47 Nutrition Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Learning Outcomes 1. Define nutrition, nutrients, energy balance. 2. Identify factors influencing nutrition. 3. Identify nutritional variations among adults. 4. Discuss essential components and purposes of nutritional assessment and nutritional screening. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Learning Outcomes (cont'd) 5. Identify risk factors for and clinical signs of malnutrition. 6. Describe nursing interventions to promote optimal nutrition. 7. Discuss nursing interventions to treat clients with nutritional problems. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Learning Outcomes (cont'd) 9. Plan, implement, and evaluate nursing care associated with nursing diagnoses related to nutritional problems. 10. Demonstrate appropriate documentation and reporting of nutritional therapy 11. Verbalize the steps used for: a) Measuring body weight and height b) Inserting a nasogastric tube c) Removing a nasogastric tube d) Administering a tube feeding Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Introduction Nutrition is the sum of all the interactions between an organism and the food it consumes Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Introduction Nutrients: organic and inorganic substances found in foods that are required for body functioning • organic nutrients: carbohydrates, fats, proteins, and vitamins • inorganic nutrients: dietary minerals, oxygen, water Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Introduction Foods differ greatly in their nutritive value (nutrient content of specified amount of food) http://www.sparkpeople.com/resource/food_lists_s nacks.asp Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Essential Nutrients • Most basic nutrient needed: water • Next, nutrients that provide fuel or energy: (carbohydrates, fats, proteins) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Energy Balance •Energy Balance: Relationship between energy derived from food and energy used by body •energy intake vs. energy output Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Energy Balance •Body obtains energy in form of calories from carbohydrates, proteins, & fats •Body uses energy for voluntary activities such as walking, talking and for involuntary activities such as breathing and secreting enzymes Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Energy Balance Energy intake: Amount of energy that foods supply to body is caloric value https://www.momsteam.com/nutrition/sportsnutrition-basics/nutritional-needsguidelines/carbohydrate-and-calorie-content-of-foods Energy output : Metabolism refers to all biochemical & physiological processes by which body grows & maintains itself Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Energy Balance Rate of heat liberated during chemical reaction is metabolic rate. •Basal metabolic rate (BMR) is rate at which body metabolizes food to maintain energy requirement of a person who is awake & at rest Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Factors Influencing Nutrition • Development • Gender • Ethnicity and culture • Beliefs about food • Personal preferences • Religious practices • Lifestyle • Economics • Medications and therapy • Health • Alcohol consumption • Advertising • Psychological factors Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Factors affecting nutrition Development: • Adolescence rapid period of growth with increased needs for nutrients. • Older adults need fewer calories and need some dietary changes with their increased risk for CHD, osteoporosis, & hypertension Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Factors Influencing Nutrition Gender: • Nutrient requirements differ between males & females (body composition and reproductive functions). • Larger muscle mass in men means greater needs for calories and proteins • Females need more iron than men prior to menopause • Pregnant and lactating women have ↑ fluid & caloric needs Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Factors Influencing Nutrition Ethnicity and culture: Ethnicity determines food preferences • However, universally accepted guidelines: Eat a wide variety of foods to supply adequate nutrients Eat moderately to maintain body weight Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Factors Influencing Nutrition Beliefs about food • Beliefs about effects of foods on health can affect food choices; people acquire their beliefs from television, magazines, and other media. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Factors Influencing Nutrition Personal preferences: • People develop likes and dislikes based on associations with foods (foods prepared by mother or grandmother) and are sometimes carried through adulthood; likes and dislikes can also be related to familiarity • Preferences in tastes, smells, flavors, temperatures, colors, shapes, and sizes of food influence person’s food choices; textures also play great role in food preferences Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Factors Influencing Nutrition Lifestyle: Certain lifestyles are linked to food-related behavior (people who stay at home prepare foods from scratch; people in a hurry might eat more readymade meals) Muscular activity affects metabolic rate more than any other factor Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Factors Influencing Nutrition Economics: What, how much, and how often a person eats is affected by socioeconomic status; also affected: food preparation and food storage facilities Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Factors Influencing Nutrition Medications and therapy: • Some medications may change appetite, disturb taste perception or interfere with nutrient absorption or excretion • Some nutrients can decrease drug absorption; others enhance absorption • Older adults are at increased risk for drug-food interactions due to number of medications they take, decrease in renal or hepatic functions, and age-related changes • Chemotherapy may adversely affect eating patterns and nutrition Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Table 47-1 Selected Drug– Nutrient Interactions Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Factors Influencing Nutrition Health: • Client’s health status: missing teeth, ill-fitting dentures & dysphagia can prevent person from getting adequate nourishment • Disease processes & surgery of GI tract can affect digestion, absorption, metabolism and excretion; create nausea, vomiting, and diarrhea • Gallstones (affecting flow of bile) will affect lipid digestion Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Factors Influencing Nutrition Alcohol consumption: • Alcohol has large number of calories, can lead to weight gain; excessive alcohol use contributes to nutritional deficiencies, can depress appetite, toxic effect on intestinal mucosa leading to decrease in absorption of nutrients Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Factors Influencing Nutrition Advertising: influences people’s food choices and eating patterns to some extent. • Advertising targets products such as coffee, frozen foods and soft drinks more than advertising breads, vegetables and fruits • Australia, Canada, Sweden and England have adopted regulations prohibiting food advertising on programs targeting young children Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Factors Influencing Nutrition Psychological factors. • Psychological status may affect eating patterns • Anorexia and weight loss can indicate severe stress or depression • In female adolescents: bulimia (binge eating and purging); anorexia nervosa (distorted body self-perception, food restriction, inappropriate eating habits or rituals, obsession with having thin figure, irrational fear of weight gain) https://www.youtube.com/watch?v=ltf_N7ZhPv8 Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Variations • Adolescents • Increased need for nutrients and calories during growth spurts (protein, Ca, vitamin D, Fe and B vitamins) • Have active lifestyles and irregular eating patterns • Encourage healthy snacks and limit junk foods • Common problems: obesity, anorexia nervosa and bulimia Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder • Young adults Nutritional Variations (cont’d) • Nutritional habits established earlier • Need help in knowing how many servings of each food group is needed • Young adult females need adequate Fe intake (iron-rich foods: organ meats, eggs, fish, poultry, leafy vegetables, and dried fruits) to prevent Fe deficiency anemia; folic acid supplements for all women of child-bearing ability (to prevent neural tube defects in fetus) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Variations (cont’d) • Young adults (cont.) • Adequate intake of Ca to maintain bones and decrease chances of osteoporosis in later life • Adequate intake of vitamin D, necessary for entry of Ca into bloodstream; if no sufficient sun exposure, supplements indicated • Obesity common in sedentary adults: at risk of hypertension Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Variations (cont’d) Middle-aged adults • Continue to eat healthy diet, special attention to protein and calcium intake & limit cholesterol and caloric intake • 2-3 liters of fluid in daily diet • Postmenopausal women need to take sufficient Ca and vitamin D to reduce osteoporosis; antioxidants such as vitamins A, C, and E reduce risk of heart disease in women • At risk of obesity, reduce caloric intake and do regular exercise; also at risk for DM, hypertension, and arthritis Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Variations (cont'd) Older adults • Require same basic nutrition as younger adult, but fewer calories due to lower metabolic rate and decrease in physical activity • Some may need more carbohydrates for fiber and bulk, but most nutrient requirements remain relatively unchanged Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Variations (cont'd) Older adults (cont.) • Physical changes as teeth loss and impaired sense of taste and smell may affect eating habits • Decreased saliva and gastric juice secretion may also affect nutrition • Psychological factors such as depression, loss of spouse, empty nest may result in poor dietary habits • Factors such as lack of transportation, poor access to stores, and inability to prepare food, lowered income also affect nutritional status Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Standards for healthy diet • Various daily food guides have ben developed to help healthy people meet the daily requirements of essential nutrients and to facilitate meal planning U.S. Department of Agriculture's Food Guidance System (MyPlate, MyPyramid) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Standards for healthy diet Myplate • Introduced in 2011 as simpler reminder of how to implement dietary guidelines • Promotes getting more fruits and vegetables, whole grains, and low-fat diary foods into diet Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Altered Nutrition • Malnutrition: lack of necessary or appropriate food substances; includes both over nutrition and undernutrition Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Altered Nutrition • Over nutrition: caloric intake in excess of daily energy requirements, resulting in fat storage leading to overweight or obesity which predisposes to chronic health problems. If obesity affects mobility /breathing, it is called morbid obesity Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Altered Nutrition • Undernutrition: intake of nutrients insufficient to meet daily energy requirements because of inadequate food intake or improper digestion & absorption of food Inadequate nutrition results in weight loss, weakness, delayed wound healing, altered functional ability, susceptibility to infection, impaired pulmonary function, prolonged hospital stay Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Assessing • Responsibility of nutritional assessment: primary care provider, dietician and nurse Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Screening and Assessment (cont’d) • Nutritional screening • Nursing history • Anthropometric measurements • Biochemical (laboratory) data • Physical examination • Dietary data Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Screening and Assessment (cont’d) • Nutritional screening • comprehensive nutritional assessment is time consuming and expensive, other types of assessment done Nutritional screen: performed by nurses to identify clients at risk for malnutrition or those who are undernourished (done through routine nursing history and physical examination); those with moderate or high risk for malnutrition, f/u with comprehensive assessment by dietitian Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Box 47-7 Nutritional Screening Tool Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Screening Nursing history: obtained in routine admission nursing history • age, sex, activity level • difficulty eating (impaired chewing or swallowing) • condition of teeth, mouth, dentures • changes in appetite • changes in weight Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Screening Nursing history (cont.) • physical disabilities that affect purchasing, preparing and eating • cultural and religious beliefs • living arrangements (living alone), economic status • general health status & medical condition • medication history Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Screening • Anthropometric measurements (anthropometry: scientific study of the measurements and proportions of the human body) Anthropometric measurements are noninvasive techniques that aim to quantify body composition: Height and weight (nursing skill) Skin fold measurement (non nursing skill) Mid-arm circumference (non nursing skill) Mid-arm muscle area (non nursing skill) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Biochemical (Laboratory) Data Most common tests: • Serum proteins • Urinary tests: urinary urea nitrogen & urinary creatinine • Total lymphocyte count Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Serum proteins • Serum protein levels give estimate of visceral protein stores Tests include: hemoglobin, albumin, and transferrin, total lymphocyte count Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Serum proteins • Low hemoglobin level may be evidence of iron deficiency anemia rule out: abnormal blood loss or pathologic process like GI cancer Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Serum proteins • Albumin: accounts for over 50% of total serum protein; albumin half life of 18-20 days, so albumin concentrations change slowly; thus, low serum albumin level is indicator of prolonged protein depletion. However other reasons for decreased albumin concentration: altered liver function, hydration status and losses from open wounds and burns Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Serum proteins • Transferrin binds & carries iron from intestine through the serum. With its shorter half-life than albumin (8-9 days), transferrin responds more quickly to protein depletion than albumin • Transferrin levels below normal are found with protein loss, Fe deficiency anemia, pregnancy, liver dysfunction Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Serum proteins • Total lymphocyte count The total number of lymphocyte white blood cells decreases as protein depletion occurs Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Urinary tests • Urinary urea & urinary creatinine are measures of protein catabolism & the state of nitrogen balance • Urea: chief end product of amino acid metabolism, is detoxified by liver, circulated in blood, and transported to kidneys for excretion in urine; urea concentrations in blood & urine directly reflect intake & breakdown of dietary protein, rate of urea production in liver and rate of urea removal by kidneys Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Urinary tests • Urinary creatinine reflects person’s total muscle mass; the greater the muscle mass, the greater the excretion of creatinine; as skeletal muscle atrophies during malnutrition, creatinine excretion decreases Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Assessment Clinical data (physical examination) Assessment focuses on skin, hair, nails, eyes, and mucosa Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Assessment Clinical data (physical examination) •Calculating percentage of weight loss: (compare current body weight with usual body weight; any weight loss or gain, duration and if intentional or unintentional) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Body weight and body mass standards •Maintaining healthy or ideal body weight requires balance between expenditure of energy and intake of nutrients •When energy requirements of an individual equate with the daily caloric intake, body weight remains stable Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Measuring body weight Electronic scale https://www.youtube.com/watch?v=9xYwUqUVKr8&list=PL5F 5C0CBEE7315048&index=2 (go to 1:11-end) https://point-ofcare.elsevierperformancemanager.com/skills/19429/quicksheet?skillId=GNMS_59#scrollToTop (no video, quick sheet) Physician Mechanical Beam Scale https://www.youtube.com/watch?v=BpY7xDZ_1Cg Time 2:32 Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Measuring height Stadiometer (Frankfort horizontal plane) https://www.youtube.com/watch?v=0LNCuP24 MSc&list=PL5F5C0CBEE7315048&index=3 Time 0-2:22 Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Body weight and body mass standards Ideal body weight: optimal weight recommended for optimal health; consult standardized tables. https://globalrph.com/medcalcs/adjustedbody-weight-ajbw-and-ideal-body-weightibw-calc/ Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder IBW Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Body weight and body mass standards • Many health professionals consider body mass index (BMI) to be more reliable indicator of person's healthy weight • For people older than 18 years, BMI is indicator of changes in body fat stores and whether person’s weight is appropriate for height • Caution: results must be used with caution in people with fluid retention, athletes, or older adults BMI = weight (kg) (height in meters)² Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder BMI Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Other Measures • Percent body fat (men 6-19%; women 13-31%) https://www.youtube.com/watch?v=saR8zNPRTio Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Other Measures • Waist circumference (skill not required of you) https://www.youtube.com/watch?v=KacU_TW50Zo&feature=rel mfu (0.51 of video) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Other Measures • Skinfold testing (skill not required of you) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Other Measures • Bioelectrical impedance analysis: to estimate body fat, it determines the electrical impedance, or opposition to the flow of an electric current through body tissues which can then be used to estimate total body water (TBW), which can be used to estimate fat-free body mass and, by difference with body weight, body fat https://www.youtube.com/watch?v=vTcUS3qCLSU Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Bioelectrical impedance analysis Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Assessment •Dietary data (client’s usual eating patterns and habits, food preferences, allergies, and intolerances) 24-hr food recall: typical 24-hr food recall when at home Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Assessment Dietary data (cont.) food frequency record: checklist that indicates how often general food groups or specific foods are eaten, could be times/day, or times/week, times/month, seldom, or never; no indication here of quantities consumed, only types of foods Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Nutritional Assessment •Dietary data (cont.) food diary: detailed record of measured amounts of all foods and fluids consumed during specified period, usually 3-7 days diet history: comprehensive time consuming assessment of client’s food intake done by nutritionist or dietitian Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder NANDA Nursing Diagnoses •Related to nutritional problems: •Imbalanced Nutrition: Less Than Body Requirements •Obesity •Overweight •Readiness for enhanced nutrition •Feeding Self-Care Deficit Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Planning Major goals for clients with or at risk for nutritional problems include: •Maintain or restore optimal nutritional status •Promote healthy nutritional practices •Prevent complications associated with malnutrition •Decrease weight •Regain specified weight Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Implementing • Hospitalized Client Provided in collaboration with the primary care provider and the dietician • Reinforce information presented by dietician • Create an atmosphere that encourages eating • Provide and assist with eating • Monitor the client’s appetite and food intake • Administer enteral and parenteral feedings • Consult with primary care provider and dietician about nutritional problems Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Implementing •Assisting with diet: for hospitalized clients regular diet 2,000 Kcal menu to choose from Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Implementing •Assisting with diet: for hospitalized clients light diet (postoperative/those not ready for regular diet): plainly cooked, minimal fat & lots of fiber. Diets include: clear liquid, full liquid, soft diet, & diet as tolerated. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Implementation Clear liquid diet (Box 47-8) • Limited to water, tea, coffee, clear broths, strained and clear juices, and plain gelatin, carbonated beverages • Supplies client with fluid and carbohydrates (in form of sugar) but not adequate protein, fat, vitamins, minerals or calories • It is a short-term diet (24 to 36 hours) provided to clients after surgeries or in acute stages of infection, especially of GI tract • Major objectives of this diet: relieve thirst, prevent dehydration, and minimize stimulation of GI tract Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Implementation Full liquid diet (Box 47-8) • Contains only liquids or foods that turn into liquid at body temperature, e.g.: ice cream, yogurt, custards • For client with GI disturbances or who cannot tolerate solid or semisolid foods. • Not recommended long-term: low in Fe, protein, calories; cholesterol content high due to cow’s milk Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Implementation Soft diet (Box 47-8) • Easily chewed & digested, for clients with difficulty chewing and swallowing, • Low fiber diet; soft /semisoft diet e.g., pureed diet Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Implementation Diet as tolerated • Ordered when client’s appetite, ability to eat and tolerance for certain foods may change • Example, on first postoperative day, clear liquid diet if no nausea, active bowel sounds, client reports passing gas and feels like eating, advance to full liquid, light or regular diet Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Box 47-9 Examples of Foods for Clear Liquid, Full Liquid, and Soft Diets Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Assisting Clients with Meals Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 85 Assisting Clients with Meals • Clients who frequently need assistance with their meals include: Older adults who are weakened Individuals with disabilities such as visual impairment (use clock system to describe location of food on plate) Box 47-10 Clients who must remain in back-lying position Clients who cannot use their hands • Whenever possible, nurse should help clients feed themselves rather than feed them Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 86 Figure 47-11 For a client who is blind, the nurse can use the clock system to describe the location of food on the plate. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Assisting Clients with Meals • Nurses should try to appear unhurried and convey that they have ample time • Ask client in which order he likes to eat the food (if client cannot see, tell client which food is being given) • Always allow ample time for the client to chew and swallow the food before offering more • Also, provide fluids as requested or, if the client cannot communicate, offer fluids after every three or four mouthfuls of solid food. • Make mealtime a pleasant one, choosing topics of conversation that are of interest to clients who want to talk • Although normal utensils should be used whenever possible, special utensils may be needed to assist a client to eat and promote independence Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 88 Figure 47-12 Left to right: glass holder, cup with hole for nose, two-handled cup holder. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Figure 47-13 Dinner plate with guard attached and lipped plate facilitate scooping; wide-handled spoon and knife facilitate grip. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Box 47-11 Providing Client Meals Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Enteral Nutrition • When client cannot ingest foods or upper GI tract is impaired and transport of food to small intestine is interrupted , alternative feeding methods that ensure adequate nutrition include enteral (through GI system) methods Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Enteral access devices • Achieved through: 1. Nasogastric or nasointestinal tubes or 2. Gastrostomy or jejunostomy tubes Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder NGT Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder NGT, Gastrostomy, Jejunostomy Tube Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Purposes of Nasogastric Tube Insertion Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 96 • To administer tube feedings and medications to clients unable to eat by mouth or swallow a sufficient diet without Purposes Nasogastric aspirating food or fluids into the lungs Tube Insertion • To prevent nausea, vomiting, and gastric distention following surgery. In this case, the tube is attached to a suction source • To remove stomach contents for laboratory analysis https://www.msdmanuals.com/professional/gastrointestinal-disorders/diagnostic-and-therapeutic-gastrointestinalprocedures/gastric-analysis • To lavage (wash) the stomach in case of poisoning or overdose of medications Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Enteral Nutrition • Nasogastric tube inserted through one of nostrils, down nasopharynx and into alimentary tract placed into stomach. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Indications for nasogastric tube • Feed clients with adequate gastric emptying and who require short-term feedings Not advised for feeding clients without intact gag and cough reflexes because risk of accidental placement of tube into the lungs is much higher in those clients Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 99 Inserting a Nasogastric Tube Swallowing closes the epiglottis. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Enteral Nutrition Nasogastric Tubes • Feeding tubes come in various sizes. • Larger tubes may be needed to pass medications without clogging. • Smaller, more flexible ones are more comfortable for the patient. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 101 Inserting a Nasogastric Tube Measuring the appropriate length to insert a nasogastric tube. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Inserting a Nasogastric Tube Taping a nasogastric tube to the bridge of the nose. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Single-lumen Levin tube Enteral Nutrition Nasogastric Tubes Traditional firm, large-bore nasogastric tubes • Levin tube, flexible rubber or plastic, single-lumen tube with holes near the tip • Salem sump tube, with a double lumen Double-lumen Salem sump tube with filter on air vent port and connector on suction port Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 104 Enteral Nutrition Nasogastric Tubes •Softer, more flexible and less irritating small-bore feeding tubes , smaller than 12 Fr in diameter, are frequently used for enteral nutrition Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 105 Enteral Nutrition •Nasoenteric (nasointestinal) tube is longer tube than NGT (at least 40 cm for an adult), inserted through one nostril down into upper small intestine. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Figure 47-15 Nasoenteric feeding tubes: A, 12 Fr 36 in. A Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Figure 47-15 (continued) Nasoenteric feeding tubes: B, 8 Fr opaque, 45 in., stylet, weighted tip. Note that both have a Y-port connector to permit irrigation and medication administration without disconnecting the feeding device. B Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Purposes Nasoenteric (nasointestinal) Feeding Used for clients at risk for aspiration, such as those with: 1.Decreased level of consciousness 2.Poor cough or gag reflexes 3.Inability to participate in procedure 4.Restlessness or agitation Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Enteral Nutrition • Gastrostomy and jejunostomy devices used for long-term nutritional support, generally more than 6-8 weeks • Tubes placed surgically or by laparoscopy through abdominal wall into stomach (gastrostomy) or jejunum (jejunostomy) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Enteral Nutrition Percutaneous endoscopic gastrostomy (PEG) tube • A percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) is created by using an endoscope to visualize the inside of the stomach, making a puncture through the skin and subcutaneous tissues of the abdomen into the stomach, and inserting the PEG or PEJ catheter through the puncture. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Low-profile gastrostomy feeding tube Enteral Nutrition • The surgical opening is sutured tightly around the tube or catheter to prevent leakage. Care of this opening before it heals requires surgical asepsis. • The catheter has an external bumper and an internal inflatable retention balloon to maintain placement. • When the tract is established (about 1 month), the tube or catheter can be removed and reinserted for each feeding. Alternatively, a skin-level tube can be used that remains in place Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Testing feeding tube placement • Before feedings are introduced, tube placement is confirmed by radiography, particularly when a small-bore tube has been inserted or when the client is at risk for aspiration. • After placement is confirmed, nurse marks the tube with indelible ink or tape at its exit point from the nose and documents the length of visible tubing for baseline data. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Testing feeding tube placement • The nurse is responsible for verifying tube placement (i.e., GI placement vs. respiratory placement) before each intermittent feeding and at regular intervals (e.g., at least once per shift) when continuous feedings are being administered Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Testing feeding tube placement •To check tube placement, radiographic verification of tube placement is done (definitive method); however repeated xray studies are not feasible in terms of cost and exposure of client to radiation. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Testing feeding tube placement • Methods nurses use to check tube placement include the following: 1. Injecting air 2. Aspirate GI secretions 3. Measure pH of aspirated fluid 4. Test aspirate for bilirubin. Bilirubin levels in lungs should be almost zero, while levels in the stomach will be approximately 1.5 mg/dL and in intestine more than 10 mg/dL 5. Confirm length of tube insertion Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Testing feeding tube placement 1. Inject Air Inject 10-30 mL of air into tube while listening with stethoscope for whooshing sound over epigastrium (below sternum and above umbilicus) 2. Aspirate GI secretions Because small-bore tubes offer more resistance during aspirations than largebore tubes and are more likely to collapse when negative pressure is applied, it may not be possible to obtain an aspirate. If obtained, gastric secretions tend to be a grassy-green, off-white, or tan color; intestinal fluid is stained with bile and has a golden yellow or brownish green color. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Testing feeding tube placement 3. Measure pH of aspirated fluid Testing the pH of aspirate can help distinguish gastric from respiratory and intestinal placement as follows: • Gastric aspirates tend to be acidic and have a pH of 1 to 4 but may be as high as 6 if the client is receiving medications that control gastric acid. • Small intestine aspirates generally have a pH equal to or higher than 6. • Respiratory secretions are more alkaline with values of 7 or higher. However, there is a slight possibility of respiratory placement when the pH reading is as low as 5. • Therefore, when pH readings are 5 or higher, radiographic confirmation of tube location needs to be considered, especially in clients with diminished cough and gag reflexes. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Testing feeding tube placement 4. Confirm length of tube insertion • Confirm length of tube insertion with the insertion mark. If more of the tube is now exposed, the position of the tip should be questioned. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Testing feeding tube placement More research is required to devise effective alternatives to radiographic verification of tube placement, especially for placement of small-bore tubes. In the meantime, nurses should: (a) ensure initial radiographic verification of small-bore tubes (b) aspirate contents when possible and check their acidity (c) closely observe the client for signs of obvious distress (d) consider tube dislodgment after episodes of coughing, sneezing, and vomiting. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Enteral feedings Purpose: 1. To restore or maintain nutritional status 2. To administer medications Assessment: 1. For any clinical signs of malnutrition or dehydration 2. For allergies to any food in the feeding 3. For presence of bowel sounds 4. For any signs of lack of tolerance to previous feedings Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 121 Enteral Feedings • Type and frequency of feedings and amounts to be administered are ordered by physician. • Liquid feeding mixtures are available commercially or may be prepared by the dietary department in accordance with the physician’s orders • A standard formula provides 1 Kcal per milliliter of solution with protein, fat, carbohydrate, minerals, and vitamins in specified proportions. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 122 Enteral Feeding • Enteral feedings can be given: - intermittently or - continuously Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Enteral Feeding • Enteral feedings can be given: - intermittently (administration 300-500 mL of enteral formula several times per day, over at least 30 minutes, into stomach; bolus intermittent feedings are not recommended as it is rapid), or Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Enteral Feeding Enteral feedings can be given: -continuously (administered over 24hour period using infusion pump (kangaroo pump) that guarantees constant flow rate; no more than 60 mL/hr) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Enteral Feeding Assess residual feeding contents 1. If the tube is placed in the stomach, aspirate all contents and measure the amount before administering the feeding Rationale: to evaluate absorption of the last feeding; whether undigested formula from a previous feeding remains. If tube is in small intestine, residual contents cannot be aspirated. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 126 Enteral Feeding Assess residual feeding contents 2. If 100 mL (or more than half of the last feeding) is withdrawn, check with the nurse in charge or refer to agency policy before you proceed. The precise amount is usually determined by the primary care provider’s order or by agency Rationale: At some agencies, a feeding is delayed when the specified amount Or 3. Reinstill the gastric contents into the stomach if this is the agency policy or primary care provider’s order Rationale: Removal of the contents could disturb the client’s electrolyte balance. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 127 Enteral Feeding Assess residual feeding contents 4. If the client is on continuous feeding, check the gastric residual every 4 to 6 hours or according to agency protocol Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 128 Enteral Feeding • Enteral feedings administered through: -open systems (use open-top container or syringe for administration; enteral feedings used with open systems are provided in flip-top cans or powdered formulas that are constituted with sterile water. Open systems should have no more than 8-12 hours of formula poured at one time; at the end of these hours, remaining formula should be discarded and container rinsed before new formula is poured); bag and tubing should be replaced q 24 hours) -closed systems (prefilled container attached to enteral access device, can hang safely for 48 hours) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Closed system Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 130 Enteral Feedings • Before administering a tube feeding, nurse must determine any food allergies of client and assess tolerance to previous feedings • Also nurse must assess expiration date on commercially prepared formula or preparation date and time of agency-prepared solution and discard any formula that has expired or that was prepared more than 24 hours previously Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 131 Enteral Feedings • Feedings are usually administered at room temperature unless the order specifies otherwise • The nurse warms the specified amount of solution in warm water or leaves it to stand for a while until it reaches room temperature • Continuous-feeding formulas should be kept cold; however, excessively cold formulas can reduce flow of digestive enzymes by causing vasoconstriction and may cause cramps Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 132 Managing clogged feeding tubes • To prevent clogged feeding tubes, flush liberally (at least 30 mL water) before, between, and after each separate medication is instilled, using 60-mL piston syringe • Don not add medication to formula as combination could create precipitate that clogs the tube • If all efforts to unclog tube fail, tube need to be removed Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 133 Removing a Nasogastric Tube Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Removing a Nasogastric Tube Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Removing a Nasogastric Tube Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Sample documentation 11/4/2019 1030 #8 Fr feeding tube inserted without difficulty through R nare. Ascertained proper placement using auscultation of injected air and aspiration of 20 mL gastric content, green in color, c pH=4. Tube secured to nose. ------------------------------------------------------R. Fakhry, RN Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder 137 Evaluation • The goals established in the planning phase are evaluated according to specific desired outcomes • If the outcomes are not achieved, the nurse should explore the reasons Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder
