1. Chapter 45
Nutrition
Nutrition is a basic component of health and is essential for normal growth and development, tissue repair and maintenance, cellular metabolism, and organ function.
The human body needs an adequate supply of nutrients for essential functions of cells.
Food security is critical for all members of a household. This means that all household members have access to sufficient, safe, and nutritious food to maintain a healthy lifestyle. Household members have sufficient food available on a consistent basis and the resources to obtain appropriate food for a nutritious diet.
Medical nutrition therapy (MNT) uses nutrition therapy and counseling to manage diseases.
The U.S. Department of Health and Human Services (USDHHS) and the Public Health Service established nutritional goals and objectives for Healthy People Healthy People 2020 is the United States’ contribution to the “Health for All” strategy of the World Health Organization.
[Review Box 45-1, Examples of Nutrition Objectives for Healthy People 2020, with students.]
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2. Case Study
Mrs. Gonzalez is a 65-year-old Hispanic woman who comes to the emergency department with slurred speech, right facial droop, and weakness in her upper and lower right-side extremities. She is admitted to the hospital with a diagnosis of acute stroke.
She has a daughter and two teenage grandchildren who live in another town nearby.
[Ask students: What special nutritional needs will Mrs. Gonzalez face during her recovery? Discuss.]
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3. Nutrients: The Biochemical Units of Nutrition
Basal metabolic rate (BMR)
Energy needed at rest to maintain life-sustaining activities for a specific amount of time
Resting energy expenditure (REE)
Amount of energy needed to consume over 24-hour period for the body to maintain internal working activities while at rest
Nutrients
Energy necessary for the normal function of numerous body processes
Factors such as age, body mass, gender, fever, starvation, menstruation, illness, injury, infection, activity level, and thyroid function affect energy requirements.
Factors that affect metabolism include illness, pregnancy, lactation, and activity level.
When the kilocalorie (kcal) of the food we eat meets our energy requirements, our weight does not change (Nix, 2012). When the kilocalories ingested exceed our energy demands, we gain weight. Likewise, if the kilocalories ingested fail to meet our energy requirements, we lose weight.
We meet energy needs through a variety of nutrients: carbohydrates, proteins, fats, water, vitamins, and minerals. The nutrient density of food refers to the proportion of essential nutrients to the number of kilocalories. High–nutrient dense foods such as fruits and vegetables provide a large number of nutrients in relationship to kilocalories. Low–nutrient-dense foods such as alcohol or sugar are high in kilocalories but nutrient poor.
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4. Nutrients: The Biochemical Units of Nutrition (Cont.)
Carbohydrates
Complex and simple saccharides
Main source of energy
Proteins
Amino acids
Necessary for nitrogen balance
Fats
Saturated, polyunsaturated, and monounsaturated
Calorie-dense
Carbohydrates, composed of carbon, hydrogen, and oxygen, are the main source of energy in the diet.
Each gram of carbohydrate produces 4 kcal/g and serves as the main source of fuel (glucose) for the brain, skeletal muscles during exercise, erythrocyte and leukocyte production, and cell function of the renal medulla. You obtain carbohydrates primarily from plant foods, except for lactose (milk sugar). Carbohydrate classification occurs according to their carbohydrate units, or saccharides.
Monosaccharides such as glucose (dextrose) or fructose do not break down into a more basic carbohydrate unit.
Disaccharides such as sucrose, lactose, and maltose are composed of two monosaccharides and water. The classification of both monosaccharides and disaccharides is as simple carbohydrates; found primarily in sugars.
Polysaccharides such as glycogen make up carbohydrate units too (i.e., complex carbohydrates). They are insoluble in water and digested to varying degrees. Starches are polysaccharides.
The body is unable to digest some polysaccharides because we do not have enzymes capable of breaking them down. Fiber, a polysaccharide, is the structural part of plants that is not broken down by our digestive enzymes. The inability to break down fiber means it does not contribute calories to the diet. Therefore, insoluble fibers are not digestible and include cellulose, hemicellulose, and lignin. Soluble fibers dissolve in water and include barley, cereal grains, cornmeal, and oats.
Proteins provide a source of energy (4 kcal/g), and they are essential for the growth, maintenance and repair of body tissue.
Collagen, hormones, enzymes, immune cells, deoxyribonucleic acid (DNA), and ribonucleic acid (RNA) are all made of protein. In addition, blood clotting, fluid regulation, and acid–base balance require proteins. Proteins transport nutrients and many drugs in the blood. Ingestion of proteins maintains nitrogen balance.
The simplest form of protein is the amino acid, consisting of hydrogen, oxygen, carbon, and nitrogen. Because the body does not synthesize indispensable amino acids we need these to be provided in our diet.
The body synthesizes dispensable amino acids. Examples of amino acids synthesized in the body are alanine, asparagine, and glutamic acid. Amino acids can link together. Albumin and insulin are simple proteins because they contain only amino acids or their derivatives. The combination of a simple protein with a nonprotein substance produces a complex protein such as lipoprotein, formed by a combination of a lipid and a simple protein.
A complete protein, also called a high-quality protein, contains all essential amino acids in sufficient quantity to support growth and maintain nitrogen balance.
Incomplete proteins are missing one or more of the nine indispensable amino acids and include cereals, legumes (beans, peas), and vegetables. Complementary proteins are pairs of incomplete proteins that, when combined, supply the total amount of protein provided by complete protein sources.
Achieving nitrogen balance means that the intake and output of nitrogen are equal. When the intake of nitrogen is greater than the output, the body is in positive nitrogen balance. Positive nitrogen balance is required for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing. The body uses nitrogen to build, repair, and replace body tissues. Negative nitrogen balance occurs when the body loses more nitrogen than it gains (e.g., with infection, burns, fever, starvation, head injury, and trauma). The increased nitrogen loss is the result of body tissue destruction or loss of nitrogen-containing body fluids. Nutrition during this period needs to provide nutrients to put patients into positive balance for healing.
Protein provides energy but, because its essential role is to growth, maintenance, and repair, a diet needs to provide adequate kilocalories from nonprotein sources. When there is sufficient carbohydrate in the diet to meet the body’s energy needs, protein is spared as an energy source.
Fats (lipids) are the most calorie-dense nutrient, providing 9 kcal/g.
Fats are composed of triglycerides and fatty acids.
Triglycerides circulate in the blood and are composed of three fatty acids attached to a glycerol.
Fatty acids are composed of chains of carbon and hydrogen atoms with an acid group on one end of the chain and a methyl group at the other. Fatty acids can be saturated, in which each carbon in the chain has two attached hydrogen atoms; or unsaturated, in which an unequal number of hydrogen atoms are attached and the carbon atoms attach to each other with a double bond.
Monounsaturated fatty acids have one double bond, whereas polyunsaturated fatty acids have two or more double carbon bonds. The various types of fatty acids, referred to in the dietary guidelines have significance for health and the incidence of disease.
We also classify fatty acids as essential or nonessential. Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans. Linolenic acid and arachidonic acid, another type of unsaturated fatty acids, are important for metabolic processes. The body manufactures them when linoleic acid is available. Deficiency occurs when fat intake falls below 10% of daily nutrition. Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids.
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5. Scientific Knowledge Base: Nutrients (Cont.)
Water
All cell function depends on a fluid environment
Vitamins
Essential for metabolism
Water-soluble or fat-soluble
Minerals
Catalysts for enzymatic reactions
Macrominerals; trace elements
Water is critical because cell function depends on a fluid environment.
Water makes up 60% to 70% of total body weight.
Infants have the greatest percentage of total body water due to greater surface area, and older people have the least. When deprived of water, a person usually cannot survive for more than a few days.
We meet our fluid needs by drinking liquids and eating solid foods high in water content such as fresh fruits and vegetables.
Digestion produces fluid during food oxidation.
In a healthy individual, fluid intake from all sources equals fluid output through elimination, respiration, and sweating. An ill person has an increased need for fluid (e.g., with fever or gastrointestinal [GI] losses). By contrast, he or she also has a decreased ability to excrete fluid (e.g., with cardiopulmonary or renal disease), which often leads to the need for fluid restriction.
Vitamins are organic substances present in small amounts in foods that are essential to normal metabolism. They are chemicals that act as catalysts in biochemical reactions.
Certain vitamins are currently of interest in their role as antioxidants. These vitamins neutralize substances called free radicals, which produce oxidative damage to body cells and tissues. Researchers think that oxidative damage increases a person’s risk for various cancers. Antioxidant vitamins include beta-carotene and vitamins A, C, and E.
The body is unable to synthesize vitamins in the required amounts. Vitamin synthesis depends on dietary intake. Vitamin content is usually highest in fresh foods that have minimal exposure to heat, air, or water prior to their use. Vitamin classifications include either the labels of fat-soluble or water-soluble.
The fat-soluble vitamins (A, D, E, and K) are stored in the fatty compartments of the body. With the exception of vitamin D, people acquire vitamins through dietary intake.
Hypervitaminosis of fat-soluble vitamins results from megadoses (intentional or unintentional) of supplemental vitamins, excessive amounts in fortified food, and large intake of fish oils.
The water-soluble vitamins are vitamin C and the B complex (which is eight vitamins). Water-soluble vitamins absorb easily from the GI tract. Although they are not stored, toxicity can still occur.
Minerals are inorganic elements essential to the body as catalysts in biochemical reactions.
They are classified as macrominerals when the daily requirement is 100 mg or more and microminerals or trace elements when less than 100 mg is needed daily.
Macrominerals help to balance the pH of the body, and specific amounts are necessary in the blood and cells to promote acid–base balance. Interactions occur among trace minerals.
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6. Digestion
Mechanical breakdown that results from chewing, churning, and mixing with fluid and chemical reactions in which food reduces to its simplest form
Each part of the gastrointestinal (GI) system has an important digestive or absorptive function.
Enzymes are the proteinlike substances that act as catalysts to speed up chemical reactions. They are an essential part of the chemistry of digestion.
Most enzymes have one specific function. Each enzyme works best at a specific pH.
The mechanical, chemical, and hormonal activities of digestion are interdependent.
Enzyme activity depends on the mechanical breakdown of food to increase its surface area for chemical action.
Hormones regulate the flow of digestive secretions needed for enzyme supply. Physical, chemical, and hormonal factors regulate the secretion of digestive juices and the motility of the GI tract.
Nerve stimulation from the parasympathetic nervous system (e.g., the vagus nerve) increases GI tract action.
Digestion begins in the mouth, where chewing mechanically breaks down food. The food mixes with saliva, which contains ptyalin (salivary amylase), an enzyme that acts on cooked starch to begin its conversion to maltose.
Proteins and fats are broken down physically but remain unchanged chemically because enzymes in the mouth do not react with these nutrients.
The epiglottis is a flap of skin that closes over the trachea as a person swallows to prevent aspiration. Swallowed food enters the esophagus, and wavelike muscular contractions (peristalsis) move the food to the base of the esophagus, above the cardiac sphincter. Pressure from a bolus of food at the cardiac sphincter causes it to relax, allowing the food to enter the fundus, or uppermost portion, of the stomach.
The chief cells in the stomach secrete pepsinogen; and the pyloric glands secrete gastrin, a hormone that triggers parietal cells to secrete hydrochloric acid (HCl). The parietal cells also secrete HCl and intrinsic factor (IF), which is necessary for absorption of vitamin B12 in the ileum. HCl turns pepsinogen into pepsin, a protein-splitting enzyme.
The body produces gastric lipase and amylase to begin fat and starch digestion, respectively. A thick layer of mucus protects the lining of the stomach from autodigestion. Alcohol and aspirin are two substances directly absorbed through the lining of the stomach. The stomach acts as a reservoir where food remains for approximately 3 hours, with a range of 1 to 7 hours.
Food leaves the antrum, or distal stomach, through the pyloric sphincter and enters the duodenum. Food is now an acidic, liquefied mass called chyme.
Manufactured in the liver, bile is then concentrated and stored in the gallbladder. It acts as a detergent because it emulsifies fat to permit enzyme action while suspending fatty acids in solution. Pancreatic secretions contain six enzymes: amylase to digest starch; lipase to break down emulsified fats; and trypsin, elastase, chymotrypsin, and carboxypeptidase to break down proteins.
Peristalsis continues in the small intestine, mixing the secretions with chyme. The mixture becomes increasingly alkaline, inhibiting the action of the gastric enzymes and promoting the action of the duodenal secretions. Epithelial cells in the small intestinal villi secrete enzymes (e.g., sucrase, lactase, maltase, lipase, and peptidase) to facilitate digestion.
The major portion of digestion occurs in the small intestine, producing glucose, fructose, and galactose from carbohydrates; amino acids and dipeptides from proteins; and fatty acids, glycerides, and glycerol from lipids. Peristalsis usually takes approximately 5 hours to pass food through the small intestine.
[Shown is Figure 45-1: Summary of digestive system anatomy/organ function. HCl, Hydrochloric acid.]
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7. Absorption
The small intestine, lined with fingerlike projections called villi, is the primary absorption site for nutrients.
The body absorbs nutrients by means of passive diffusion, osmosis, active transport, and pinocytosis.
Absorption of carbohydrates, protein, minerals, and water-soluble vitamins occurs in the small intestine.
Villi increase the surface area available for absorption.
[Review Table 45-1, Mechanisms for Intestinal Absorption of Nutrients, with students.]
Absorption of carbohydrates, protein, minerals, and water-soluble vitamins occurs in the small intestine, then processed in the liver, and released into the portal vein circulation. Fatty acids are absorbed in the lymphatic circulatory systems through lacteal ducts at the center of each microvilli in the small intestine.
Approximately 85% to 90% of water is absorbed in the small intestine (McCance et al., 2013). The GI tract manages approximately 8.5 L of GI secretions and 1.5 L of oral intake daily. The small intestine resorbs 9.5 L, and the colon absorbs approximately 0.4 L. Elimination of the remaining 0.1 L occurs via feces. In addition, electrolytes and minerals are absorbed in the colon, and bacteria synthesize vitamin K and some B-complex vitamins. Finally, feces form for elimination.
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8. Metabolism and Storage of Nutrients
All biochemical reactions within the cells of the body
Anabolism
Building of more complex biochemical substances by synthesis of nutrients
Catabolism
Breakdown of biochemical substances into simpler substances; occurs during physiological states of negative nitrogen balance
Metabolic processes are anabolic (building) or catabolic (breaking down).
Amino acids are anabolized into tissues, hormones, and enzymes. Normal metabolism and anabolism are physiologically possible when the body is in positive nitrogen balance.
Starvation is an example of catabolism when wasting of body tissues occurs.
Nutrients absorbed in the intestines, including water, transport through the circulatory system to the body tissues.
Through the chemical changes of metabolism, the body converts nutrients into a number of required substances.
Carbohydrates, protein, and fat metabolism produce chemical energy and maintain a balance between anabolism and catabolism. To carry out the work of the body, the chemical energy produced by metabolism converts to other types of energy by different tissues. Muscle contraction involves mechanical energy, nervous system function involves electrical energy, and the mechanisms of heat production involve thermal energy.
Some of the nutrients required by the body are stored in tissues.
The major form of body reserve energy is fat, stored as adipose tissue. Protein is stored in muscle mass.
When the energy requirements of the body exceed the energy supplied by ingested nutrients, stored energy is used.
Monoglycerides from the digested portion of fats convert to glucose by gluconeogenesis.
Amino acids also converted to fat and stored or catabolized into energy through gluconeogenesis.
All body cells except red blood cells and neurons oxidize fatty acids into ketones for energy when dietary carbohydrates (glucose) are not adequate. Glycogen, synthesized from glucose, provides energy during brief periods of fasting (e.g., during sleep). It is stored in small reserves in liver and muscle tissue.
Nutrient metabolism consists of three main processes:
1. Catabolism of glycogen into glucose, carbon dioxide, and water (glycogenolysis).
2. Anabolism of glucose into glycogen for storage (glycogenesis).
3. Catabolism of amino acids and glycerol into glucose for energy (gluconeogenesis).
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9. Elimination
Chyme moves by peristaltic action through the ileocecal valve into the large intestine, where it becomes feces.
Water absorbs in the mucosa as feces move toward the rectum.
The longer the material stays in the large intestine, the more water is absorbed, causing the feces to become firmer. Exercise and fiber stimulate peristalsis, and water maintains consistency. Feces contain cellulose and similar indigestible substances, sloughed epithelial cells from the GI tract, digestive secretions, water, and microbes.
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10. Dietary Guidelines Dietary reference intakes (DRIs) Food guidelines
Acceptable range of quantities of vitamins and minerals for each gender and age group
Food guidelines
Daily values
Needed protein, vitamins, fats, cholesterol, carbohydrates, fiber, sodium, and potassium
Four components of dietary reference intakes (DRIs):
1. Estimated average requirement (EAR)—amount of nutrient that appears sufficient to maintain a specific body function for 50% of population based on age and gender.
2. Recommended dietary allowance (RDA)—average needs of 98% of population, not exact needs of an individual.
3. Adequate intake (AI)—suggested intake for individuals based on observed or experimentally determined estimates of nutrient intakes used when not enough evidence to set RDA.
4. Tolerable upper intake level (UL)—highest level that poses no risk of adverse health events.
The U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (USDHHS) published the Dietary Guidelines for Americans 2010 and provide average daily consumption guidelines for the five food groups: grains, vegetables, fruits, dairy products, and meats.
These guidelines are for Americans older than the age of 2 years.
As a nurse, consider the food preferences of patients from different racial and ethnic groups, vegetarians, and others when planning diets.
[Review Box 45-2, 2010 Dietary Guidelines for Americans: Key Recommendations for the General Population, with students.]
The U.S. Department of Agriculture developed the ChooseMyPlate program to replace the My Food Pyramid program. ChooseMyPlate provides a basic guide for making food choices for a healthy lifestyle. The ChooseMyPlate program includes guidelines for balancing calories; decreasing portion size; increasing healthy foods; increasing water consumption; and decreasing fats, sodium, and sugars.
The Food and Drug Administration (FDA) created daily values for food labels in response to the 1990 Nutrition Labeling and Education Act (NLEA). The FDA first established two sets of reference values.
The referenced daily intakes (RDIs) are the first set, comprising protein, vitamins, and minerals based on the RDA.
The daily reference values (DRVs) make up the second set and consist of nutrients such as total fat, saturated fat, cholesterol, carbohydrates, fiber, sodium, and potassium.
Combined, both sets make up the daily values used on food labels. Daily values did not replace RDAs but provided a separate, more understandable format for the public. Daily values are based on percentages of a diet consisting of 2000 kcal/day for adults and children 4 years or older.
[Shown is Figure 45-2: ChooseMyPlate.]
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11. Case Study (Cont.)
Mrs. Gonzales is awake and alert in her hospital room, yet is drooling from the right side of her mouth. When she tries to drink water, she starts to cough. The physician has ordered nothing by mouth (NPO). Evaluation by the speech language pathologist (SLP) indicates inadequate clearance of food and liquid from the vocal folds and aspiration of thickened liquids.
Mrs. Gonzalez has trouble swallowing with oropharyngeal dysphagia. The SLP recommends enteral feedings, and speech and swallowing therapy to help her return to oral feedings.
[Ask students: Were you able to predict that Mrs. Gonzales would receive enteral feedings? What challenges do her nurses face in helping her progress back to oral feedings? Discuss.]
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12. Quick Quiz!
1. A 22-year-old new mother is breastfeeding. You ask her if she is taking the correct quantities of nutrients. Which statement reflects that she understands the dietary guidelines? A. “I am not concerned with what I am eating.” B. “I am taking vitamin doses based on TV.” C. “I am taking a daily MVI.” D. “I am making eating choices according to the recommended dietary allowances.”
Answer: D
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13. Nursing Knowledge Base
Factors influencing nutrition
Environmental factors
Developmental needs
Infants through school age
Breastfeeding, formula, solid foods
Adolescents
Young and middle adults
Older adults
Sociological, cultural, psychological, and emotional factors are associated with eating and drinking in all societies.
Nutritional requirements depend on many factors. Individual caloric and nutrient requirements vary by stage of development, body composition, activity levels, pregnancy and lactation, and the presence of disease. Registered dietitians (RDs) use predictive equations that take into account some of these factors to estimate patients’ nutritional requirements.
Environmental factors beyond the control of individuals contribute to the development of obesity.
Environmental factors can limit a person’s likelihood of healthy eating and participation in exercise or other activities of healthy living.
The likelihood of healthy eating and participation in exercise or other activities of healthy living is limited by environmental factors. Lack of access to full-service grocery stores, high costs of healthy food, widespread availability of less healthy foods in fast food restaurants, widespread advertising of less healthy food, and lack of access to safe places to play and exercise are environmental factors that contribute to obesity.
Each of these groups has specific needs.
Infants through school age: rapid growth and high protein
Breastfeeding is recommended for first 6 months of life with benefits including reduced food allergies and intolerances, easier digestion, and fewer infant infections.
Formula: Protein in the formula is whey, soy, cow’s milk, casein hydrolysate, or elemental amino acids; infants should not have regular cow’s milk during the first year because it is too concentrated for the kidneys to handle and is a poor source of iron and vitamins C and E.
Solid food: Introduce solid foods one at a time 4 to 7 days apart to identify allergies; keep in mind that the growth rate slows in toddlers; they exhibit strong food preferences.
Toddlers: consume more than 24 ounces of milk daily in place of other foods; sometimes develop milk anemia because milk is a poor source of iron.
School age (6-12 years): assess diets for adequate protein and vitamins A and C. School-age children, 6 to 12 years old, grow at a slower and steadier rate, with a gradual decline in energy requirements per unit of body weight.
Adolescents: Physiological age is better than chronological age for estimating nutritional needs. Adolescents have increased energy needs owing to higher metabolic growth demands; protein increase is needed; calcium and continuous iron are especially important in females; B-complex vitamins assist in metabolic activity. Pregnancy occurring within 4 years of menarche places a mother and fetus at risk because of anatomical and physiological immaturity. The onset of eating disorders, such as anorexia nervosa or bulimia nervosa, often occurs during adolescence. Many factors other than nutritional needs influence the adolescent’s diet, including concern about body image and appearance, desire for independence, eating at fast-food restaurants, peer pressure, and fad diets.
[Review Box 45-3, Potential Assessment for Eating Disorders, with students.]
Young and middle-age adults: energy requirements for maintenance and repair only as growth slows. Pregnancy and lactation become significant in considering energy needs and are related to mother’s body weight and activity. Lactation requires an additional 500 calories above usual allowance with greater than protein requirements in pregnancy.
Poor nutrition during pregnancy causes low birth weight in infants and decreases chances of survival. Folic acid intake is particularly important for deoxyribonucleic acid (DNA) synthesis and the growth of red blood cells. Inadequate intake can lead to fetal neural tube defects, anencephaly, or maternal megaloblastic anemia.
Adults 65 years and older: decreased needs for energy due to slowing of their metabolic rate. Age-related changes in appetite, taste, smell, and the digestive system affect nutrition. Fixed incomes influence the ability to purchase food. The elderly often have difficulty chewing, missing teeth, or oral pain, causing difficulty in food consumption. The diet of older adults needs to contain choices from all food groups and often requires a vitamin and mineral supplement. The USDHHS Administration on Aging requires states to provide nutritional screening services to older adult patients who benefit from home-delivered or congregate meal services. The program requires meals to provide at least one third of DRI for older adults and to meet the Dietary Guidelines for Americans.
[Review Box 45-4, Focus on Older Adults: Factors Affecting Nutritional Status; and Table 45-2, Sample of Drug–Nutrient Interactions, with students.]
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14. Case Study (Cont.)
Matt is a nursing student assigned to Mrs. Gonzalez. As he prepares to assess her, he recalls information about the effects of dysphagia on nutrition and rehabilitation. He will assess Mrs. Gonzales’ weight, weight history, diet history, and cultural customs.
Matt knows to consult with a registered dietitian (RD) to assess Mrs. Gonzales’s nutritional status and interventions. Matt is responsible for inserting Mrs. Gonzalez’s small-bore nasogastric feeding tube and starting her tube feedings. The RD has recommended continuous tube feeding for 12 hours during the day.
[Ask students: What are the effects of dysphagia on nutrition? Discuss.]
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15. Alternative Food Patterns
Based on religion, cultural background, ethics, health beliefs, and preference
Vegetarian diet consists predominantly of plant foods:
Ovolactovegetarian (avoids meat, fish, and poultry, but eats eggs and milk)
Lactovegetarian (drinks milk but avoids eggs)
Vegan (consumes only plant foods)
Zen macrobiotic
Fruitarian (consumes fruit, nuts, honey, and olive oil)
Through careful selection of foods, individuals following a vegetarian diet can meet recommendations for proteins and essential nutrients.
[Review Table 45-3, Religious Dietary Restrictions; and Box 45-5, Cultural Aspect of Care: Nutrition, with students.]
Vegans lack complete proteins in single foods, although they can use complementary proteins from two or more foods to get all the amino acids. Knowledge of complementary proteins is necessary. They are at risk for vitamin B12 deficiency because it is available only from animal sources. Children who follow a vegetarian diet are especially at risk for protein and vitamin deficiencies such as vitamin B12.
Zen macrobiotic diets consist primarily of brown rice, other grains, and herb teas. Zen macrobiotic and fruitarian diets are nutrient poor and frequently result in malnutrition.
Students need to consult with dietitians to ensure that patients receive the nutrients needed for recovery and rehab.
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16. Critical Thinking Synthesis of knowledge, experience, information
Apply professional standards
DRIs
USDA MyPlate dietary guidelines
Healthy People 2020
American Heart Association
American Diabetes Association
American Cancer Society
American Society for Parenteral and Enteral Nutrition
Successful critical thinking requires a synthesis of knowledge, experience, information gathered from patients, critical thinking attitudes, and intellectual and professional standards. Clinical judgments require you to anticipate information, analyze the data, and make decisions regarding your patient’s care. During assessment, consider all elements that build toward making an appropriate nursing diagnosis
Use of professional standards such as the DRIs, the USDA MyPlate dietary guidelines, and Healthy People 2020 objectives provide guidelines to assess and maintain patients’ nutritional status. Other professional standards by the American Heart Association (AHA, 2010), the American Diabetes Association (ADA, 2012), The American Cancer Society (ACS, 2015), and the American Society for Parenteral and Enteral Nutrition (ASPEN, 2014) are available. These standards are evidence based and regularly updated for optimal patient care.
[Review Figure 45-3, Critical thinking model for nutrition assessment, with students.]
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17. Assessment Through the patient’s eye Screening
Assess patient’s nutritional history.
Ask patient about food preferences, values regarding nutrition, and expectations from nutritional therapy.
Screening
Patient-centered clinical decisions required for safe nursing care. Early recognition of malnourished or at-risk patients has a strong positive influence on both short- and long-term health outcomes. Studies demonstrate a link between malnutrition in adult hospitalized patients and readmission rates, higher mortality rates and increased cost.
Close contact with patients and their families enables you to observe physical status, food intake, food preferences, weight changes, and response to therapy.
Nutrition screening is an essential part of an initial assessment. Screening a patient is a quick method of identifying malnutrition or risk of malnutrition using sample tools.
Nutrition screening tools need to gather data on the current condition, stability of the condition, assessment of whether it will worsen, and if the disease process accelerates. These tools typically include objective measures such as height, weight, weight change, primary diagnosis, and the presence of other co-morbidities.
Combine multiple objective measures with subjective measures related to nutrition to adequately screen for nutritional problems. Identification of risk factors such as unintentional weight loss, presence of a modified diet, or the presence of altered nutritional symptoms (i.e., nausea, vomiting, diarrhea, and constipation) requires nutritional consultation.
Several standardized nutritional screening tools are available for use in the outpatient and inpatient settings. The Subjective Global Assessment (SGA) uses the patient history, weight, and physical assessment data to evaluate nutritional status (Tsai et al., 2013). The SGA is a simple, inexpensive technique that is able to predict nutrition-related complications. The Mini Nutritional Assessment (MNA) screens older adults in home care programs, nursing homes, and hospitals. The tool has 18 items divided into screening and assessment. If a patient scores 11 or less on the screening part, the health care provider completes the assessment part. A total score of less than 17 indicates protein-energy malnutrition.
[Shown is Figure 45-4: Mini Nutritional Assessment (MNA).]
Assess patients for malnutrition when they have conditions that interfere with their ability to ingest, digest, or absorb adequate nutrients.
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18. Assessment (Cont.)
Anthropometry is a measurement system of the size and makeup of the body.
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 and biochemical tests.
Serial measures of weight over time provide more useful information than a single measurement. The patient needs to be weighed at the same time each day, on the same scale, and with the same clothing or linen.
Rapid weight gain or loss is important to note because it usually reflects fluid shifts. One pint or 500 mL of fluid equals 1 lb (0.45 kg).
Calculate body mass index (BMI) by dividing the patient’s weight in kilograms by height in meters squared: weight (kg) divided by height2 (m2).
No single laboratory or biochemical test is diagnostic for malnutrition. Factors that frequently alter test results include fluid balance, liver function, kidney function, and the presence of disease.
Common laboratory tests used to study nutritional status include measures of plasma proteins such as albumin, transferrin, prealbumin, retinol binding protein, total iron-binding capacity, and hemoglobin.
Nitrogen balance can be calculated to determine serum protein status. Calculate nitrogen balance by dividing 6.25 into the total grams of protein ingested in a day (24 hours).
Factors that affect serum albumin levels include hydration; hemorrhage; renal or hepatic disease; large amounts of drainage from wounds, drains, burns, or the GI tract; steroid administration; and exogenous albumin.
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19. Assessment (Cont.) Dietary and health history Physical examination
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)
The diet history focuses on a patient’s habitual intake of foods and liquids and includes information about preferences, allergies, and other relevant topics such as the patient’s ability to obtain food. Gather information about the patient’s illness/activity level to determine energy needs and compare food intake.
[Review Box 45-6, Nursing Assessment Questions, with students.]
In outpatient setting, the patient keeps a 3- to 7-day food diary. This allows you to calculate nutritional intake and to compare it with DRI to see if the patient’s dietary habits are adequate. Use food questionnaires to establish patterns over time. In health care setting, nurses collaborate with RDs to complete calorie counts for patients.
The physical examination is one of the most important aspects of a nutritional assessment. Because improper nutrition affects all body systems, observe for malnutrition during physical assessment. Complete the general physical assessment of body systems and recheck relevant areas to evaluate a patient’s nutritional status. The clinical signs of nutritional status serve as guidelines for observation during physical assessment.
[Review Table 45-4, Physical Signs of Nutritional Status, with students.]
Dysphagia refers to difficulty swallowing. The causes and complications of dysphagia vary.
[Review Box 45-7, Cause of Dysgphagia, with students.]
Be aware of warning signs for dysphagia. They include cough during eating; change in voice tone or quality after swallowing; abnormal movements of the mouth, tongue, or lips; and slow, weak, imprecise, or uncoordinated speech. Abnormal gag, delayed swallowing, incomplete oral clearance or pocketing, regurgitation, pharyngeal pooling, delayed or absent trigger of swallow, and inability to speak consistently are other signs of dysphagia.
Dysphagia often leads to an inadequate amount of food intake, which often results in malnutrition.
Dysphagia screening quickly identifies problems with swallowing and helps you initiate referrals for more in-depth assessment by a speech pathologist
[Review Skill 45-1, Aspiration Precautions, with students.]
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20. Case Study (Cont.) Assessment findings:
Mrs. Gonzales starts to cough when she tries to drink water.
Mrs. Gonzales is unable to swallow and aspirates pills and thickened liquid.
Lung sounds are clear. Respirations are regular at 12/min. She has no dyspnea. Oxygen saturation is 96% on room air.
Enteral nutrition will begin at 60 mL/hr.
Matt assessed Mrs. Gonzalez for risk of aspiration, evaluated Mrs. Gonzalez’ swallowing ability, monitored her respiratory status, and assessed her nutritional status.
[Ask students: What diagnosis would you expect? Discuss.]
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21. Nursing Diagnosis Risk for aspiration Diarrhea Deficient knowledge
Readiness for enhanced nutrition
Feeding self-care deficit
Impaired swallowing
Imbalanced nutrition: less than body requirements
Possible nursing diagnoses are shown on the slide. Nursing diagnoses may be related to actual nutrition problems (e.g., inadequate intake) or to problems that place the patient at risk for nutritional deficiencies such as oral trauma, severe burns, and infections.
Be sure to select the appropriate related factor for a nursing diagnosis. Related factors need to be accurate so you select the appropriate interventions. In addition, there are also clinical situations in which patients have multiple related problems.
Use a concept map.
[Review Box 45-8, Nursing Diagnostic Process: Imbalanced Nutrition: Less than Body Requirements.]
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22. Case Study (Cont.)
Diagnosis: Risk for aspiration related to impaired swallowing
Goals:
Mrs. Gonzales will receive adequate nutrients through enteral tube feeding without aspiration by the time of discharge.
Mrs. Gonzalez will regain swallowing ability from speech therapy by the time of discharge.
[Ask students: What are some expected outcomes for these goals? Discuss:
Mrs. Gonzalez’s weight at discharge will be within 2 lbs of admission weight.
Mrs. Gonzalez will not exhibit signs of aspiration before discharge.
Mrs. Gonzalez’ albumin and prealbumin levels will remain normal before discharge.
Mrs. Gonzalez will progress to an oral diet before discharge to a restorative care facility.]
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23. Planning Goals and outcomes Setting priorities
Reflect a patient’s physiological, therapeutic, and individualized needs
Setting priorities
Teamwork and collaboration
Discharge planning
Enteral tube feedings
Nutrition education and counseling are important to prevent disease and promote health. Educate your patients about the therapeutic diet prescribed, specifically, on how it controls their illnesses and if there are any implications. When planning care, be aware of all factors that influence a patient’s food intake. Patients with heart failure experience decreased hunger, dietary restrictions, fatigue, shortness of breath, anxiety, and sadness, which influences their food intake.
Individualized planning is essential. Explore patients’ feelings about their weight and diet and help them set realistic and achievable goals. Mutually planned goals negotiated among the patient, RD, and nurse ensure success.
Meeting nutritional goals requires input from the patient and the multidisciplinary team. Knowledge of the role of each discipline in providing nutrition support is necessary to maximize nutritional outcomes.
After identifying patients’ nursing diagnoses, determine priorities in order to plan timely and successful interventions.
During acute illness and surgery, food intake varies in the perioperative period. The priority of care is to provide optimal preoperative nutrition support in patients with malnutrition. The priority for the resumption of food intake after surgery depends on the return of bowel function, the extent of the surgical procedure, and the presence of any complications.
The patient and family must collaborate with the nurse in planning care and setting priorities. This is important because food preferences, food purchases, and preparation involve the entire family. The plan of care cannot succeed without their commitment to, involvement in, and understanding of the nutritional priorities.
Communicate patient goals and planned interventions to all team members to achieve expected patient outcomes.
Consult with an SLP, RD, pharmacist, and/or occupational therapist about patients with dysphagia, as well as those who need ongoing nutritional assessment and interventions to meet their nutritional needs.
Administration of enteral tube feedings typically enters through the stomach or intestines via a tube inserted through the nose or a percutaneous access.
[Review Skill 45-2, Inserting a Small-bore Nasoenteric Tube for Enteral Feedings; and Skill 45-3, Administering Enteral Feedings via Nasoenteric, Gastrostomy, or Jejunostomy Tubes, with students.]
Patients who cannot tolerate nutrition through the GI tract receive parenteral nutrition, a solution consisting of glucose, amino acids, lipids, minerals, electrolytes, trace elements, and vitamins, through an indwelling peripheral or central venous catheter (CVC).
When patients have difficulty feeding themselves, occupational therapists work with them and their families to identify assistive devices. Devices such as utensils with large handles and plates with elevated sides help a patient with self-feeding.
[Review Figure 45-5, Concept map for Mrs. Cooper, with students.
[Review Figure 45-6, Critical thinking model for nutrition planning, with students.]
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24. Implementation Health promotion Education
Early identification of potential or actual problems
Meal planning
Weight loss plans
Food safety
The focus of health promotion is to educate patients and family caregivers about balanced nutrition and to assist them in obtaining resources to eat high-quality meals.
Early identification of potential or actual problems is the best way to avoid more serious problems.
Meal planning takes into account the family’s budget and different preferences of family members.
Help patients develop a successful weight loss plan that considers their preferences and resources and includes awareness of portion sizes and knowledge of the energy content of food.
Planning menus a week in advance helps ensure good nutrition or compliance with a specific diet and helps a family stay within their allotted budget.
Support individuals who are interested in losing weight. patients develop a successful weight-loss plan that considers their preferences and resources and includes awareness of portion sizes and knowledge of energy content of food.
Health care professionals not only need to be aware of factors related to food safety but also should provide patient education to reduce risks for foodborne illnesses.
[Review Table 45-5, Food Safety; and Box 45-9, Patient Teaching: Food Safety, with students.]
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25. Implementation Acute care Risk factors in acutely ill patient
Advancing diets = Gradual progression of dietary intake or therapeutic diet to manage illness
Promoting appetite
Assisting with oral feedings
[Ask students: What factors influence nutritional intake in the acutely ill patient? Discuss.]
Diagnostic testing and procedures in the acute care setting disrupt food intake. Often as preparation for or immediately following a diagnostic procedure, a patient is to receive nothing by mouth (NPO).
Patients with decreased immune function (e.g., from cancer, chemotherapy, human immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], or organ transplants) require special diets that decrease exposure to microorganisms and are higher in selected nutrients.
[Review Table 45-6, Nutrition and the Immune System, with students.]
Health care providers order a gradual progression of dietary intake or therapeutic diet to manage patients’ illness.
[Review Box 45-10, Diet Progression and Therapeutic Diets, with students.]
Providing an environment that promotes nutritional intake includes keeping a patient’s environment free of odors, providing oral hygiene as needed to remove unpleasant tastes, and maintaining patient comfort. Offering smaller, more frequent meals often helps. In addition, certain medications affect dietary intake and nutrient use.
Mealtime is usually a social activity. If appropriate, encourage visitors to eat with the patient.
When a patient needs help with eating, it is important to protect his or her safety, independence, and dignity. Clear the table or over-bed tray of clutter. Assess his or her risk of aspiration. Patients with dysphagia are at risk for aspiration and need more assistance with feeding and swallowing.
Provide opportunities for patients to direct the order in which they want to eat the food items and how fast they wish to eat.
[Shown is Figure 45-7: Adaptive equipment. Clockwise from upper left: Two-handled cup with lid, plate with plate guard, utensils with splints, and utensils with enlarged handles.]
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26. Enteral Tube Feeding
Enteral nutrition (EN) provides nutrients into the GI tract. It is physiological, safe, and economical nutritional support.
Nasogastric, jejunal, or gastric tubes
Surgical or endoscopic placement
Nasointestinal
Gastrostomy
Jejunostomy
PEG (percutaneous endoscopic gastrostomy)
PEJ (percutaneous endoscopic jejunostomy)
Risk of aspiration
When oral feeding assistance is inadequate in providing appropriate nutrition, enteral or parental feeding is required. Enteral nutrition (EN) is the preferred method of meeting nutritional needs if a patient is unable to swallow or take in nutrients orally, yet has a functioning GI tract.
[Review Box 45-11, Indications for Enteral and Parenteral Nutrition, with students.]
Patients at low risk for gastric reflux receive gastric feedings; however, if risk of gastric reflux, which leads to aspiration, is present, jejunal feeding is preferred.
Types of formulas include:
Polymeric: milk-based, blenderized; the patient’s gastrointestinal tract needs to be able to absorb whole nutrients.
Modular: single-macronutrient (protein, glucose, polymers, or lipids) formulas are added to other foods to meet patients’ needs.
Elemental formulas: predigested nutrients, easier for partially dysfunctional gastrointestinal tract to absorb.
Specialty formulas: designed to meet specific nutritional needs in certain illnesses.
[Review Box 45-12, Advancing the Rate of Tube Feeding, with students.]
Before beginning a tube feeding, you will learn in the skills lab to flush the line with a small amount of water to ensure that the tube is clear and patent. Tube feedings typically are started at full strength at slow rates. Increase the hourly rate every 8 to 12 hours per health care provider’s order if no signs of intolerance appear.
Feeding by the enteral route reduces sepsis, minimizes the hypermetabolic response to trauma, decreases hospital mortality, and maintains intestinal structure and function.
Tubes are inserted through the nose (nasogastric or nasointestinal), surgically (gastrostomy or jejunostomy), or endoscopically (percutaneous endoscopic gastrostomy or jejunostomy).
If for less than 4 weeks total, nasogastric or nasojejunal feeding tubes may be used. Surgical or endoscopically placed tubes are preferred for long-term feeding.
A serious complication associated with enteral feedings is aspiration of formula into the tracheobronchial tree, which leads to infection.
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27. Enteral Access Tubes
When patients are unable to ingest food but are still able to digest and absorb nutrients, the use of enteral tube feeding is supported
When patients are unable to ingest food but are still able to digest and absorb nutrients, the use of enteral tube feeding is supported. Feeding tubes are inserted through the nose (nasogastric or nasointestinal), surgically (gastrostomy or jejunostomy), or endoscopically (percutaneous endoscopic gastrostomy or jejunostomy [PEG or PEJ]). If EN therapy is for less than 4 weeks, total, nasogastric, or nasojejunal feeding tubes may be used. Surgical or endoscopically placed tubes are preferred for long-term feeding (more than 6 weeks) to reduce the discomfort of a nasal tube and provide a more secure, reliable access.
Most health care settings use small-bore feeding tubes because they create less discomfort for a patient. For the adult, most of these tubes are 8- to 12-French and 36 to 44 inches (90 to 110 cm) long. A stylet is often used during insertion of a small-bore tube to stiffen it. The stylet is removed when correct positioning of the feeding tube is confirmed. Skill 45-3 describes the procedure for initiating nasogastric, gastrostomy, and jejunostomy enteral feedings.
Historically, nurses verified feeding tube placement by injecting air through the tube while auscultating the stomach for a gurgling or bubbling sound or asking the patient to speak. However, evidence-based research repeatedly demonstrates auscultation is ineffective in detecting tubes accidentally placed in the lung.
Measurement of the pH of secretions withdrawn from the feeding tube helps to differentiate the location of the tube.
[Review Box 45-13, Procedural Guidelines: Obtaining Gastrointestinal Aspirate for pH Measurement, Large-Bore, and Small-Bore Feeding Tubes: Intermittent and Continuous Feeding; Box 45-14, Evidence-Based Practice: Accuracy in Determining Placement of Feeding Tubes; and Table 45-7, Enteral Tube Feeding Complications, with students.]
[Shown is Figure 45-8: A, Enteral tubes, small-bore. B, Enteral-only connector (ENFit) designed to fit the specific enteral tube.]
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28. Case Study (Cont.) Nutritional management Aspiration precautions
Insert feeding tube as ordered.
Initiate enteral feeding as prescribed.
Advance tube feeding as tolerated; monitor for tolerance.
Aspiration precautions
Position Mrs. Gonzalez with head of bed elevated a minimum of 30 degrees.
Check tube placement every 4 to 6 hours.
Check gastric residual volume every 4 hours.
Continue with speech therapy.
[Ask students: What are the rationales for these interventions? Discuss:
The enteral tube feeding will allow for safe provision of nutrients while swallowing is rehabilitated with the assistance of the SLP.
Tube feeding is initiated at a low rate of infusion and is increased slowly to allow for maximum tolerance.
Abdominal pain, large volume of gastric residuals, and diarrhea are signs of feeding intolerance and need to be evaluated promptly.
Head of bed elevated a minimum of 30 to 40 degrees decreases the risk for aspiration.
Improperly positioned tubes increase the risk for aspiration.
Gastric residual volume indicates whether gastric emptying is delayed. Delayed gastric emptying increases the risk for aspiration.
Regularly provided speech therapy will assist the patient in regaining the ability to swallow foods and liquids.
Speech therapy includes trials of various consistencies of foods and liquids. Aspiration of food and liquids lead to chest congestion and pneumonia.]
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29. Quick Quiz!
2. You receive an order to begin enteral tube feedings. The first step is to: A. place the patient in a prone position. B. irrigate the tube with normal saline. C. check to see that the tube is properly placed. D. introduce a small amount of fluid into the tube before feeding.
Answer: D
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30. Parenteral Nutrition Nutrients are provided intravenously
Patients unable to digest or absorb enteral nutrition or are in highly stressed physiological states
Peripheral or central line
Initiating parenteral nutrition
Preventing complications
Parenteral nutrition (PN) is a form of specialized nutrition support provided intravenously.
A basic PN formula is a combination of crystalline amino acids, hypertonic dextrose, electrolytes, vitamins, and trace elements. Total PN (TPN), administered through a central line, is a 2-in-1 formula in which administration of fat emulsions occurs separately from the protein and dextrose solution.
Safe administration depends on appropriate assessment of nutrition needs, meticulous management of the central venous catheter (CVC), and careful monitoring to prevent or treat metabolic complications. Administration of PN happens in a variety of settings, including a patient’s home. Regardless of the setting, adhere to principles of asepsis and infusion management to ensure safe nutrition support.
Patients who are unable to digest or absorb EN benefit from PN. Patients in highly stressed physiological states such as sepsis, head injury, or burns are candidates for PN therapy.
PN therapy requires clinical and laboratory monitoring by a multidisciplinary team. Consistent reevaluation for the continuation of PN is required. The goal to move toward use of the GI tract is constant.
Sometimes adding intravenous fat emulsions to PN supports the patient’s need for supplemental kilocalories, prevent essential fatty acid deficiencies, and help control hyperglycemia during periods of stress. Administer these emulsions through a separate peripheral line, through the central line by using Y-connector tubing.
Patients with short-term nutritional needs often receive intravenous (IV) solutions of less than 10% dextrose via a peripheral vein in combination with amino acids and lipids.
TPN is more calorically dense than peripheral solutions, and therefore peripheral solutions are usually temporary. PN with greater than 10% dextrose requires a CVC that a health care provider places into a high-flow central vein such as the superior vena cava under sterile conditions. If you are using a CVC that has multiple lumens, use a port exclusively dedicated for the TPN. Label the port for TPN and do not infuse other solutions or medications through it. Nurses with special training insert peripherally inserted central catheters (PICCs) that start in a vein of the arm and then threaded into the subclavian or superior vena cava vein.
After catheter placement, wait to flush and use the catheter until position confirmation by radiology. The health care provider secures the CVC with a securement device and covers the site with a sterile bio-occlusive dressing. Prior to applying the sterile dressing, stabilize the PICC with sterile strips of tape. A chest x-ray verifies catheter tip placement for a CVC or PICC before starting a PN infusion.
Before beginning any PN infusion, verify the health care provider’s order and inspect the solution for particulate matter or a break in the fat emulsion.
Complications of PN include catheter-related problems and metabolic alterations
[Review Table 45-8, Metabolic Complications of Parenteral Nutrition, with students.]
Pneumothorax results from a puncture insult to the pulmonary system and involves the accumulation of air in the pleural cavity with subsequent collapse of the lung and impaired breathing.
An air embolus possibly occurs during insertion of the catheter or when changing the tubing or cap.
Catheter occlusion is present when there is sluggish or no flow through the catheter.
Suspect catheter sepsis if a patient develops fever, chills, or glucose intolerance and has a positive blood culture.
PN solutions contain most of the major electrolytes, vitamins, and minerals. Patients also need supplemental vitamin K as ordered throughout therapy. Synthesis of vitamin K occurs by the microflora found in the jejunum and ileum with normal use of the GI tract; however, because PN circumvents GI use, patients need to receive exogenous vitamin K.
Electrolyte and mineral imbalances often occur.
[Review Skill 45-4, Blood Glucose Monitoring, with students.]
[Shown is Figure 45-10: Blood glucose monitor.]
Too-rapid administration of hypertonic dextrose can result in an osmotic diuresis and dehydration.
The goal is to move patients from PN to EN and/or oral feeding.
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31. Restorative and Continuing Care
Medical nutrition therapy (MNT)
Specific nutritional therapy usage for treating illness, injury, or a certain condition
Necessary for
Metabolizing certain nutrients
Correcting nutritional deficiencies
Eliminating foods that worsen disease states
Most effective with collaborative health care team and dietitian
Restorative care includes both immediate postsurgical care and routine medical care and therefore includes patients in the hospital and at home.
Optimal nutrition is important in health and illness, but the specific dietary intake pattern that results in modification of optimal nutrition for patients with par­ticular diseases. Medical nutrition therapy (MNT) is the use of specific nutritional therapies to treat an illness, injury, or con­dition. MNT is necessary to help the body metabolize certain nutrients, correct nutritional deficiencies related to the disease, and eliminate foods that may exacerbate disease symptoms. It is most effective using a team approach that promotes collaboration between the health care team and an RD.
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32. Medical Nutrition Therapy
Gastrointestinal diseases
Peptic ulcer etiology
Helicobacter pylori
Stress
Acid overproduction
Peptic ulcer treatments
Avoid caffeine
Avoid spicy foods
Avoid aspirin, nonsteroidal antiinflammatory drugs (NSAIDs)
Consume small, frequent meals
Control peptic ulcers with regular meals and medications such as histamine receptor antagonists that block secretion of HCl or proton pump inhibitors. Marshall and Warren first identified Helicobacter pylori in H. pylori, a bacterium that causes up to 85% of peptic ulcers, is confirmed by laboratory tests or a biopsy during endoscopy.
Antibiotics treat and control the bacterial infection. Stress and overproduction of gastric HCl also irritate a preexisting ulcer. Encourage patients to avoid foods that increase stomach acidity and pain such as caffeine, decaffeinated coffee, frequent milk intake, citric acid juices, and certain seasonings (hot chili peppers, chili powder, black pepper). Discourage smoking, alcohol, aspirin, and nonsteroidal antiinflammatory drugs (NSAIDs). Teach patients to eat a well-balanced, healthy diet; avoid eating large meals; and eat three regular meals (or several small meals) without snacks, especially at bedtime.
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33. Medical Nutrition Therapy (Cont.)
Gastrointestinal diseases
Inflammatory bowel disease
Crohn’s and idiopathic ulcerative colitis
Elemental diets
Parenteral nutrition
Vitamins and iron supplements
Fiber increase
Fat reduction
Large meal avoidance
Lactose and sorbitol avoidance
Inflammatory bowel disease includes Crohn’s disease and idiopathic ulcerative colitis. Treatment of acute inflammatory bowel disease includes elemental diets (formula with the nutrients in their simplest form ready for absorption) or PN when symptoms such as diarrhea and weight loss are prevalent. In the chronic stage of the disease, a regular highly-nourishing diet is appropriate. Vitamins and iron supplements are often required to correct or prevent anemia. Patients manage irritable bowel syndrome by increasing fiber, reducing fat, avoiding large meals, and avoiding lactose or sorbitol-containing foods for susceptible individuals.
The treatment of malabsorption syndromes such as celiac disease includes a gluten-free diet. Gluten is present in wheat, rye, barley, and oats. Short-bowel syndrome results from extensive resection of bowel, after which patients suffer from malabsorption caused by lack of intestinal surface area. These patients require lifetime feeding with either elemental enteral formulas or PN.
Diverticulitis is a condition that results from an inflammation of diverticula, which are abnormal but common pouch-like herniations that occur in the bowel lining. Nutritional treatment for diverticulitis includes a moderate- or low-residue diet until the infection subsides. Afterward, prescribing a high-fiber diet for chronic diverticula problems ensues.
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34. Case Study (Cont.)
Matt must keep in mind that Mrs. Gonzalez will progress to restorative care and return to oral feedings, and also must consider cultural preferences. Matt knows that food safety is an important issue.
Matt consults the dietitian, and together they develop a teaching plan regarding food safety for the foods that Mrs. Gonzalez’s family will be preparing at home.
[Ask students: What expected outcomes would Matt set for the teaching session? Discuss:
At the end of the teaching session, Mrs. Gonzalez’s family is able to state measures to reduce foodborne illnesses:
Wash hands, preparation surfaces, and utensils.
Cook meat, poultry, fish, and eggs at 180 degrees.
Wash fresh fruits and vegetables.
Refrigerate foods at 40° degrees within 2 hours of cooking.
Discard spoiled foods.
Use plastic laminate or solid surface cutting boards.
Wash dishrags, towels, and sponges with bleach.
Clean inside of refrigerator and microwave regularly with bleach or soap.
Matt could also evaluate the family in preparing Mrs. Gonzalez’s food and preventing foodborne illnesses by making a home visit.]
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35. Medical Nutrition Therapy (Cont.)
Diabetes mellitus
Type 1: insulin and dietary restrictions
Type 2: exercise and diet therapy initially
Individualized diet
Carbohydrate consistency and monitoring
Saturated fat less than 7%
Cholesterol intake less than 200 mg/dL
Protein intake 15% to 20% of diet
Goals
Type 1 diabetes mellitus (DM) requires both insulin and dietary restrictions for optimal control, with treatment beginning at diagnosis (ADA, 2010). By contrast, patients often control type 2 DM initially with exercise and diet therapy. If these measures prove ineffective, it is common to add oral medications. Insulin injections often follow if type 2 DM worsens or fails to respond to these initial interventions.
Individualize the diet according to a patient’s age, build, weight, and activity level. Maintaining a prescribed carbohydrate intake is the key in diabetes management. The ADA recommends a diet that includes carbohydrates from fruits, vegetables, whole grains, legumes, and low-fat milk (American Dietetic Association, 2010b). Monitoring carbohydrate consumption is a key strategy in achieving glycemic control.
Limit saturated fat to less than 7% of the total calories and cholesterol intake to less than 200 mg/day. In addition, varieties of foods containing fiber are recommended. Patients are able to substitute sucrose-containing foods for carbohydrates but need to make sure to avoid excess energy intake. Diabetics can eat sugar alcohols and nonnutritive sweeteners as long as they follow the recommended daily intake level.
Patients with diabetes and normal renal function should continue to consume usual amounts of protein (15% to 20% of energy).
The goal of MNT treatment is to have glycemic levels that are normal or as close to normal as safely possible; lipid and lipoprotein profiles that decrease the risk of microvascular (e.g., renal and eye disease), cardiovascular, neurological, and peripheral vascular complications; and blood pressure in the normal or near-normal range (ADA, 2010). Be aware of signs and symptoms of hypoglycemia and hyperglycemia.
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36. Medical Nutrition Therapy (Cont.)
Cardiovascular diseases
American Heart Association (AHA) dietary guidelines
Balance caloric intake and exercise.
Maintain a healthy body weight.
Eat a diet rich in fruits, vegetables, and complex carbohydrates.
Eat fish twice per week.
Limit foods and beverages high in sugar and salt.
Limit trans-saturated fat to less than 1%.
The goal of the American Heart Association (AHA) dietary guidelines is to reduce risk factors for the development of hypertension and coronary artery disease. Diet therapy for reducing the risk of cardiovascular disease includes balancing calorie intake with exercise to maintain a healthy body weight; eating a diet high in fruits, vegetables, and whole-grain high-fiber foods; eating fish at least 2 times per week; and limiting food and beverages that are high in added sugar and salt. The AHA guidelines also recommend limiting saturated fat to less than 7%, trans-fat to less than 1%, and cholesterol to less than 300 mg/day. To accomplish this goal, patients choose lean meats and vegetables, use fat-free dairy products, and limit intake of fats and sodium.
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37. Medical Nutrition Therapy (Cont.)
Cancer and cancer treatment
Malignant cells compete with normal cells for nutrients.
Anorexia, nausea, vomiting, and taste distortions are common.
Malnutrition associated with cancer increases morbidity and mortality.
Radiation causes anorexia, stomatitis, severe diarrhea, intestinal strictures, and pain.
Nutrition management.
Malignant cells compete with normal cells for nutrients, increasing a patient’s metabolic needs. Most cancer treatments cause nutritional problems. Patients with cancer often experience anorexia, nausea, vomiting, and taste distortions. The goal of nutrition therapy is to meet the increased metabolic needs of a patient.
Malnutrition in cancer is associated with increased morbidity and mortality. Enhanced nutritional status often improves a patient’s quality of life.
Radiation therapy destroys rapidly dividing malignant cells; however, normal rapidly dividing cells such as the epithelial lining of the GI tract are often affected. Radiation therapy causes anorexia, stomatitis, severe diarrhea, strictures of the intestine, and pain. Radiation treatment of the head and neck region causes taste and smell disturbances, decreased salivation, and dysphagia. Nutrition management of a patient with cancer focuses on maximizing intake of nutrients and fluids. Individualize diet choices to a patient’s needs, symptoms, and situation.
Use creative approaches to manage alterations in taste and smell. For example, patients with altered taste often prefer chilled foods or foods that are spicy. Encourage patients to eat small frequent meals and snacks that are nutritious and easy to digest.
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38. Medical Nutrition Therapy (Cont.)
Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS)
Body wasting and severe weight loss
Severe diarrhea, GI malabsorption, altered nutrient metabolism
Hypermetabolism as a result of cytokine elevation
Maximize kilocalories and nutrients
Encourage small, frequent, nutrient-dense meals with fluid in between
Patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) typically experience body wasting and severe weight loss related to anorexia, stomatitis, oral thrush infection, nausea, or recurrent vomiting, all resulting in inadequate intake. Factors associated with weight loss and malnutrition includes severe diarrhea, GI malabsorption, and altered metabolism of nutrients. Systemic infection results in hypermetabolism from cytokine elevation. The medications that treat HIV infection often cause side effects that alter the patient’s nutritional status.
Restorative care of malnutrition resulting from AIDS focuses on maximizing kilocalories and nutrients. Diagnose and address each cause of nutritional depletion in the care plan. The progression of individually tailored nutrition support begins with administering oral, to enteral, and finally to parenteral. Good hand hygiene and food safety are essential because of a patient’s reduced resistance to infection. For example, minimization of exposure to Cryptosporidium in drinking water, lakes, or swimming pools is important. Small, frequent, nutrient-dense meals that limit fatty and overly sweet foods are easier to tolerate. Patients benefit from eating cold foods and drier or saltier foods with fluid in between.
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39. Case Study (Cont.)
What nursing actions are appropriate for evaluating whether goals have been met?
Consider the patient’s perspective.
Check measurable outcomes.
Consult with interdisciplinary staff.
[Discuss: Nursing actions taken to verify achievement of outcome include:
Asking Mrs. Gonzalez if she is experiencing any gastrointestinal discomfort.
Weighing Mrs. Gonzalez weekly.
Monitoring her laboratory values.
Asking the SLP about Mrs. Gonzalez’ swallowing rehabilitation.]
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40. Evaluation Through the patient’s eyes Patient outcomes
Patients expect nurses to recognize when the outcomes are unsuccessful and modify the plan
Patient outcomes
Compare actual to expected
Use multidisciplinary collaboration
Expectations and health care values held by nurses frequently differ from those held by patients. Successful interventions and outcomes require nurses to know what patients expect in addition to nursing knowledge and skill. Work closely with patients to define their expectations, and talk with them about their concerns if their expectations are not realistic. Consider the limits of their conditions and treatment, their dietary preferences, and their cultural beliefs when evaluating outcomes.
You need to evaluate the patient’s current weight in comparison with their baseline weight, serum albumin or prealbumin, and protein and kilocalorie intake routinely. If you do not observe gradual weight gain or if weight loss continues, evaluate the dietary EN prescription and determine if the patient is experiencing any adverse effects from medications that are affecting his or her nutritional status.
Changes in condition also indicate a need to change the nutritional plan of care.
Consult multidisciplinary members of the health care team in an effort to better individualize this plan. The patient is an active participant whenever possible. In the end, a patient’s ability to incorporate dietary changes into his or her lifestyle with the least amount of stress or disruption facilitates attainment of outcome measures.
Failing to meet expected outcomes requires revising the nursing interventions or expected outcomes based on the patient’s needs or preferences. When not meeting outcomes, ask questions such as “How has your appetite been?” “Have you noticed a change in your weight?” “How much would you like to weigh?” or “Have you changed your exercise pattern?”
[Review Figure 45-9, Critical thinking model for nutrition evaluation, with students.]
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41. Case Study (Cont.)
Matt sees Mrs. Gonzalez before discharge to a restorative care facility for rehabilitation before returning home. Mrs. Gonzalez now is able to consume all of her required nutrients with a ground diet and nectar-thickened liquids. Matt removes the feeding tube in preparation for her transport to the new facility.
Matt advises Mrs. Gonzalez to continue the care plan and emphasizes that it is important to continue speech therapy.
Matt also discusses the importance of compliance with diet modifications until swallowing function returns completely.
[Ask students: What would Matt write in a documentation note? Discuss.]
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