Developed by Ginger Mize RN, MN
Modified by Jill K. Ray
NUR302

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

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Necessary to survive
Source of pleasure
Pastime
Social event
Different meanings to different people….

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

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Not synthesized in the body
Made in insufficient amts
Must be provided in the diet

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3 supply energy
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Carbohydrates
Proteins
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Lipids
3 are needed to regulate body processes
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Vitamins
Minerals
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Water

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Energy is derived from foods consumed.
Measured in form of kilocalories, abbreviate as calories.

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What are the body’s sources of energy?
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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.

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Main source of energy
Glucose
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Brain
Skeletal muscles

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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 increases.

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

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Triglycerides and fatty acids
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Saturated or
Unsaturated fatty acids

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Synthesis of body tissue
Collagen, hormones, enzymes, immune cells
Amino acids: essential and nonessential
Nitrogen balance

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Comprises 60% to 70% of body weight
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Cell function depends on a fluid environment

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

Sources, functions, & significance of Carbohydrates
, proteins, & fats
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Note food sources of the nutrient.
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Which of the following should this same patient eat 1 st on his lunch tray: orange, chicken tenders, Lima beans, whole wheat roll.

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Water soluble (Vitamin C and the Bcomplex vitamins)
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Not generally stored in body
Need daily intake to prevent symptoms of deficiency

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Fat soluble (ADEK)
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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…)

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Some provide structure within the body
Some help regulate body processes
Macro minerals (those needed by the body in amts greater than 100mg/day)
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Calcium
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Phosphorus
Sulfur
Sodium
Chloride
Potassium magnesium

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Major body constituent present in every body cell
More vital to life than food.

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Provides the fluid medium necessary for all chemical reactions,
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 participates in many reactions, is not stored in the body.
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Acts as a solvent, aiding in digestion
Assists in the regulation of body temperature
Acts as a lubricant for mucous membranes

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

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Energy required to carry on the involuntary activities of the body at rest; 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?
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Men
Women
Why
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Because of higher muscle mass.
Men are about 1cal/kg and women .9 cal/kg.

What other factors increase
BMR?
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Growth
Fever
Infections
Emotional tension,
Extremes in temperature
Hormone levels (thyroid hormone, epinephrine)

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Aging
Prolonged fasting sleep

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Body Mass Index
Waist circumference
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Formula:
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BMI = wt in kg/(ht in meters) times (height in meters)
BMI = (wt in lbs/(ht in inches) times (height in inches )) times 703

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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.
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BMI = (wt in lbs/(ht in inches) times
(height in inches )) times 703
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BMI = (100/60 times 60) times 703
BMI = (100/3600) times 703
BMI = .027 times 703 = 19.52

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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
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How would you characterize this pt’s
BMI?

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Usual wt – present wt /usual wt times 100
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Significant if:
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1%-2% in 1 week
5% in 1 month
7.5% in 3 months
10% in 6 months

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Food intake
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Decreased food intake can be related to
 disease,
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 psychosocial causes, impaired ability to smell and taste, drug therapy, medical treatments, difficulty chewing and swallowing, chronic GI problems, certain chronic illnesses (ca)
Inadequate food budgets
Nausea pain

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

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Increased food intake:
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Excess wt increases the risk
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 for numerous medical problems assoc with surgery
For complications during pregnancy, labor, and delivery
Incr morbidity and mortality
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Reasons for overeating….

Physiologic and physical factors that influence nutrient requirements
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Developmental considerations:
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Throughout the life cycle nutrient needs change in relation to growth, development, activity, and age-related changes in metabolism and body composition.
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Review each area in this section of the required reading

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Men have more muscle mass and therefore have higher caloric and protein requirements than women.

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Trauma (major surgery, burns, crush injuries)
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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 recovery.
Mental health problems can cause to forget to eat, or lack motivation to eat.

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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.

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Especially drugs that
 alter the pH of the GI tract
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Increase GI Motility,
 damage intestinal mucosa,
 bind with nutrients

Sociocultural and Psychosocial
Factors
Religion:
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Mormons: no coffee, tea, alcohol, encouraged to limit meat consumption
Hindus do not eat beef, many Hindus are vegetarians
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Kosher dietary laws: special food preparation techniques and prohibit the intake of pork and shellfish

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See box 42-4. p. 1434.

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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.

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Health History
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Dietary History
Physical
Assessment
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Anthropometrics
Laboratory Tests
DETERMINE reviewed in the text on p. 1435

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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
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Lunch: Hamburger w/fries-”supersized”, lg. sweet tea
Afternoon: pack of M&M’s
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Dinner: Steak, baked potato, green beans, salad, apple pie a la mode, lg. sweet tea
After dinner: 2 beers

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Dietary referenced intakes (DRIs)
Food Guide Pyramid
Daily values
Healthy People 2010

24 Hour-Food-Intake
Assessment
 http://www.mypyramid.gov/mypyra mid/results.html?age=54&gender=m ale&activity=sed

Assessment of 24 Hr. Food
Recall
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Grains: potato(7) bagel(2) danishes(4) bun(2),fries(6) [
>19 oz.] 5oz.
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Veggies: lettuce, tom, pickles, green beans, salad [~ 2 cups] 2 cups
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Fruits: 0 1½ cups
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Milk: cream??!!! [oils] 3 cups/5 tsp oil
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Meat/beans: Hb(4-6), steak (8-12) [~12-18] 5 oz.

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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

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Urine
Diarrhea
Vomitus
Gastric suction
Drainage from surgical tube and wounds
Stool if it is liquid enough to be measured

Liquids taken:
Oral
Enteral
Parenteral

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Height and weight. Most common.
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Weigh pt on same scales at the same time of day
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Self reported ht in the elderly is often inaccurate
BMI and waist circumference
Triceps Skin fold measurement

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Hemoglobin and Hematocrit
Serum albumin levels
Serum transferrin levels (iron transporting protein)
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.

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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.

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Imbalanced nutrition as the problem:
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Could be the only issue dealing with.
Imbalanced nutrition as the etiology:
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Could cause other problems that the nurse must deal with.

Outcome identification and
Planning
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Maintain or restore optimal nutritional status

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Teaching
Monitoring nutritional status
Stimulating appetite
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Allow food choices
Small frequent meals
Provide encouragement and PLEASANT environment
Control pain, nausea, depression
Good oral hygiene
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Arrange so that it is within easy reach
Ask about rituals
Allow opportunity to wash hands

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Assisting with eating when necessary…last resort! Why?
Liquid diets
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Used frequently with transition diets
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Decision to advance diet is based on return of gi function
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Advance as tolerated is most common order…what do you think this means?

Diets of Modified Consistency
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NPO
Clear liquid
Full liquid
Pureed
Mechanical or dental soft
Soft/Low residue
High Fiber

Diets of Modified Consistency
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Nothing by mouth:
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Patient not allowed to eat/drink.
Preop order, postop often until Bowel sounds return, before certain procedures.
Nsg indications:
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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:
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Clear liquids: food that are clear liquids at room or body temperature
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Full liquids: all items on a clear liquid plus,
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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:
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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.

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

1800 ADA

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

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Oral feeding is preferred and most effective
Enteral is next best.
Involves passing tube into the GI tract to administer a formula containing adequate nutrients.
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Procedure: Percutaneous Endoscopic Gastrostomy
(PEG) or a surgically placed Gastrostomy tube.

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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
Tubes)

Enteral Feeding Tubes (Dobhoff)

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Pt’s on tube feedings:
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Head of bed is kept elevated at all times while the tube feeding is being instilled….why?
The nurse will turn the feeding off about
30 minutes before lowering the head of the bed….not you, yet!

Nasogastric tubes for decompression
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These tubes are also used when the stomach has excess fluid that need to be drained…
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After GI surgery so the intestines can rest
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Pt with GI complications and the intestines are not functioning properly
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Post operative pt who is not alert enough to “handle” their secretions. Preventing the risk of vomiting.

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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).

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Output greater than intake
Decreased blood pressure
Increased pulse
Rapid weight loss > 5%
Dry mouth
Dry skin
Tenting
Slow venous filling of dependent hands

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

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