Bonnie M. Wivell, MS, RN, CNS Chapter 44: Nutrition Bonnie M. Wivell, MS, RN, CNS

Scientific Knowledge Base: Nutrients Carbohydrates Starches and sugars Fiber Proteins Amino acids Fats Saturated, monounsaturated, and polyunsaturated Water Cells depend on a fluid environment Vitamins Essential to metabolism Water or fat soluble Minerals Catalysts for biochemical reactions The body requires fuel to provide energy for cellular metabolism and repair, organ function, growth, and body movement. 2. The basal rate (BMR) is the energy needed to maintain breathing, circulation, heart rate, and temperature. 3. What is resting metabolic rate (AKA Resting energy expenditure)? Amount of energy an individual needs to consume over a 24-hour period for the body to function normally while at rest. Nutrients are the elements needed for body processes and functions. Fat-soluable vitamins: A, D, E and K Water-soluable vitamins: C and B complex

Anatomy and Physiology of the Digestive System Digestion Begins in the mouth and ends in the small and large intestine Absorption Intestine is the primary site for absorption Metabolism and Storage of Nutrients Anabolic and catabolic reactions Elimination Chyme is moved through peristalsis into the large intestines and turned into feces Functions of Digestive System (above on chart) MECHANICAL BREAKDOWN CHEWING, CHURNING, MIXING OF FOOD CHEMICAL BREAKDOWN FOOD REDUCED TO SIMPLEST FORM USING ENZYMES Enzymes Catalysts to speed up chemical reactions. The food mass in liquefied form is called chyme. 3.Peristalsis - food moves through the GI tract Absorption uses the processes of active transport – energy dependent, move from lesser concentration to greater concentration passive diffusion – greater concentration to lesser concentration Osmosis – movement through a membrane pinocytosis – engulfing large molecules of nutrients by the absorbing cell Approximately 8.5 L of GI secretions and 1.5 L of oral intake is managed daily within the GI tract. The small intestines reabsorbs 9.5 L and the colon absorbs approximately 0.4 L. The remaining 0.1 L is eliminated in the feces Anabolism is the building of more complex biochemical substances by synthesis of nutrients Catabolism is the breakdown of biochemical substances into simpler substances and occurs during physiological states of negative nitrogen balance (example: starvation) Metabolic reactions include Glycogenolysis – catabolism of glycogen into glucose, carbon dioxide, and water Glycogenesis – anabolism of glucose into glycogen for storage in liver Gluconeogenesis- catabolism of amino acids and glycerol into glucose for energy As feces move toward the rectum, water is absorbed in the mucosa. The longer the material stays in the large intestines, the firmer the feces. Feces contains cellulose, indigestible substances, GI tract cells, digestive secretions, water, and microbes.

Dietary Guidelines Food guidelines Daily values Dietary Reference Intakes Acceptable range of amounts of vitamins and minerals to avoid deficiencies for age and gender groups Food guidelines Food Pyramid Guide, basic guide for meal preparations Daily values Needed protein, vitamins, minerals, fats, cholesterol, carbohydrates, fiber, sodium, and potassium The Food Pyramid appears in print, on food packages, and in TV ads. The US Department of Agriculture and the US Department of Health and Human Services publish the Dietary Guidelines (see Box 44-3). 3. Students need to be cognizant of the needs of the young, the old, and the culturally diverse to ensure that these populations receive the nutrients necessary to meet their needs.

Nutrition During Growth & Development Infants: as they grow they need protein, vitamins, and minerals; high growth rate Toddlers: small, frequent meals; picky eaters; need fewer calories, higher protein School-age: Don’t eat the required nutrients; growth spurts Adolescents: concerned with body image Young and middle adults: reduced need for nutrients as their growth periods end Older adults – decreased need for calories Each one of these groups has specific needs. Infants are breast fed or put on formula. Between 4 to 6 months, infants are introduced to solid foods. Toddlers (1 to 3 years) eat up to 6 times a day, with small frequent meals. They soon become picky eaters. School-age children (6 to 12 years) often do not eat the required nutrients. They are prone to a diet high in fat, sugar, and salt because of their fondness for fast foods and snacks; GROW AT A SLOW STEADY PACE; DECLINE IN ENERGY REQUIREMENTS; GROWTH SPURTS Adolescents are concerned with their body image. Anorexia nervosa and bulimia nervosa. The main nutritional source for this group is carbohydrates both simple and complex. MAY HAVE MET GROWTH POTENTIAL (FEMALES) BASE NEEDS ON PHYSIOLOGICAL AGE RATHER THAN CHRONOGICAL AGE STILL HAVE HIGH CALORIC NEEDS TO MEET CHANGES IN METABOLISM EATING DISORDERS MAY ARISE 5. Young and middle adults have a reduced need for nutrients as their growth period ends. Obesity may become a problem due to decreased physical exercise. Pregnancy and lactation puts additional demands on women. 6. Older adults have a decreased need for calories as their metabolic rate slows. VITAMIN AND MINERAL REQUIREMENTS DO NOT CHANGE Avoid grapefruit and grapefruit juice because these will decrease absorption of many drugs S/S of dehydration: confusion, weakness, hot dry skin, furrowed tongue, rapid pulse, and high urinary sodium

Factors Affecting Nutritional Status Age-related GI changes Changes in teeth and gums Reduced saliva production Atrophy of oral mucosal epithelial cells Increased taste threshold Decreased thirst sensation Reduced gag reflex Decreased esophageal and colonic peristalsis Presence of Chronic Illness Malnutrition Adverse affects of meds Cognitive impairment AVAILABLE FOOD (money) ABILITY TO EAT ABILITY TO ABSORB ABILITY TO METABOLIZE ABILITY TO EXCRETE

Alternative Food Patterns Based on religion, cultural background, ethics, health beliefs, preference Vegetarian diet: Ovolactovegetarian: eat eggs and milk Lactovegetarian: drink milk but avoid eggs Vegans: consume no animal products of any kind Fruitarian: eat only fruit, nuts, honey and olive oil Zen Macrobiotic Eat brown rice, other grains, & herb teas 1, Vegetarian diets – Plant food – are nutrient poor – lack complete proteins Ovolactovegetarian: avoid meat, fish and poultry but eat eggs and milk Students need to consult with dieticians to ensure that clients receive the nutrients needed for recovery and rehab. See Table 44-2 for religious dietary restrictions. Children following vegetarian diet especially at risk for protein and vitamin deficiencies such as Vit B12

Assessment Nurses are in an excellent position to recognize signs of poor nutrition Pts who are malnourished are at greater risk of life-threatening complications during hospitalization such as arrhythmia, sepsis, hemorrhage A nutritional assessment is more than taking a diet history Screening http://www.mna-elderly.com/user_guide.html Some prescription drugs, many over-the-counter drugs, and herbal/natural therapy can affect a client’s nutritional state. It is also important to know food interactions and medication administration – see table 44-2 on pages 1095-1096 Especially be aware of interactions between milk and citrus fruits or juices and alcohol.

Assessment Continued Anthropometry = a systematic measurement of the size and makeup of the body at specific body sites Laboratory and biochemical tests CBC, albumin, pre-albumin transferrin (transferrin is a blood plasma protein for iron), electrolytes, BUN, creatinine, glucose, cholesterol, triglycerides, and retinol (form of Vitamin A). Dietary and health history Physical examination Dyphagia (difficulty swallowing) s/s of dysphagia Silent aspiration Aspiration precautions – see pg 1103

Nursing Diagnosis and Planning Select from the NANDA-I–approved list after assessment Plan outcomes and goals to assist client’s needs Improving a client’s diet takes care and planning Imbalanced nutrition – more than body requirements OR less than body requirements NIC – nutritional counseling (coordinate plan of care with healthcare provider, individualized menu, teach about food pyramid, nutritional monitoring by monitor wt, anemia, serum albumin levels and total lymphocyte count (indicators of nutritional level) Risk for aspiration Constipation Diarrhea Health-seeking behaviors Deficient knowledge Risk for imbalanced nutrition Feeding self-care deficit Example Diagnosis: AT RISK FOR IMBALANCED NUTRITION R/T INTAKE LESS THAN BODY REQUIREMENTS AS EVIDENCED BY INABILITY TO SWALLOW Example Goals: PATIENT WILL REFLECT NOT LOSE WEIGHT OVER THE NEXT THREE DAYS PATIENT WILL HAVE LABORATORY VALUES WITHIN NORMAL LIMITS WITH DAILY MONITORING

Implementation Ill, debilitated, and recovering clients often have poor diets Socioeconomic, psychosocial, and environmental factors can contribute to a poor diet Advancing diets – see Box 44-10 Promoting appetite Clean and odor free environment Oral hygiene Social time Music therapy NURSE WILL FOLLOW DIETICIAN RECOMMENDED ENTERAL FEEDING NURSE WILL WEIGH PATIENT AT 6AM DAILY NURSE WILL MONITOR LAB VALUES DAILY

Implementation Continued Make sure clients can feed themselves, can swallow and are positioned properly If clients have visual difficulties, they may need assistance with feeding. You can also help clients by telling them where food is placed, according to the face of a clock (e.g., peas at 3 o’clock)

Enteral Tube Feeding Nasogastric Nasointestinal Gastrostomy Jejunostomy PEG PEJ Video 1. Enteral feeding delivers nutrition directly into the GI tract through a small bore feeding tube or a G-Tube. This is a preferred method for providing nutrients. Indicators for tube feedings – cancers, trauma, neruological and muscular disorders (ALS), GI disorders, Respiratory failure with prolonged intubation, Extended bowel rest, preoperative TPN Types of formulas include: Milk based, blenderized Protein glucose, polymers or lipids Predigested nutrients Specialty formulas PEG - percutaneous (through the skin) endoscopic gastrotomy (stomach tube). PEJ – percutaneous endoscopic jejunostomy tube Each one of these methods to administer EN has specific indications, assessments, and precautions. You will follow hospital policy and procedures. You will learn how to care for and assess tubes in the nursing skills lab.

INSERTING THE FEEDING OR ASPIRATING TUBE ASSEMBLE EQUIPMENT EXPLAIN PROCEDURE TO PATIENT MEASURE TUBE INSERT (will practice in lab) INSERT 20ml AIR TO COMFIRM PLACEMENT ASPIRATE 5ml OF GASTRIC CONTENTS TO TEST pH Discuss medication administration Bolus feedings vs infusion feedings IS PATIENT TOLERATING TUBE FEEDING? ASSESS FOR NAUSEA AND EMESIS Q4h ASSESS RESIDUAL IN STOMACH SHOULD NOT BE ABLE TO WITHDRAW MORE THAN 2 HOURS OF FEEDING AFTER 4H. RETURN ASPIRATE TO PATIENT (USUALLY)

Enteral Tube Feeding Complications Aspiration Diarrhea Constipation Tube occlusion Tube displacement Abd. Cramping, nausea, vomiting Delayed gastric emptying Electrolyte imbalance Fluid overload Hyperosmolar dehydration

Total Parenteral Nutrition Specialized nutrition support in which nutrients are provided intravenously Must be infused via a central catheter Average 50% Dextrose solution + Amino acids, vitamins, minerals, electrolytes Lipids (Fat Emulsion) provide supplemental kilocalories and prevent essential fatty acid deficiencies Administered to clients who are unable to digest or absorb enteral nutrition Can be administered peripherally but will only be 10% Dextrose Always use an infusion pump Rate gradually increased No other fluids can be administered in the same line with TPN Placement of the line needs to be confirmed by x-ray Nurses need to provide continuous monitoring, assessments, and documentation. NUTRITIONALLY ADEQUATE SOLUTION PRESCRIBED FOR PATIENTS THAT ARE: MALNOURISHED UNABLE TO EAT NEED SUPPLEMENTAL NUTRITION

Complications From Total Parenteral Nutrition Catheter occlusion Catheter infection Electrolyte imbalance Hypo/hyperglycemia HHNC (Hperglycemic Hyperosmolar Nonketotic Coma)

Medical Nutrition Therapy GI diseases PUD H. Pylori Inflammatory bowel disease Malabsorption syndromes (celiac disease) Diverticulitis DM (American Dietetic Association) CV Disease (American Heart Association) Cancer HIV

Evaluation To measure the effectiveness of nutritional interventions To ascertain if client has met goals and outcomes To amend nursing interventions