Nutrition
Teresa V. Hurley. MSN, RN
Factors Affecting Food Habits
• Physical —
– geographic location,
– food technology,
– income
• Physiologic —
– health,
– hunger
– stage of development
• Psychosocial —
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culture,
religion,
tradition,
education
Psycho/Social
Developmental
Human Growth and Development
• Infants through School-Age
-rapid growth with high protein, vitamin,
mineral and energy demand; infant
doubles birth weight in 4-5months; triples
weight at 1 year
Breast Feeding encouraged
-reduces allergy risks
What other factors?
Infants
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Formula
Cow’s milk causes GI bleeding
Kidney’s unable to handle
Research: milk in 1st and the development
of Type I Diabetes later in life
• Honey and corn syrup maybe be source of
botulism
Introduction of Solid Food
• 4 to 6 months of age
• Introduce one at a time 4 to 7 days apart
to identify allergies
Toddlers
• Picky eaters around 18 months of age
• 3 meals and 3 snacks
• Calcium and phosphorous for bone growth
Hot dogs, candy, nuts, grapes, raw veggies,
popcorn frequently lead to choking deaths
School Age
• Growth slower and steadier
• Check for protein, vitamins A and C
• High fat, sugar and salt intake lead to
childhood obesity compounded by
sedentary lifestyle
Adolescents
• Energy needs increase to meet the
increase metabolic demands of growth
• protein., calcium, iron (females) and
muscle growth (males)
• Fad dieting, oral contraceptive use, fast
foods, skipping meals
• Eating disorders anorexia nervosa and
bulimia nervosa
Young and Middle-Age
• Energy demands less
• Fetal development affected by mother’s
nutritional status and weight at time of
conception; protein, calcium, iron, folic
acid
• Lactation: protein, calcium, Vitamins A, C,
B; avoid caffeine, alcohol and drugs
Older Adults
• Lifestyle
• Income
• Lack of teeth, dentures, thirst sensation
less with resultant dehydration (confusion,
weakness, hot dry skin, rapid pulse
• Nutrient dense foods: peanut butter,
cheese, eggs, cream and meat-based
soups
Cultural
Alternative Food Patterns
• Vegetarian
– Ovolactovegetarian (no meat, fish and poultry
but will have milk and eggs)
– Lactovegetarians (drink milk but no eggs)
– Vegans (plant foods)
-A Zen vegan eats brown rice, grains, herb
teas
-Fruitarians eat only fruits, nuts, honey and olive
oil
Religious Dietary Restrictions
• Islam (no pork, caffeine, ritual slaughter of
animals; Ramadan fasting sunrise to
sunset for a month)
• 7th day Adventists (no pork, shellfish,
alcohol, vegetarianism encouraged)
• Hinduism (no meats)
• Latter Day Saints (no alcohol, tobacco ,
caffeine)
Risk Factors for Poor Nutritional
Status
• Developmental
factors
• Alcohol abuse
• Medications
• State of health
• Megadoses of
nutrient supplements
Anorexia
Anorexia
-poor appetite related to ketosis an
appetite suppressant
Surgical Procedures with resultant pain
Diagnostic testing (NPO, bowel evacuations)
Promoting Appetite
• Keep environment free of odors
• Oral hygiene
• Insulin, glucosteriods, thyroid hormones
affect metabolism
• Antifungals alter taste
• Psychotropics affect appetite, nausea,
alter taste
Nursing Interventions
• Risk for Aspiration
– Assess LOC
– Decrease or absent gag or cough reflex
– Surgical procedures
– Neuromuscular impairments
– Sensory impairments
Nursing Interventions
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Upright position
Food placed stronger side of mouth
Thickening agents
Rate of eating slower to provide for
chewing and swallowing
• Use clock as guide to identify food location
for visually impaired
• Use assistive devices (padded forks,
spoons etc)
Nursing Interventions
• Client to direct order and preferences of
food items to eat
Therapeutic Diets
• NPO nothing by mouth
• Clear Liquid: broth, bouillon cubes, tea,
carbonated beverages, clear fruit juices,
popsicles
• Full Liquid: add to clear liquid diet smooth
textured dairy products as custard, refined
cooked cereals, pureed veggies, all fruit
juices
Diets Continued
• Pureed ( continue to add to the previous)
scrambled eggs, pureed meats, veggies,
fruits, mashed potatoes and gravy
• Mechanical Soft (add to the previous)
ground or diced meats, flaked fish, cottage
cheese, cheese, rice, potaotes, pancakes,
light breads, cooked vegetables and fruits,
canned fruits, bananas, soups, peanut
butter
Diets Continued
• Soft Low Residue: add pastas, casseroles,
moist tender meats, canned cooked fruits
and vegetables, desserts, cakes, cookies
without nuts or coconut
• High Fiber: add fresh uncooked fruits,
steamed veggies, bran, oatmeal, dried
fruits
• Low Sodium: 4g (no added salt) 2gm to
500mg Na diets require selective choices
Medications
• Stimulate appetite
– Periactin
– Megace
– Marinol’
Diets Continued
• Low Cholesterol 300mg/day in accordance
with AHA guidelines for serum lipid
reduction
• Diabetic: Food exchanges with balanced
intake of protein, CHO and fats and vary
according to energy demands as exercise,
pregnancy, illness
• Regular NO restrictions
Enteral Nutrition
• Short-term nutritional
support
– Nasogastric
– nasointestinal route
• Long-term nutritional
support
– Enterostomal tube
created into
• stomach (gastrostomy)
– Percutaneous
endoscopic
gastrostomy (PEG)
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jejunum (jejunostomy)
Enteral Nutrition (EN)
• Nutrients given via the GI tract
• Formula given via NGT,PEG, PEJ
• Initial tube placement verified by x-ray which is the most
accurate indicator
• Traditional Method for placement
– Measure distance from tip of nose to earlobe to xiphoid process
of sternum
– Water soluble lubricant
– Insert through naris toward posterior nasopharynx
– Flex head toward chest after passage through posterior
nasopharynx
– Have client mouth breathe and swallow small sips of water
– Stop advancing if client choking, coughing, cyanotic
Types of Tubes
• Naso-Gastric
Salem Sump
Types of Tubes
Gastrostomy Tube
Jejunostomy Tube
Tube Placement
Evidence Based Research
• X-ray verification most accurate
• X-ray method not feasible, the next best
method is pH testing of gastric aspirate
with readings between 0-4.
• pH of 6 or more placement in lung,
intestine
• Ausculatory method should not be used
but in some agencies still in use
Gastrostomy or Jejunostomy Tube
• HOB elevated 45 degrees
• Auscultate for bowel sounds
• Verify placement by testing pH of gastric
aspirate
• Check gastric residual
– If over 100 ml notify MD
– Would you replace the gastric contents?
– Would you stop the feeding?
Some Complications of Feeding
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Aspiration
Tube displacement
Cramping from using cold formula
Diarrhea
Impaired skin integrity
Nosocomial infections
Parenteral Nutrition
• Total parenteral
nutrition (TPN)
• Partial parenteral
nutrition (PPN)
Total Parenteral Nutrition
TPN- Total Parenteral Nutrition
• complete form of nutrition
– protein
– CHO
– fat
– vitamin
– minerals
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Indications for TPN
• Inability to eat
– Ventilator dependency
– Additional surgery
– Altered mental status affecting ability to eat
• Diminished nutrient intake
– Anorexia
– Dyspepsia from medications
– Gastrointestinal problems including nausea, vomiting,
diarrhea, and distention
• Increased nutrient requirements
– Hyper metabolism
– Nitrogen loss caused by surgery and corticosteroid
administration
– Malabsorption
TPN ACCESS DEVICES
Complications of Parenteral
Nutrition
• Insertion problems
• Fluid, electrolyte, and
acid-base imbalances
• Infection
• Phlebitis
• Metabolic alterations
PN Complications
• Electrolyte and Mineral imbalances: refeeding
syndrome
-high concentrations of glucose
leads to endogeneous insulin production which
leads to
-cations moving from inter to intracellular
(potassium, magnesium and phosphorus) which
leads to cardiac dysarrthymias, CHF.
Respiratory distress, convulsions, coma, death
Complications of PN
• Rapid administration of hypertonic
dextrose leads to osmotic diuresis and
dehydration
– DO NOT SPEED UP IF BEHIND
– DO NOT STOP LEADS TO HYPOGLYCEMIA
Glucose Testing
• Diabetes is a metabolic disorder
– Inadequate insulin production by pancreatic
beta cells or
– Insulin resistance whereby glucose unable to
cross sell membrane
• Cellular starvation
• Fluid and electrolyte imbalances
Diabetes
• Hypoglycemia: pancreas secretes
glucagon
• Hyperglycemia: pancreas secretes insulin
– Polyuria
– Polydyspia
– Polyphagia
– Glycosuria
– Ketones
Hypoglycemia
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Rapid onset with BS 80 or below
Cool, pale, diaphoretic skin
Disorientation---coma
Shaky, dizzy, agitated
Pulse maybe tachy
B/P maybe high
Seizures common
Treat with PO or IV Glucose
Hyperglycemia
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Gradual onset with BS 200 or above
Skin warm, dry, flush
Awake, lethargic
Hungry, blurred vision
Deep, rapid respirations
Pulse, weak, rapid
B/P maybe low
Breath: fruity odor
Dehydrated
Polyuria
Polydyspia
Treatment: IV, insulin and K
Glucose Monitoring
• ac and at hs
• Range 70-110 mg
• Insulin Coverage
– Regular Insulin (Rapid Acting) 3-4 hr
– NPH/reg (Fast Acting) 30 min---24hr
– Lente, NPH (Intermediate Acting) 1-3 hr---1828 hr
– Ultra-lente (Long Acting) 4-6 hr---36 hr