Nutrition Slides PDF

Nutrition Fundamentals of Nursing Taylor 10th ed. Chapter 37 Wei Liu Ph.D, MANP, RN, CNE Acknowledgements: Fran Gallina MSN, RN Susan Zori, DNP, RN, NEA-BC Basal Metabolism/Basal Metabolic Rate (BMR)  Amount of energy required to carry out involuntary activi...

Nutrition Fundamentals of Nursing Taylor 10th ed. Chapter 37 Wei Liu Ph.D, MANP, RN, CNE Acknowledgements: Fran Gallina MSN, RN Susan Zori, DNP, RN, NEA-BC Basal Metabolism/Basal Metabolic Rate (BMR)  Amount of energy required to carry out involuntary activities of body  Factors which increase BMR: growth, infection, fever, emotional tension, extreme environmental temp; excess thyroid hormone or epinephrine  Factors which decrease BMR: aging, sleep, cold temp, decreased thyroid hormone, prolonged fasting  Body Mass Index (BMI)  BMI – ratio of weight (in Kg.) to height (in meters)  BMI – estimate of risk for diseases: heart disease, type II diabetes, hypertension, certain cancers Underweight 40 inches o Women > 35 inches A & P of the GI System Digestion Absorption Begins in the mouth and ends in Intestine is the primary area of the small and large intestines absorption. Metabolism and storage of Elimination nutrients Chyme is moved through Consist of anabolic and catabolic peristalsis and is changed into reactions feces. Factors Influencing Nutrition Developmental considerations Infants: rapid growth and high protein, vitamin, mineral & energy requirements o Breastfeeding, formula, solid foods Toddlers and preschoolers: growth rate slows – picky eater School-aged children: increase foods of high nutritional value Adolescents: increased energy needs Young and middle adults: reduction in nutrient demands Pregnant and lactating women: increased nutrient and caloric needs Older adults: decreased need for energy Factors Influencing Nutrition in Older Adults  Decreased BMR  Decreased activity  Tooth loss, properly fitting dentures  Decrease in peristalsis - constipation  Loss of taste & smell – effect on appetite  Decreased sense of thirst – encourage fluid intake to prevent dehydration  Social isolation (loss of partner) – Meals On Wheels  Financial difficulties Factors Influencing Nutrition (cont’d)  Sex Assigned at Birth/Gender  State of Health  Alcohol Use Disorder  Medication  Megadoses of Vitamins/ Nutrient Supplements Can have drug like effects Interact with each other and medications Herbs, vitamins, minerals Sociocultural and Psychological Factors Influence Food Choices  SoDH/economic resources  Health literacy and stability  Language barriers  Religion  Lack of caregiver support  Meaning of food to a person  Social isolation  Culture  Limited ability to obtain or purchase food  Lack of knowledge for cooking or food preparation Nursing Process: Assessment  Nutritional screening using Mini Nutritional Assessment (MNA) tool: Screening questions Anthropometric measurements (height, weight, weight changes, BMI, waist circumference, S & S of altered nutrition) Nutritional habits General condition Self evaluation  Assess dietary intake 24-hr recall method (the easiest way) Food diaries/calorie counts Food frequency record Diet history Assessment (cont’d)  Dietary and health history Health status; age; cultural background; religious food patterns; socioeconomic status; personal food preferences; psychological factors; use of alcohol or illegal drugs; use of vitamin, mineral, or herbal supplements; prescription or over-the-counter (OTC) drugs; and the patient’s general nutrition knowledge  Physical examination Dysphagia (difficulty swallowing or the inability to swallow) o Complications: aspiration pneumonia, dehydration, weight loss, altered nutrition o Causes: neurogenic (e.g. stroke, Parkinson's, cerebral palsy, multiple sclerosis); myogenic (e.g. muscular dystrophy, aging); obstructive (e.g. head and neck Ca, trauma/surgery) Assessment (cont’d) Laboratory/ biochemical data  Albumin (normal 3.5-5.5 g/dL) & pre-albumin (normal 19-38 mg/dL)  Transferrin (normal 250-425 mg/dL)  Hgb (normal 12-18 g/dl)/Hct (normal 46-52%)  BUN (6-20 mg/dL) & Creatinine (0.6-1.2 mg/dL)  24 hour urine Refer to Box 37-5 Biochemical Data with Nutritional Implications on p. 1409 Warning Signs for Dysphagia  Coughing/choking during eating  Change in voice after eating/wet voice  Slow, imprecise, uncoordinated speech  Abnormal gag  Delayed swallowing – prolonged chewing  Incomplete oral clearance (pocketing)  Pharyngeal pooling  “Silent aspiration” Occurs without a cough Common after stroke Must have swallow test before feeding Feeding Patients with Dysphagia/ Aspiration Precautions  Provide 30 min. rest prior to  Some pts may drink meals insufficient fluids as thickened  Sit upright; flex the head slightly liquids are unpalatable   Observe for coughing, Check gag reflex; mouth care before meals gagging, drooling, pocketing   Inspect oral cavity for retained Avoid rushed or forced feeding foods  Reduce, eliminate distractions  Avoid or minimize sedatives  Alternate solids and liquids or hypnotics – may impair  Place food on unaffected side of cough or swallowing mouth  Suction if necessary  Obtain a speech therapy and  Sit upright for 30 – 60 minutes nutrition consult after meal Nursing Diagnosis Risk for Diarrhea Deficient knowledge aspiration Readiness for Feeding self-care Impaired swallowing enhanced nutrition deficit Imbalanced Imbalanced Risk for imbalanced nutrition: more than nutrition: less than nutrition: more than body requirements body requirements body requirements Implementation: Stimulating Appetite  Small, frequent meals  Solicit food preferences – respect cultural/religious aspects (holidays )  Provide pleasant environment  Food looks attractive  Schedule procedures and meds when they won’t interfere with eating  Give anti-nausea meds(anti-emetics) & pain meds  Food alternatives  Good oral hygiene before and after meals & well-fitting dentures  Remove clutter; odor free  Arrange food on the tray so person can reach  Positioning  Mealtime rituals  If pt. missed a meal, order a late tray, heat up  Do not disturb mealtime; do not interrupt Assisting with Eating   Visually impaired patients Offer toileting before beginning  Explain placement of food – Involve the person and maximize independence like a clock  Provide appropriate drinks Special plate guards and  Sit at eye level, make eye utensils contact Place food and dishes in  Engage in conversation similar places for meals  Place a napkin, not a bib Use straws if do not have  Dentures, hearing aids dysphagia  Supervision as needed Open containers, cut meats  Monitor for aspiration  Therapeutic Diets  NPO – nothing by mouth  Clear liquid diet – water, tea, black coffee, ice pops, clear broth, plain gelatin, popsicles, clear fruit juice without pulp (apple, grape, cranberry), commercially prepared clear liquid supplements  Full liquid diet – clear liquid items; milk; puddings, ice cream, cream soup, custards, plain frozen desserts, pasteurized eggs, cereal gruels, vegetable juices, milk and egg substitutes  Soft diet – easily chewed & digested  Pureed diet – blenderized liquid diet  Mechanically altered diet – regular diet with modifications for texture, excludes most raw fruits and vegetables and foods with seeds, nuts, and dried fruits.  Dysphagia – thickened liquids  Diet as tolerated/Regular  Low residue – low fiber, easily digested – roast lamb, buttered rice, sponge cake, “white” processed foods.  High residue – high fiber  Sodium-restricted, fat-restricted (e.g. fruit, vegetables, cereals, lean meat), renal diet (protein, sodium, potassium and fluid restrictions dependent on patient situation)  Consistent Carbohydrate Diet – Diabetic How to determine if a patient can advance his or her diet? Enteral Tube Feeding  Enteral nutrition (EN) provides nutrients into the GI tract. It is physiological, safe, and economical nutritional support. Second best to feeding by mouth  Tube is placed in GI tract to administer a formula containing nutrients  Indications Head, neck, upper GI cancers Critical illness/trauma Neurological and muscular disorders (e.g. CVA, myopathy, dementia) GI disorders (e.g. inflammatory bowel disease, mild pancreatitis) Respiratory failure/prolonged intubation Inadequate oral intake (e.g. anorexia, impaired chewing/swallowing)  Contraindications: peritonitis, bowel obstruction, intractable vomiting, paralytic ileus  Enteral Access Tubes  Short term (< 4 weeks): nasogastric (NG) tube or nasointesinal tube  Long term: tube placed via surgical or endoscopic placement Gastrostomy (G-tube) Jejunostomy (J-tube) PEG (percutaneous endoscopic gastrostomy) PEJ (percutaneous endoscopic jejunostomy)  Avoid naso route in pts with facial trauma, nasal injury, dysfunctional gag reflex, patient who can’t keep head of the bed elevated  Enteral tubes should be placed into the intestine when high risk or Hx of aspiration and pts intolerance to gastric EN, delayed gastroduodenal motility, gastric outlet stenosis. Avoid PEG.  Nurse responsibilities include placing and/or caring for the tube, administering nutrient formula, and preventing complications – aspiration. Enteral Tubes Double-lumen salem Sump Tube Levin Tube (nasogastric tube) Dobbhoff Tube (nasogastric or nasointestinal tube) NG Tube  Inserted from nose into stomach  Requires a functional GI tract  Pt is at risk for aspirating  Measure length of tube to be inserted:  From tip of Nostril to tip of Earlobe, and then to the point Midway between Xiphoid process and Umbilicus (NEMU)  Alternatively, from xiphoid process to the earlobe, to the nose and add 10cm. Gastrostomy (G-tube) or Jejunostomy (J-tube)  Endoscopically or surgically placed  Local anesthesia for PEG  More comfortable  Not as easily dislodged  Daily care to the stoma site (clean skill) Evidence-Based Practice Enteral feeding  NG tube insertion – Blind placement  Inadvertent pulmonary intubation  Aspiration  Verification of correct tube placement after the initial insertion and every time before use (before beginning a feeding or instilling liquids, and at regular intervals q 4-6 h during continuous feedings) X-ray is the most reliable method to confirm placement. Mandatory to verify initial placement of a feeding tube.  Monitor for tolerance of enteral feeding Absence of N & V, diarrhea and constipation Absence of abdo. pain, feeling of fullness, and distension Normal bowel sounds Achievement of target goal nutrition administration GRV is not a suitable parameter to determine feeding intolerance. Automatic cessation of EN should be avoided if GRV < 500 mL in the absence of other signs of intolerance. Tolerance of gastric feeding can be improved through use of prokinetic agent, continuous infusion, and elevation HoB.  Verifying Feeding Tube Placement  Radiographic examination to verify initial placement  Measurement of tube length and measurement of tube marking  Assessment of aspirate pH (gastric pH =< 5.5) – the lower the pH, the stronger the evidence for placement in the stomach  CO2 monitoring (capnographic) If CO2 present – tube is in patient’s airway – Danger!!  Ultrasound as an alterative for radiologic examination Injecting air and listening for swish of air is unreliable – don’t use!!! Obtain repeat x-ray confirmation if there is any doubt Enteral Feedings: Feeding Schedule Feeding Schedule – ordered by provider  Continuous – allow gradual introduction of formula and maximal absorption Nasointestinal – always continuous, initiate at a lower rate with a gradual increase to prevent dumping syndrome  Intermittent Preferred method Delivered at regular intervals in equal portions Given via gravity or pump  Bolus, intermittent Syringe used to deliver formula quickly  Cyclic – administer continuous feeding for a portion of the 24-hr period Volume-based feeding protocols within 24 hr or daily instead of hourly rates increases volume of nutrition delivered.  Feeding via pump Gravity Feeding Bolus tube feeding Administering Enteral Feeding: Promoting Patient Safety  MD will order: formula, rate of feeding, type. Secure all connections in the tubing to prevent injury.  Always check expiration dates of formula. Administer at room temperature  Elevate HOB at least 30 degrees. Verify correct tube placement, ensure normal digestion of the GI tract  Flush feeding tube with 30 ml water or sterile water ( for immunocompromised pts.)  Systems are open (containers must be filled) or closed (ready to hang).  Feeding must infuse within 8 hours if open system  Disposable tubing & container change every 24 hrs; closed system can be used up to 48 hrs.  Never add fresh formula to formula hanging  Never administer meds while a feeding is being infused. Never add meds directly to the formula.  Feedings are initiated at full strength. Do not dilute feedings!  Assess bowel sounds & feeding tolerance (no abd. distention, increased abdominal girth, N/V, bloating, pain). Starting feeding at a slower rate improves tolerance (rate may be ordered at 25mL – 50mL/hour then advanced by 10 – 25 mL/hr every 8 – 12 hours).  Elevate HOB at least 30 degrees, preferably upright during feeding and 1 hr afterward. Assess insertion site and tube insertion site care, mouth care  Fingerstick blood glucose every 6 h or per facility protocol. Record on I/ O sheet  Complications of Enteral Tube Feedings  Aspiration (most serious): HOB elevated 30 degrees or more; check placement; give small & frequent feeding; avoid over sedation of the patient; check residual volume per policy.  Clogged tube: irrigate tube with 15-30 mL of water (5-10 mL for children) before, between and after medication administration; use liquid medications when available; completely dissolve crushed medications in 15-30 mL of water if liquid medication is unavailable.  Nasal erosion  Diarrhea  Nausea, vomiting, distention  Unplanned extubation  Stoma site infection  Nausea, vomiting, distention Refer to Table 37-5 for Preventing Complications of Enteral Feeding on p.1424 Parenteral Nutrition  Used for pts with nonfunctioning GI tracts  Patients unable to digest or absorb enteral nutrition or are in highly stressed physiological states: Sepsis Head injury Burns  Total Parenteral Nutrition (TPN): infusing a nutrient rich hypertonic solution intravenously through a central line (25% glucose, lipids, insulin, vitamins, etc.) Expensive, high potential for complications especially infections. TPN can promote tissue and wound healing TPN used to “rest” the bowel  Peripheral Parenteral Nutrition (PPN): infusing isotonic solution through peripheral vein (not as concentrated – 10% glucose) Moderate nutritional deficiencies May be done for short term (