and colonic peristalsis
Presence of Chronic Illness
Malnutrition
Adverse affects of meds
Cognitive impairment
AVAILABLE FOOD (money)
ABILITY TO EAT
ABILITY TO ABSORB
ABILITY TO METABOLIZE
ABILITY TO EXCRETE

7. Alternative Food Patterns
Based on religion, cultural background, ethics, health beliefs, preference
Vegetarian diet:
Ovolactovegetarian: eat eggs and milk
Lactovegetarian: drink milk but avoid eggs
Vegans: consume no animal products of any kind
Fruitarian: eat only fruit, nuts, honey and olive oil
Zen Macrobiotic
Eat brown rice, other grains, & herb teas
1, Vegetarian diets – Plant food – are nutrient poor – lack complete proteins
Ovolactovegetarian: avoid meat, fish and poultry but eat eggs and milk
Students need to consult with dieticians to ensure that clients receive the nutrients needed for recovery and rehab.
See Table 44-2 for religious dietary restrictions.
Children following vegetarian diet especially at risk for protein and vitamin deficiencies such as Vit B12

8. Assessment
Nurses are in an excellent position to recognize signs of poor nutrition
Pts who are malnourished are at greater risk of life-threatening complications during hospitalization such as arrhythmia, sepsis, hemorrhage
A nutritional assessment is more than taking a diet history
Screening
Some prescription drugs, many over-the-counter drugs, and herbal/natural therapy can affect a client’s nutritional state.
It is also important to know food interactions and medication administration – see table 44-2 on pages
Especially be aware of interactions between milk and citrus fruits or juices and alcohol.

9. Assessment Continued
Anthropometry = a systematic measurement of the size and makeup of the body at specific body sites
Laboratory and biochemical tests
CBC, albumin, pre-albumin transferrin (transferrin is a blood plasma protein for iron), electrolytes, BUN, creatinine, glucose, cholesterol, triglycerides, and retinol (form of Vitamin A).
Dietary and health history
Physical examination
Dyphagia (difficulty swallowing)
s/s of dysphagia
Silent aspiration
Aspiration precautions – see pg 1103

10. Nursing Diagnosis and Planning
Select from the NANDA-I–approved list after assessment
Plan outcomes and goals to assist client’s needs
Improving a client’s diet takes care and planning
Imbalanced nutrition – more than body requirements OR less than body requirements
NIC – nutritional counseling (coordinate plan of care with healthcare provider, individualized menu, teach about food pyramid, nutritional monitoring by monitor wt, anemia, serum albumin levels and total lymphocyte count (indicators of nutritional level)
Risk for aspiration
Constipation
Diarrhea
Health-seeking behaviors
Deficient knowledge
Risk for imbalanced nutrition
Feeding self-care deficit
Example Diagnosis:
AT RISK FOR IMBALANCED NUTRITION R/T INTAKE LESS THAN BODY REQUIREMENTS AS EVIDENCED BY INABILITY TO SWALLOW
Example Goals:
PATIENT WILL REFLECT NOT LOSE WEIGHT OVER THE NEXT THREE DAYS
PATIENT WILL HAVE LABORATORY VALUES WITHIN NORMAL LIMITS WITH DAILY MONITORING

11. Implementation
Ill, debilitated, and recovering clients often have poor diets
Socioeconomic, psychosocial, and environmental factors can contribute to a poor diet
Advancing diets – see Box 44-10
Promoting appetite
Clean and odor free environment
Oral hygiene
Social time
Music therapy
NURSE WILL FOLLOW DIETICIAN RECOMMENDED ENTERAL FEEDING
NURSE WILL WEIGH PATIENT AT 6AM DAILY
NURSE WILL MONITOR LAB VALUES DAILY

12. Implementation Continued
Make sure clients can feed themselves, can swallow and are positioned properly
If clients have visual difficulties, they may need assistance with feeding. You can also help clients by telling them where food is placed, according to the face of a clock (e.g., peas at 3 o’clock)

13. Enteral Tube Feeding Nasogastric Nasointestinal Gastrostomy
Jejunostomy
PEG
PEJ
Video
1. Enteral feeding delivers nutrition directly into the GI tract through a small bore feeding tube or a G-Tube. This is a preferred method for providing nutrients.
Indicators for tube feedings – cancers, trauma, neruological and muscular disorders (ALS), GI disorders, Respiratory failure with prolonged intubation, Extended bowel rest, preoperative TPN
Types of formulas include:
Milk based, blenderized
Protein glucose, polymers or lipids
Predigested nutrients
Specialty formulas
PEG - percutaneous (through the skin) endoscopic gastrotomy (stomach tube).
PEJ – percutaneous endoscopic jejunostomy tube
Each one of these methods to administer EN has specific indications, assessments, and precautions. You will follow hospital policy and procedures. You will learn how to care for and assess tubes in the nursing skills lab.

17. INSERTING THE FEEDING OR ASPIRATING TUBE
ASSEMBLE EQUIPMENT
EXPLAIN PROCEDURE TO PATIENT
MEASURE TUBE
INSERT (will practice in lab)
INSERT 20ml AIR TO COMFIRM PLACEMENT
ASPIRATE 5ml OF GASTRIC CONTENTS TO TEST pH
Discuss medication administration
Bolus feedings vs infusion feedings
IS PATIENT TOLERATING TUBE FEEDING?
ASSESS FOR NAUSEA AND EMESIS
Q4h ASSESS RESIDUAL IN STOMACH
SHOULD NOT BE ABLE TO WITHDRAW MORE THAN 2 HOURS OF FEEDING AFTER 4H.
RETURN ASPIRATE TO PATIENT (USUALLY)

24. Enteral Tube Feeding Complications
Aspiration
Diarrhea
Constipation
Tube occlusion
Tube displacement
Abd. Cramping, nausea, vomiting
Delayed gastric emptying
Electrolyte imbalance
Fluid overload
Hyperosmolar dehydration

25. Total Parenteral Nutrition
Specialized nutrition support in which nutrients are provided intravenously
Must be infused via a central catheter
Average 50% Dextrose solution + Amino acids, vitamins, minerals, electrolytes
Lipids (Fat Emulsion) provide supplemental kilocalories and prevent essential fatty acid deficiencies
Administered to clients who are unable to digest or absorb enteral nutrition
Can be administered peripherally but will only be 10% Dextrose
Always use an infusion pump
Rate gradually increased
No other fluids can be administered in the same line with TPN
Placement of the line needs to be confirmed by x-ray
Nurses need to provide continuous monitoring, assessments, and documentation.
NUTRITIONALLY ADEQUATE SOLUTION
PRESCRIBED FOR PATIENTS THAT ARE:
MALNOURISHED
UNABLE TO EAT
NEED SUPPLEMENTAL NUTRITION

28. Complications From Total Parenteral Nutrition
Catheter occlusion
Catheter infection
Electrolyte imbalance
Hypo/hyperglycemia
HHNC (Hperglycemic Hyperosmolar Nonketotic Coma)

29. Medical Nutrition Therapy
GI diseases
PUD
H. Pylori
Inflammatory bowel disease
Malabsorption syndromes (celiac disease)
Diverticulitis
DM (American Dietetic Association)
CV Disease (American Heart Association)
Cancer
HIV

30. Evaluation To measure the effectiveness of nutritional interventions
To ascertain if client has met goals and outcomes
To amend nursing interventions