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Chapter 44 Nutrition

STUDY
PLAY
You are teaching a client about healthy nutrition. You recognize that the client understands the teaching when he states:
i will make sure that I eat a balanced diet and exercise regularly
As a nurse, you teach a client who has had surgery to increase which nutrient to help with tissue repair?
Protein
You are caring for a client experiencing dysphagia. Which interventions will help decrease the risk of aspiration during feeding?
Sit the client upright in a chair.
Place food in the strong side of the mouth.
Feed the client slowly, allowing time to chew and swallow.
The nurse suspects that the client receiving PN through a CVC has an air embolus. What action does the nurse need to take first?
Turn client to left lateral decubitus position.
Which action is initially taken by the nurse to verify correct position of a newly placed small-bore feeding tube?
Place an order for x-ray examination to check position.
The catheter of the client receiving PN becomes occluded. Order the steps for caring for the occluded catheter in the oder in which you would perform them.
Attempt to aspirate a clot.
Temporarily stop the infusion.
Flush line whit saline or heparin.
Use a thrombolytic agent if ordered or per protocol.
Based on knowledge of peptic ulcer disease (PUD), the nurse anticipates the presence of which bacteria when reviewing the lavoratory data for a client suspected of having PUD?
Helicobacter pylori
You are assessing a client receiving enteral feedings via a small-bore nasogastric tube. Which assessment findings need further intervention?
Gastric residual aspirate of 300 mL for the second consecutive time
The home care nurse is seeing the following clients. Which client is at greatest risk for experiencing inadequate nutrition?
A recently widowed 76-year-old woman recovering from a mild stroke
Basal Metabolic Rate (BMR)
Energy (kcals) needed to maintain life-sustaining activities such as breathing, circulation, heart rate and temperature, for a specific period of time at rest.
Things that factor energy requirements
injury, infection, activity level, thyroid function, age, body mass, gender, fever, starvation, menstruation, illness.
Resting Energy Expenditure (REE) or Resting Metabolic Rate
The amount of energy an individual needs to consume over a 24 hour period for the body to maintain all its internal working activities while at rest.
Factors that affect metabolism
illness, pregnancy, lactation, activity level.
Carbohydrates
Main source of energy in the diet. Each gram of carbogydrate produces 4 kcal and serves as the main source of fuel (glucose) for the brain, skeletal muscles during exercise, erythrocyte and leukocte prodcution, and cell function of the renal medulla.
Foods that contain carbohydrates
Plants and milk products
2 Simple Carbohydrates
Monosaccharides and Disaccharides
Monosaccharide
Glucose, dextrose, fructose. Cannot be broken down further.
Disaccharide
Sucrose, lactose, maltose. Made up of two monosaccharides and water.
Complex Carbohydrate
Polysaccharide
Polysaccharide
Glycogen, starches, fiber. Body is unable to break these down. Insoluble in water.
Proteins
Each gram provides 4 kcal. Essential for body growth and repair. Collagen, hormones, enzymes, DNA, RNA, blood clotting, fluid regulation, acid-base balance.
Amino Acid
Simplist form of a protien.
Food sources of protien
Meats, beans and cheese.
Nitrogen Balance
When enough carbs are in the diet, protien is spared as an energy source. This allows for growth and repair, wound healing, normal pregnancy, maintenance of vital organs. You need a positive nitrogen balance for growth, pregnancy and maintenance of muscle mass and vital organs.
nitrogen balance indicates
Occurs when the body loses more nitrogen then it gains. Infection, sepsis, burns, fever, trauma
Positive Nitrogen Balance
When intake of nitrogen is greater than the output. This allows for growth and repair, wound healing, normal pregnancy, maintenance of vital organs. You need a positive nitrogen balance for growth, pregnancy and maintenance of muscle mass and vital organs.
Fats (Lipids)
Provide 9 kcals/g. Composed of triglycerides and fatty acids.
Saturated Fatty Acids
Each carbon in the chain has two attached hydrogen atoms.
Unsaturated Fatty Acids
Enequal number of hydrogen atoms are attached and the carbon atoms attach to each other with a double bond.
Composition of fatty acids
Chains of carbon and hydrogen atoms with an acid group on one end of the chain and a methy group at the other.
Monounsaturated fatty acid
have one double bond
Polyunsaturated fatty acids
have two or more double bonds.
Linoleic acid
Only unsaturated fatty acid that is essential for humans.
Fat deficiency
Fat intake below 10% of daily nutrition.
Food source with high proportions of saturated fatty acids
animal fats
Food source with high proportions of unsaturated fatty acids
vegetable fats
60-70% of total body weight
Water
Factors that effect unequal intake and output
Illness can increase fluid needs. Some illnesses decrease the ability to excrete fluid, leading to the need for fluid restriction such as renal disease.
How we meet our water intake needs
Ingesting fluids and foods with high water content.
A way the body produces water
During digestions when food is oxidized.
Vitamins
Organic substances present in small amounts in foods that are essential to normal metabolism. They are used as catalysts in biochemical reactions.
Minerals
Inorganic elements that are essential to the body as catalysts in biochemical reactions.
Fat-soluble vitamins
A, D, E and K. Stored in the fatty compartments of the body. With the exception of vitamin D, these vitamins are provided through dietary intake.
Hypervitaminosis of fat soluble vitamins
Results from megadoses (intentional or unintentional) of supplemental vitamins, excessive amounts in fortified food and large intake of fish oils.
Water-soluble vitamins
C, and B complex (which is 8 vitamins). The body does not store water soluble vitamins, so these need to be provided in the daily intake of food. Although these vitamins are not stored, toxicity can still occur.
Enzymes
Protein like substances that act as catalysts to speed up chemical reactions and are an essential part of the chemistry of digestion.
Mouth
Breaks down food particles.
Salivary glands
Moistens and lubricates food. Amylase digests carbs.
Pharynx
Swallows
Esophagus
transports food
Stomach
Stores and churns food. HCL activates enzymes, breaks up food, kills germs. Mucus protects stomach wall. Limited absorption.
Small intestine
Completes digestion. Mucus protects gut wall. Absorbs nutrients, most water.
Large intestine
Reabsorbs some water, ions and vitamins. Forms and stores feces.
Rectum
Stores and expels feces.
Anus
Opening for elimination of feces.
Gallbladder
Stores and concentrates bile.
Pancreas
Hormones regulate blood glucose levels. Bicarbonates neutralize stomach acid.
Liver
Breaks down and builds up many biological molecules. Stores vitamins and iron. Destroys old blood cells. Destroys poisons. Produces bile to aid digestion.
Pathway of digestion
Mouth, Phyarynx, Esophagus, Stomach, Small Intestine, Large Intestine, Rectum, Anus
Chyme
Food leaves the distal stomch, through pyloric sphincter and enters the duodenum, food is now this acidic, liquefied mass.
4 stages of food intake and output
digestion, absorption, metabolism and storage of nutrients, eliminaion
Metabolism
all the biochemical reactions within the cells of the body. Can be anabolic or catabolic
Anabolism
building of more complex biochemical substances by synthesis of nutrients. Occurs in a state of positive nitrogen balance.
Catabolism
Breakdown of biochemical substances into simpler substances and occurs during a state of negative nitrogen balance.
Glycogenolysis
Catabolism of glycogen into glucose, carbon dioxide, and water.
Glycogenesis
Anabolism of glucose into glycogen for storage.
Gluconeogenesis
Catabolism of amino acids and glycerol into glucose for energy.
Dietary Reference Intakes (DRI's)
Present evidence based criteria for an acceptable range of amounts of vitamins and nutrients to avoid deficiencies or toxicities for each gender and age group.
4 components a DRI
Estimated average requirement (EAR), Recommended dietary allowance (RDA), Adequate intake (AI), tolerable upper intake level (UL).
Estimated average requirement (EAR)
recomended amount of a nutrient that appears sufficient to maintain a specific body function for 50% of the population based on age and gender.
recommended Dietary Allowance (RDA)
Average needs of 98% of the population, not the exact needs of the individual
Adequate intake (AI)
the suggested intake for individuals based on observed or experimentally determined estimates to set the RDA.
Tolerable Upper intake level (UL)
The highest level that likely poses no risk of adverse health events. It is not the recommended level of intake.
Food pyramid
basic guide for buying foods and meal preparations. Includes daily intake of grains, vegetables, fruits, milk, meat and beans.
Benefits of breast-feeding
reduced food allergies and intolerances; fewer infant infections, easier digestion; convenient, always correct temperature, available and fresh; economical; increased time for mother and infant interaction
Formula
protein in formula is typically whey, soy, cow's milk base, casein hydrolysate, or elemental amino acids
Reasons not to use cow's milk
infants less than 1 year of life, can have gi bleeding, it is too concentrated for the infant's kidneys to manage, increases the risk of milk product allergies, and is a poor source or iorn and vitamins C and E
poor oral health can cause the following diseases:
bacteremia, endocarditis, cardiopulmonary disease, dm, and adverse outcomes in pregnancy
Vegetarianism
diet consisting predominantly of plant foods
Ovolactovegetarian
eat eggs and milk
lactovegetarian
ovoid eggs but drink milk
vegans
eat only plant food
Zen macrobiotic
eat primarily brown rice, other grains, and herb teas
Fruitarian
eat only fruit nuts honey and olive oil
Analgesic: Acetaminophen
Decreased drug absorption with food; overdose associated with liver failure
Analgesic: Aspirin
Absorbed directly through stomach; decreased drug absorption with food; decreased folic acid, vitamins C and K, and iron absorption
Anatacide: Aluminum hydroxide
Decreased phosphate absorption
Sodium bicarbonate
Decreased folic acid absorption
Antiarrhythmic: Amiodarone
Taste alteration
Antiarrhythmic: Digitalis
Anorexia, decreased renal clearance in older persons
See Table 44-2 for other Drug nutrient interactions pg. 1095
pg 1095
Anthropometry
measurement system of the size and makeup of the body; height and weight obtained
ideal body weight (IBW)
compare height and weight to standards for height weight relationships
Body Mass Index (BMI)
measures weigt corrected for height and serves as alternative to traditional height-weight relationships. calculate BMI by dividing the client's weight in kilograms by height in meters squared
dysphagia
refers to difficulty when swallowing, causes can be neurogenic, myogenic, and obstructive
Complications of dysphagia
aspiration pneumonia, dehydration, decreased nutritional status, and weight loss
Signs of Dysphagia
cough during eating; change in voice tone or quality after swallowing; abnormalmovements of the mouth, tongue, or lips; and slow, weak, imprecise, or uncoordinated speech
other signs of dsyphagia
Abnormal gag, delayed swallowing, incomplete oral clearance or pocketing, regurgiatation, pharyngeal pooling, delayed or abesnt trigger of swallow and inbaility to speak consistently
Organism, food source and symptoms of Botulism
C. botulinum. Improperly home-canned foods, smoked and salted fish, ham, sausage, shellfish. Symptoms are varied from mild discomfort to death in 24 hours, initially nausea and dizziness, prgressing to motor (respiratory) paralysis.
Organism, food source and symptoms of Escherichia Coli
E. Coli. Underooked ground beef. Severe cramps, nausea, vomitting, diarrhea (may be bloody), renal failure. Appears 1-8 days after eating and lasts 1-7 days.
Organism, food source and symptoms of listeriosis
Listeria or L. monocytogenes. Soft cheese, meath (hot dogs and lunch meats), unpsteurized milk, poultry, seafood. Severe diarrhea, fever, headache, pneumonia, meningitis, endocarditis. Appears 3-21 days after infection.
Organism, food source and symptoms of Perfringens enteritis
Clostridium or C. perfringens. Cooked meats, meat dishes heald at room or warm temp. Mild diarrhea, vomiting. Appears 8-24 hours after eating, lasts 1-2 days.
Organism, food source and symptoms of Salmonellosis
Salmonella or S. typhi, S. paratyphi. Milk, custards, egg dishes, salad dressings, sandwich fillings, polluted shellfish. Mild to severe diarrhea, cramps, vomitting. Appears 12-24 hours after ingestion, lasts 1-7 days.
Organism, food source and symptoms of Shigellosis
Shigella or S. dysenteriae. Milk, milk products, seafood and salad. Mild diarrhea to fatal dysentery. Appears 7-36 hours after ingestion; lasts 3-14 days.
Organism, food source and symptoms of Staphylococcus
Staphylococcus or S. aureus. Custards, cream fillings, processed meats, ham, cheese, ice cream, potato salad, sauces, casseroles. Severe abdominal cramps, pain, vomiting, diarrhea, perspiration, headache, fever, prostration. Appears 1-6 hours after ingestion, lasts 1-2 days.
Clear liquid diet
broth, coffee, tea, clear fruit juices, jello, popsicles.
Full liquid diet
smooth-textured dairy products (ice cream), custard, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices.
Pureed diet
Scrambled eggs, pureed meats, vegetables, and fruits; mashed potatoes and gravy
Mechanical soft diet
Ground or finely diced meats, flacked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter.
Soft/low residue diet
Low fiber, easily digested foods such as pasta, casserole, moist ender meat, canned cooked fruits or vegetables. Desserts, cakes and cookies without nuts or coconut
High fiber diet
Fresh uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruit.
Low sodium diet
4g (no added salt), 2g, 1g or 500 mg sodium diet. These diets vary from no added salt to severe sodium restriction that requires selective food purchases.
Low cholesterol
300 mg/day. Keeps with AMA's guidelines for serum lipid reduction
Diabetic
Usually the caloric intake recommended is 1800/day. The diet needs to include a balanced intake of carbs, fats, and protiens. Caloric recommendations vary to accommodate the client's metabolic demands.
Regular diet
No restrictions, unless specified.
Parenteral nutrition (PN)
form of specialized nutrition support in which nutrients are provided intraveneously.
Lipid emulsions
Provide supplemental kcals and prevent essential fatty acid deficiencies.
Enteral tube feeding complications
pulmonary aspiration, diarrhea, constipation, tube occlusion, tube displacement, abdominal cramping, n&v, delayed gastric emptying, serum electrolyte imbalance, fluid overload, pyerosmolar dehydration, electrolyte imbalance, hyercapnia, hypo/hyperglycemia, hyperglycemic hyperosmolar nonketotic dehydration/coma (HHNC)
Medical nutrition therapy (MNT)
use of specific nutritional therapies to treat an illness, injury or condition.
treatment of Malabsorption symptoms
gluten free diet
Diabetes mellitus Type 1
Requires both insulin and dietary restrictions for optimal control
Diabetes millitus Type 2
Controlled with exercise and diet therapy
nutrition
the study of how food nourishes the body
nutrients
specific biochemical substances used by the body for growth, development, activity, reproduction, lactation, health maintenance, and recovery from illness or injury
macronutrients
essential nutrients that supply energy and build tissue ( such as carbohydrates, fats, and protien) provides calories
micronutrients
vitamins and minerals, are required in much smaller amounts to regulate and control body processes does not provide calories
calories
energy in the diet is measured in the form of kilocalories, commonly abbriviated as cal.
carbohydrates, protein, and fat
provide energy
vitamins and minerals
needed for the metabolism of energy, do not provide calories
kCalories
a measure of energy, the amount of energy that carbohydrates, fats, and protein release
carbohydrates ____kCall = _____ gm
4kcal=1gm
protein ____kCall = _____ gm
4kcal=1gm
fat ____kCall = _____ gm
9kcal=1gm
fat
has a greater energy density, a kind of body tissue containing stored fat that serves as a source of energy
weight gain
if energy intake exceeds energy expenditure you will gain weight
basal metabolism
energy required to carry on the involuntary activites of the body at rest
body mass index (BMI)
ideal body weight
carbohydrate
A class of nutrients made of sugars; these nutrients include sugar, starch, and fiber. All but fiber provide energy. Often referred to in the plural, carbohydrates.
glucose
the form of sugar that circulates in the blood and provides the major source of energy for body tissues. When its level is low, we feel hunger.
monosaccharides
simple sugars (glucose, galactose (from milk), fructose (from fruit))
disaccharides
Carbohydrates that are made up of two monosaccharides, Sucrose, Lactose, Maltose
polysaccharides
, carbohydrates that are made up of more than two monosaccharides.starch, glycogen, and fiber
liver and muscles
where the body stores much of its glucose and glycogen
normal blood sugar
70-100 mg/dl
hypoglycemia
abnormally low blood sugar usually resulting from excessive insulin or a poor diet <70 mg/dl
hyperglycemia
abnormally high blood sugar usually associated with diabetes > 126 mg/dl
prediabetes
diagnosed when fasting glucose levels are higher than normal (100 mg/dl) but lower than 126 mg/dl; people with prediabetes usually develop type II diabetes within 10 years; treat with weight loss and exercise to prevent onset of type II diabetes
insulin and glucagon
work together to keep the level of glucose in the blood stable. insulin stimulates cells in the liver and muscles to remove sugar from the blood and store it as glycogen or fat. glucagon stimulates the liver to break down glycogen and release glucose back into the blood. also stimulates the release of fatty acids from stored fats. made in the pancreas
soluble fiber
water soluble slows gastric emptying, lowers serum cholseterol level, delays glucose absorption, helps improve glucose tolerance, forms gels, easily digested by bacteria in the human large intestine, Sources-fruits, oats, barley, and legumes
celllulose and other insoluble fiber
does not dissolve in water, does not form gels; nondigestible, absorbs water to increase fecal bulk, decrease intestinal transit time, helps relieve constipation EX. strings of celery, hulls of seeds, and skins of corn kernels, fiber retain their structuure and texture even after cooking
recommended dietary allowance
___ is the average daily amount of a nutrient considered adequate to meet the known nutrient needs of practicallly all healthy people, a goal for dietary intake by individuals
ketosis
an abnormal accumulation of ketone bodies that is frequently associated with acidosis
protein
any of a large group of nitrogenous organic compounds that are essential constituents of living cells
digestion of carbohydrate
mouth & teeth: begin digestion
stomach: holds food, mixes food with gastric jucies, slowly empties into small intestines
small intestines: bulk of digestion and nutrient absorption
large intestine: has bacteria that will break down fiber and cellulose
signs and symptoms of inadequate CHO intake
energy deficit,fatigue, wasting of lean tissue, impairment of disease resistance, lowering body temp.,disturbances of the body's fluid and electrolyte balances
energy from CHO is in the form of
heat, muscle contraction, synthesis of essential compounds, conduction of nerve impulses
fat
a member of the class of compounds called lipids. The lipids in food and the human body include triglycerides(fats and oil), phospholipids, and sterols
lipids
in the body serve as energy reserves, protect the body from temperature extremes, cushion the vital organs, and provide the major material of cell membranes
emulsion
A uniform mixture of two unmixable liquids; it is often temporary (for example, oil in water)
trans fat
the least healthy, made to make oils into solids and increase shelf life, high in cholesterol aka "partially hydrogenated"
saturated fat
generally solid at room temperature, originate in animal fats (exception in palm oil and avocados)
cholesterol
a waxy substance produced and needed by the body, also found in animal fats and some plant foods
vitamins
organic molecules that help regulate body processes, often working with enzymes
fat-soluble vitamins
A, D, E, K
minerals
nutrients that are needed by the body in small amounts and are not made by living things
polyunsaturated fatty acids
plant origin, liquid at room tempeture, sunflower oils, some margarines, French dressing, and walnuts
BMI
underweight
<18.5
BMI
normal
18.5-24.9
BMI
overweight
>25.0
water
the major body constituent present in every body cell, accounts for between 50% and 60% of the adult's total weight
The Dietary Guidelines for Americans
Eat a variety of foods, Maintain healthy weight, Choose a diet low in fat, saturated fat, and cholesterol, Choose a diet with plenty of vegetables, fruits, and grain products, Use sugar in moderation, Use sodium and salt in moderation, Avoid alcoholic beverages
anthropometric
measurements including height, weight and other body measurements such as fat composition and head and chest circumferences
linoleic acid: omega-6
polyunsaturated fat sources, found in the seeds of plants and in the oils produced from the seeds
linolenic acid: omega-3
polyunsaturated fat sources, found in fish oil
hemoglobin
female 12.0-16.0
male 13.5-17.5 , iron-containing protein molecule in red blood cells that binds to oxygen and carries it from the lungs to the body's cells
hematocrit
The proportion of blood occupied by erythrocytes after centrifugation (measured in %).

Men (40-54%)
Women (37-47%)
albumin
Protein in blood; maintains the proper amount of water in the blood
3.4-4.8g/dl
total protein
6.4 - 8.4 g/dL
transferrin
Iron binding proteins that inhibit the growth of certain bacteria by reducing amount of available iron; Found in BLOOD and TISSUE FLUIDS

200-400mg/dl
factors affecting eating
culture, religion, socioeconomic, personal preference, emotions, health
Jewish
don;t mix meat and dairy at the same meal (kosher)
clear liquid diets
Contain only foods that are clear liquids at room temp. Gelatin, fat-free broth, bouillon, ice pops, clear juices and carbonated beverages.
full liquid diets
This type of diet includes clear liquids with the addition of cream soups, milk, and ice cream.
soft diets
usually regular diets that have been modified to eliminate foods that are hard to digest and tochew, including those that are high in fiber, high in fat, and highly seasoned
enteral nutrition
nourishment provided through the stomach or small intestine rather than by the oral route is delivered by tube feeding.
parenteral nutrition
The administration of nutritional support via the intravenous route. Can be administered centrally (TPN) or peripherally through (PPN)
nasogastric tube (NG)
Soft tube (rubber or plastic) inserted through a nostril and into the stomach; for instilling liquid foods or other substances or for withdrawing gastric contents
nasointestinal tube (NI)
passed thru the nose an dinto the upper portion of the small intestine
percutaneous endoscopic gastrostomy (PEG)
feeding catheter inserted into the stomach through the skin and subcutaneous tissues of the abdomen
total parenteral nutrition (TPN)
nutritional therapy that bypasses the gastrointestinal tract for patients who are unable to take food orally; meets the patient's nutritional needs by way of nutrient-filled solutions administered intravenously through a central vein
peripheral parenteral nutrition (PPN)
Administration of nutrients directly into veins via IV infusion. Used for patients requiring nutritional support for a limited time, usually lasting less than 3-4 weeks. Requires high fluid volume ~2000mL/day.
Solutions consist of: 2-5% crystalline amnio acid preparations with 5-10% dextrose and added electrolytes and vitamins.
ideal body weight (IBW)
for adult females
100lb(for height of 5 ft) +5lbs for each additional inch over 5 ft
ideal body weight
for adult males
106lb (for height of 5ft ) + 6lbs for each additional inch over 5 ft
BMi
BMI= weight/heightheight 703 if in pound and inches