%5,'*( 6 6WXG\*XLGH Nutrition %5,'*( 3DYLQJ JWKH H5RDG GWR R6XFFHVVV lOMoARcPSD|16245032 Tablet of Content Nutrition 3 Metabolism 3 BMR 3 Anabolism 3 Catabolism 3 Nutrients 4 Carbohydrates 4 Fibers 5 Fats 6 Proteins 8 Water 9 Vitamins 10 Minerals 14 Antioxidants 15 Digestion 15 Dietary Guidelines 15 Diversity Considerations 15 Gender 16 Culture, Ethnicity & Religion 16 Disability 16 Musculoskeletal Alterations 17 Neurological Alterations 17 Cardiopulmonary Alterations 18 Gastrointestinal Alterations 18 Dysphagia 18 Malabsorption 18 Marasmus 18 Kwashiorkor 18 Phenylketonuria 18 Metabolic Alterations 19 Diabetis Mellitus 19 Allergies and Intolerances 19 Obesity 19 Malnutrition 19 Psychological Alterations 20 Anorexia Nervosa 20 Bulimia Nervosa 20 Nutrition History 20 Screening for Malnutrition in Older Adults 21 Physical Assessment 21 Morphology 21 Anthropometric Measurements 21 BMI 22 Skin and Hair 22 Dentition 23 Swallow Studies 23 Labs Studies 23 Albumin 24 Transferrin 24 Hemoglobin & Hematocrit 26 BUN & Creatinine 25 Elimination Patterns 25 Dietary Preferences 25 Food pattern based on Religion or Culture 26 Kosher Diet 26 Special Diets 26 Clear Diet 26 Full Diet 26 Pureed Diet 26 Mechanical Soft Diet 26 Thickened Liquid 26 Regular Dites 27 Diabetic Diet 27 Cardiac Diet 27 Renal Diet 27 Assisting with feeding 27 NPO Patients 28 Enteral Feeding Tube 28 PEG 29 Medication administration via Enteral Tube 29 Total Parental Nutrition 30 Appendix A: Digestive System overview 31 Appendix B: Electrolytes Disorders 34 Appendix C: Electrolyte Relationships 40 2 lOMoARcPSD|16245032 Nutrition - - - The body’s intake and use of adequate amounts of necessary nutrients for tissue growth and energy production Nutrients: are the necessary substances obtained from ingested food that supply the body with: Energy Build and maintain bones Muscles and skin And aid in normal growth and function of each body system Healthy eating can reduce the risk of chronic diseases across the lifespan Malnutrition: an imbalance in the amount of nutrient intake and the body’s needs Choosing nutrient rich foods helps people get the most benefit from the calories ingested, resulting better nutritional intake and fewer calories consumed Strong relationship is recognized between infection and malnutrition Metabolism - - Metabolism is the process of chemically changing nutrients, such as fats and proteins, into end products that are used to meet the energy needs of the body and stored for future use, to help maintain homeostasis in the body - Body processes that are the result of metabolism include: - Repair and replacement of cells - Elimination of waste through the kidneys - Functioning of the brain to maintain pulse rate and respirations BMR (Basal metabolic rate) - Minimum amount of energy required to maintain body functions in the resting and awake state - Even during sleep the body requires a certain amount of calories to support critical processes such as cardiac function and breathing - Continuous process within the body and is dependent on the intake of proper nutrients - Is necessary to maintain life and composed of two major biochemical processes: and be thought of cons - Anabolism - Use of energy to change simple materials into complex body substances and tissue - Constructive - Permits cell growth, such as materialization of bone or development of muscle mass - Catabolism - Breaking down of substances from complex to simple, resulting in release of energy 3 lOMoARcPSD|16245032 - Destructive Breaking down of proteins and conversion into amino acids Nutrients - - - Macronutrients: nutrients needed in large amounts - Carbohydrates include: - Sugar, starches, dietary fibers - Provide energy for cells, tissues, organs, and fats - Fats: major sources of energy and promote absorption of vitamins and proteins which build, maintain, and repair muscles and tissue - Water is also a macronutrient that is essential for proper functioning as well as for assisting the body with metabolic processes (metabolism) Micronutrients: nutrients needed by the body in limited amounts - Minerals: - chemicals needed for energy, muscle building, nerve conduction, blood clotting, and immunity to disease - Vitamins: - Organic compounds responsible for the regulation of body processes, reproduction, and growth Failure of the body to properly use nutrients can result in diseases and other conditions, such as heart and kidney disease, renal disorders, diabetes, malnutrition, and obesity - Obesity: result of a person’s energy intake consistently exceeding energy use - Excessive accumulation of body fat - Considered a preventable condition - Affects 1 in 5 children in the US - 71.6% of 20 years or older is considered overweight or obese Carbohydrates - - - Carbohydrates are chemical substances composed of carbon, hydrogen, and oxygen molecules Supply the body with 4 kilocalories per gram - Kilocalorie is the amount of heat energy it takes to raise the temperature of 1000 grams of water 1 degree celsius. Major suppliers of energy and include sugars, starches, and fiber Keep the body from using valuable proteins for energy, prevent ketosis and enhance memory and learning capabilities - Ketosis: when the body burns fat in the absence of adequate carbohydrate intake Simple Carbs: - Broken down and absorbed quickly, providing a quick source of energy - Examples: - sugars (fruit or or fructose) - table sugar ( sucrose) - milk products (lactose) 4 lOMoARcPSD|16245032 - - - Fiber - - - - - blood sugar (glucose) Complex Carbs - Take longer to break down before absorption and are used by the body’s cells - Composed of starches, glycogen, and fiber - Provide body with vitamins and minerals - Bread - Rice - Pasta - Legumes (dried beans, peas, and lentils) - Starchy vegetables (corn, pumpkins, green peas, potatoes) Proper functioning of the brain and other tissues depends on a sufficient supply of carbohydrates in the form of GLYCOGEN - Major portion of glycogen from complex carbs that is necessary for functioning is derived from stored FUEL - Muscles store glycogen and use it for strenuous exercise - Person suffers from extreme fatigue without glycogen Adults should consume 50% of their calories from carbohydrates - Foods containing processed sugars (cakes, pies, pastries) should be avoided bc of no nutrient value and adds to calories Fiber is a complex carbohydrate and is classified as soluble or insoluble Older children, adults, and adolescents should consume 20 to 35 grams of fiber per day Food sources: - Whole grains - Wheat bread/bran - Cereals - Fresh fruit - Vegetables and legumes Solubility: refers to disposition of the fiber when mixed with another substance, such as water - Soluble fiber: mixes water with gel like substance resulting in slower digestion - Insoluble fiber: does not retain water but allows formation of bulk, resulting in accelerated passage of the end products of food through the intestines and a slowing of starch absorption Benefits of high fiber diet: - promotion of cardiovascular health by lowering serum cholesterol levels and blood pressure - Assistance in weight control - Improvement of glycemic control in diabetes - Improvement of regularity Intake of Soluble fibers enhances: - Immune function in humans 5 - Decreases inflammation lOMoARcPSD|16245032 - - Reduces symptoms of depression Lack of fiber: - Bowel related conditions - Constipation - Hemorrhoids - Formation of diverticula - Which are protrusions of the intestinal membrane through the muscular layer of the intestine, most often in large colon - Protrusions known as Diverticulosis Fats - - - Composed of carbon hydrogen and oxygen 9 kilocalories per gram when metabolized in the body Lipids: refer to any fat found within the body including fats and oils - Fatty acids, cholesterol, phospholipids Total fat intake should be 20-35% of caloric intake each day - Less than 5 to 6% should be from saturated fat Dietary fats take longer to digest than other major nutrients and requires the presence of carbohydrates to associate with oxygen and and produce energy for the body Triglycerides are the most abundant lipids in food - Although the intake of triglycerides is important, an excess can be unhealthy and contribute to health problems: - Coronary artery disease - Obesity Benefits of fat: - Energy production - Support and insulation of major organs and nerve fibers - Energy storage of adipose tissue - Lubrication of body tissues - Vitamin absorption - Transportation of fat solubles Vitamins: A, D, E, and K - Plays a role in development of the cell membrane structure Also composed of one monoglyceride and three triglycerides - Consist of chains made up of hydrogen and carbon atoms Saturated fatty acids: - Contains as many hydrogen atoms as the carbon atoms can bond with and no double carbon bonds - Hard margarines - Vegetable shortenings - Pastries - Crackers - Fried foods 6 lOMoARcPSD|16245032 - - - - Cheese Ice cream Processed foods Monounsaturated fatty acids: - Have only one double bond between carbon atoms - Contain fiber and antioxidants - Canola - Olive - Peanut oils - Almonds - Sesame seeds - Avocados - cashews Polyunsaturated Fatty Acids: - Have multiple pairs of double carbon bonds - Corn - Safflower - Sesame - Soybean - Sunflower seed oils - Fish (halibut, herring, mackerel, salmon, sardines, fresh tuna, trout, whitefish) Animal source foods, such as meats, lamb, processed beef, remain major sources of total fat, cholesterol and dietary intake Patients are usually recommended to increase their intake of monounsaturated (which have fiber and antioxidants) fats and decrease their intake of polyunsaturated and saturated fats Trans Fat (trans fatty acid): is composed of partially hydrogenated fatty acids, and saturated fats are known to raise the body’s cholesterol Cholesterol: waxy, fatlike substance that is found in all cells of the body - 75% is produced by the liver and intestines - 25% is obtained by dietary intake - Necessary for production of hormones (estrogen, testosterone, adrenaline, and cortisone) - Aids in digestion as a component of bile salts Omega 3 (Linolenic Acid) and Omega 6 ( Linoleic acid): - Referred to as unsaturated essential fatty acids that need to be included in the diet because human metabolism can’t produce them - Necessary for: - Blood clotting - Normal brain and nervous system function - Help prevent atherosclerosis - Lower triglyceride levels - Omega 3 helps with: - Improving learning ability in children 7 lOMoARcPSD|16245032 Enhance immune function Relieve arthritis symptoms Eating 2-3 servings of fish with omega 3 reduces the risk of heart disease and sudden cardiac death - Fish, nuts, seeds, oils, - FLAXSEED oil contains highest amount of omega 3 - Linoleic acid plays important role in lowering cholesterol levels Omega 6 - Unsaturated fat found in seeds, nuts, vegetable oils - - Proteins - - - - Active participant in development maintenance, and repair of body’s tissues, organs, and cells Hemoglobin is one type of protein important to regulating body function Prothrombin, protein necessary for clotting blood Proteins helps with: - Production of hair and nails - Muscle movement - Nerve conduction - Digestion - Defense against bacteria and viruses Amino Acids: building blocks of protein - Must be consumed in food every day unlike fats and carbs - Human body does not produce or store excess amino acids for later use When accumulation of protein exceeds need for growth and repair of tissues, protein is removed and excreted by kidneys in urea If production of fats or carbs is deficient, protein can assume role of providing energy - Demand of protein stores can lead to deficiency of protein in the body 2,000 calorie diet recommends 5.5 ounces of protein per day Protein supply 4 kilocalories of energy per gram and supply 15% of total energy intake Complete proteins: - Have all essential amino acids - Animal based foods: - Milk - Eggs - Cheese - Fish - Meat - Poultry - Can’t be manufactured by the body and must be consumed - Only plant protein considered complete is soybeans Nonessential proteins can be made by the body using amino acids Incomplete Proteins: 8 lOMoARcPSD|16245032 - Water - - - Lack one or more essential amino acids Beans Peas Nuts Seeds Fruits Veggies Bread and bread products in some cases two or more complementary proteins can form complete protein and provide essential amino acids - Ex: pasta and broccoli, rice and beans, pb and whole wheat bread Helps control body temperature Maintain acid-base balance Regulates fluid and electrolytes Transports nutrients and waste products from the kidneys Water Is a component of extracellular and intracellular fluids within the body ⅔ of fluid within body are contained within cells (INTRACELLULAR) Extracellular are composed of: - Blood - Interstitial fluid between cells - Within certain structures When water loss is continued without replacement, blood volume is diminished - Ample blood and oxygen cannot be furnished into body cells - Carbon dioxide and waste products cannot be efficiently removed - Every organ is affected including brain and CNS Water makes up 60% of adult weight Water makes up 50% in older adults—-Risk for dehydration Most people obtain water through food and liquids intake Thirst in children and adults means they need liquid - DOES NOT MEAN elderly need water Diarrhea, slight decrease in water, excessive sweating, or vomiting can result in dehydration - - Symptoms of dehydration include headaches and loss of concentration Excessive water intake or failure to excrete adequate amounts of urine (Seen in renal conditions) can lead to water INTOXICATION - - Can dilute amount of sodium in the body and cause hyponatremia Fluid intake needs to be monitored in patients with fluid overload, congestive heart failure, or a renal disease in which fluid intake is limited 9 lOMoARcPSD|16245032 Vitamins Organic compounds that contribute to important metabolic and physiologic functions in the body - Regarded as indispensable in proper dietary intake - Characteristics include: - Body's inability to manufacture them - Limitation of production by environmental factors - Do not produce energy - ARE CRUCIAL in chemical reactions within the body from nutrients such as fats, carbs, and proteins - Characterized according to solubility in fat, water and their absorption, transportations, and storage princesses within the body Fat Soluble Vitamins: - - - - Fat assists with the absorption of Vitamin A, D, E, and K. Excess are stored in the liver and fat tissue and are not excreted by the kidenys - Bc of this storage if excessive amunt of these vitamins is taken, toxicity may result esp with Vitamin A and D Vitamin A: - Important for its ability to increase resistance to infection - Promotes night vision through formation of visual pigment - Develop and maintain normal function of epithelial tissue - Aid in development of normal bones and teeth - Responsible for maintaining integrity and function of skin and mucosal cells - Bodies first line of defense against infection - Hemoglobin receives stored iron with assistance of Vitamin A - Deficiencies may cause: - Night blindness - Poor appetite - Decreased immunity to infections - Impaired growth and development - Foods with vitamin A include: - Liver - Milk - Egg yolk - Dark, leafy green veggies - Yellow and orange veggies and fruits - Sweet potatoes - Pumpkins - Carrots - Apricots Vitamin D - Known as sunshine vitamin bc its synthesized in skin when exposed to sunlight 10 lOMoARcPSD|16245032 - - - - Important for bone and tissue formation bc it collaborates with minerals to strengthen bones - Calcium and phosphorus Recommended for people to get at least 15 minutes of sunlight several times a week to maintain and store vitamin D Vitamin D assists in development of collagen - Constituent of bone that aids in bone strengthening Foods include: - Dairy products - Eggs - Fortified food products - Liver - Fatty fish (salmon and mackerel) Vitamin E - Antioxidant that protects cells from injury from free-radicals - Free Radicals: by-products that result when the body transforms food into energy - Accumulation of free radicals is responsible for aging process - Can also contribute to heart disease, cancer, and inflammatory conditions - Risk factors of harmful oxygen free radicals: - Cigarette smoking - Extensive exposure to sun - Air pollution- damages cells, tissues, and organs - Maintains healthy immune system - Foods include: - Nuts - Seeds - Soybean - Canola - Corn - Other veggie oils Vitamin K - Synthesized by bacteria found in large intestine - Essential for synthesis of proteins that promote coagulation of blood - Liver produces protein prothrombin and is dependent on Vitamin K - Deficiency results in bruising and bleeding - Foods include: - Dark green veggies - Broccoli - Spinach - Brussel sprouts - Cabbage 11 lOMoARcPSD|16245032 Water-soluble Vitamins - Dissolve in the body and are excreted in the urine Easily destroyed by air, light, and heat Are not stored in the body so must be ingested daily through foods or supplements Vitamin C: - - Ascorbic acid Super important to promote healthy body Can synthesize collagen - Collagen is important for wound healing, connective tissue, repair and maintenance of cartilages, bone, and teeth Effective as an antioxidant that guards against cellular damage from toxic chemicals and pollutants in the environment Aids in development of immune system Foods include: - Orange fruits - Papaya - Kiwi - Broccoli - Sweet and white potatoes Vitamin B complex: - - - Help form red blood cells and act in part as coenzymes, small chemical combining with enzyme to make it active - Enzymes: protein responsible for catalyzing most chemical reactions in the body, such as digesting food and synthesizing new compounds Vitamin B1 Thiamine: - Essential for metabolism of proteins, fats, carbs - Essential for sugar to produce energy in body’s cells - Important for normal growth and development and promotes normal heart, muscle, and nervous system functions - Necessary for production of hydrochloric acid (for digestions - Foods include: - Egg yolk, fruits, organ meat, lean pork, legumes, nuts, veggies, hold grains Vitamin B2 Riboflavin - Assist in metabolism of protein and function of other B vitamins like B3 and B6 - Helps in promoting visual adaptation to light and promoting healthy skin - Foods include: - Milk and dairy products - Whole grains - Enriched bread and cereals - Legumes - Dark green veggies - Organ meats 12 lOMoARcPSD|16245032 - - - - Vitamin B3 Niacin - Nicotinic acid or nicotinamide - Is a coenzyme for energy production - Critical role in formation of fatty acids - Foods include: - Meats, poultry, fortified breads, cereals, brewers yeast, fish (swordfish and salmon), mushrooms, whole grain, green leafy veggies, dried beans, peanuts - COFFEE contains alot of niacin - Helps prevent deficiencies in cultures that consume little protein and large amounts of coffee Pantothenic acid (Vitamin b5) and Biotin (Vitamin B4) - Used in body to produce energy - Biotin: - Necessary to form purines, essential components of DNA and RNA - Found in liver, legumes, tomatoes, and egg yolk - Pantothenic Acid: - Metabolizes fats, carbs, and protein and synthesis of acetylcholine - High amounts of pantothenic adid are found in whole grain cereals, potatoes, legumes, broccoli, egg yolks Vitamin B6 (pyridoxine) - Assists as a coenzyme in the synthesis and catabolism of amino acids Vitamin B12 (cyanocobalamin) - Essential for production of red blood cells - Facilitate entrance of folate into cells and maintain protective sheath (myelin) surrounding nerve fibers - Necessary to make DNA - Found in animal products Folic Acid (Vitamin B9) - Water soluble vitamin must be provided in diet - Not supplied by the body - Necessary for synthesis of DNA - Used in red blood cell formation - Necessary for rapid growing cells - Blood and fetal and GI tissue cells - Absorption affected by drugs such as contraceptives and antibiotics - Folic acid supplements taken before and during pregnancy are best to prevent nueral tube defects in newborns - Foods include: - Leafy green veggies, oranges, strawberries, dried beans, peas, nuts, enriched breads, cereals, fortified grain products Folic acid has been shown to reduce neural tube defects of the brain and spinal cord by more than 70% and is the most recommended nutrient to be taken to prevent birth defects. 13 lOMoARcPSD|16245032 Minerals - - - Considered to be micronutrients Potassium, chloride, and sodium play critical role in maintaining fluid balance within the body - Important in nerve conduction and muscle contraction - Potassium foods include: - Milk, bananas, legumes, green veggies, orange juice, tomatoes, vegetable juice, avocados, cantaloupe - Sodium foods include: - Table salt, smoked meat, fish, olives, and pickled foods - Chloride foods include: - Tomatoes, celery, seaweed, and olives Calcium, phosphorus, and magnesium are minerals most important for production and maintenance of bone tissue - Calcium required for: - Nerve conduction, muscle contraction, blood vessel expansion and contraction, secretion of hormones and enzymes - Contains milk and milk products, salmon with bones, spinach, kale, fortified whole wheat bread, tofu and orange juice - Phosphorus: - Aids in development of bone, contraction of muscles, kidney function, nerve conduction, and maintenance of regular heartbeat - Intake of phosphorus is considered adequate if intake of milk and meat products is sufficient Magnesium works with calcium to promote structural support - Regulates blood pressure - Maintains regular heartbeat and nerve and muscle function - Nutrient is associated with production of dopamine, norepinephrine, and epinephrine - Can produce calming effect - Deficiency may result from dietary intake of bad nutritional value - Additives, refined sugars, foods high in calories, and low in protein, vitamins, and minerals - Excessive zinc may lower magnesium levels - Foods include: - Halibut, seeds, nuts, tofu, swiss chard, spinach, whole grain wheat, brewers yeast, molasses 14 lOMoARcPSD|16245032 Antioxidants - Substances that protect body cells against effects of free radicals Free radicals: - Molecules produced when body breaks down food or is subjected to environmentals exposure to potential toxins like smoke, tobacco, and radiation - Prevent oxidative process (damage from oxygen) which is caused by free radicals - Can lead to cell dysfunction, and diseases - Promote immune function and lower risk for infection and cancer - Antioxidants include beta carotene, lutein, lycopene, selenium, vitamins A, C, and E Digestion - Catabolism- the body receives nutrients needed to provide energy for physical activity - Needed to build and repair muscle Anabolism- body using energy sources to build tissue Ketones: incomplete fat oxidation when carbs are not available Dietary Guidelines - - Healthy eating pattern is one that: - Combines healthy choices from all food groups and pays attention to calories limits - Emphasizes fruits, veggies, whole grains, and fat-free or low-fat milk and milk products - Includes seafoods, lean means, poultry, beans, eggs, nuts, seeds, and soy products - Low in saturated fats, trans fat, sodium, and added sugars - Based on eating smaller portions and drinking water rather than sugary beverages - Consuming less than 10% of calories per day from added sugars - Less than 10% from saturated fats - Sodium intake of less than 2300 mg Myplate is intended for healthy people, not for those on a prescribed or special diet Diversity Considerations Life Span: - - The longer a woman breastfeeds her child, the lower her risk for serious diseases and lower the child's risk for infections, obesity, diabetes US department of health recommends breastfeeding for 6 months to 1 year 15 lOMoARcPSD|16245032 - - - Babies with milk allergies or medical conditions could take soy-based or hydrolyzed (predigested) proteins Infants double birth weight at 5-6 months and triple by year 1 - Require more nutrients than adults Adolescents needs calcium to meet the body’s demand for mineralization of bone - Adolescent boys need increase in iron to aid in the development of lean body mass - Adolescent girls need to replenish iron lost during menstruation Pregnant woman are at risk for development of iron deficiency anemia Older adults at risk for development of osteoporosis as a consequence of increased bone loss and low calcium intake in this age group - Also need an increase of vitamins and minerals such as Vitamin D, calcium, and phosphorus - Nurses shoulder recommend for older adults to consume a variety of colors and textures of fruits and veggies, adding whole grain breads and cereals, and decreasing amount of saturated fatty foods in diet - Can also recommend addition of spices and herbs to enhance taste of foods Older adults should choose foods that are nutrient dense - Should visit MOWAA to investigate causes of lonely eating and homebound older adults Gender - - Women and men should avoid excess protein to decrease calorie loss and help prevent osteoporosis and kidney stones Excess calcium intake in men can lead to advanced prostate cancer Culture, Ethnicity and Religion - Foods traditionally consumed by various ethnic groups may contribute to development of chronic illnesses Consuming large amounts of salted pork products may lead to hypertension Ethnic groups with diet high in carbs may be prone to obesity and diabetes During Ramadan, people of islamic faith will not eat or drink from sunrise to sunset - Nurse has to take these factors into consideration when providing care Disability - Enteral Feeding (tube feeding) poses certain challenges: - Selection of appropriate formula according to what the patient needs is dependent on: - Nutritional adequacy - Digestibility - Viscosity - Osmolality (ionic concentration) - Ease of use - cost 16 lOMoARcPSD|16245032 Morphology - Patients who had surgery to help with obesity (gastric bypass or banding) are at risk for nutritional deficiencies bc of altered state of digestion and absorption - Supplemental nutrients are necessary to minimize the effects of vitamin and mineral deficiencies - Patients with anorexia nervosa is compounded by patients distorted self perception and internal physical sensation - Anorexia patients do not perceive hunger as hunger, or after eating little food feel full - May also result in excessive strenuous exercising without awareness of fatigue - Nurses can help with patient with the contracting of a certain amount of food each day, establishing a target weight, and having patient discuss any fears related to weight gain and loss of control - Exercise should be limited in people with are underweight Musculoskeletal Alterations - - Poor nutritional intake affects the musculoskeletal system and a person can become at risk for bone defects as a result of an imbalance of vitamins, A and D. - Osteomalacia: - Softening of the bone bc of Vitamin D deficiency - Poor absorption of calcium, which is made from Vitamin D can lead to osteopenia or osteoporosis, which bone mass density decreases and bone tissue deteriorates - Increases risk of fractures Absorption of calcium is higher in children than adults Decreased muscle size and strength (atrophy) limit the protection of connective tissue and bones and ability of the body to produce heat Neurological Alterations Excess sodium can lead to hypertension, which can increase chance of stroke - Should not exceed 1500 mg per day to lower blood pressure or encourage sodium intake of less than 2300 mg/day - Choose foods prepared with little or no salt - Deficiency of folate (folic acid) contributes to the incidence of macrocytic or megaloblastic anemia. • May be evident in symptoms such as: 1. Depression 2. mental confusion 3. glossitis (inflamed tongue) 4. Loose stools 5. Decrease in nerve function - 17 lOMoARcPSD|16245032 - Folic Acid and B vitamins have been researched for treatment of memory loss and Alzheimer Cardiopulmonary alterations Substances secreted from fat cells produce most of pathologic changes that result in atherosclerotic heart disease - Atherosclerotic: blood flow to part of heart is occluded bc of plaque that has entered the arteries - May lead to heart attack or cardiac damage bc of lack of blood flow to heart tissue - Cholesterol and lipids attach to walls of arteries, leading to coronary artery disease - Digestive System Alterations - Dysphagia (difficulty swallowing): - May result from the presence of an obstruction from a mass or tumor, residual effects of a CVA, neurological damage, or physiological disorders - Malabsorption (problematic or inadequate absorption of nutrients in the intestinal tract): - May cause: - weight loss - Fatigue - GI upset (celiac disease - gluten sensitive enteropathy) - and vitamin and mineral deficiencies such as rickets (Vitamin D deficiency) - - - Scurvy (Vitamin C deficiency) Vitamin C deficiency may result in gingivitis, swollen or bleeding gums with loosened teeth, and painful and stiff joints Malabsorption may also cause anemia, excessive bleeding, petechiae (bleeding under the skin), poor wound healing, neural tube defects Marasmus: - Resulting from both protein and calorie deficiency Kwashiorkor: - Lack of protein accompanied by fluid retention Phenylketonuria: - Condition in which an infant's body fails to metabolize amino acid phenylalanine - May result in impaired brain development, progressive cognitive delays, and lots of damage 18 lOMoARcPSD|16245032 Metabolic Alterations Diabetis Mellitus - - Failure of pancreas to produce adequate insulin to regulate glucose levels allows accumulation of glucose into the circulatory system and decreased diffusions, (entry into the cells) Insulin through injections is necessary for metabolism in patient with type 1 Insulin used to be from pigs or cattles but now its biosynthetic for people who don't eat pork or beef Oral antiglycemic agents, diet, and exercise are best for type 2 High risk for developing blindness bc of retinal changes, renal failure, neuropathy (loss of sensation) in lower extremities, and poor wound healing The body turns carbohydrates into glucose and eating too many carbohydrates can cause the blood glucose levels to elevate. Diabetics should avoid simple sugars. Diabetic diets recommend less than 2500 calories. Sodium intake is not the main focus of a diabetic diet. - - - Allergies and intolerances - Allergies are a response of the immune system when body erroneously identifies an ingredient or food product as harmful and produces antibodies to fight it - Food intolerances trigger digestive system response which results in irritation of the digestive tract or inability to digest or break down food - Lactose intolerance is the most common food intolerance - Food allergies are life threatening and food intolerance cause discomfort Obesity - BMI of 30 or higher - Mobridly obese when BMI is 40 or more than 50% ideal body weight - Overweight is 25-29.9 - As BMI levels rise, blood pressure and cholesterol levels also rise, and average high density lipoprotein (HDL)--or good cholesterol levels decrease - Men with a high BMI above 31.1 are at risk for hypertension, hyperlipidemia, or both - Hyperlipidemia: elevation of plasma cholesterol, triglycerides, or both - Along with low HDL levels contribute to development of atherosclerosis (buildup of fat deposits on arterial vessel walls) - Women with elevated BMI (above 32.3) have both times the risk of development of these conditions Malnutrition - May result from absorption or digestive problems, illness, or an inadequate or imbalanced intake of calories - Lack of just one vitamin can cause person to be malnourished - Children especially vulnerable 19 lOMoARcPSD|16245032 Psychological Alterations - - - Two major alterations of anorexia is linked to improper nutritional intake, lack of absorption, and metabolism of nutrients Anorexia Nervosa - Serious disorder in which person exhibits life threatening practices are a result of an altered mental state - May be used to gain some sense of control for adolescents and young adults - Include limited caloric intake, omission of healthy foods, excessive exercise routines, obsessive behaviors - Include excessive use of laxatives or diuretics, self induced vomiting, refusal to be around others when food is involved - Circulatory collapse, organ failure, or cachexia common causes of premature death in anorexia patients - Suicide being second leading cause of death - How to treat as a nurse: - Involve teens in decisions about care - Determining extent to which adolescents may harm themselves - Tube feedings not always the best option - Highly skilled nursing care with hospitalization is preferred before BMI drop below 13 kg/m2 - Best way to treat is through collaboration w physician, nurse counslepr, spiritual advisor, parents, and others Bulimia Nervosa - Involves obsession with binging, about 2000-300 calories at one time followed by purging - May also result from use of laxatives or diuretics - Complications include tooth decay, or GI symptoms like electrolyte imbalances, cardiac dysrhythmia, heart failure and death Nutrition History - - Nurse should conduct nutrition history to note dietary intake or any changes in weight or appetite by the patient Nurse should take into consideration patients culture and ethnicity Collection of data allows nurse to analyze data regarding type and quantity of foods, establish baseline for recognizing cues regarding health problems Two common practices are 24-hour recall and food diary - 24 hour recall is dependent on patient ability to remember consumption of foods and their quantities from the previous day - May not be factual intake may not be from typical day - Food diary has journal food entries from 3-5 days and include dietary intake for a typical weekend - Type and amount of food and how food was prepared 20 lOMoARcPSD|16245032 Screening for Malnutrition in older Adults - Assessment for older adult must include mouth, teeth, and gums Consideration to decrease in sense organ function related to aging, and ability to smell, taste, chew, or digest food Physical Assessment Includes height and weight measurements, determination of BMI, evaluation of lab values, notation of any adverse signs and symptoms of malnourished people, recognition of any existing or physiological illness - Malnourished people: poor dentition, poor skin turgor, dull, thinning hair - Waist circumference: - Valuable tool in addition to BMI to determine patient's risk for cardiovascular disease - Asses fat distribution and indicates body shape Morphology - - Patients BMI is helpful in determining presence of obesity, malnutrition and cachexia Cachexia: physical wasting - is often seen in patients suffering from terminal illnesses who are unable to consume an adequate intake of food - Effects are evident in weight loss and loss of muscle mass Anthropometric Measurements - - Anthropometry: study of measurements of the human body - Used to perform nutritional or growth and development assessment of infants and children - Height, weight, length, and head circumference - For Adults: - Height, weight, BMI, and waist to hip ratio - Findings are compared against reference standards to assess weight status and risk for diseases Waist circumference can be used as a strong diagnostic criterion for metabolic syndrome: - Cluster of medical conditions characterized by insulin resistance and presence of: - obesity - abdominal fat - elevated blood glucose - serum triglycerides and cholesterol - Hypertension 21 lOMoARcPSD|16245032 - Skinfold measurements can help determine a person's body composition and body fat percentage - Percentage of body fat is measured by measuring skinfold thickness, using calipers at specific locations in the body - Thickness of the folds is a measure of fat under the skin called subcutaneous adipose tissue - Results rely on formulas that convert the numbers into an estimate of body fat stores and nutritional status for the person’s age and gender BMI - Underweight: less than 18.5 kg/m^2 Normal weight: 18.5-29.8 Overweight: 25-29.9 Obese (class 1): 30-34.9 Obese class 2: 35-39.9 Extreme obesity class 3: above 39.9 Skin and Hair - - - - Influence of improper nutrition on the skin is evident during physical assessment Poor nutrition is reflected by the presence of thinning hair that has a dry, stiff, texture and lack of shine - In severe cases hair may totally lose its color and appear pale Lips can have a deep red appearance with open lesions and deep cracks in the corners of the mouth Oral mucosa may be darker red than normal, with oral lesions the tongue may reveal white irregular areas Pernicious anemia: - Sore, smooth surfaced, beefy red tongue - Soreness may interfere with chewing certain foods Dry rough appearance of skin, pallor, and changes in pigmentation of the skin may be noted - Skin may be easily bruised or or have small pinpoint hemorrhages under the skin: known as PETECHIAE Skin changes in extremely malnourished: - Loose wrinkled skin—loss of underlying fat tissue - Deep wounds that will not heal Skin turgor can indicate level of hydration - In dehydration when skin is pinched, takes form of a tent and takes a while to return to normal position 22 lOMoARcPSD|16245032 Dentition Loss of natural dentition affects nutrient consumption and may result in increased development of cardiovascular disease - Edentulous (toothless) people: - Experience lower BMI values bc of inability to chew - Swallow Studies - - - Stroke or CVA and other injury patients may experience dysphagia or choking during meals People who have difficulty swallowing are at risk of aspirating food and fluid into lungs People at risk for aspiration: - Seizures - CVA - Dementia - Gastroesophageal reflux disease GERD - Diseases affecting mobility—cerebral pasly, muscular dystrophy, sclerosis, parkinsons, - Endoscopy procedures - Medications with sedative or relaxant like anesthesia - Feeding of patient by another person or eating too fast How to prevent aspiration: - Elevate head of the bed 45 degrees during and after eating for 45 mins - Keep head of bed elevated 30 degrees at all other times, including enteral feeding - Avoid drinking and eating 2-3 hours before sleep - Administer GI medications as ordered - Inspect mouth for pocketing of food - Observe patient for correct swallowing - instruct patient to alternate between bites of food and sips of water for better swallowing - Maintain patient NPO status after procedures i which throat was anesthetized until gag reflex has been verified People with risk factors for aspiration should have a swallow study or dysphagia screening Swallow studies conducted by speech therapist Lab Studies - Prealbumin: - Levels that measure the amount of protein contained in the internal organs - Levels under 11 mg/dl indicate presence of malnutrition - May result from stress, inflammation, surgery, or renal failure - Half life: 2 days - Normal values: 16-30 mg/dl 23 lOMoARcPSD|16245032 - - - - Mild values: 10-15 Moderate: 5-10 Sever: less than 5 Albumin - Assessment of plasma protein levels used to determine liver function - Synthesized in liver and accounts for almost half of the total serum protein in the body - Levels should be included on initial chemistry profile for nutritional screening and monitored during inpatient to determine presence of ample supply of protein over extended period of time - Decreased levels may be cause by renal and liver disorders, altered fluid status, medications, chronic diseases, and malnutrition - Elevated levels may result from decreased fluid imbalance (dehydration), exercise, or medications - Half life: 21 days - Normal: 3.5-5 - Mild: 2.8-3.5 - Moderate: 2.1-2.7 - Severe: less than 2.1 Transferrin - Transports iron in the body and is sensitive to a decrease in protein and iron stores, as seen in iron deficiency anemia and kwashiorkor - May be elevated in acute fasting, chronic infection, inflammation, burns, or pernicious anemia - Levels elevate as iron deficiency worsens and and decrease as the iron levele responds to treatment and returns to within an acceptable range - Half life: 8-9 days - Normal: 200-400 - Mild: 150-200 - Moderate: 100-150 - Severe: less than 100 Hemoglobin and Hematocrit - Used to identity the number and percentage of circulating erythrocytes, ability to provide oxygen to the cells, and the body’s iron store status - Iron is essential portion of hemoglobin–assist with gas exchange in the lungs and helps meet oxygen demands in the body - If iron is depleted, less o2 is available to meet the demands of the body resulting in: - Fatigue - Pallor - Shortness of breath - Rapid respirations 24 lOMoARcPSD|16245032 - - - Iron deficiency anemia indicated by low hemoglobin levels is often treated by is treated by providing iron in form of oral supplement or intramuscular injections - In severe situations it can be administered IV People low in iron encouraged to increase intake of foods with iron: - Liver - Dark green leafy veggies - Seafood - Bran Hematocrit indicates number and size of red blood cells found in whole blood - Expressed as percentage of total blood volume occupied by the erythrocytes - Low hematocrit indicates anemia - Size and shape of red blood cell can indicate type of anemia person is suffering from Hemoglobin 138 to 172 g/L 121 to 151 g/L 95 to 130 g/L 140 to 240 g/L Hematocrit 40.7% to 50.3% 36.1% to 44.3% 32% to 42% 45% to 61% - Normal Values - Males - Females - Infants - Newborns - Blood Urea Nitrogen and Creatinine - Evaluate kidney function in people with disease processes like diabetes or hypertension - Determine extent of kidney dysfunction, progression, and effectiveness of treatment - Elevated levels may be a result of dehydration, atherosclerosis, or injury to kidneys from infection or trauma - Normal Values: 10-20 Elimination Patterns - Constipation results from slowed digestion of food in GI tract Diarrhea may be results of high fat intake, artificial sweeteners, or excessive intake of insoluble fibers Dietary Preferences: - Vegetarians are at risk for pernicious anemia and should supplement diet with Vitamin B12 to minimize this risk 25 lOMoARcPSD|16245032 Food patterns based on religion or culture Kosher diet: - - - Not allowed: pork, shellfish, rare meats, blood, combination of milk and dairy products with meat Cooking restrictions on the sabbath Some Jewish holidays only can eat unleavened bread or fasting Catholic have holy days with fasting, especially on fridays during Lent Islamic tradition: - Prohibits alcohol, pork, caffeine - Halal food preparation rules share similarities with kosher laws Month long holy season of ramadan people cannot eat during daytime It is important to ask patients about dietary restrictions before administration of alcohol based medications such as antitussives—cough syrup Special Diets - - - - - Clear Liquid - Limited nutrients and is used only for a short period of time - Clear juices do not contain pulp such as: - Apple or cranberry juice - Gelatin - Popsicles - Clear broths - Ordered for patients with GI problems and for preop and postop patients also for some diagnostic test Full liquid - Foods that are or may become liquid at room or body temperature: - Juices with and without pulp - Milk and milk products - Yogurt - Strained cream soups - Liquid dietary supplements - Ordered for patients with GI disturbances, dental work, or who cannot tolerate solid foods when not NPO Pureed Diets: Blended - Food that is placed into a blender and made into a pulp like mixture - Patients who cannot safely chew or swallow solid food - Raw eggs, nuts, and seeds should be avoided Mechanical soft: - Food consistencies that have been modified - Ground meat or soft-cooked foods - Used for those who have difficulty chewing effectively Thickened Liquids: - Patients who have difficulty swallowing and are at risk for aspiration - Liquids can be thickened by adding a commercially prepared thickening agent - Nuts, seeds, and other hard foods should be avoided bc of risk for aspiration 26 lOMoARcPSD|16245032 - - Regular Diets: - General diets that are tolerated and that should supply everyone with the proper nutrients Diabetic Diets: - Prescribed to control amount of calories by controlling carbohydrate intake - Foods that have high glycemic concentration and that can rapidly raise blood glucose is a big NO NO - High fiber complex carbs are from veggies and fruits are preferred to simple carbs that have sugars or starchy foods The body turns carbohydrates into glucose and eating too many carbohydrates can cause the blood glucose levels to elevate. Diabetics should avoid simple sugars. Diabetic diets recommend less than 2500 calories. Sodium intake is not the main focus of a diabetic diet. - - Cardiac Diets: - Used to control the dietary intake of foods that contribute to conditions affecting the cardiovascular system - Consist of low cholesterol and low sodium diets - Minimize the intake of animal products, which contain cholesterol, and soups, and processed foods - Pickles and lunch meat—high in sodium - Include patients with hypertension, high cholesterol, atherosclerosis, chronic kidney disease, Renal diets: - Restrict potassium, sodium, protein, and phosphorus intake - Fresh fruits (NOT BANANAS) and veggies are excellent choices for this diet - Meats, processed foods, peanut butter, cheese, nuts, caramels, icecream, and colas, are sometimes allowed in limited quantities unless contraindicated Clients with kidney problems have difficulty maintaining fluid and electrolyte balance. There are challenges with excreting sodium, phosphorus, and protein, as well as potassium. Assistance with Feeding - Extremely important to elevate the bed 30-45 degrees unless contraindicated Closely observe patients ability to swallow, and watch for signs and symptoms of dysphagia - Dysphagia Signs include: - Coughing - Incomplete lip closure - Poor tongue control - Excessive chewing - Gagging before swallowing - Failure to swallow - Pocketing foods in the cheek - Or refusal to eat 27 lOMoARcPSD|16245032 - Patients who have to be supine or in flat position should be log rolled to side lying for meals to aid in swallowing and aspiration prevention Have suction machine at bedside at all times Feeding should never be rushed If patient has one sided muscle weakness, have patient turn head to the affected side to assist in air-way protection Chin-tucking may help prevent aspiration Make sure patient can see you Allow at least 30 minutes for each meal—small bites (½ to 1 teaspoon) 10 seconds between each bite Alternate food with fluids Avoid unnecessary use of straws to prevent air ingestion Observe rise and fall of larynx to ensure swallowing Check for pocketing of food NPO Patients - - Often in place before and after surgery to allow intestinal tract to rest and decrease the stimulation of nerves that can lead to vomiting of the stomach contents GI bleeding or intestinal blockage may warrant NPO orders Mouth care is super important to help keep oral mucosa moist and aid in swallowing - Lateral position for unconscious patient to allow drainage of secretions Enteral Feeding Tube - - Used to provide short term nutrition support for patients who have functional GI tract but cannot swallow, refuse to eat, or need nutrients for the body NG feeding tubes are placed through one of the nares and into the stomach - Are also used for short-term nutritional therapy and bowel decompression Confirming Enteral tube placement: - Radiographic confirmation is only reliable method to date confirming enteral tube placement - Using pH and appearance of aspirate from newly inserted tube is NOT a safe method of verifying proper gastric tube placement especially in patients receiving antacid medications - Auscultation of an air bolus to assess tube placement is no longer recognized as a reliable source in determine proper placement of gastric tube ALWAYS check to make sure that tube feeding are properly connected to enteral tubes ONLY - Accidental hookup of enteral feeding tube to IV line can be deadly - Joint commission requires all enteral tubes have an ENFit connected to prevent inadvertent connection of feeding tubes with other bad tubes 28 lOMoARcPSD|16245032 - Percutaneous endoscopic gastronomy (PEG) are surgically placed through incision in upper left quadrant of the abdomen - Long term nutritional therapy and for patients who are neurologically impaired - CVA - Or have a condition that affects the stomach and its normal function - Patients who have esophageal cancer or traumatic injury to the nose and mouth may be candidates for PEG - MONITOR the patient's skin around PEG tube for signs of skin breakdown or infection - Several types of PEG tubes: - Traditional G tube placed in the stomach - Double lumen gastrojejunostomy tube (GJ) - One lumen (gastronomy) or G tube, is placed in the stomach - Other lumen Jejunostomy or J tube, placed in jejunum for compression - Low profile MIC-KEY gastrostomy feeding tube - Low profile MIC transgastric-jejunal feeding tube - Procedural concerns: - Surgical asepsis required for newly inserted - Clean site with warm water and mild soap - Occasional use of hydrogen peroxide or normal saline is permitted - Cleansing should be based on the patient's routine and facility policy and procedure - Dry site thoroughly to prevent skin breakdown - A split drain dressing may be applied to provide comfort and to prevent or treat skin breakdown - If tube becomes occluded, flush with small amount of air - If this is unsuccessful, flush the tube using 30-60 mL syringe and warm water - If still unsuccessful, use special enzyme solutions or declogging devices Medication Administration via Enteral Tube - Compatibility, medication solubility, and possible reduction in effectiveness pr increase in toxicity must be considered Medications should be given in liquid form or ground into powder (depending on the medication) - Should be dissolved in 15-30 mL of sterile water before instillation into the tube - Once enteral tube placement is verified: 1. tube is flushed with minimum 15 mL of sterile water 2. diluted medication flows into the tube by gravity or pushed gently by the plunger 3. Then 15-30 mL of sterile water to flush tube after medication administration 29 lOMoARcPSD|16245032 - Tube feeding may continue after med administration unless contents interfere with absorption of medication - Feeding would then be delayed for certain time period Total Parenteral Nutrition - - - TPN, also known as hyperalimentation, may be given through peripherally inserted central catheter PICC line or Central venous catheter (CVC) through infusion pump Infusions with greater than 10% dextrose concentration require CVC rather than peripheral intravenous site for infusion TPN may be the only option for patients who: don't have functioning GI tract or for patients unable to digest, ingest, or absorb nutrients Crohns ulcerative gastritis GI obstruction diarrhea unresponsive to treatment abdominal trauma, burns, or postop. Should NOT be used for patients with responsive GI tract TPN causes more complications, does not preserve GI tract well, and is more expensive TPN formula is made to fit patient needs and concentration has to be recalculated until patients nutritional needs are met Assessment of patients receiving TPN include: - Weight - CBC - Electrolytes - And BUN—daily for inpatients - Measurement of plasma glucose and electrolytes helps determine tolerance to solution - Glucose levels should be checked every 6 hours Tubing should be changed every 24 hours, with aseptic technique Dressing for the site should be changed every 48 hours Numerous complications include site infections, air embolism, catheter related infections, and dislodgement or occlusion of tubing TPN tubing is to be changed every 24 hours and per facility protocol. Glucose is a part of the TPN solution; thus, blood glucose levels are monitored at least every 6 hours. Clients are weighed daily. TPN must be administered through a central venous catheter or peripherally inserted central catheter and must be administered using an infusion pump for safety purposes. 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