Nutrition is important for
normal growth and development tissue maintenance and repair cellular metabolism organ function body movement
Food can hold
symbolic meaning
The U.S. Department of Health and Human Services established nutritional goals and objectives for Healthy People 2020
Weight and growth Food and nutrient consumption Iron deficiency and anemia Schools, work sites, and nutrition counseling Food security
The basal metabolic rate
The energy needed to maintain life-sustaining activities (breathing, circulation, HR, temperature) for a specific period of time at rest.
The resting energy requirements (REE)
The amount of energy that an individual needs to consume over a 24 hour period for the body to maintain all of its vital functions at rest
Kilocalories
when food intake equals energy requirements
no change in weight
Nutrients
Elements necessary for normal function of body processes: carbohydrates, proteins, fats, water, vitamins and minerals
Nutrient density
…
Carbohydrates is composed of
Carbon
Hydrogen
Oxygen
Each gram of carbohydrates produce how many kcals?
each gram produces 4 kcal/g
Carbohydrates
serves as a main source of fuel (glucose)
Carbohydrate classification
based on the number of carbohydrate units = saccharides.
Simple Carbohydrates
Primarily in sugars
monosaccharides and disaccharides.
Monosaccharides
do not break down into smaller carbohydrate units includes glucose (dextrose) and fructose
Disaccharides
composed of two monosaccharides and water
includes sucrose, maltose and lactose
Complex Carbohydrates include
polysaccharides
Polysaccharides
insoluble in water
soluble in water
Protein function
- provide source of energy (4 kcals/g)
- assist in transport of nutrients and certain medications
- ingestion of proteins maintains nitrogen balance
Proteins are essential for
growth, maintenance, and repair of the body tissue
Proteins are the building blocks for the synthesis of
DNA and RNA Collagen Hormones Enzymes Immune cells
Amino acids
the simplest form of protein
Amino acids consist of
Hydrogen, Oxygen, Carbon and Nitrogen
Indispensable amino acids
Not synthesized by the body
Needs to be provided via diet
Dispensable amino acids
synthesized by the body
Fats
also known as lipids
provides 9 kcal/g
is the most calorie dense nutrient
Fats are composed of
triglycerides and fatty acids
Triglycerides
three fatty acids attached to a glycerol
Fatty Acids
Saturated
Unsaturated - Monounsaturated and Polyunsaturated
Water is critical because
it makes up 60-70% of body weight
Percentage of total body weight is based on
muscle mass.
greater in lean people and lesser in obese people.
In healthy people, fluid intake equals output through
Elimination, respiration and sweating
In ill people, there might be a need for
Fluid intake d/t fever or GI losses
Fluid restriction d/t cardiopulmonary issues or renal insufficiency
Vitamins
neutralize free radicals
Free radicals
produce oxidative damage to body cells and tissues
increases risk for certain cancers
Vitamin synthesis depends on
dietary intake.
Vitamins are high in
fresh foods not exposed to heat, air and water
Vitamin Classification
Fat soluble: A, D, E and K
Water soluble: C and B-complex
Minerals
inorganic elements essential to the body - acts as catalyst in biochemical reactions. Acts as antioxidants.
Minerals are classified as
Microminerals and Trace elements
Microminerals
Daily requirement more than 100 mg
Help to balance the pH of the body
Promotes acid-base balance
Trace elements
Daily requirement is less than 100 mg
Excess of one trace mineral can cause deficiency of another trace mineral
Digestion
breakdown of food by chewing, mixing and churning (break down of food into absorbable nutrients)
Enzymes
protein substances that act as catalysts to speed up chemical reactions
ex. in saliva-amylase (digest carbohydrates)
Peristalsis
wavelike muscular contractions to move swallowed food through digestive tract
Chyme
acidic and liquefied food
What nutrients are absorbed in the small intestine?
carbohydrates, minerals, protein and water soluble vitamins
After absorption, the nutrients absorbed in the small intestine are processed in the ________ and released into the _________.
After absorption, the nutrients absorbed in the small intestine are processed in the LIVER and released into the PORTAL VEIN CIRCULATION.
About how much water is absorbed in the small intestine?
close to 90% of water is absorbed in the small intestine
Villi
fingerlike projections responsible for nutrient absorption
increase surface area for absorption
Mechanisms for Intestinal Absorption
Active Transport
Passive Diffusion
Osmosis
Pinocytosis
Metabolism
Biochemical reactions in the body.
Metabolism can be
anabolic or catabolic
anabolic
building of complex biochemical substances by synthesis of nutrients
catabolic
breakdown of biochemical substances into simpler forms
Nutrient metabolism consists of three processes
- glycogenolysis
- glycogenesis
- gluconeogenesis
glycogenolysis
breaking glycogen into glucose, carbon dioxide and water
glycogenesis
anabolism of glucose into glycogen for storage
gluconeogenesis
catabolism of amino acids and glycerol into glucose for energy
Chyme
becomes feces in the large intestine
During elimination, water is absorbed into the
mucosa while feces move toward the rectum
The longer the feces stay in the large intestine,
the firmer they become
What stimulates peristalsis?
exercise and fiber
Feces contain
- cellulose
- indigestible substances
- sloughed epithelial cells from the GI tract
- digestive secretions
- microbes
Dietary reference intakes (DRI)
criteria for acceptable range of amounts of vitamins and nutrients for each gender and age group
Food guidelines
Dietary guidelines for Americans (2015-2020) (Box 45-2, p. 1058)
ChooseMyPlate
Daily Values (Food Labels)
Recommended daily values by the US Food and Drug Administration based on 2000 kcal/day for adults and children
There are two sets of reference values
- Referenced Daily Intake (RDI)
2. Daily Reference Values (DRV)
Factors influencing nutrition and eating
sociological
cultural
psychological
emotional
In relation to nutrition, nurse’s need to understand patient’s
values, beliefs, and attitudes about food and how it affects food purchase, preparation and intake.
Environmental factors that influences nutrition
sedentary lifestyle
work schedules
poor meal choices
Factors Influencing Nutrition
Living on a fixed income Good oral health/Periodontal disease (difficulty chewing, missing teeth, oral pain) Medications Type of Diet (Vegetarian, vegan) Eating disorders
Nutrition in young and middle-aged adults
reduction in nutrient demands as the growth period ends
What happens to energy needs over the years?
energy needs decline over the years
Obesity becomes a problem d/t
decreased physical exercise
dining out more often
increased ability to afford more luxury foods
Poor nutrition in pregnancy causes
low birth weight in infants
meeting the needs of a fetus is at the expense of the mother
What can you teach pregnant mothers about nutrition?
quality food intake protein intake (60 g/day) calcium, iron and folic acid intake
Lactation
production of milk increased energy and protein requirements
increased need for vitamins (A and C)
Nutrition in Older Adults (65 and older)
Decreased need for energy d/t slower metabolic rate
Vitamin and mineral requirements remain unchanged
Factors affecting nutritional status in older adults
- Gastrointestinal changes affecting digestion of foods
- Presence of chronic illnesses
- Adverse effects of medications
- Factors contributing to food insecurity (limited income, lack of transportation, limited mobility)
- Cognitive impairments
Nutrition: Assessment
- Assess for an early recognition of malnourished and at-risk patients
- Identify the signs and symptoms associated with altered nutrition
- Gather data from patients regarding nutritional practices and obtain patient’s dietary history
- Determine patient’s nutritional energy needs
- Assess effects of chronic conditions on the ability to prepare meals
Nutrition Screening
Quick method to identify malnutrition or risk for malnutrition
Nutrition Screening includes objective measures such as
height
weight and weight changes
diagnosis and presence of other comorbidities
Nutrition Screenings identify risk factors such as
- unintentional weight loss
- presence of modified diet
- presence of altered nutritional symptoms (N/V, diarrhea, and constipation)
Assess patients for malnutrition when their conditions interfere with
ability to ingest, digest or absorb nutrients
Anthropometry
measurement system of the size and makeup of the body (height and weight)
Weight
weight the patient at the same time each day
on the same scale
with the same type of clothing or linen
Ideal body weight
provides an estimate on how much a person should weigh
Body mass index
measures weight corrected for height
BMI between 25-30
overweight
BMI above 30
obesity
Nutrition: Laboratory and Biochemical Tests
common tests used to measure nutritional status includes measures of plasma proteins, fluid balance, liver function, kidney function and presence of disease.
Diet history and health history includes
- Dietary intake and food preferences
- Unpleasant symptoms
- Allergies
- Taste, chewing, and swallowing
- Appetite and weight
- Use of medications
Dysphasia
difficulty swallowing
Difficulty swallowing can cause complications such as
Aspiration pneumonia
Dehydration
Decreased nutritonal status
Weight loss
Warning signs for dysphasia
- Cough during eating
- Change in voice tone and quality after swallowing
- Abnormal movements of the mouth, tongue, or lips
- Slow, weak, imprecise, or uncoordinated speech
- Incomplete oral clearance or pocketing
- Delayed or absent trigger of swallow
Silent aspiration
- Occurs in patients with neurological problems that lead to decreased sensation
- Often occurs without a cough
Silent aspiration symptoms usually don’t appear for
24 hours
Silent aspiration accounts for
majority of aspirations in patients with dysphasia after stroke
Valid dysphasia-screening tools
increase quality of care
decrease of aspiration pneumonia (bedside swallowing assessment, acute stroke dysphasia screen, standardized swallowing assessment)
Possible nursing diagnosis RT Nutrition
Risk for Aspiration
Diarrhea
Imbalanced Nutrition : Less than Body Requirements
Imbalanced Nutrition: More than Body Requirements
Readiness for Enhanced Nutrition
Impaired Swallowing
Feeding Self-Care Deficit
Planning
- Select interventions to promote optimal nutrition
- Select interventions consistent with therapeutic diets
- Consult with other healthcare professionals to adopt interventions that reflect the patient’s needs
- Involve family when designing interventions
In acute care, patients
- Are often refrained from drinking and eating anything by mouth (NPO)
- Have frequent interruptions during meal times
- Have poor appetites
- Are too tired or uncomfortable to eat
Advancing diets
-NPO patients after extended time or NPO patients who had surgical procedures require specific orders on:
Diet progression
Therapeutic diets
Promoting Appetite
- Keep environment free of odors
- Provide oral hygiene as needed
- Maintain patient comfort
- Offer small frequent meals
- Encourage use of seasoning to improve food taste
- Encourage visitors to eat with the patient
Mealtime is an excellent time for
patient education
Teach patients about
therapeutic diets and adaptive devices to help with in depended feeding
Assisting patients with oral feedings
Protect patient’s safety, independence, and dignity
Clear the side table of clutter
Assess for risk of aspiration
In patients with dysphasia,
- Feed the patient slowly
- Provide small size bites
- Allow the patient to empty the mouth after each spoonful
- Match the speed of feeding to the patient’s readiness *
Enteral tube feeding (enteral nutrition)
preferred in patients unable to swallow or take nutrients orally but have functional GI tract
Enteral Tube feedings via
Nasogastric Jejunal (surgically inserted=jejunostomy) Gastric (surgically inserted= gastrostomy)
After insertion of an enteral tube, placement should be
verified by x-ray
Before patient receives first enteral feeding, what is needed?
confirmation of placement
When advancing the rate of tube feeding, you typically start at
a slow rate (advancing is institution specific, follow the order)
When advancing the rate of tube feeding, the nurse should
- Check for signs of intolerance
- Keep the head of the bed elevated minimum 30-45 degrees
- Measure gastric residual volumes per hospital policy
- Evaluate for aspiration an use measures to reduce risk of aspiration
Parenteral Nutrition or Total Parenteral Nutrition
Nutrition provided intravenously
Administered via central line
Adhere to principles of asepsis and infusion management
Received over a 24-hour period
Parenteral Nutrition or Total Parenteral Nutrition is for patients
unable to digest or absorb enteral nutrition
Parenteral Nutrition or Total Parenteral Nutrition requires
laboratory monitoring
The goal of parenteral nutrition or total parenteral nutrition is to
eventually use the GI tract
Initiating parenteral nutrition
Placement of central line into central vein
Placed by specially trained nurses under sterile conditions
Catheter placement placement confirmation required by radiology
Before starting TPN verify the order
Complications of Parenteral Nutrition
Catheter related problems
Metabolic alternations
Preventing complications of parenteral nutrition
Change TPN tubing every 24 hours Lipid tubing change every 12 hours Do not hang TPN for longer than 24 hours Use chlorhexidine to clean the catheter hub for 15 seconds before and after each time it is used Monitor blood glucose Q6H
Sudden discontinuation of TPN can cause
hypoglycemia (recommended to infuse 10% Dextrose in the meantime, see orders)
During central line dressing changes use
sterile mask and gloves and assess the site for S/S of infection
When should central line dressings be changed?
Change central line dressing per hospital policy or when wet or soiled
Medical nutritional therapy
specific therapies to treat illness, injury or condition
Peptic ulcers are mainly caused by
(up to 85%) by Helicobacter pylori
Peptic ulcers
Stress and overproduction of HCL irritate pre-existing ulcer
Peptic ulcers can be controlled with
regular meals
Patient teaching for peptic ulcers
-Encourage patients to avoid foods that increase stomach acidity
(caffeine, decaffeinated coffee, frequent milk intake, citric acid juices, spices)
-Discourage smoking, alcohol, aspirin, NSAIDs
-Teach patients to avoid eating large meals without snacks especially at bedtime
Inflammatory Bowel Diseases include
Crohn’s Disease
Idiopathic Ulcerative Colitis
Treatment of acute IBDs include
elemental diets
PN when symptoms of diarrhea and weight loss
Treatment of chronic IBDs include
Regularly, highly nourishing diets
Vitamins and iron supplements
Irritable Bowel Syndrome Treatments include
increasing fiber, reducing fats, avoiding large meals and avoiding lactose and sorbitol containing foods
Treatment for Celiac disease (Malabsorption syndrome)
gluten-free diet
Short-bowel syndrome (Malabsorption Syndrome)
results from extensive resection of bowel (lack of intestinal surface area)
Treatments for Short-bowel syndrome (Malabsorption Syndrome)
lifetime feeding with either elemental formula or PN
Diverticulitis
inflammation of diverticula in bowel lining (pouch-like herniations)
Treatment for Diverticulitis
- moderate or low-residue diet in acute diverticulitis
- prescription of high-fiber diet for chronic diverticula problems
Treatment for Diabetes Mellitus
- insulin/oral medications
- maintaining/monitoring a prescribed carbohydrate intake to balance glycemic levels
Treatment for Cardiovascular Diseases
balanced caloric diet intake with exercise to maintain healthy weight
Treatment for Cancer
maximized nutritional therapy that meets the increased metabolic needs
Treatment for HIV/AIDS
restorative care of malnutrition focuses on maximizing Kcal and nutrients
Evaluation: Reassess signs and symptoms associated with altered nutrition including
Weight Calorie intake Protein intake Laboratory results Determine patient's satisfaction with nutritional therapy
Carbohydrates are essential for normal function of the
Brain
Skeletal muscles during exercise
Erythrocytes and leukocyte production
Cell function of the renal medulla
Carbohydrates are primarily obtained from
Plant sources (except milk)
Complex carbohydrates
Made up of many carbohydrate units. Insoluble in water and digested to arming degrees. Ex) glycogen, starches (fiber: not broken down by the human digestive system)
Additionally _____________________________________ all require proteins.
blood clotting, fluid regulation and acid-base balance
Complete protein
Contains all essential amino acids to support growth and maintain nitrogen balance.
Ex. Fish, poultry, soybeans, cheese
Incomplete proteins
Missing one or more of the nine essential amino acids.
Ex. Cereals, legumes, vegetables
Nitrogen Balance
When the intake and output of nitrogen are equal.
Nitrogen Balance = Intake - Output.
Negative Nitrogen Balance
When the intake is less than what the body requires
Negative Nitrogen Balance may occur with
Infections, burns, fever, starvation, head injury, trauma.
Positive Nitrogen Balance
When intake is greater than output.
Positive Nitrogen Balance is essential for
Growth
Normal pregnancy
Maintenance of lean muscle mass and vital organs
Wound healing (to build, repair, and replace body tissues)
Adequate amounts of _______________ for energy expenditure are essential for healing to prevent the body from using _________ as its primary energy source.
Carbohydrates
Protein
Antioxidants neutralizes
Free radicals
Bile
Manufactured in the liver and stored in the gallbladder to emulsify fats
Pancreatic secretions
Contain enzymes to digest starch, emulsify fats and break down proteins
What organ is the primary absorption site for nutrients?
Small intestine
The energy produced by metabolism involves
Mechanical energy: muscle contraction
Electrical energy: nerve impulses
Thermal energy: Heat production
Recommended Daily Allowances
The average needs of 98% of the population (not the exact needs of an individual)
Estimated Average Requirement
The recommended amount of nutrients that appears sufficient to maintain a specific body function for 50% of the population based on age and gender.
Referenced Daily Intakes
Protein, vitamins and minerals based on RDA
Daily Reference Values
Total fat, saturated fat, cholesterol, carbohydrates, fiber, sodium and potassium
Nutritional Requirements are dependent on
Stage of development Body composition Activity Levels Pregnancy and Lactation Presence of disease
Registered Dietitians
Helps develop nutrition treatment plans. I.e calorie counts
Patients that are malnourished on admission are at greater risk of life-threatening complications including
Arrhythmias, sepsis and hemorrhage
Laboratory Tests: Plasma proteins
Albumin
Factors affecting serum albumin include: hydration, hemorrhage, renal or hepatic disease, large amounts of drainage from wounds or the GI tract, steroid administration, exogenous albumin infusions, age and trauma.
Dysphasia leads to
Decreased functional status Increased length of stay Increased cost Increased likelihood of being discharge to LTAC Increased mortality
Pharmacists
Develop PN orders/mixtures
Physical Therapists
Builds strength and endurance
Occupational Therapist
Identify assistive devices.
I.e utensils with large handles, plates with sides
Speech therapists
Help with swallowing exercises and techniques to reduce risk of aspiration.
Understand the effects of medications on:
Taste, appetite and metabolism
Assisting a patient with dysphasia
Sit patient up 90 degrees Head position slightly chin down Place food in stronger side of the mouth Have sanction equipment available Utilize speech therapy to determine viscosity of foods tolerated best.
Four levels of liquid
Thin (low viscosity)
Nectar-like
Honey-like
Spoon-thick (pudding)
Diet progression
Clear liquid -> regular diet
NG tube
Therapy lasting < 4 weeks
G-Tube
For patients with a lower risk of aspiration.
Inserted surgically or through endoscopy
J-tube
(For patients with a higher risk of aspiration)
Inserted surgically or through endoscopy
Benefits of feeding by the enteral route
Reduces sepsis
Minimizes the hyper metabolic response to trauma
Decreases hospital mortality
Maintains intestinal structure and function
Signs of Intolerance for Enteral Feeding
High Gastric Residuals
N/V/D
Cramping
Conditions that increase the risk of aspiration includes
Coughing GERD Nasotracheal suction isn't Any artificial airway Decreased LOC Lying flat
Patients in highly stressed physiological states are candidates for PN
Sepsis, head injury and burns
When is PN therapy usually discontinued?
When 75% of nutritional needs are being met by enteral feelings
HIV precipitates
Weight loss and body wasting, anorexia, stomatitis, oral thrush infection, N/V/D
