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GASTROINTESTINAL SYSTEM -BASIC CONCEPTS OF NUTRITION -NUTRITIONAL NEEDS -INTESTINAL ELIMINATION OBJECTIVES Syllabus page 39-41 PRETEST 1. Name 1 fat-soluble vitamin 2. Name 1 water-soluble vitamin 3. How often should a nasogastric tube be changed on a client? 4. Identify 1 type of enema 5. Define effluence ANSWERS 1. K, A, D, E 2. C, vitamin B-complex: folic acid, niacin, thiamine, riboflavin, pyridoxine, cobalamin 3. PRN and per agency policy 4. Hypertonic, hypotonic, isotonic, soap, oil 5. Product or drainage from an ostomy WHAT IS NUTRITION? Nutrition is the sum of all the interactions between an organism and the food it consumes It is what a person eats & how the body uses it WHAT ARE NUTRIENTS? Nutrients are the organic & inorganic substances found in foods & required for body functioning Essential nutrients in food are needed for growth & maintenance of all body tissues & the normal functioning of all body processes WHAT ARE THE ESSENTIAL NUTRIENTS? (6) 1. 2. 3. 4. 5. 6. Water Carbohydrates (CHO) Proteins Fats Vitamins Minerals WHAT ARE THE FUNCTIONS OF NUTRIENTS? (3) 1. Providing energy for body process & movement 2. Providing structural material for body tissues 3. Regulating body processes WHAT DOES NUTRITIVE VALUE MEAN? It is the nutrient content of a specified amount of food No one food provides all essential nutrients WHAT DOES CALORIC VALUE MEAN? It is the amount of energy that nutrients or foods supply to the body WHAT IS A CALORIE? A calorie is the amount of heat required to raise the temperature of 1 gram of water 1 degree C 1 gm of CHO =4 kcal (after metabolization) 1 gm of protein = 4 kcal (after metabolization) 1 gm of fat= 9 kcal after (metabolization) WHAT DOES NUTRIENT DENSITY MEAN? It refers to foods that deliver the most nutrient for the lowest kilocalorie Nutrient-dense food provides a high quantity of 1 or more essential nutrients with a small quantity of kilocalories eg: 1 baked potato + butter= 260 KCAL 3oz sirloin = 240 KCAL WHAT IS METABOLISM? Metabolism refers to all biochemical & physiologic processes by which the body grows and maintains itself It is normally expressed in terms of the rate of heat liberated during these chemical reactions WHAT IS BASAL METABOLIC RATE? (BMR) It is the rate at which the body metabolizes food to maintain the energy requirements of a person who is awake and at rest the energy in food maintains the basal metabolic rate of the body & provides energy for activities WHAT FACTORS AFFECT CALORIC NEEDS? (8) 1. 2. 3. 4. 5. 6. 7. 8. Age Growth Gender Climate Sleep Activity Fever Illness WHAT IS THE BODY’S MOST BASIC NUTRIENT? WATER WHAT ARE MACRONUTRIENTS? These are energy-providing nutrients (3)= carbohydrates (CHO), fats, and proteins Hunger impels people to eat enough of these to meet their energy needs WHAT ARE MICRONUTRIENTS? These are vitamins and minerals which are needed by the body WHAT ARE CARBOHYDRATES COMPOSED OF? 3 elements: Carbon (C), hydrogen (H), and oxygen (O); abbreviated CHO There are 2 basic kinds: Simple CHO (sugars) and complex CHO (starches and fiber) WHAT IS A SUGAR? A sugar is the simplest of all CHO It is water soluble it is produced naturally by both plants & animals There are monosaccharides (single molecules) and Disaccharides ( double molecules) WHAT ARE THE 3 MONOSACCHARIDES? 1. Glucose; this one is the most abundant 2. Fructose 3. Galactose Examples of foods containing sugars are sugar cane, fruits, lactose and processed sugars such as cookies, candy, ice cream WHAT IS A STARCH? A starch is an insoluble, nonsweet form of CHO They are polysaccharides = composed of branched chains of dozens or hundreds of glucose molecules Nearly all starches exist naturally in plants, such as grains, legumes & potatoes They are processed as cereals, etc. WHAT IS FIBER? It is a complex CHO derived from plants Cannot be digested by humans; supplies roughage Bulk satisfies appetite & helps the digestive tract to function effectively to eliminate wastes WHAT ARE OTHER FUNCTIONS OF CHO? 1. Supply vital nutrients: protein, vitamins, minerals, & dietary fiber that are not found in processed foods 2. Refined CHO foods are relatively low in nutrients in relation to the large number of calories they contain= “empty calories” WHAT IS A PROTEIN? It is an organic substance composed of amino acids Contain carbon, hydrogen , oxygen & nitrogen Every cell in the body contains some protein 3/4 of body solids are proteins WHAT ARE THE TYPES OF AMINO ACIDS? 1. Essential amino acids- cannot be manufactured by body & must be supplied through protein ingested in diet; 9 essential amino acids necessary for tissue growth & maintenance 2. Nonessential amino acids= body can manufacture by taking apart amino acids derived from diet & reconstructing new ones WHAT ARE THE TYPES OF PROTEIN? (4) 1. Complete proteins= contain all essential amino acids + many nonessential ones; eg.: most animal proteins like meats, poultry, fish, dairy products & eggs 2. Partially complete proteins=contain less than the required amt. of 1 or more essential amino acids; cannot alone support growth e.g. milk protein casein (CON’t) 3. Incomplete proteins= lack 1 or more essential amino acids; are usually derived from vegetables; if an appropriate mixture of plant proteins is provided in diet, a balanced ration of essential amino acids can be achieved 4. Complementary proteins= combinations of 2 or more vegetables WHAT IS THE FUNCTION OF PROTEIN? Protein is essential in building, maintaining & repairing body tissue WHAT DOES PROTEIN METABOLISM CONSIST OF? 1. Anabolism= building tissue 2. Catabolism= breaking down tissue 3. Balance WHAT IS NITROGEN BALANCE? Measure of the degree of protein anabolism & catabolism it is the net result of intake and loss of nitrogen Nitrogen intake should equal nitrogen output= Nitrogen balance; this is the normal state of healthy people WHEN DOES POSITIVE NITROGEN EXIST? 1. During periods of growth= childhood & adolescence, pregnancy, phases of physical exercise 2. During periods of tissue replacement= convalescence from protein-depleting illness and after fasting or inadequate intake of protein & calories when body tissues are regenerated WHEN DOES -NITROGEN BALANCE EXIST? 1. Pt. does not consume adequate essential amino acids &/or calories 2. Pt. is inmobilized 3. Pt. is exposed to unusual stress as a result of trauma WHAT IS A LIPID? Lipids are organic substances that are greasy and insoluble in H2O but soluble in ETOH or ether Fats are lipids that are solid at room temp. Oils are lipids that are liquid at room temp WHAT IS AN UNSATURATED FATTY ACID? It is a fatty acid that could accommodate more H atoms than it currently does; e.g.: vegetable oil These products are usually liquid at room temp. WHAT ARE FUNCTIONS OF FATS? 1. Energy metabolism 2. Skin/hair (shine);provides structure 3. Provides insulation ( insulates body from extreme temp) 4. Provides protection of vital organs 5. Transportation of fat soluble vitamins (KADE) 6. Adds flavor to food WHAT IS CHOLESTEROL? It is a lipid that is both produced by the body and found in foods of animal origin Most of the body’s cholesterol is synthesized in the liver Some is absorbed from the diet eg: milk, egg yolk, & organ meats WHAT ARE FUNCTIONS OF CHOLESTEROL? Important component of cell membrane Abundant in brain & nerve cells Used to synthesize bile acids Is a precursor of steroid hormones & vitamin D High levels = ^ risk of ASHD; < by eating less total fat (saturated fat ) & ^ fiber intake to increase fecal excretion of cholesterol WHAT ARE FOOD SOURCES OF CHOLESTEROL? Egg Yolks Shell fish organ meats Dairy fats WHAT ARE THE MICRONUTRIENTS? 1. Vitamins 2. Minerals WHAT IS A VITAMIN? It is an organic compound that cannot b manufactured by the body & is need in small quantities to catalyze metabolic processes When vitamins are lacking in the diet, metabolic deficits result WHAT ARE THE TYPES OF VITAMINS? 1. Water soluble= C and B-complex (B1, B2, B3, B6, B9, B 12 Pantothenic acid & biotin) 2. Fat soluble vitamins= K, A, D, & E FAT SOLUBLE VITAMINS Dissolve in fatty tissue Not destroyed by ordinary cooking methods Absorbed with fats from intestines Soluble in fat WATER SOLUBLE VITAMINS Dissolve in H2O Easily absorbed in small intestine then passed into blood stream Not stored in body Must be taken daily WHAT IS A SATURATED FATTY ACID? It is a fatty acid in which all C atoms are filled to capacity with H; e.g.: butter These products are usually solid at room temp. WHAT IS A MINERAL? It is found in organic compounds as free ions there are 2 categories of minerals= macrominerals = those required daily in amts. over 100mg microminerals = those required daily in amounts less than 100 mg WHAT ARE THE MINERALS? Macro minerals: Calcium, Potassium, Chloride, Phosphorus Micro minerals; Iron, and Zinc WHAT ARE RECOMMENDED DIETARY ALLOWANCES? RDA = standards list published by Committee on Dietary Allowances of the Food and Nutrition Board of the National Academy of Sciences RDAs= levels of intake in gms and mgs of essential nutrients that adequately meet the known nutritional needs of most healthy people; most appropriate for pros. (con’t) RDAs nutrient levels are high enough to meet the needs of 97.5% of people in the group & to allow some loss of nutrient as it makes its way through the body the effect of illness or injury & the variability among individuals within any given subgroup are not taken into account in the RDAs WHAT ARE DIETARY GUIDELINES? These guides were developed to help healthy people meet the daily requirements of essential nutrients & to facilitate meal planning e.g.: The Food Guide Pyramid Dietary Guidelines for Americans BASIC FOUR FOOD GUIDE Based on 4 basic food groups: 1. Milk & milk products 2. Meats & alternatives 3. Breads & cereals 4. Fruits & vegetables Introduced by USDA in 1956 WHAT DOES THE FOOD PYRAMID CONSIST OF? Combines Dietary Guidelines + old Basic Four Food Guide Divides food into 6 groups Designed to help reduce intake of fat & concentrated sugars Doesn’t address fluid intake or combo foods Doesn’t guarantee consumption of necessary levels of all essential nutrients WHAT FACTORS AFFECT CHOICE OF FOOD? 1. 2. 3. 4. 5. 6. 7. Ethnicity & culture Age Religion Economic status Peer Groups Personal Preference & uniqueness Life-Style (Con’t) 8. Beliefs About Health 9. ETOH Abuse 10. Advertising 11. Psychologic Factors 12. Health Status 13. Therapy 14. Medications MEETING NUTRITIONAL NEEDS HOW IS A NUTRITIONAL ASSESS. DONE? A. Anthropometric measurements B. Biochemical data C. Examine Pt. for clinical signs of nutritional status D. Obtain Diet History WHAT ARE ANTHROPOMETRIC MEASUREMENTS? 1. Direct Measurements=Height, Weight, Skin fold measurements, Midupper arm circumference 2. Calculated measures= mid-upper arm muscle circumference, body mass index WHAT BIOCHEMICAL DATA (6) CAN BE USED? 1. 2. 3. 4. 5. 6. H&H Serum Albumin Transferrin Total Lymphocyte count Nitrogen Balance Creatinine Excretion WHAT ARE CLINICAL S/S OF NUTRITIONAL STATUS? 1. 2. 3. 4. 5. 6. 7. Hair Skin Eyes Tongue Mucous membranes CV GI 8. Nervous 9. Vitality 10. Weight HOW IS A DIET HX DONE? 1. Includes Hx. About Pt.s usual eating patterns & habits, food preferences & restrictions, daily fluid intake, use of vitamin or mineral supplements, dietary problems, physical activity, Health Hx., concerns re. buying & preparing food 2. Do a 24-hr diet Hx 3. Ask re. Pt.s meds (especially pc or ac) WHAT ARE SPECIAL OR THERAPEUTIC DIETS? A diet in which the amount of food or the frequency of eating is prescribed Can be used to Tx. a disease process or to prepare for special exam or surgery Can be used to promote health Can be temporary or lifetime WHAT ARE THE TYPES OF SPECIAL HOSPITAL DIETS? 1. Regular diet= no special needs 2. Light diet= postop Pt.; foods plainly cooked; lge amts of bran & fat omitted 3. Soft diet= easily chewed & digested; low-residue 4. Pureed diet= liquid is added to food for semi solid consistency (Con’t) 5. Full liquid diet= foods + liquids that turn to liquid at body temp.; is only short term; it is for Pt.s with GI disturbances; is monotonous 6. Clear Liquid = H2O = tea, coffee, clear broths, ginger ale or carbonated beverages, strained & clear fruit juices, plain jello, sugar & hard candy; relieves thirst (Con’t) 7. Restricted Diets in Calories or Minerals e.g. = a. 1800 Calorie ADA diet b. 2000 mg Na Diet WHAT FACTORS DEPRESS APPETITE OF HOSPITALIZED PATIENTS? 1. Physical illness 2. Unfamiliar or unpalatable food 3. Environmental factors 4. Psychologic factors 5. Physical discomfort or pain What principles Improve the appetite? 1. Relieve illness s/s= < pain,fever 2. Provide familiar food Pt. likes 3. Select small portions 4. Avoid unpleasant or uncomfortable Tx around meal time 5. Provide tidy, clean environment 6. Encourage oral hygiene 7. Reduce psychological stress WHAT ARE NSG. RESPONSIBILITIES WHEN PROVIDING MEALS? 1. Check Pt.s kardex or chart for appropriate diet 2. Notify dietary staff of chgs in diet 3. Offer Pt. bathroom facility & hygiene 4. Assist with sitting if permitted 5. Clear overbed table or arrange table close to bedside (CON’t) 6. Assist Pt. prn with food preparation 7. For blind Pt. Identify placement of food using clock image 8. Replace food covers & do I & O & record % food taken after meal 9. If Pt. not eating notify nurse in charge or dietician WHAT ARE 2 GROUPS OF PTS. WITH SPECIAL NEEDS? 1. Elderly= weakened and quickly fatigued when ill 2. Handicapped= blind Pts and those who cannot use their hands or those who must remain in a back lying position WHAT CAN BE DONE FOR THESE SPECIAL POPULATIONS? 1. Be sensitive to Pt.’s feelings of embarrassment, resentment & loss of autonomy= Help Pt. feed himself; Try to appear unhurried ; Ask what order Pt. would like to eat food; use adaptive devices, allow ample time for chewing & swallowing; offer fluids, make pleasant conversation WHAT PTS. ARE AT RISK FOR NUTRITIONAL PROBLEMS? 1. Any Pt. with a condition that interferes with the ability to ingest, digest, absorb & metabolize nutrients 2. Pt.s with ^ demand for nutrients= pregnant women, hyperthyroidism, cancer WHAT NSG. MEASURES ARE USED FOR FEEDING INFANTS? 1. Do not prop the bottle of formula 2. Start feeding solids at 6 months or as per Pediatricians orders 3. Encourage breast feeding when possible 4. Be cognizant of lactose insensitivity 5. Fluid needs of infants are proportionately greater than adults WHAT ARE INFANT VARIATIONS IN NUTRITION? Demand feeding Regurgitation Iron Deficiency anemia Bottle mouth Syndrome WHAT NSG. MEASURES APPLY TO FEEDING TODDLERS? 1. Use finger foods 2. Be aware of food “Jags” 3. Offer fluids often 4. Allow parents to bring in food from home when possible WHAT ARE SPECIAL COMMUNITY NUTRITIONAL SVS? 1. Commodity Supplemental Food Program 2. Emergency Food Assistance program 3. Food Stamp Program 4. Supplemental Food Program for Women, Infants & Children (WIC)= provides food stamps & vouchers for pregnant &lactating women & children WHAT ARE ALTERNATIVE FEEDING METHODS? (2) 1. Parenteral methods of nutrition= Intravenous= TPN 2. Enteral= Gastrointestinal other than Oral; Using : Nasogastric, Gastrostomy, Jejunostomy tubes; chg. Tube prn or per agency protocol WHAT ARE THE PURPOSES OF A NASOGASTRIC TUBE? 1. Prevent nausea, vomiting & gastric surgery post-op ( connected to suction) 2. To remove stomach contents for lab analysis 3. To lavage (wash) stomach in cases of poisoning or overdose of meds. 4. For feeding clients who are unable or unwilling to take nutrients orally HOW IS NG FEEDING DONE? 1. Specially prepared nutrients are instilled into the GI tract through a tube inserted through one of nostrils, down nasopharynx & into alimentary tract 2. Large-bore tubes are placed into stomach 3. Small-bore tubes are placed either into stomach or upper small intestine: duodenum or jejunum HOW IS PLACEMENT VERIFIED WITH LARGE BORE TUBES? 1. Aspirate GI secretions 2. Measure the pH of aspirated fluid 3. Inject 5 to 20 ml of air through feeding tube while auscultating epigastrum or Lft upper abd. Quad & listening for whooshing sound 4. Ask pt to hum or speak 5. Obs. Pt. for coughing & choking WHAT IS THE TUBE FED PT. ASSESSED FOR? 1. Allergies to any food in the feeding 2. Bowel sounds prior to each feeding or q 4-8 hrs with continuous feedings 3. Abdominal distention q day 4. Correct placement of tube before feedings 5. Dumping symdrome (Con’t) 6. Diarrhea, constipation or flatulence 7. Urine for sugar & acetone 8. Hematocrit & urine specific gravity 9. Serum BUN & Na levels 10. Presence of regurgitation & feelings of fullness after feedings WHAT IS A GASTROSTOMY FEEDING? Instillation of liquid nourishment through a tube that enters a surgical opening through the abd. wall into the stomach; usually a temporary measure Percutaneous endoscopic gastrostomy (PEG) is long-term WHAT ARE THE TYPES OF ENTERAL FEEDINGS? 1. Bolus or intermittent 2. Continuous; use enteral feeding pump ALWAYS PREVENT ASPIRATION WHAT ARE PEDI CONSIDERATIONS FOR ENTERAL FEEDING? 1. Use pacifier while feeding to maintain suck reflex 2. Prevent aspiration 3. Prevent tube dislodgment through secure anchoring & frequent oral care INTESTINAL ELIMINATION WHAT ARE THE CHARACTERISTICS OF FECES? 1. 2. 3. 4. 5. 6. Color Consistency Shape Amount Odor Constituents WHAT ARE COMMON FECAL ELIMINATION PROBLEMS? 1. 2. 3. 4. 5. Constipation Fecal impaction Diarrhea Fecal incontinence Flatulence CAUSES & FACTORS= CONSTIPATION 1. 2. 3. 4. 5. 6. 7. Irregular defecation habits Overuse of laxatives Increased psychologic stress Inappropriate diet Insufficient fluid Medications Insufficient exercise (con’t) 8. Age 9. Disease Process DEFINING CHARACTERISTICS OF CONSTIPATION 1. 2. 3. 4. 5. 6. 7. Decreased frequency of defecation Hard, dry, formed stools Straining at stool; painful defecation Palpable mass Reports of fullness or pressure Abd. Cramping or pain or distention Use of laxatives, decreased appetite NSG. INTERVEN. & RATIONALE FOR CONSTIPATION MGMT WHAT IS FECAL IMPACTION? Mass or collection of hardened, puttylike feces in folds of rectum Results from prolonged retention & accumulation of fecal material Passage of liquid fecal seepage (diarrhea) & no normal stool are defining characteristics Digital removal of impaction/ or enemas are sometimes needed WHAT ARE THE MAJOR CAUSES OF DIARRHEA? BOWEL INCONTINENCE FLATULENCE Presence of excessive flatus in intestines Primary Causes: 1. Action of bacteria on chyme in large intestine 2. Swallowed air 3. Gas diffusing into intestine from bloodstream COMMON CAUSES OF FLATULENCE 1. Constipation 2. Codeine, barbituates (anesthetics) 3. States of anxiety during which large amts. of air are swallowed 4. Dietary changes 5. Decreased activity DECREASING FLATULENCE 1. Decrease gas-producing foods 2. Encourage exercise 3. Reposition clients 4. Insert rectal tube & leave in rectum for no longer than 30 mins 5. Admin. Return flow enema DIAGNOSTIC STUDIES OF GI 1. Direct visualization techniques=endoscopic studies 2. Indirect visualization=roentgenography through use of barium 3. Lab tests for abnormal consituents=stool samples for lab; bedside testing for occult blood= Guiac WHAT ARE THE TYPES OF LAXATIVES? Laxative= mild drug that induces defecationwith frequent, soft or liquid BM + abd cramps Cathartic=strong drug that induces defecation with purgative effect Contraindicated in Pt. with n/v, cramps, colic, undiagnosed abd. Pain WHAT ARE ANTIDIARRHEAL MEDS? Decrease defecation frequency “Guideines for Using Antidiarrheal Medications” WHAT ARE ENEMAS? A sln. Introduced into the rectum & sigmoid colon 4 groups= cleansing, carminative, retention, return flow Cleansing Enema Types of Solutions (4)= hypertonic, hypotonic, isotonic, soap, oil WHAT ARE COMMONLY USED ENEMA SLN. ACTIONS & ADVERSE EFFECTS? WHAT IS A BOWEL DIVERSION OSTOMY? Opening into the abdominal wall for elimination of feces or urine 1. Ileostomy 2. Colostomy 3. Gastrostomy 4. Jejunostomy 5. Ileal conduit HOW ARE BOWEL DIVERSION OSTOMIES CLASSIFIED? 1. Permanence 2. Anatomic location 3. Construction of stoma HOW ARE STOMAS ASSESSED? 1. Color 2. Size and shape 3. Bleeding 4. Status of peristomal skin 5. Amt & type of feces from stoma= effluence 6. complaints NSG. INTERVENTIONS FOR APPLIANCE CHANGE TOILET TRAINING OF CHILDREN Daytime control is normally attained by age 2 1/2 yrs. 1. Provide clothing child can remove independently 2. Give child personal, comfortable seat 3. Allow sufficient time 4. Offer positive reinforcement (Con’t) 5. Avoid punishment or disapproval 6. Initiate toilet training during nonstressful periods of child’s life WHAT FACTORS AFFECT DEFECATION? 1. 2. 3. 4. 5. 6. 7. Age & development Diet Fluid Activity Psychologic factors Life-style Medications (Con’t) 8. Diagnostic Procedures 9. Anesthesia & Surgery 10. Pathologic Conditions 11. Irritants 12. Pain