1. Nutrition Vema Sweitzer, MN, RN 1

2. Independent learning – The factors influencing Nutrition of the older adults (pg 1003) – The five components of a nutrition assessment: Screening for malnutrition for risk factors Anthropometry BMI Labs and tests Dietary history 2

3. Nursing Knowledge Base Factors influencing nutrition – Environmental factors – Developmental needs Infants through school age Adolescents Young and middle adults Older adults 3 Page 1002

4. Alternative Food Patterns Based on religion, cultural background, ethics, health beliefs, and preference (Table 44-3), Vegetarian diet consists predominantly of plant foods 4

5. Assessment Screening a patient is a quick method of identifying malnutrition or risk of malnutrition using sample tools: – Height – Weight – Weight change – Primary diagnosis – Comorbidities – Screening tools Combine multiple objective measures with subjective measures r/t nutrition to adequately screen for nutritional problems. 5

6. Assessment Assess patients for malnutrition – Conditions that interfere with their ability to ingest, digest, or absorb adequate nutrients. – Congenital anomalies and surgical revisions of the GI tract – Only IV therapy – Chronic diseases or increased metabolic requirements – Infants and older adults are at great risk 6

7. Assessment – An ideal body weight (IBW) provides an estimate of what a person should weigh. – Body mass index (BMI) measures weight corrected for height and serves as an alternative to traditional height-weight relationships. Laboratory – Albumin: 3.5-5.0 g/dL (half life 21 days) – Transferrin and total iron-binding capacity (TIBC) – Hemoglobin (12-18%) – Prealbumin (half life 1.9 days) 7

8. Assessment Dietary and health history – Health status; age; cultural background; religious food patterns; socioeconomic status; personal food preferences; psychological factors; use of alcohol or illegal drugs; use of vitamin, mineral, or herbal supplements; prescription or over-the-counter (OTC) drugs; and the patient’s general nutrition knowledge Physical examination Dysphagia (difficulty swallowing) 8

9. Dysphagia Dysphagia refers to difficulty swallowing. 9

10. Acute Care The nutritional care of acutely ill patients requires monitoring. – Patients are interrupted at meal time – NPO status – Poor appetites – Fatigued or feel uncomfortable – Patient who are NPO and receive only IV fluids for more than 4-7 days are at nutritional risk. page 1016 10

11. Advancing Diets Clear liquids: broth, coffee, tea, clear soda & juice, jello, popsicle Full: above + smooth dairy Pureed: above + scrambled eggs, pureed meat – vegetables –fruits, mashed potatoes Mechanical soft: above + diced meats, flaked fish, cottage cheese, rice, potatoes, etc. Soft/low residue: low fiber foods, pasta, tender meat, canned fruits/vegetables Box 44-10 pg 1017 11

12. Nutrition: Types of Diets High fiber: fresh fruit, steamed vegetables, bran, oatmeal, dried fruit Low sodium: 4 g, 2 g, 1 g Low cholesterol: 300 mg/day Diabetic: usually 1800 cal/day Regular: no restrictions In your learning group, identify the Nursing Diagnosis and outcome for a patient who is eating poorly.

13. Enteral Tube Feedings Enteral nutrition (EN) provides nutrients into the GI tract. Feedings are provided for patients who can not swallow and have a functioning GI tract. Feedings can be delivered through a nasogastric (NGT), jejunal (JT) or gastric tube (GT). 13

14. Enteral Tube Feedings Procedure: Start at full strength Slow rate Increase every 8-12 hours as ordered Assess for signs of intolerance High gastric residuals, nausea, cramping, vomiting and diarrhea Assess for complications Aspiration, Diarrhea, Bacterial contamination, Tube occlusion, delayed gastric emptying 14

15. Tube Placement The most reliable method for verification of placement of small-bore feeding tubes is x-ray film examination. Check pH of gastric aspirate, < 4 Observe aspirate color Do not use auscultation method 15

16. Parenteral Nutrition Parenteral nutrition (PN) is a form of specialized nutrition support in which nutrients are provided intravenously. A basic PN formula is a combination of amino acids, hypertonic dextrose (10-50%), electrolytes, vitamins, and trace elements. Fat emulsions: provides calories and fatty acids – Delivered through Central venous catheter Peripheral line pg 1021 16

17. Parenteral Nutrition If using a CVC that has multiple lumens, use a port that is exclusively dedicated for the TPN. Label it! Verify the HCP’s order Inspect the solution for particulate matter Always use an infusion pump First 24-48 hrs: delivers 50% of estimated needs and then rate has will be increased 17

18. Parenteral Nutrition: Complications Catheter-related Problems – Pneumonthorax Sudden sharp chest pain, dyspnea, and coughing Monitor for 24 hrs – Air embolus Occurs during insertion of the catheter or when changing the tubing or cap. Turn pt to left side and have pt perform a Valsalva maneuver (hold breath and bear down during catheter insertion to help prevent air embolus Keep IV system closed 18

19. Parenteral Nutrition: Complications Catheter-related Problems – Catheter occlusion If sluggish or no flow, stop infusion and flush with NS or heparin (per protocol). Attempt to aspirate clot or follow protocol for thrombolytic agent (urokinase) – Sepsis Fever, chills, or glucose intolerance and positive blood culture Change tubing q 24 hrs Hang bag for only 24 hr; lipids 12 hrs Check to see if solution needs a filter 19

20. Parenteral Nutrition: Complications Metabolic alterations – Electrolyte and mineral imbalances – Hyperglycemia Thirst, HA, lethargy, increased urination. Monitor BS q 6 hrs Give insulin – Hypoglycemia Diaphoresis, shakiness, confusion, loss of consciousness Do not abruptly discontinue TPN Taper rate Give IV bolus of dextrose – Dehydration 20