Good Nutrition

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Good Nutrition
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Nutrition

• Developed by Ginger Mize RN, MN
• Modified by Jill K. Ray
• NUR302

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Nutrition

• Basic Human Need
• Changes throughout the life cycle
• Changes along the wellness-illnes continuum.

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Eating

• Necessary to survive
• Source of pleasure
• Pastime
• Social event
• Different meanings to different people.

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Nutrients

• Specific biochemical substances used by the body
  for growth, development, activity, reproduction,
  lactation, health maintenance, and recovery from
  illness (p. 1413).

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Essential Nutrients

• Not synthesized in the body
• Made in insufficient amts
• Must be provided in the diet

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Six Classes of Nutrients

• 3 supply energy
• Carbohydrates
• Proteins
• Lipids
• 3 are needed to regulate body processes
• Vitamins
• Minerals
• Water

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Energy Balance

• Energy is derived from foods consumed.
• Measured in form of kilocalories, abbreviate as
  calories.

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Energy Balance

• What are the bodys sources of energy?
• Carbohydrates, protein, and fat
• If a persons daily energy intake is equal to
  total daily energy expenditure the persons wt
  will remain stable.

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Carbohydrates

• Main source of energy
• Glucose
• Brain
• Skeletal muscles

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Carbohydrates

• Sugars Starches
• Easy to produce and store
• In some countries where grains are dietary
  stable, CHO may contribute as much as 90 to
  daily calorie consumption
• Some sources correlate to income. Speculating
  that as income increases, CHO intake decrease and
  protein intake increases.

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Carbohydrates

• More easily and quickly digested than protein and
  fat. 90 is digested. This percentage decreases
  as ____intake increases.
• fiber

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Fats (Lipids)

• Triglycerides and fatty acids
• Saturated
• or
• Unsaturated fatty acids

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Proteins

• Synthesis of body tissue
• Collagen, hormones, enzymes, immune cells
• Amino acids essential and nonessential
• Nitrogen balance

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Water

• Comprises 60 to 70 of body weight
• Cell function depends on a fluid environment

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Sources, functions, significance of
Carbohydrates, proteins, fats

• P.1419 Table 42-3
• Note functions that this table lists for the
  nutrient.
• Which nutrient should a patient increase in his
  diet after surgery?

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Sources, functions, significance of
Carbohydrates, proteins, fats

• Note food sources of the nutrient.
• Which of the following should this same patient
  eat 1st on his lunch tray orange, chicken
  tenders, Lima beans, whole wheat roll.

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Vitamins

• Water soluble (Vitamin C and the B-complex
  vitamins)
• Not generally stored in body
• Need daily intake to prevent symptoms of
  deficiency

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Vitamins

• Fat soluble (ADEK)
• Must be attached to a protein to be transported
  through the blood
• Secondary deficiencies can occur anytime fat
  digestion or absorption is altered (i.e.
  malabsorption syndromes, mega diets)

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Minerals

• Some provide structure within the body
• Some help regulate body processes
• Macro minerals (those needed by the body in amts
  greater than 100mg/day)
• Calcium
• Phosphorus
• Sulfur
• Sodium
• Chloride
• Potassium
• magnesium

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Water

• Major body constituent present in every body cell
• More vital to life than food.

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Water

• Provides the fluid medium necessary for all
  chemical reactions,
• participates in many reactions,
• is not stored in the body.
• Acts as a solvent, aiding in digestion
• Assists in the regulation of body temperature
• Acts as a lubricant for mucous membranes

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Water

• Accounts for 50-60 of adult total wt
• 2/3 is contained in the bodys cells
  (intracellular fluid ICF)
• 1/3 all other body fluids (extracellular fluid
  ECF) this includes plasma and interstitial
  fluid.

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Basal Metabolism

• Energy required to carry on the involuntary
  activities of the body at rest
• the energy needed to sustain the metabolic
  activities of cells and tissues and to maintain
  circulatory, respiratory, gastrointestinal, and
  renal processes (p. 1415).

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Who has the highest Basal Metobolism Rate?

• Men
• Women
• Why
• Because of higher muscle mass. Men are about
  1cal/kg and women .9 cal/kg.

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What other factors increase BMR?

• Growth
• Fever
• Infections
• Emotional tension,
• Extremes in temperature
• Hormone levels (thyroid hormone, epinephrine)

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What decreases BMR?

• Aging
• Prolonged fasting
• sleep

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Ideal Body Weight

• Body Mass Index
• Waist circumference
• Formula
• BMI wt in kg/(ht in meters) times (height in
  meters)
• BMI (wt in lbs/(ht in inches) times (height in
  inches)) times 703

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General Guidelines

• BMI below 18.5 is underweight
• BMI of 25 29.9 is overweight
• BMI of 30 or greater obesity
• BMI of 40 or greater extreme obesity

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Calculate BMI for a patient who weighs 100 pounds
and is 5 feet tall.

• BMI (wt in lbs/(ht in inches) times (height in
  inches)) times 703
• BMI (100/60 times 60) times 703
• BMI (100/3600) times 703
• BMI .027 times 703 19.52

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19.52

• BMI below 18.5 is underweight
• BMI of 25 29.9 is overweight
• BMI of 30 or greater obesity
• BMI of 40 or greater extreme obesity
• How would you characterize this pts BMI?

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Weight loss

• Usual wt present wt /usual wt times 100
• Significant if
• 1-2 in 1 week
• 5 in 1 month
• 7.5 in 3 months
• 10 in 6 months

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Factors Affecting Nutrition

• Food intake
• Decreased food intake can be related to
• disease,
• psychosocial causes,
• impaired ability to smell and taste,
• drug therapy,
• medical treatments,
• difficulty chewing and swallowing, chronic GI
  problems,
• certain chronic illnesses (ca)
• Inadequate food budgets
• Nausea
• pain

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Nursing Indications.

• If a pt is NPOwhat is our responsibility as a
  healthcare provider to ensure that he maintains
  an adequate nutritional status?
• Consider
• Nutrients (which ones?)
• Water balance
• Can we feed a pt that a MD has made NPO?

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Factors food intake

• Increased food intake
• Excess wt increases the risk
• for numerous medical problems
• assoc with surgery
• For complications during pregnancy, labor, and
  delivery
• Incr morbidity and mortality
• Reasons for overeating.

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Physiologic and physical factors that influence
nutrient requirements

• Developmental considerations
• Throughout the life cycle nutrient needs change
  in relation to growth, development, activity, and
  age-related changes in metabolism and body
  composition.
• Review each area in this section of the required
  reading

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Gender

• Men have more muscle mass and therefore have
  higher caloric and protein requirements than
  women.

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State of Health

• Trauma (major surgery, burns, crush injuries)
• Dramatically alters the bodys use of nutrients.
• Nutrient requirements increase dramatically to
  allow the body to preserve or replenish body
  nutrient stores and to promote healing and
  recovery.
• Mental health problems can cause to forget to
  eat, or lack motivation to eat.

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Alcohol Abuse

• Affects the intestinal mucosa. Interferes with
  normal nutrient absorption, so requirements for
  the nutrients increase as the efficiency of
  absorption decreases.
• Need for B vitamin increases because they are
  used to absorbed alcohol.

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Medication

• Especially drugs that
• alter the pH of the GI tract
• Increase GI Motility,
• damage intestinal mucosa,
• bind with nutrients

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Sociocultural and Psychosocial Factors

• Religion
• Mormons no coffee, tea, alcohol, encouraged to
  limit meat consumption
• Hindus do not eat beef, many Hindus are
  vegetarians
• Kosher dietary laws special food preparation
  techniques and prohibit the intake of pork and
  shellfish

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Culture

• See box 42-4. p. 1434.

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The Nsg Process

• During illness, good nutritional status can
  reduce the risk for complications and speed
  recovery
• Poor nutritional status can increase the risk for
  illness or death and prolong the healing process.

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Assessment

• Health History
• Dietary History
• Physical Assessment
• Anthropometrics
• Laboratory Tests
• DETERMINE reviewed in the text on p. 1435

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24 Hour Food Recall

• Upon waking large glass of water
• OTWTW 1 cup of coffee w/sugar cream, large
  bagel w/cream cheese
• During morning 2 coffees w/2 Danishes
• Lunch Hamburger w/fries-supersized, lg. sweet
  tea
• Afternoon pack of MMs
• Dinner Steak, baked potato, green beans, salad,
  apple pie a la mode, lg. sweet tea
• After dinner 2 beers

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Dietary Guidelines

• Dietary referenced intakes (DRIs)
• Food Guide Pyramid
• Daily values
• Healthy People 2010

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Food Pyramid
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24 Hour-Food-Intake Assessment

• http//www.mypyramid.gov/mypyramid/results.html?ag
  e54gendermaleactivitysed

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Assessment of 24 Hr. Food Recall

• Grains potato(7) bagel(2) danishes(4)
  bun(2),fries(6) gt19 oz. 5oz.
• Veggies lettuce, tom, pickles, green beans,
  salad 2 cups 2 cups
• Fruits 0 1½ cups
• Milk cream??!!! oils 3 cups/5 tsp oil
• Meat/beans Hb(4-6), steak (8-12) 12-18 5
  oz.

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Intake and Output
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Monitoring I and O

• Assistance
• Record as soon as specimen is measured
• Independent vs. dependent nursing action
• All clients
• Totaled and evaluated at the end of shift or at
  specified times
• Compare

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Record all output

• Urine
• Diarrhea
• Vomitus
• Gastric suction
• Drainage from surgical tube and wounds
• Stool if it is liquid enough to be measured

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Intake Output
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Record all intake

• Liquids taken
• Oral
• Enteral
• Parenteral

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Anthropometric Data

• Height and weight. Most common.
• Weigh pt on same scales at the same time of day
• Self reported ht in the elderly is often
  inaccurate
• BMI and waist circumference
• Triceps Skin fold measurement

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Biochemical Data

• Hemoglobin and Hematocrit
• Serum albumin levels
• Serum transferrin levels (iron transporting
  protein)
• Total lymphocyte count (reflects immune status)
• Blood glucose
• Blood cholesterol
• Blood triglycerides
• 24 hour urine tests measure protein metabolism
  include urine creatinine excretion and urine urea
  nitrogen (reflects the breakdown of amino acids
  (protein) for energy.

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DETERMINE

• Disease any disease impacting
• Eating poorly too little or too much
• Tooth loss, mouth pain
• Economic hardship
• Reduced social contact
• Multiple medicines
• Involuntary wt loss/gain
• Needs asst in self care walking, shopping,
  purchasing, cooking food help
• Elder years above age 80.

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Diagnosing

• Imbalanced nutrition as the problem
• Could be the only issue dealing with.
• Imbalanced nutrition as the etiology
• Could cause other problems that the nurse must
  deal with.

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Outcome identification and Planning

• Maintain or restore optimal nutritional status

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Implementing

• Teaching
• Monitoring nutritional status
• Stimulating appetite
• Allow food choices
• Small frequent meals
• Provide encouragement and PLEASANT environment
• Control pain, nausea, depression
• Good oral hygiene
• Arrange so that it is within easy reach
• Ask about rituals
• Allow opportunity to wash hands

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• Assisting with eating when necessarylast resort!
  Why?
• Liquid diets
• Used frequently with transition diets
• Decision to advance diet is based on return of gi
  function
• Advance as tolerated is most common orderwhat do
  you think this means?

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Diets of Modified Consistency

• NPO
• Clear liquid
• Full liquid
• Pureed
• Mechanical or dental soft
• Soft/Low residue
• High Fiber

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Diets of Modified Consistency

• Nothing by mouth
• Patient not allowed to eat/drink.
• Preop order,
• postop often until Bowel sounds return,
• before certain procedures.
• Nsg indications
• Encourage good oral hygiene
• Lemon glycerin swaps (if no oral lesions)
• Ice chips only if MD has OKd
• Avoid watching others eat

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Diets of Modified Consistency

• Clear liquids food that are clear liquids at
  room or body temperature
• Full liquids all items on a clear liquid plus,
• Milk, puddings, custards, plain frozen desserts,
  pasteurized eggs, cereal gruels, vegetable
  juices, milk and egg substitutes.
• High calorie, high protein supplements usually
  accompany this diet if used more that 3 days.

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Diets of Modified consistency

• Soft/Low Residue diets regular diets that have
  been modified to eliminate foods that are hard to
  digest and to chew, including those that are high
  in fiber, high in fat, and highly seasoned. Also
  called bland or low-fiber. Adequate in calories
  and nutrients and may be used long-term.

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Therapeutic Diets

• Restricted fluid intake
• Sodium-restricted
• Fat-modified
• Sugar-restricted (diabetic or ADA)
• Protein-restricted (renal)

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Prescribed Diet

• 1800 ADA

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Enteral/parenteral nutrition

• Enteral administering nutrients directly into
  the stomach
• Parenteral providing nutrition via IV therapy,
  nutrition

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Enteral Nutrition

• Oral feeding is preferred and most effective
• Enteral is next best.
• Involves passing tube into the GI tract to
  administer a formula containing adequate
  nutrients.
• Procedure Percutaneous Endoscopic Gastrostomy
  (PEG) or a surgically placed Gastrostomy tube.

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Enteral Nutrition

• Short-term (less than 6 weeks) use nasogastric
  tube.
• Nasointestinal tube (Dobhoff) (more than 6 wks)
  Passed through the nose and into the small
  intestine. This bypasses the valve in the
  stomach that controls volume entering intestine.
  Results in gas, bloating.
• Long-term intestinal support enterostomal tube
  placed through an opening created into the
  stomach from the abdominal wall.

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Nasogastric Tubes
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Enteral Feeding Tubes (Nasogastric Tubes)
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Enteral Feeding Tubes (Dobhoff)
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Gastrostomy Tube
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Jejunostomy Tube
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Safety Alert

• Pts on tube feedings
• Head of bed is kept elevated at all times while
  the tube feeding is being instilled.why?
• The nurse will turn the feeding off about 30
  minutes before lowering the head of the bed.not
  you, yet!

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Nasogastric tubes for decompression

• These tubes are also used when the stomach has
  excess fluid that need to be drained
• After GI surgery so the intestines can rest
• Pt with GI complications and the intestines are
  not functioning properly
• Post operative pt who is not alert enough to
  handle their secretions. Preventing the risk
  of vomiting.

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Parenteral
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Parenteral Nutrition

• Administration of nutritional support via IV
  route.
• Used for pts who cannot meet their nutritional
  needs by the oral or enteral routes.
• Can be administered centrally or peripherally.
• Total Parenteral Nutrition (TPN) highly
  concentrated, hypertonic nutrient solution.
  Provides calories, restores nitrogen balance,
  etc. Note that major nsg implication is
  monitoring Blood Glucose Levels (BGL).

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Fluid Volume Deficit

• Output greater than intake
• Decreased blood pressure
• Increased pulse
• Rapid weight loss gt 5
• Dry mouth
• Dry skin
• Tenting
• Slow venous filling of dependent hands

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Fluid Volume Excess

• Intake greater than output
• Rapid weight gain
• Pitting edema
• Crackles heard in lungs
• Bounding pulse

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Dysphagia

• Monitor and assist with feedings/meals
• Maintain high-fowlers position
• Place food on unaffected side of mouth
• No straws
• Verbal coaching through swallowing process
• Thickeners