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NUTRITION
Pamela Llana, MSN, RN
Essential Nutrients
 Carbohydrates
 Proteins
 Lipids
(Fats)
 Vitamins
 Minerals
 Water
Energy from food – measured in
calories
BMR-basal metabolic rate
Nutrient Groups

Macronutrients
Carbohydrates
 Proteins
 Lipids (Fats)



Micronutrients
Vitamins
 Minerals

 Trace
elements
Water - essential to maintain normal fluid
balance and body function
Carbohydrates

Simple





Glucose – corn sugar
Fructose – fruit
Sucrose – table sugar
Lactose – milk sugar
Complex


Starch – grains,
legumes, root
vegetables
Fiber


does not yield
energy
indigestible plant
parts
Proteins

Function: growth, development, normal
function of body systems
 Complete
– contain all 9 essential amino acids
 Partially complete
 Incomplete

Sources: meat, beans, peanut butter

Nitrogen balance: should be equal;
may be positive or negative
Lipids (Fats)

Classified: saturated fats (beef, lamb)
unsaturated fats (chicken, fish)
trans fats (fried & baked goods)

No more than 30% of total calories from
fats

Less than 10% from saturated fats
Vitamins/Minerals

Water soluble:



Fat soluble:


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B complex and C
Excrete what is not needed
K, A, D, E
Excess can occur
Minerals:

calcium, iron, iodine,
fluoride, sodium, potassium
Water





Thirst - signals need for
water; diminished in
elderly; 1st sign of
dehydration
Avoid caffeinated drinks
Encourage fruit juices,
soups, flavored water
Minimum for healthy
adult = 1500 mL/day
More for athletes, fever,
vomiting/diarrhea, heat
Healthy Eating


 Cancer prevention
Healthy Bones
 Fluid intake
 Weight-bearing
exercises
 High fiber
 Calcium, magnesium,
 Limit sodium
phosphorus, vitamin D
 Limit alcohol
 Dairy group
 Exercise regularly
Healthy Nervous
 Limit fat – especially
System
saturated fat
 B-complex vitamins
 Calcium and sodium
 Grains and dairy foods
USDA’s ChooseMyPlate.gov
The Digestive SystemStructure & Function

Conversion of food
 Digestion
 Mechanical
 Chemical
 Absorption
 Metabolism
 Excretion

Immunologic function
 Gastrointestinal (GI) tract: Major immunologic organ
 GI tract contains 70% to 80% of all immune-secreting cells
 25% of the GI tract is lymphoid tissue
Characteristics of Normal Nutrition
• USDA dietary guidelines for Americans
(Craven, p. 890)
• Ideal Body Weight-IBW
• General guide: F 5 ft = 100 lbs + 5 lbs/inch
M 5 ft = 105 lbs + 6 lbs/inch
• Body Mass Index-BMI
• underweight, normal weight, overweight, obese
• Wt in kg divided by ht in meters squared; OR
• Wt in lbs divided by ht in inches squared, then
multiply by 703
• CDC guidelines correlate BMI w/ total body fat
Lifespan Considerations

Pregnancy and lactation


Newborn and infant


most common deficiency is iron
Child and adolescent


grow more rapidly than any other time
Toddler and preschooler


folic acid to prevent neural tube defects
Most common deficiencies are iron, calcium, vitamin A
Adult and older adult

Most common deficiency is calcium; need for iron reduced
in post-menopausal women; elderly deficient in fiber
Factors Affecting Nutrition:
Intake of Nutrients

Ability to acquire and prepare food


Swallowing impairment


infection, gall bladder disease, general anesthesia
Knowledge


sore throat, mouth sores, ill-fitting dentures
Anorexia; nausea and vomiting


congenital, stroke, or head injury
Discomfort during or after eating


financial and/or transportation issues
Lack of knowledge about proper nutrition for heath
status or age group
Excessive intake of calories and fat leads
to obesity (66% of Americans are obese)
Factors Affecting Nutrition:
Ability to Use Nutrients

Inability to use ingested nutrients due to:

Inflammation of the gastrointestinal tract
 IBS

Obstruction of the gastrointestinal tract
 Hiatal

hernia
Malabsorption of nutrients
 Lactose

intolerance
Diabetes mellitus
 Type
I and Type II
Other Factors Affecting Nutrition
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Lifestyle and habits (overeating, sedentary lifestyle,
food fads, vegetarians)
Culture and religious beliefs (special diets)
Economic resources (transportation, availability,
price of food)
Gender
Surgery or Cancer, and cancer treatment
Alcohol and drug abuse
Psychological state


Anorexia Nervosa/Bulimia
Binge Eating Disorder/Compulsive Overeating
ASSESSMENT



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

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Anthropometry-System of
measuring the size and
makeup of the body
BMI/IBW/body fat
Ht/Wt - same time on same
scales with same clothes;
Always do on admission!
Recent weight loss or gain
Decreased energy
Altered bowel patterns
Other signs - Table 28-2 on
pg. 897
Diet History

Normal pattern
identification

24-hour recall:
type, amt, prep
of all food eaten
 Food
diary:
keep same log
for 3 days-1 wk
 Calorie
counts
Assessment:
Risk Identification

Identify health problems

Document: Chronic health conditions;
treatments; intake of drugs, alcohol

Assess socioeconomic factors

Note tests and procedures; NPO status

When ability to swallow is questionable,
NEVER give oral food or fluid until a
complete evaluation is done.
Laboratory Values






CBC (complete blood count-look at
hemoglobin for anemia),
Albumin & Prealbumin(protein markers)
Creatinine excretion
Transferrin
Immunity Testing
Electrolytes, glucose,
cholesterol, and
triglycerides
Acute Care:
Disruptive Influences

Poor appetite

Diagnostic testing

NPO – nothing by
mouth

Stress

Medications –
taste/smell/nausea &
vomiting
Nursing Interventions to
Promote Nutrition

Patient Teaching

Provide a comfortable environment
free of treatment reminders/ odors

Give good mouth care

Place in comfortable position

Replace foods with suitable
alternative if foods refused

Diet can be decreased but
not advanced without order
***NPO > 7 days, pt needs TPN
(total parenteral nutrition)
Hospital Therapeutic
Diets
Therapeutic Diets


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Clear liquid
Full liquid
Soft and Mechanical soft
Regular
DAT - diet as tolerated or advance as tolerated;
nurse’s judgment after assessment
Restrictive (Table 28-4, p. 904)

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AHA-cardiac diet
ADA-diabetic diet
Renal diet
Weight loss diet – 1500 Calories
May need supplements - increased calorie/protein
“shakes” such as Ensure, etc.
Medical Conditions that
Require Special Diets

High-Fiber
 (> 5 g/day)
 Constipation,
prevent colon
cancer

Low-Fiber
 Diarrhea,
diverticulitis,
malabsorption, prep
for bowel surgery


Nausea/vomiting
 Various causes
 Clear liq full liq
advance as
tolerated
 Avoid greasy foods
 Avoid hot and spicy
foods
Anorexia
 Small frequent
meals
 Avoid high-fat foods
Medical Conditions that
Require Special Diets (cont.)

Hypertension/
Congestive Heart Failure



Renal Disease

Low sodium
CHF-may need fluid
restriction

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Avoid potassium-rich foods
Limit phosphorus intake
Low protein
Heart Disease



Low-fat, low-cholesterol
GERD (reflux)


Avoid large meals and
bedtime snacks
Avoid trigger foods

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Citrus/Spicy
Carbonated/Alcohol
Caffeine/Chocolate
Peppermint

Diabetes Mellitus



Complex carbohydrates
Low fat
Limit alcohol/Encourage
weight loss and exercise
Potassium Rich Foods


Avoid in renal
disease (or other
condition with high
potassium levels)
Encourage if low
potassium


Taking diuretics
Excessive excretion

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
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Sweet and white
potatoes
White and lima beans
Tomatoes
Yogurt
Carrots
Molasses
Tuna, halibut, cod
Bananas, peaches,
prunes
http://www.health.gov/dietaryguidelines/dga2005/docume
nt/html/appendixB.htm
Food-Drug Interactions

Coumadin
(warfarin)




Blood-thinner (anticoagulant
Avoid Vit K rich
foods (antidote)



Liver
Eggs
Green leafy vegsspinach, broccoli,
cabbage
Grapefruit juice


Interferes with
metabolism of many
meds
Increases serum
level of some
medications
Antacid

Can interfere with
absorption & action
of medications
Assisting Clients With
Feeding

Promote independence

Allow them to be involved
by directing the order of
food and the rate of
feeding

NEVER feed a patient that
can not swallow or lacks a
gag reflex (after surgery)
they could aspirate-food or
fluid go into lung
Aspiration

Dysphagia-swallowing dysfunction

Can be silent – doesn’t or can’t cough

Red flags-coughing or clearing throat, spitting, wet
vocal quality, delayed swallowing reflex

Watch pts: intubated, weak, CVA, trach, surgery,
sedated

We swallow 2000 times/day – only takes 72 hours
for muscles to atrophy

Precautions procedure
Safety Tips to Prevent
Aspiration

HOB up – chair is best

No straws

Use thickened liquids

100 % Supervision and
Compliance

Chin tuck/double swallow

Speech therapist for
screening/assess/eval.

Modified barium swallow
Enteral Feeding

Feeding tube into
esophagus to
stomach (NG-nose;
OG-mouth)

Used if patients can
not ingest, chew or
swallow

Pt must at least
partially digest and
absorb nutrients
PEG tube & J-tube

Percutaneous
Endoscopic
Gastrostomy


Technique for
positioning a feeding
tube in the stomach
(PEG tube)
PEJ tube

Same, except in
jejunum (J-tube)
Enteral Feeding: Precautions

Aspirate stomach
contents (fairly
reliable)

Measure pH (less
reliable)

Verify by x-ray;
most reliable method
for small-bore tube

Assess for abdominal
distention, N&V

Keep HOB at least 30
degrees especially during
feedings, for insertion and
removal

Total feeding and irrigant
should not exceed 450
mL
Enteral Feeding: Formula

Commercial products
preferred

Administer at room
temp

Packaged in cans or
pre-filled bags

Monitor for
complications

Hanging bags
discarded every 24
hours (bacterial
contamination)

Begin with small
amounts-half strengthincrease steadily

Refrigerate bags
Enteral Feeding: Dosing

Bolus



Given every 4-6 hrs
250-400ml over 15 mins
Directly into stomach

Continuous



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Intermittent



Given every 4-6 hrs
200-300ml over 30-60
mins
Used for non-critical,
home-tube feedings,
rehab patients

Best for critically ill
Better residuals
Less aspiration
Flush Q 4 hours
Consistent flow rates
Enteral Feeding:
Complications

GI







Constipation
Diarrhea
Cramping
Pain
Abdominal
distention
Dumping syndrome


Usually avoided with
PEG tubes
Nausea/vomiting
Mechanical

Irritation




Nose, esophagus and
mucosa
Tube dislodgement
Aspiration
Tube obstruction or
rupture


Flush q4 hr (20-60ml
warm water)
Dilute meds well
Gastric Residual Volume



Contents found in the stomach since last
meal
Check every 4-6 hrs
Return to stomach


Electrolytes, nutrients,
& digestive enzymes
Hold feeding if
exceeds amount
given in past 2 hrs
Parenteral Feeding

IV therapy thru peripheral or central vein

Supplies water, glucose and electrolytes (peripheral
vein)

TPN includes protein & lipids
(central vein – subclav or jugular, PICC)

Temporary maintenance solution:
peripheral – less than 10 days
subclavian or jugular – less than 4 wks
PICC line – greater than 4 wks
PICC = peripherally inserted central catheter