Nutrition and Diet therapy

Nutrition and Diet therapy
Foundations of Nursing Lecture 11/10/2015

Learning Objectives Theory
Use the components of the USDA MyPlate website to assist patients in planning their diets. List medical conditions that may occur as a result of protein, calorie, vitamin, or mineral deficiency or excess. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Effects of Aging on GI Tract
Dental caries and tooth loss Decrease a person’s ability to chew food Decreased gag reflex Increases the risk of aspiration Decreased sense of taste May lead to loss of appetite Ask the students to identify at least one lifestyle intervention to prevent or slow the effects of aging on each of the above. Ask students if they know of any older family members or patients who have complained about a decrease in appetite and taste, and an increase in choking. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Effects of Aging on GI Tract (cont’d)
Decreased muscle tone at sphincters Increases risk of esophageal reflux Decreased gastric secretions May interfere with digestion of food Decreased peristalsis Increased risk of constipation Ask the students to identify at least one lifestyle intervention to prevent or slow the effects of aging on each of the above. Ask students if they know of any family or friends who presently avoid foods they once enjoyed due to one of the above symptoms. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Dietary Guidelines USDA MyPyramid
Emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products Includes lean meats, poultry, fish, beans, eggs, and nuts Is low in saturated fats, trans fats, cholesterol, sodium, and added sugars Ask the students how easy it is to shop for a healthy diet. Ask if time, money, both, or neither are issues. It seems many in the United States do not care for vegetables. Why? A variety of foods from each group is needed to achieve a healthy diet. What is included in the bread group? Fruit group? Milk group? Meat group? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Protein Constant supply essential for rebuilding and replacing body tissues Plays a role in hormone production, fluid balance, antibody production, and transportation of nutrients Supplies approximately 4 calories/g Composed of amino acids 9 essential 11 nonessential What specific types of hospital patients are in need of protein? (probably most, if not all of them) What are amino acids? Why are they important? Is there a lab test to check a patient’s protein content? (serum protein; also a serum iron) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Food Sources: Protein Animal sources Plant sources
Red meat, eggs, milk and milk products, poultry, fish Complete, or high-quality proteins Plant sources Grains, legumes, and most vegetables Incomplete, or low-quality proteins Is it difficult to obtain appropriate and reasonably priced protein sources at the grocery store? Can vegetarians easily obtain a protein source at the grocery store? Does a vegetarian have to go a health food store? Ask the students to calculate, based on an 1800-calorie diet, how many of those calories will be protein. (180 to 270 calories) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Food Sources: Protein (cont’d)
Average DRI is 46 to 56 g of protein per day for the healthy adult Protein intake should be 10% to 15% of the total daily calories May vary depending on activity level, state of health, and availability of protein food sources The body requires more protein (1) during times of illness or injury, for such processes as cell repair and antibody production; and (2) during times of rapid tissue growth, such as pregnancy and lactation. How do you calculate the protein requirement per day for a healthy adult? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Proteins Protein deficiency Marasmus Kwashiorkor
A form of protein energy and nutrient malnutrition Occurring chiefly in the first year of life, characterized by growth retardation and wasting of subcutaneous fat and muscle Kwashiorkor A condition occurring in infants and young children soon after weaning from breast milk Based on current events, ask the students to give recent global examples of children at risk. Determine if the risk is based on agriculture, politics, both, or neither. Identify how the global community is responding. Based on current lifestyles, why is American fast food and most restaurant food linked to increasing obesity in adults and children? Identify how employers who provide health insurance are responding. How does marasmus differ from kwashiorkor? Symptoms of kwashiorkor include edema, pigment changes in the hair and skin, impaired growth and development, distention of the abdomen, and liver changes. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Proteins (cont’d) Protein excess Stressful to the liver and kidneys
Kidneys must rid the body of excess waste products Liver function is strained with the excess load of protein to metabolize Can lead to excess fat in the diet How much protein does the average American diet supply? High-fat diets are associated with increased risk of obesity, heart disease, and certain types of cancer (colon, breast, pancreas, and prostate). Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Vegetarian Diets Lacto-ovo-vegetarian Lactovegetarian Vegan
Dairy products, eggs, and plant foods included in the diet Lactovegetarian Eggs are excluded; dairy products and plant foods included Vegan All animal food sources are excluded, including honey If there are any vegetarian students, ask them if they would like to share how they secure adequate amounts of protein. Ask the students if they have cared for vegetarian patients. What assessments would be appropriate in determining how to meet the nutritional requirements of an ill vegetarian patient? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Vegetarian Diets (cont’d)
Well-planned vegetarian diets offer health benefits Decreased risk of heart disease, hypertension, diabetes, and obesity Vegans may have a diet deficient in Vitamin B6, vitamin B12, iron, zinc, riboflavin, and vitamin D Where do vegetarians obtain their vitamins? Are vitamin supplements a possible solution, or do the vitamins have to be obtained from a food source? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Discuss the function of proteins, carbohydrates, fats, vitamins, minerals, and water in the human body. Identify food sources of proteins, carbohydrates, fats, vitamins, and minerals. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Carbohydrates The body’s main source of energy
Should make up 50% to 60% of the daily diet Supply 4 calories/g Regulate protein and fat metabolism, fight infection, and promote growth of body tissues Three main types: Simple, complex, and fiber Ask the students if there are carbohydrates in fast food. Ask the students if there are carbohydrates in snacks. Review that carbohydrates are important and the intake needs to be balanced. Ask the students to calculate, for an 1800-calorie diet, how many calories would be carbohydrates. (900 to 1080 calories) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Carbohydrates (cont’d)
Simple carbohydrates Glucose is the metabolized form of sugar found in the body and is found in: Table sugar (sucrose), the major sweetener found in foods Fruit sugar (fructose) Milk sugar (lactose) Quickly absorbed into the bloodstream Cause a quick rise in serum glucose These are a source of glucose. These sources are used for diabetics who have low blood sugar. In non-type 1 diabetic people, these simple sugars stimulate insulin production. Simple carbohydrates should be no more than 25% of the total carbohydrate allowance. Ask the students to calculate the amount of carbohydrates allowed for an 1800-calorie diet. (Total carbohydrates is 50% to 60%; or 900 to 1080 calories. 25% of 900 to 1080 calories = 225 to 270 calories) Compare the answers with the number of sodas, desserts, cookies, etc., a person may eat in one day. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Complex carbohydrates Breads, pasta, cereals, and rice Broken down into simple sugars for use by the body Provide a more consistent serum glucose level than simple sugars provide Recommended that 85% to 95% of consumed carbohydrates are complex carbohydrates The intake of these must be balanced. Complex carbohydrates are good, but fad diets often portray them in a bad light because Americans consume more than is necessary. Carbohydrates are needed to keep glucose and insulin levels consistent. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fiber The portion of the carbohydrate that cannot be broken down during digestion Passes through the intestine undigested Increases bulk in the stool Aids in elimination May decrease absorption of fat Recommended intake 21 to 38 g/day These types of carbohydrates make excellent “munchies” or snack food. Ask students how to manage the abdominal distention, bloating, and flatus often associated with the intake of fiber. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Food Sources: Fiber Fruits Vegetables Grains and cereals
Apples, bananas, oranges, grapefruits Cantaloupe, strawberries Vegetables Green beans, broccoli, cauliflower, celery Corn, potato (with skin), sweet potato Grains and cereals Breads, All Bran, oatmeal, Shredded Wheat Legumes (cooked) Beans: kidney, pinto, lima; black-eyed peas What is usually the first thing a person sees when entering the food aisle of the grocery store? (usually colorful fruits and vegetables) Are Americans buying and consuming adequate quantities of fruits and vegetables? Are they affordable? Easy to fix? Tasty? Ask the students to discuss how to encourage the intake of more fruits and vegetables. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fats An essential nutrient Supplies a concentrated form of energy
Supplies 9 calories/g consumed Provides source of fatty acids Adds flavor to foods and contributes to texture Dissolves and transports fat-soluble vitamins and fat-soluble phytonutrients (carotenoids) Insulates and controls body temperature Makes food smell appetizing Cushions and protects body organs Facilitates transmission of nerve impulses Gives feeling of fullness after eating Ask the students about fat-free products. A review of the nutrition label indicates a product may be fat-free, but also loaded with simple carbohydrates or simple sugars. Fats are very important for puberty. Menstruation is linked to the amount of body fat. Many female athletes do not menstruate when they are at peak physical performance because of lack of body fat. Very thin or anorexic women also may not menstruate. Adequate body fat and nutrition may be indirectly linked to fertility in men. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fats (cont’d) Made up of fatty acids and glycerol
Fatty acids are classified as saturated or unsaturated Fatty liquids at room temperature are called oils Oils containing unsaturated fats: Corn oil, safflower oil, canola oil Fat is necessary to protect the inner organs. Necessary for mammary glands in females and the function of breast-feeding Fats should be 25% to 30% of total calories. Ask students to calculate the number of fat calories allowed for an 1800-calorie diet. (450 to 540 calories) Of that, saturated fats should be no more than 10% of total fats. (10% of 450 to 540 calories = 45 to 54 calories) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fats (cont’d) Omega-3 fatty acids
The most unsaturated form of fatty acid Found in salmon, halibut, sardines, tuna, canola oil, soybean oil, chicken, eggs, and walnuts Should be added to the diet as sources of unsaturated fats Fish is excellent nutrition—but not if it’s deep-fried. The federal government has cautioned against eating fish more than once a week because of elevated levels of lead and mercury found in fish. Ask the students how the environment affects a safe and healthy food source. Review the blood studies associated with fats: HDL—high-density lipids—these are the “good” lipids LDL—low-density lipids—the lipids that need to be lowered Triglycerides—blood lipids Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Vitamins Essential nutrients that must be taken in through food sources or supplements Water-soluble vitamins Easily absorbed into the bloodstream for use by the body B-complex vitamins and vitamin C Fat-soluble vitamins Absorbed in the small intestine the same as other fats by action of bile in the duodenum and stored in the liver A, D, E, and K Ask the students to identify the sources of vitamins and minerals. Ask the students about the practice and safety of using megavitamins. Ask the students about vitamins for colds, weight loss, etc Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Minerals Inorganic substances found in animals and plants
Essential for metabolism and cellular function Major minerals Calcium, magnesium, sodium, potassium, phosphorus, sulfur, chlorine Trace minerals Iron, copper, iodine, manganese, cobalt, zinc, molybdenum, selenium, fluoride, chromium Ask the students to identify the sources of vitamins and minerals. Ask the students about the practice and safety of using megavitamins. Ask the students about vitamins for colds, weight loss, etc. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Water Water is the most essential of all nutrients
Adult body is 50% to 69% water Water requirement is 1 mL/calorie of intake Used in every body process, from digestion to absorption to elimination or secretion; large amount must be stored in the body General rule: intake needs to be equal to recorded output plus 500 mL Water is essential for life. Patients may be on fluid restriction, so calculate and monitor I&O carefully. Ask the students about specific situations in which a patient’s fluid intake would be restricted. Ask students to share experiences in caring for a patient on fluid restriction. Discuss strategies to encourage fluid intake in children and teenagers. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 1 Which nutrient is involved in all of the body’s chemical processes and the most essential of all nutrients? Water Protein Sodium Sugars Answer: 1 Rationale: Water is the most essential of all nutrients. The adult body is 50% to 60% water by weight. It is used in every body process from digestion, to absorption, to elimination, to secretion. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 2 All of the following are functions of fats except they:
provide a source of fatty acids. add flavor to foods. make food smell appetizing. provide a quick source of protein. Answer: 4 Rationale: Carbohydrates provide a quick source of energy. Fats can be burned as a source of energy, but they are not a quick source of energy and are primarily used when carbohydrates are not available. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 3 Liz has an Orthodox Jewish patient. When ordering her diet it is important to remember that: pork and pork products are allowed. no alcohol is permitted. shellfish are allowed. meat and milk may not be mixed or eaten at the same meal. Answer: 4 Rationale: In the Jewish faith, meat and milk may not be eaten at the same meal. Pork, pork products, and shellfish are not allowed. Alcohol is allowed in the Jewish faith. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Identify the nurse’s role related to diet therapy and special diet. Compare and contrast a full liquid with a clear liquid diet. Explain the different dietary modification levels: puréed, mechanically altered, advanced, and regular. Describe health issues related to nutrition. List disease processes that may benefit from diet therapy. Clinical Practice Use therapeutic communication with a patient who needs a special diet. Develop a teaching plan for nutritional therapy. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Goals of Diet Therapy Treat and manage disease
Prevent complications and restore health Specific diet for each patient is prescribed on the physician’s order sheet Patients can have nutritional goals met after a thorough diet assessment Some patients may need assistance with feeding Energy needs diminish with age—metabolic rate and activity decrease, indicating that calorie requirement is reduced. Some patients have unrestricted diets similar to the meals they eat at home. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Patients Needing Feeding Assistance
Patients with paralysis of the arms Patients with visual impairment Patients with intravenous lines in their hands Severely impaired or weak patients Confused patients Feeding may be delegated to a nursing assistant or family member Patient’s food and fluid intake should be closely monitored and documented. Weight gain/loss, percentage of meals eaten, and ability to tolerate diet should also be documented. Diet can be modified for more effective therapy; should be discussed with patient, physician, and dietitian. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 27-1: Assisting with feeding
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Postoperative Patient
Should be well-nourished preoperatively to facilitate postoperative healing and recovery Preoperative patients are usually NPO 6 to 8 hours before the procedure Postoperative patients progress from a clear liquid to full liquid diet May progress to a soft diet before attempting a general or regular diet What foods are included in a clear liquid diet? Full liquid? Soft diet? NPO status reduces risk of vomiting while under anesthesia and decreases threat of aspiration. When are solid foods added to the patient’s diet? (when patient can tolerate them without nausea, vomiting, or abdominal discomfort) Liquids should be warm or cold, not tepid. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Foods Allowed on a Liquid Diet
Clear liquids Grape, apple, cranberry juices Strained fruit juices Vegetable broth Carbonated water Clear, fruit-flavored drinks Tea, coffee Gelatin and ices Clear candies Popsicles Clear broth Full liquids Milk and milk beverages Yogurt, eggnog, pudding Custard and ice cream Puréed meat, vegetables in cream soups Vegetable juices Sweetened plain gelatin Cooked refined cereals Strained or blended gruel All other beverages Cream Clear liquid diets do not meet the nutritional requirements for health and healing. Full liquid diets can be used to meet long-term dietary needs. What foods are allowed in a soft diet? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Postoperative Patient
Liquid diet is usually started when bowel sounds return Presence or absence of bowel sounds is determined by auscultation Goal is to have low-residue, easily digested foods A liquid diet decreases risk of abdominal discomfort, nausea, and vomiting Patient may progress to soft diet before advancing to regular Check patient’s swallowing reflexes. Check for bowel sounds and distention. Encourage ice chips 4 hours before first meal. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Anorexia Nervosa Mental disorder characterized by refusal to maintain a normal weight and fear of becoming obese Patient may refuse to eat despite being extremely underweight If not corrected, may be fatal Treatment is: Nutritional intervention Counseling Mainly occurs in teenage girls and young women, less frequently in teenage boys. Patients avoid high-calorie foods and exercise excessively. May require hospitalization, as well as tube feeding or TPN. Collaboration among patient, family, physician, nurse, dietitian, and mental health professional is very important for treatment. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Bulimia Eating disorder characterized by episodic binge eating followed by behaviors to prevent weight gain; e.g., purging, fasting, using laxatives Patients aware of their behavior and often feel ashamed Treatment is: Nutritional counseling Psychological counseling Usually involves young adults, primarily women. Characterized by bingeing and purging. Patients with bulimia are usually aware and ashamed of their behavior, which makes it easier to treat. What other health problems are caused by anorexia and bulimia? What are the proper nursing interventions for anorexic and bulimic patients? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Obesity Excessive accumulation of fat, not just being overweight according to height and weight scales Incidence in United States is increasing 65% of Americans are overweight Approximately 30% are obese Mildly obese: 20% to 30% above ideal body weight Morbidly obese: At least 100 lb above ideal body weight What are the common disorders linked to obesity? (cardiovascular disease, stroke, kidney disease, diabetes, arthritis, emotional disorders) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Obesity (cont’d) Contributing factors
Genetics, environment, poor eating habits, lack of knowledge about good nutrition, body physiology, age, and gender Goal of diet therapy is to improve health and quality of life Must expend more energy than is consumed through intake of calories Obesity is not merely being overweight. It is an excessive accumulation of fat that causes stress on vital organs. Surgical intervention for obesity is popular, but complicated and high-risk. Psychological interventions and support groups are effective. What other factors can be included in diet therapy? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Pregnancy Nutritional status before and during pregnancy can influence health status of mother and fetus Weight gain should be 2 to 4 lb for the first trimester and 1 lb/week during the second and third trimesters Recommended—no caloric increase in the first trimester, then 300 calories/day for the second and third trimesters Nutritional state of pregnant patients is affected by: previous health status of the mother. nausea and vomiting in the first trimester. appetite, which may be emotional and physical. access to food of proper nutritional value. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Substance Abuse Abuse of alcohol and other drugs
Interferes with food intake by decreasing appetite and decreasing financial resources for food May lead to impaired absorption of nutrients Thiamine deficiency is seen in alcohol abuse Discuss the signs and symptoms of liver damage caused by substance abuse. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Substance Abuse (cont’d)
Patients with a history of substance abuse should have dietary counseling Treatment Fluid and electrolyte supplements Vitamin and mineral supplements (particularly thiamine) High-calorie, high-carbohydrate diet Dietary fat restriction if liver function impaired What role does the nurse play in treatment of substance abuse? What nursing interventions are appropriate for substance abuse patients? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disease
Includes diseases of the blood vessels, hypertension, myocardial infarction, and congestive heart failure Focused on reduction of fat and sodium intake to decrease atherosclerosis Cholesterol, three types: High-density lipoprotein Low-density lipoprotein Very-low-density lipoprotein Sodium: 1 teaspoon salt contains 2300 mg sodium Many foods in their natural state contain sodium; sodium, rather than salt, must be limited. Describe atherosclerosis and how it affects the body. What foods contain large amounts of saturated fat? (red meat, eggs, high-fat dairy products) What foods help lower cholesterol? (vegetable oils, low-fat dairy products, fish, poultry) Discuss the advantages of the DASH diet. What other suggestions can the nurse provide to help patients prevent cardiovascular disease? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disease
Sodium (NA+)- control of sodium in the diet can be therapeutic in prevention and management of CV disease. DASH diet (Dietary Approaches to Stop Hypertension) ↓sodium & dairy products, ↑fruits, vegetables, nuts & seeds may limit sodium from 250mg to 4 g. Vitamin D –may prevent CV disease- many Americans deficient in Vitamin D Teach patients to read food n beverage labels and to avoid added extra salt with cooking

Diabetes Mellitus Disturbance of the metabolism of carbohydrates and the use of glucose by the body Two main types Type 1: insulin dependent (juvenile onset) Type 2: non–insulin dependent (adult onset) Higher risk in African Americans and Hispanics Factors to consider for diabetic dietary management: Types and quantity of foods eaten and insulin supply. If food intake is more than the patient can metabolize, ketosis may occur. If food intake is insufficient, patient can become malnourished and be in danger of insulin shock. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diabetes Mellitus (cont’d)
Diet therapy to control carbohydrate intake to maintain serum glucose at 75 to 115 mg/dL Patients should avoid large amounts of carbohydrates in one meal Meals should contain 45% to 60% carbohydrates, 20% to 25% protein, and 20% to 25% fat Calories restricted if patient is overweight Carbohydrates should be complex In calculating a diabetic diet, consider the following factors: Sex, age, height, and weight Employment and activity General health status Dietary likes and dislikes Cultural background Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diabetes Mellitus (cont’d)
Diabetic patients are at higher risk for: Cardiovascular disease Hypertension Kidney disease Blindness Stroke Dietary counseling is essential Patient should eat at prescribed intervals throughout the day. Diet should provide a steady supply of carbohydrates in relation to insulin supply. Teach the patient to plan menus and meals. Teach the importance of weight control, skin care, exercise, and infection prevention. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

HIV/AIDS HIV/AIDS patients often have: Therapy is aimed at:
Severe diarrhea Profound weight loss Muscle wasting Therapy is aimed at: Replacement of fluids and electrolytes Weight gain Replacement of lost muscle mass Maintaining the immune system Why is HIV/AIDS a socially, psychologically, and physiologically complex disease? Describe the function of the immune system. Loss of appetite, nausea, and vomiting can interfere with diet therapy. Diet therapy may delay the onset of AIDS. Gastric tube feedings or TPN may be required. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Dysphagia (difficulty swallowing)
Commonly after Stroke (CVA)- clients may experience difficulty swallowing Referred to speech-language pathologist for evaluation Swallowing evaluation to determine safe consistency of liquids (dietary modifications) Common signs of swallowing problems : Coughing when drinking, drooling, food remaining in mouth Risk for aspirations

Dysphagia Dietary Modifications
Thickened Liquids Liquids are thickened to prevent aspiration (breathing in of liquids) Dr. will order desired thickness level (nectar thick, honey thick) Solid textures Level I-puree (pudding consistency) Level II –mechanically altered (moist, minced) Level III – advanced (moist bite sized, no hard/crunchy) Level IV- regular (all foods) Sometimes dysphagia gets worse and patients have to advance to feeding tube.

Question 1 Diabetes mellitus is a disturbance of carbohydrate metabolism. Which two ethnic backgrounds are at greatest risk of developing diabetes? Whites and African Americans Whites and Hispanics African Americans and Hispanics African Americans and Asians Answer: 3 Rationale: The incidence of diabetes mellitus is increasing at an alarming rate in the United States. Although all ethnic backgrounds are at risk of developing diabetes, African Americans and Hispanics are at greatest risk of developing this disease. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 2 Bill is a recently diagnosed HIV patient. Both Bill and his partner Pat are present for the nurse’s discharge teaching regarding diet. Which of the following is true regarding diet therapy in HIV patients? Patients should be referred to a dietitian within the first year of diagnosis. Emphasis should be placed on carbohydrate intake. Patients should be encouraged to eat three full meals a day. Research suggests that diet therapy can be a factor in delaying full-blown AIDS. Answer: 4 Rationale: Research suggests that diet therapy can be a factor in delaying the onset of full-blown AIDS. HIV patients should be referred to dietitians as soon as possible. Emphasis should be placed on protein intake, and meals should consist of small, frequent meals instead of three full meals. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 3 Gabrielle’s patient is admitted with a diagnosis of alcohol abuse. She is assessing her patient for any nutritional deficits. Which deficiency is often present with alcohol abuse? Niacin Thiamine Potassium Sodium Answer: 2 Rationale: Thiamine deficiency is often present with alcohol abuse. Medical treatment often includes a diet that is high in calories and high in carbohydrates. Diets also usually include fluid and electrolyte supplements and vitamin and mineral supplements, especially thiamine. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Verbalize the rationale for assisted feedings and tube feedings. List the steps for the procedure to insert, irrigate, and remove a nasogastric tube. Clinical Practice Demonstrate insertion, irrigation, and removal of a nasogastric tube. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Nasogastric and Enteral Tubes
Usually a temporary measure to provide nutritional support Check tube placement prior to feeding or administering medications Irrigate to ensure it is patent Nasogastric and enteral tubes provide needed nutrition and medications. These are the lifelines used to provide life-giving nutrition for patients. Treat tubes with care and respect because without them, the patient will not be able to have needed nutrition. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Nasogastric and Enteral Tubes (cont’d)
Reasons for use Dysphagia following stroke Inflammatory bowel disease Decompression of the stomach before or after surgery Obtaining gastric specimens for analysis Gastric feeding or lavage Administration of medications Insertion and care (Review Skill 27-2) Review the anatomy involved in insertion of nasogastric and enteral tubes. Best most definitive way to check placement is x ray- once x ray results obtained then can use. After initial x ray then can check using litmus paper (gastric contents acidic) Must keep HOB elevated 30 degrees during feeding and for at least 1 hr after to prevent aspiration Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 27-2: Duodenal tube

Figure 27-2: Gastrostomy tube

Figure 27-2: Jejunostomy tube

Percutaneous Endoscopic Gastrostomy Tubes
Generally used when a patient requires long-term nutritional support Tube placement should be checked every shift and before feeding or administering medication Before feeding or administering medications, amount of residual fluid in the stomach should be assessed Review the technique and procedures for inserting gastric tubes. Review tube-feeding techniques and procedures. How frequently should the tubes be removed and replaced? Check residual prior to intermittent feedings and at least every 4 hrs for continuous feeds. If > 150 mL stop/hold feed for 1 - 2hr *replace residual amount back into pt Tube. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Theory Discuss the procedure for tube feeding.
Identify medical rationale and nursing care for a patient receiving peripheral parenteral nutrition (PPN) and total parenteral nutrition (TPN). Understand the possible complications associated with modified diets, tube feedings, PPN, and TPN. Clinical Practice Demonstrate feeding a patient through a nasogastric tube or percutaneous endoscopic gastrostomy (PEG) tube. Know your facility’s policies, procedures, and protocols for nutrition-related problems and complications with tube feedings. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Types of Feeding Tubes Plastic nasogastric tubes: can be used for lavage, tube feeding, and administering medications Small-bore silicone feeding tubes: usually used only for tube feeding Percutaneous endoscopic gastrostomy (PEG) tube and jejunostomy tube: used for tube feeding and administering medication Review the technique and procedures for inserting gastric tubes. Review tube-feeding techniques and procedures. How frequently should the tubes be removed and replaced? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 27-3: Nasogastric and enteral feeding tubes

Feeding Pumps Continuous feeding effective for patients who cannot tolerate large amounts of fluids at one time Intermittent feeding beneficial for patients who are able to feed themselves or when beginning to reintroduce oral feeding Amount of tube feeding is prescribed by the physician; ranges from 8 to 12 oz per feeding Feeding pumps are often used for long-term nutritional support or for patients who cannot tolerate large volumes of feeding formula at one time. These patients usually have limited gastric capacity because of the nature and stage of illness (for example, intestinal blockage from cancer). Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Total Parenteral Nutrition
A method of delivering total nutrition through a catheter placed in a large central vein High concentrations of carbohydrates main source of energy Started slowly to allow the body to adjust to the high level of glucose concentration and the hyperosmolality Used for patients on long-term therapy for: Burns, intestinal obstruction, inflammatory bowel disease, AIDS, cancer (chemotherapy) Before administering TPN, the nurse should: check for patient drug allergies. make sure the solution is clear and free from floating material. gently squeeze the bag or check the container for leaks. check the insertion site for leakage and signs of infection. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 5 As a nurse, when taking care of a patient with a nasogastric tube, you should remember all of the following except: that tube placement should be checked at least every shift and before every feeding. to elevate the head of the bed 15 degrees before feedings and leave it up for 30 to 60 minutes after the feeding. that the amount of the tube feeding is prescribed by the physician. to record intake and output. Answer: 2 Rationale: Elevate the head of the bed 30 to 90 degrees before feedings. Leave the head of the bed up for 30 to 60 minutes after the feedings. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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