nutrition chapter 37 ATI 39 & 54

1. A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient’s diet should not be advanced?


1. The patient consumed 75% of the liquids on the breakfast tray.
2. The patient tells you they are hungry.
3. The patient’s abdomen is soft, nondistended, with bowel sounds.
4. The patient reports fullness and diarrhea after breakfast.

D

1. A patient hospitalized for a stroke has a prescription for continuous tube feedings through a small-bore nasogastric tube. Following tube placement, which action by the nurse best confirms correct tube placement?


1. Auscultating the bowel sounds
2. Measuring the pH of gastric aspirate
3. Measuring the amount of residual in the stomach
4. Ensuring validation of tube placement by x-ray

D

1. A nurse specializing in care of older adults speaks to a group of nursing students about that population’s challenge with obtaining sufficient nutrition. Which points will the nurse include in the discussion? Select all that apply.


1. An increase in BMR and physical activity require additional calories.
2. Tooth loss and periodontal disease may make chewing more difficult.
3. Decreased peristalsis can result in constipation, requiring additional fiber and fluid.
4. Loss of taste between sweet and salty occurs with a preference for sweets.
5. Older adults express an increase thirst sensation.
6. Caloric needs decrease, and the need for nutrients increases, especially protein.

B, C, D, F

1. A nurse in the intensive care unit is reviewing diagnostic studies to evaluate a patient’s nutritional status. What findings consistent with inadequate nutrition require follow-up by the nurse? Select all that apply.


1. Decreased hemoglobin
2. Low prealbumin level
3. Increased transferrin
4. Anemia
5. Elevated lymphocytes

A, B, D, E

1. A nurse plans to administer a bolus tube feeding for a patient but is unable to aspirate gastric contents due to a clogged tube. What action will the nurse take next?


1. Use warm water or air, applying gentle pressure to remove the clog.
2. Use the tube’s stylet to unclog the tubes.
3. Administer a cola beverage to remove the clog.
4. Replace the tube with a new one.

A

1. A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient assessment requires collaboration with the surgeon, as the procedure could need to be postponed?


1. 19-year-old patient who is a vegan
2. Older adult patient who takes daily nutritional drinks
3. 43-year-old patient who takes ginkgo biloba and an aspirin daily
4. Infant who is breastfeeding

C

1. A nurse is caring for a patient with ill-fitting dentures. What modification to their diet will the nurse suggest?


1. Clear liquid
2. Full liquid
3. Mechanically altered
4. Honeylike liquids

C

Low cholesterol diet

no more than 300 mg/ day of dietary cholesterol

regular diet

no restrictions

low sodium diet

no added salt or 1 to 2g sodium

high fiber diet

* whole grains
* raw and dried fruits

diabetic diet

balanced intake of proteins, fats, and carbohydrates of about 1,800 calories

dysphagia

pureed food and thickened liquids

Soft/low residue diet

foods that are low in fiber and easy to digest

* dairy
* eggs
* ripe bananas

vitamin E

Fat soluble

* an antoxidant that protects vitamin A

Vitamin K

Fat Soluble

* helps the synthesis of certain proteins necessary for blood clotting

Nutrients

\
**Specific biochemical substances used by the body for growth**, development, activity, reproduction, lactation, health maintenance, and recovery from illness or injury > work better together than alone

* essential
* macro
* micro

essential nutrients

Not synthesized in the body or are made in insufficient amounts; must **be provided in the diet or through supplements**

macro nutrients

Supply energy and build tissue; i.e., carbohydrates, fats, and proteins

micro nutrients

Regulate and control body processes; i.e., vitamins and minerals

Nutrients that supply energy

* carbohydrates
* protein
* lipids (fats)

How does the body convert excess carbohydrates and protein?

Turn them into fat and store them into triglycerides

nutrients that regulate body processes

* vitamins
* minerals
* water

food

complex mix of essential and nonessential nutrients

energy balance

total daily energy expenditure & total daily energy intake

* Daily intake and expenditure differences determine stable weight, weight loss, or weight gain

energy

Derived or obtained from foods consumed

* measured in kilocalories
* only carbs, proteins, and fat provide calories > energy

Total daily energy expenditure

All of the calories used to perform physical activity, maintain metabolism, and digest, absorb, and metabolize food

Total daily energy intake

\
Total calories for each food item eaten

Basal Metabolic Rate (BMR)

**Energy (number of calories) required to fuel the involuntary activities** of the body at rest after 12 hours; the energy needed to sustain metabolic activities of cells and tissues

* Males have a higher BMR due to larger muscle mass

**< (up)** Growth, infections, fever, emotional tension, extreme environmental temperatures, elevated levels of certain hormones

**> (down)** Aging, prolonged fasting and sleep

increased BMR

Growth, infections, fever, emotional tension, extreme environmental temperatures, elevated levels of certain hormones

decreased BMR

Aging, prolonged fasting and sleep

Body Mass Index (BMI)

**Provides an estimate of body fat; ratio of height to weight**

•Ratio of weight in kilograms to height in meters squared

•Can be used as an initial assessment of the nutritional status

•May be inaccurate for certain groups of people

**Provides an estimation of relative risk for diseases that can occur with more body fat: heart disease, type 2 diabetes, hypertension, and certain cancers**

nutrition

**the study of the intake of food and how food nourishes the body.**

study of the nutrients and how they are handled by the body, as well as the impact of human behavior and environment on the process of nourishment

obesity

weight greater than 20% above ideal body weight

* 30 - 39.9

Body Fat Distribution

The location of where body fat is deposited is an important/reliable indicator of disease risk

\-Central abdominal obesity poses a greater risk

* Waist circumference is a good indicator of abdominal fat
* Risk increases with a waist measurement of 40 inches or more for men and 35 inches or more for women

\-Waist-to-hip ratio (WHR)—tool used to identify central obesity

normal

18\.5 - 24.9

overweight bmi

25 - 29.9

carbohydrates

**Primary function = supply energy** / **45% to 60% of total calories for adults**

* ***Sugars*** **and starches;** organic compounds composed of carbon, hydrogen, and oxygen
* **Serve as the structural framework of plant**s; **lactose is only animal source** (the sugar present in milk)
* **Most abundant and least expensive source of calories in the world**
* Most intakes often r/t income- income increases, carb intake decrease

• **More easily and quickly digested than protein and fat**

**• 90% of carbohydrate intake is ingested**

• **Converted to glucose for transport through the blood**

what are all carbohydrates converted into?

glucose for transport through the blood and use for energy

simple sugars (carbohydrates)

* **monosaccharides**
* **disaccharides**

complex sugars (carbohydrates)

**polysaccharides**

what determines the classification of carbohydrates?

The number of molecules in the structure

Digestion

occurs largely in the small intestine

\- **Gastrointestinal system’s breakdown process of food into particles small enough to pass into the cells and be used by the cells**

* peristalsis

metabolism

Efficient fuel that certain tissues rely on almost exclusively for energy (i.e., nervous system)

• Transported from the GI tract, through the portal vein, to the liver

• Liver stores glucose and regulates entry into the blood

• **Glycogenesis: the creation of glucose vs. glycogenolysis**

* cells oxidize glucose to provide energy, carbon dioxide, and water

dysphagia

difficulty in swallowing or inability to swallow

protein

primary function = **maintain body fluids that breakdown from normal wear and tear + to support the growth of new tissue**

* **vital component of every living cell**; **required for the formation of all body structures**
* **More than 1,000 different proteins are made in the body by combining various of the 22 amino acids**

what are always in a state of flux ?

The body’s protein tissues

dietary protein

**broken down into amino acids by pancreatic enzymes in the small intestine**

* **absorbed in intestinal mucosa**
* **transported to the liver**


* may be labeled complete (high quality) or incomplete (low quality), based on their amino acid composition.

complete protein

contain sufficient essential amino acids to support growth (animal protein

* animal or plant protein

animal protein *or* plant protein + small amount of animal protein or two complementary vegetable proteins.

incomplete protein

deficient in one or more essential amino acids (plant protein)

metabolism protein

* Dietary protein is **broken down into amino acids by pancreatic enzymes in the small intestine** which are **absorbed and transported to the liver**
* In the liver, **amino acids are recombined into new proteins** or are released for use by tissues and cells
* Protein tissues are in a constant state of flux. Tissues are continuously being broken down (catabolism) and replaced (anabolism)

fats

* **Insoluble in water and blood**; composed of carbon, hydrogen, and oxygen
* **95% of lipids in diet are triglycerides**
* Most concentrated source of energy in the diet
* Recommended intake: limit saturated fats to less than 10% of daily calories and intake of trans fats to as low as possible

\

where is fat digested?

small intestine

cholesterol

 a fatlike substance found only in animal products: the body makes sufficient amounts

* an important component of cell membranes and is especially abundant in brain and nerve cells
* used to synthesize bile acids and is a precursor of the steroid hormones and vitamin D
* high serum levels are clearly associated with an increased risk for atherosclerosis

trans fat

are a form of dietary fat that raise LDL (“bad”) cholesterol and lower HDL (“good”) cholesterol

* increases the risk of developing heart disease and stroke and is associated with a higher risk of developing type 2 diabetes 

classifications of fats

Contain mixtures of __**saturated > contain more hydrogen**__ (raise cholesterol levels) and __**unsaturated**__ (lower cholesterol levels) fatty acids

* Most animal fats are saturated
* Most vegetable fats are unsaturated

fat metabolism

\
* **Digestion occurs largely in the small intestine**
* Bile which is secreted by the liver and stored in the gallbladder emulsifies fat so that pancreatic enzymes can break it down for digestion
* **Fats are absorbed into the lymphatic circulation** and **transported to the liver**

vitamins

* **Organic compounds are needed by the body in small amounts; do not provide calories; active coenzymes**
* DO NOT PROVIDE CALORIES/energy
* Fresh foods are higher in vitamins than processed
* **Needed for the metabolism of carbohydrates, protein, and fat**
* Water-soluble—intake daily
* Fat-soluble—daily intake is not imperative
* The absence or insufficient use of vitamins in the body causes specific deficiency syndromes.

water soluble

\
**C, B**-complex vitamins; **not stored in the body**

**Absorbed through the intestinal wall directly into the bloodstream; Not stored in the body & Need to intake these daily**

fat soluble

* **A vitamin**
* **D vitamin**
* **E vitamin**
* **K vitamin**

**Absorbed with fat into the lymphatic system**

**• Must be attached to the protein to be transported in the blood**

**• Body stores excess in liver and adipose tissue**

**• Daily intake is not imperative**

**• Can have toxicities with Vit A & D**

minerals

\
* **Organic elements found in all body fluids and tissues in the form of salts**
* DO NOT PROVIDE CALORIES/ energy
* Some **function to provide structure in the bod**y, others help **regulate body processes**
* **Contained in the ash that remains after digestion**

Vitamin A

Fat soluble

* affects visual acuity, skin, and mucous membranes
* immune function

Vitamin D

Fat-soluble

* provides calcium and phosphorus metabolism and stimulates calcium absorption

macrominerals

calcium, phosphorus (phosphates), sulfur (sulfate), sodium, chloride, potassium, and magnesium

microminerals

iron, zinc, manganese, chromium, copper, molybdenum, selenium, fluoride, and iodine

absorption

process by which drugs are transferred from the site of entry into the body to the bloodstream

anorexia

loss or lack of appetite for food

gastric residual volume

feeding remaining in the stomach

gastrostomy

opening created into the stomach

gastrostomy tube

opening created into the stomach

anthropometric

measurements of the body and body parts

aspirations

misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract

water

• Accounts for between **50% and 60% of adult’s total weight**

• **Two-thirds of body water is contained within the cells (intracellular fluid [ICF])**

• The **remainder of body water is extracellular fluid (ECF), body fluids (plasma, interstitial fluid)**

• Provides fluid medium **necessary for all chemical reactions in the body**

• Acts as a **solvent and aids digestion, absorption, circulation, and excretio**

Dietary Guidelines for Americans

Science-based strategies that are published every 5 years to reflect up to date guidance

Dietary Reference Intakes (DRIs)

\
* Provide recommended nutrient intakes to maintain health and prevent deficiency diseases
* Recommended dietary allowance (RDA): average daily dietary \n intake that meets requirements of most people
* Adequate intake (AI): established if unable to determine RDA

recommended dietary allowance

 recommendations for average daily amounts of essential nutrients that healthy population groups should consume over time

waist circumference

a numerical measurement of the waist, used to assess an individual’s abdominal fat and establish ideal body weight+

MyPlate food guide

Illustrates 5 food groups to encourage balanced diet

food labeling

All foods should be clearly labeled with nutrition facts

Physiologic and physical factors > factors affecting nutrition

Stage of development, state of health, medications

Social determinants of health > factors affecting nutrition

• Economic stability, health care access and quality, social and community context, education access and quality, neighborhood \n and built environments

factors affecting nutrition

\
Culture, religion, food ideology, and learned aversions

Developmental Considerations

* growth: infancy, adolescence, pregnancy, and lactation increase nutritional needs


* Activity increases nutritional needs
* Age-related changes in metabolism and body composition
* Nutritional needs level off in adulthood
* Fewer calories required in adulthood because of decrease in BMR

Factors That Influence Nutritional Requirements

* sex assigned at birth
* state of health
* alcohol use disorder
* medications
* mega-doses of nutrient supplements

History taking

Dietary, medical, socioeconomic data

physical assessments

Anthropometric and clinical data

biochemical data

Protein status, body vitamin, mineral, and trace element status

dietary data

* 24 hour recall method
* food frequency record
* food diaries/ calorie counts
* diet history

nursing interventions

* teaching nutritional information
* monitoring nutritional status
* stimulate appetite
* assisting w/ eating
* providing oral nutrition
* providing long-term nutritional support

Therapeutic diets

• __**Consistent carbohydrate**__: focus is general nutritional balance to help \\n maintain healthy weight (T1DM, T2DM, gest. DM)

• __**Fat or sodium restricted**__: low-fat diets help lower total intake of fat \\n (Cholecystitis, heart disease)

• **High fiber** (__constipation, IBS, diverticulosis__)

• **Low fiber** (__before surgery, UC, CKD, liver disease__)

• Renal: decreases workload on kidneys to prevent damage, protein and sodium restrictions (nephrotic syndrome, CKD, diabetic kidney disease)

Modified consistency diets

* Clear liquid: anything that becomes clear at body temperature, requires minimal digestion and leaves minimal residue (apple/cranberry/grape juice, popsicles, jello)
* Pureed: made of liquid and food to make liquid form (smoothies, mashed potatoes)
* Mechanically altered: regular diet with modifications for texture,

foods are chopped/ground/soft (applesauce, ground sausage instead of patties)

nasogastric tube

tube inserted through the nose and into the stomach

naso-intestinal tube

 tube inserted through the nose and into the upper portion of the small intestine

NPO

nothing by mouth

* no food or fluid at all by mouth > not even ice chips requiring a prescription before intake

Full liquid diet

clear liquids plus liquid dairy, all juices, some pureed veggies

mechanical soft diet

clear and full liquids plus diced or ground foods

clear liquid diets

liquids that leave little residue

* clear fruit juice
* gelatin
* broth

pureed diet

clear and full liquids plus pureed meats, fruits, and scrambled eggs

Short-Term Nutritional Support

**ideally 4 weeks or less**

* __**Nasogastric route:**__ through t**he nose to the stomach**, the **risk for aspiration**
* __**Nasointestinal route:**__ through **the nose into the small intestine**, with a **smaller risk for aspiration**