Nutrition
Nutrition is a basic component of health and is essential for normal growth
and development, tissue repair and maintenance, cellular metabolism, and
organ function. The main focus of nutrition both oral and enteral or
parenteral is on balancing the 6 basic nutrients, three that are energy giving
(carbohydrates, protein, lipids) and three are needed to regulate body
processes (vitamins, minerals, water). Refer to your nutrition class for the
sources, functions, and significance of these nutrients (See posted sources).
Emphasis should be on nutrient dense rather than energy dense foods.
Factors affecting food habit
 Physiologic and physical factors: stage of development, state of health,
medications
 Sociocultural, and psychosocial factors influencing food choices include
culture, religion, tradition, education, politics, social status, food
ideology
Vegetarian diets
Vegetarian diet consists predominantly of plant foods:
Ovolactovegetarian (avoids meat, fish, and poultry, but eats eggs and milk)
Lactovegetarian (drinks milk but avoids eggs)
Vegan (consumes only plant foods)
Vegans lack complete proteins in single foods, although they can use
complementary proteins from two or more foods to get all the amino acids.
Knowledge of complementary proteins is necessary. They are at risk for
vitamin B12 deficiency because it is available only from animal sources.
Encourage vegetarians to incorporate foods enriched with vitamin B 12 or
and/or take vitamin B12 supplements.
Nutritional Assessment
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Nutrient needs change in relation to growth, development, activity, and agerelated changes in metabolism and body composition and influences growth
and development throughout the life cycle. Nutritional requirements depend
on many factors. Individual caloric and nutrient requirements vary by stage
of development, body composition, activity levels, pregnancy and lactation,
and the presence of disease.
Nutritional assessment is a systematic approach used to identify the patient’s
actual or potential needs, formulate a plan to meet those needs, initiate the
plan, and evaluate the effectiveness of the plan. Combine multiple objective
measures with subjective measures related to nutrition to adequately screen
for nutritional problems. Identification of risk factors such as unintentional
weight loss, presence of a modified diet, or the presence of altered nutritional
symptoms (i.e., nausea, vomiting, diarrhea, and constipation) requires
nutritional consultation. Assess patients for malnutrition when they have
conditions that interfere with their ability to ingest, digest, or absorb
adequate nutrients.
No single laboratory or biochemical test is diagnostic for malnutrition. Nurses
can collect nutritional assessment data through history taking (diet recall,
medical, socioeconomic data), physical assessments (inspection, palpation,
auscultation, percussion), Anthropometric and laboratory data.
Body Mass Index (BMI) is a reliable indicator of total body fat stores.
Calculate body mass index (BMI) by dividing the patient’s weight in
kilograms by height in meters squared: weight (kg) divided by height 2 (m2).
Waist measurement is a good indicator of abdominal fat.
Overweight and obesity is caused by multiple factors. A person with a BMI
below 18.5 is underweight, a BMI of 18.5 to 24.9 is a healthy weight, a BMI
of 25 to 29.9 indicates an overweight person, a BMI of 30 or greater
indicates obesity, and a BMI of 40 or greater indicates extreme obesity. BMI
also provides an estimation of relative risk for diseases such as heart
disease, diabetes, and hypertension.
***Note MyPlate, Food labels, & Dietary guidance of America. On food labels,
note serving sizes and differentiate it from portion size. Daily values are
based on percentages of a diet consisting of 2000 kcal/day for adults and
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children 4 years or older.
Diagnosis
Nursing diagnoses may be related to actual nutrition problems (e.g.,
inadequate intake) or to problems that place the patient at risk for nutritional
deficiencies such as oral trauma, severe burns, and infections.

Risk for aspiration

Diarrhea

Constipation

Deficient knowledge

Readiness for enhanced nutrition

Feeding self-care deficit

Impaired swallowing

Imbalanced nutrition: less than body requirements

Imbalanced nutrition: more than body requirements
Goals/Outcomes: Explore patients’ feelings about their weight and diet and
help them set realistic and achievable goals.
***Pause & Think
Diagnosis: Risk for aspiration related to impaired swallowing
Goal: will receive adequate nutrients through enteral tube feeding without
aspiration by the time of discharge.
Outcomes: Brainstorm 2 expected outcomes for the above goal
Nursing Interventions
Meeting nutritional goals requires input from the patient and the
multidisciplinary team. Consult with an Speech therapists, Registered
dietician, pharmacist, and/or occupational therapist about patients with
dysphagia, as well as those who need ongoing nutritional assessment and
interventions to meet their nutritional needs. When patients have difficulty
feeding themselves, occupational therapists work with them and their
families to identify assistive devices. Devices such as utensils with large
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handles and plates with elevated sides help a patient with self-feeding.
Types of Clinical or Therapeutic Diets
Health care providers order a gradual progression of dietary intake or
therapeutic diet to manage patients’ illness (see posted therapeutic diet)
Providing an environment that promotes nutritional intake includes keeping a
patient’s environment free of odors, providing oral hygiene as needed to
remove unpleasant tastes, and maintaining patient comfort. Offering smaller,
more frequent meals often helps. In addition, certain medications affect
dietary intake and nutrient use.
When a patient needs help with eating, it is important to protect his or her
safety, independence, and dignity. Clear the table or over-bed tray of clutter.
Assess his or her risk of aspiration. Patients with dysphagia are at risk for
aspiration and need more assistance with feeding and swallowing. Before
assisting the patient, confirm the type of diet that has been ordered for the
patient. Also, it is important to assess for any food allergies and religious or
cultural preferences. Check to make sure the patient does not have any
scheduled laboratory or diagnostic studies that may impact whether he or
she is able to eat a meal.
Sit facing the patient at eye level. Allow enough time for the patient to chew
and swallow the food. At the end of feeding for all patients both for feeders
and those who can feed self, document the type and amount of food
consumed. Document solids in percentages and liquid in mLs.
Provide opportunities for patients to direct the order in which they want to
eat the food items and how fast they wish to eat. Arrange food in the order
of the clock for visually impaired patients who can feed themselves.
Nutrition Support
When oral feeding assistance is inadequate in providing appropriate nutrition,
enteral or parental feeding is required. Enteral nutrition (EN) is the preferred
method of meeting nutritional needs if a patient is unable to swallow or take
in nutrients orally, yet has a functioning GI tract and are still able to digest
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and absorb nutrients. Enteral nutrition (EN) administers nutrients directly
into the stomach or intestine.
Feeding tubes are inserted through the nose (nasogastric or nasointestinal),
surgically (gastrostomy or jejunostomy), or endoscopically (percutaneous
endoscopic gastrostomy or jejunostomy [PEG or PEJ]). If EN therapy is for
less than 4 weeks, nasogastric, or nasojejunal feeding tubes may be used.
Surgical or endoscopically placed tubes are preferred for long-term feeding
(more than 6 weeks) to reduce the discomfort of a nasal tube and provide a
more secure, reliable access. Most health care settings use small-bore
feeding tubes because they create less discomfort for a patient. For the
adult, most of these tubes are 8- to 12-French and 36 to 44 inches (90 to
110 cm) long.
Measure the distance to insert the tube by placing the tube tip at the
patient’s nostril and extending it to the tip of the earlobe and then to tip of
the xiphoid process. Add any extra length based on facility policy to ensure
that the tube extends beyond the xiphoid process to reach the gastric body
Mark the tube with an indelible marker. Measurement ensures that the tube
will be long enough to enter the patient’s stomach.
After selecting the appropriate nostril, ask the patient to extend the head
slightly back against the pillow. Gently insert the tube into the nostril while
directing the tube upward and backward along the floor of the nose. The
patient may gag when the tube reaches the pharynx. When pharynx is
reached, instruct the patient to touch chin to chest. Encourage the patient to
sip water through a straw or swallow. Advance the tube in downward and
backward direction when patient swallows. Stop when the patient breathes.
If gagging and coughing persist, stop advancing the tube and check
placement of the tube with a tongue blade and flashlight. If the tube is
curled, straighten the tube and attempt to advance again. Keep advancing
the tube until pen marking is reached. Do not use force. Rotate the tube if it
meets resistance. Discontinue the procedure and remove the tube if there
are signs of distress, such as gasping, coughing, cyanosis, and inability to
speak or hum.
Secure the tube loosely to the nose or cheek until it is determined that the
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tube is in the patient’s stomach. Confirm placement of the NG tube in the
patient’s stomach using at least two methods, based on the type of tube in
place.
Evidenced based best practice for verification of feeding tube placement
includes radiographic confirmation of correct tube placement prior to initial
use. The tube’s exit site from the nose or mouth should be marked and
length documented immediately after radiographic confirmation of correct
tube placement. The mark should be observed routinely and the external
tube measured to assess for a change in length of the external portion of the
tube. Bedside techniques to assess tube location should be used at regular
intervals to determine if the tube has remained in its intended position.
These bedside techniques include measuring the pH and observing the
appearance of fluid withdrawn from the tube.
A serious complication associated with enteral feedings is aspiration of
formula into the tracheobronchial tree, which leads to infection. Improperly
positioned tubes increase the risk for aspiration. Patients at low risk for
gastric reflux receive gastric feedings; however, if risk of gastric reflux, which
leads to aspiration, is present, jejunal feeding is preferred.
Historically, nurses verified feeding tube placement by injecting air through
the tube while auscultating the stomach for a gurgling or bubbling sound or
asking the patient to speak. However, evidence-based research repeatedly
demonstrates auscultation is ineffective in detecting tubes accidentally placed
in the lung.
***Check tube placement before administering any fluids, medications, or
feedings.
Use
multiple
techniques:
x-ray,
external
length
marking/measurement, pH testing, and aspirate characteristics.
Note that Radiographic (x-ray) examination of the tube after the initial
insertion or when in doubt is the gold standard for checking placement. After
establishing placement, introduce a small amount of fluid into the tube
before feeding.
Tube feeding is initiated at a low rate of infusion and is increased slowly to
allow for maximum tolerance.
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 Aspiration precautions
Check tube placement every 4 to 6 hours.
Abdominal pain, large volume of gastric residuals, and diarrhea are signs of
feeding intolerance and need to be evaluated promptly.
Head of bed elevated a minimum of 30 to 40 degrees decreases the risk for
aspiration.
Check gastric residual volume every 4 hours. Gastric residual volume
indicates whether gastric emptying is delayed. Delayed gastric emptying
increases the risk for aspiration. Residual volume of more than 100-150 mLs
is excessive. Remember that the 60 mLs syringe usually used is changed
every 24 hrs.
Regularly provided speech therapy will assist the patient in regaining the
ability to swallow foods and liquids.
Speech therapy includes trials of various consistencies of foods and liquids.
Aspiration of food and liquids lead to chest congestion and pneumonia.
 Each part of the gastrointestinal (GI) system has an important
digestive or absorptive function. Refer to your nutrition class for site of
digestive processes, actions of enzymes and hormones with resultant
end product of digestion of each of the energy giving nutrients. The
longer the material stays in the large intestine, the more water is
absorbed, causing the feces to become firmer. Exercise and fiber
stimulate peristalsis, and water maintains consistency. Adequate water
intake is 8-12 cups in a day.
 Absorption of carbohydrates, protein, minerals, and water-soluble
vitamins occurs in the small intestine, then processed in the liver, and
released into the portal vein circulation. Fatty acids are absorbed in
the lymphatic circulatory systems through lacteal ducts at the center
of each microvilli in the small intestine. Following absorption,
metabolic processes are anabolic (building) or catabolic (breaking
down). Through the chemical changes of metabolism, the body
converts nutrients into a number of required substances.
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***Dysphagia refers to difficulty swallowing. The causes and
complications of dysphagia vary. Be aware of warning signs for
dysphagia. They include cough during eating; change in voice tone or
quality after swallowing; abnormal movements of the mouth, tongue, or
lips; and slow, weak, imprecise, or uncoordinated speech. Abnormal gag,
delayed swallowing, incomplete oral clearance or pocketing, regurgitation,
pharyngeal pooling, delayed or absent trigger of swallow, and inability to
speak consistently are other signs of dysphagia.
Educate your patients about the therapeutic diet prescribed, specifically,
on how it controls their illnesses and if there are any implications.
Parenteral Nutrition (PN)
Parenteral nutrition (PN) is a solution consisting of glucose, amino acids,
lipids, minerals, electrolytes, trace elements, and vitamins, through an
indwelling peripheral (Peripheral Parenteral Nutrition (PPN) or central venous
catheter (Total Parenteral Nutrition (TPN). In some cases, TPN is a 2-in-1
formula in which administration of fat emulsions occurs separately from the
protein and dextrose solution.
Patients who have nonfunctional GI tracts, who are comatose, or who cannot
consume a nutritionally adequate diet enterally may require parenteral
nutrition. Safe administration depends on appropriate assessment of nutrition
needs, meticulous management of the central venous catheter (CVC), and
careful clinical and laboratory monitoring by a multidisciplinary team to
prevent or treat metabolic complications. The goal is to move patients from
PN to EN and/or oral feeding.
Sometimes adding intravenous fat emulsions to PN supports the patient’s
need for supplemental kilocalories, prevent essential fatty acid deficiencies,
and help control hyperglycemia during periods of stress. Administer these
emulsions through a separate peripheral line, through the central line by
using Y-connector tubing. Insulin can be added to the PN bag due to the
increased amount of glucose and the fat emulsion is the only thing that can
be connected to the TPN.
When using central line that has multiple lumens, use a port exclusively
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dedicated for the TPN. Label the port for TPN and do not infuse other
solutions or medications through it. A chest x-ray verifies catheter tip
placement for a central line catheter before starting a PN infusion.
Before beginning any PN infusion, verify the health care provider’s order and
inspect the solution for particulate matter or a break in the fat emulsion. Two
nurses usually confirm the order before administration. Both the bag, tubing,
and syringe used for checking residual are changed every 24 hours.
PN solutions contain most of the major electrolytes, vitamins, and minerals.
Patients also need supplemental vitamin K as ordered throughout therapy.
Synthesis of vitamin K occurs by the microflora found in the jejunum and
ileum with normal use of the GI tract; however, because PN circumvents GI
use, patients need to receive exogenous vitamin K.
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