Transcript NUR 102 Module J nutrition student copyx

Chapter 44
Nutrition
Background
• Food security is critical for all members of a household.
• Food holds symbolic meaning.
• Medical nutrition therapy uses nutrition therapy and
counseling to manage disease.
– Type 1 diabetes mellitus
– Hypertension
– Inflammatory bowel disease
– Enteral nutrition (EN); parenteral nutrition (PN)
Nutritional Guidelines
• Healthy People 2020; Health for All (WHO)
• Guidelines for dietary change recommend reduced fat,
saturated fat, sodium, refined sugar, and cholesterol, and
increased intake of complex carbohydrates and fiber.
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.
Energy Requirements
• Basal metabolic rate—the energy needed to maintain life-sustaining
activities for a specific period of time at rest
• Resting energy expenditure (REE) (aka resting metabolic rate)—the
amount of energy that an individual needs to consume over a 24-hour
period for the body to maintain all of its internal working activities while at
rest
• In general, when energy requirements are completely met by kilocalorie
intake in food, weight does not change.
Scientific Knowledge Base:
Nutrients
Carbohydrates
Complex and simple saccharides
Main source of energy
Proteins
Amino acids
Necessary for nitrogen balance
Fats
Saturated, polyunsaturated and monounsaturated
Calorie-dense
Scientific Knowledge Base:
Nutrients (cont’d)
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
Digestion
Digestion
Absorption
Begins in the mouth and ends in
the small and large intestines
Intestine is the primary area of
absorption.
Metabolism and storage of
nutrients
Elimination
Consist of anabolic and catabolic
reactions
Chyme is moved through
peristalsis and is changed into
feces.
Dietary Guidelines
• Dietary reference intakes (DRIs)
– Acceptable range of quantities of vitamins and minerals for each gender and age
group
• Food guidelines
– Dietary Guidelines, average daily consumption
• Daily values
– Needed protein, vitamins, fats, cholesterol, carbohydrates, fiber, sodium, and
potassium
ChooseMyPlate
Case Study (cont’d)

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.
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 and intakes.”
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
Case Study (cont’d)
• 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.
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)
– Fruitarian (consumes fruit, nuts, honey, and olive oil)
• Zen macrobiotic
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
Assessment (cont’d)
• 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
Assessment (cont’d)
• 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)
Case Study (cont’d)
• 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.
Nursing Diagnosis
Risk for aspiration
Deficient knowledge
Readiness for
enhanced nutrition
Diarrhea
Feeding self-care
deficit
Impaired swallowing
Imbalanced
nutrition: more than
body requirements
Imbalanced
nutrition: less than
body requirements
Risk for imbalanced
nutrition: more than
body requirements
Case Study (cont’d)
• 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.
Planning
• Nutrition education and counseling are important for all patients to
prevent disease and promote health.
• Refer to professional standards for nutrition.
• Collaboration with a registered dietitian (RD) helps develop appropriate
nutrition treatment plans.
• Considerations:
– Perioperative food intake
– Enteral and parenteral feedings
– Assistive devices
Implementation
• Health promotion
– Education
– Early identification of potential or actual problems
– Meal planning
– Weight loss plans
– Food safety
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
• When a patient needs help with eating, it is important to protect his or her safety,
independence, and dignity.
Adaptive Equipment
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
Enteral Tubes
pH Measurement for Tube Location
Case Study (cont’d)
• Nutritional management
– 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.
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 w/normal saline.
C. Check to see that the tube is properly placed.
D. Introduce a small amount of fluid into the tube before feeding.
Parenteral Nutrition
• Nutrients are provided intravenously.
• Patients unable to digest or absorb enteral nutrition or are in highly
stressed physiological states:
– Sepsis
– Head injury
– Burns
• Peripheral or central line
• Initiating parenteral nutrition
• Preventing complications
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
Medical Nutrition Therapy
• Gastrointestinal diseases
– Peptic ulcer etiology
• Helicobacter pylori
• Stress
• Acid overproduction
– Peptic ulcer treatments
•
•
•
•
Avoid caffeine.
Avoid spicy foods.
Avoid aspirin, NSAIDs.
Consume small, frequent meals.
Medical Nutrition Therapy (cont’d)
• 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
Case Study (cont’d)
• 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.
• What expected outcomes would Matt set for the teaching session?
Medical Nutrition Therapy
• Malabsorption syndromes
– Celiac disease
• Gluten-free diet
– Short bowel syndrome
• Intestinal surface decrease
• Lifetime EN or PN
– Diverticulitis
• Inflammation of diverticula
• Low- to moderate-residue diet for infection
• High-fiber diet for chronic conditions
Medical Nutrition Therapy (cont’d)
• 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
Medical Nutrition Therapy (cont’d)
• Diabetes mellitus
– Goals
•
•
•
•
Normal to near-normal glucose levels
Less than 100 mg/dL low-density lipoprotein (LDL)
Less 130/85 mm Hg
Avoidance of hypoglycemia
Medical Nutrition Therapy (cont’d)
• 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%.
Medical Nutrition Therapy (cont’d)
• 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.
Medical Nutrition Therapy (cont’d)
• Cancer and cancer treatment
– Nutrition management
• Maximize fluid and nutrient intake.
• Individualize diet choices to patient’s needs, symptoms, and situation.
• Encourage small, frequent meals and snacks that are easy to digest.
Medical Nutrition Therapy (cont’d)
• Human immunodeficiency virus/acquired immunodeficiency
syndrome
– 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.
Case Study (cont’d)
• What nursing actions are appropriate for evaluating whether
goals have been met?
– Consider the patient’s perspective.
– Check measurable outcomes.
– Consult with interdisciplinary staff.
Evaluation
• Multidisciplinary collaboration remains essential in providing
nutritional support.
• Changes in condition indicate a need to change the nutritional
plan of care.
• Consider the limits of patients’ conditions and treatments, their
dietary preferences, and their cultural beliefs when evaluating
outcomes.