1. Chapter 44
Nutrition
Nutrition is a basic component of health and is essential for normal growth and development, tissue repair and maintenance, cellular metabolism, and organ function.
Ingestion of a diet balanced with carbohydrates, fats, proteins, vitamins, and minerals provides the essential nutrients to carry out the normal physiological functioning of the body throughout the life span.

2. Background Food security is critical for all members of a household.
Food holds symbolic meaning.
Medical nutrition therapy uses nutrition therapy and counseling to manage disease.
Type 1 diabetes mellitus
Hypertension
Inflammatory bowel disease
Enteral nutrition (EN); parenteral nutrition (PN)
Food security means that all household members have access to sufficient, safe, and nutritious food to maintain a healthy lifestyle; sufficient food is available on a consistent basis; and the household has resources to obtain appropriate food for a nutritious diet.
Giving or taking food is part of ceremonies, social gatherings, holiday traditions, religious events, the celebration of birth, and the mourning of death.
The difficulty of the decision to withdraw food in a terminal illness, even in the form of intravenous (IV) nutrients, is a testament to the symbolic power of food and feeding.
In some illnesses such as type 1 diabetes mellitus (DM) or mild hypertension, diet therapy is often the major treatment for disease control. Other conditions such as severe inflammatory bowel disease require specialized nutritional support such as enteral nutrition (EN) or parenteral nutrition (PN).
Current standards of care promote optimal nutrition in all patients.

3. Nutritional Guidelines
Healthy People 2020; Health for All (WHO)
Guidelines for dietary change recommend reduced fat, saturated fat, sodium, refined sugar, and cholesterol, and increased intake of complex carbohydrates and fiber.
The U.S. Department of Health and Human Services (USDHHS) and the Public Health Service have established nutritional goals and objectives for Healthy People Healthy People 2020 is the United States’ contribution to the “Health for All” strategy of the World Health Organization. Healthy People 2020 continues the objectives initiated in Healthy People 2000 and Healthy People 2010, with overall goals of promoting health and reducing chronic disease. All nutrition-related objectives include baseline data from which progress is measured. The challenge remains to motivate consumers to put these dietary recommendations into practice.
[Review Box 44-1 on text p. 997 Examples of Nutrition Objectives: for Healthy People 2020.]

4. Case Study
Mrs. Gonzalez is a 65-year-old Hispanic woman who comes to the emergency department with slurred speech, right facial droop, and weakness in her upper and lower right-side extremities. She is admitted to the hospital with a diagnosis of acute stroke.
She has a daughter and two teenage grandchildren who live in another town nearby.
[Ask the class: What special nutritional needs will Mrs. Gonzalez face during her recovery? Discuss.]

5. Energy Requirements
Basal metabolic rate—the energy needed to maintain life-sustaining activities for a specific period of time at rest
Resting energy expenditure (REE) (aka resting metabolic rate)—the amount of energy that an individual needs to consume over a 24-hour period for the body to maintain all of its internal working activities while at rest
In general, when energy requirements are completely met by kilocalorie intake in food, weight does not change.
The body requires fuel to provide energy for cellular metabolism and repair, organ function, growth, and body movement. Life-sustaining activities include breathing, circulation, heart rate, and temperature.
Factors such as age, body mass, gender, fever, starvation, menstruation, illness, injury, infection, activity level, and thyroid function affect energy requirements.
Factors that affect metabolism include illness, pregnancy, lactation, and activity level.
When the kilocalories ingested exceed a person’s energy demands, the individual gains weight. If the kilocalories ingested fail to meet a person’s energy requirements, the individual loses weight.

6. Scientific Knowledge Base: Nutrients
Carbohydrates
Complex and simple saccharides
Main source of energy
Proteins
Amino acids
Necessary for nitrogen balance
Fats
Saturated, polyunsaturated and monounsaturated
Calorie-dense
Nutrients are the elements needed for body processes and functions. Ingestion of a diet balanced with carbohydrates, fats, proteins, vitamins, and minerals provides the essential nutrients to carry out normal physiological functioning of the body throughout the life span.
Food is sometimes described according to its nutrient density (i.e., the proportion of essential nutrients to the number of kilocalories). High–nutrient dense foods such as fruits and vegetables provide a large number of nutrients in relationship to kilocalories. Low–nutrient dense foods such as alcohol or sugar are high in kilocalories but nutrient poor.
Each gram of carbohydrate produces 4 kcal and is the main source of fuel. Carbohydrate ingestion is best if supplied by complex carbs. Fiber is a polysaccharide that is the structural part of plants not broken down by human digestive enzymes. Simple carbohydrates are monosaccharides and disaccharides. Polysaccharides such as glycogen are made up of many carbohydrate units; they are complex carbohydrates.
Proteins provide a source of energy of 4 kcal/g and are essential for tissue growth, maintenance, and repair. The simplest form is an amino acid. The body does not synthesize indispensable amino acids; thus they need to be provided in the diet. The body synthesizes dispensable amino acids. A complete protein, also called a high-quality protein, contains all essential amino acids in sufficient quantity to support growth and maintain nitrogen balance. Proteins provide nitrogen. Nitrogen balance is essential for a normal functioning body. Examples of foods that contain complete proteins are fish, chicken, soybeans, turkey, and cheese. Incomplete proteins are missing one or more of the nine indispensable amino acids. Complementary proteins are pairs of incomplete proteins that, when combined, supply the total amount of protein provided by complete protein sources. Positive nitrogen is required for growth, normal pregnancy, wound healing, and vital organ functioning. Negative nitrogen occurs in infection, burns, fever, starvation, and trauma.
Fats are the most calorie-dense nutrients, providing 9 kcal/g. Fats are composed of triglycerides and fatty acids.
Fatty acids may be essential or nonessential. Linoleic acid is the only essential fatty acid in humans; linolenic and arachidonic acids are manufactured by the body if linoleic acid is available.
Triglycerides circulate in the blood and are composed of three fatty acids attached to a glycerol. Fatty acids are composed of chains of carbon and hydrogen atoms with an acid group at one end of the chain and a methyl group at the other. Fatty acids can be saturated, in which case each carbon in the chain has two attached hydrogen atoms; or unsaturated, in which case unequal numbers of hydrogen atoms are attached, and the carbon atoms attach to each other with a double bond. Monounsaturated fatty acids have one double bond, whereas polyunsaturated fatty acids have two or more double carbon bonds.

7. Scientific Knowledge Base: Nutrients (cont’d)
Water
All cell function depends on a fluid environment.
Vitamins
Essential for metabolism
Water-soluble or fat-soluble
Minerals
Catalysts for enzymatic reactions
Macrominerals; trace elements
Humans are water-based systems! In all, 60% to 70% of total body weight is water. Water is critical because cell function depends on a fluid environment.
Vitamins are organic substances present in small amounts in foods that are essential to normal metabolism. Fat-soluble vitamins: A, D, E, K. Water-soluble vitamins: C and B complex.
Minerals are inorganic elements essential to the body as catalysts in biochemical reactions. We need 100 mg or more daily of macrominerals and 100 mg or less of trace elements.

8. Digestion Digestion Absorption Metabolism and storage of nutrients
Begins in the mouth and ends in the small and large intestines
Absorption
Intestine is the primary area of absorption.
Metabolism and storage of nutrients
Consist of anabolic and catabolic reactions
Elimination
Chyme is moved through peristalsis and is changed into feces.
Digestion causes food to break down to simplest form for absorption, mainly in the small intestines. Ingestion is the taking in of food.
Enzymes are the catalysts that speed up chemical reactions. Food moves through the GI tract through peristalsis, or wavelike muscular contractions. The food mass in liquefied form is called chyme.
Absorption uses the processes of active transport, passive diffusion, osmosis, and pinocytosis.
[See Box 44-1 on text page 1000 and Table 44-1 Mechanisms for Intestinal Absorption of Nutrients.]
Metabolism refers to all of the biochemical reactions within the cells of the body. Anabolism is the building of more complex biochemical substances through synthesis of nutrients. Catabolism is the breakdown of biochemical substances into simpler substances; it occurs during physiological states of negative nitrogen balance.
Metabolic reactions include glycogenolysis, glycogenesis, and gluconeogenesis.
As feces move toward the rectum, water is absorbed in the mucosa. The longer the material stays in the large intestines, the firmer are the feces. Feces contains cellulose, indigestible substances, GI tract cells, digestive secretions, water, and microbes.
[See also Figure 44-1 on text p. 999 Summary of digestive system anatomy/organ function.]

9. Dietary Guidelines Dietary reference intakes (DRIs) Food guidelines
Acceptable range of quantities of vitamins and minerals for each gender and age group
Food guidelines
Dietary Guidelines, average daily consumption
Daily values
Needed protein, vitamins, fats, cholesterol, carbohydrates, fiber, sodium, and potassium
The U.S. Department of Agriculture and the U.S. Department of Health and Human Services publish the Dietary Guidelines (see Box 44-2 on text page 1001).
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.
Four components of dietary reference intakes (DRIs):
1. Estimated average requirement (EAR)—amount of nutrient that appears sufficient to maintain a specific body function for 50% of population based on age and gender 2.
2. Recommended dietary allowance (RDA)—average needs of 98% of population, not exact needs of an individual
3. Adequate intake (AI)—suggested intake for individuals based on observed or experimentally determined estimates of nutrient intakes used when not enough evidence to set RDA
4. Tolerable upper intake level (UL)—highest level that poses no risk of adverse health events.
The Food and Drug Administration (FDA) created daily values for food labels in response to the 1990 Nutrition Labeling and Education Act. Daily values did not replace RDAs but provided a separate, more understandable format for the public. Daily values are based on percentages of a diet consisting of 2000 kcal/day for adults and children 4 years or older.

10. ChooseMyPlate
The ChooseMyPlate program was developed by the U.S. Department of Agriculture to replace the My Food Pyramid program. ChooseMyPlate provides a basic guide for making food choices for a healthy lifestyle. The ChooseMyPlate program includes guidelines for balancing calories; decreasing portion size; increasing healthy foods; increasing water consumption; and decreasing fats, sodium, and sugars.
[Shown is Figure 44-2 from text p ]

11. Case Study (cont’d)
Mrs. Gonzales is awake and alert in her hospital room, yet is drooling from the right side of her mouth. When she tries to drink water, she starts to cough. The physician has ordered nothing by mouth (NPO). Evaluation by the speech language pathologist (SLP) indicates inadequate clearance of food and liquid from the vocal folds and aspiration of thickened liquids.
Mrs. Gonzalez has trouble swallowing with oropharyngeal dysphagia. The SLP recommends enteral feedings, and speech and swallowing therapy to help her return to oral feedings.
[Ask the class: Were you able to predict that Mrs. Gonzales would receive enteral feedings? What challenges do her nurses face in helping her progress back to oral feedings?]

12. Quick Quiz!
1. A 22-year-old new mother is breastfeeding. You ask her if she is taking the correct quantities of nutrients. Which statement reflects that she understands the dietary guidelines? A. “I am not concerned with what I am eating.” B. “I am taking vitamin doses based on TV.” C. “I am taking a daily MVI.” D. “I am making eating choices according to the recommended dietary allowances and intakes.”
Answer: D

13. Nursing Knowledge Base
Factors influencing nutrition
Environmental factors
Developmental needs
Infants through school age
Breastfeeding, formula, solid foods
Adolescents
Young and middle adults
Older adults
The likelihood of healthy eating and participation in exercise or other activities of healthy living is limited by environmental factors. Lack of access to full-service grocery stores, high costs of healthy food, widespread availability of less healthy foods in fast food restaurants, widespread advertising of less healthy food, and lack of access to safe places to play and exercise are environmental factors that contribute to obesity.
Each of these groups has specific needs.
Infants through school age: rapid growth and high protein
Breastfeeding is recommended for first 6 months of life with benefits including reduced food allergies and intolerances, easier digestion, and fewer infant infections.
Formula: Protein in the formula is whey, soy, cow’s milk, casein hydrolysate, or elemental amino acids; infants should not have regular cow’s milk during the first year because it is too concentrated for the kidneys to handle and is a poor source of iron and vitamins C and E.
Solid food: Introduce solid foods one at a time 4 to 7 days apart to identify allergies; keep in mind that the growth rate slows in toddlers; they exhibit strong food preferences.
Toddlers: consume more than 24 ounces of milk daily in place of other foods; sometimes develop milk anemia because milk is a poor source of iron.
School age (6-12 years): assess diets for adequate protein and vitamins A and C. School-aged children, 6 to 12 years old, grow at a slower and steadier rate, with a gradual decline in energy requirements per unit of body weight.
Adolescents: Physiological age is better than chronological age for estimating nutritional needs. Adolescents have increased energy needs owing to higher metabolic growth demands; protein increase is needed; calcium and continuous iron are especially important in females; B complex vitamins assist in metabolic activity. Pregnancy occurring within 4 years of menarche places a mother and fetus at risk because of anatomical and physiological immaturity. The onset of eating disorders such as anorexia nervosa or bulimia nervosa often occurs during adolescence.
[See also Box 44-3 on text p Potential Assessment for Eating Disorders.]
Young and middle adults: energy requirements for maintenance and repair only as growth slows. Pregnancy and lactation become significant in considering energy needs and are related to mother’s body weight and activity. Lactation requires an additional 500 calories above usual allowance with greater than protein requirements in pregnancy.
Older adults 65 years and older: decreased needs for energy due to slowing of their metabolic rate. Age-related changes in appetite, taste, smell, and the digestive system affect nutrition. Fixed incomes influence the ability to purchase food. The elderly often have difficulty chewing, missing teeth, or oral pain, causing difficulty in food consumption. The diet of older adults needs to contain choices from all food groups and often requires a vitamin and mineral supplement. The USDHH Administration on Aging requires states to provide nutritional screening services to older adult patients who benefit from home-delivered or congregate meal services. The program requires meals to provide at least one third of DRI for older adults and to meet the Dietary Guidelines for Americans.
[See also Box 44-4 on text p Focus on Older Adults: Factors Affecting Nutritional Status; and Table 44-2 on pp Sample of Drug-Nutrient Interactions.]

14. Case Study (cont’d)
Matt is a nursing student assigned to Mrs. Gonzalez. As he prepares to assess her, he recalls information about the effects of dysphagia on nutrition and rehabilitation. He will assess Mrs. Gonzales’ weight, weight history, diet history, and cultural customs.
Matt knows to consult with a registered dietitian (RD) to assess Mrs. Gonzales’s nutritional status and interventions. Matt is responsible for inserting Mrs. Gonzalez’s small-bore nasogastric feeding tube and starting her tube feedings. The RD has recommended continuous tube feeding for 12 hours during the day.

15. Alternative Food Patterns
Based on religion, cultural background, ethics, health beliefs, and preference
Vegetarian diet consists predominantly of plant foods:
Ovolactovegetarian (avoids meat, fish, and poultry, but eats eggs and milk)
Lactovegetarian (drinks milk but avoids eggs)
Vegan (consumes only plant foods)
Fruitarian (consumes fruit, nuts, honey, and olive oil)
Zen macrobiotic
Through careful selection of foods, individuals following a vegetarian diet can meet recommendations for proteins and essential nutrients.
•Vegans lack complete proteins in single foods, although they can use complementary proteins from two or more foods to get all the amino acids. Knowledge of complementary proteins is necessary. They are at risk for vitamin B12 deficiency because it is available only from animal sources. Children who follow a vegetarian diet are especially at risk for protein and vitamin deficiencies such as vitamin B12.
Zen macrobiotic diets consist primarily of brown rice, other grains, and herb teas. Zen macrobiotic and fruitarian diets are nutrient poor and frequently result in malnutrition.
Students need to consult with dietitians to ensure that patients receive the nutrients needed for recovery and rehab.
[On text p. 1006, see Table 44-3 for religious dietary restrictions, and Box 44-5 Cultural Aspects of Care: Nutrition.]

16. Assessment
Screening a patient is a quick method of identifying malnutrition or risk of malnutrition using sample tools:
Height
Weight
Weight change
Primary diagnosis
Comorbidities
Screening tools
A nutritional assessment is more than taking a diet history. Some prescription drugs, many over-the-counter drugs, and herbal/natural therapy can affect a patient’s nutritional state.
It is also important to know food interactions and medication administration, especially between milk and citrus fruits and between juices and alcohol.
Screening is an essential part of initial assessment. Standardized nutrition screening tools include Subjective Global Assessment (SGA) (an inexpensive technique to predict nutrition-related complications), Mini-Nutritional Assessment (MNA) (an 18-item tool divided into screening and assessment; used to assess older adults in home care programs, nursing homes, and hospitals), and the Malnutrition Screening Tool (MST) (an effective measure of nutritional problems in a variety of health care settings).
Identification of risk factors such as unintentional weight loss, the presence of a modified diet, or the presence of altered nutritional symptoms (i.e., nausea, vomiting, diarrhea, and constipation) requires nutritional consultation.
[See also Figure 44-3 on text p Critical thinking model for nutrition assessment; and Figure 44-4 on text p Mini-Nutritional Assessment (MNA).]

17. Assessment (cont’d)
Anthropometry is a measurement system of the size and makeup of the body.
An ideal body weight (IBW) provides an estimate of what a person should weigh.
Body mass index (BMI) measures weight corrected for height and serves as an alternative to traditional height-weight relationships.
Laboratory and biochemical tests
Serial measures of weight over time provide more useful information than a single measurement. The patient needs to be weighed at the same time each day, on the same scale, and with the same clothing or linen.
Rapid weight gain or loss is important to note because it usually reflects fluid shifts. One pint or 500 mL of fluid equals 1 lb (0.45 kg).
No single laboratory or biochemical test is diagnostic for malnutrition. Factors that frequently alter test results include fluid balance, liver function, kidney function, and the presence of disease.
Common laboratory tests used to study nutritional status include measures of plasma proteins such as albumin, transferrin, prealbumin, retinol binding protein, total iron-binding capacity, and hemoglobin.
Nitrogen balance can be calculated to determine serum protein status.
Factors that affect serum albumin levels include hydration; hemorrhage; renal or hepatic disease; large amounts of drainage from wounds, drains, burns, or the GI tract; steroid administration; and exogenous albumin.

18. Assessment (cont’d) Dietary and health history Physical examination
Health status; age; cultural background; religious food patterns; socioeconomic status; personal food preferences; psychological factors; use of alcohol or illegal drugs; use of vitamin, mineral, or herbal supplements; prescription or over-the-counter (OTC) drugs; and the patient’s general nutrition knowledge
Physical examination
Dysphagia (difficulty swallowing)
The diet history focuses on a patient’s habitual intake of foods and liquids and includes information about preferences, allergies, and other relevant topics such as the patient’s ability to obtain food. Gather information about the patient’s illness/activity level to determine energy needs and compare food intake.
[Review Box 44-6 on text p Nursing Assessment Questions.]
Physical examination is one of the most important aspects of nutritional assessment because improper nutrition affects all body systems.
[Review Table 44-4 on text p Physical Signs of Nutritional Status.]
During the physical examination, you will assess for dysphagia. This may cause difficulty for patients while eating, drinking, or taking medications. Validated screening tools for dysphagia include Bedside Swallowing Assessment, Burke Dysphagia Screening Test, Acute Stroke Dysphagia Screen, and Standardized Swallowing Assessment.
Dysphagia leads to disability or decreased functional status, increased length of stay and cost of care, increased likelihood of discharge to institutionalized care, and increased mortality.
[See also Figure 44-3 on text p Critical thinking model for nutrition assessment; and Box 44-7 on text p Causes of Dysphagia.]

19. Case Study (cont’d) Assessment findings:
Mrs. Gonzales starts to cough when she tries to drink water.
Mrs. Gonzales is unable to swallow and aspirates pills and thickened liquid.
Lung sounds are clear. Respirations are regular at 12/min. She has no dyspnea. Oxygen saturation is 96% on room air.
Enteral nutrition will begin at 60 mL/hr.
[Matt assessed Mrs. Gonzalez for risk of aspiration, evaluated Mrs. Gonzalez’ swallowing ability, monitored her respiratory status, and assessed her nutritional status.
What diagnosis would you expect?]

20. Nursing Diagnosis Risk for aspiration Diarrhea Deficient knowledge
Readiness for enhanced nutrition
Feeding self-care deficit
Impaired swallowing
Imbalanced nutrition: more than body requirements
Imbalanced nutrition: less than body requirements
Risk for imbalanced nutrition: more than body requirements
Possible nursing diagnoses are shown on the slide. Nursing diagnoses may be related to actual nutrition problems (e.g., inadequate intake) or to problems that place the patient at risk for nutritional deficiencies such as oral trauma, severe burns, and infections.
[See also Box 44-8 on text p Nursing Diagnostic Process: Imbalanced Nutrition: Less than Body Requirements; and Figure 44-5 Concept map on text p ]

21. Case Study (cont’d)
Diagnosis: Risk for aspiration related to impaired swallowing
Goals:
Mrs. Gonzales will receive adequate nutrients through enteral tube feeding without aspiration by the time of discharge.
Mrs. Gonzalez will regain swallowing ability from speech therapy by the time of discharge.
[Ask the class: What are some expected outcomes for these goals? Discuss:
Mrs. Gonzalez’s weight at discharge will be within 2 lbs of admission weight.
Mrs. Gonzalez will not exhibit signs of aspiration before discharge.
Mrs. Gonzalez’ albumin and prealbumin levels will remain normal before discharge.
Mrs. Gonzalez will progress to an oral diet before discharge to a restorative care facility.]

22. Planning
Nutrition education and counseling are important for all patients to prevent disease and promote health.
Refer to professional standards for nutrition.
Collaboration with a registered dietitian (RD) helps develop appropriate nutrition treatment plans.
Considerations:
Perioperative food intake
Enteral and parenteral feedings
Assistive devices
Planning to maintain optimal nutritional status requires a higher level of care than just nutritional problem corrections.
Referring to professional standards for nutrition is especially important during this step because published standards are based on scientific findings.
Goals and outcomes of care reflect a patient’s physiological, therapeutic, and individualized needs. Patients on therapeutic diets need to understand the implications of their diets and how prescribed diets help to control their illnesses.
Individualized planning is essential. Explore patients’ feelings about their weight and diet, and help them set realistic and achievable goals.
During acute illness or surgery, intake of food is often altered in the perioperative period. The priority of care is to provide optimal preoperative nutrition support in patients with malnutrition. The priority for the resumption of food intake after surgery depends on the return of bowel function, the extent of the surgical procedure, and the presence of any complications. It is important that discharge planning include nutritional interventions as patients return to their homes or extended care facilities.
Enteral tube feedings are often administered into the stomach or intestines via a tube inserted through the nose or a percutaneous access. These enteral feedings supplement a patient’s oral nutritional intake in the home, acute care, extended care, or rehabilitation setting when they cannot meet their nutritional needs by mouth.
Patients who cannot tolerate nutrition through the GI tract receive parenteral nutrition, a solution consisting of glucose, amino acids, lipids, minerals, electrolytes, trace elements, and vitamins, through an indwelling peripheral or central venous catheter.
When patients have difficulty feeding themselves, occupational therapists work with them and their families to identify assistive devices.
[See also Box 44-8 on text p Nursing Diagnostic Process: Imbalanced Nutrition: Less than Body Requirements; Figure 44-5 Concept map on text p. 1012; Nursing Care Plan on text pp Imbalanced Nutrition: Less Than Body Requirements; and Figure 44-6 on text p Critical thinking model for nutrition planning.]

23. Implementation Health promotion Education
Early identification of potential or actual problems
Meal planning
Weight loss plans
Food safety
The focus of health promotion is to educate patients and family caregivers about balanced nutrition and to assist them in obtaining resources to eat high-quality meals.
Early identification of potential or actual problems is the best way to avoid more serious problems.
Meal planning takes into account the family’s budget and different preferences of family members.
Help patients develop a successful weight loss plan that considers their preferences and resources and includes awareness of portion sizes and knowledge of the energy content of food.
Health care professionals not only need to be aware of factors related to food safety but also should provide patient education to reduce risks for foodborne illnesses.
[See also Table 44-5 on text p Food Safety; and Box 44-9 on text p Patient Teaching: Food Safety.]

24. Implementation Acute care Risk factors in acutely ill patient
Advancing diets = Gradual progression of dietary intake or therapeutic diet to manage illness
Promoting appetite
Assisting with oral feedings
When a patient needs help with eating, it is important to protect his or her safety, independence, and dignity.
[Ask the class: What factors influence nutritional intake in the acutely ill patient? Discuss:
Diagnostic testing and procedures in the acute care setting disrupt food intake. Often as preparation for or immediately following a diagnostic procedure, a patient is to receive nothing by mouth (NPO).
Mealtimes in a health care setting are frequently interrupted, or patients have poor appetites.
Patients often are too fatigued or uncomfortable to eat. It is important to continuously assess a patient’s nutritional status and adopt interventions that promote normal intake, digestion, and metabolism of nutrients.
Patients who are NPO and receive only standard IV fluids for longer than 4 to 7 days are at nutritional risk.]
Acute and chronic conditions affect a patient’s immune system and nutritional status. Patients with decreased immune function (e.g., from cancer, chemotherapy, human immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], or organ transplant) require special diets that decrease their exposure to microorganisms and are higher in selected nutrients. Table 44-6 on text p gives an overview of the immune system, the malnutrition impact, and which nutrients are beneficial. In addition, patients who are ill, who have had surgical procedures, or who were NPO for a period of time have specialized dietary needs. Health care providers order a gradual progression of dietary intake
or a therapeutic diet to manage patients’ illness (see Box on text p Diet Progression and Therapeutic Diets).
Patients who are ill or debilitated often have poor appetites (anorexia). Anorexia has many causes. Help patients understand the factors that cause anorexia, and use creative approaches to stimulate appetite.
A pleasant environment will improve a patient’s appetite. The environment should be clean and free of odor. Oral hygiene will remove unpleasant tastes. Mealtime is often a social time, so company may help.
Make sure patients can feed themselves, can swallow, and are positioned properly. If patients have visual difficulties, they may need assistance with feeding. You can also help patients by telling them where food is placed, according to the face of a clock (e.g., peas at 3 o’clock).
Patients with dysphagia are at risk for aspiration. Four levels of diet include dysphagia puree, dysphagia mechanically altered, dysphagia advanced, and regular. The four levels of liquid include thin liquids (low viscosity), nectarlike liquids (medium viscosity), honeylike liquids (viscosity of honey), and spoon-thick liquids (viscosity of pudding). Feed patients slowly, smaller-size bites, with more frequent chewing and swallowing.

25. Adaptive Equipment
This photo shows the following adaptive equipment, clockwise from upper left: two-handled cup with lid, plate with plate guard, utensils with splints, and utensils with enlarged handles.
Patients with impaired vision and those with decreased motor skills are more independent during mealtimes with the use of large-handled adaptive utensils. These are easier to grip and manipulate.
[Shown is Figure 44-7 from text p ]

26. Enteral Tube Feeding
Enteral nutrition (EN) provides nutrients into the GI tract. It is physiological, safe, and economical nutritional support.
Nasogastric, jejunal, or gastric tubes
Surgical or endoscopic placement
Nasointestinal
Gastrostomy
Jejunostomy
PEG (percutaneous endoscopic gastrostomy)
PEJ (percutaneous endoscopic jejunostomy)
Risk of aspiration
When oral feeding assistance is inadequate in providing appropriate nutrition, enteral or parental feeding is required. EN is the preferred method of meeting nutritional needs if a patient is unable to swallow or take in nutrients orally, yet has a functioning GI tract.
[Box on text p lists indications for EN or PN.]
Patients at low risk for gastric reflux receive gastric feedings; however, if risk of gastric reflux, which leads to aspiration, is present, jejunal feeding is preferred.
Types of formulas include
Polymeric: milk-based, blenderized; the patient’s gastrointestinal tract needs to be able to absorb whole nutrients
Modular: single-macronutrient (protein, glucose, polymers, or lipids) formulas are added to other foods to meet patients’ needs
Elemental formulas: predigested nutrients, easier for partially dysfunctional gastrointestinal tract to absorb
Specialty formulas: designed to meet specific nutritional needs in certain illnesses
Before beginning a tube feeding, you will learn in the skills lab to flush the line with a small amount of water to ensure that the tube is clear and patent. Tube feedings typically are started at full strength at slow rates. Increase the hourly rate every 8 to 12 hours per health care provider’s order if no signs of intolerance appear.
Feeding by the enteral route reduces sepsis, minimizes the hypermetabolic response to trauma, decreases hospital mortality, and maintains intestinal structure and function.
Tubes are inserted through the nose (nasogastric or nasointestinal), surgically (gastrostomy or jejunostomy), or endoscopically (percutaneous endoscopic gastrostomy or jejunostomy).
If for less than 4 weeks total, nasogastric or nasojejunal feeding tubes may be used. Surgical or endoscopically placed tubes are preferred for long-term feeding.
A serious complication associated with enteral feedings is aspiration of formula into the tracheobronchial tree, which leads to infection.
[Review Box on text p Advancing the Rate of Tube Feeding.]

27. Enteral Tubes Shown are small-bore enteral tubes.
Most health care settings use small-bore feeding tubes because they create less discomfort for a patient. For the adult, most of these tubes are 8- to 12-French and 36 to 44 inches (90 to 110 cm) long. A stylet is often used during insertion of a small-bore tube to stiffen it. The stylet is removed when correct positioning of the feeding tube is confirmed. Skill 44-3 describes the procedure for initiating nasogastric, gastrostomy, and jejunostomy enteral feedings.
Measurement of the pH of secretions withdrawn from the feeding tube helps to differentiate the location of the tube.
[Review Table 44-7 on text p Enteral Tube Feeding Complications.]
[Shown is text Figure 44-8 from p ]

28. pH Measurement for Tube Location
Measurement of pH of secretions withdrawn from the feeding tube helps to differentiate the location of the tube. At present, the most reliable method for verification of placement of small-bore feeding tubes is x-ray film examination.
On the left are gastrointestinal contents. A, Stomach. B, Stomach. C, Intestinal tract.
The photo on the right shows a comparison of the pH strip with a color chart.
[See Box on text p Procedural Guidelines: Obtaining Gastrointestinal Aspirate for pH Measurement, Large-Bore, and Small-Bore Feeding Tubes: Intermittent and Continuous Feeding; and Box on text p Evidence-Based Practice: Accuracy in Determining Placement of Feeding Tubes.]
[Figures are from Box ]

29. Case Study (cont’d) Nutritional management Aspiration precautions
Insert feeding tube as ordered.
Initiate enteral feeding as prescribed.
Advance tube feeding as tolerated; monitor for tolerance.
Aspiration precautions
Position Mrs. Gonzalez with head of bed elevated a minimum of 30 degrees.
Check tube placement every 4 to 6 hours.
Check gastric residual volume every 4 hours.
Continue with speech therapy.
[Discuss the rationales for these interventions:
The enteral tube feeding will allow for safe provision of nutrients while swallowing is rehabilitated with the assistance of the speech-language pathologist (SLP).
Tube feeding is initiated at a low rate of infusion and is increased slowly to allow for maximum tolerance.
Abdominal pain, large volume of gastric residuals, and diarrhea are signs of feeding intolerance and need to be evaluated promptly.
Head of bed elevated a minimum of 30 to 40 degrees decreases the risk for aspiration.
Improperly positioned tubes increase the risk for aspiration.
Gastric residual volume indicates whether gastric emptying is delayed. Delayed gastric emptying increases the risk for aspiration.
Regularly provided speech therapy will assist the patient in regaining the ability to swallow foods and liquids.
Speech therapy includes trials of various consistencies of foods and liquids. Aspiration of food and liquids lead to chest congestion and pneumonia.]

30. Quick Quiz!
2. You receive an order to begin enteral tube feedings. The first step is to A. Place the patient in a prone position. B. Irrigate the tube w/normal saline. C. Check to see that the tube is properly placed. D. Introduce a small amount of fluid into the tube before feeding.
Answer: D

31. Parenteral Nutrition Nutrients are provided intravenously.
Patients unable to digest or absorb enteral nutrition or are in highly stressed physiological states:
Sepsis
Head injury
Burns
Peripheral or central line
Initiating parenteral nutrition
Preventing complications
Parenteral nutrition consists of concentrated nutrients delivered directly to the superior vena cava near the right atrium of the heart.
Intravenous fat emulsions sometimes are added to parenteral nutrition (PN) to provide supplemental kilocalories, prevent essential fatty acid deficiencies, and help control hyperglycemia during periods of stress.
PN greater than 10% dextrose requires a central venous catheter, placed into a high-flow central vein. Patients with short-term nutritional needs often receive IV solutions less than 10% in the peripheral vein.
Placement of the line needs to be confirmed by x-ray.
Before beginning any PN infusion, verify the health care provider’s order and inspect the solution for particulate matter or a break in the fat emulsion.
Complications can occur at the site, with tubing, with infusion rate, and with electrolyte imbalances. Examples of complications include pneumothorax, air embolus, catheter occlusion, catheter sepsis, osmotic diuresis, and dehydration.
The goal is to move patients from PN to enteral nutrition (EN) and/or oral feeding. When 1/3 to 1/2 of kilocalorie needs are met, PN is decreased to half the original volume. When 75% of needs are met by EN or dietary intake, PN therapy is discontinued, preparing the patient for discharge and restorative and continual care.
[Review Table 44-8 Metabolic Complications of Parenteral Nutrition on text p ]

32. Restorative and Continuing Care
Medical nutrition therapy (MNT)
Specific nutritional therapy usage for treating illness, injury, or a certain condition
Necessary for
Metabolizing certain nutrients
Correcting nutritional deficiencies
Eliminating foods that worsen disease states
Most effective with collaborative health care team and dietitian
Optimal nutrition is significant in health and illness and thus is modified in patients with particular diseases; thus medical nutrition therapy (MNT) is needed. The next few slides discuss the various important disease states dependent on MNT; these include both acute and chronic disease states.

33. Medical Nutrition Therapy
Gastrointestinal diseases
Peptic ulcer etiology
Helicobacter pylori
Stress
Acid overproduction
Peptic ulcer treatments
Avoid caffeine.
Avoid spicy foods.
Avoid aspirin, NSAIDs.
Consume small, frequent meals.
Medical nutrition therapy is extremely significant in gastrointestinal diseases such as peptic ulcer, inflammatory bowel disease, and malabsorption syndrome.

34. Medical Nutrition Therapy (cont’d)
Gastrointestinal diseases
Inflammatory bowel disease
Crohn’s and idiopathic ulcerative colitis
Elemental diets
Parenteral nutrition
Vitamins and iron supplements
Fiber increase
Fat reduction
Large meal avoidance
Lactose and sorbitol avoidance
For treating inflammatory bowel disease, best practices are shown on the slide.
Elemental diets are formulas with nutrients in their simplest form ready for absorption.

35. Case Study (cont’d)
Matt must keep in mind that Mrs. Gonzalez will progress to restorative care and return to oral feedings, and also must consider cultural preferences. Matt knows that food safety is an important issue.
Matt consults the dietitian, and together they develop a teaching plan regarding food safety for the foods that Mrs. Gonzalez’s family will be preparing at home.
What expected outcomes would Matt set for the teaching session?
[Outcome: At the end of the teaching session, Mrs. Gonzalez’s family is able to state measures to reduce foodborne illnesses:
Wash hands, preparation surfaces, and utensils.
Cook meat, poultry, fish, and eggs at 180 degrees.
Wash fresh fruits and vegetables.
Refrigerate foods at 40° within 2 hours of cooking.
Discard spoiled foods.
Use plastic laminate or solid surface cutting boards.
Wash dishrags, towels, and sponges with bleach.
Clean inside of refrigerator and microwave regularly with bleach or soap.
Matt could also evaluate the family in preparing Mrs. Gonzalez’s food and preventing foodborne illnesses by making a home visit.]

36. Medical Nutrition Therapy
Malabsorption syndromes
Celiac disease
Gluten-free diet
Short bowel syndrome
Intestinal surface decrease
Lifetime EN or PN
Diverticulitis
Inflammation of diverticula
Low- to moderate-residue diet for infection
High-fiber diet for chronic conditions
Gluten is contained in wheat, rye, barley, and oats.

37. Medical Nutrition Therapy (cont’d)
Diabetes mellitus
Type 1: insulin and dietary restrictions
Type 2: exercise and diet therapy initially
Individualized diet
Carbohydrate consistency and monitoring
Saturated fat less than 7%
Cholesterol intake less than 200 mg/dL
Protein intake 15% to 20% of diet
Diabetes is a disease that is focused intensely on diet and exercise with requirements limiting carbohydrate intake. Monitoring carbohydrate consumption is a key strategy in achieving glycemic control.

38. Medical Nutrition Therapy (cont’d)
Diabetes mellitus
Goals
Normal to near-normal glucose levels
Less than 100 mg/dL low-density lipoprotein (LDL)
Less 130/85 mm Hg
Avoidance of hypoglycemia
Maintaining these goals will reduce microvascular (renal and eye disease), cardiovascular, neurological, and peripheral vascular complications.
Be aware of signs and symptoms of hypoglycemia and hyperglycemia. [Discuss.]

39. Medical Nutrition Therapy (cont’d)
Cardiovascular diseases
American Heart Association (AHA) dietary guidelines
Balance caloric intake and exercise.
Maintain a healthy body weight.
Eat a diet rich in fruits, vegetables, and complex carbohydrates.
Eat fish twice per week.
Limit foods and beverages high in sugar and salt.
Limit trans-saturated fat to less than 1%.
By following these guidelines, hypertension and coronary artery disease can be reduced.
American Heart Association (AHA) guidelines also recommend limiting saturated fat to less than 7% and cholesterol to less than 300 mg/day. To accomplish this goal, patients choose lean meats and vegetables, use fat-free dairy products, and limit intake of fats and sodium.

40. Medical Nutrition Therapy (cont’d)
Cancer and cancer treatment
Malignant cells compete with normal cells for nutrients.
Anorexia, nausea, vomiting, and taste distortions are common.
Malnutrition associated with cancer increases morbidity and mortality.
Radiation causes anorexia, stomatitis, severe diarrhea, intestinal strictures, and pain.
The goal of nutrition treatment in cancer patients is to meet the increased metabolic demands. Enhanced nutritional status often improves a patient’s quality of life.

41. Medical Nutrition Therapy (cont’d)
Cancer and cancer treatment
Nutrition management
Maximize fluid and nutrient intake.
Individualize diet choices to patient’s needs, symptoms, and situation.
Encourage small, frequent meals and snacks that are easy to digest.
Malignant cells compete with normal cells for nutrients, thus increasing the patient’s metabolic needs. It is important to enhance nutritional status to improve the patient’s quality of life.

42. Medical Nutrition Therapy (cont’d)
Human immunodeficiency virus/acquired immunodeficiency syndrome
Body wasting and severe weight loss
Severe diarrhea, GI malabsorption, altered nutrient metabolism
Hypermetabolism as a result of cytokine elevation
Maximize kilocalories and nutrients.
Encourage small, frequent, nutrient-dense meals with fluid in between.
This disease state results in several consequences that alter nutritional attainment.
Diagnose and address each cause of nutritional depletion in the care plan. Individually tailored nutrition support progresses in stages from oral, to enteral, and finally to parenteral.
Good hand hygiene and food safety are essential because of a patient’s reduced resistance to infection.

43. Case Study (cont’d)
What nursing actions are appropriate for evaluating whether goals have been met?
Consider the patient’s perspective.
Check measurable outcomes.
Consult with interdisciplinary staff.
[Nursing actions taken to verify achievement of outcome include:
Asking Mrs. Gonzalez if she is experiencing any gastrointestinal discomfort
Weighing Mrs. Gonzalez weekly
Monitoring her laboratory values
Asking the SLP about Mrs. Gonzalez’ swallowing rehabilitation]

44. Evaluation
Multidisciplinary collaboration remains essential in providing nutritional support.
Changes in condition indicate a need to change the nutritional plan of care.
Consider the limits of patients’ conditions and treatments, their dietary preferences, and their cultural beliefs when evaluating outcomes.
Upon care plan completion, it is necessary to evaluate prior interventions and responses for optimal outcomes.
If ongoing nutrition therapies do not result in successful outcomes, patients expect nurses to recognize this and alter the plan of care accordingly.
When outcomes are not met, ask questions such as “How has your appetite been?” “Have you noticed a change in your weight?” “How much would you like to weigh?” or “Have you changed your exercise pattern?”
[Figure 44-9 from text p Critical thinking model for nutrition evaluation.]

45. Case Study (cont’d)
Matt sees Mrs. Gonzalez before discharge to a restorative care facility for rehabilitation before returning home. Mrs. Gonzalez now is able to consume all of her required nutrients with a ground diet and nectar-thickened liquids. Matt removes the feeding tube in preparation for her transport to the new facility.
Matt advises Mrs. Gonzalez to continue the care plan and emphasizes that it is important to continue speech therapy.
Matt also discusses the importance of compliance with diet modifications until swallowing function returns completely.
[Ask the class: What would Matt write in a documentation note? Discuss.]