NCLEX Review

Nutrition

Fat Soluble Vitamins• Vitamin A (Retinol) occuvite

– Needed for: Vision, skin, immune system and mucous membranes

• Stored in liver

– Foods: • Vegetables: Dark green, yellow, orange• Fruits: Apricots, Cantaloupe• Beef liver

– Deficiency causes night blindness to total blindness

• Vitamin D (Cholecalciferol) – Aids in absorption of calcium– Naturally occurring: Human body and Fish liver oil – Foods: Cream, Butter, Egg Yolks, Milk– Severe deficiency causes Rickets

Fat-Soluble Vitamins• Vitamin E (tocopherol)

– Strong Antioxidant needed for cell wall structure– Premature infants lack this causing Hemolytic

Anemia– Deficiency: Disrupts synthesis of myelin– Foods: Raw avocado and mango, Almonds,

hazelnuts and peanuts and oils

• Vitamin K (-quinone)– Needed for blood-clotting and bone development– ½ of our Vit K is supplied by intestinal bacteria– Foods: Leafy greens

Water Soluble Vitamins• Vitamin C (ascorbic acid)

– Needed for antioxidant, connective tissue, iron absorption

– Deficiency: Scurvy– Foods: Citric fruits

• Vitamin B1 (thiamin)– Needed for energy production and storage– Deficiency: beriberi (“I can’t I can’t”) In the US

Alcoholics are at risk– Foods: Wheat germ, grains, lean pork, beef,

liver, and legumes

Water Soluble Vitamins• Vitamin B2 (riboflavin)

– Needed for energy production and tissue health and growth. Also an antioxidant

– Deficiency: cracked lips, swollen, red tongue, burning, itching, or tearing eyesand scaly greasy dermatitis

– Foods: Milk (keep from light) and liver

• Vitamin B3 (niacin)– Needed for energy production, high doses can reduce

LDL and Triglycerides– Deficiency: Pellagra: Dermatitis, diarrhea, dementia,

death– Foods: Meat, avocado, bread products

Water Soluble Vitamins• Vitamin B6 (pyridoxine)

– Needed for metabolism, hemoglobin synthesis, neurotransmitter synthesis

– Deficiency: CNS dysfunction and certain anemias– Foods: Grains and meats

• Folate (folic acid)– Needed for DNA synthesis and hemoglobin formation– Deficiency: Megaloblastic anemia during pregnancy

and diet deficiencies, Neural Tube Defects: spina bifida and anencephaly

– Foods: Chicken and beef liver, spinach, yeast and beans

Water Soluble Vitamins

• Vitamin B12 (cobalamin)– Needed for blood formation and nervous

system function– Deficiency: Anemia, seen in intrinsic factor

deficiency (Pernicious Anemia) and vegans– Foods: Beef and Chicken liver, clams, crab,

oysters and mussels

Minerals• Calcium

– Needed for Bone and tooth formation, blood clotting, muscle and nerve action

– Deficiency: (Common in postmenopause and chronic renal failure) Osteoporosis, Tetany (muscle spasm) and hyperreflexia, and hyperphosphatemia

– Foods: Milk and milk products, dried figs, and sardines

• Phosphorus– Needed for calcium regulation, energy metabolism,

and acid-base balance– Deficiency: Hypercalcemia (confusion, lethargy,

dysrhythmias)– Foods: High protein foods usually have high

phosphorus, and carbonated drinks

Minerals• Sodium

– Needed for fluid balance, acid-base balance and muscle action

– Deficiency: Usually caused by excessive sweating or diarrhea, can lead to: weakness, drowsiness, or seizures

– Foods: Table salt, meat/animal products, and processed foods

• Potassium– Needed for fluid balance, conversion of blood glucose to

stored glycogen, muscle action, and release of insulin from pancreatic cells

– Deficiency: Seen in vomiting/diarrhea, non-K sparing diuretics, severe malnutrition, or surgery. Leads to muscle (all) weakness

– Foods: Unprocessed fruits and vegetables: Avocado, dried figs, pinto beans and soybeans

Minerals• Magnesium

– Deficiency seen in alcoholics, and leads to muscle weakness

• Iron – Needed for hemoglobin synthesis and metabolism– Deficiency leads to anemia and primarily caused by

deficient diet – Foods: Beef (esp. liver), black-eyed peas, oysters and

clams, and Cream of Wheat

• Iodine– Deficiency leads to hypothyroidism (goiter)– Foods: Most processed foods and table salt is iodized

Protein• Complete proteins

– Animal origin

• Incomplete proteins– Plant origin

• Vegetarians/Vegans– Teach complementary proteins

• Grains and lentils or beans– Peanut butter and bread– Rice and dal– Tofu and rice

• Legumes and seeds– Soybeans and pumpkin seeds

• Grains and Dairy– Pasta and cheese– Cereal and milk

Gastroesophageal Reflux Diseaseaka GERD

• Severe reflux (heartburn) 30-60 minutes after eating

• Pain may mimic cardiac chest pain (radiation to arm, neck, jaws)

• Causes– Hiatal Hernia– Pregnancy– Obesity– Aggressive Vomiting – NG Tubes

Acid Stimulating Agents• Food intake

– Stimulates acid production– Avoid constant snacking during the day

• Large meals – Distend the stomach leaving the esophageal

sphincter slightly open

• Milk – Stimulates more acid than it can buffer

• Seasonings– Peppermint and Spearmint– Hot chili peppers, Black pepper, Chili powder

Acid Stimulating Agents

• Coffee, Tea, Soda, Chocolate– Individual tolerance– Regular and decaf

• Citric Acid Juices and Tomato Juice

• Alcohol– Concentrated 40% (80 proof)– Beer

• Smoking – Affects acid production, ulcer healing, and the

effectiveness of drug therapy

General Care of GERD

• Increase protein and decrease fat• Decrease size of meals and increase number of

meals• Drink between meals and sip liquids during meal• Sit upright for 2 hours after eating• Elevate HOB at night• Avoid constipation• Stop smoking• Avoid NSAIDs and Anticholinergics when possible• Decrease stress• Avoid tight fitting clothing

Diarrhea• DEHYDRATION

– Orthostatic hypotension• Decrease BP, increase HR, dizziness

– Replace fluids (not just water)

• Electrolyte loss– Sodium and Potassium– May cause weakness, drowsiness– Extremely low sodium levels may cause seizure

• Metabolic Acidosis– Bicarbonate loss

• Modified BRAT Diet – Only until regular diet tolerated

Upper GI Loss• Caused by: Vomiting or NG suction• Vomiting: Aspiration Risk• Fluid Loss• Electrolyte Loss

– Sodium, Chlorine (which will affect other electrolytes)– NG Flushing to be done with NS

• Metabolic Alkalosis– Hydrogen loss (Gastric Acid: HCl)

Absorption Disorders• Celiac Disease or SprueCeliac Disease or Sprue

– Ingestion of gluten (found in grains) causes damaging changes in the GI tract and malabsorption of vitamins, minerals, and calories

– Diet• Replace Grain products with corn or rice products• Increase calories (protein)• Decrease fats• Carbs should be simple (fruits)

– Supplements• Vitamins: A, B, C, D, and E• Minerals: Iron (if anemic)

Absorption Disorders

• Cystic Fibrosis– Genetic Disorder causing increased

secretions and decreased pancreatic enzymes

– Nutrition defecits• Malabsorption• Sodium loss through perspiration

– Diet • Higher calorie: Protein• Vitamin Supplements: Fat soluble• Pancreatic Enzyme Replacement: Pancrease

Bowel Disorders• Ulcerative Colitis and Crohn’s Disease

– High protein and calorie– Vitamin and mineral supplements– Avoid gas producing foods– Bulk-forming agents

• Diverticular Disease– Increase fiber as tolerated, but avoid indigestible roughage– Avoid seeds, nuts, popcorn, dried fruit (raisins)

• IBS– Increase fiber, decrease fat– Smaller meals– Avoid carbonated beverages and gum chewing– Pay attention to triggering foods

• Constipation– Increase activity, fiber, and maintain hydration

Liver Disorders• Hepatitis

– High protein, carbs, calories– Moderate fats

• Cirrhosis– High protein– Low sodium, fluid restriction as ordered– Diets for PUD and varices

• See GERD slides• Soft texture

– B-VITAMINS!!!!! and folate – NO ALCOHOL

Gallbladder/Pancreatic Diseases

• Cholecystitis and Cholelithiasis– Low Fat diets (even the good fats)

• Pancreatitis– Acute- IV nutrition– Chronic-

• Low-fat, small meals, may need supplements • Avoid: alcohol, caffeine and nicotine• Pancreatic Enzymes• Insulin?

Kidney Diseases• Acute Renal Failure

– Increase carbs– Decrease sodium and potassium

• End-Stage Renal Disease– As above, add low phosphorus– Moderate protein (just enough)

• Nephrotic Syndrome or Nephrosis– Low sodium , Moderate protein (just enough)

• Acute Glomerulonephritis – Increase carbs, high calorie– Protein, sodium and fluid restriction

• Chronic Glomerulonephritis– Same as above

• Polycystic Kidney Disease– Increase sodium

Stones• Calcium phosphate

– Decrease dietary calcium, avoid excess Vit. D

• Calcium Oxalate – Avoid oxalate rich foods

• Tea, almonds, cashews, chocolate, cocoa, beans, spinach, rhubarb

• Struvite– Limit high phosphorus foods (dairy, red/organ meats, and

whole grains)

• Uric Acid – Limit purines (organ meat, gravy, red wine, sardines

• Cystine– Limit methionine (meat, cheese, eggs, and milk)– Increase fluid intake to 3L/day

Ash Diets

• Alkaline Ash Diet (Uric Acid Stones)– Increases pH (reduces acidity of urine)– Milk, fruits (except cranberries, plums, prunes),

rhubarb, vegetables, small amounts of meats: Beef, halibut, veal, trout, and salmon

• Acid Ash Diet (?)– Decreases pH (increases acidity of urine)– Cheese, eggs, meat, fish, oysters, poultry, bread,

cereal, whole grains, pastries, cranberries, prunes, plums, tomatoes, corn and legumes

Burn/Thermal Injuries• Stage 1- Up to 48 hours

– Hypovolemia– Replace fluid and

electrolytes

• Stage 2- 48-72 hours– Fluid overload a concern– Possible electrolyte toxicity

• Stage 3- Over 72 hours– Increase in metabolism– Increase urine output

Burn/Thermal Injuries• Stage 4- Healing

– Increase protein (2) and calories (2-3)– 25% Protein, 50% Carbs, 25% Fat– Vitamins: A (immune), B (energy and protein

metabolism), C (tissue rebuilding)– Minerals: Iron (anemia), Zinc (immune),

Calcium/Phosphorus Balance

– Curling’s Ulcer

Endocrine• Diabetes

– Carbs (low simple sugars),

1 exchange = 15 carbs

3-4 exchanges/meal

1 exchange for snacks– Protein

• Thyroid– Hyper- increase calories– Hypo- decrease calories

• Parathyroid– Hyper- decrease calcium– Hypo- increase calcium

Cardiac• Atherosclerosis

– Low fat, low cholesterol

• CHF– Low sodium, fluid restriction– Watch potassium

• Anemia– Iron, folic acid, B12– Z-track Iron injections

Hypertension and CHF

• Sodium-Restricted Diet– Mild

• 2-3 g sodium per day

– Moderate• 1 g sodium per day

– Strict• 500 mg sodium per day

Hypertension• DASH Diet

– Dietary Approaches to Stop Hypertension

• 4-6 servings of fruits per day• 4-6 servings of vegetables per

day• 2-3 servings of low fat dairy

foods per day• Lean meats and high fiber

grains

Cardiovascular Disease

Modifying Risk Factors

• TLC Diet (Therapeutic Lifestyle Changes)– Calories taken in should equal calories used in a day– Reduce total fat intake to less than 30% of calorie

intake– Reduce saturated fats to 7%, polyunsaturated fat to

10%, and monounsaturated fat to 20% of total fat intake

– Reduce cholesterol to 200 mg/day– Complex carbohydrates should make up about 50%

of calorie intake– Increase soluble fiber to 10-25g– Protein should account for 15% of calorie intake– Diet rich in vegetables, fruits, whole grains, low in

trans fats and saturated fats

Peri-operative• Pre-op

– Protein – Vitamin K

• Post-op– Protein– Iron (with vitamin C)– Vitamin A, B, C– Potassium– ADAT in 24-48 hours– AMBULATE

Pediatrics

• Food Progression (one at a time)– Iron fortified cereal, fruits/vegetables

(cooked/mashed), meats (strained), toast– Non-reduced fat milk- end of first year

• Hydrocephalus– Small feedings

• Pyloric Stenosis– After feeding

• HOB up 60 degrees• Position on Right side

Miscellaneous• Anorexia

– Attractive food

• Neutropenic Precautions– Peeled fruits and veggies only

• Rheumatoid Arthritis– Increase protein during acute attacks

• Dumping Syndrome– Decrease fluids with meals

• Lithium (salt)– Increase fluids

• COPD– Carbs