GI Edapt Notes.pdf

Idan (pronouns: he/him/his) has been admitted to the hospital for a bowel obstruction. During the admission assessment, Idan identifies himself as a practicing Jew who follows kosher dietary practices. Which statement made by the nurse is most appropriate? “You will be NPO for now, so we can discus...

Idan (pronouns: he/him/his) has been admitted to the hospital for a bowel obstruction. During the admission assessment, Idan identifies himself as a practicing Jew who follows kosher dietary practices. Which statement made by the nurse is most appropriate? “You will be NPO for now, so we can discuss your diet later.” “While in the hospital, you will not be able to follow Kosher practices.” “Your family can cook your food at home and bring it to you.” “I will document your preferences in your chart.” The nurse is teaching recommended daily nutritional intake to a group of nursing students. Which proportions are correct? 34% Protein 33% Carbohydrates 33% Fats 25% Protein 30% Carbohydrates 45% Fats 30% Protein 55% Carbohydrates 15% Fats 55% Protein 35% Carbohydrates 10% Fats Which health problems are associated with metabolic syndrome? Select all that apply. High blood glucose Infertility Osteoarthritis Low lipid levels Hypertension Good nutritional intake and daily physical activity are vital for a healthy lifestyle. The client’s age, gender, past and current medical history, physical activity, and body type all influence their required caloric intake for the day. A middle-aged person who has a chronic illness is going to have different daily caloric requirements than someone who is younger and healthy. Remember, energy needs may be greater during illnesses. The common components of nutritional intake include: Carbohydrates Carbohydrates are the body’s primary source of energy and are classified as either simple or complex. 45%–65% of total calories should come from carbohydrates. Fats The two types of fats are potentially harmful (saturated fat/trans fat) and healthier dietary fats (monounsaturated and polyunsaturated fats). Diets high in excessive calories (usually due to high fat intake) contribute to the development of obesity. Fats should be no more than 20%–35% of total calories. Proteins Proteins are required for tissue growth, repair and maintenance, body regulatory functions, and energy production. 10%–35% of daily caloric intake should be from protein. Vitamins Vitamins are organic compounds required in small amounts for normal metabolism. Metabolic Syndrome Metabolic syndrome is not a disease but a group of factors placing a client at risk for cardiac disease, hypertension, cerebral vascular accidents (CVA), and diabetes mellitus type 2. Clients who have altered nutrition, as evidenced by overnutrition, have an increased risk for metabolic syndrome. Medical diagnosis by a healthcare professional consists of having a certain number of risk factors and leading to adverse health outcomes. Image Description Diets Some diets can put clients at an increased risk of vitamin or protein deficiencies, while others can provide too many nutrients, leading to overnutrition. For example, some types of vegetarian diets exclude red meat, placing a client at higher risk of developing vitamin, iron, or protein deficiencies. Certain variations of vegetarianism, such as a client who excludes all meat and animal products, are at risk for developing cobalamin (vitamin B12) deficiencies as this vitamin is fortified or found in higher amounts in animal proteins. Nutritional Assessment Cultural preferences are important factors to consider when conducting a nutritional assessment. People have unique cultural values and beliefs regarding food and unique times to eat, which may affect eating habits. Culture and religion may also influence what foods are considered acceptable, how they are prepared, and how and who prepares them. For example: • A client who follows the Hindu faith may follow the Halal dietary practice and require avoidance of certain meats and meat preparations. • A client with ulcerative colitis who follows Jewish dietary practice may find comfort in knowing that enteral feeding preparations will be prepared kosher. A thorough nutrition assessment can help clients trust in the care being provided and feel supported in their beliefs while they heal. Obesity and Weight Classifications In discussions about altered nutrition, it is important to discuss the concept of obesity or an excessively high amount of body fat or tissue. Obesity is a major risk factor for multiple disease processes and healing issues, including heart disease, stroke, diabetes mellitus, and more. Attitudes about obesity can create a bias or discrimination toward clients who are obese. Obesity must be viewed and treated as a chronic disease. The most common measure of obesity is the body mass index (BMI). BMI is calculated by dividing a client’s weight (in kilograms) by the square of their height (in meters). While the BMI calculation is easy, cost-effective, and reliable, other factors must be taken into consideration, such as the client’s age, gender, and body build. For example, a bodybuilder may have a BMI that is technically classified as obese but, because of their high muscle mass, the BMI may not be an accurate indicator. Other measures, such as waist circumference, are another tool to assess obesity. Health risks increase if a client has a waist circumference of greater than 40 inches in men or 35 inches in women. With obesity, the client is at risk of developing metabolic syndrome. Metabolic syndrome is a group of risk factors that increase a client’s chance of developing cardiovascular disease, stroke, and diabetes mellitus. Obesity is one of those risk factors, along with hypertension, abnormal lipid levels, and high blood glucose levels. Image Transcript Idan (pronouns: he/him/his) is postoperative day 3 from a bowel obstruction. He currently has a nasogastric (NG) tube for nutrition and medication administration. The healthcare provider has prescribed enteral feeding. Idan is concerned about the formula not following kosher dietary practices. Which statement made by the nurse is most appropriate? “Enteral formulas are usually kosher prepared, I will check to make sure.” “You aren’t actually drinking the formula, so kosher rules do not apply.” “You don’t need to follow kosher rules when you’re sick.” “I will call the healthcare provider to switch your order for parenteral nutrition instead.” Idan (pronouns: he/him/his) is postoperative day 3 from a bowel obstruction. He currently has a nasogastric (NG) tube for nutrition and medication administration. The healthcare provider has prescribed enteral feeding. Idan is concerned about the formula not following kosher dietary practices. What is the most appropriate nursing action? The nurse asks Idan to explain his kosher preferences. The nurse asks a Jewish colleague to come and talk to Idan instead. The nurse excuses themselves to read an internet article on kosher food preparation to answer Idan’s question. The nurse tells Idan that since his bowel obstruction was surgically corrected, it cannot reoccur. Health Risks and Obesity Obesity is a disease that is categorized with other chronic diseases, such as hypertension or diabetes mellitus. The risk of secondary health issues is elevated in clients who are obese, so it is vital for healthcare providers to work on educating clients to prevent further risks. The consequences of obesity are not only physical but psychosocial. Stigma and discrimination surrounding obesity occur in various environments, such as: • employment • education • healthcare Major depressive disorders, social withdrawal, and anxiety are common. As a nurse, it is important to understand potential mental health concerns. Review some risk factors and complications of obesity by selecting each tab. Cardiovascular Disease Obesity is a significant risk factor for cardiovascular disease. Android obesity (an “apple-shaped” body with fat primarily located in the abdominal area) is the best predictor of this risk. Hypertension, chronic inflammation of vessels, and poor perfusion can cause systemic issues for health and healing. The excessive weight on the client’s chest can also increase the risk of developing sleep apnea. Insulin Effectiveness Excessive weight decreases the effectiveness of insulin, making obesity a major risk factor for type II diabetes mellitus. It also complicates the management of diabetes by increasing insulin resistance and glucose intolerance, making medications that would normally treat these processes less effective than in an individual of normal weight. Osteoarthritis Extra stress on the joints increases the incidence of osteoarthritis (OA) in clients who are obese, especially in the knees and hips. While joint replacements are an option for these clients, the recovery is more strenuous and complicated in the obese client. Cancer Obesity is the most important preventable cause of cancer. Cancers such as breast, endometrial, and kidney are all highly linked to excessive body fat. This is another reason why education for clients is vital to their longterm health goals. Surgical Interventions Surgical interventions involve a higher risk in clients with obesity. Laying completely supine may be difficult for some clients as the extra weight is directly over their chest area, making breathing difficult. A patent airway may be more difficult to obtain, and anesthesia may metabolize at a different rate due to the size of the client. Nursing Management of Obesity Review this slideshow to learn about nursing management of obesity. Goals Like assessing a client who smokes, it is important to see if clients who are obese are ready to make a change in their lifestyle. Understanding any barriers to compliance with dietary, exercise, or medication changes will help the client be successful long-term. It can be an incredibly challenging healthcare problem to manage and overcome, but with thoughtful planning, implementation, and resources, clients can be prosperous. Overall goals for plans of care are that the client who is obese will: • • • • modify eating patterns participate in regular physical activity achieve and maintain weight loss to a discussed level minimize or prevent health problems related to obesity Nursing Management of Obesity Review this slideshow to learn about nursing management of obesity. Acute-Care Setting In the acute-care setting, some different equipment may be necessary to safely take care of clients who are obese. Larger blood pressure cuffs may be appropriate for the client to accurately assess vital signs. A bariatric bed (a hospital bed with a higher weight capacity and a larger bedframe) may also be appropriate. Shower chairs, scales, commodes, bedside chairs, and hospital gowns are all available in larger sizes if necessary. More staff members may be needed to assist in transferring or moving clients who are obese. While these tools may be needed to help safely care for the client, it is also important not to draw any unnecessary attention to these changes as the client may already have mental health concerns related to their weight. It is also important to remember the changes that must occur with medication administration. Larger or longer needles may be required for subcutaneous or intramuscular (IM) injections in clients who are obese. Nursing Management of Obesity Review this slideshow to learn about nursing management of obesity. Planning Care Planning care for clients who are obese centers around realistic goals. Are we setting the client up for success? Is the goal achievable? Is it appropriate for the individual? Exploring a client’s motivation for weight loss can be beneficial in adhering to their plan of care. Ask the client what they like to do and incorporate that into a physical activity routine. For example, a client with a dog can take them on walks around the block at least three times a day. The client who does not know how to swim should probably not be forced into a water aerobics class. Nursing Management of Obesity Review this slideshow to learn about nursing management of obesity. Diet Recommendations While there is no “magic diet” to ensure consistent and safe weight loss, encouraging dietary intake with fewer calories than energy requirements is a cornerstone in weight reduction. It is best to recommend a diet that includes adequate amounts of fruits and vegetables, provides enough bulk/fiber to avoid constipation, and meets daily vitamin requirements. Very low-calorie diets (less than 800 calories a day) are not sustainable on a long-term basis. These diets should only be under the supervised care of a healthcare provider who can routinely monitor the client. A multicomponent, interdisciplinary approach to weight loss and lifestyle changes is the best chance the client has at compliance and sustainability. This can include nutritional therapy, exercise, behavioral modification, and, for some, drugs and surgical interventions. What would be appropriate long-term goals for Carol (pronouns: she/her/hers) who had gastric bypass surgery? Select all that apply. Begin a low-carbohydrate, high-protein, and low-fat diet with one “cheat day” per week. Maintain a daily physical exercise program. Attain her goal weight within 8 months of her surgery. Be free from signs of malnutrition. Join a community support group. Behavioral and Lifestyle Modifications The nurse is attending a community event for clients who are obese and teaching about behavior modifications and lifestyle changes to lose weight. Which nursing action is most appropriate? Discuss the benefits of eating frequent, small meals throughout the day instead of scheduled mealtimes. Teach clients to eat fast to feel fuller longer. Encourage clients to plan rewards, such as sugarless candy, for achieving their weight loss and exercise goals. Ask clients what types of situations make them want to eat or increase their appetites. Surgical Management of Obesity Surgical interventions may be an option for some clients. Bariatric surgery, or surgery on the stomach and/or intestines, has become a viable option for treatment for those with morbid obesity. Surgery has been the only treatment that has been found to have a successful and lasting impact on sustained weight loss, but it does have necessary lifestyle modifications and associated risks/complications. Bariatric Surgery Clients who have a body mass index (BMI) of 40 kg/m2, or a BMI of 35 kg/m2 with associated obesity comorbidities (diabetes mellitus, heart failure, hypertension, etc.) could consider bariatric surgery. Before being accepted for the procedure, the clients must undergo psychological, physical, and behavioral assessments to identify concerns or barriers such as untreated depression, binge eating disorders, or substance and alcohol misuse. Two bariatric surgeries are the gastric sleeve (sleeve gastrectomy) and the Roux-en-Y gastric bypass (RYGB). Details of these procedures are provided on the next slides. Surgical Management of Obesity Surgical interventions may be an option for some clients. Bariatric surgery, or surgery on the stomach and/or intestines, has become a viable option for treatment for those with morbid obesity. Surgery has been the only treatment that has been found to have a successful and lasting impact on sustained weight loss, but it does have necessary lifestyle modifications and associated risks/complications. Gastric Sleeve The sleeve gastrectomy is a surgical intervention where approximately 75% of the stomach is removed. This is considered a restrictive surgery. With only 25% of the stomach remaining, clients feel full more quickly. Although the stomach loses the majority of its capacity, its function remains intact. The remaining portion of the stomach, however, can stretch back to almost normal capacity if the client is not adherent to their therapies. Surgical Management of Obesity Surgical interventions may be an option for some clients. Bariatric surgery, or surgery on the stomach and/or intestines, has become a viable option for treatment for those with morbid obesity. Surgery has been the only treatment that has been found to have a successful and lasting impact on sustained weight loss, but it does have necessary lifestyle modifications and associated risks/complications. Roux-en-Y Gastric Bypass The Roux-en-Y gastric bypass (RYGB) is a combination of restrictive and malabsorptive surgery. It is the most commonly performed bariatric surgery in the U.S. and is considered the gold standard for bariatric procedures. A small gastric pouch is created which is attached directly to the small intestine. After the procedure, food bypasses 90% of the stomach, the duodenum, and a small segment of the jejunum (so less food is absorbed). A complication of RYGB is dumping syndrome. This is where the gastric contents empty too quickly into the small intestine, overwhelming its ability to digest nutrients. Clients with dumping syndrome may exhibit signs such as vomiting, sweating, and weakness. It is important to educate clients to avoid eating sugary foods and to not drink fluids with (only before or after) their meals after surgery to avoid dumping syndrome. Surgical Management of Obesity Surgical interventions may be an option for some clients. Bariatric surgery, or surgery on the stomach and/or intestines, has become a viable option for treatment for those with morbid obesity. Surgery has been the only treatment that has been found to have a successful and lasting impact on sustained weight loss, but it does have necessary lifestyle modifications and associated risks/complications. Post-operative The focus of care is on any complications, electrolyte imbalances, and monitoring for surgical anastomosis leaks. The client’s head should be at a 35- to 40-degree angle to reduce abdominal pressure and increase lung expansion. Using deep vein thrombosis (DVT) prophylaxis, such as sequential compression devices or compression stockings and low-dose heparin, is important to avoid DVT risks post-operatively. Clients may also experience considerable amounts of abdominal pain after bariatric surgery. Surgical Management of Obesity Surgical interventions may be an option for some clients. Bariatric surgery, or surgery on the stomach and/or intestines, has become a viable option for treatment for those with morbid obesity. Surgery has been the only treatment that has been found to have a successful and lasting impact on sustained weight loss, but it does have necessary lifestyle modifications and associated risks/complications. Nursing Considerations • Abdominal wounds require frequent assessment and observation for signs of infection, inflammation, or hemorrhage. To ease pain and promote comfort, remind the client to splint or brace their incision (for example, with a pillow) while coughing and deep breathing. • During the immediate post-operative period, 30 mL of water and sugar-free liquids should be offered every 2 hours while awake. • Clients will transition to a high-protein liquid diet before discharge. • Client teaching includes eating slowly, stopping eating when feeling full, and not consuming liquids with solid food. A registered dietitian is a part of the multidisciplinary team, providing teaching, and can help with acclimating the client to a new diet lifestyle. During the post-operative period, which nursing actions are most appropriate for a client with gastric bypass surgery? Select all that apply. Teach the client to eat slowly and to stop eating when feeling full. Discuss the importance of a high-protein, liquid diet before discharge. Teach the client how to use a pillow to brace an incision while coughing. Provide the client with 240 mL of water to drink every 2 hours while awake. Teach the client to drink liquids while eating solid foods. Case Study: Alyssa Alyssa Smith : 48-year-old female Allergies: Latex Weight: 349.8 lb Height: 5’ 4” Past Medical History: Asthma, diabetes mellitus type 2, gastroesophageal reflux disease (GERD), hypertension Alyssa (pronouns: she/her/hers) arrives at the healthcare provider’s office for an annual physical. The nurse is conducting a nutritional assessment and inquires about her 50-pound weight gain over the last year. Alyssa states that the only reason she is at her current weight and has health problems is due to genetics, not because of food intake or lack of exercise. Recognizing Cues Calculate Alyssa’s body mass index (BMI). Alyssa's BMI falls into the category of: Obese Normal weight Extreme obesity Overweight Underweight Case Study: Alyssa Alyssa Smith : 48-year-old female Allergies: Latex Weight: 349.8 lb Height: 5’ 4” Past Medical History: Asthma, diabetes mellitus type 2, gastroesophageal reflux disease (GERD), hypertension Alyssa (pronouns: she/her/hers) arrives at the healthcare provider’s office for an annual physical. The nurse is conducting a nutritional assessment and inquires about her 50-pound weight gain over the last year. Alyssa states that the only reason she is at her current weight and has health problems is due to genetics, not because of food intake or lack of exercise. Analyzing Cues Alyssa has made an informed decision to undergo a sleeve gastrectomy. She has arrived at the preoperative surgical area and is placed on a hospital cart. She presses her call light button for help to the bathroom. The nurse and a student nurse have arrived to help. Which statement made by the student nurse needs immediate attention by the nurse? “I will get the unlicensed assistive personnel (UAP) to help her.” “We can’t help move her alone! I’m getting five more staff members for this.” “Is Alyssa allowed to stand before surgery?” “I am going to get Alyssa some nonskid socks from the supply closet.” Case Study: Alyssa Alyssa Smith : 48-year-old female Allergies: Latex Weight: 349.8 lb Height: 5’ 4” Past Medical History: Asthma, diabetes mellitus type 2, gastroesophageal reflux disease (GERD), hypertension Alyssa (pronouns: she/her/hers) arrives at the healthcare provider’s office for an annual physical. The nurse is conducting a nutritional assessment and inquires about her 50-pound weight gain over the last year. Alyssa states that the only reason she is at her current weight and has health problems is due to genetics, not because of food intake or lack of exercise. Prioritizing Hypotheses Which priority nursing diagnosis is currently most appropriate for this client? Disturbed body image Ineffective coping Increased social isolation Risk for injury Case Study: Alyssa Alyssa Smith : 48-year-old female Allergies: Latex Weight: 349.8 lb Height: 5’ 4” Past Medical History: Asthma, diabetes mellitus type 2, gastroesophageal reflux disease (GERD), hypertension Alyssa (pronouns: she/her/hers) arrives at the healthcare provider’s office for an annual physical. The nurse is conducting a nutritional assessment and inquires about her 50-pound weight gain over the last year. Alyssa states that the only reason she is at her current weight and has health problems is due to genetics, not because of food intake or lack of exercise. Question 2 / 3 Taking Action An unlicensed assistive personnel (UAP) has been assigned to work with Alyssa’s nurse on the unit. Which tasks could the nurse delegate to an unlicensed assistive personnel (UAP)? Select all that apply. Create a passive range of motion schedule for Alyssa. Obtain compression socks . Stock the room with a bariatric gown and large adult blood pressure cuff . Place a NPO sign at the head of the bed . A client who is obese and has inflammatory bowel disease is tearful, alerting the unlicensed assistive personnel (UAP) of pain 9 out of 10 on the pain scale. The UAP reports the clinical findings back to the primary nurse. The primary nurse enters the room and the client says, “I’m so sorry to put my call light on. I know I must be a bother to you all. I know caring for me can be more complicated because of my size. The pain will go away. Thank you for checking on me.” Which action taken by the nurse is the best therapeutic response? Sit with the client and ask about the pain they are experiencing. Thank the client and leave the room quietly, putting the call light back within reach. Ask the client how they have handled pain in the past. Remind the client that they have inflammatory bowel disease, so pain is expected. The nurse is preparing to provide discharge teaching for a client who had gastric bypass surgery. Which teaching points will the nurse plan to include in the discharge summary? Support groups should be initiated one year postoperatively. Drink fluids before or after mealtimes. Exercise programs can be discontinued. Include high-fat foods for 35% of total daily intake.