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					Good Nutrition

Developed by Ginger Mize RN, MN
     Modified by Jill K. Ray

 Basic Human Need
 Changes throughout the life cycle
 Changes along the wellness-illnes

 Necessary to survive
 Source of pleasure
 Pastime
 Social event

Different meanings to different

   Specific biochemical substances used
    by the body for growth, development,
    activity, reproduction, lactation,
    health maintenance, and recovery
    from illness (p. 1413).
       Essential Nutrients

 Not synthesized in the body
 Made in insufficient amts
 Must be provided in the diet
        Six Classes of Nutrients

   3 supply energy
     Carbohydrates
     Proteins
     Lipids

   3 are needed to regulate body
     Vitamins
     Minerals
     Water
         Energy Balance
 Energy is derived from foods
 Measured in form of kilocalories,
  abbreviate as calories.
              Energy Balance
   What are the body’s sources of
       Carbohydrates, protein, and fat
   If a person’s daily energy intake is
    equal to total daily energy
    expenditure the person’s wt will
    remain stable.

   Main source of
   Glucose
       Brain
       Skeletal muscles
       Sugars & Starches
       Easy to produce and store
       In some countries where grains are dietary
        stable, CHO may contribute as much as 90% to
        daily calorie consumption
   Some sources correlate to income.
    Speculating that as income increases, CHO
    intake decrease and protein intake

   More easily and quickly digested than
    protein and fat. 90% is digested.
    This percentage decreases as
    ____intake increases.

   fiber
                 Fats (Lipids)
   Triglycerides and fatty

   Saturated
    Unsaturated fatty acids

   Synthesis of body
   Collagen, hormones,
    enzymes, immune
   Amino acids: essential
    and nonessential

       Nitrogen balance

   Comprises 60% to 70% of body

   Cell function depends on a fluid
Sources, functions, & significance of Carbohydrates
                 , proteins, & fats

 P.1419 Table 42-3
 Note functions that this table lists for
  the nutrient.
      Which nutrient should a patient increase in
      his diet after surgery?
Sources, functions, & significance of Carbohydrates
                 , proteins, & fats

   Note food sources of the nutrient.
       Which of the following should this same
       patient eat 1st on his lunch tray: orange,
       chicken tenders, Lima beans, whole wheat
   Water soluble (Vitamin C and the B-
    complex vitamins)
       Not generally stored in body
       Need daily intake to prevent symptoms of
   Fat soluble (ADEK)
       Must be attached to a protein to be
        transported through the blood
       Secondary deficiencies can occur anytime fat
        digestion or absorption is altered (i.e.
        malabsorption syndromes, mega diets…)
   Some provide structure within the body
   Some help regulate body processes
   Macro minerals (those needed by the body
    in amts greater than 100mg/day)
         Calcium
         Phosphorus
         Sulfur
         Sodium
         Chloride
         Potassium
         magnesium

 Major body constituent present in
  every body cell
 More vital to life than food.
 Provides the fluid medium necessary for
  all chemical reactions,
 participates in many reactions,
 is not stored in the body.
 Acts as a solvent, aiding in digestion
 Assists in the regulation of body
 Acts as a lubricant for mucous

 Accounts   for 50-60% of adult
  total wt
 2/3 is contained in the body’s
  cells (intracellular fluid – ICF)
 1/3 all other body fluids
  (extracellular fluid – ECF) this
  includes plasma and interstitial
        Basal Metabolism

 Energy required to carry on the
  involuntary activities of the body at
 the energy needed to sustain the
  metabolic activities of cells and
  tissues and to maintain circulatory,
  respiratory, gastrointestinal, and
  renal processes (p. 1415).
     Who has the highest Basal
        Metobolism Rate?
 Men
 Women
 Why

   Because of higher muscle mass.
    Men are about 1cal/kg and
    women .9 cal/kg.
    What other factors increase
 Growth
 Fever
 Infections
 Emotional tension,
 Extremes in temperature
 Hormone levels (thyroid hormone,
    What decreases BMR?

 Aging
 Prolonged fasting
 sleep
           Ideal Body Weight

 Body Mass Index
 Waist circumference

   Formula:
     BMI = wt in kg/(ht in meters) times (height in
     BMI = (wt in lbs/(ht in inches) times (height in
      inches)) times 703
        General Guidelines

 BMI   below 18.5 is underweight
 BMI   of 25 – 29.9 is overweight
 BMI   of 30 or greater obesity
 BMI   of 40 or greater extreme obesity
Calculate BMI for a patient who weighs
     100 pounds and is 5 feet tall.

     BMI = (wt in lbs/(ht in inches) times
     (height in inches)) times 703

 BMI = (100/60 times 60) times 703
 BMI = (100/3600) times 703
 BMI = .027 times 703 = 19.52

 BMI   below 18.5 is underweight
 BMI   of 25 – 29.9 is overweight
 BMI   of 30 or greater obesity
 BMI   of 40 or greater extreme obesity

   How would you characterize this pt’s
                 Weight loss
   Usual wt – present wt /usual wt times 100

   Significant if:
       1%-2% in 1 week
       5% in 1 month
       7.5% in 3 months
       10% in 6 months
    Factors Affecting Nutrition
   Food intake
       Decreased food intake can be related to
            disease,
            psychosocial causes,
            impaired ability to smell and taste,
            drug therapy,
            medical treatments,
            difficulty chewing and swallowing, chronic GI
            certain chronic illnesses (ca)
            Inadequate food budgets
            Nausea
            pain
         Nursing Indications….

   If a pt is NPO…what is our
    responsibility as a healthcare provider
    to ensure that he maintains an
    adequate nutritional status?
       Consider:
         Nutrients(which ones?)
         Water balance
         Can we feed a pt that a MD has made NPO?
        Factors food intake:

   Increased food intake:
       Excess   wt increases the risk
           for numerous medical problems
           assoc with surgery
           For complications during pregnancy, labor, and
           Incr morbidity and mortality
       Reasons    for overeating….
    Physiologic and physical factors that
      influence nutrient requirements

   Developmental considerations:
     Throughout the life cycle nutrient needs
      change in relation to growth,
      development, activity, and age-related
      changes in metabolism and body
     Review each area in this section of the
      required reading

   Men have more muscle mass and
    therefore have higher caloric and
    protein requirements than women.
                State of Health
   Trauma (major surgery, burns, crush
       Dramatically alters the body’s use of nutrients.
       Nutrient requirements increase dramatically to
        allow the body to preserve or replenish body
        nutrient stores and to promote healing and
   Mental health problems can cause
    to forget to eat, or lack
    motivation to eat.
          Alcohol Abuse

 Affects the intestinal mucosa.
  Interferes with normal nutrient
  absorption, so requirements for the
  nutrients increase as the efficiency of
  absorption decreases.
 Need for B vitamin increases because
  they are used to absorbed alcohol.

   Especially drugs that
     alterthe pH of the GI tract
     Increase GI Motility,
     damage intestinal mucosa,
     bind with nutrients
 Sociocultural and Psychosocial
 Mormons: no coffee, tea, alcohol,
  encouraged to limit meat
 Hindus do not eat beef, many Hindus
  are vegetarians
 Kosher dietary laws: special food
  preparation techniques and prohibit
  the intake of pork and shellfish

   See box 42-4. p. 1434.
         The Nsg Process

 During illness, good nutritional status
  can reduce the risk for complications
  and speed recovery
 Poor nutritional status can increase
  the risk for illness or death and
  prolong the healing process.

        Health History
            Dietary History
        Physical
            Anthropometrics
            Laboratory Tests
        DETERMINE
         reviewed in the text
         on p. 1435
           24 Hour Food Recall
   Upon waking: large glass of water
   OTWTW: 1 cup of coffee w/sugar & cream, large bagel
    w/cream cheese
   During morning: 2 coffees w/2 Danishes

   Lunch: Hamburger w/fries-”supersized”, lg. sweet tea
   Afternoon: pack of M&M’s

   Dinner: Steak, baked potato, green beans, salad, apple pie
    a la mode, lg. sweet tea
   After dinner: 2 beers
       Dietary Guidelines

 Dietary referenced intakes (DRIs)
 Food Guide Pyramid
 Daily values
 Healthy People 2010
Food Pyramid
        24 Hour-Food-Intake
      Assessment of 24 Hr. Food

   Grains: potato(7) bagel(2) danishes(4) bun(2),fries(6)      [
    >19 oz.] 5oz.

   Veggies: lettuce, tom, pickles, green beans, salad   [~ 2
    cups] 2 cups

   Fruits: 0 1½ cups

   Milk: cream??!!!    [oils] 3 cups/5 tsp oil

   Meat/beans: Hb(4-6), steak (8-12) [~12-18] 5 oz.
Intake and Output
          Monitoring I and O
   Assistance
   Record as soon as specimen is measured
   Independent vs. dependent nursing action
   All clients
   Totaled and evaluated at the end of shift or
    at specified times
   Compare
              Record all output
1.   Urine
2.   Diarrhea
3.   Vomitus
4.   Gastric suction
5.   Drainage from surgical
     tube and wounds
6.   Stool if it is liquid enough
     to be measured
Intake   Output
         Record all intake

Liquids taken:

        Anthropometric Data

   Height and weight. Most common.
     Weigh pt on same scales at the same
      time of day
     Self reported ht in the elderly is often
 BMI and waist circumference
 Triceps Skin fold measurement
            Biochemical Data
   Hemoglobin and Hematocrit
   Serum albumin levels
   Serum transferrin levels (iron transporting
   Total lymphocyte count (reflects immune status)
   Blood glucose
   Blood cholesterol
   Blood triglycerides
   24 hour urine tests: measure protein metabolism
    include urine creatinine excretion and urine urea
    nitrogen (reflects the breakdown of amino acids
    (protein) for energy.

   Disease: any disease impacting
   Eating poorly: too little or too much
   Tooth loss, mouth pain:
   Economic hardship:
   Reduced social contact:
   Multiple medicines:
   Involuntary wt loss/gain:
   Needs asst in self care: walking, shopping,
    purchasing, cooking food help
   Elder years: above age 80.

   Imbalanced nutrition as the problem:
       Could   be the only issue dealing with.
   Imbalanced nutrition as the etiology:
       Couldcause other problems that the nurse
       must deal with.
     Outcome identification and
   Maintain or restore optimal nutritional
   Teaching
   Monitoring nutritional status
   Stimulating appetite
          Allow food choices
          Small frequent meals
          Provide encouragement and PLEASANT environment
          Control pain, nausea, depression
          Good oral hygiene
          Arrange so that it is within easy reach
          Ask about rituals
          Allow opportunity to wash hands
 Assisting with eating when
  necessary…last resort! Why?
 Liquid diets
     Used   frequently with transition diets
     Decision to advance diet is based on return
      of gi function
     Advance as tolerated is most common
      order…what do you think this means?
Diets of Modified Consistency

        NPO
        Clear liquid
        Full liquid
        Pureed
        Mechanical or dental soft
        Soft/Low residue
        High Fiber
Diets of Modified Consistency
   Nothing by mouth:
     Patient not allowed to eat/drink.
     Preop order,
     postop often until Bowel sounds return,
     before certain procedures.
     Nsg indications:
           Encourage good oral hygiene
           Lemon glycerin swaps (if no oral lesions)
           Ice chips only if MD has OK’d
           Avoid watching others eat…
Diets of Modified Consistency:

 Clearliquids: food that are clear liquids
 at room or body temperature

     liquids: all items on a clear liquid
 Full
            Milk, puddings, custards, plain frozen desserts,
             pasteurized eggs, cereal gruels, vegetable juices,
             milk and egg substitutes.
            High calorie, high protein supplements usually
             accompany this diet if used more that 3 days.
Diets of Modified consistency:

 Soft/Low  Residue diets: regular diets
 that have been modified to eliminate
 foods that are hard to digest and to
 chew, including those that are high in
 fiber, high in fat, and highly seasoned.
 Also called bland or low-fiber. Adequate
 in calories and nutrients and may be
 used long-term.
    Therapeutic Diets

 Restricted fluid intake
 Sodium-restricted
 Fat-modified
 Sugar-restricted (diabetic or ADA)
 Protein-restricted (renal)
    Prescribed Diet

1800 ADA
    Enteral/parenteral nutrition

 Enteral: administering nutrients
  directly into the stomach
 Parenteral: providing nutrition via IV
  therapy, nutrition
              Enteral Nutrition

   Oral feeding is preferred and most
   Enteral is next best.
   Involves passing tube into the GI tract to
    administer a formula containing adequate
          Procedure: Percutaneous Endoscopic Gastrostomy
           (PEG) or a surgically placed Gastrostomy tube.
          Enteral Nutrition
   Short-term (less than 6 weeks): use
    nasogastric tube.
   Nasointestinal tube (Dobhoff) (more than 6
    wks): Passed through the nose and into the
    small intestine. This bypasses the valve in the
    stomach that controls volume entering
    intestine. Results in gas, bloating.
   Long-term intestinal support: enterostomal
    tube placed through an opening created into
    the stomach from the abdominal wall.
Nasogastric Tubes
Enteral Feeding Tubes (Nasogastric
Enteral Feeding Tubes (Dobhoff)
Gastrostomy Tube
Jejunostomy Tube
               Safety Alert

   Pt’s on tube feedings:
     Head of bed is kept elevated at all times
      while the tube feeding is being
     The nurse will turn the feeding off about
      30 minutes before lowering the head of
      the bed….not you, yet!
         Nasogastric tubes for
   These tubes are also used when the
    stomach has excess fluid that need to
    be drained…
     After GI surgery so the intestines can
     Pt with GI complications and the
      intestines are not functioning properly
     Post operative pt who is not alert enough
      to “handle” their secretions. Preventing
      the risk of vomiting.
          Parenteral Nutrition
   Administration of nutritional support via IV route.
   Used for pts who cannot meet their nutritional
    needs by the oral or enteral routes.
   Can be administered centrally or peripherally.
   Total Parenteral Nutrition (TPN) highly
    concentrated, hypertonic nutrient solution.
    Provides calories, restores nitrogen balance, etc.
    Note that major nsg implication is monitoring
    Blood Glucose Levels (BGL).
         Fluid Volume Deficit
   Output greater than intake
   Decreased blood pressure
   Increased pulse
   Rapid weight loss > 5%
   Dry mouth
   Dry skin
   Tenting
   Slow venous filling of dependent hands
Fluid Volume Excess

 Intake greater than output
 Rapid weight gain
 Pitting edema
 Crackles heard in lungs
 Bounding pulse

 Monitor and assist with
 Maintain high-fowler’s position
 Place food on unaffected side of
 No straws
 Verbal coaching through swallowing
 Thickeners

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