Nutritional Patterns Part I

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Nutritional PatternsPart I

• Terry Moorman, RN, MSN

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Nausea and Vomiting

• When did it start?
• When does it occur?
• What does it look like?
• Amount?

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Indigestion

• Is it related to food intake?
• What worsens it or makes it better?
• Medications or antacids affect it?

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Intestinal Gas

• Belching?
• Flatulence?
• Bloating or abdominal distention?

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Abdominal pain

• When did it begin?
• Describe the character and intensity.
• Does it radiate?
• Food worsen or ease the pain?
• What makes it better or worse?

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Changes in Bowel Habits or Stool Characteristics

• What is normal routine?
• Diarrhea?
• Constipation?
• Stool characteristics?
• Color
• Melena
• Maroon colored
• Bright red
• Clay colored
• Steatorrhea
• Mucus threads or pus

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Other Areas To Assess

• Appetite and weight gain or loss
• Current medications
• Smoking history
• ETOH intake
• Family history of GI problems
• Previous medical history
• Allergies to food
• Travel to foreign countries

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Assessment of the Mouth

• Teeth
• Mucosa and gums
• Pharynx
• Tongue
• Breath

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Inspection of Abdomen

• Scars on abdomen
• Contour and symmetry of abdomen
• Skin

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Auscultation Of The Abdomen

• Begin in the right lower quadrant
• Bowel sounds present every 5-20 seconds
• Use bell to listen for
• Hum
• Bruit
• Friction rub

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Palpation

• Palpate in a quadrant to quadrant manner
• Begin with non-tender areas first
• Palpate for masses or areas of tenderness
• Note areas of involuntary abdominal rigidity or
  guarding

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Assessment of Perineal and Anal Area

• Inspect for rashes, fissures, fistulas,
  hemorrhoids
• Digital rectal exam

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Laboratory Tests For GI Dysfunction

• Hemoglobin
• Schilling test
• Serum proteins
• D-Xylose absorption test
• Liver function tests (LFTs)

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• Cholesterol and triglycerides
• Amylase and lipase
• H-pylori antibody test
• Carcinoembryonic antigen (CEA)
• DNA testing

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Radiologic Tests

• Flat plate of the abdomen
• Upper GI series
• NPO 8-12 hours
• No smoking morning of test
• No oral medications morning of test
• Lax and force fluids after test

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• Lower GI series
• Low residue 1-2 days prior to test
• Clear liquids and lax evening before test
• NPO 8-12 hours prior to test
• Enemas till clear morning of test
• Lax and force fluids after test

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• Oral cholecystography
• NPO 8-12 hours prior to test
• Assess for iodine or shellfish allergies
• Abdominal ultrasonography
• Computed tomography (CT)
• Magnetic Resonance Imaging (MRI)

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Medical Blooper

• Dictated If no improvement, prepare the patient
  for a CAT scan.
• Transcribed If no improvement, prepare the
  patient for a casket.

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Gastric Analysis

• Aids in the diagnosis of
• Duodenal ulcer
• Zollinger-Ellison Syndrome (ZES)
• Pernicious anemia
• Gastric cancer

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Basal Cell Secretion Test

• NPO
• With-hold meds that affect gastric secretions
  24-48 hours
• No smoking the morning of test
• NG tube passed
• Gastric samples collected every 15 min for 1 hour
• If results abnormal, proceed with Gastric
  Stimulation Test

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Gastric Stimulation Test

• Histamine or pentagastrin given SQ
• Gastric samples collected every 15 min for 1 hour
• Measure vital signs frequently to detect
  anaphylactic reaction and shock
• Results
• Increased HCL - duodenal ulcer
• Decreased HCL - cancer
• Achlorhydria - pernicious anemia

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Ambulatory pH Monitoring

• NPO 6 hours before test
• All meds affecting gastric secretion held 36
  hours before test
• Probe inserted through nose into stomach
• Connected to external recording device for 24
  hours

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Endoscopic Procedures To Diagnose GI Dysfunction

• Esophagogastroduodenoscopy (EGD)- visualize upper
  GI tract to duodenum.
• Endoscopic retrograde cholangiopancreatography
  (ERCP)- visualize CBD, hepatic pancreatc ducts

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• Client Preparation
• NPO for 6-12 hours
• Client sedated
• Anticholinergics may be given
• Local anesthetic sprayed on posterior pharynx
• Client placed in left lateral Sims
• Scope passed

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• Client care during procedure
• Monitor vital signs
• Monitor heart rate and rhythm
• Monitor oxygen saturation
• Have emergency equipment with narcotic
  antagonists available

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• Client care post-procedure
• Place in Sims position
• With-hold fluids and solids for 2 hours until gag
  reflex returns
• Monitor vital signs and oxygen saturation
• Assess for esophageal or gastric perforation
• Have someone to drive client home
• Give written instructions on when to call
  physician

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• Colonoscopy- visualize large intestines to cecum
• Client care before procedure
• Instruct on colon cleansing- GoLYTELY or Colyte
• Clear liquids starting at noon day before
• NPO after MN
• Consult MD regarding medications
• Clients with prosthetic valves or joints, or MVP
  will need prophylactic antibiotics

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• Nursing care during procedure
• Client is sedated and placed in left Sims
• Glucagon may be given
• Air insufflated to dilate colon
• Specimens obtained or polyps removed
• Monitor for respiratory and cardiac complications
• Vasovagal reactions
• Respiratory depression
• Cardiac dysrhythmias

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• Nursing care post-procedure
• Bedrest until fully recovered
• Monitor vital signs and oxygen saturation
• Assess for bowel perforation
• Have someone to drive home
• Give written instructions on when to call
  physician

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• Anoscopy - used to exam anal canal
• Sigmoidoscopy - used to exam rectum and sigmoid
  colon
• Clear liquids for 24 hours
• NPO after MN
• 1-2 Fleet enemas morning of procedure
• No sedation administered

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Fecal Analysis

• Hemoccult or fecal occult blood test (FOBT)
• Stool for ova and parasites
• Stool cultures
• Fecal analysis

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Breath Tests

• Hydrogen breath test evaluates CHO absorption,
  bacterial overgrowth, short bowel syndrome
• Urea breath test detects presence of H pylori
  in stomach

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Ensure Client Safety With Nasogastric Intubation

• Measurement of tube length
• Assessment of aspirate
• pH measurement of aspirate
• Auscultating while injecting air

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Reasons For Tube Feedings

• Meet nutritional needs when oral intake not
  possible
• Advantageous over TPN
• GI integrity is preserved
• Intestinal and hepatic metabolism maintained
• Normal insulin/glucagon ratios are maintained

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Clinical Manifestations Of Dumping Syndrome

• Fullness
• Nausea
• Diarrhea
• Dehydration
• Hypotension
• Tachycardia

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Methods Of Administering Tube Feedings

• Intermittent or bolus
• Continuous

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Enteral Access

• Nasogastric or nasoenteric
• Gastrostomy or jejunostomy tube

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Imbalanced nutrition less than body requirements
R/T inadequate intake

• Weights
• Intake and output
• Monitor clients ability to tolerate feeding
• Monitor labs

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• Maintain tube function and decrease chance of
  bacterial growth
• Flush tubing according to policy
• Flush tubing before and after medication
  administration
• Flush tubing if feeding stopped
• Change tubing and formula according to policy

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Risk for aspiration R/T tube feedings

• Check for tube placement every shift or before
  and after each use
• Elevate HOB 30 degrees if continuous or for 1
  hour after bolus
• Check for residuals

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Risk for deficient fluid volume R/T hypertonic
solution or diarrhea

• Intake and output
• Give supplemental water
• Observe for dehydration
• Decrease rate of feeding as ordered
• Administer feedings at room temperature

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Risk for infection R/T presence of wound and tube

• Monitor vital signs
• Monitor WBC
• Evaluate insertion site daily
• Wash with soap, water and pat dry daily unless
  otherwise ordered
• May apply dressing

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Total Parenteral Nutrition (TPN)

• Improve nutritional status
• Establish a positive nitrogen balance
• Promote weight gain
• Enhance healing

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Composition Of TPN

• Carbohydrates - account for 50-70 of nutrient
  prescription
• Fat emulsions - account for up to 30 of nutrient
  prescription
• Amino acids - account for 3-15 of nutrient
  prescription
• Trace elements, vitamins, and electrolytes

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Imbalanced nutrition, less than body requirements
R/T inadequate intake

• Weigh
• Intake and output
• Monitor labs - glucose, albumin, HH, lytes

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Risk for infection R/T contamination of insertion
site or infusion

• Monitor TPR
• Monitor labs
• Perform central line dressing changes using
  sterile technique
• Assess insertion site
• Use designated line only for TPN and lipids
• Change bag and lines according to policy

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Risk for deficient fluid volume R/T TPN

• Use infusion pump for administration
• IO
• Weights
• Assess for dehydration
• Monitor glucose

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Cancers of the Oral Cavity

• Curable if diagnosed early
• Associated with chronic irritation
• Most are found on lips or tongue
• Leukoplakia is most frequent symptom
• Diagnosed by biopsy of lesion

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Symptoms of Esophageal Disease

• Dysphagia difficulty swallowing
• Odynophagia pain on swallowing

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Achalasia

• Absent or ineffective peristalsis of distal
  esophagus with failure of esophageal sphincter to
  relax
• Section above sphincter dilates

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Manifestations Of Achalasia

• Difficulty in swallowing liquid and solids
• Sensation of food sticking
• Regurgitation of food
• Pyrosis

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Diagnostic Findings With Achalasia

• Barium swallow
• EGD
• Esophageal manometry

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Management Of Achalasia

• Instruct client to eat slowly and drink liquids
  with meals
• Ca channel blockers and nitrates
• Botulinum injections
• Dilation of narrowed portion of esophagus
• Esophagomyotomy

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Esophageal Spasms

• Diffuse spasms of smooth muscles of the esophagus
• Often precipitated by stressful situations
• Manifestations - chest pain similar to angina or
  MI, dysphagia, odynophagia
• Diagnostic findings
• BaS
• Esophageal manometry

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Management Of Esophageal Spasms

• Sedatives
• Nitrates and calcium channel blockers
• Soft diet with small frequent feedings
• Dilation or esophagomyotomy may be needed

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Hiatal Hernia (HH)

• Opening in diaphragm, where esophagus passes,
  becomes enlarged
• Portion of stomach moves up into thoracic cavity
• Two types
• Sliding
• Paraesophageal
• Women more affected than men

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Clinical Manifestations of HH

• Dysphagia
• Heartburn
• Regurgitation
• Diagnostic findings Upper GI and fluroscopy

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Management of HH

• Frequent small feedings
• Do not recline for 2 hours after eating
• Elevate HOB on 6-8 blocks
• Lose weight
• Avoid tight fitting clothing around waist
• Surgery - fundoplication

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Gastroesophageal Reflux Disease (GERD)

• Backflow of gastric contents into the esophagus
• Gastric acid and pepsin cause inflammation and
  breakdown of esophageal mucosa

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Factors Contributing To GERD

• Incompetent lower esophageal sphincter
• Obesity and pregnancy
• Tobacco, alcohol use
• High fat fools, chocolate, caffeine, milk
• Age related

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Clinical Manifestatins Of GERD

• Pyrosis
• Odynophagia
• Dyspepsia
• Coughing in early morning after rising
• Substernal chest pain

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Diagnostic Tests For GERD

• Upper GI
• EGD
• Esophageal pH monitoring

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Management of GERD

• Lifestyle changes to decrease reflux
• Avoid fats, caffeine, ETOH, milk, peppermint,
  carbonated sodas, tobacco
• Restrict diet to small, frequent feedings
• Avoid eating/drinking 2 hours before bedtime
• Lose weight
• Avoid tight fitting clothes around waist
• Elevate HOB on 6-8 in blocks
• Avoid meds that cause GI irritation

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• Medications to decrease HCL or protect esophagus
• Proton pump inhibitors - Aciphex, Protonix
• H2 receptor blockers Pepcid, Zantac
• Antacids liquid Maalox, Gaviscon
• GI stimulants Reglan (metoclopramide)
• Surgical intervention - fundoplication

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Barretts Esophagus

• Pre-cancerous condition metaplasia of
  esophageal cells
• Increased incidence with long-standing untreated
  GERD
• More common in middle-aged white men
• Clinical manifestations of GERD
• Diagnosed with EGD and biopsies
• Treated the same as GERD

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Risk Factors For Esophageal Cancer

• Alcohol
• Use of tobacco
• Chronically ingesting excessively hot liquids
• GERD/Barretts esophagus
• Nutritional deficiencies

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Clinical Manifestations For Esophageal Cancer

• Dysphagia
• Odynophagia
• Regurgitation
• Chronic cough and foul breath
• Substernal pain
• Weight loss

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Diagnostic Tests For Esophageal Cancer

• EGD
• Bronchoscopy
• CT scan

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Treatment of Esophageal Cancer

• Radiation therapy
• Chemotherapy
• Photodynamic therapy
• Maintain nutrition
• Surgical removal of tumor with anastamosis

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Nursing Management Of The Surgical Patient

• Improve nutritional status
• Pre-op teaching
• Maintain airway - highest priority after surgery
• NG tube marked for position do not reinsert if
  displaced

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• Place in semi-fowlers position if no NG
• Advance diet as tolerated
• Teach client to use oral suction if unable to
  swallow oral secretions

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Medical Blooper

• I entered an elderly patients room to assess his
  hearing and lung sounds. He was hard of hearing
  so I raised my voice and spoke distinctly, Mr.
  Jenkins, I would like to listen to your heart.
  He raised his eyebrows and asked, What? I
  repeated, I need to listen to your heart. He
  gave me an odd look and asked, Why do you want
  me to fart?