NUR 241 Module B5 Nutrition

What are things you are looking for during nutritional assessment?

Nutrition Assessment –

Height, weight, adequacy of diet

Nutrition-related health problems or risk factors (DM, obesity, gastric bypass, etc.)

Establish dietary goals for appropriate weight gain –

Well-balanced, varied diet

Appropriate supplements

Appropriate physical activity

Referral to nutritionist (if indicated)

Which nutritional needs can have an effect on neural tube defects?

Folate and Folic Acid.

Neural tube begins to close in 1st month of pregnancy (before a woman knows she's pregnant)

Where is Folate and Folic Acid derived from?

Folate – form of vitamin B9 found naturally in food

Folic acid– form used in fortification of grains and other foods/supplements

Adolescents and women of child bearing age should consume how much folate and folic acid a day? What about if there is a history of neural tube defects how much should you take then?

Adolescents and women of childbearing age should consume adequate food sources AND take additional 0.4 mg (400 mcg) of folic acid daily

History of a child with neural tube defect (NTD)  recommended to take 4 mg of folic acid daily, starting at least a month before trying to conceive

What should the caloric intake be for non pregnant women, 1st trimester, 2nd trimester, and 3rd trimester?

Non-pregnant women – 1800–2200 kcal/day

1st trimester – no additional calories needed

2nd trimester – +340 kcal/day

3rd trimester – +452 kcal/day

What are some Maternal factors related to the increased needs for caloric intake?

Development/growth of uterine-placental-fetal unit

Total blood volume (TBV) increases by 40–50%

Maternal mammary development

20% increased metabolic rate

What are the recommendations for weight gain during pregnancy?

General Rule – 25–35 lbs throughout pregnancy

1–4 lbs during 1st trimester

What are the BMI categories for Normal, underweight, overweight, and obese during pregnancy?

o Normal BMI – 18.5–24.9 (+25 – 35 lbs total )(1 lb/week in 2nd & 3rd trimester)

o Underweight BMI – less than 18.5 (+28 – 40 lbs total). (1 lb/week in 2nd & 3rd trimester)

o Overweight BMI – 25–29.9 (+15 – 20 lbs total) (0.6lb/week in 2nd & 3rd trimester)

o Obese BMI – 30 and higher ( +11 – 20 lbs total) (0.5lb/week in 2nd & 3rd trimester)

If you are normal weight, underweight, overweight, and obese, how much weight should be recommended you gain during pregnancy?

Normal weight is 25-35 pounds

Underweight 28-40 pounds

Overweight is 15-20 pounds

Obese is 11-20 pounds

What is defined as inappropriate weight gain?

What is the recommendations for weight gain based off of?

LESS than 1kg/month after 1st trimester

MORE than 3kg/month after 1st trimester

Recommendations for weight gain are based on pre-pregnancy weight*

Low pre pregnancy weight and Inadequate weight gain during pregnancy can cause what? This can be difficult for who? What can inhibit food intake?

Increased risk of LBW (low birth weight) and SGA (small for gestational age) infant

Can be difficult psychologically for some women

N/V can inhibit food intake

For low pre pregnancy weight and inadequate weight gain what must the nurse assess and emphasize?

Assess for pre-existing eating disorders or for its development during pregnancy,

Assess access to food sources and financial resources,

Emphasize importance of nutrient-dense foods and avoiding empty calories,

Emphasize positive effects of good nutrition vs negative effects of poor nutrition

A women with low pre pregnancy weight and/or inadequate weight gain must be instructed to not what?

Have any weight-reduction dieting in pregnancy

If a patient is obese or has excessive weight gain during pregnancy what should a nurse educate them of?

Educate and emphasize quality of food & regular physical activity

What are the risks of perinatal outcomes related to obesity and excessive weight gain during pregnancy?

Miscarriage

Birth defects

Stillbirth

Abnormal fetal growth

Preterm birth

What are the maternal risks related to obesity and excessive weight gain during pregnancy?

Gestational diabetes mellitus (DM)

Hypertension

Vacuum/forceps-assisted birth

Cesarean section

Surgical site infection

Venous thromboembolism (VTE)

Depression

What are the indicators of nutritional risk during pregnancy?

Adolescence or less than 2 years post-menarche

Frequent pregnancies (3 within 2 years)

Poor fetal outcome in a previous pregnancy

Poverty / food insecurity

Poor dietary habits and resistance to change

Any weight loss during pregnancy

Use of tobacco, alcohol, or drugs

Being overweight or underweight at the time of conception

Inappropriate weight gain during pregnancy

Low hemoglobin and hematocrit (anemia)

What is the distribution of weight gain that a women goes through during pregnancy at 40 weeks?

o 7–8.5 lbs – Fetus

o 2–2.5 lbs – Placenta

o 4–5 lbs – Increased blood volume

o 4–6 lbs – Increased fat stores

o 3–5 lbs – Increased tissue fluid

Calories are necessary for growth of what?

What food sources are calories found in?

Growth of fetal and maternal tissues

Calories are found in Carbohydrates, Proteins, and fat

Water intake is necessary for what? What food sources can you find water in?

Water intake is necessary for expansion of blood volume and excretion of wastes.

Food sources you can find water in are - Water and beverages made with water;

milk, juices; all foods (esp. frozen desserts, fruits, lettuce and other fresh vegetables)

What is protein necessary for and what food sources have protein?

Necessary for Synthesis of the products of conception; growth of maternal tissue and expansion of blood volume

Food sources - Meats, eggs, cheese, yogurt, legumes (dry beans and peas), peanuts, nuts, grains

What is fiber necessary for and what food sources contain it?

Fiber is necessary for - Promotes regular bowel elimination

Reduces long-term risk for heart disease, diverticulosis, and diabetes

Food sources that contain fiber include Whole grains

Bran

Vegetables

Fruits

Nuts

Seeds

What is calcium necessary for and what food sources can it be found in?

Calcium is necessary for Fetal skeleton and tooth formation; maintenance of maternal bone and tooth mineralization

Food sources calcium can be found in are Milk, cheese, yogurt, sardines or other fish eaten with bones left in, dark green leafy vegetables (except spinach and Swiss chard), calcium-set tofu, baked beans, tortillas

Iron is necessary for what? What food sources is iron found in?

Iron is necessary for Maternal hemoglobin formation

Fetal liver iron storage

Iron is found in Liver, meats, whole grains or enriched breads and cereals; dark green leafy vegetables, legumes, dried fruits

What is zinc necessary for and what food sources can it be found in?

Zinc is necessary for Component of numerous enzyme systems; important in preventing congenital malformations; increased maternal metabolic rate

Zinc can be found in Meats, Shellfish, Milk products, Whole grains, Legumes

Iodine is necessary for what? What food sources can it be found in?

Iodine is necessary for Energy and protein metabolism

Tissue growth

Muscle function

Food sources it can be found in are Iodized salt,

Seafood,

Milk and milk products,

Commercial bread.

Magnesium is necessary for what? Where can magnesium be found in food sources?

Magnesium is necessary for Absorption of calcium and phosphorus; improves mineralization

Magnesium can be found in Dark green leafy vegetables

Nuts

Whole grains

Legumes

Some fruits

What is Vitamin A necessary for and what food sources is Vitamin A in?

Vitamin A is necessary for Essential for cell development

Tooth bud formation

Bone growth

Vitamin A can be found in Dark green leafy vegetables

Deep yellow vegetables and fruits, liver, fortified margarine and butter

Vitamin D is necessary for what? What food sources can it be found in?

Vitamin D is necessary for Absorption of calcium and phosphorus; improves mineralization

Vitamin D can be found in Fortified milk and breakfast cereals Margarine

Butter

Liver

Fatty fish

Sun exposure

Vitamin E is necessary for what? What food sources can vitamin E be found in?

Vitamin E is necessary for Antioxidant (protects cell membranes from damage), especially important for preventing breakdown of red blood cells (RBCs)

Vitamin E can be found in Vegetable oils

Dark green leafy vegetables,

Whole grains,

Liver,

Nuts and seeds,

Cheese,

Fish

What is Vitamin C necessary for and what food sources can it be found in?

Vitamin C is necessary for Tissue formation and integrity, formation of connective tissue, iron absorption.

Vitamin C can be found in Citrus fruits, strawberries, melons, broccoli, tomatoes, peppers, raw dark green leafy vegetables

What is B12 necessary for and what food sources can it be found in?

B12 is necessary for Production of nucleic acids and proteins, especially important in formation of RBCs and neural functioning.

B12 can be found in Milk and milk products,

Eggs, meats, liver,

Fortified soy milk

What is B6 necessary for and what food sources can it be found in?

B6 is necessary because it is Involved in protein metabolism.

B6 can be found in Meats, liver, dark green leafy vegetables, whole grains

What is B9 necessary for?

B9 is necessary for Prevention of neural tube defects

Increased maternal RBC formation

What are some sources of Folate? (B9)

≥ 500 mcg/serving:

-Liver: chicken, turkey, goose

≥ 200 mcg/serving:

-Liver: lamb, beef, veal

≥ 100 mcg/serving:

-Legumes (cooked): (½ c)

-Peas: black-eyed, chickpea (garbanzo)

-Beans: black, kidney, pinto, red, navy

-Lentils

-Vegetables: (½ c)

-Asparagus

-Spinach (cooked)

-Papaya

-Breakfast cereal (½ -1 c)

-Wheat germ (¼ c)

≥ 50 mcg/serving:

-Vegetables: (½ c)

-Broccoli

-Beans: lima beans, baked beans, pork & beans

-Greens: collards or mustard (cooked)

-Spinach (raw)

-Fruits: (½ c)

-Avocado

-Orange or orange juice

-Pasta (1c)

-Rice (1c)

≥ 20 mcg/serving:

-Bread (1 slice)

-Egg (1 large)

Corn (½ c)

The best source of B9 is what?

Chicken, turkey, or goose liver.

What are the recommendations regarding sodium during pregnancy?

Avoid excessive salt intake, especially low nutrient, high sodium foods (pretzels, chips, pickles, ketchup, mustard, bouillon, some soft drinks)

High-sodium foods include –

o Most canned and processed foods, frozen entrees, baked goods, mixes for casseroles/grains, soups, condiments

What electrolyte is normally lacking in women and what are the recommendations for this electrolyte during pregnancy?

Potassium is often lacking in diets of women

Encourage 8–10 servings of unprocessed fruits/veggies & moderate amount oflow-fat meat/dairy-reduces sodium while providing adequate potassium

Magnesium intake is what?

Magnesium is essential for what?

Magnesium intake is likely low during childbearing years, especially in adolescents and those with low-income

Essential for protein synthesis, muscle & nerve function, glycolysis, & regulation ofblood pressure

Alcohol is considered what during pregnancy? What can it cause?

o Absolutely contraindicated in pregnancy

o Teratogen that can lead to birth defects & other developmental problems

Is caffeine okay during pregnancy?

Yes but limit intake. Recommended intake is < 200 mg daily (1 cup of coffee is 100 mg)

o Be mindful of other caffeine sources –

tea, soft drinks, chocolate, energy drinks, coffee-flavored items

Are artificial sweeteners okay during pregnancy?

o Aspartame and Sucralose are FDA approved in pregnancy (Equal; Splenda)

Stevia or Agave are not – no acceptable daily intake established

Listeria and other pathogens can cause women to get sick during pregnancy. What are things that should be avoided?

Unpasteurized milk and products can make her very sick

Avoid soft cheeses (brie, feta, bleu cheese) unless the label states it’s pasteurized

Wash fruits and veggies

Can a pregnant women eat deli meat?

Never cold. Deli meats should be heated to steaming

What are the recommendations regarding fish during pregnancy?

o Avoid fish high in mercury – swordfish, big eye tuna, mackerel, orange roughy, shark

o Limit white albacore tuna to 6 oz / week

o 2–3 servings of low-mercury fish/shellfish is safe

o No raw/undercooked seafood or fish

What are the recommendations for undercooked meats during pregnancy?

o Heat all meats and poultry thoroughly

o No fridge-stored pates or meat spreads

§ shelf-stable and potted meats are safe

o Cook eggs until yolks and whites are firm

What is Pica and what is it associated with?

Consuming non-food substances (clay, soil, laundry starch) OR excessive amounts of foodstuffs low in nutritional value (ice, uncooked rice, flour, baking powder)

Strongly associated with iron deficiency anemia

How does pica interfere with pregnancy? When do nurses screen for pica and what are some screening questions?

May interfere with absorption of nutrients (esp. minerals)

Screen each trimester, starting with the first

o Screening questions –

“Have you had any cravings?

“Have you craved anything that isn’t food, such as ice, clay, or dirt?

“How much have you eaten, and how often

Do food cravings disrupt nutrient absorption? What are some things you can teach your patient about cravings?

· Most food cravings don’t disrupt dietary balance

Encourage eating regularly, including healthy snacks, to avoid glucose drops & use distractionto curb cravings

What's the difference between Lacto Vegetarian, Lacto-ovo Vegetarian, and Vegan?

Lacto-vegetarian – consume milk & milk products

Lacto-ovo vegetarian – consume eggs & dairy

Vegan – only consume plant-based foods

Vegan/Vegetarians should be referred to who? Are vegan/vegetarian diets adequate?

Should be referred to dietician for nutritional counseling, preferably prior to conception or as early as possible

Can be adequate diet if well-planned – less likely to be deficient in iron, zinc, vitamins D, E, & B12; choline; calcium; & essential fatty acids if well planned

Vegetarian diets do have protein in them but they can lack what? How do you work around this?

Well-balanced vegetarian diets provide adequate protein, but plant proteins tend to be “incomplete”  lack one or more amino acids required for growth/maintenance of body tissues

Consuming variety of plant proteins (grains, dried beans/peas, nuts, seeds) can provide all essential amino acids

What are the nutritional considerations for Bariatric surgery?

Macro-micronutrient deficiencies (folate, B12, iron, calcium, Vitamin D)

Screen for deficiencies throughout pregnancy, provide supplements as needed

Infants have increased risk r/t prematurity, SGA, & NICU (esp. if < 2 years since surgery)

What are the underweight, normal weight, over weight, and obese BMIs?

o Underweight BMI: < 18.5

o Normal BMI: 18.5–24.9

o Overweight BMI: 25–29.9

Obese BMI:> 30

Easy way to remember this is 18, 25, 30, then everything above 30 is obese.

How do you calculate appropriate weight gain?

· Pre-pregnancy weight & (BMI): 145 lbs (BMI 23)

· Current weight and gestation: 164 lbs @ 32 weeks

o Step 1: ACTUAL WEIGHT GAIN

§ 164-145 = 19 lbs

o Step 2: Based on her BMI, how much should she gain?

§ Normal BMI (23)  should gain 1lb/week in 2nd & 3rd trimester (+25-35 total)

o Step 3: How many weeks PAST first trimester is she?

§ Subtract 13 (number of weeks in first trimester) from her current gestation

o 32 – 13 = 19 weeks

o Step 4: Multiply how many lbs she can gain in 2nd & 3rd trimester

§ 19 x 1lb/week = 19 lbs

o Step 5: Calculate in weight gained in 1st trimester

§ Add 4lbs (from 1st trimester)

o 19 + 4 = 23 lbs

o Step 6: RECOMMENDED WEIGHT GAIN

§ 23 lbs total weight gain so far in pregnancy is recommended

§ **A range of within 5lbs (+/-) is within target**

§ Client has gained 19 lbs  WITHIN APPROPRIATE WEIGHT GAIN

How do you calculate Narcan dose? Baby weighs 8 Lbs 9 oz.

All Narcan doses are 0.1 mg / kg

NEVER MORE THAN 0.5 UNLESS BABY IS OVER 11 POUNDS

First get everything to pounds so take 9 oz and divide it by 16 oz. Which equals 0.5625. Always only take 2 numbers past the decimal so it equals 0.56

Then put that 0.56 into the pounds so its 8.56 pounds.

Then divide 8.56 pounds by 2.2 to get to kilograms which equals 3.89.

Take 3.89 and times it by 0.1 which gives you your answer at 0.38

Should a pregnant women who is overweight try to restrict her calorie count to try and get back to normal accepted weight? What should you ask her?

**She should NOT restrict her calories while pregnant even though she is not in the appropriate weight gain target!**

o Ask about access to healthy food

o Encourage physical activity, as long it’s not contraindicated

o Most important  educate her on balanced, nutrient-dense diet and to avoid empty calories