1. ALTERATIONS IN NUTRITION Jennifer B. Cowley, RN, MSN

2. Objectives: * Who’s at risk? * Labs? Diagnostic tests? * Assessment - What do they look like? * Nursing Diagnoses - What’s the problem? * Therapeutic diets - What should they eat? * Nursing interventions - What should you do? * Enteral & parenteral nutrition - What are the nursing implications?

3. Clients with Nutritional Problems: Who’s at Risk? 4 Dietary history 4 Medical history

4. Lab Values 4 Serum hemoglobin & hematocrit –“H&H” 4 Serum albumin 4 Serum pre-albumin

5. Hemoglobin & Hematocrit 4 Hgb - iron-containing pigment of the RBC’s –Normal lab values: female - 12-16 g/100 ml male - 14-18 g/100 ml 4 Hct - % of whole blood occupied by RBC’s –Normal lab values: female - 37-47% male - 40-54%

6. Albumin 4 Synthesized in the liver from amino acids 4 Accounts for > 50% total serum proteins 4 Indicator of prolonged protein depletion 4 Normal lab value: –3.5-5 g/dl

7. Pre-albumin 4 A precursor to albumin 4 Determines protein depletion in acute conditions 4 Normal lab values: –15-36 mg/kl

8. Diagnostic Tests 4 Gastroscopy –direct visualization 4 Upper Gastrointestinal Series (UGI) –indirect x-ray exam

9. Manifestations of Major Nutritional Deficiencies… Harkreader, p.703, Table 30-1

10. The nursing assessment enables the nurse to determine whether actual or potential nutritional problems exist.

11. NANDA Nursing Diagnoses 4 Altered Nutrition: Less than Body Requirements 4 Altered Nutrition: More than Body Requirements 4 Risk for Altered Nutrition: More than Body Requirements

12. Examples of Secondary Nursing Diagnosis for Clients with Nutritional Problems 4 Activity Intolerance r/t insufficient energy from protein depletion 4 Altered Oral Mucous Membranes r/t oral intake 4 Constipation r/t inadequate dietary intake and fiber 4 Self-Esteem Disturbance r/t obesity 4 Risk for Impaired Skin Integrity r/t intake of proteins, vitamins, and minerals

13. Commonly Prescribed Therapeutic Diets 4 Regular Diet –Who? Clients who do not have special needs –What? 2500 cal/day, variety of food groups

14. Diets: NPO 4 Nothing by Mouth (NPO) –Who? Prior to surgery/certain diagnostic test To rest the GI tract When problem has not been identified –What? NPO

15. Diets: Clear Liquid 4 Clear Liquid Diet –Who? Surgical clients –What? Only liquids that keep the GI tract empty (no residue) - i.e., apple juice, broth, carbonated beverages, gelatin. No dairy products

16. Diets: Full Liquid 4 Full Liquid Diet –Who? Primarily postoperative clients –What? Consists of liquids or foods that turn to liquid at body temperature

17. Diets: Soft 4 Soft Diet –Who? For clients experiencing difficulty in chewing and swallowing; also for those with impaired digestion/absorption –What? Avoid nuts, sees, raw fruits/vegetables, fried foods, whole grain.

18. Diets: Mechanical Soft 4 Mechanical Soft Diet –Who? For clients experiencing difficulty chewing - i.e., poorly fitting dentures –What? Similar to soft; however, allows clients variation - permitting foods with different tastes, such as chili beans

19. Diets: Pureed 4 Pureed Diet –Who? For clients with dysphagia –What? Food that has been blenderized to a smooth consistency

20. Diets: Low-Residue 4 Low-residue Diet –Who? Clients that need minimal GI irritation (diverticulitis, ulcerative colitis, Crohn’s disease) –What? Has reduced fiber and cellulose. Avoid raw fruits (except bananas), vegetables, seeds, plant fiber, and whole grains. Limited dairy products (2 servings/day)

21. Diets: High-Fiber 4 High-fiber Diet –Who? To increase elimination –What? Opposite of low-residue

22. Diets: Bland 4 Bland Diet –Who? Clients with gastritis and ulcers –What? Eliminates chemical and mechanical food irritants, such as fried and spicy foods, alcohol and caffeine I don’t think so!

23. Diets:Fat-Controlled 4 Low-Fat Diet –Who? Clients with heart disease, atherosclerosis, and obesity –What? Decreased saturated fats (replace with mono/polyunsaturated fats) and restricting cholesterol Uh-oh!

24. Diets: Sodium-Controlled 4 Low-Sodium Diet –Who? Clients with hypertension, heart failure, myocardial infarction/MI (heart attack), renal failure –What? Mild - 2-3 g Moderate - 1000 mg Strict - 500 mg Severe - 250 mg

25. Diets: American Diabetic Association (ADA) 4 Diabetic Diet –Who? Diabetics (of course!) –What? Specified number of calories, amount of fat, carbohydrates, and protein at each meal, with snacks included. No concentrated sweets (NCS). A no-no!

26. Any diet is only as good as the client’s willingness to follow it. Meal plans should be individualized and developed in collaboration with the client.

27. Monitoring Intake & Output/ “I&O” 4 Purpose: To monitor client’s fluid status over a 24 hour period 4 Who should be on I&O? 4 Medical vs. nursing decision? 4 Check clinical agency policy 4 Inaccuracies of I&O

28. I&O: Intake 4 Oral fluids 4 Ice chips 4 Foods that become liquid at room temperature 4 Tube feedings 4 Intravenous fluids/medications 4 Catheter/tube irrigants

29. I&O: Output 4 Urine 4 Diarrhea 4 Vomitus (emesis) 4 Tube drainage

30. I&O: Nursing Responsibilities 4 Client/family teaching 4 Documentation 4 Relay to others that client is on I&O 4 Look for trends over 48-72 hours

31. The Malnourished Client: Nursing Interventions 4 Stimulate the appetite 4 Assist the client with eating 4 Initiate client/family counseling

32. Assisting the Client with Feeding

33. ENTERAL NUTRITION

34. If the client will not, should not, or cannot eat, enteral nutrition may be provided with nasogastric, gastric or jejunal tubes.

35. Feeding tubes: Placement 4 Nasoenterally 4 Surgically –Gastrostomy –Jejunostomy 4 Endoscopically –Percutaneous endoscopic gastrostomy (PEG)

36. Placement of Enteral Nutrition Tubes

37. Nasoenteral Feeding Tubes: Types 4 Large-bore 4 Small-bore –90-95% of clients in hospital have small bore –more flexible, comfortable –stylet inserted into lumen

38. Nasoenteral: Small-bore Feeding Tube 4 Short term 4 RN performs blindly at the bedside 4 X-ray the only reliable method of placement verification 4 Nasogastric, nasoduodenal, or nasojejunal 4 Small bowel usually preferred over stomach in acutely ill clients

39. Feeding Tube: Who does what? 4 MD orders: –Type of tube –Rate and type of formula 4 RN: –Inserts feeding tube –Administers/monitors tube feeding

40. Enteral Feeding Tube: Confirmation of Tube Placement 4 Radiologic confirmation 4 Bedside methods: –Auscultatory method –Aspiration of gastric contents –pH method

41. Gastrostomy/Jejunostomy: “G-tube/J-tube” 4 Long term 4 MD performs in OR 4 Incision through abdominal wall creating an artificial fistula 4 More cosmetically appealing/more comfortable 4 Larger lumen allows more flexibility for feeding/medication administration

42. Percutaneous endocscopic gastrostomy: “PEG” tube 4 Long term 4 MD performs at bedside or in endoscopy room 4 Does not require surgery, therefore less risky and expensive than G/J tube insertion

43. Percutaneous Endoscopic Gastrostomy Tube

44. PARENTERAL NUTRITION PARENTERAL NUTRITION Total Parenteral Nutrition “TPN”

45. Total Parenteral Nutrition 4 Candidates for 4 What’s in 4 Tonicity of 4 Complications r/t 4 Lipids given with TPN

46. That’s All, Folks!