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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Chapter 24
Nutritional Care and Support
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Types of Nutrition
 Enteral: delivers nutrition via the GI tract
 Parenteral: administered directly into
bloodstream bypassing GI tract
 Partial parenteral: inserted into smaller vein
 Total parenteral: inserted into a larger vein
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors Impeding Nutritional Intake
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Anxiety
Pain
Fatigue
Anorexia (lack of appetite)
Nausea and vomiting
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nutritional Assessments
 Identify specific allergies
 Identify special diets at home and dietary
preferences
 Note cultural or ethnic requirements or
restrictions
 Assess physical capabilities and need for
assistance
 Assess medications that might affect diet
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Interventions for
Mealtime Preparation
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Remove odors
Prepare the environment
Position the patient
Ensure patient comfort
Wash patient’s face and hands
Assist the patient to eat
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Assisting Patients
 Box 24-1, pg. 498
 Tips for assisting patients with meal planning
and eating
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
True/False Questions
Assisting a patient with meals is a task that
can be delegated to unlicensed assistive
personnel (UAPs) or nursing assistants.
A. True
B. False
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Intake/Output
 Intake
 Fluids taken by mouth, administered via IV, or
administered per enteral or parenteral feedings
 Output
 All bodily fluids that are lost, including urine,
emesis, liquid stool, blood, suctioned gastric
contents, and drainage from drainage devices
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Intake and Output
 Examples of standard container volumes
 Box 24-2, pg. 501
 Milliliters must be used to document—
CANNOT document in ounces
 Document on I&O sheet
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Common Food Allergies
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Peanuts
Wheat
Dairy products
Eggs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Food Allergies vs. Food Intolerances
 Food allergy
 A reaction by the patient’s immune system to a
food protein that causes a response by the
immune system
 Food intolerance
 Not an allergic reaction; it is an adverse reaction
to a food without activation of the immune
response
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Allergic Response
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Inhalation
Touch
Consume
Reaction—mild to severe
Reaction time—minutes to hours after
exposure
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Allergy
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What is patient allergic to?
Symptoms experienced
Interventions used in the event of a reaction
Range of reactions
 Mild to severe (life threatening)
 Anaphylaxis
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Food Intolerance
 Not an allergic reaction
 Immune system not activated
 Due to properties in food or metabolic
disorder
 Usually GI symptoms—bloating, flatulence,
diarrhea, or nausea
 Identify and limit or eliminate from diet
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
NPO
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NPO—nothing by mouth
Restricted from oral intake—liquids and solids
Inform patient and family—more compliant
NPO sign should be placed
 Outside room—on door or doorway
 Above bed in room
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
NPO
 Empty water pitcher
 Remove glasses and water pitcher
 Any cans or bottles of liquid in patient room—
place inside bedside table
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Regular Diet
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No special nutritional needs or limitations
2,000 calories/day
Specific cultural or ethic needs
Asian, kosher, or vegetarian
If unavailable—family may bring in food—as
long as there are no dietary limitations
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diets Modified for Consistency
 Clear liquid: water, broth, tea without milk
 Full liquid: add opaque liquids to clear diet
 Mechanical soft: add soft foods to full liquid
diet
 Pureed diet: any food processed in blender
 Table 24-1, pg. 503
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diets Modified for Disease
 Diabetic
 Manage calorie and carbohydrate intake
 Calorie-restricted
 Patients who must lose weight
 Sodium-restricted
 Patients with hypertension, CHF, kidney or liver
failure and to prevent or correct fluid retention
 Degree of restriction = disease severity,
symptoms and medication
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diets Modified for Disease
 2,000 to 3,000 mg/day
 Not just adding salt to food
 Read labels for sodium content
 Fat-restricted
 Fat malabsorption—disorders affecting
gallbladder, liver, lymphatic system, pancreas, or
intestines
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diets Modified for Disease
 Elevated triglyceride, lipid, or cholesterol levels
 General weight loss
 Fiber-restricted
 Intestinal disorders
 Pre-op and post-op intestinal surgery
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diets Modified for Disease
 Renal
 Manage or limit fluids and electrolytes
 Complex
 Dietician
 Protein-restricted
 Manage protein intake for liver and kidney disease
patients
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diets Modified for Disease
 High-calorie, high-protein
 Increase calorie and protein
 Wound healing, growth promotion, and increasing
or maintaining weight
 Antigen-avoidance
 Allergies or food intolerance
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diets Modified for Disease
 Five to six small, frequent feedings
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Difficulty tolerating large meals
Gradually reintroduce foods
Elderly
Better chance of receiving necessary nutrients
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Responsibilities
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Monitor diet type
Percentage of food eaten
Did patient tolerate meal?
Physician order: Advance diet as tolerated
 % eaten
 Patient tolerance
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Responsibilities
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Experience any nausea
Vomiting
Abdominal distention
Cramping
Absent or hypoactive bowel sounds
Complaints of indigestion
Diarrhea
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Multiple Choice Question
A nurse is caring for a patient with an inflamed
gallbladder. What type of diet would be
prescribed for this patient?
A. Fat restricted
B. Fiber restricted
C. Protein restricted
D. High calorie, high protein
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Patient Teaching for Patients
with Diabetes
 Eat a well-balanced diet
 Know the difference between simple and complex
carbohydrates; reduce simple carbohydrate intake
on a daily basis; a rare exception to this rule is
acceptable
 Eat three meals and an evening snack daily
 Do not skip meals
 Increase fiber intake
 Reduce fat intake
 Lose weight if overweight
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Blood Glucose Monitoring
 Glucose is a simple sugar that is the end
product of carbohydrate digestion
 Source of energy for body cells
 Fasting blood sugar (FBS)—generally 70 to 110
mg/dL or 80 to 120 mg/dL
 Blood sugar may rise to 139 mg/dL within 2 to
4 hrs of eating a meal
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Blood Glucose Monitoring
 Diabetes is controlled through diet, exercise,
and in some cases medication
 Diabetics may experience low or high blood
glucose levels, both of which can have life
threatening consequences
 Monitor capillary blood glucose levels
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Blood Glucose Monitoring
 Capillary blood sugars
 Glucometer—instrument that measures glucose in
capillary blood
 FBS—Fasting blood sugar
 Hemoglobin A1c (HgbA1c)—glycosylated
hemoglobin
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
FBS
 Fasting blood sugar
 Part of basic metabolic panel (BMP) or Chem 7
or more
 Patient must fast prior to test---at least 8⁰ fast
 Glucose present in blood at the time of the
test
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Hgb A1c
 Red blood cell
 Average life span
 Hgb A1c
 Measures the amount of glucose present over 2 to
3 months
 Non-diabetics result usually < 6%
 Diabetics—goal is < 7%
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
CBS
 Capillary blood sugar
 Small sample of blood from the fingertip to
test amount of glucose in the blood
 Cost effective, less traumatic and convenient
 Blood sample collected on strip
 Placed in glucometer
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Guidelines
 Many different types of glucometers
 MUST follow manufacturer’s instructions for
accurate results
 Common times
 ac and hs
 2° PP (post-prandial)
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Three Golden Rules
 Make sure the blood is flowing freely from a
clean, warm, dry puncture site
 Wipe away the first drop of blood
 Squeeze slowly and rhythmically, gripping the
digit firmly between the base of thumb and
first finger
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Guidelines
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Wear gloves
Risk for contact with blood
Document results
Coverage may be ordered and must be
administered properly
 Abnormal results—recheck glucose according
to facility policy—if symptomatic—treat
according to policy
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
CBS With or Without Coverage
 CBS without coverage
 Perform CBS
 If hypoglycemic—treat according to policy
 Document results in chart
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
CBS With Coverage
 Perform CBS
 Determine how much insulin to give based on
coverage
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Sliding Scale
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Blood Sugar (BS) result
Check where BS falls on sliding scale
Administer insulin according to scale
BS---224
120 to 139—0 units
140 to 180—2 units
181 to 210—4 units
211 to 250—6 units
251 to 290—8 units
291 to 330—10 units
331 to 370—12 units
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Carbohydrate (CHO) Ratio
 Ratio—amount of carbohydrates ingested to
the insulin dose
 8:1----for every 8 gms. of CHO ingested give 1
unit of insulin
 10:1----for every 10 gms. of CHO ingested give
1 unit of insulin
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Formula Coverage
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BS minus target glucose/sensitivity factor
Target glucose (120, 130, 140) will be ordered
Sensitivity factor (20, 30, 40) will be ordered
BS – 120/30
180 – 120/30
(60)
2
2 units of insulin
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Hypoglycemia
 S/S of hypoglycemia
 Fatigue, diaphoresis, shaking, dizzy,
lightheadedness, nausea, hunger, restlessness,
confusion, unusually irritability, difficulty
concentrating, change in behavior or mood,
headache, numbness or tingling around the
mouth, or palpitations
 Never place anything into the mouth of an
unconscious or incoherent patient
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Hyperglycemia
 S/S of hyperglycemia
 Hunger, thirst, increased urination, blurred vision,
fatigue, recurrent infections, poor wound healing
 Left untreated can lead to life threatening
ketoacidosis—fruity breath, nausea, vomiting, dry
mouth, SOB
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Purposes of Enteral Tubes
 Decompress the stomach postoperatively,
following abdominal injury
 Treat intestinal obstruction
 Provide nutritional support or medication
administration
 Collect a specimen of stomach contents for
diagnostic assessment of the GI tract
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Types of Enteral Tubes
 Nasogastric tube (NG)
 Levine or salem sump
 Nasointestinal tube (NI)
 Dobhoff
 Smaller bore, more flexible, some weighted
 Enteral feedings for high risk aspiration
patients—absent or diminished gag reflex, severe
GERD
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Types of Enteral Tubes
 Percutaneous endoscopic gastrostomy (PEG)
 Jejunostomy tube (J-tube)
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Enteral Feeding Methods
 Intermittent tube feedings
 Bolus feedings
 Continuous infusion feedings
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Intermittent Feedings
 Gradual instillation of liquid nourishment four
to six times a day
 Administered over 30 to 60 minutes
 Usually 250 to 400 ml/administration
 Use of feeding pump
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Intermittent Feedings
 Rinse container after use to reduce growth of
microorganisms
 Replace administration set every 24 hours
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Bolus Feedings
 Instillation of liquid nourishment in <30
minutes four to six times a day
 Usually 250 to 400 ml/administration
 Distends stomach rapidly—may cause gastric
discomfort and increased risk for reflux
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Continuous Feedings
 Continuous instillation of liquid nutrition
without interruption
 Administered at a rate of approx. 1.5 ml/min
 Feeding pump is used to regulate instillation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Cyclic Feedings
 Instillation of liquid nourishment for 8 to 12
hours
 Late evening or overnight
 During day—may eat some food orally
 As oral intake increases—volume and duration
of tube feeding gradually decreases
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Enteral Feeding
 Use a formula that will provide the right
amount of protein, fat, carbohydrates,
vitamins, minerals and fluid
 Table 24-3, pg. 515
 Standard-----hydrolyzed-----high-protein----diabetic-----renal-----pulmonary----fibercontaining
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Confirming Tube Placement
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Must be confirmed prior to any instillation
Check for gastric contents
Measure pH (1-4)
X-ray confirmation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Prior to Tube Feeding
 Proper position
 Check placement
 Check residual—aspirate contents until
stomach empty
 Never discard residual aspirate
 Flush
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Enteral Tube Feedings
 Nursing responsibilities for a patient with a
PEG or J-tube
 Page 517
 Techniques to prevent aspiration
 Box 24-4, pg 517
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Complications of
Enteral Tube Feedings
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Clogged tubes
Aspiration
Electrolyte imbalance
Hyperglycemia
Severe diarrhea
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
PPN vs. TPN
 Partial parenteral nutrition (PPN)
 Administered through a peripheral intravenous central
catheter (PICC) inserted into a smaller peripheral vein
 Total parenteral nutrition (TPN)
 Administered through a central venous catheter (CVC)
placed in a larger central vein
 Core differences are the vessel selected to receive
the nutrition and the concentration of solution
infused
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
PPN
 Partial Parenteral Nutrition
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Administered through IV infusion
Can eat or temporarily not eating
Short term use
Glucose, amino acids, salts, lipids and vitamins
Varying amounts to meet the patient’s needs
Medications or additional nutrients can be added
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
TPN
 Total Parenteral Nutrition
 Administered through a central line
 Protein, carbohydrates, glucose, fat, vitamins, and
minerals
 Problem with GI function
 May be temporary or permanent
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Possible Complications
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Fluid and electrolyte imbalance
Hyperglycemia
Infection
Monitor blood tests
Strict sterile technique
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Monitoring Status of Patients
Receiving Parenteral Nutrition
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Daily weights
Electrolyte levels
Prealbumin, albumin, and total protein
Glucose level
Copyright © 2011 F.A. Davis