Transcript Nutrition
1. Define and describe the concept of nutrition including antecedents & attributes 2. Review physical assessment and nursing interview-history of patients experiencing adequate 3. Identify when nutrition imbalance (negative consequence) is developing 4. Identify which conditions which place a patient at risk for nutrition imbalance. 5. Discuss exemplars of common nutrition disorders. (See above). 6. Formulate and apply the nursing process including appropriate goals, interventions (including collaborative ) for individuals experiencing problems with nutrition imbalance 7. Demonstrate basic nursing measures to promote necessary optimal nutritional balance, dependent on patient needs related to health risks, illness or disorder; alterations of physiologicalpsychological function. 8. Anticipate the outcomes of planned nursing care for patients with nutritional imbalance. 9. Educate-Teach overweight and obese patients the importance of lifestyle changes to promote health. Nutrition the process by which the body ingests, absorbs, transports uses and eliminates nutrients and foods. Oral intake Digestion breakdown of food so it can more easily be absorbed (saliva, enzymes, bile, etc.) Absorption movement of molecules across the GI tract, end products absorbed in the small intestines (vitamins, mineral and water) Elimination Metabolism Catabolism Organized process in which nutrients (CHO, fats, & proteins are broken down, transformed into energy Anabolism uses energy to construct components of cells such as proteins and nucleic acids. More than 90% of body energy is stored as triglycerides in the fat cells of the body Dietary CHO are converted into glucose and stored as glycogen in the liver and skeletal muscles Amino acids from protein are stored as structural proteins, enzymes, nucleoproteins The excess is converted to glucose and used for energy or stored in the liver as glycogen Normally energy utilization is balanced with energy expenditure When a person is overfed and the intake of food consistently exceeds energy expenditure, the excess is stored as fat Conversely, when food intake is less than energy expenditure, fat stores and other tissues are broken down and the person loses weight Collaborative Learning #1 In your learning group, discuss the meaning of the following terms: – Macronutrients – Micronutrients – Carbohydrates – Proteins – Lipids – Vitamins – Minerals – How do the terms relate to the concept of nutrition? Energy output: Basal Metabolic rate (BMR) the rate at which the body metabolizes food to maintain energy requirements Body Weight/Body Mass (indicator of changes in body fat stores) Ideal Body Weight Standardized table BMI = weight in kg divided by height in meters (squared) Waist circumference, skin-fold testing, Bioelectrical Impedance Analysis (BIA), CT and MRI BMI Classification 18.5 or less 18.6 to 24.99 25 to 29.99 30 to 34.99 35 to 39.99 40 or greater Underweight Normal Weight Overweight Obesity (Class 1) Obesity (Class 2) Morbid Obesity All individuals are potentially at risk Socioeconomic status and race or ethnicity can influence risk Populations at greatest risk for problems with nutrition are Very young children Elderly adults Collaborative Learning #2 In your groups identify factors that affect nutrition and discuss why? Development People in rapid periods of growth (infants and adolescents) have increased need for nutrients Elders need fewer calories and dietary changes related to the risk of coronary heart disease, osteoporosis, hypertension, type 2 diabetes, periodontal disease, decrease in peristalsis, loss of taste between sweet and salty prone to dehydration and lack interest in eating Gender Ethnicity and culture body composition differences effects of reproductive function (higher iron needed) may influence food preferences Cooking, preparation, types of diets, selection of food (no pork) Food beliefs may be related to the popular media food fads may also influence nutrition Religious /Cultural practices Prohibit pork, avoid meat Hindus do not eat beef Kosher special food preparation Lifestyle economics Medications may affect appetite, taste, absorption, excretions Nutrient absorption, change the pH, increase GI motility damage mucosal Alter renal function drug-food interactions, therapy (chemotherapy and radiation) Health Dental problems, dysphagia, disease processes, and surgery can influence nutrition Alcohol consumption Interferes with normal absorption Requirements increase as efficiency of absorption decreases (Vitamin B) may cause weight gain excessive use may cause nutritional deficiencies Moderate use health benefits Advertising attempts to persuade people to purchase certain foods and may target specific age groups Meaning of food (drastic weight loss, association with family, celebrations, etc.) Psychological factors Some people who are stressed, depressed, or lonely may overeat while others eat less Certain psychophysiological diseases (anorexia nervosa and bulimia) will influence nutrition Illiteracy Language barriers Knowledge of nutrition Lack of care giver or social support Social isolation limited ability to obtain or purchase food Inadequate cooking and/or food preparation Shift to more plant-based foods such as vegetables, fruits, grains, beans, and nuts Significantly reduce foods with added sugars and solid fats Engage in regular exercise (30 min/day) Consume foods including milk products, each day that increase commonly insufficient nutrients: vitamin D, calcium, potassium and fiber If you drink alcohol do so in moderation Vegetarians must eat complementary protein foods Foods of animal origin are the best source of vitamin B12 therefore, vegans need to obtain this vitamin from other sources Iron from plant sources are not absorbed as efficiently as iron from meat, therefore vegans should eat iron-rich foods and eat a food rich in vitamin C at each meal to enhance iron absorption Plate = New Symbol for Healthy Eating • The pyramid had six vertical stripes to represent the five food groups plus oils. • The plate features four sections (vegetables, fruits, grains, and protein) plus a side order of dairy in blue • http://youtu.be/SEFmSk08LIE • http://youtu.be/qJChJmDwQLo Protein-Calorie Malnutrition (PCM) Most common form of malnutrition Primary cause - poor eating habits Starving children in underdeveloped countries Long-term caloric intake deficiencies Secondary causes - defective ingestion, digestion, absorption, or metabolism; GI obstruction; cancer; malabsorption syndrome; medications; infectious diseases Cognition Thermoregulation Attributes Adequate Intake for: Development-Energy- GrowthTissue Repair Ideal Ht-Wt-BMI—(MAC) (MAMM) Muscle Tone-Strength-Agility-Reflex Response Cognitive & Mood Response. Albumin WNL Hemoglobin & Hematocrit WNL Electrolytes WNL Nursing Care Patient Education Metabolism Clotting Interrelated Concepts Fluid and Electrolytes Diversity-(Lifestyle-Culture) Human Development Antecedents Normal Alimentary Tract and Associated Organs Adequate Ingestion of Nutrients and Water Normal Temperature Normal ph Nutrition The process by which the body ingests, absorbs, transports uses and eliminates nutrients and foods (NC) Medical Conditions Consequences (Outcomes) Negative Malnutrition Insufficient/Excess Intake Failure to thrive--Obesity Malnutrition Physiological-Psychological- Dysfunction Ingestion- Digestion-Absorption-Metabolism Risk factors Physiological & Psychological Development Medications Age-Gender-Genetics Sub Concepts Ethnicity Socioeconomics Knowledge Lifestyle Behaviors Diets Growth & Tissue Repair Positive Homeostasis/Adequate Nutrition Hydration Nutrients Food Allergies Physiological and Psychological Wellness Engage in Physical Activity Altered Hydration Status Low energy-Fatigue Depression-Isolation Growth/ Developmental Delay Decreased Bone Density Delayed-Inadequate Healing Illness-Muscle wasting-Death ATTRIBUTES -CHARACTERISTICS Adequate intake Ideal height, weight, BMI Presence of adequate muscle tone, strength, agility Appropriate cognition and mood response Albumin, Electrolytes and Hbg, Hct, within defined limits ANTECEDENTS – WHAT COMES BEFORE Normal alimentary track and associated organs Adequate intake of nutrients and water Normal temperature Normal pH INTERRELATED CONCEPTS Thermoregulation Metabolism Cognition Clotting Fluid and Electrolytes Immunity Lifestyle and Culture Developmental SUB-CONCEPTS Age, Gender, Genetics Risk factors Ethnicity, Socioeconomics Lifestyle behaviors Medications Medical conditions Food allergies Physiological/Psycholo gical development POSITIVE CONSEQUENCES Homeostasis, adequate nutrition and hydration Physiological/Psycholo gical wellness Growth and tissue repair Ability to engage in physical activity NEGATIVE CONSEQUENCES Malnutrition – obesity Malnutrition – failure to thrive Low energy, fatigue Depression Growth and development delay Decreased bone density Delayed or inadequate healing Illness, muscle wasting, death Collaborative Learning #3 In your groups select one of the nutrition exemplars in the green box and link it to the elements of concept analysis in the beige box. Upon completion present to the class. Elements of Concept • • • • Nutrition Exemplars 1)Dysphagia 2)Protein–calorie malnutrition 3)Iron deficiency anemia 4) Obesity • • • • • • Analysis Category Risk factors Physiologic process and consequences Assessment Collaborative management Interrelated concepts 3 Basic Components Nutrition History Physical Exam Diagnostic and lab data Assessment Nutritional Screening Nursing history Physical examination Calculating percentage of weight loss Dietary history Anthropometric measurements Measuring skinfold Laboratory data Age, sex, activity level Difficulty eating – chewing, swallowing, mouth, teeth, dentures Changes in appetite and weight Physical disabilities that affect purchasing, preparing and eating food Cultural/religious beliefs that affect food choices Living arrangements/socioeconomic issues Medical condition, medication history Purpose Performed to identify patients at risk for malnutrition or with poor nutritional status Carry out nutritional screens through routine nursing histories and physical exams Patients found to be at moderate or high risk are followed with a comprehensive assessment by a dietician Nursing homes residents whose percent of meals eaten falls below 75% receive a full nutritional assessment by a nurse DETERMINE can be used to screen for warning signs of poor nutritional health: Disease: Any disease, illness or chronic condition that causes a change in appetite Eating poorly: eating too little or too much Tooth loss/mouth pain: missing, loose, or rotten teeth or dentures that don’t fit well Economic hardship: having less or choosing to spend less on food Reduced social contact: being with people has a positive effect on eating PE reveals some nutritional deficiencies and excesses in addition to obvious weight changes Assessment of skin, hair, nails, eyes and mucosa, tongue, muscles of GI system, NS To confirm malnutrition, clinical findings need to be substantiated with laboratory tests and dietary data i.e., dry, dull hair may be related excessive sun exposure rather then severe protein malnutrition Laboratory tests Albumin; blood glucose; hemoglobin A1c; lipid profile; electrolytes; blood urea nitrogen; tests to rule out anemia; calcium, phosphorus, and vitamin D levels Radiographic scans DXA scans (bone density) Measuring triceps skinfold: measures body composition measures fat stores Measuring mid-arm circumference Serum protein Prealbumin “gold standard” in assessing possible protein malnutrition responses to rapid changes Low serum albumin indicates prolonged protein depletion (could also be indicative of altered liver function, hydration status, and losses from open wounds and burns) Hemoglobin (may be evidence of Fe deficiency anemia) Total Iron Binding Capacity (TIBC) – carries Fe from intestine through serum (measures protein depletion through transferrin) Nitrogen balance Reflects the status of protein nutrition in the body Net result of intake and loss of nitrogen When nitrogen intake equals nitrogen output, a state of nitrogen balance exist Total lymphocyte count the total number of lymphocytes decrease as protein decreases Protein calorie malnutrition can depress the immune system What is the main difference between albumin and prealbumin? Albumin- most useful when used to monitor long term nutrition changes in protein (sometimes normal values are still found among patients who are recently malnourished (10-14 day half life) Prealbumin- monitors short term protein status b/co of short half life (2days) Urea (BUN 10-20 mg/dL) Chief end product of amino acid metabolism Excreted by kidneys Urea in the blood and urine directly reflect the intake and breakdown of dietary protein Urine Creatinine Excretion (0.7-1.4 mg/dL) Creatinine is the product of muscle creatinine catabolism, the greater the muscle mass, the greater the excretion of creatinine Influenced by protein intake, exercise, age, sex, height, renal function and thyroid function 24 Hour Food Recall Food Frequency Record How frequent specific foods or food groups are eaten, categorized as times/day, seldom, frequent, etc., specifies types of food not quantity Food Diary all food and beverages consumed in a 24 hour period 3 to 7 day detailed record of food intake, portion Diet History In addition to a 24-hour recall Calorie counts/food diaries and food frequency record Nutritionist or Dietitian conducts Imbalanced Nutrition: More than/less than Body Requirements Readiness for Enhanced Nutrition Risk for Imbalanced Nutrition: More Than Body Requirements Activity Intolerance Constipation Low Self-Esteem Risk for Infection Knowledge deficit Ineffective management of therapeutic regimen Swallowing impaired Risk for impaired skin/tissue integrity Risk for Aspiration Patient will maintain or restore optimal nutritional status as evidenced by (AEB): Patient will demonstrate healthy nutritional practices as evidenced by (AEB): Patient will demonstrate absence of complications associated with malnutrition as evidenced by: Patient will have a decrease in weight of ___by_________: Patient will regain weight of___ by________: Weight reduction assistance Nutritional counseling Behavior modification To promote optimal nutrition for hospitalized patient done in collaboration with physician/dietician Nurse reinforces instruction Monitors and assist with eating In the community setting, the nurse's role is largely educational Health fairs, schools, prenatal classes, homes Special diets (clear liquids, full liquid, pureed, soft and diet as tolerated) (Taylor, pg. 1185) Diet modification for disease-calorie restriction (diabetic diet or supplements) Improving appetite (p. 1183) Assist with meals (utensils, adaptive feeding aids, plates (p. 1184) Review stimulating appetite (Taylor, p. 1183) When might the following diets be used: clear liquid, full liquid, mechanical soft, and soft diet? clear liquid- before/after surgery; hydrates but no energy (fat, protein, carbs) full liquid- patients who can’t chew or swallow solid food, more variety and nutritious mechanical soft- problems chewing/swallowing regular food soft diet- transition between liquid and regular diets Dysphagia A reduced gag reflex indicates the patient will have difficulty swallowing, May have inadequate solid or fluid intake May be unable to swallow their medications May aspirate food or fluids in their lungs Patients at risk for dysphagia include: older adults, those who have experienced a stroke, patients with cancer who have had radiation therapy to the head and neck and others with cranial nerve dysfunction Dysphagia Consult with dietitian, occupational therapist, swallowing specialist, speech-language pathologist, and/or primary care provider on approach Four levels of liquid foods are thin, nectar-like, honey-like, and spoon-thick liquids Four levels of semisolid/solid foods are pureed, mechanically altered, advanced/mechanically soft, and regular/general Dysphagia Provide at least a 30-minute rest period prior to mealtime Sit the patient upright or elevate HOB 90° Avoid rushed or forced feeding Initiate a nutrition consult Alternate solids and liquids Assess for signs of aspiration Hand washing Positioning (clock system) Over-the-bed tables Correct diet (name check) Assist the patient as required (remove covers, cut meat, etc.) Use straws when possible Record % eaten and fluids consumed Record observations (choking, nausea, fatigue or pain) If not eating, record so collaborative changes can be made Nasogastric Tubes Salem sump used for decompression Feeding tube Nasogastric tube (salem sump) short term use, not advised for patients with intact gag reflex Nasoenteric tube (Dobhoff) used for patients at risk for aspiration Gastrostomy tube (long term use > 6-8 weeks) Percutaneous Endoscopic Gastrostomy Tube (PEG) Percutaneous Endoscopic Jejunostomy Tube (PEJ) SALEM SUMP (NG TUBE) DOBHOFF FEEDING TUBE Before feedings are introduced, tube placement is confirmed by: Radiography, particularly when a small-bore tube has been inserted or when the patient is at risk for aspiration Methods used to check tube placement Aspirate GI secretions (pH <5.5) Measure the pH of aspirated fluid (acidic 5> confirm with x ray) Confirm length of tube insertion with the insertion mark CO2 sensor *Auscultate the epigastrium while injecting 5-20 ml air The type and frequency of feedings, amounts to be administered are ordered by the physician Enteral feedings can be given intermittently or continuously Bolus intermittent feedings are those that use a syringe to deliver the formula into the stomach monitor closely for distention and aspiration administered 300-500 ml several times/day over 30 minutes Intermittent feedings are preferred for gastric feeding Delivered at regular intervals in equal portions, introducing formula gradually in equal portions Cyclic feeding Allows the patient to attempt eating regular meals during the day and feed continuously for a portion of the 24-hour period 12-16 hours (usually at night) Continuous feedings are generally administered over a 24-hour period using an infusion pump Essential when feedings are administered in the small bowel To avoid dumping syndrome (over distension) What position during feeding should a patient be in and for how long afterwards? Patient should be in a Fowler’s position at least 30 degrees elevation in bed or a sitting position in a chair for 1 hour afterwards to prevent reflux and aspiration What are three types of tube-feeding complications? GI diarrhea, N/V, cramping, distention, constipation Mechanical tube displacement, aspiration, mucosal damage obstruction, Reposition patient, flush, commercial declogging kits Metabolic Dehydration, overhydration, abnormal blood levels of Na+, P, Mg+, rapid weight gain, hyperglycemia Refeeding syndrome (F&E shift due to malnutrition) Total Parenteral Nutrition (TPN) Mix of 10% to 50% dextrose in water, fat, proteins, electrolytes, vitamins, trace elements fat emulsions may be given to provide essential fatty acids ONLY administered via central lines (hypertonic) What is the greatest concern with TPN? Infection control is greatest concern Observe surgical asepsis when changing solutions, tubing, dressings, and filters Total Parenteral Nutrition (TPN) At increased risk of fluid, electrolyte and glucose imbalances start gradually to prevent hyperglycemia Patient needs to adapt to TPN therapy by increasing insulin output Glucose levels are monitored during the infusion When discontinued, rates are decreased slowly to prevent hyperinsulinemia and hypoglycemia May take up to 48 hours Peripheral Parenteral Nutrition Delivered into the smaller peripheral veins Solutions are isotonic Cannot handle as concentrated solution as central lines, (max dextrose 10 to 12%) can accommodate lipids Major disadvantage – high incidence of phlebitis If the gut is functioning but oral (PO) intake is poor, which should be started—enteral or parenteral feedings? Enteral What is the difference between total parenteral nutrition (TPN) and peripheral parenteral nutrition (PPN)? TPN- parenteral nutrition delivered into large diameter vein (vena cava) Formula is a higher concentration of glucose Fat or lipid emulsions added PPN- small periphery vein (forearm) Provide fewer calories and supplements a patient’s oral intake Contains 10% glucose Bariatric surgery Nonmalabsorptive procedures Malabsorptive procedures Common complications Surgical complications Nutrient deficiencies Weight loss medications Antilipid agents Micronutrient supplements Parenteral nutrition General Discussion Question Why does the figure above show overlapping of the concepts of glucose regulation and nutrition?