ALTERATIONS IN NUTRITION
Jennifer B. Cowley, RN, MSN
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?
Clients with Nutritional Problems:
Who’s at Risk?
Dietary history
Medical history
Lab Values
 Serum hemoglobin & hematocrit
– “H&H”
 Serum albumin
 Serum pre-albumin
Hemoglobin & Hematocrit
 Hgb - iron-containing pigment of the RBC’s
– Normal lab values:
• female - 12-16 g/100 ml
• male - 14-18 g/100 ml
 Hct - % of whole blood occupied by RBC’s
– Normal lab values:
• female - 37-47%
• male - 40-54%
Albumin
 Synthesized in the liver from amino acids
 Accounts for > 50% total serum proteins
 Indicator of prolonged protein depletion
 Normal lab value:
– 3.5-5 g/dl
Pre-albumin
 A precursor to albumin
 Determines protein depletion in acute
conditions
 Normal lab values:
– 15-36 mg/kl
Diagnostic Tests
 Gastroscopy
– direct visualization
 Upper Gastrointestinal Series (UGI)
– indirect x-ray exam
Manifestations
of Major
Nutritional Deficiencies…
Harkreader, p.703, Table 30-1
The nursing assessment
enables the nurse to determine
whether actual or potential
nutritional problems exist.
NANDA Nursing Diagnoses
 Altered Nutrition: Less than Body
Requirements
 Altered Nutrition: More than Body
Requirements
 Risk for Altered Nutrition:
More than Body
Requirements
Examples of Secondary Nursing
Diagnosis for Clients with Nutritional
Problems
 Activity Intolerance r/t insufficient energy from
protein depletion
 Altered Oral Mucous Membranes r/t oral intake
 Constipation r/t inadequate dietary intake and fiber
 Self-Esteem Disturbance r/t obesity
 Risk for Impaired Skin Integrity r/t intake of
proteins, vitamins, and minerals
Commonly Prescribed Therapeutic
Diets
Regular Diet
– Who?
• Clients who do not have special needs
– What?
• 2500 cal/day, variety of food groups
Diets: NPO
 Nothing by Mouth (NPO)
– Who?
• Prior to surgery/certain diagnostic test
• To rest the GI tract
• When problem has not been identified
– What?
• NPO
Diets: Clear Liquid
 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
Diets: Full Liquid
 Full Liquid Diet
– Who?
• Primarily postoperative clients
– What?
• Consists of liquids or foods that turn to liquid at
body temperature
Diets: Soft
 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.
Diets: Mechanical Soft
 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
Diets: Pureed
 Pureed Diet
– Who?
• For clients with dysphagia
– What?
• Food that has been blenderized to a smooth
consistency
Diets: Low-Residue
 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)
Diets: High-Fiber
 High-fiber Diet
– Who?
• To increase elimination
– What?
• Opposite of low-residue
Diets: Bland
I don’t think so!
 Bland Diet
– Who?
• Clients with gastritis and ulcers
– What?
• Eliminates chemical and mechanical food irritants,
such as fried and spicy foods, alcohol and caffeine
Diets:Fat-Controlled
Uh-oh!
 Low-Fat Diet
– Who?
• Clients with heart disease, atherosclerosis, and
obesity
– What?
• Decreased saturated fats (replace with
mono/polyunsaturated fats) and restricting
cholesterol
Diets: Sodium-Controlled
 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
Diets: American Diabetic
Association (ADA)
 Diabetic Diet
A no-no!
– 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).
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.
Monitoring Intake & Output/
“I&O”
 Purpose: To monitor client’s fluid status
over a 24 hour period
 Who should be on I&O?
 Medical vs. nursing decision?
 Check clinical agency policy
 Inaccuracies of I&O
I&O: Intake
 Oral fluids
 Ice chips
 Foods that become liquid at room
temperature
 Tube feedings
 Intravenous fluids/medications
 Catheter/tube irrigants
I&O: Output
 Urine
 Diarrhea
 Vomitus (emesis)
 Tube drainage
I&O: Nursing Responsibilities
 Client/family teaching
 Documentation
 Relay to others that client is on I&O
 Look for trends over 48-72 hours
The Malnourished Client:
Nursing Interventions
 Stimulate the appetite
 Assist the client with eating
 Initiate client/family counseling
Assisting the Client with Feeding
ENTERAL NUTRITION
If the client will not,
should not, or cannot eat,
enteral nutrition may be provided
with nasogastric, gastric
or jejunal tubes.
Feeding tubes: Placement
Nasoenterally
Surgically
– Gastrostomy
– Jejunostomy
Endoscopically
– Percutaneous endoscopic gastrostomy
(PEG)
Placement of
Enteral Nutrition
Tubes
Nasoenteral Feeding Tubes:
Types
 Large-bore
 Small-bore
– 90-95% of clients in hospital have small bore
– more flexible, comfortable
– stylet inserted into lumen
Nasoenteral:
Small-bore Feeding Tube
 Short term
 RN performs blindly at the bedside
 X-ray the only reliable method of placement
verification
 Nasogastric, nasoduodenal, or nasojejunal
 Small bowel usually preferred over stomach
in acutely ill clients
Feeding Tube: Who does what?
 MD orders:
– Type of tube
– Rate and type of formula
 RN:
– Inserts feeding tube
– Administers/monitors tube feeding
Enteral Feeding Tube:
Confirmation of Tube Placement
 Radiologic confirmation
 Bedside methods:
– Auscultatory method
– Aspiration of gastric contents
– pH method
Gastrostomy/Jejunostomy:
“G-tube/J-tube”
 Long term
 MD performs in OR
 Incision through abdominal wall creating an
artificial fistula
 More cosmetically appealing/more
comfortable
 Larger lumen allows more flexibility for
feeding/medication administration
Percutaneous endocscopic gastrostomy:
“PEG” tube
 Long term
 MD performs at bedside or in endoscopy
room
 Does not require surgery, therefore less
risky and expensive than G/J tube insertion
Percutaneous Endoscopic Gastrostomy Tube
PARENTERAL NUTRITION
Total Parenteral Nutrition
“TPN”
Total Parenteral Nutrition
 Candidates for
 What’s in
 Tonicity of
 Complications r/t
 Lipids given with
TPN
That’s All, Folks!