Kozier Ch 47 Nutrition

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Kozier Ch 47 Nutrition
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Kozier Ch 47 Nutrition
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  1. Essential Nutrients and Sources
    •Water

    • •Macronutrients
    • –Carbohydrates
    • •Simple, Starch, Complex (fiber)
    • –Protein
    • •Essential amino acids (not made by body)
    • •Nonessential amino acids (body can make)
    • •Pro. Metabolism- anabolism, catabolism, nitrogen
    • balance
    • –Lipids (Room temp: Fats- solid, Oil- liquid
    • •Fatty acids (sat & unsat), monounsat & polyunsat
    • •Triglycerides
    • •Cholesterol

    • •Micronutrients
    • –Vitamins- not made by body
    • •Water-soluble: not stored- C, B complex
    • •Fat soluable: stored- A,D,E,K
    • –Minerals
    • •Macrominerals- over 100mg /day: Ca, P, Na, K, Mg, Cl, sulfur
    • Micromineral- less than 100 mg: iron, zinc, iodine, etc
  2. Energy Balance
    •Relationship between the energy derived from food and the energy used by the body

    • •Caloric value is the amount of energy that nutrients or foods supply to the body
    • –CHO: 4 calories/gram
    • –Pro: 4 calories/gram
    • –Fat: 9 calories
    • –Alcohol: 7 calories/gram

    Basal metabolic rate (BMR): the rate at which the body metabolizes food to maintain the energy requirements of a person who is awake and at rest

    • •Resting energy expenditure (REE): amount of energy required to maintain basic body functions & maintain life
    • –1 cal/kg of body wt/hr for men
    • –0.9 cal/kg of body wt/hr for women
  3. Healthy Body Weight
    •Balance between the expenditure of energy and the intake of nutrients

    •Ideal body weight (IBW): the optimal weight recommended for optimal health

    • •Body mass index (BMI): considered to be
    • the more reliable indicator of a person’s healthy weight
  4. IBW
    • •IBW = Ideal Body Weight (Box 47-1 page 1236)
    • Female: 100 lbs for 5 feet + 5 lbs for each additional inch

    • Male:106 lbs for 5 ft. + 6 lbs for each additional inch
    • + or – for body frame based on wrist size

    Actual wt x 100 = % IBW <70% severe malnut. IBW
  5. BMI
    • •BMI = Body Mass Index < 18.5 underwt.
    • Wt. In Kg 18.5-24.9 normal
    • Ht. In meters 2 (squared) 25-29.9 overwt.
    • 30-34.9 mild obese
    • 35-39.9 moderate obese
    • > 40 extremely obese
    • •1 kg = 2.2 lb
    • •1 meter = 39.6 inches
  6. Health Body Weight
    • •Can measure body mass by measuring % of fat
    • •Underwater weighing
    • •DEXA- expensive test
    • •Waist circumference- greater waist = greater risk of
    • Diabetes
    • •Skinfold testing
    • •Bioelectrical impedance analysis (BIA)- on some
    • scales. Electrical signal passes thro the body
  7. Factors Influencing Nutrition
    • •Developmental considerations
    • •Gender
    • •Ethnicity and culture
    • •Beliefs about food
    • •Personal preferences
    • •Religious practices
    • •Lifestyle
    • •Economics
    • •Medications and therapy
    • •Health
    • •Alcohol consumption
    • •Advertising
    • •Psychologic factors
  8. Nutritional Variations Throughout the Life Cycle
    • •Young adults
    • –Females- iron intake, 18 mg of iron/day
    • –Calcium is needed to maintain bones and help
    • decrease the chances of developing osteoporosis in later life.
    • –Adequate vitamin D is needed for the calcium absorption.
    • –Low-fat and/or low-cholesterol diets play a significant role in both the prevention and treatment of cardiovascular disease.
    • –Prevent obesity- risk for HTN & CV disease

    • •Middle age Adults
    • –Continue to eat a healthy diet, with special attention to protein, calcium, and limiting cholesterol and caloric intake
    • –Two or three liters of fluid should be included in the daily diet
    • –Postmenopausal women need to ingest sufficient calcium and vitamin D to reduce osteoporosis
    • –Antioxidants such as vitamin A, C, and E may be
    • helpful in reducing the risks of heart disease in women

    • •Older adults
    • –Require the same basic nutrition as the younger adult
    • –Fewer calories are needed by elders because of the
    • lower metabolic rate & the decrease in physical activity
    • –Some may need more carbohydrates for fiber &
    • bulk, but most nutrient requirements remain relatively unchanged
    • –Physical changes as tooth loss & impaired sense of taste and smell may affect eating habits
    • –Decreased saliva, gastric juice secretion, decreased
    • intestinal absorption may also affect nutrition
    • –Psychosocial factors may also contribute to nutritional problems
  9. Standards for a healthy diet
    • •Healthy People 2020 (www.healthypeople.gov)
    • •Americans with a healthful diet:
    • –Consume a variety of nutrient-dense foods within and across the food groups, especially whole grains, fruits, vegetables, low-fat or fat-free milk or milk products, and lean meats and other protein sources.
    • –Limit the intake of saturated and trans fats,
    • cholesterol, added sugars, sodium (salt), and alcohol.
    • –Limit caloric intake to meet caloric needs.
    • •All Americans should avoid unhealthy weight gain, and those whose weight is too high may also need to lose weight.

    • •2010 Dietary Guidelines for Americans (USDA)
    • –Nutrient dense food
    • –Maintain healthy wt
    • –Engage in physical activity
    • –Eat fruit, veges, grains, milk
    • –Keep fat 20-35% of total calories
    • –Decrease sodium to <2,300/day
    • –Drink alcohol in moderation
  10. Food Pyramid
    • •The Food Pyramid- USDA picture
    • –Anatomy of MYPyramid- designed to be simple
    • –Food Pyramid for children
    • –Food Pyramid for Older Adults
  11. Alternations in Nutrition
    • Overweight/ Obesity: Consuming nutrients
    • •In excess of metabolic demands
    • •More than needed for activity, gender, height, and
    • weight
    • •Overweight = BMI >25 but <29.9
    • •Obesity = BMI >30
    • Interventions
    • •Food diary
    • •Teach balanced diet and kcal content of food, fat substitutes
    • •Weigh weekly
    • •Increase physical activity

    • Underweight/Undernutrition:
    • •Insufficient intake of protein, fat, vitamins, minerals
    • •Consuming less calories than needed according to activity, gender, height, and weight
    • •Underweight: BMI < 18.5 Interventions
    • •Offer high calorie & high protein foods
    • •Consult with dietician
    • •Weigh 1-2x/week
    • •Offer high protein supplements
    • •Community resources

    • Malnutrition
    • –Lack of necessary food substances

    • Protein-calorie Malnutrition- severe malnutrition
    • from long-term caloric deficiency. There is weight & fat loss. Also proteins stores are affected- skeletal muscle (wasting) & visceral proteins (hemoglobin, albumin) - low albumin indicates low protein
  12. Risk Factors for Nutritional Problems
    • Diet
    • –Chewing & swallowing difficulties
    • –Inadequate food budget, food intake, preparation and storage facilities
    • –IV fluids
    • –Living and eating alone
    • –No intake for > 7 days
    • –Physical disabilities
    • –Restricted or fad diets

    • Medical
    • –Adolescent pregnancy or closely spaced pregnancies
    • –Alcohol/substance abuse
    • –Catabolic or hypermetabolic conditions
    • –Chronic illnesses
    • –Dental problems
    • –Neurologic or cognitive impairments
    • –Oral and GI surgeries
    • –Unintentional weight loss or gain

    • Medications- pages 1253 & 1239
    • –Increase appetite (prednisone & antidepressants)
    • –Decrease in appetite – many meds
    • –Electrolyte loss- K from diuretics
    • –Grapefruit- doesn’t mix with certain meds
    • –Vit K- decreases affect of Coumadin
  13. Nursing & Diet History
    • •Age & gender
    • •Activity level
    • •Any difficulty eating
    • •Condition of mouth, teeth, dentures
    • •Changes in appetite and weight
    • •Physical disabilities affecting purchasing, preparing &
    • eating food
    • •Ethnicity/religion/income

    • •What & how much is eaten
    • •Living arrangements
    • •General health status
    • •Food allergies
    • •Medical conditions
    • •Medication history
    • •Do a 24 hour food recall/diary
  14. Physical Exam
    • •Clinical Manifestations of Malnutrition (p.1257)
    • -red beefy tongue
    • •Calculating % of weight loss
    • –There is a formula
    • •Calculate usual body weight (UBW)
    • •Calculate current weight
    • –Looking for the amount of weight change
    • loss of 5% in one month - cancer?
  15. Lab Assessment
    • Proteins- types have different half lives
    • Albumin- is 60% of total body protein, used to measure prolonged depletion
    • Prealbumin – fluctuates daily, marks acute change
    • Transferrin – a protein that binds with iron, responds quickly to protein depletion
    • Lymphocytes –WBCs, low is leukopenia Hemoglobin – heme (iron), globulin (serum protein)

    • Urea nitrogen
    • End product of protein metabolism, excreted by
    • kidney.
    • Reflects intake & breakdown of dietary protein
    • Creatinine –
    • End product skeletal muscle metabolism
    • As skeletal muscle atrophies, creatinine decreases
  16. Nursing Diagnoses
    • Imbalanced Nutrition : More than Body Requirements
    • Imbalanced Nutrition:
    • Less than Body Requirements
    • Risk for imbalanced nutrition
    • Impaired swallowing
    • •Risk for infection
    • •Constipation related to inadequate fluid intake
    • •Low self-esteem related to obesity
    • •Activity intolerance
    • Impaired dentition
  17. Nursing Plannin
    • •Maintain optimal nutritional status
    • –Client will ingest 2000kcal/day
    • –Client will gain/lose 1-2 lbs./month until IBW
    • –Client will demonstrate understanding of the
    • nutritional requirements for meal planning by end of shift
  18. Interventions - Special Diets
    Regular diet- as tolerated, no restriction

    • Clear liquid- short term for surgery or tests.
    • Coffee/tea, carbonated beverages, bouillon/fat free
    • broth, clear fruit juices (apple, cranberry, grape), gelatin, popsicles, sugar, honey, hard candy

    • Full liquid- GI distrubances.
    • Clear liquids plus items liquid at room temp. Soups, milk, puddings, custards, yogurt/ice cream.

    • Mechanical Soft- easy to chew & digest
    • •difficulty swallowing or chewing , missing teeth, jaw problems.
    • All items on full liquid plus soft vegetables, chopped, ground or shredded meat. Can cook food extensively or blend & grind to alter texture. This diet is full of nutrients but low in fiber. Constipation is a risk.

    • Pureed- type of soft. Blended diet. Any food can be
    • eaten, liquid is added
  19. Intervention - Special Diets
    • •Calorie restricted: - obesity
    • •Fat restricted: - High cholesterol, or tryglycerides, weight loss
    • •Sodium restricted: BP or fluid balance problems
    • •DASH diet: for hypertention - high in grains, low in salt
    • •ADA diet:
    • •Renal:

    • Dysphagia DIet - difficulty swallowing
    • -elders, stroke, radiation to neck, nerve damage
    • - Gag reflex not reliable, done through x-ray
  20. Interventions - Hospitalized client
    • –Provided in collaboration with the primary care
    • provider and the dietician
    • –Reinforce information presented by dietician
    • –Create an atmosphere that encourages eating
    • –Provide and assist with eating
    • –Help client choose food he/she likes
    • –Monitor the client’s appetite and food intake
    • –Administer enteral and parenteral feedings
    • –Consult with primary care provider and dietician
    • about nutritional problems

    • •Clients who are NPO (nothing by mouth)
    • –Assist with oral hygiene, ice chips, hard candy, chewing gum
    • •Stimulating a person’s appetite – Box 47-10 pg 1263
    • •Providing Client Meals – Box 47-11 pg 1264
    • •Special Community Nutritional Services
    • –Meals on wheels
  21. Enteral & Parenteral Nutrition
    • •Alternative methods to get nutrients needed
    • •Enteral (EN)- Directly into the GI tract via tube
    • •Parenteral- directly through a vein
    • –Intravenous hyperalimentation
  22. Enteral Nutrition
    • •Enteral nutrition:
    • ¡Enteral access devices
    • –Nasogastric tube
    • –Nasoenteric tube
    • –Gastrostomy/jejunostomy
    • –PEG/PEJ
    • ¡Test for placement
    • ¡Aspirate stomach contents
    • ¡Test pH- stomach higher than intestines & lungs
    • ¡Feedings- different formulas
    • ¡Procedure Inserting & removing- learn in lab
  23. Complications of enteral feedings
    • •Aspiration
    • –Prevent- HOB 30 or above
    • –Check lung sounds
    • •Diarrhea/constipation/flatulence
    • •Assessing the client receiving feedings
    • –Check how much remains in stomach. Check hosp.
    • policy for 100 ml
    • •Skin breakdown around insertion site
    • •Prevent clogged tubes- flush
    • •Prevent infection
    • –Change formal every 8-12 hours
  24. Parenteral Nutrition
    • •Unable to meet nutritional needs
    • •Shortened small bowel due to disease or injury
    • •Used in addition to oral to meet caloric & nutritient needs
    • •Severly malnourished
    • •Burns or trauma
    • •Conditions that require resting the GI tract
    • •Because TPN solutions are hypertonic, they must administered in a large, high flow vein.
    • •Subclavian vein is site of choice
    • •High flow through the vessel causes rapid dilution of the concentrated TPN preventing vessel damage.
  25. Parenteral nutrition- Contents
    • •10-50% concentrations of dextrose in H2O with amino acids
    • •Vitamins
    • •Minerals
    • •Trace elements
    • •Standard solutions or custom
    • •Lipid emulsions/fatty acids and triglycerides are also admin. weekly
  26. Parenteral Nutrition- Considerations
    • • Supplied in Liter batches
    • • Must be refrigerated to prevent bacterial growth
    • •Cannot hang for more than 12 hours
    • • TPN line used only for TPN
    • •Because the line is central, infection at the site can lead rapidly to sepsis.
    • •Surgical asepsis used when changing solution, tubing, and dressing
    • •Begin infusion slowly to decrease potential for hyperglycemia
    • •May require insulin during therapy to facilitate absorption of glucose
    • •Therapy must be discontinued slowly to decrease potential for hypoglycemia

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