Chapter 21 Kidney Disease 1.

Chapter 21 Kidney Disease 1

Key Concepts Kidney disease interferes with the normal capacity of nephrons to filter waste products of body metabolism. Short-term kidney disease requires basic nutrition support for healing rather than dietary restriction. 3.8 million Americans have some form of kidney disease. 42,000 persons die from such diseases each year. 2

Kidney Disease, cont’d Figure information:
Incident counts and adjusted rates, by race of ESRD. From U.S. Renal Data System: USRDS 2007 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States, Bethesda, MD, 2007, National Institutes of Health. 3

Dual Role of the Kidneys
Kidneys make urine, through which they excrete most of the waste products of metabolism. Kidneys control the concentrations of most constituents of body fluids, especially blood. What are examples of metabolic waste products? How much fluid is filtered through the kidneys on a daily basis? What is a normal output of urine per day? 4

Basic Structure and Function
Structures Basic unit is the nephron Glomerulus Tubules Function Excretory and regulatory Endocrine 5

Basic Structure Figure information:
Top, Reprinted from Peckenpaugh NJ: Nutrition essentials and diet therapy, ed 10, Philadelphia, 2002, Saunders; bottom, reprinted from Thibodeau GA, Patton KT: Anatomy & physiology, ed 6, St Louis, 2007, Mosby. 6

Renal Nephrons Basic functional unit of the kidney
Major nephron functions Filtration of materials in blood Reabsorption of needed substances Secretion of hydrogen ions to maintain acid-base balance Excretion of waste materials Additional functions Renin secretion (for body water balance) Erythropoietin secretion (for red cell production) Vitamin D activation What are the key parts of the nephron? How many nephrons are present at birth? Why would anemia be linked to kidney disease? Why are kidneys referred to as “master chemists”? 7

Nephron Structures Glomerulus Tubules Cluster of branching capillaries
Cup-shaped membrane at the head of each nephron forms the Bowman’s capsule Filters waste products from blood Glomerular filtration rate: Preferred method of monitoring kidney function Tubules Proximal tubule Loop of Henle Distal tubule Collecting tubule How does osmotic pressure relate to kidney structure and function? What is the glomerular filtration rate, and why is it a useful indicator of kidney function? What is another name for antidiuretic hormone? Who discovered the function of the glomerulus? What does the Latin word “glomus” mean? 8

Tubules 9

Causes of Kidney Disease
Infection and obstruction Damage from other diseases Toxins Genetic defect Risk factors What is the primary cause of kidney disease in the United States? How does hypertension relate to kidney disease? What are treatments for infection or obstruction of the kidneys? How does malnutrition contribute to kidney disease? Can a person born with only one kidney lead a healthy life without treatment? 10

Causes of Kidney Disease, cont’d
Figure information: Prevalence of chronic kidney disease by primary diagnosis. From U.S. Renal Data System: USRDS 2007 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States, Bethesda, MD, 2007, National Institutes of Health. 11

Risk Factors and Causes of Kidney Disease
Sociodemographic factors Older age Racial or ethnic minority status Exposure to certain chemical and environmental conditions Low income or education 12

Risk Factors and Causes of Kidney Disease, cont’d
Clinical factors Poor glycemic control in diabetes Hypertension Autoimmune disease Systemic infections Urinary tract infections Urinary stones 13

Risk Factors and Causes of Kidney Disease, cont’d
Clinical factors Lower urinary tract obstruction Neoplasia Family history of chronic kidney disease Recovery from acute kidney failure Reduction in kidney mass Exposure to certain nephrotoxic drugs Low birth weight Copyright National Kidney Foundation. 14

Medical Nutrition Therapy
Based on the nature of the disease process and individual responses Length of disease Long term: More specific nutrient modifications Degree of impaired renal function Extensive: Extensive nutrition therapy required Individual clinical symptoms How is renal function assessed and monitored? Why is treatment of chronic renal disease so complex and challenging? List other conditions often present with renal disease and their exacerbating effects. 15

Acute Glomerulonephritis or Nephritic Syndrome
Clinical symptoms: Hematuria, proteinurea, edema, mild hypertension, depressed appetite, possible oliguria or anuria Why is dietary therapy less complicated with glomerulonephritis? Why is bed rest required? What are risk factors for glomerulonephritis? 16

Acute glomerulonephritis Uncomplicated disease: Antibiotics and bed rest Advanced disease: Possible restriction of protein, sodium Liberal intake of carbohydrates Potassium intake may be monitored Fluid intake may be restricted 17

Nephrotic Syndrome Clinical symptoms: Massive edema, ascites, proteinurea, distended abdomen, reduced plasma protein level, body tissue wasting What is ascites? Why is the abdomen distended? How is protein intake calculated? How does dietary management of nephrotic syndrome differ from other renal disorders? 18

Nephrotic syndrome Protein intake to meet nutrition/growth needs (without excess) Carbohydrate Lipids Sodium (~3 g/day) Potassium Water Other minerals and vitamins 19

Key Concepts The progressive degeneration of chronic renal failure requires dialysis treatment and modification according to individual disease status. 20

Key Concepts, cont’d Current therapy for renal stones depends more on basic nutrition and health support for medical treatment than on major food and nutrient restrictions. 21

Acute Kidney Failure Prerenal Intrinsic Postrenal obstruction 22

Acute Renal Failure Clinical symptoms: Oliguria, proteinurea, hematuria, loss of appetite, nausea/vomiting, fatigue, edema, itchy skin Short-term dialysis may be needed May progress to chronic renal failure 23

Acute kidney failure Goal is to improve or maintain nutritional status Parenteral nutrition therapy may be required Recommendations for protein intake have been debated Individualized therapy based on renal function (indicated by glomerular filtration rate) Are dietary restrictions necessary as with chronic renal failure? What are other differences between acute and chronic renal failure? Is dialysis ever required to treat acute renal failure? 24

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Chronic Kidney Failure
Caused by progressive breakdown of renal tissue, which impairs all renal functions Develops slowly No cure (other than kidney transplant) Clinical symptoms: Polyuria/oliguria/anuria, electrolyte imbalances, nitrogen retention, anemia, hypertension, azotemia, weakness, shortness of breath, fatigue, thirst, appetite loss, bleeding, muscular twitching Is polyuria a late or early symptom in chronic renal failure? Why? What is meant by azotemia? Why does muscular twitching occur in renal failure? How does uncontrolled hypertension relate to kidney failure? Mosby items and derived items © 2006 by Mosby, Inc. Slide 26 26

Medical Nutrition Therapy Objectives
Reduce protein breakdown Avoid dehydration or excess hydration Correct acidosis Correct electrolyte imbalances Control fluid and electrolyte losses Maintain optimal nutritional status Maintain appetite and morale Control complications of hypertension, bone pain, nervous system involvement Slow rate of renal failure What is a byproduct of protein metabolism? What symptoms does a buildup of urea cause? Why is the kidney unable to retain adequate serum protein in the face of nephron damage? How does pH change in kidney disease? What are nursing interventions for stimulation of appetite? Is depression related to kidney disease? If so, why? Can acute renal failure progress to a more chronic form of the disease? 27

Medical Nutrition Therapy Principles
Provide enough protein therapy to maintain tissue integrity while avoiding excess Provide amino acid supplements for protein supplementation Reserve protein for tissue synthesis by ensuring adequate carbohydrates and fats Maintain adequate urine volume with water (Possibly) restrict sodium, phosphate, calcium Supplement diet with multivitamin Why is protein therapy essential in kidney disease? Discuss the importance of individual monitoring of disease based on causes and clinical presentation. How does nutrition therapy vary for short-term and long-term kidney disease? What is the role of the clinical nutritionist in kidney disease management? 28

Stages of Chronic Kidney Disease
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End-Stage Kidney Disease
Occurs when patient’s glomerular filtration rate decreases to 15 ml/min Irreversible damage to most nephrons Dialysis or transplant are only options Why is the glomerular filtration rate used to assess kidney function? Why should patients in end-stage renal disease have an advanced directive? What ethnic groups are at risk for end-stage renal disease? How can controlling diabetes prevent end-stage renal disease? Is treatment for end-stage renal disease costly? How is quality of life affected? 30

Hemodialysis Uses an artificial kidney machine to remove toxic substances from blood, restore nutrients and metabolites Two to three treatments per week typically required Patient’s blood makes several “round trips” through machine Dialysis solution (dialysate) removes excess waste material Where is hemodialysis provided? Can LPNs/LVNs supervise hemodialysis treatments? What does an arteriovenous fistula look like? What are complications of hemodialysis? 31

Hemodialysis, cont’d Figure information:
Modified from National Institute of Diabetes and Digestive and Kidney Diseases: Treatment methods for hemodialysis, NIH publication No , 2006, Bethesda, MD, National Institute of Health. 32

Hemodialysis, cont’d Figure information:
Types of access for hemodialysis. A, Forearm AV fistula. B, Artificial loop graft. C, Venous catheter for temporary hemodialysis access. Modified from National Institute of Diabetes and Digestive and Kidney Diseases: Kidney failure: choosing a treatment that’s right for you, NIH publication No , 2007, Bethesda, MD, National Institute of Health. 33

Hemodialysis Patient Medical nutrition therapy
Maintain protein and energy balance Prevent dehydration or fluid overload Maintain normal serum potassium and sodium levels Maintain acceptable phosphate and calcium levels Are the dietary objectives similar for hemodialysis and peritoneal dialysis patients? Why is individualized dietary monitoring important? What other health conditions may be present in patients receiving hemodialysis? How does that affect their organ function? 34

Hemodialysis Patient, cont’d
Other dietary concerns Avoid protein energy malnutrition by careful calculation of protein allowance Maintain body mass index of 25 to 28 kg/m2 Fluid intake: 1000 ml/day, plus amount equal to urine output Sodium: 2000 mg/day Potassium: mg/day Supplement of water-soluble vitamins (e.g., B complex, C) How can intake and output be monitored? What are dietary sources of sodium? Why should vitamins be supplemented for hemodialysis patients? How is protein allowance calculated? 35

Peritoneal Dialysis Performed at home
Patient introduces dialysate solution directly into peritoneal cavity four to five times per day Surgical insertion of permanent catheter is required Disposable bag containing dialysate solution is attached to catheter Diet is more liberal than with hemodialysis What is an advantage of peritoneal dialysis compared with hemodialysis? What does the dialysate solution look like? How is it disposed of? Is infection a risk? What are some quality-of-life considerations for patients on dialysis? 36

Peritoneal Dialysis, cont’d
Figure information: Modified from National Institute of Diabetes and Digestive and Kidney Diseases: Treatment methods for kidney failure: peritoneal dialysis, NIH publication No , 2006, Bethesda, MD, National Institute of Health. 37

Figure information: Modified from National Institute of Diabetes and Digestive and Kidney Diseases: Treatment methods for kidney failure: peritoneal dialysis, NIH publication No , 2006, Bethesda, MD, National Institute of Health. 38

Medical nutrition therapy Increase protein intake to 1.2 to 1.5 g/kg body weight Increase potassium with a wide variety of fruits and vegetables Encourage liberal fluid intake of 1500 to 2000 ml/day Avoid sweets and fats Maintain lean body weight Why does protein loss occur with kidney disease? What foods are high in phosphorus? What are dietary sources of potassium? How are phosphorus and potassium levels monitored? Why is dehydration a risk with peritoneal dialysis? 39

Comorbid Conditions Osteodystrophy Neuropathy
Bone disease resulting from defective bone formation Found in about 40% of patients with decreased kidney function and 100% of patients with kidney failure Neuropathy Central and peripheral neurologic disorders Found in up to 65% of patients at the initiation of dialysis How is osteodystrophy managed? Why is neuropathy related to diabetes as well as kidney disease? What nursing interventions can be used for neuropathy? Why is pain management important? 40

Kidney Stones Basic cause is unknown
Factors relating to urine or urinary tract environment contribute to formation Present in 5% of U.S. women and 12% of U.S. men Major stones are formed from one of three substances: Calcium Struvite Uric acid Why are men more predisposed to stone formation? How does genetics relate to creation of kidney stones? 41

Kidney Stones, cont’d 42

Risk Factors 43

Calcium Stones 70% to 80% of kidney stones are composed of calcium oxalate Almost half result from genetic predisposition Other causes Excess calcium in blood (hypercalcemia) or urine (hypercalciuria) Excess oxalate in urine (hyperoxaluria) Low levels of citrate in urine (hypocitraturia) Infection What risk factors can be minimized by the patient? What does a calcium stone look like? 44

Examples of Food Sources of Oxalates
Fruits: Berries, Concord grapes, currants, figs, fruit cocktail, plums, rhubarb, tangerines Vegetables: Baked/green/wax beans, beet/collard greens, beets, celery, Swiss chard, chives, eggplant, endive, kale, okra, green peppers, spinach, sweet potatoes, tomatoes Nuts: Almonds, cashews, peanuts/peanut butter Beverages: Cocoa, draft beer, tea Other: Grits, tofu, wheat germ What types of kidney stones are related to oxalates? Should wine be avoided? 45

Struvite Stones Composed of magnesium ammonium phosphate
Mainly caused by urinary tract infections rather than specific nutrient No diet therapy is involved Usually removed surgically Why is diet therapy not indicated? What are symptoms of a urinary tract infection? Why is surgery required? 46

Other Stones Cystine stones Xanthine stones
Caused by genetic metabolic defect Occur rarely Xanthine stones Associated with treatment for gout and family history of gout What is gout? 47

Kidney Stones: Symptoms and Treatment
Clinical symptoms: Severe pain, other urinary symptoms, general weakness, fever Several considerations for treatment Fluid intake to prevent accumulation of materials Dietary control of stone constituents Achievement of desired pH of urine with medication Use of binding agents to prevent absorption of stone elements Drug therapy in combination with diet therapy What type of pain is it often likened to? Labor pain/cramps What are pain management strategies for kidney stones? How is stone composition determined? What are binding agents? What types of medications are used in treatment? 48

Nutrition Therapy: Calcium Stones
Low-calcium diet (~400 mg/day) recommended for those with supersaturation of calcium in the urine and who are not at risk for bone loss If stone is calcium phosphate, sources of phosphorus (e.g., meats, legumes, nuts) are controlled Fluid intake increased Sodium intake decreased Fiber foods high in phytates increased What types of patients are at risk for bone loss? Why should fluid intake be increased? Should soda intake be reduced? What are food sources high in sodium? What are examples of high-fiber foods? 49

Nutrition Therapy: Uric Acid Stones
Low-purine diet sometimes recommended Avoid: Organ meats Alcohol Anchovies, sardines Yeast Legumes, mushrooms, spinach, asparagus, cauliflower Poultry How does this type of stone relate to gout? Provide examples of organ meats. What are examples of protein sources that are acceptable with this type of kidney stone? 50

Medical Nutrition Therapy: Cystine Stones
Low-methionine diet (essentially a low-protein diet) sometimes recommended In children, a regular diet to support growth is recommended Medical drug therapy is used to control infection or produce more alkaline urine Is this type of stone caused by a genetic disorder? Why does age determine dietary treatment? What are the different metabolic needs of children compared with adults? What is methionine? What medications are used as treatments and why? 51

General Dietary Principles: Kidney Stones
52

Summary The nephrons are the functional units of the kidneys. Through these unique structures the kidney maintains life-sustaining blood levels of materials required for life and health. The nephrons accomplish their tremendous task by constantly “laundering” the blood many times each day, returning necessary elements to the blood and eliminating the remainder in concentrated urine. 53

Summary, cont’d Various diseases that interfere with the vital function of nephrons can cause kidney disease. At its end stage, chronic kidney disease is treated by dialysis or kidney transplantation. Dialysis patients require close monitoring for protein, water, and electrolyte balance. 54

Summary, cont’d Kidney diseases have predisposing factors (e.g., recurrent urinary tract infections may lead to renal calculi, and progressive glomerulonephritis may lead to chronic nephrotic syndrome and kidney failure). Kidney stones may be formed from a variety of substances. For some patient, a change in dietary intake of the identified substance (e.g. fluid, sodium, oxalate, purine) may decrease stone formation. 55

Surgery and Nutrition Support
Chapter 22 Surgery and Nutrition Support 56

Key Concepts Surgical treatment requires nutrition support for tissue healing and rapid recovery. To ensure optimal nutrition for surgery patients, diet management may involve enteral and parenteral nutrition support. Why would surgery require special nutrition support? What health care team members are involved in nutrition support for surgery patients? What are the various roles of the surgeon, clinical nutritionist, pharmacist, and nursing staff? 57

Nutrition Needs of General Surgery Patients
Nutrition needs are greatly increased in patients undergoing surgery Deficiencies easily develop Pay careful attention to: Nutritional status before surgery Individual nutrition needs after surgery How can nutritional status be assessed preoperatively? Why is it important to consider nutritional status before surgery? During recovery? What relations do age and general health status have on nutrition care? 58

Poor Nutritional Status
Associated with: Impaired wound healing, immune system Increased risk of postoperative infection Reduced quality of life Impaired function of gastrointestinal tract, cardiovascular system, respiratory system Increased hospital stay, cost, mortality rate What nutrients are related to wound healing? How is nutrition related to immune function? What postoperative complications can be reduced with adequate nutrition care? How does nutritional status affect a patient’s quality of life? How does adequate nutritional status keep health care costs down? 59

Preoperative Nutrition Care: Nutrient Reserves
Nutrient reserves can be built up before elective surgery to fortify a patient Protein deficiencies are common Sufficient kilocalories are required Extra carbohydrates maintain glycogen stores Vitamin and mineral deficiencies should be corrected Water balance should be assessed What is protein energy malnutrition? How is it defined? Why are older adults especially at risk? Why is extra protein so important? To counteract blood loss during surgery, prevent tissue breakdown, and promote bone healing after surgery What are examples of high-protein foods or drinks? Describe a sample preoperative menu for increasing protein reserves. Why are adequate carbohydrates necessary when building protein stores? What relation do vitamins and minerals have to protein balance? 60

Immediate Preoperative Period
Patients are typically directed not to take anything orally for at least 8 hours before surgery. Before gastrointestinal surgery, a nonresidue diet may be prescribed. Nonresidue elemental formulas provide complete diet in liquid form. Why is it recommended to avoid eating 8 hours before surgery? To prevent aspiration of food during anesthesia and complications from food in the stomach What can aspiration cause? How does anesthesia contribute to risk of aspiration? What complications could occur with food in the stomach during surgery? What are the implications for emergency surgery? 61

Nonresidue Diet Includes only foods free of fiber, seeds, and skins
Prohibited foods include fruits, vegetables, cheese, milk, potatoes, unrefined rice, fats, pepper Vitamin and mineral supplements required for prolonged nonresidue diet Examples of foods to include in a nonresidue diet: Crackers, melba toast, Cream of Wheat, cornflakes, Rice Krispies, pasta Plain cakes and cookies, gelatin desserts, water ices Hard-boiled eggs, tender beef, chicken, fish, lamb, liver, veal Salt, clear soups, carbonated beverages, coffee, tea What nutrients might be lacking in these allowable foods? Would supplements be indicated? What benefits does a nonresidue diet offer? 62

Postsurgical Nonresidue Diet
Nonresidue diet plus: Processed cheese, mild cream cheeses Potatoes Bread without bran All desserts except those containing fruit and nuts Condiments as desired When can additional foods be introduced? Why? How might the introduction of these foods enhance appetite and caloric intake? 63

Postoperative Nutrition Care: Nutrient Needs for Healing
Postoperative nutrient losses are great but food intake is diminished. Protein losses occur during surgery from tissue breakdown and blood loss. Catabolism usually occurs after surgery (tissue breakdown and loss exceed tissue buildup). Negative nitrogen balance may occur. Why is a nutritional deficit resulting in weight loss a risk after surgery? Compare catabolism and anabolism. What results from a negative nitrogen balance? 64

Need for Increased Protein
Building tissue for wound healing Controlling shock Controlling edema Healing bone Resisting infection Transporting lipids What protein components are essential for tissue building? How does plasma protein contribute to blood volume and edema? What is the relation between protein and bone repair? What vitamins and minerals are also necessary for bone healing? What are lymphocytes and how do they relate to immune function? Why is infection a secondary complication of many surgeries? How can adequate nutrition reduce this risk? 65

Problems Resulting from Protein Deficiency
Poor healing of wounds and fractures Rupture of suture lines (dehiscence) Depressed heart and lung function Anemia, liver damage Failure of gastrointestinal stomas to function Reduced resistance to infection Extensive weight loss Increased mortality risk How can protein cause wound dehiscence? Why is anemia a risk? What is the overall effect of nutrition on length of hospital stay, morbidity, and mortality rates? Why would liver damage occur? Why is it important to have a balance of nutrients? 66

Other Postoperative Concerns
Ensure sufficient fluids to prevent dehydration Provide sufficient nonprotein kilocalories for energy to spare protein for tissue building Ensure adequate vitamins Ensure adequate potassium, phosphorus, iron, zinc Avoid electrolyte imbalances How is dehydration postoperatively assessed? How many daily grams of carbohydrates are needed to spare protein for tissue building? Vitamins required include: Vitamin C to build connective tissue B vitamins to metabolize protein and energy B-complex vitamins to build hemoglobin Vitamin K to promote blood clotting How do minerals affect fluid balance and wound healing? 67

Energy Mifflin–St. Jeor equations:
Male: BMR = 10 × Weight × Height – 5 × Age + 5 Female: BMR = 10 × Weight × Height – 5 × Age – 161 Energy needs for burn patients directly depend on percent of body surface area (BSA) burned and are calculated as follows: Energy needs = 20 kcal/kg + (40  % of BSA burned) 68

Initial Intravenous Fluid and Electrolytes
Oral feeding is encouraged soon after surgery. Routine postoperative intravenous fluids supply hydration and electrolytes, not kilocalories and nutrients. Why is oral feeding the preferred method? When can foods be reintroduced after surgery? 69

Methods of Feeding Enteral: Nourishment through regular gastrointestinal route, either by regular oral feedings or by tube feedings Parenteral: Nourishment through small peripheral veins or large central vein What are examples of enteral and parenteral routes? What complications are associated with either of these methods of feeding? 70

Oral Feeding Allows more needed nutrients to be added
Stimulates normal action of the gastrointestinal tract Can usually resume once regular bowel sounds return Progresses from clear to full liquids, then to a soft or regular diet How do these benefits compare with parenteral routes? How soon should oral feedings begin? What nursing assessments are important regarding oral feeding after surgery? What are aspiration precautions? What does “NPO” mean? Individual tolerance and needs serve as the guide. Frequent small meals may be advised. 71

Enteral Feeding Used when oral feeding cannot be tolerated
Nasogastric tube is most common route Nasoduodenal or nasojejunal tube more appropriate for patients at risk for aspiration, reflux, or continuous vomiting How are nasogastric tubes inserted? Is this a nursing action? How is aspiration minimized? How is proper tube placement confirmed? How can comfort be maximized for the patient? Why is dry mouth a problem? What are nursing interventions? What is a common side effect of nasogastric feedings? 72

Enteral Feeding, cont’d
Figure information: Copyright Rolin Graphics. 73

Alternate Routes for Enteral Tube Feeding
Esophagostomy Percutaneous endoscopic gastrostomy Percutaneous endoscopic jejunostomy Why would these alternate routes be indicated? How are they inserted? What are potential complications? What are nursing care actions and goals? How do nasogastric tubes differ from percutaneous endoscopic gastrostomy or percutaneous endoscopic jejunostomy tubes? 74

Tube-Feeding Formula Generally prescribed by the physician
Important to regulate amount and rate of administration Diarrhea is most common complication Wide variety of commercial formulas available Name examples of products used for tube feedings. Why are amount and rate regulation important? Why should skin care be addressed? Are feeding pumps used? 75

Enteral Nutrition Monitoring
Monitoring the patient receiving enteral nutrition Weight (at least three times per week) Signs and symptoms of edema (daily) Signs and symptoms of dehydration (daily) Fluid intake and output (daily) Adequacy of enteral intake (at least twice per week) 76

Enteral Nutrition Monitoring, cont’d
Abdominal distention and discomfort Gastric residuals (every 4 hours) if appropriate Serum electrolytes, blood urea nitrogen, creatinine (two to three times per week) Serum glucose, calcium, magnesium, phosphorus (weekly or as ordered) Stool output and consistency (daily) 77

Sample Calculation* How much formula (in milliliters) does the following patient need at each feeding? 37-year-old woman, 5 feet, 7 inches tall Under considerable catabolic stress, with an injury factor of 1.8 Formula: 1.5 kcal/ml Schedule: 6 bolus feedings per day IBW: 100 lb + (7 in  5 lb) = 135 lb/2.2 = 61.4 kg RMR: (10  61.4 kg) + (6.25  cm) - (5  37) = 1332 kcal/day 1332 kcal/day  1.8 = 2398 kcal/day Formula: 2398 kcal/day  1.5 kcal/ml = ml/day Feeding schedule: 1599 ml/day  6 feedings/day = ml/feeding *These equations require the weight in kilograms, the height in centimeters, and the age in years. 78

Parenteral Feeding Routes
Peripheral parenteral nutrition uses less-concentrated solutions through small peripheral veins when feeding is necessary for a brief period (10 days) Total parenteral nutrition used when energy and nutrient requirement is large or to supply full nutrition support for long periods through large central vein How do peripheral parenteral nutrition and total parenteral nutrition concentrations differ? What are the psychosocial issues to consider? What conditions might require parenteral feedings? 79

Catheter Placement for Parenteral Nutrition
80

Catheter Placement for Parenteral Nutrition, cont’d
81

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Administration of Parenteral Nutrition
Careful administration of total parenteral nutrition formulas is essential. Specific protocols vary somewhat but usually include the following points: Start slowly Schedule carefully Monitor closely Increase volume gradually Make changes cautiously Maintain a constant rate Discontinue slowly 84

Nutrition after GI Surgery Key Concepts
Nutrition problems related to gastrointestinal surgery require diet modifications because of the surgery’s effect on normal food passage. Gastrointestinal surgery requires special nutrition attention Nutrition therapy varies depending on the surgery site 85

Mouth, Throat, and Neck Surgery
This surgery requires modification in the mode of eating. Patients cannot chew or swallow normally. Oral liquid feedings ensure adequate nutrition. Mechanical soft diet may be optimal. Tube feedings are required for radical neck or facial surgery. Why might depression be a component of the disease process? What nursing interventions can promote adequate nutrition and psychosocial adjustment? What is the role of saliva in digestion? Review side effects and nursing care for tube feedings. 86

Gastric Surgery Because the stomach is the first major food reservoir in the gastrointestinal tract, stomach surgery poses special problems in maintaining adequate nutrition. Problems may develop immediately after surgery or after regular diet resumes. Describe causes for stomach surgery and its incidence. Review the anatomy and physiology of the stomach in relation to the entire gastrointestinal system. Why is gastric surgery challenging from a nutrition perspective? How can nurses use a holistic model of care to support a patient after stomach surgery? What problems would you expect after gastric surgery or during the extended recovery period? 87

Immediate Postoperative Period
Increased gastric fullness and distention may result if gastric resection involved a vagotomy (cutting of the vagus nerve) Weight loss is common Patient may be fed by jejunostomy Frequent small, simple oral feedings are resumed according to patient’s tolerance Possible results of vagotomy: stomach empties poorly, allowing food to ferment; this can lead to gas and diarrhea. What is a function of the vagus nerve? What does the term “atonic” refer to? What does food fermentation lead to? What is a jejunostomy? How is it cared for? Is it temporary? How should feedings progress? 88

Dumping Syndrome Common complication of extensive gastric resection in which readily soluble carbohydrates rapidly “dump” into small intestine Symptoms include: Cramping, full feeling Rapid pulse Wave of weakness, cold sweating, dizziness Nausea, vomiting, diarrhea Occurs 30 to 60 minutes after meal Results in patient eating less food Why are shock symptoms present? Is anxiety a complication of dumping syndrome? How does this syndrome lead to weight loss? Define higher osmolality and describe its implications. How are blood glucose levels affected in dumping syndrome? Once dumping syndrome is stabilized, how is dietary tolerance tested? 89

Diet for Postoperative Gastric Dumping Syndrome
Five or six small meals daily Relatively high fat content, low simple carbohydrate content, low-roughage foods, high protein content No milk, sugar, alcohol, or sweet sodas; no very hot or very cold foods Fluids avoided 1 hour before and after meals; minimal fluids during meals What is the advantage of small, frequent meals? Why is fat an important component? What is high-quality protein? Why should simple carbohydrates be restricted? What are examples of low-roughage foods? What position is recommended after meals to prevent dumping syndrome? 90

Gallbladder Surgery Cholecystectomy is the removal of the gallbladder.
Surgery is minimally invasive. Some moderation in dietary fat is usually indicated after surgery. Depending on individual tolerance and response, a relatively low-fat diet may be needed over a period of time. Where is the gallbladder located? What is its function? Why is a low-fat diet recommended? Describe how surgical advances have changed for cholecystectomy. 91

Gallbladder with Stone
92

Intestinal Surgery Intestinal resections are required in cases involving tumors, lesions, or obstructions. When most of the small intestine is removed, total parenteral nutrition is used with small allowance of oral feeding. Stoma may be created for elimination of fecal waste (ileostomy, colostomy). Why is total parenteral nutrition required if most of the small intestine is removed? In less-severe cases, a low-fiber diet may be used briefly. Provide an example of a low-fiber diet. The goal is to advance to a regular diet. How does a regular diet affect quality of life and psychosocial adjustment? 93

Intestinal Surgery, cont’d
94

Intestinal Surgery, cont’d
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Rectal Surgery Clear fluid or nonresidue diet may be indicated after surgery to reduce painful elimination and allow healing. Return to a regular diet is usually rapid. What is a hemorrhoidectomy? Describe items included in a clear liquid diet. What is a nonresidue diet? What items are contraindicated when on a nonresidue diet? Provide an example of a nonresidue commercial formula. 96

Nutrition Needs for Burn Patients
Tremendous nutritional challenge Plan of care influenced by: Age Health condition Burn severity Plan constantly adjusted Critical attention paid to amino acid needs Why is nutrition support a challenge in caring for the burn patient? Why are amino acid needs so important at each stage? For tissue rebuilding, fluid-electrolyte balance, energy (kilocalorie) support What are special considerations regarding children and older adults with full-thickness burns? Describe the specialized features of a burn center. Who has a burn care facility in their community? 97

Type and Extent of Burns
Figure information: From Lewis SM and others: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St Louis, 2007, Mosby. 98

Stages of Nutrition Care of Burn Patients
Stage 1, part 1: Immediate shock period Immediate loss of water, electrolytes, protein Immediate intravenous fluid therapy with salt solution administered Albumin solutions or plasma used after 12 hours to restore blood volume Little attempt made to meet protein and energy requirements Why does shock occur in response to burn injury? What types of intravenous fluids are indicated and why? How does albumin affect blood volume? How are albumin levels monitored? What are normal values? Why is the focus at this stage not on nutrition and energy needs? 99

Stages of Nutrition Care of Burn Patients, cont’d
Stage 1, part 2: Recovery period Tissue fluids and electrolytes are gradually reabsorbed after 48 to 72 hours. Diuresis indicates successful initial therapy. Constant attention to fluid intake and output remains essential. What is diuresis? How is it assessed? What are signs of dehydration? Overhydration? 100

Stage 2, part 1: Secondary feeding period Adequate bowel function returns after 7days. Life depends on rigorous nutrition therapy. Protein and electrolytes lost through tissue destruction must be replaced. Lean body mass and nitrogen are lost through tissue catabolism. Increased metabolism occurs. Increased energy is needed. When can oral feedings be introduced? What coexisting problems (e.g., depression) present challenges to nutritional status? For what reasons are high-protein, high-energy diets required to treat burn patients? 101

Stage 2, part 2: Nutrition therapy High protein intake High energy intake Caloric needs based on total BSA burned Liberal portion of kilocalories from carbohydrates Avoid overfeeding High vitamin and mineral intake How are protein requirements calculated for burn patients? Why is overfeeding a concern? What is a recommended ratio of nutrients at this stage? Which vitamins and minerals are needed? Vitamins A and C, zinc, thiamin, riboflavin, niacin Pay close attention to electrolytes and calcium/phosphorus ratios. How do vitamins and minerals relate to tissue healing? 102

Stage 2, part 3: Dietary management Enteral feeding Solid foods based on individual preferences Concentrated liquids with added protein or amino acids Calculated tube feedings when required Parenteral feeding When enteral feeding is impossible or inadequate How are intake and output documented? What type of feeding method is preferred? What are the advantages and disadvantages of each method? Are commercial formulas used as supplements during this stage? Provide examples of formula supplements. After a burn injury, when are solid foods usually tolerated? 103

Stage 3: Follow-up reconstruction Continued nutrition support to maintain tissue strength for successful grafting or reconstructive surgery How does stress affect a person’s recovery and response to follow-up surgery? How can a team approach improve a patient’s outcome with reconstructive surgery? Relate how general nutrition concepts apply to reconstructive therapy. 104

Summary The nutritional demands of surgery begin before a patient reaches the operating table. Before surgery, the task is to correct any existing deficiencies and build nutritional reserves to meet surgical demands. After surgery, the task is to replace losses and support recovery. 105

Summary, cont’d Postsurgical feedings are given in a variety of ways.
The oral route is always preferred. However, inability to eat or damage to the intestinal tract may require feeding through a tube or into veins. Special formulas are used for such alternate means of nourishment and are designed to meet specific individual needs. 106

Summary, cont’d For patients undergoing surgery on the gastrointestinal tract, special diets are modified according to the surgical procedure performed. For patients with massive burns, increased nutrition support is necessary in successive stages in response to the burn injury and to the continuing tissue rebuilding requirements. 107

Nutrition Support in Cancer and AIDS
Chapter 23 Nutrition Support in Cancer and AIDS 108

Key Concepts Environmental agents, genetic factors, and weaknesses in the body’s immune system can contribute to the development of cancer. The strength of the body’s immune system relates to its overall nutritional status. 109

Cancer Malignant tumor (neoplasm) can express itself in multiple forms
Tumors identified by primary site of origin and state of growth Stages of tumor development depend on growth rate, degree of functional self-control, and amount of spread No single treatment or special diet exists to arrest cancer. Relation between cancer care and nutrition centers on prevention and therapy. 110

Causes of Cancer Cell Development
Underlying cause is the functional loss of cell control over normal cell reproduction from: Mutations Chemical carcinogens Radiation damage Viruses Epidemiologic factors Stress and dietary factors A mutant gene may be inherited or arise from environmental stimulus. Several chemical substances can interfere with structure or function of regulatory genes. Radiation damage may come from radiographs or sunlight. Viruses take over the cell machinery to reproduce themselves. 111

Epidemiology Figure information: Incidence rates for United States.
From National Cancer Institute: Cancer state profile, gov/map/map.withimage.php?00&001&053&00&0&1&0&1&6&0#map, accessed October 2007.) 112

The Body’s Defense System
Two populations of lymphocytes in immune system T cells Derived from thymus cells Activate phagocytes that attack antigens B cells Derived from bursal intestinal cells Produce antibodies that attack antigens Lymphocytes develop early in life from a common stem cell in the bone marrow. 113

T- and B-Cell Development
Figure information: Courtesy Eileen Draper. 114

Nutrition and Immunity
Inadequate nutrition weakens the immune system and causes atrophy of tissues in gastrointestinal structures Antibodies are proteins Nutrition support is needed to maintain the integrity of the immune system. Severely malnourished people show changes in the structure and function of their immune systems. 115

Nutrition and Healing Body tissue strength depends on ability to build and rebuild, which requires optimal nutrition intake Protein and key vitamins and minerals, as well as nonprotein energy sources, must be constantly supplied by the diet Careful, early use of vigorous nutrition support provides recovery of normal nutritional status and immunocompetence of cancer patients. 116

Key Concepts Nutrition problems affect the nature of the disease process and the medical treatment methods in patients with cancer or AIDS. 117

Surgery All surgery requires nutrition support for the healing process. General condition of cancer patients often is weakened by the disease process. Nutrition support is required before and after surgery. Changes in food texture or nutrient content may be required depending on surgical site or function of the organ involved. 118

Radiation Therapy Involves high-energy radiographs targeted on the cancer site Often kills surrounding healthy cells as well as cancerous cells Nutrition problems driven by site and intensity of radiation treatment For example, radiation to the abdominal area affects intestinal mucosa, causing loss of villi and, subsequently, absorption. Malabsorption problems follow. 119

Chemotherapy Highly toxic drugs administered by the bloodstream to kill cancer cells Use of monoamine oxidase inhibitors (pretreatment antidepressant drugs) requires tyramine-restricted diet Side effects include: Food intolerance: nausea and vomiting, loss of normal taste sensations, lack of appetite, diarrhea, ulcers, malabsorption, stomatitis Reduction in red and white blood cells and blood platelets Interference with normal hair growth 120

Systemic Effects of Cancer
Several systemic effects cause continuing weight loss Anorexia, loss of appetite Increased metabolism Negative nitrogen balance Anorexia results in poor food intake. Increased metabolism results in increased nutrient and energy needs. Negative nitrogen balance results in more catabolism (breaking down of body tissues). 121

Cachexia Extreme weight loss and weakness caused by inability to ingest or use nutrients Body feeds off its own tissue protein Experienced by half of all cancer patients Aggressive nutrition therapy is necessary Drugs are used to increase appetite, decrease nausea, spare protein degradation, and improve caloric intake. 122

Objectives of Nutrition Therapy
Prevention of catabolism Meet increased metabolic demands Relief of symptoms Individualized strategies are developed to meet the patient’s nutrition needs and help the patient to eat. Requires multidisciplinary support from member of the health care team. 123

Principles of Nutrition Care
Nutrition assessment Determine and monitor nutritional status Body measurements, calculations of body composition, laboratory tests, physical examination, clinical observation, dietary analysis Personal care plan Daily plan for nutrition therapy incorporated into nursing care plan Personal care plan is revised as required. 124

Nutrition Needs Energy Protein Vitamins and minerals
Adequate fluid intake Energy: Carbohydrate and fat intake frees up protein (essential amino acids and nitrogen) so that it can be used for tissue building. Vitamins and minerals: Control protein and energy metabolism through their coenzyme roles. Adequate fluid intake: Replace losses, help kidneys dispose of metabolic waste from destroyed cancer cells and toxic drugs. 125

Enteral: Oral Diet Oral diet with supplementation is optimal when tolerated Food plan must include adjustments in food texture and temperature, food choices, and tolerances A well-planned diet provides energy and nutrient density in small quantities of food. Nurses must assist in addressing loss of appetite, mouth problems, gastrointestinal problems, and pain/discomfort. 126

Tips for Controlling Nausea and Vomiting
Try smaller, more frequent meals. Eat more when feeling better. Eat drier foods with fluids in between. Try cold foods, saltier foods. Avoid fatty or overly sweet foods. Do not recline immediately after eating. Replace fluids and electrolytes. Use foods with pleasant aromas. Avoid strong odors. Create a pleasant, relaxed environment. Take breaks in between bites; eat slowly. 127

Tips for Increasing Energy and Protein Intake
Add high-calorie condiments, sauces, dressings Add extra ingredients during food preparation Drink commercial food supplements Avoid low-calorie foods and beverages Have a meal or snack every 1 to 2 hours Patient teaching: Eat more when appetite is good. Prepare foods in small serving sizes for snacks. 128

Enteral: Tube Feeding When gastrointestinal tract can be used but patient is unable to eat 129

Parenteral Feeding When gastrointestinal tract cannot be used
Peripheral vein feeding (for brief period) Central vein feeding (for extended period) 130

Prevention American Cancer Society U.S. Food and Drug Administration
Eat a variety of healthful foods Adopt a physically active lifestyle Maintain a healthful weight Limit alcohol consumption U.S. Food and Drug Administration Low-fat diets rich in grain products, fruits, and vegetables may reduce the risk of some cancers National Cancer Institute is the federal research body funded by the Department of Health and Human Services. Describe their 5-a-Day for Better Health program. 131

Key Concepts Nutrition problems affect the nature of the disease process and the medical treatment methods in patients with cancer or AIDS. The progressive effects of HIV, through its three stages of white T-cell destruction, have many nutrition implications and often require aggressive medical nutrition therapy. 132

Human Immunodeficiency Virus
Virus causes immune system suppression Created a widespread epidemic Like all viruses, HIV is a parasite that uses its host to replicate itself. 133

Stages of Disease Progression
Stage 1: Clinical category A Flulike symptoms 4 to 8 weeks after initial exposure Stage 2: Clinical category B Infectious illnesses invade the body Stage 3: Clinical category C Rapidly declining T-helper lymphocyte counts Stage 1: 8 to 10 years of “wellness” as virus incubates Stage 2: Persistent fatigue, mouth sores, night sweats, diarrhea, fever, weight loss, headache, skin rash Stage 3: Tuberculosis, Kaposi’s sarcoma, cytomegalovirus, lymphoma 134

Goals of Medical Management
Delay progression of the infection and improve the immune system Prevent opportunistic illnesses Recognize the infection early Recognize the infection early and provide rapid treatment for complications, including infections and cancers. 135

Severe Malnutrition, Weight Loss
Decreased appetite, insufficient energy intake in addition to elevated resting energy expenditure Major weight loss, eventual cachexia Malnutrition suppresses cellular immune function, perpetuating the onset of opportunistic infections Megestrol: Used to treat cachexia Majority of weight gained is fat mass (lipodystrophy) with continued wasting of lean tissue 136

Causes of Body Wasting Inadequate food intake
Malabsorption of nutrients Disordered metabolism 137

Nutrition Assessment Anthropometry Biochemical tests
Clinical observations Diet observations Environmental, behavioral, and psychological assessment Financial assessment The clinical dietician on the AIDS team conducts this assessment and calculates daily nutrition needs. 138

Principles of Nutrition Counseling
Motivation for dietary changes Rationale for nutrition support Provider-patient agreement on plan Development of manageable steps for change Development of personal food management skills Identification of community programs Provision of psychosocial support 139

Summary The general term cancer is given to various abnormal, malignant tumors in different tissue sites. The cancer cell is derived from a normal cell that loses control over its growth and reproduction. Cancer cell development occurs from mutation of regulatory genes and is influenced by environmental chemical carcinogens, radiation, and viruses. 140

Summary, cont’d Cell integrity is mediated by the body’s immune system, primarily through its two types of white blood cells: T cells that kill invading agents that cause disease and B cells that make specific antibodies to attack these agents. Cancer therapy primarily consists of surgery, radiation, and chemotherapy. 141

Summary, cont’d Likewise, nutrition care of patients with AIDS must be built on knowledge and compassion, with a sensitivity and concern for individual patient needs. The current worldwide spread of HIV and its fatal consequences have reached epidemic proportions and are still growing. 142

Summary, cont’d Nutrition management centers on providing individual nutrition support to counteract the severe body wasting and malnutrition characteristic of the disease. The process of nutrition care involves comprehensive nutrition assessment and evaluation of personal needs, planning care with patient and caregivers, and meeting practical food needs. 143

Chapter 21 Kidney Disease 1.

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