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Good Nutrition Nutrition Developed by Ginger Mize RN, MN Modified by Jill K. Ray NUR302 Nutrition Basic Human Need Changes throughout the life cycle Changes along the wellness-illnes continuum. Eating Necessary to survive Source of pleasure Pastime Social event Different meanings to different people…. Nutrients Specific biochemical substances used by the body for growth, development, activity, reproduction, lactation, health maintenance, and recovery from illness (p. 1413). Essential Nutrients Not synthesized in the body Made in insufficient amts Must be provided in the diet Six Classes of Nutrients 3 supply energy Carbohydrates Proteins Lipids 3 are needed to regulate body processes Vitamins Minerals Water Energy Balance Energy is derived from foods consumed. Measured in form of kilocalories, abbreviate as calories. Energy Balance What are the body’s sources of energy? Carbohydrates, protein, and fat If a person’s daily energy intake is equal to total daily energy expenditure the person’s wt will remain stable. Carbohydrates Main source of energy Glucose Brain Skeletal muscles Carbohydrates Sugars & Starches Easy to produce and store In some countries where grains are dietary stable, CHO may contribute as much as 90% to daily calorie consumption Some sources correlate to income. Speculating that as income increases, CHO intake decrease and protein intake increases. Carbohydrates More easily and quickly digested than protein and fat. 90% is digested. This percentage decreases as ____intake increases. fiber Fats (Lipids) Triglycerides and fatty acids Saturated or Unsaturated fatty acids Proteins Synthesis of body tissue Collagen, hormones, enzymes, immune cells Amino acids: essential and nonessential Nitrogen balance Water Comprises 60% to 70% of body weight Cell function depends on a fluid environment Sources, functions, & significance of Carbohydrates , proteins, & fats P.1419 Table 42-3 Note functions that this table lists for the nutrient. Which nutrient should a patient increase in his diet after surgery? Sources, functions, & significance of Carbohydrates , proteins, & fats Note food sources of the nutrient. Which of the following should this same patient eat 1st on his lunch tray: orange, chicken tenders, Lima beans, whole wheat roll. Vitamins Water soluble (Vitamin C and the Bcomplex vitamins) Not generally stored in body Need daily intake to prevent symptoms of deficiency Vitamins Fat soluble (ADEK) Must be attached to a protein to be transported through the blood Secondary deficiencies can occur anytime fat digestion or absorption is altered (i.e. malabsorption syndromes, mega diets…) Minerals Some provide structure within the body Some help regulate body processes Macro minerals (those needed by the body in amts greater than 100mg/day) Calcium Phosphorus Sulfur Sodium Chloride Potassium magnesium Water Major body constituent present in every body cell More vital to life than food. Water Provides the fluid medium necessary for all chemical reactions, participates in many reactions, is not stored in the body. Acts as a solvent, aiding in digestion Assists in the regulation of body temperature Acts as a lubricant for mucous membranes Water Accounts for 50-60% of adult total wt 2/3 is contained in the body’s cells (intracellular fluid – ICF) 1/3 all other body fluids (extracellular fluid – ECF) this includes plasma and interstitial fluid. Basal Metabolism Energy required to carry on the involuntary activities of the body at rest; the energy needed to sustain the metabolic activities of cells and tissues and to maintain circulatory, respiratory, gastrointestinal, and renal processes (p. 1415). Who has the highest Basal Metobolism Rate? Men Women Why Because of higher muscle mass. Men are about 1cal/kg and women .9 cal/kg. What other factors increase BMR? Growth Fever Infections Emotional tension, Extremes in temperature Hormone levels (thyroid hormone, epinephrine) What decreases BMR? Aging Prolonged fasting sleep Ideal Body Weight Body Mass Index Waist circumference Formula: BMI = wt in kg/(ht in meters) times (height in meters) BMI = (wt in lbs/(ht in inches) times (height in inches)) times 703 General Guidelines BMI BMI BMI BMI below 18.5 is underweight of 25 – 29.9 is overweight of 30 or greater obesity of 40 or greater extreme obesity Calculate BMI for a patient who weighs 100 pounds and is 5 feet tall. BMI = (wt in lbs/(ht in inches) times (height in inches)) times 703 BMI = (100/60 times 60) times 703 BMI = (100/3600) times 703 BMI = .027 times 703 = 19.52 19.52 BMI BMI BMI BMI below 18.5 is underweight of 25 – 29.9 is overweight of 30 or greater obesity of 40 or greater extreme obesity How would you characterize this pt’s BMI? Weight loss Usual wt – present wt /usual wt times 100 Significant if: 1%-2% in 1 week 5% in 1 month 7.5% in 3 months 10% in 6 months Factors Affecting Nutrition Food intake Decreased food intake can be related to disease, psychosocial causes, impaired ability to smell and taste, drug therapy, medical treatments, difficulty chewing and swallowing, chronic GI problems, certain chronic illnesses (ca) Inadequate food budgets Nausea pain Nursing Indications…. If a pt is NPO…what is our responsibility as a healthcare provider to ensure that he maintains an adequate nutritional status? Consider: Nutrients (which ones?) Water balance Can we feed a pt that a MD has made NPO? Factors food intake: Increased food intake: Excess wt increases the risk for numerous medical problems assoc with surgery For complications during pregnancy, labor, and delivery Incr morbidity and mortality Reasons for overeating…. Physiologic and physical factors that influence nutrient requirements Developmental considerations: Throughout the life cycle nutrient needs change in relation to growth, development, activity, and age-related changes in metabolism and body composition. Review each area in this section of the required reading Gender Men have more muscle mass and therefore have higher caloric and protein requirements than women. State of Health Trauma (major surgery, burns, crush injuries) Dramatically alters the body’s use of nutrients. Nutrient requirements increase dramatically to allow the body to preserve or replenish body nutrient stores and to promote healing and recovery. Mental health problems can cause to forget to eat, or lack motivation to eat. Alcohol Abuse Affects the intestinal mucosa. Interferes with normal nutrient absorption, so requirements for the nutrients increase as the efficiency of absorption decreases. Need for B vitamin increases because they are used to absorbed alcohol. Medication Especially drugs that alter the pH of the GI tract Increase GI Motility, damage intestinal mucosa, bind with nutrients Sociocultural and Psychosocial Factors Religion: Mormons: no coffee, tea, alcohol, encouraged to limit meat consumption Hindus do not eat beef, many Hindus are vegetarians Kosher dietary laws: special food preparation techniques and prohibit the intake of pork and shellfish Culture See box 42-4. p. 1434. The Nsg Process During illness, good nutritional status can reduce the risk for complications and speed recovery Poor nutritional status can increase the risk for illness or death and prolong the healing process. Assessment Health History Physical Assessment Dietary History Anthropometrics Laboratory Tests DETERMINE reviewed in the text on p. 1435 24 Hour Food Recall Upon waking: large glass of water OTWTW: 1 cup of coffee w/sugar & cream, large bagel w/cream cheese During morning: 2 coffees w/2 Danishes Lunch: Hamburger w/fries-”supersized”, lg. sweet tea Afternoon: pack of M&M’s Dinner: Steak, baked potato, green beans, salad, apple pie a la mode, lg. sweet tea After dinner: 2 beers Dietary Guidelines Dietary referenced intakes (DRIs) Food Guide Pyramid Daily values Healthy People 2010 Food Pyramid 24 Hour-Food-Intake Assessment http://www.mypyramid.gov/mypyra mid/results.html?age=54&gender=m ale&activity=sed Assessment of 24 Hr. Food Recall Grains: potato(7) bagel(2) danishes(4) bun(2),fries(6) >19 oz.] 5oz. Veggies: lettuce, tom, pickles, green beans, salad cups] 2 cups Fruits: 0 1½ cups Milk: cream??!!! Meat/beans: Hb(4-6), steak (8-12) [~12-18] 5 oz. [oils] 3 cups/5 tsp oil [~ 2 [ Intake and Output Monitoring I and O Assistance Record as soon as specimen is measured Independent vs. dependent nursing action All clients Totaled and evaluated at the end of shift or at specified times Compare Record all output 1. 2. 3. 4. 5. 6. Urine Diarrhea Vomitus Gastric suction Drainage from surgical tube and wounds Stool if it is liquid enough to be measured Intake Output Record all intake Liquids taken: Oral Enteral Parenteral Anthropometric Data Height and weight. Most common. Weigh pt on same scales at the same time of day Self reported ht in the elderly is often inaccurate BMI and waist circumference Triceps Skin fold measurement Biochemical Data Hemoglobin and Hematocrit Serum albumin levels Serum transferrin levels (iron transporting protein) Total lymphocyte count (reflects immune status) Blood glucose Blood cholesterol Blood triglycerides 24 hour urine tests: measure protein metabolism include urine creatinine excretion and urine urea nitrogen (reflects the breakdown of amino acids (protein) for energy. DETERMINE Disease: any disease impacting Eating poorly: too little or too much Tooth loss, mouth pain: Economic hardship: Reduced social contact: Multiple medicines: Involuntary wt loss/gain: Needs asst in self care: walking, shopping, purchasing, cooking food help Elder years: above age 80. Diagnosing Imbalanced nutrition as the problem: Could be the only issue dealing with. Imbalanced nutrition as the etiology: Could cause other problems that the nurse must deal with. Outcome identification and Planning Maintain or restore optimal nutritional status Implementing Teaching Monitoring nutritional status Stimulating appetite Allow food choices Small frequent meals Provide encouragement and PLEASANT environment Control pain, nausea, depression Good oral hygiene Arrange so that it is within easy reach Ask about rituals Allow opportunity to wash hands Assisting with eating when necessary…last resort! Why? Liquid diets Used frequently with transition diets Decision to advance diet is based on return of gi function Advance as tolerated is most common order…what do you think this means? Diets of Modified Consistency NPO Clear liquid Full liquid Pureed Mechanical or dental soft Soft/Low residue High Fiber Diets of Modified Consistency Nothing by mouth: Patient not allowed to eat/drink. Preop order, postop often until Bowel sounds return, before certain procedures. Nsg indications: Encourage good oral hygiene Lemon glycerin swaps (if no oral lesions) Ice chips only if MD has OK’d Avoid watching others eat… Diets of Modified Consistency: Clear liquids: food that are clear liquids at room or body temperature Full liquids: all items on a clear liquid plus, Milk, puddings, custards, plain frozen desserts, pasteurized eggs, cereal gruels, vegetable juices, milk and egg substitutes. High calorie, high protein supplements usually accompany this diet if used more that 3 days. Diets of Modified consistency: Soft/Low Residue diets: regular diets that have been modified to eliminate foods that are hard to digest and to chew, including those that are high in fiber, high in fat, and highly seasoned. Also called bland or low-fiber. Adequate in calories and nutrients and may be used long-term. Therapeutic Diets Restricted fluid intake Sodium-restricted Fat-modified Sugar-restricted (diabetic or ADA) Protein-restricted (renal) Prescribed Diet 1800 ADA Enteral/parenteral nutrition Enteral: administering nutrients directly into the stomach Parenteral: providing nutrition via IV therapy, nutrition Enteral Nutrition Oral feeding is preferred and most effective Enteral is next best. Involves passing tube into the GI tract to administer a formula containing adequate nutrients. Procedure: Percutaneous Endoscopic Gastrostomy (PEG) or a surgically placed Gastrostomy tube. Enteral Nutrition Short-term (less than 6 weeks): use nasogastric tube. Nasointestinal tube (Dobhoff) (more than 6 wks): Passed through the nose and into the small intestine. This bypasses the valve in the stomach that controls volume entering intestine. Results in gas, bloating. Long-term intestinal support: enterostomal tube placed through an opening created into the stomach from the abdominal wall. Nasogastric Tubes Enteral Feeding Tubes (Nasogastric Tubes) Enteral Feeding Tubes (Dobhoff) Gastrostomy Tube Jejunostomy Tube Safety Alert Pt’s on tube feedings: Head of bed is kept elevated at all times while the tube feeding is being instilled….why? The nurse will turn the feeding off about 30 minutes before lowering the head of the bed….not you, yet! Nasogastric tubes for decompression These tubes are also used when the stomach has excess fluid that need to be drained… After GI surgery so the intestines can rest Pt with GI complications and the intestines are not functioning properly Post operative pt who is not alert enough to “handle” their secretions. Preventing the risk of vomiting. Parenteral Parenteral Nutrition Administration of nutritional support via IV route. Used for pts who cannot meet their nutritional needs by the oral or enteral routes. Can be administered centrally or peripherally. Total Parenteral Nutrition (TPN) highly concentrated, hypertonic nutrient solution. Provides calories, restores nitrogen balance, etc. Note that major nsg implication is monitoring Blood Glucose Levels (BGL). Fluid Volume Deficit Output greater than intake Decreased blood pressure Increased pulse Rapid weight loss > 5% Dry mouth Dry skin Tenting Slow venous filling of dependent hands Fluid Volume Excess Intake greater than output Rapid weight gain Pitting edema Crackles heard in lungs Bounding pulse Dysphagia Monitor and assist with feedings/meals Maintain high-fowler’s position Place food on unaffected side of mouth No straws Verbal coaching through swallowing process Thickeners