Chapter 44
Nutrition
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Background
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Food security is critical for all members of a
household.
Food holds symbolic meaning.
Medical nutrition therapy uses nutrition
therapy and counseling to manage disease.
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Type 1 diabetes mellitus
Hypertension
Inflammatory bowel disease
 Enteral nutrition (EN); parenteral nutrition (PN)
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Nutritional Guidelines
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Healthy People 2020; Health for All (WHO)
Guidelines for dietary change recommend
reduced fat, saturated fat, sodium, refined
sugar, and cholesterol, and increased intake
of complex carbohydrates and fiber.
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Case Study
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Mrs. Gonzalez is a 65-year-old Hispanic
woman who comes to the emergency
department with slurred speech, right facial
droop, and weakness in her upper and lower
right-side extremities. She is admitted to the
hospital with a diagnosis of acute stroke.
She has a daughter and two teenage
grandchildren who live in another town
nearby.
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Energy Requirements
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Basal metabolic rate—the energy needed to maintain
life-sustaining activities for a specific period of time at
rest
Resting energy expenditure (REE) (aka resting
metabolic rate)—the amount of energy that an
individual needs to consume over a 24-hour period
for the body to maintain all of its internal working
activities while at rest
In general, when energy requirements are completely
met by kilocalorie intake in food, weight does not
change.
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Scientific Knowledge Base:
Nutrients
Carbohydrates
Complex and simple saccharides
Main source of energy
Proteins
Amino acids
Necessary for nitrogen balance
Fats
Saturated, polyunsaturated and
monounsaturated
Calorie-dense
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Scientific Knowledge Base:
Nutrients (cont’d)
Water
All cell function depends on a fluid environment.
Vitamins
Essential for metabolism
Water-soluble or fat-soluble
Minerals
Catalysts for enzymatic reactions
Macrominerals; trace elements
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Digestion
Digestion
Absorption
Begins in the mouth and
ends in the small and
large intestines
Intestine is the primary
area of absorption.
Metabolism and
storage of nutrients
Elimination
Consist of anabolic and
catabolic reactions
Chyme is moved through
peristalsis and is
changed into feces.
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Dietary Guidelines
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Dietary reference intakes (DRIs)
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Food guidelines
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Acceptable range of quantities of vitamins and minerals for
each gender and age group
Dietary Guidelines, average daily consumption
Daily values
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Needed protein, vitamins, fats, cholesterol, carbohydrates,
fiber, sodium, and potassium
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ChooseMyPlate
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Case Study (cont’d)
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Mrs. Gonzales is awake and alert in her hospital
room, yet is drooling from the right side of her mouth.
When she tries to drink water, she starts to cough.
The physician has ordered nothing by mouth (NPO).
Evaluation by the speech language pathologist (SLP)
indicates inadequate clearance of food and liquid
from the vocal folds and aspiration of thickened
liquids.
Mrs. Gonzalez has trouble swallowing with
oropharyngeal dysphagia. The SLP recommends
enteral feedings, and speech and swallowing therapy
to help her return to oral feedings.
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Quick Quiz!
1. A 22-year-old new mother is breastfeeding.
You ask her if she is taking the correct
quantities of nutrients. Which statement
reflects that she understands the dietary
guidelines?
A. “I am not concerned with what I am eating.”
B. “I am taking vitamin doses based on TV.”
C. “I am taking a daily MVI.”
D. “I am making eating choices according to the
recommended dietary allowances and
intakes.”
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Nursing Knowledge Base
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Factors influencing nutrition
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Environmental factors
Developmental needs
• Infants through school age

Breastfeeding, formula, solid foods
• Adolescents
• Young and middle adults
• Older adults
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Case Study (cont’d)
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Matt is a nursing student assigned to Mrs. Gonzalez.
As he prepares to assess her, he recalls information
about the effects of dysphagia on nutrition and
rehabilitation. He will assess Mrs. Gonzales’ weight,
weight history, diet history, and cultural customs.
Matt knows to consult with a registered dietitian (RD)
to assess Mrs. Gonzales’s nutritional status and
interventions. Matt is responsible for inserting Mrs.
Gonzalez’s small-bore nasogastric feeding tube and
starting her tube feedings. The RD has
recommended continuous tube feeding for 12 hours
during the day.
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Alternative Food Patterns
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Based on religion, cultural background,
ethics, health beliefs, and preference
Vegetarian diet consists predominantly of
plant foods:
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Ovolactovegetarian (avoids meat, fish, and
poultry, but eats eggs and milk)
Lactovegetarian (drinks milk but avoids eggs)
Vegan (consumes only plant foods)
Fruitarian (consumes fruit, nuts, honey, and olive
oil)
Zen macrobiotic
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Assessment
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Screening a patient is a quick method of
identifying malnutrition or risk of malnutrition
using sample tools:
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Height
Weight
Weight change
Primary diagnosis
Comorbidities
Screening tools
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Assessment (cont’d)
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Anthropometry is a measurement system of
the size and makeup of the body.
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An ideal body weight (IBW) provides an estimate
of what a person should weigh.
Body mass index (BMI) measures weight
corrected for height and serves as an alternative
to traditional height-weight relationships.
Laboratory and biochemical tests
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Assessment (cont’d)
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Dietary and health history
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Health status; age; cultural background; religious
food patterns; socioeconomic status; personal
food preferences; psychological factors; use of
alcohol or illegal drugs; use of vitamin, mineral, or
herbal supplements; prescription or over-thecounter (OTC) drugs; and the patient’s general
nutrition knowledge
Physical examination
Dysphagia (difficulty swallowing)
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Case Study (cont’d)
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Assessment findings:
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Mrs. Gonzales starts to cough when she tries to
drink water.
Mrs. Gonzales is unable to swallow and aspirates
pills and thickened liquid.
Lung sounds are clear. Respirations are regular at
12/min. She has no dyspnea. Oxygen saturation is
96% on room air.
Enteral nutrition will begin at 60 mL/hr.
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Nursing Diagnosis
Risk for
aspiration
Readiness for
enhanced
nutrition
Imbalanced
nutrition: more
than body
requirements
Diarrhea
Feeding selfcare deficit
Imbalanced
nutrition: less
than body
requirements
Deficient
knowledge
Impaired
swallowing
Risk for
imbalanced
nutrition: more
than body
requirements
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Case Study (cont’d)
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Diagnosis: Risk for aspiration related to
impaired swallowing
Goals:
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Mrs. Gonzales will receive adequate nutrients
through enteral tube feeding without aspiration by
the time of discharge.
Mrs. Gonzalez will regain swallowing ability from
speech therapy by the time of discharge.
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Planning
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Nutrition education and counseling are important for
all patients to prevent disease and promote health.
Refer to professional standards for nutrition.
Collaboration with a registered dietitian (RD) helps
develop appropriate nutrition treatment plans.
Considerations:
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Perioperative food intake
Enteral and parenteral feedings
Assistive devices
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Implementation
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Health promotion
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Education
Early identification of potential or actual problems
Meal planning
Weight loss plans
Food safety
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Implementation
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Acute care
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Risk factors in acutely ill patient
Advancing diets = Gradual progression of dietary
intake or therapeutic diet to manage illness
Promoting appetite
Assisting with oral feedings
• When a patient needs help with eating, it is important to
protect his or her safety, independence, and dignity.
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Adaptive Equipment
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Enteral Tube Feeding
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Enteral nutrition (EN) provides nutrients into
the GI tract. It is physiological, safe, and
economical nutritional support.
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Nasogastric, jejunal, or gastric tubes
Surgical or endoscopic placement
• Nasointestinal
• Gastrostomy
• Jejunostomy
• PEG (percutaneous endoscopic gastrostomy)
• PEJ (percutaneous endoscopic jejunostomy)
Risk of aspiration
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Enteral Tubes
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pH Measurement for Tube Location
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Case Study (cont’d)
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Nutritional management
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Aspiration precautions
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Insert feeding tube as ordered.
Initiate enteral feeding as prescribed.
Advance tube feeding as tolerated; monitor for tolerance.
Position Mrs. Gonzalez with head of bed elevated a
minimum of 30 degrees.
Check tube placement every 4 to 6 hours.
Check gastric residual volume every 4 hours.
Continue with speech therapy.
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Quick Quiz!
2. You receive an order to begin enteral tube
feedings. The first step is to
A. Place the patient in a prone position.
B. Irrigate the tube w/normal saline.
C. Check to see that the tube is properly
placed.
D. Introduce a small amount of fluid into the
tube before feeding.
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Parenteral Nutrition
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Nutrients are provided intravenously.
Patients unable to digest or absorb enteral nutrition
or are in highly stressed physiological states:
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Sepsis
Head injury
Burns
Peripheral or central line
Initiating parenteral nutrition
Preventing complications
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Restorative and Continuing Care
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Medical nutrition therapy (MNT)
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Specific nutritional therapy usage for treating
illness, injury, or a certain condition
Necessary for
• Metabolizing certain nutrients
• Correcting nutritional deficiencies
• Eliminating foods that worsen disease states
Most effective with collaborative health care team
and dietitian
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Medical Nutrition Therapy
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Gastrointestinal diseases
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Peptic ulcer etiology
• Helicobacter pylori
• Stress
• Acid overproduction
 Peptic ulcer treatments
• Avoid caffeine.
• Avoid spicy foods.
• Avoid aspirin, NSAIDs.
• Consume small, frequent meals.
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Medical Nutrition Therapy (cont’d)
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Gastrointestinal diseases
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Inflammatory bowel disease
• Crohn’s and idiopathic ulcerative colitis
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Elemental diets
Parenteral nutrition
Vitamins and iron supplements
Fiber increase
Fat reduction
Large meal avoidance
Lactose and sorbitol avoidance
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Case Study (cont’d)
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Matt must keep in mind that Mrs. Gonzalez will
progress to restorative care and return to oral
feedings, and also must consider cultural
preferences. Matt knows that food safety is an
important issue.
Matt consults the dietitian, and together they develop
a teaching plan regarding food safety for the foods
that Mrs. Gonzalez’s family will be preparing at home.
What expected outcomes would Matt set for the
teaching session?
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Medical Nutrition Therapy
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Malabsorption syndromes
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Celiac disease
• Gluten-free diet
Short bowel syndrome
• Intestinal surface decrease
• Lifetime EN or PN
Diverticulitis
• Inflammation of diverticula
• Low- to moderate-residue diet for infection
• High-fiber diet for chronic conditions
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Medical Nutrition Therapy (cont’d)
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Diabetes mellitus
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Type 1: insulin and dietary restrictions
Type 2: exercise and diet therapy initially
• Individualized diet
• Carbohydrate consistency and monitoring
• Saturated fat less than 7%
• Cholesterol intake less than 200 mg/dL
• Protein intake 15% to 20% of diet
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Medical Nutrition Therapy (cont’d)
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Diabetes mellitus
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Goals
• Normal to near-normal glucose levels
• Less than 100 mg/dL low-density lipoprotein (LDL)
• Less 130/85 mm Hg
• Avoidance of hypoglycemia
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Medical Nutrition Therapy (cont’d)
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Cardiovascular diseases
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American Heart Association (AHA) dietary
guidelines
• Balance caloric intake and exercise.
• Maintain a healthy body weight.
• Eat a diet rich in fruits, vegetables, and complex
carbohydrates.
• Eat fish twice per week.
• Limit foods and beverages high in sugar and salt.
• Limit trans-saturated fat to less than 1%.
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Medical Nutrition Therapy (cont’d)
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Cancer and cancer treatment
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Malignant cells compete with normal cells for
nutrients.
Anorexia, nausea, vomiting, and taste distortions
are common.
Malnutrition associated with cancer increases
morbidity and mortality.
Radiation causes anorexia, stomatitis, severe
diarrhea, intestinal strictures, and pain.
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Medical Nutrition Therapy (cont’d)
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Cancer and cancer treatment
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Nutrition management
• Maximize fluid and nutrient intake.
• Individualize diet choices to patient’s needs, symptoms,
and situation.
• Encourage small, frequent meals and snacks that are
easy to digest.
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Medical Nutrition Therapy (cont’d)
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Human immunodeficiency virus/acquired
immunodeficiency syndrome
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Body wasting and severe weight loss
Severe diarrhea, GI malabsorption, altered
nutrient metabolism
Hypermetabolism as a result of cytokine elevation
Maximize kilocalories and nutrients.
Encourage small, frequent, nutrient-dense
meals with fluid in between.
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Case Study (cont’d)
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What nursing actions are appropriate for
evaluating whether goals have been met?
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Consider the patient’s perspective.
Check measurable outcomes.
Consult with interdisciplinary staff.
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Evaluation
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Multidisciplinary collaboration remains
essential in providing nutritional support.
Changes in condition indicate a need to
change the nutritional plan of care.
Consider the limits of patients’ conditions and
treatments, their dietary preferences, and
their cultural beliefs when evaluating
outcomes.
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Case Study (cont’d)
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Matt sees Mrs. Gonzalez before discharge to
a restorative care facility for rehabilitation
before returning home. Mrs. Gonzalez now is
able to consume all of her required nutrients
with a ground diet and nectar-thickened
liquids. Matt removes the feeding tube in
preparation for her transport to the new
facility.
Matt advises Mrs. Gonzalez to continue the
care plan and emphasizes that it is important
to continue speech therapy.
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