Foundations Exam 1 (Nutrition and Tissue Integrity)

Nutrition

The basics of a healthy diet include consuming fruits and vegetables, choosing whole grain foods, limiting unhealthy fats, eating more low fat proteins, and reducing salt intake

Energy balance

-Energy is derived or obtained from foods we consume

-Measured in kilocalories (calories)

-Daily intake and expenditure determine stable weight, weight loss, or weight gain

-Adult calorie intake is 1600-2600 / day

Macronutrients

Nutrients that the body needs in relatively large quantities

Protein, carbohydrates, and fat

Micronutrients

Nutrients needed in smaller amounts but are crucial for overall health

Vitamins and minerals

Water

Recommended intake from beverages and food

Female: 2.7 - 3 L

Male 3.5 - 3.7 L

Basal metabolic rate (BMR)

-Energy (number of calories) required to fuel the involuntary activities of the body at rest after 12 hours;

-Energy needed to sustain metabolic activities of cells and tissues

-Males have a higher BMR due to larger muscle mass

Factors that increase BMR

-Growth

-Infections

-Fever

-Extreme environmental temperatures

-Elevated level of hormones

Factors that decrease BMR

-Aging

-Prolonged fasting

-Sleep

Body Mass Index (BMI)

A numerical measure that is commonly used to assess an individuals body weight in relation to their neigh

Underweight: BMI < 18.5

Ideal Weight: BMI 18.5 - 24.9

Overweight: BMI 25 - 29.9

Obese: BMI > 30

Extreme obesity: BMI > 40

BMI = (weight / height) ^2

Protein

-Recommended 10% to 35% of calories intake

-Activity level, age, and gender help determine the amount of daily protein that the body requires

-Vital component of every living cell

-Broken down in small intestines by pancreatic enzymes

Complete proteins (animal)

-Contain sufficient essential amino acids to support growth

-More complete amino acids

Incomplete proteins (plant)

Deficient in one or more amino acids

Why is protein needed

-Growth and repair

-Enzymes

-Hormones

-Immune function

-Transportation

-Energy

Carbohydrates

-Recommended 45% - 60% of total calories for adults

-Primary energy source

-Naturally occurring carbohydrates can be found in vegetables, fruits, milk, nuts, grains, legumes, and seeds

-Fiber is found in fruits, vegetables, beans, and whole grains

-Converted to glucose for transport through blood

Glycemic index

Blood sugar in body

Why do we need carbohydrates?

-Energy source

-Brain function

-Muscle function

-Metabolic health

-Digestive health

-Energy reserves

-Spares protein

Fats (lipids)

-Limited saturated fats to

Bile

-Secreted by the liver

-Stored in gallbladder

-Emulsifies fat so that pancreatic enzymes can break down and store in liver

Why do we need fats?

-Energy source

-Cell membranes (cell growth)

-Insulation and temperature regulation

-Protection of organs

-Absorption of fat soluble vitamins

-Hormone production

-Brain health

-Flavor and satisfaction

Vitamins

-Organic compounds needed by the body in small amounts

-Fresh foods are higher than processed

Water soluble vitamins

-B

-C

Have to consume often

know

Fat soluble vitamins

-A

-D

-E

-K

Stay in body longer

ALL DOGS EAT KIBBLE

know

Minerals

-Calcium

-Chromium

-Copper

-Iodine

-Iron

-Magnesium

-Manganese

-Phosphorus

-Potassium

-Selenium

-Sodium

Nutrition labels

Contain:

-Serving information

-Calories

-Nutrients

-Quick guide to percent daily value (%DV)

-5% is low

-20% is high

-If on a special diet, don't look at % look at grams

Infants and toddlers developmental considerations

-Weight

-Breast / bottle

-Solids

-Allergies (slowly introduce)

-Reward / punishment (bad)

Children and adolescents developmental considerations

-Growth pattern

-Health promotion of healthy foods

-Food choices

-Anorexia / bulimia (teenagers) lead to teeth breakdown, GI problems, and appearance

Older adults developmental considerations

-Decrease BMR (struggle with food intake)

-Loss of taste (need to add more flavor)

-Lowered sensation of thirst

Pregnant women developmental considerations

-Folic acid increased intake

-Fruits and vegetables

Factors affecting nutrition

Alcohol use:

-Nutrient absorption decrease

-Higher need for vitamin B

Medication and supplements:

-Absorption and metabolism may be altered

Megadose of nutrient supplements:

-Excess leads to deficiency

Nutritional assessment

-Physical assessment

-Food choices / preference

-Cultural considerations

-Economics (what they can afford; tip: rinse canned veggies if can't afford fresh)

-Meaning of food

-Mealtime

-24 hour food diary

-Restriction

-Medications and supplements

-Appetite

-Fluid intake

-Allergies

Patient problems with nutrition

-Impaired nutritional status

-Failure to thrive

-Body weight (over / under)

-Anorexia

-Nausea / vomiting

-Poor oral hygiene

-Self care deficit (can't eat / feed themselves)

Interventions: monitoring nutritional status

-Nourishment

Diet progression:

-absence or symptoms

-ability to consume at least 50% to 75% of the food on the meal tray

Interventions: assist with eating

-dignity

-engage the person in pleasant conversation to ease tension

-place a napkin, not a bib, over the person's clothes for protection

-use straws or special eating utensils whenever possible

-ensure that if a person wears dentures, hearing aids, or glasses, they are in place before mealtime

-involve them

Consider patients preferences on food and provide appropriate drinks

Promoting PO fluid intake

-Keep water / fluids at bedside

-Evaluate preferences (flavors? juice?)

-Consider ice chips

-High water content foods

-Limit caffeine / alcohol

-Electrolyte replacement

Visual impairment impact on nutrition

-Explain placement of foods on plates and food tray

-Can explain where food is in relation to a clock (chicken is at 4)

-Provide special plate guards, utensils, double handles, and compartmentalized plates

-Place foods and dishes in similar locations at each meal

-Use straws for beverages, if not contraindicated by dysphagia

-Provide supervision as needed

Stimulating appetite

-Serve small, frequent meals to avoid overwhelming the person with large amounts of food

-Solicit food preferences and encourage favorite foods from home or prepared when at home if possible

-Provide encouragement and pleasant eating environment

-Be sure that any prepared food looks attractive

-Scheduled procedures and medications at times when they are least likely to interfere with appetite

-Control pain, nausea, or depression with medication

-Offer alternative items

-Encourage good oral hygiene

-Check dentures are good

-Remove clutter

-No bad odors

-Good position to eat

Age related changes in nutrition

-Chewing difficulty

-Decreased gastric secretions

-Reduction in appetite and thirst

-Physical disability

-Reduced income

NPO

NOTHING BY MOUTH

-No fluid or food at all by mouth

-Not even ice chips

-Requires a providers prescription before resuming oral intake

Clear liquid diet

Liquids that leave little residue

-Clear fruit juices

-Gelatin

-Broth

-Beer if alcoholic

Full liquid diet

Foods that liquids at room temperature

-Juices

-Pudding

-Milkshakes

-Tea

-Strained soups

-Popsicles

-Jell-o

Pureed diet

Foods that are soft and smooth and do not need to be chewed

-Pudding

-Mashed potatoes

-Yogurt

-Pureed meats

-Ice cream

Mechanical soft diet

Clear and full liquids plus diced or ground foods

Regular diet

No resitrictions

Soft / low residue

Contains foods that are soft, easy to digest, low in fiber, and can be swallowed without difficulty

-well cooked vegetables

-low fiber cereals

-easy to chew proteins

low fiber and UNHEALTHY!!

High fiber diet

-Whole grains

-Raw and dried fruits

Diabetic / constant carbohydrate diet

Balanced intake of protein, fats, and carbohydrates

(complex)

Cardiac diet

-Controlled portions

-More fruits and vegetables

-Limit unhealthy fats

-Low fat protein sources

-Decreased sodium intake

Renal diet

-No added salt

-Low potassium because it directly affects kidneys

Measurement of solid foods

-Solid foods does not count as fluid intake

-Measure solid foods as % of meal eaten

-Measurement varies upon nurse

Intake (inflows)

-Oral intake

-Intravenous (IV) fluids

-Tube feedings

-Check for fluid volume overload

Oral intake

-Measure all fluids taken orally, including water, beverages, and medications

-Use graduated cups or containers to accurately measure the volume consumed

Intravenous (IV) fluids

-Include fluids administered through IV lines

-Record the type of fluid, infusion rate, and total volume infused over a specified time period

Tube feeding

-Measure fluids administered via nasogastric or gastrostomy tubes

-Note the type of formula, volume administered, and any residual volume aspirated

Output (outflows)

-Urinary output

-Fecal output

-Other loses

-Check for fluid volume overload

Urinary output

-Measure urine output using a calibrated collection container or a urinary catheter bag

-Record the volume and characteristics or urine (ex: color / clarity)

Fecal output

-Document the presence and consistency of stool output, if relevant to the patients condition

-Document number of bowel movements

Other losses

Include any other fluid losses, such as drainage from surgical drains or wound exudate

1 tablespoon

Equals 15 ml

2 tablespoons

Equals 1 ounce

1 ounce

Equals 30 ml

1 cup

= 8 oz = 240 mL

Ice chips

1/2 fluid volume

Short term enteral nutrition

-Nasogastric tube (NG)

-Nasointestine tube (NI)

Nasogastric (NG) tube

-Nurse places

-Short term therapy

-Large bore (compression of stomach) vs small bore (only feeding)

Contraindications:

-dysfunctional gag reflex

-high risk of aspiration

-gastric stasis

-gastroesophageal reflux

-nasal injuries

-those unable to have head of bed elevated during feeding

Nasointestinal (NI) tube

-Provider places

-Short term therapy

-Indicated for clients with increased risk of aspiration or have certain medical conditions

-Dumping syndrome

Tube placement confirmation

-Xray

-pH of aspirate contents (can see contents in stomach)

Long term enteral nutrition

-Percutaneous endoscopic gastrostomy (PEG)

-G tube

-J tube

-G - J tube

-Low profile gastrostomy device (LPGD)

Percutaneous endoscopic gastrostomy (PEG) tube

Directly through the skin of the upper abdomen (abdominal wall) and into the interior of the stomach.

-Specific type of G tube

Gastrostomy tube (G tube)

Directly in the stomach, passing through a small opening in the abdominal wall

Jejunostomy tube (J-tube)

Placed through the skin of the abdomen directly into the jejunum, the middle part of the small intestine

Gastrojejunostomy Tube (GJ Tube)

A soft feeding tube that enters through the skin of the abdomen into the stomach AND extends into the small intestine

Low profile gastrostomy device (LPGD)

-A skin-level feeding tube used to deliver food, fluids, and medications directly into the stomach

-Sits nearly flush against the skin, whereas a traditional long G-tube hangs several inches outward from the abdomen

Enteral feedings nursing considerations

-Continuous v. intermittent v. cyclic

-ALWAYS check tube placement before administration

-Checking gastric residuals

-Sterile v. tap water

-Tube feeding tolerance

-Abdominal assessment

-HOB >30 degrees (stop feeding when dropping head to change)

-Prevent contamination

-Pause to administer medications

Total parenteral nutrition (IV TPN)

-Cannot be given with enteral feedings

Indications:

-nonfunctional GI tracts

-comatose

-high caloric or nutrient needs

-failure to thrive

Nursing implicationsL

-dedicated intravenous lumen with filter

-frequent blood glucose monitoring

-taper infusion gradually

-increased risk of infection (central line associated blood stream infection (CLABSI))

-complications of central lines

-fluid, electrolyte, acid base imbalances

Tube feed nursing interventions

-Assessment of site and placement of tube

-Pause feedings when laying flat (HOB at least 30 degrees)

-Ensure getting correct formula and enough fluids

-Suction

-Crushed medications

-Frequent blood sugar checks

-Extra supplies at bedside

-Lung / bowel sounds to check for aspiration

Complications of enteral feedings

Aspiration:

-confirm tube placement

-elevate HOB

-avoid over sedation

Clogged tube:

-flush tube before / after feeding and Q4h

Nasal skin breakdown:

-assess nares

-"Floating" securement

Diarrhea:

-prevent contamination

-change delivery set Q24h

Unplanned removal:

-secure tube

-frequently check on patient

Stoma care

Aspiration precautions

-Frequent rest periods

-HOB at least 30 degrees

-Remain upright for at least 30 mins after eating

-Provide mouth care

-Ensure patient swallow food

-Small frequent meals

-Thicken liquids

-Alternate solids and fluids

-Avoid sedatives if possible

-Chin tuck

Skin assessment

-Assess the color of the hair, skin, and nails uniformly

-Skin color is influenced by genetics so assess changes from the normal baseline

Skin turgor:

-tenting means dehydration

-should recoil

-hydration status

-Skin integrity

-Skin turgor

-Edema

-Temperature and texture of areas of redness, wounds, or breakdown

Edema

Accumulation of fluid in the tissues most often from direct trauma or impaired venous return

-Assess by +1 - +4 scale

+1

-Trace edema

-2mm

-rapid skin response

+2

-Mild edema

-4 mm

-10-15 sec skin response

+3

-Moderate edema

-6 mm

-Prolonged skin response

+4

-Severe edema

-8 mm

-Prolonged skin response

Pallor

-Loss of color

-Change to gray color or loss of red undertones

Location:

-face

-nail beds

-palms

-lips

-buccal mucosa

Cyanosis

-Bluish color

-Poor oxygenation / lack of circulation

Location:

-nail beds

-lips

-mouth mucosa

-skin

-palms

Jaundice

-Yellow to orange color

Location:

-skin

-sclera

-mucous membranes

Erythema

-Redness

-Areas of injury

Location:

-face

-trunk

-extremities

-areas of trauma or pressure injury

Wound classifications

-Intentional (surgical site) vs. unintentional (break in arm)

-Acute vs. chronic

-Open vs. closed

-Superficial vs. partial thickness / full thickness

Wound healing

-Primary intention

-Secondary intention

-Tertiary intention

Primary intention

-Clean incision

-Early suture

-Hairline scar

Secondary intention

-Gaping irregular wound

-Granulation

-Epithelium grows over scar

Tertiary intention

-Wound

-Increased granulation (deeper)

-Late suturing with wide scare (heal from bottom up)

Factors affecting wound healing

-Age

-Overall wellness

-Decreased leukocyte count

-Infection

-Malnutrition

-Tissue perfusion

-Low hemoglobin levels

-Obesity

-Chronic diseases

-Smoking

-Wound stress

Risk assessment of wounds

-Braden scale

-Patients history

-Pain assessment

Physical wound assessment

-Location

-Dimensions (measure wound)

-Wound description

-Drainage

-Dressings

Wound types

-Intact skin

-Laceration (cut)

-Abrasions (scrape)

-Punctures (hole - bites / needles)

-Skin tear (top layer gets pushed to side)

-Avulsions (whole skin is removed - degloving)

-Bruises

-Burns

-Surgical wounds

-Ulcers

-Pressure injuries

-Diabetic

-Venous stasis (poor circulation)

Granulation tissue

Good healthy tissue

Necrotic eschar tissue

-Dead tissue

-Have to debris

Slough

-Body is pushing out bacteria

-Has to be removed

Hyper granulation tissue

Granulation tissue forms above the surface of the surrounding epithelium.