Harding University NURS 3000 Fluid and Electrolytes PDF

NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs Fluid and Electrolytes: Nutritional Needs Harding University - Active Learning Guide, Module 11 Name: Sean Whitfield Instructions Complete the module active learning guide as you work through the module content. Take notes, a...

NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs Fluid and Electrolytes: Nutritional Needs Harding University - Active Learning Guide, Module 11 Name: Sean Whitfield Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on the guide, and respond to any case studies and client scenarios. All of these activities will assist in your preparation for exams, help you plan and implement care in the clinical setting, and facilitate your development as a Christian nurse servant. You will submit your completed guide to the instructor at the end of the week. The completed learning guide will be worth a maximum of 10 points. If you have questions or are unsure about your answers; or you may email your instructor for clarification. Note: The Active Learning Guide provides a general outline of topics covered in this module; it is not all inclusive of all information needed for the exam. You are responsible for all content in readings and activities throughout the module. I. Fluid and Electrolytes: Chapter 51: Fluid, Electrolyte, and Acid-Base Balance 1. Define homeostasis: In good health, a delicate balance of fluids, electrolytes, acids, and bases maintains the body. This balance, or homeostasis, depends on multiple physiologic processes that regulate fluid intake and output, as well as the movement of water and the substances dissolved in it between body compartments. What are some things that can affect homeostasis? Even in daily living, factors such as excessive temperatures or vigorous activity can affect homeostasis if adequate water and salt intake are not maintained. Therapeutic measures, such as the use of diuretics or nasogastric suction, can also disturb the body’s homeostasis unless water and electrolytes are replaced. 2. Total body water: How does it differ between males, Approximately 60% of the average healthy adult’s (Men) weight is water, the primary body fluid. females, Approximately 55% of the average healthy adult’s (Women) weight is water, the primary body fluid. infants, Infants have the highest proportion of water, accounting for 70% to 80% of their body weight. Elderly, In adults older than 60 years of age, it represents only about 50% of total body weight. 3. Describe the different body fluid compartments. ICF: is found within the cells of the body. It constitutes approximately two-thirds of the total body fluid in adults. NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs ECF: is found outside the cells and accounts for about one-third of total body fluid. ECF is further subdivided into compartments. The two main compartments of ECF are intravascular and interstitial. Intravascular: accounts for approximately 20% of ECF and is found within the vascular system. Interstitial: accounting for approximately 75% of ECF, surrounds the cells. 4. What are electrolytes? Many salts dissociate in water; that is, they break up into electrically charged ions. The salt called sodium chloride breaks up into one ion of sodium (Na+) and one ion of chloride (Cl−). These charged particles are called electrolytes because they are capable of conducting electricity. How are they generally measured? Electrolytes generally are measured in milliequivalents per liter (mEq/L) or milligrams per 100 milliliters (mg/100 mL). The term milliequivalent refers to the chemical combining power of the ion, or the capacity of cations to combine with anions to form molecules, whereas the term milligram refers to the weight of the ion. Therefore, 1 mEq of any anion equals 1 mEq of any cation in terms of their capacity to combine into molecules. For example, sodium and chloride combine equally, so 1 mEq of Na+ equals 1 mEq of Cl−; however, a molecule of sodium is not equal in weight to a molecule of chloride. 5. What is osmotic pressure? is the power of a solution to pull water across a semipermeable membrane. When two solutions of different concentrations are separated by a semipermeable membrane, the solution with the higher solute concentration exerts a higher osmotic pressure, pulling water across the membrane to equalize the concentrations of the solutions. 6. Briefly describe the four methods of fluids and solutes movement. Diffusion: occurs when two solutes of different concentrations are separated by a semipermeable membrane. Osmosis: is a specific kind of diffusion in which water moves across cell membranes, from the less concentrated solution (the solution with less solute and more water) to the more concentrated solution (the solution with more solute and less water). Filtration: is a process whereby fluid and solutes move together across a membrane from an area of higher pressure to an area of lower pressure. Active transport:is the movement of solutes across cell membranes from a less concentrated solution to a more concentrated one. This process differs from diffusion and osmosis, which are passive processes, in that metabolic energy is expended. 7. Table 51.1 What are the main sources of fluid intake for an adult? Describe the thirst mechanism. NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs The thirst mechanism is the primary regulator of fluid intake. The thirst center is located in the hypothalamus of the brain. A number of stimuli trigger the thirst center, including the osmotic pressure of body fluids, vascular volume, and angiotensin (a hormone released in response to decreased blood flow to the kidneys), causing the sensation of thirst and the desire to drink fluids. 8. Table 51.2 What are the main sources of fluid output for an adult? 9. Describe the kidneys’ role as the primary regulator of body fluids and electrolyte balance. The kidneys are the primary regulator of body fluids and electrolyte balance. They regulate the volume and osmolality of ECF by regulating water and electrolyte excretion. The kidneys control the reabsorption of water from plasma filtrate and ultimately the amount excreted as urine. Electrolyte balance is maintained by selective retention and excretion by the kidneys. The kidneys also play a significant role in acid–base regulation, excreting hydrogen ion (H+) and retaining bicarbonate. 10. How does ADH assist in fluid balance? The antidiuretic hormone (ADH) regulates water excretion from the kidney, is synthesized in the anterior portion of the hypothalamus, and acts on the collecting ducts of the nephrons. When serum osmolality rises, ADH is produced, causing the collecting ducts to become more permeable to water. This increased permeability allows more water to be reabsorbed into the blood. As more water is reabsorbed, urine output falls and serum osmolality decreases because NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs the water dilutes body fluids. Conversely, if serum osmolality decreases, ADH is suppressed, the collecting ducts become less permeable to water, and urine output increases. Excess water is excreted, and serum osmolality returns to normal 11. Describe aldosterone’s role in fluid balance. In addition, it stimulates the release of aldosterone from the adrenal cortex. Aldosterone also promotes sodium retention in the distal nephron. The net effect of the renin-angiotensinaldosterone system is to increase blood volume (and renal perfusion) through sodium and water retention. 12. Why are electrolytes important to the body? Electrolytes, charged ions capable of conducting electricity, are present in all body fluids and fluid compartments. Just as maintaining fluid balance is vital to normal body functioning, so is maintaining electrolyte balance. Although the concentration of specific electrolytes differs between fluid compartments, a balance of cations (positively charged ions) and anions (negatively charged ions) always exists. Electrolytes are important for:  Maintaining fluid balance  Contributing to acid–base regulation  Facilitating enzyme reactions  Transmitting neuromuscular reactions. 13. Table 51.3 Regulation and Functions of Electrolytes. Become familiar with these electrolytes, their functions, and how they are regulated. Sodium:   Normal range: 135 ←→ 145 Primary functions: ◦ Regulating ECF volume and distribution ◦ Maintaining blood volume ◦ Transmitting nerve impulses and contracting muscles Potassium:   Normal range: 3.5 ← → 5 Primary functions: ◦ Maintaining ICF osmolality ◦ Transmitting nerve and other electrical impulses ◦ Regulating cardiac impulse transmission and muscle contraction ◦ Skeletal and smooth muscle function ◦ Regulating acid–base balance Calcium:   Normal range: 9 ← → 11 Primary functions: NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs ◦ ◦ ◦ ◦ ◦ Forming bones and teeth Transmitting nerve impulses Regulating muscle contractions Maintaining cardiac pacemaker (automaticity) Blood clotting Magnesium:   Normal range: 1.5 ← → 2.5 Primary functions: ◦ Intracellular metabolism ◦ Operating sodium–potassium pump ◦ Relaxing muscle contractions ◦ Transmitting nerve impulses ◦ Regulating cardiac function 14. Factors which affect fluid and electrolyte balance. Briefly discuss what effect these factors have. Age: Why are older adults at increased risk of imbalances? In older individuals, the normal aging process may affect fluid balance. The thirst response is often diminished. Antidiuretic hormone levels remain normal or may even be elevated, but the nephrons become less able to conserve water in response to ADH. Higher levels of atrial natriuretic factor in older adults may also contribute to this impaired ability to conserve water. These normal changes of aging increase the risk of dehydration. When combined with the increased likelihood of heart diseases, impaired renal function, and multiple drug regimens, the older adult’s risk for fluid and electrolyte imbalance is significant. Older adults are at high risk for fluid and electrolyte imbalance because of decreases in:  Thirst sensation  Ability of the kidneys to concentrate urine  Intracellular fluid and total body water  Response to body hormones that help regulate fluid and electrolytes. Other factors that may influence fluid and electrolyte balance in older adults are:     Use of diuretics for hypertension and heart disease. Decreased intake of food and water, especially in older adults with dementia or who are dependent on others to feed them and offer them fluids. Preparations for diagnostic tests that include being NPO for long periods of time, laxatives, or contrast dyes. Impaired renal function, for example, in older adults with diabetes. Gender: NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs Total body water also is affected by sex and body size. Fat cells contain little or no water, but lean muscle tissue has a high water content; therefore, individuals with a higher percentage of body fat have less body water than individuals with a higher percentage of lean muscle. Women generally have proportionately more body fat and, therefore, less body water than men. Environmental temp: Individuals with an illness and those participating in strenuous activity are at increased risk for fluid and electrolyte imbalances when the environmental temperature is high. Fluid losses through sweating are increased in hot environments as the body attempts to disperse heat. These losses are even greater in individuals who are not accustomed to a hot environment. Both electrolytes and water are lost through sweating. When only water is replaced, electrolyte depletion is a risk. An individual who is electrolyte depleted may experience fatigue, weakness, headache, and gastrointestinal symptoms such as anorexia and nausea. The risk of adverse effects is even greater if lost water is not replaced. Body temperature rises, and the individual is at risk for heat exhaustion or heatstroke; this happens when an individual’s heat production exceeds the body’s ability to dissipate heat. Consuming adequate amounts of cool liquids, particularly during strenuous activity, reduces the risk of adverse effects from heat. Balanced electrolyte solutions and carbohydrate-electrolyte solutions such as sports drinks are recommended because they replace both water and electrolytes lost through perspiration. Lifestyle: Lifestyle factors such as diet, exercise, stress, and alcohol consumption affect fluid, electrolyte, and acid–base balance. Intake of fluids and electrolytes is affected by diet. Individuals with anorexia nervosa or bulimia are at risk for severe fluid and electrolyte imbalances because of inadequate intake or purging regimens (e.g., induced vomiting, use of diuretics and laxatives). Seriously malnourished individuals have decreased serum protein levels, and may develop edema because serum osmotic pressure is reduced. When calorie intake is not adequate to meet the body’s needs, fat stores are broken down and fatty acids are released, increasing the risk of acidosis. Stress can increase cellular metabolism, blood glucose concentration, and catecholamine levels. In addition, stress can increase production of ADH and stimulate the renin-angiotensinaldosterone system, both of which decrease urine production. The overall response of the body to stress is to increase blood volume. Regular weight-bearing exercise such as walking or running has a beneficial effect on calcium balance. The rate of bone loss that occurs in postmenopausal women and older men is slowed with weight-bearing exercise, reducing the risk of osteoporosis. Heavy alcohol consumption increases the risk of low calcium, magnesium, and phosphate levels. Individuals who drink large amounts of alcohol are also at risk for acidosis associated with breakdown of fat tissue. 15. Fluid Imbalances: Briefly describe these. Fluid Volume Deficit: (Causes and S/S) NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs Causes: Loss of water and electrolytes from:  Vomiting  Diarrhea  Excess sweating  Polyuria  Fever  Nasogastric Suction  Abnormnal drainage or wound losses r/t:  Anorexia  Nausea  Inability to access fluids  Impaired swallowing  Confusion, depression Sign and Symptoms:  Decreased skin turgor  Dry mucous membranes, sunken eyeballs, decreased tearing  Subnormal temperature  Weak pulse; tachycardia  Decreased blood pressure  Postural (orthostatic) hypotension (significant drop in BP when moving from lying to sitting or standing position)  Decreased capillary refill  Decreased central venous pressure  Decreased urine volume (1.030)  Increased hematocrit  Increased blood urea nitrogen (BUN) Fluid Volume Excess: (Causes and S/S) Causes:  Excess intake of sodium containing IV fluids  Excess ingestion of sodium in diet or medication (e.g., sodium bicarbonate antacids such as Alka-Seltzer or hypertonic enema solutions such as Fleet’s). r/t:  Heart failure  Renal failure  Cirrhosis of the liver Signs and Symptoms: Weigh gain:  2% gain = FVE  5% gain = moderate NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs  8% gain = severe Fluid intake greater than output Full, bounding pulse;  tachycardia Increased blood pressure and central venous pressure Distended neck veins Moist crackles (rales) in lungs;  dyspnea, shortness of breath Mental confusion Dehydration: (Causes and S/S) Or a hyperosmolar fluid imbalance, occurs when water is lost from the body, leaving the client with excess sodium. Because water is lost while electrolytes, particularly sodium, are retained, serum osmolality and serum sodium levels increase. Water is drawn into the vascular compartment from the interstitial space and cells, resulting in cellular dehydration. Older adults are at particular risk for dehydration because of decreased thirst sensation. Dehydration can also affect clients who are hyperventilating, have a prolonged fever, are in diabetic ketoacidosis, or are receiving enteral feedings with insufficient water intake. Overhydration: (Causes and S/S) Or a hypo-osmolar fluid imbalance, occurs when water is gained in excess of electrolytes, resulting in low serum osmolality and low serum sodium levels. Water is drawn into the cells, causing them to swell. In the brain, this can lead to cerebral edema and impaired neurologic function. Overhydration, sometimes called water intoxication, often occurs when both fluid and electrolytes are lost, for example, through excessive sweating, but only water is replaced. It can also result from the syndrome of inappropriate antidiuretic hormone (SIADH), a disorder that can occur with some malignant tumors, AIDS, head injury, or administration of certain drugs such as barbiturates or anesthetics. 16. Table 51.7 Electrolyte Imbalances; Focus on key s/s and interventions for the following imbalances: Hyponatremia: Signs and Symptoms ◦ Lethargy, confusion, apprehension ◦ Muscle twitching ◦ Abdominal cramps ◦ Anorexia, nausea, vomiting ◦ Headache ◦ Seizures, coma Laboratory finding: ◦ Serum sodium < 135 mEq/L ◦ Serum osmolality < 280 mOsm/kg Interventions: Assess clinical manifestations NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs Monitor fluid intake and output Monitor laboratory data (e.g., serum sodium). Assess client closely if administering hypertonic saline solutions. Limit water intake as indicated. Encourage food and fluid high in sodium if permitted (e.g., table salt, bacon, ham, processed cheese). Hypernatremia: Loss of Sodium Hypokalemia: Loss of Potassium Hyperkalemia: Decreased Potassium Excretion Hypocalcemia: Inadequate Vitamin D Intake. Surgical Removal of the Parathyroid Glands. Hypercalcemia: Prolonged immobilization Hypomagnesemia: Excessive loss from the gastrointestinal tract (e.g., from nasogastric suction, diarrhea, fistula drainage). Hypermagnesemia: Abnormal retention of magnesium, as in: Renal failure, Adrenal insufficiency and Treatment with magnesium salts. 17. Describe the three main clinical measurements r/t fluid balance.  Daily Weight: Helps to assess fluid balance. Maintain accurate I&O records. Accurate records are critical in assessing the client’s fluid balance  Vital Signs: Monitor vital signs as appropriate. Vital sign changes such as increased heart rate, decreased blood pressure, and increased temperature indicate hypovolemia.  Fluid Intake and Output: Give fluids as appropriate. As her nausea decreases encourage oral intake of fluids as tolerated, again to replace lost volume. Administer IV therapy as prescribed. Mrs. Chapman will probably require IV replacement of fluid. This is especially true because her oral intake is limited because of nausea and vomiting. 18. Table 51.9 Focused Physical Assessment r/t Fluid and Electrolyte Balance Discuss the main areas of assessment and possible abnormal findings. Skin Focus: Color temperature moisture Turgor Edema Possible Abnormal Findings: Flushed, warm, very dry Moist or diaphoretic Cool and pale Poor turgor: Skin remains tented for several seconds instead of immediately returning to normal position Skin around eyes is puffy, lids appear swollen; rings are tight; shoes leave impressions on feet Mucous membranes NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs Focus: Color moisture Possible Abnormal Findings: Mucous membranes dry dull in appearance; tongue dry and cracked Eyes Focus: Firmness Possible Abnormal Findings: Eyeball feels soft to palpation Fontanls (infant) Focus: Firmness, level Possible Abnormal Findings: Fontanel bulging, firm Fontanel sunken, soft Cardiovascular system Focus: Heart rate Peripheral pulses Blood pressure Capillary refill Venous filling Possible Abnormal Findings: Tachycardia, bradycardia; irregular; dysrhythmias Weak and thready; bounding Hypotension Postural hypotension Slowed capillary refill Jugular venous distention; flat jugular veins, poor venous refill Respiratory System Focus: Respiratory rate and pattern Possible Abnormal Findings: Increased or decreased rate and depth of respirations Neurologic Focus: Level of consciousness (LOC) NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs Orientation, cognition Motor function Reflexes Abnormal reflexes Possible Abnormal Findings: Decreased LOC, lethargy, stupor, or coma Disoriented, confused; difficulty concentrating Weakness, decreased motor strength Hyperactive or depressed DTRs Facial muscle twitching including eyelids and lips on side of stimulus Carpal spasm: contraction of hand and fingers on affected side 19. What are three questions you would ask the client if you suspected a fluid/electrolyte imbalance? a. Have you gained or lost weight in recent weeks? b. Have you recently experienced any symptoms such as excessive thirst, dry skin or mucous membranes, dark or concentrated urine, or low urine output? c. Do you have problems with selling of your hands, feet, or ankles? Do you ever have difficulty breathing, especially when lying down or at night? How many pillows do you use to sleep? d. Have you recently experienced any of the following symptoms: difficult concentrating or confusion; dizziness or feeling faint; muscle weakness, twitching, cramping, or spasm; excessive fatigue; abnormal sensations such as numbness, tingling, burning, or prickling; abdominal cramping or distension; heart palpitation? 20. Lab tests pertinent to fluid/electrolyte imbalances; Briefly discuss. CBC: A complete blood count (CBC), another basic screening test, includes information about hematocrit (Hct), which measures the percentage of the volume of whole blood that is composed of RBCs. Hematocrit is a measure of the volume of cells in relation to plasma and is, therefore, affected by changes in plasma volume; hematocrit increases with dehydration and decreases with overhydration. Normal hematocrit values are 40% to 54% in men and 37% to 47% in women. Urine specific gravity: Specific gravity is an indicator of urine concentration that correlates with urine osmolality, and it can be measured quickly and easily by nursing personnel. Normal specific gravity ranges from 1.005 to 1.030 (usually 1.010 to 1.025). When urine osmolality is high, in fluid volume deficit, the specific gravity rises; when urine osmolality is low, in fluid volume excess, the specific gravity is low. Urine pH: Measurement of urine pH may be obtained by laboratory analysis or by using a dipstick on a freshly voided specimen. Because the kidneys play a critical role in regulating acid– base balance, assessment of urine pH can be useful in determining whether the kidneys are NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs responding appropriately to acid–base imbalances. Normally the pH of the urine is relatively acidic, averaging about 6.0, but a range of 4.6 to 8.0 is considered normal. In metabolic acidosis, urine pH should decrease as the kidneys retain bicarbonate and excrete hydrogen ions; in metabolic alkalosis, the pH should increase as the kidneys retain hydrogen ions and excrete bicarbonate. ABGs: Arterial blood gases (ABGs) are performed to evaluate a client’s acid–base balance and oxygenation. Arterial blood is used because it provides a more accurate reflection of gas exchange in the pulmonary system than venous blood. Blood gases may be drawn by laboratory technicians, respiratory therapy personnel, or nurses with specialized skills. Because a highpressure artery is used to obtain blood, it is important to apply pressure to the puncture site for at least 5 minutes after the procedure to reduce the risk of bleeding or bruising. II. Nutritional Needs: Chapter 46: Nutrition 1. Describe the six macronutrients essential to the body’s functioning. Water: Carbohydrates: Fats: are lipids that are solid at room temperature; oils are lipids that are liquid at room temperature. In common use, the terms fats and lipids are used interchangeably. Lipids have the same elements (carbon, hydrogen, and oxygen) as carbohydrates, but they contain a higher proportion of hydrogen. Protein: Minerals: are found in organic compounds, as inorganic compounds, and as free ions. Calcium and phosphorus make up 80% of all mineral elements in the body. The two categories of minerals are macrominerals and microminerals. Macrominerals are those that people require daily in amounts over 100 mg. They include calcium, phosphorus, sodium, potassium, magnesium, chloride, and sulfur. Microminerals are those that people require daily in amounts less than 100 mg. They include iron, zinc, manganese, iodine, fluoride, copper, cobalt, chromium, and selenium. Vitamins: is an organic compound that cannot be manufactured by the body and is needed in small quantities to catalyze metabolic processes. Thus, when vitamins are lacking in the diet, metabolic deficits result. Vitamins are generally classified as fat soluble or water soluble. Water-soluble vitamins include C and the B-complex vitamins: B1 (thiamine), B2 (riboflavin), B3 (niacin or nicotinic acid), B6 (pyridoxine), B9 (folic acid, folate, folacin), B12 (cobalamin), pantothenic acid, and biotin. The body cannot store water-soluble vitamins; thus, people must get a daily supply in the diet. Water-soluble vitamins can be degraded by food processing, storage, and preparation. Fat-soluble vitamins include A, D, E, and K. The body can store these vitamins, although there is a limit to the amounts of vitamins E and K the body can store. Therefore, a daily supply of fatsoluble vitamins is not absolutely necessary. Vitamin content is highest in fresh foods consumed soon after harvest. 2. What are the three basic purposes of nutrients? is the sum of all the interactions between an organism and the food it consumes. In other words, nutrition is what an individual eats and how the body uses it. Nutrients are organic and NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs inorganic substances found in foods that are required for body functioning. Adequate food intake consists of a balance of nutrients: water, carbohydrates, proteins, fats, vitamins, and minerals. Foods differ greatly in their nutritive value (the nutrient content of a specified amount of food), and no one food provides all essential nutrients. Nutrients have three major functions: providing energy for body processes and movement, providing structural material for body tissues, and regulating body processes. 3. Which vitamins are water-soluble? Water-soluble vitamins include C and the B-complex vitamins: B1 (thiamine), B2 (riboflavin), B3 (niacin or nicotinic acid), B6 (pyridoxine), B9 (folic acid, folate, folacin), B12 (cobalamin), pantothenic acid, and biotin. Which ones are fat-soluble? Fat-soluble vitamins include A, D, E, and K. 4. Factors affecting nutrition: discuss briefly. Development: People in rapid periods of growth (i.e., infancy and adolescence) have increased needs for nutrients. Older adults, on the other hand, may need fewer calories and also need some dietary changes in view of their risk for coronary heart disease, osteoporosis, and hypertension. Gender: Nutrient requirements are different for males and females because of body composition and reproductive functions. The larger muscle mass of males translates into a greater need for calories and proteins. Because of menstruation, females require more iron than males do prior to menopause. Pregnant and lactating females have increased caloric and fluid needs. Ethnicity/Culture: Ethnicity often determines food preferences. Traditional foods (e.g., rice for Asians, pasta for Italians, curry for Indians) are eaten long after other customs are abandoned. Nurses should not use a “good food, bad food” approach, but rather should realize that variations of intake are acceptable under different circumstances. The only “universally” accepted guidelines are (a) to eat a wide variety of foods to furnish adequate nutrients and (b) to eat moderately to maintain body weight. Food preference probably differs as much among individuals of the same cultural background as it does between cultures. Not all Italians like pizza, for example, and many undoubtedly enjoy Mexican food. Beliefs about food: Beliefs about effects of foods on health and well-being can affect food choices. Many people acquire their beliefs about food from television, magazines, and other media. Some people are reducing their intake of animal fats in response to evidence that excessive consumption of animal fats is a major risk factor in vascular disease, including heart attack and stroke. NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs Food fads that involve nontraditional food practices are relatively common. A fad is a widespread but short-lived interest or a practice followed with considerable zeal. It may be based either on the belief that certain foods have special powers or on the notion that certain foods are harmful. Food fads appeal to the individual seeking a miracle cure for a disease, the individual who desires superior health, or someone who wants to delay aging. Some fad diets are harmless, but others are potentially dangerous. Determining the needs a fad diet fills for the client enables the nurse both to support these needs and to suggest a more nutritious diet. Personal Preferences: People develop likes and dislikes based on associations with a typical food. A child who loves to visit his grandparents may love pickled crabapples because they are served in the grandparents’ home. Another child who dislikes a very strict aunt grows up to dislike the chicken casserole she often prepared. People often carry such preferences into adulthood. Individual likes and dislikes can also be related to familiarity. Children often say they dislike a food before they sample it. Some adults are very adventuresome and eager to try new foods. Others prefer to eat the same foods repeatedly. Preferences in the tastes, smells, flavors (blends of taste and smell), temperatures, colors, shapes, and sizes of food influence an individual’s food choices. Some people may prefer sweet and sour tastes to bitter or salty tastes. Textures play a great role in food preferences. Some people prefer crisp food to limp food, firm to soft, tender to tough, smooth to lumpy, or dry to soggy. Religious Practices: Religious practice also affects diet. Some Roman Catholics avoid meat on certain days, and some Protestant faiths prohibit meat, tea, coffee, or alcohol. Both Orthodox Judaism and Islam prohibit pork. Orthodox Jews observe kosher customs, eating certain foods only if they are inspected by a rabbi and prepared according to dietary laws. The nurse must plan care with consideration of such religious dietary practices. Lifestyle: Certain lifestyles are linked to food-related behaviors. Individuals who are always in a hurry may buy convenience grocery items or eat restaurant meals. Those who spend many hours at home may take time to prepare more meals “from scratch.” Individual differences also influence lifestyle patterns (e.g., cooking skills, concern about health). Some individuals work at different times, such as evening or night shifts. They might need to adapt their eating habits to this and also make changes in their medication schedules if they are related to food intake. Muscular activity affects metabolic rate more than any other factor; the more strenuous the activity, the greater the stimulation of the metabolism. Mental activity, which requires only about 4 Kcal per hour, provides very little metabolic stimulation. Economics: What, how much, and how often an individual eats are frequently affected by socioeconomic status. For example, people with limited income, including some older adults, may not be able to afford meat and fresh vegetables. In contrast, individuals with higher incomes may purchase more proteins and fats and fewer complex carbohydrates. Not all individuals have the financial resources for extensive food preparation and storage facilities. The nurse should not assume that clients have their own stove, refrigerator, or freezer. In some low- NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs income areas, food costs at small local grocery stores can be significantly higher than at large chain stores farther away. Medications: The effects of drugs on nutrition vary considerably. They may alter appetite, disturb taste perception, or interfere with nutrient absorption or excretion. Nurses need to be aware of the nutritional effects of specific drugs when evaluating a client for nutritional problems. The nursing history interview should include questions about the medications the client is taking. Conversely, nutrients can affect drug utilization. Some nutrients can decrease drug absorption; others enhance absorption. For example, the calcium in milk hinders absorption of the antibiotic tetracycline but enhances the absorption of the antibiotic erythromycin. Older adults are at particular risk for drug–food interactions due to the number of medications they may take, agerelated physiologic changes affecting medication actions (e.g., decrease in lean-to-fat ratio, decrease in renal or hepatic function), and disease-restricted diets. Health Issues: An individual’s health status greatly affects eating habits and nutritional status. Missing teeth, illfitting dentures, or a sore mouth makes chewing food difficult. Difficulty swallowing (dysphagia) due to a painfully inflamed throat or a stricture of the esophagus can prevent an individual from obtaining adequate nourishment. Disease processes and surgery of the GI tract can affect digestion, absorption, metabolism, and excretion of essential nutrients. GI and other diseases also create nausea, vomiting, and diarrhea, all of which can adversely affect an individual’s appetite and nutritional status. Gallstones, which can block the flow of bile, are a common cause of impaired lipid digestion. Metabolic processes can be impaired by diseases of the liver. Diseases of the pancreas can affect glucose metabolism or fat digestion. Autoimmune and genetic disorders such as celiac disease and irritable bowel syndrome may be worsened when eating foods containing wheat or gluten. Between 30 million and 50 million Americans have lactose intolerance (also called lactose maldigestion), a shortage of the enzyme lactase, which is needed to break down the sugar in milk. Certain populations are more widely affected, especially African Americans, American Indians, Ashkenazi Jews, Asians, and Hispanics and Latinos although they may not always show symptoms (DeBruyne & Pinna, 2017). Alcohol Consumption: The calories in alcoholic drinks include both those of the alcohol itself and of the juices or other beverages added to the drink. These can constitute large numbers of calories, for example, 150 calories for a regular 12-ounce beer, and 160 calories for a “screwdriver” (1.5 ounces vodka plus 4 ounces orange juice). Drinking alcohol can lead to weight gain by adding these calories to the regular diet plus the effect of alcohol on fat metabolism. A small amount of the alcohol is converted directly to fat. However, the greater effect is that the remainder of the alcohol is converted into acetate by the liver. The acetate released to the bloodstream is used for energy instead of fat and the fat is then stored. NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs Excessive alcohol use contributes to nutritional deficiencies in several ways. Alcohol may replace food in an individual’s diet, and it can depress the appetite. Excessive alcohol can have a toxic effect on the intestinal mucosa, thereby decreasing the absorption of nutrients. The need for vitamin B increases, because it is used in alcohol metabolism. Alcohol can impair the storage of nutrients and increase nutrient catabolism and excretion. Several studies have shown health benefits of moderate alcohol consumption such as with red wine. Examples include reduced risk of cardiovascular disease, strokes, dementia, diabetes, and osteoporosis. However, any benefits of alcohol must be weighed against the many harmful effects, and the possibility of alcohol abuse. Advertising: Food producers try to persuade consumers to change from the product they currently use to the brand of the producer. Popular actors are often used in television, radio, Internet, and print to influence consumers’ choices. Advertising is thought to influence individuals’ food choices and eating patterns to a certain extent. Of note is that such products as alcoholic beverages, coffee, frozen foods, and soft drinks are more heavily advertised than such products as bread, vegetables, and fruits. Convenience foods (frozen or packaged and easy to prepare) and takeout (fast) foods are heavily advertised. Children’s television show commercials often promote snack foods, candy, soda, and sugared cereals over fresh, healthy foods. Australia, Canada, Sweden, and Great Britain have adopted regulations prohibiting food advertising on programs targeting audiences of young children. There has been an increase in advertising that targets older adults in particular and encourages use of herbs and supplements. Some products are nutritionally safe, whereas others are not and can cause interactions with medications they might be taking or cause unexpected side effects. The cost of some of these supplements is also usually high, is generally not covered by health insurance, and may take money that the individual could spend for healthier food. Psychologic Factors: Although some people overeat when stressed, depressed, or lonely, others eat very little under the same conditions. Anorexia and weight loss can indicate severe stress or depression. Anorexia nervosa and bulimia are severe psychophysiologic conditions seen most frequently in female adolescents. 5. Table 46.2 Problems Associated with Nutrition in Older Adults. Client Teaching: Nutrition for Older Adults, p. 1173 Familiarize yourself with nursing interventions, including teaching, to assist older adults in meeting their nutritional needs. If necessary, make notes here of key points. NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs 6. Ways to Reduce Dietary Fat: p. 1174 List key strategies. Cook meat by grilling, baking, broiling, or microwaving rather than frying. Substitute popcorn or pretzels for such snacks as potato chips, cheese puffs, and corn chips. Read labels. Some crackers, for example, are high in fat; others are not. Limit desserts high in fat, such as ice cream, cake, and cookies. Substitute hard candies for chocolate bars. Use skim or reduced-fat milk instead of whole milk, for drinking as well as in recipes. Use less butter or margarine on breads. Remove fat from meat and skin from chicken before cooking. Eat less meat; eat more fish. Use less dressing, or use low-fat dressings, on salads. Eat plant sources of protein (e.g., kidney, lima, and navy beans). Use nuts as a source of protein, but since they are high in fat, use to replace meat rather than in addition. 7. Box 46.5 Summary of Risk factors for Nutritional Problems What are key risk factors in the client’s medical history? Alcohol or substance abuse Catabolic or hypermetabolic condition: burns, trauma Chronic illness: end-stage renal disease, liver disease, AIDS, pulmonary disease (e.g., chronic obstructive pulmonary disease [COPD]), cancer Fluid and electrolyte imbalance GI problems: anorexia, dysphagia, nausea, vomiting, diarrhea, constipation Neurologic or cognitive impairment Oral and GI surgery Unintentional weight loss or gain of 10% within 6 months 8. Lab Data r/t nutritional status: Hemoglobin: Tests commonly include hemoglobin, albumin, transferrin, and total iron-binding capacity. A low hemoglobin level may be evidence of iron deficiency anemia. However, abnormal blood loss or a pathologic process such as GI cancer must be ruled out before iron deficiency related to diet is confirmed. Albumin: which accounts for over 50% of the total serum proteins, is one of the most common visceral proteins evaluated as part of the nutritional assessment. Because there is so much albumin in the body and because it is not broken down very quickly (i.e., it has a half-life of 18 to 20 days), albumin concentrations change slowly. A low serum albumin level is a useful indicator of prolonged protein depletion rather than acute or short-term changes in nutritional status. However, many conditions besides malnutrition can depress albumin concentration, such as altered liver function, hydration status, and losses from open wounds and burns. NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs Transferrin: binds and carries iron from the intestine through the serum. Because it has a shorter half-life than albumin (8 to 9 days), transferrin responds more quickly to protein depletion than albumin. Serum transferrin can be measured directly or by a total iron-binding capacity (TIBC) test, which indicates the amount of iron in the blood to which transferrin can bind. Transferrin levels below normal are found with protein loss, iron deficiency anemia, pregnancy, hepatitis, or liver dysfunction. Total iron-binding capacity: Certain nutrient deficiencies and forms of PCM can depress the immune system. The total number of lymphocyte white blood cells decreases as protein depletion occurs. Urea: Urinary urea nitrogen and urinary creatinine are measures of protein catabolism and the state of nitrogen balance. Urea, the chief end product of amino acid metabolism, is formed from ammonia detoxified by the liver, circulated in the blood, and transported to the kidneys for excretion in urine. Urea concentrations in the blood and urine, therefore, directly reflect the intake and breakdown of dietary protein, the rate of urea production in the liver, and the rate of urea removal by the kidneys. The state of nitrogen balance is determined by comparing the nitrogen intake (grams of protein) to the nitrogen output over a 24-hour period. A positive nitrogen balance exists when intake exceeds nitrogen output; a negative nitrogen balance occurs when output exceeds nitrogen intake. Protein intake must be accurately recorded and kidney function must be normal to ensure the validity of a urinary urea nitrogen test. Urinary creatinine: reflects an individual’s total muscle mass because creatinine is the chief end product of the creatine produced when energy is released during skeletal muscle metabolism. The rate of creatinine formation is directly proportional to the total muscle mass. Creatinine is removed from the bloodstream by the kidneys and excreted in the urine at a rate that closely parallels its formation. The greater the muscle mass, the greater the excretion of creatinine. As skeletal muscle atrophies during malnutrition, creatinine excretion decreases. Urinary creatinine is influenced by protein intake, exercise, age, sex, height, renal function, and thyroid function. Total Lymphocyte count: Certain nutrient deficiencies and forms of PCM can depress the immune system. The total number of lymphocyte white blood cells decreases as protein depletion occurs. 9. Box 46.7 Malnutrition Remember these areas of focus for physical assessment and findings suggestive of nutritional problems. Make note of them if necessary. NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs 10. Special Diets: Discuss purpose and foods/fluids allowed on these diets. Clear Liquid: This diet is limited to water, tea, coffee, clear broths, ginger ale or other carbonated beverages, strained and clear juices, and plain gelatin. Note that “clear” does not necessarily mean “colorless.” This diet provides the client with fluid and carbohydrate (in the form of sugar), but does not supply adequate protein, fat, vitamins, minerals, or calories. It is a short-term diet (24 to 36 hours) provided for clients after certain surgeries or in the acute stages of infection, particularly of the GI tract. Full Liquid: This diet contains only liquids or foods that turn to liquid at body temperature, such as ice cream (see Box 46.9). Full liquid diets are often eaten by clients who have GI disturbances or cannot tolerate solid or semisolid foods. This diet is not recommended for long-term use because it is low in iron, protein, and calories. In addition, its cholesterol content may be high because of the amount of cow’s milk offered. Clients who must receive only liquids for long periods are usually given a nutritionally balanced oral supplement, such as Boost, Ensure, or Sustacal. The full liquid diet is monotonous and difficult for clients to accept. Planning six or more feedings per day may encourage a more adequate intake. Soft: The soft diet is easily chewed and digested. It is often ordered for clients who have difficulty chewing and swallowing. It is a low-residue (low-fiber) diet containing very few uncooked foods; however, restrictions vary among agencies and according to individual tolerance. Examples of foods that can be included in a soft or semisoft diet are shown in Box 46.9. Pureed: The pureed diet is a modification of the soft diet. Liquid may be added to the food, which is then blended to a semisolid consistency. Low-residue: It is a low-residue (low-fiber) diet containing very few uncooked foods; however, restrictions vary among agencies and according to individual tolerance. You can eat beef, lamb, chicken, fish (no bones), and pork, as long as they're lean, tender, and soft. Eggs are OK, too. Sodium-controlled: Sodium-controlled diets are used to reduce blood pressure in salt-sensitive hypertension and to promote the loss of ex- cess fluids in edema due to cardiovascular or renal disease and in ascites due to hepatic disease. Sodium-controlled diets may also enhance the action of some medications. Carbohydrate-controlled: A controlled carbohydrate diet means that meals contain carbohydrate-rich foods in fairly equal amounts. That is, each breakfast has about the same amount of carbohydrate-rich foods from day to day as do lunches and dinners. Dysphagia diet: texture-modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and all cultures. Foods are liquidized and liquids are thickened. NURS 3000 - Professional Nursing Fluid and Electrolytes: Nutritional Needs 11. Describe independent nursing interventions to stimulate the client’s appetite in the clinical setting. The nurse reinforces this instruction and, in addition, creates an atmosphere that encourages eating, provides assistance with eating, monitors the client’s appetite and food intake, administers enteral and parenteral feedings, and consults with the primary care provider and dietitian about nutritional problems that arise. 12. Consider the situation of a single mother of two young children. When she brings her children to the clinic for routine immunizations, you note that both she and her children are moderately overweight. You decide you should do some teaching regarding healthier eating habits. You learn that she works two jobs to provide for her family and pay the bills. How might your teaching differ coming from a Christian perspective rather than the usual teaching with pamphlets, calorie-limited diet plans, and instructions to document weight weekly? I would attempt to help the family as a whole and try and assist with finding resources that can help the mother be available to cook meals at home and not rely on fast food or take out. This can entail, putting in a request or alert with the mothers case manager to assist with finding her one job that can earn the mother enough to not need to work two jobs. Educate the patient on finding an organization that can supply pre-cooked meals or a food bank that can supply nutrient dense foods.