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NUTRITIONNursing Implications

Heather Wrenn, RN, BSN Fall 2006

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BODY WEIGHT/BODY MASS Ideal body weight Body mass index Percent body fat

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FACTORS AFFECTING NUTRITION Development Gender Ethnicity & culture Beliefs about food Personal preferences Religious practices Lifestyle Medications & therapy – table 45-1

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FACTORS AFFECTING NUTRITION Health Alcohol abuse Advertising Psychologic factors

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NUTRITION THRU THE LIFE CYCLE – Young & Middle Adult Lay foundation for lifetime nutrition pattern in

young adulthood Nutrient requirements change very little Females need to maintain/increase intake of Vit.

C , Vit D, & calcium; & maintain intake of iron Basal metabolism decreases 2-3%/decade after

age 25 Obesity, HTN , & DM may begin to form

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NUTRITION THRU THE LIFE CYCLE – Older Adults Physiologic, psychosocial, economic

changes Need fewer calories Nutrient requirements basically the same Variety & nutrient dense foods; water See Kosier & Erb table 45-2

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Factors Affecting Nutrition:Ethnicity & Culture Native American

Starches: corn, rice Fruits: berries Veggies: rhubarb, mushrooms, roots Meats: game, seafood, nuts Milk: little used

High incidence of lactose intolerance Encourage broiled, poached, steamed meats

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Factors Affecting Nutrition:Ethnicity & Culture U.S. Southern

Starches: cornbread, biscuits, potatoes Fruits: melons, peaches, bananas Veggies: collards, okra, tomatoes, cabbage Meat: pork, chicken, fish Milk: milk, ice cream

Many foods fried, cooked with lard

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Factors Affecting Nutrition:Ethnicity & Culture Mexican

Starches: tortillas, corn products Fruits: few Veggies: chili peppers, tomatoes, onions Meat: beef, poultry, eggs, pinto beans Milk: cheese; rarely drink milk

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Factors Affecting Nutrition:Beliefs & Preferences Individual likes & dislikes Beliefs about foods Fad diets

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Factors Affecting Nutrition:Religious Practices Jewish

Kosher; no pork or shellfish; cannot consume milk or dairy at same meal with meat/poultry

Christianity Catholics Eastern Orthodox Mormons Seventh Day Adventists

Islam No pork or alcohol; daylight fasting during Ramadan

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Factors Affecting Nutrition:Lifestyle Economic & social status Work/activities

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Factors Affecting Nutrition:Medications, Therapy, & Health K&E Table 45-1 – meds Therapies

Chemo, radiation Health

GI disorders, viruses, oral ulcers

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Factors Affecting Nutrition:Alcohol, Advertising, & Psych Alcohol

Can depress appetite Abuse can lead to malnutrition (esp Vit B)

Advertising May influence food choices

Psych Overeat vs. don’t eat when stressed,

depressed

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HEALTHY PEOPLE 2010 http://www.health.gov/healthypeople Goals:

Increase in span of healthy life for Americans Reduction of health disparities among Americans

Target areas: Wt control issues; dietary intake issues; school

nutrition issues;anemia in pregnancy; nutrition education, assessment, planning issues

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DIETARY GUIDELINES FOR AMERICANS Eat a variety of foods Maintain or improve your weight Be physically active every day Eat diet low in trans fat, saturated fat, &

cholesterol Eat plenty of vegetables, fruits, & grains Use sugars in moderation Use salt & sodium in moderation If you drink alcohol, do so in moderation

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FOOD GUIDE PYRAMID Healthy Eating Pyramid Daily exercise & weight control Whole grains at most meals Vegetables in abundance Fruits 2-3 times/day Nuts, legumes 1-3 times/day Fish, poultry, eggs 0-2 times/day Dairy or calcium supplement 1-2 times/day White rice, white bread, potatoes, pasta, sweets, red meat,

butter sparingly MVI for most Alcohol in moderation

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ALTERED NUTRITION Malnutrition – lack of necessary or

appropriate food substances Overnutrition – caloric intake in excess of

daily energy requirements Overweight – BMI 26-30 Obese – BMI > 30 Morbid obesity – interferes with mobility or

breathing

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ALTERED NUTRITION Malnutrition

Undernutrition – intake of nutrients insufficient to meet daily energy requirements as a result of inadequate food intake or improper digestion & absorption of food Dysphagia – difficulty swallowing Anorexia – loss of appetite Protein-calorie malnutrition

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ASSESSMENT Usual eating patterns & habits 24 hour food recall Allergies & intolerances Food frequency record Brief personal & family history Height/weight Ideal body weight Body mass index Manifestations of malnutrition (table 45-4) Social, economic, ethnic, religious factors Other risk factors for altered nutrition

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RISK FACTORS FOR NUTRITIONAL PROBLEMS Diet history

Chewing or swallowing difficulties Inadequate food intake Restricted or fad diets No intake for 10 or more days IVF Inadequate food budget Inadequate food preparation facilities Physical disabilities Living & eating alone

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RISK FACTORS FOR NUTRITIONAL PROBLEMS Medical history

Unintentional wt loss or gain of 10% within 6 months F/E imbalance Oral or GI surgery Dental problems GI problems Chronic illness Alcohol or substance abuse Neurologic or cognitive impairment Catabolic or hypermetabolic condition Adolescent pregnancy or closely spaced pregnancy

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RISK FACTORS FOR NUTRITIONAL PROBLEMS Medication history

Aspirin Antacid Antidepressants Antihypertensives Anti-inflammatory agents Antineoplastic agents Digitalis Laxatives Diuretics Potassium chloride

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PHYSICAL EXAM General appearance & vitality Weight Skin Nails Hair Eyes Lips, tongue, gums, teeth Heart Abdomen Musculoskeletal Neurologic

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ANTHROPOMETRIC MEASUREMENTS Height & weight Skinfold measurements – tricep most

common site

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LABORATORY DATA Albumin & pre-albumin Transferrin Hgb BUN 24 hour urine Total lymphocyte count

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DIAGNOSING Altered nutrition: more than body requirements Altered nutrition: less than body requirements Altered nutrition: risk for more than body

requirements Fluid volume excess, fluid volume deficit, & risk

for fluid volume deficit Activity intolerance Constipation Risk for Impaired Skin Integrity

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PLANNING Client will:

Maintain I&O balance Consume proper amounts of foods from

variety of food groups Comply with diet therapy Tolerate tube feedings Not have any complications assoc with

malnutrition

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IMPLEMENTING - Teaching Use established nutritional standards Use visualization of serving sizes to help

ID accurate serving sizes Incorporate culturally based intake patterns

or restrictions Include client & family Collaborate with dietician

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IMPLEMENTINGSpecial Diets Vegetarian

Vegan Ovo-vegetarian Lacto-vegetarian Lacto-ovo-vegetarian

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IMPLEMENTINGSpecial Diets NPO – nothing by mouth Clear liquid diet – water, tea, coffee, clear broths,

gingerale, plain gelatin Full liquid diet – clears; milk; cooked cereals,

pudding, ice cream, cream soup; Soft diet – easily chewed & digested Dysphagia – thickened liquids Diet as tolerated

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IMPLEMENTINGStimulating Appetite Relieve illness symptoms that depress appetite prior to

mealtime Provide familiar food that person likes served at

proper temp. Select small portions Avoid unpleasant or uncomfortable treatments or

activity immediately before/after meals Provide tidy, clean environment Encourage or provide oral hygiene before mealtime Reduce psychologic stress

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IMPLEMENTINGAssisting with Meals Help client feed self when possible Assist client to sit on side of bed or chair if possible Check tray for client’s name, type of diet, & completeness “which order would you like to eat?” Spread napkin, cut foods, shell egg, etc. Do not rush client; allow ample time Offer fluids every 3 or 4 mouthfuls of food if client unable

to communicate Use adaptive feeding aids as needed For blind person, identify placement of food as you would

describe time on a clock

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IMPLEMENTINGSpecial Supplements Oral

Provide calories & nutrients Can be liquid or powdered Specific types

Tube Feeds When condition prevents food intake Impairment in upper GI tract, otherwise fx GI tract Increased metabolic needs that oral intake can’t meet

Parenteral Nutrition IV nutrients (TPN, PPN)

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IMPLEMENTINGSpecial Supplements TPN

Nonfunctional GI tract Severely malnourished needing specific

supplements PPN

Nonfunctional GI tract Moderate nutritional deficiencies

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IMPLEMENTINGEnteral Nutrition Enteral access devices

NGT (short term) Small-bore feeding tube PEG (long term)

Parenteral IV

TPN - central line PPN – peripheral IV

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IMPLEMENTINGNasogastric Feeding Types of NGT

Levin, salem sump, corpak Verify tube placement

Gastric secretions pH Air bolus Xray S/S of distress

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IMPLEMENTINGEnteral Feedings

May be continuous , intermittent, or bolus Before feeding

Determine allergies, assess MD order Prepare client & inspect/verify formula Assess tube placement Assess residual (q 4h) Flush with water

Administer at room temperature Feeding must infuse within 8 hours Never add fresh to formula hanging Tubing & container change q 24h Check residual q4h

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EVALUATINGEnteral Feeds Daily wt I & O Labs Monitor for complications

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IMPLEMENTINGParenteral Nutrition

Continuous or intermittent Refrigerate solution unless using immediately Read label & double check against order for all

ingredients; double check with another nurse Monitor IV site – dedicated line New bag, tubing, filter q 24 hours Aseptic technique Monitor glucose levels & other labs Must wean off

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EVALUATINGParenteral Nutrition VS I & O Daily wt Daily/weekly labs Monitor for complications

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IMPLEMENTINGSpecial Community Services Meals-on-Wheels Grocery delivery services Food stamp program

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IMPLEMENTINGHome Care Teaching Preparation of formula Proper storage of formula Administration of feeding Mgmt of enteral or parenteral access device Daily monitoring needs S/S of complications to report Who to contact with questions/problems

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EVALUATING If outcomes not achieved,

Was cause of problem correctly identified? Was family included in teaching plan? Are they

supportive? Is client experiencing symptoms that cause loss of

appetite? Were outcomes unrealistic for this person? Were client’s food preferences considered? Is anything interfering with digestion or absorption

of nutrients?