Chapter 47 Nutrition Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives Differentiate between information found in the dietary reference intake tables and the Recommended Dietary Allowances table Identify the function of macronutrients in the body Compare and contrast the Estimated Energy Requirement for a healthy male and female of similar height, weight, and level of activity Differentiate between fat-soluble and water-soluble vitamins Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives (cont’d) Research good dietary sources of fiber Differentiate between fat-soluble and water-soluble vitamins List five functions of minerals in the body Identify exercise guidelines currently recommended for people with different daily patterns of physical activity (sedentary, low active, active, and very active) Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Principles of Nutrition Nutritional requirements depend on: Age Gender Level of activity Pregnancy/lactation Food guide pyramids Food Guide Pyramid (1991) Healthy Eating Pyramid Oldways – www.oldwayspt.org MyPyramid – www.mypyramid.gov Essential nutritional assessment: history of nutritional deficit and patient dietary practices, laboratory tests, physical changes. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Dietary Reference Intakes USDA retired the old Food Guide Pyramid and replaced it with MyPyramid, a new symbol, and interactive website (www.mypyramid.gov). Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Dietary Reference Intakes (cont’d) Set of four reference values Estimated Average Requirement (EAR) Recommended Dietary Allowances (RDAs) Adequate Intake (AI) Tolerable Upper Intake Level (UL) List average daily dietary intake levels sufficient to meet nutrient requirements of healthy individuals in a group RDA does not meet the nutritional needs of ill patients. It is based on the EAR plus 2 standard deviations. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Estimated Energy Requirement Males versus females for the same activity level, height, weight Use the formula (Table 47-4) (Using low active for physical activity level) 19-year-old male, 180 lb/82 kg, 5'11”/177 cm (0.18 m) = 2026 19-year-old female, 125 lb/56 kg, 5'4”/ 160 cm (0.16 m) = 926 EER is the average dietary energy intake that is predicted to maintain energy. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Macronutrients Macronutrients – carbohydrates, fiber, fats, proteins needed to provide energy Kilocalories (kcal): measure of energy Daily caloric needs 45% to 65% of calories should come from carbohydrates 20% to 35% of calories should come from fats 10% to 35% of calories should come from proteins Reasons for increased metabolic needs: increased activity, surgery, trauma, burns, infection. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Carbohydrates and Fiber Carbohydrates – sugars; major source of energy Simple = monosaccharides and disaccharides Complex = polysaccharides Fiber Dietary fiber – derived from plant sources Functional fiber – undigestible carbohydrates Sources of fiber – cereal bran and vegetables Total fiber = dietary fiber + functional fiber Examples of monosaccharides: glucose, fructose, and galactose. Common table sugar is known as sucrose. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Fats and Proteins Fats: lipids; body’s major form of stored energy Monounsaturated – decrease LDL; increase HDL Polyunsaturated – decrease LDL; increase HDL Saturated – increase LDL; increase HDL Trans – increase LDL; decrease HDL Proteins: molecules composed of amino acids Essential – from external sources Nonessential – can be synthesized Olive oil is a monounsaturated fat. Sources of polyunsaturated fats include nuts, seeds, and soybeans. Saturated fats come from red meats, butter, and high-fat dairy products. Some sources of trans fats are commercially fried foods, stick margarine, processed ready-to-eat foods, snack foods. Consumption of saturated fats and trans fats leads to heart disease. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Vitamins and Minerals Vitamins (total of 13) Water soluble (9) – vitamins C, B1, B2, B3, B5, B6, B12, folic acid, biotin Fat soluble (4) – vitamins A, D, E, K Minerals (e.g., calcium, iodine, iron) Functions Acid-base and water balance Cell membranes’ permeability and osmotic pressure Nerve conduction Muscle contractility Metabolism of nutrients in food Vitamin deficiencies – beriberi is a thiamine (B1) deficiency; scurvy is a vitamin C deficiency. Minerals are inorganic chemicals in nature, components of enzymes, hormones, and bone and tooth structure. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Exercise Guidelines Lifestyle and dietary choices combine to lead to obesity Recommended to maintain BMI range 18-25 Physical activity levels recommended Moderate – 30 minutes daily Moderate intensity – 60 to 90 minutes daily High intensity – 20 to 30 minutes four to seven times weekly Obesity leads to type 2 diabetes, cardiovascular disease, and premature death. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 47 Lesson 47.2 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives Describe physical changes associated with a malnourished state Describe nutritional assessments essential before the administration of tube feedings and parenteral nutrition Cite common laboratory and diagnostic tests used to monitor a patient’s nutritional status Discuss nursing assessments and interventions required during the administration of enteral nutrition Discuss home care needs of a patient being discharged on any form of enteral or parenteral nutrition Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Malnutrition Forms Physical changes Nutrition supplementation Marasmus – lack of calories and protein Kwashiorkor – protein deficiency Mixed kwashiorkor-marasmus – inadequate protein and wasting of fat stores and muscle Physical changes Muscle atrophy; dry, dull hair; dry, flaky skin; fat depletion in waist, arms, legs; edema Nutrition supplementation Enteral – administered orally or through feeding tube Parenteral – administered intravenously Patients with chronic disease are more likely to be malnourished and have nutrition deficits. Marasmus is the most common form of malnutrition in hospitalized patients who suffer from chronic disease. Patients with kwashiorkor are difficult to recognize because they appear well nourished. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Common Laboratory Tests Prescribed before initiating parenteral or enteral feeding Blood tests: serum prealbumin; albumin; urea nitrogen; creatinine; electrolytes; hemoglobin; hematocrit; lipids; liver function studies; glucose; total lymphocyte count; ferritin; transferrin Urine tests: specific gravity; ketones Slide 16 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Enteral Feeding Actions Uses Common adverse effects Provide nutrients through GI tract by nasogastric, nasoduodenal, or nasojejunal tube, feeding gastrostomy or jejunostomy Uses When oral consumption is either inadequate or contraindicated (e.g., neck surgery, esophageal obstruction, stroke, etc.) Common adverse effects Hyperglycemia Serious adverse effects Pulmonary complications, diarrhea, constipation, hypersensitivity Record accurate intake and output measurements. Ensure that sterile administration techniques are followed. Check for fluid overload. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Parenteral Feeding Actions Uses Common adverse effects Provide balanced combination of carbohydrates, amino acids, essential fats Uses Inability to take nutrition enterally for 7 days; intractable vomiting and diarrhea; malabsorption syndromes; bowel surgery; coma; massive wound or burn healing Common adverse effects Hyperglycemia Serious adverse effects Hypoglycemia, fluid and electrolyte imbalance Peripheral parenteral nutrition (PPN) is used for patients requiring nutritional support for a limited time of 3 to 4 weeks. Total parenteral nutrition (TPN) can be given long or short term, depending on indication. Be aware that hepatotoxicity or allergy to the formula may develop. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Monitoring Parenteral Feeding Double-check solutions for expiration date and bottle number Check tubing, connections, flow rates to avoid air embolism or contamination Assess venous access site for redness, swelling, drainage Observe for fluid and electrolyte imbalances, hyperglycemia Discard TPN solution that remains after 24 hours. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Home Care Needs for Parenteral and Enteral Nutrition Monitor blood glucose regularly Assess for refeeding syndrome Monitor weight, vital signs, required laboratory tests Have next container of solution prepared Do not “push” TPN if it gets behind schedule TPN must be tapered and never completely disconnected. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.