NSG 212 - Exam 3 KW

Micronutrients

regulate body processes

-vitamins

-minerals

-H20

Vitamins

-H2O soluble: B complex, C
-Fat soluble (absorbed with fat into the lymphatic circulation): ADEK
-Antioxidants: C, E, carotene, selenium

Minerals

-Necessary elements

­-Macro: >100mg/day (Ca, Phos, Mag)

­-Micro: <100mg/day (iron, zinc, iodine)

H20 (water)

Although not a nutrient, is necessary for body/cell function, as 50-60% of body is water. Get necessary water through liquid intake, foods, and metabolism byproducts to replace what is lost during perspiration, elimination & respiration

Macronutrients

-essential

-energy providing and build tissue

-carbohydrates (CHO)

-fat

-protein

Carbohydrates (CHO)

­-Most easily digested and efficiently used. Should be primary source of calories (50-60% of daily calories). Focus should be on complex CHO and fiber intake. [4 cal/g]

-­CHO are required energy source for CNS metabolism.

­-The body’s preferred energy source!

-­Excess digested CHO stored as glycogen in liver & muscles and as triglycerides.

­-CHO are broken down into sugar in the body.

Protein

­-Animal/vegetable. Need only 0.8-0.9 g/kg for adults (10-20% of calories)--more for children. [4 kcal/g]

­-Proteins broken down into 22 amino acids, 9 being “essential” (not made by body – must get from food or supplements)

­-Complete protein: Meats & soy. Other sources must be combined to provide all amino acids.

-­Amino acids maintain & support growth of body tissues.

excess protein intake is hard on the ....

kidneys

-must watch the amount of protein provided to pts with renal disease

-renal complication with Atkins-like diets

-monitor Cr+BUN

fat

­-Should be <35% caloric intake (< 10% saturated fat). Most calorie dense [9cal/g]

­-Linoleic acid is only “essential” fat.

­-Saturated (w/hydrogen bonds) vs. Unsaturated/Polyunsaturated (better for you)

­-Cholesterol: Necessary for body function; but body usually makes enough itself; excess leads to CV risk.

-Omega 3 fatty acids enhance immune system (fish, flaxseed, pumpkin seeds).

Vitamin A (fat soluble)

-visual acuity
-skin and mucous membrane
- immune function

Vitamin D (fat soluble)

calcium and phosphorus metabolism and stimulates calcium absorption

Vitamin E (fat soluble)

antioxidant that protects Vitamin A

Vitamin K (fat soluble)

helps the synthesis of certain proteins necessary for blood clotting

Vitamin C (water soluble)

-collagen synthesis
-antioxidant protection
-immune support
-enhancing iron absorption

Vitamin B (water soluble)

-B1 (Thiamine): Energy metabolism and nerve function.

-B2 (Riboflavin): Energy production and skin health.

-B3 (Niacin): Supports metabolism and DNA repair.

-B5 (Pantothenic Acid): Involved in synthesizing coenzyme A for energy production.

-B6 (Pyridoxine): Important for amino acid metabolism and neurotransmitter synthesis.

-B7 (Biotin): Supports fatty acid synthesis and energy metabolism.

-B9 (Folate): Crucial for DNA synthesis and repair; important during pregnancy for fetal development.

-B12 (Cobalamin): Vital for nerve function and red blood cell formation.

infancy

highest requirements/kg

preschool

lower nutritional requirements
-secondary to slowed growth

adolescence

growth spurt=increased requirements

throughout adulthood

decreased nutritional requirements

during illness/injury and recovery

increased calorie need

men assigned at birth

require higher protein and caloric intake secondary to increased muscle mass

menstruating women require...

increased iron

lactation requires ...

-increased caloric intake
-increased during pregnancy ( by 300 cal/day)
-increased during lactation (by 500 cal/day)

Pts with alcohol use disorder need ...

-increased Vit B
-to help metabolize ETOH(alcohol)
-they dont absorb the Vit B from food
-drink their nutrition

Wernickes Encephalopathy

-Lack of B 1 - Thiamine; neurological condition; may be irreversible
-alcoholism

Appetite Stimulation

-Encourage familiar/preferred foods
--Ask preferences and see if meet nutritional needs
-Small, attractive portions
-Clean, relaxed environment
-Open lid away from patient
-Small frequent meals
-Control pain, nausea
-Good oral hygiene
-Schedule meds, procedures, PT, dressings at times they will not interfere with appetite

special diets

Nursing role to ensure correct diet and educate client about restriction

controlled calories or nutrients

-Due to obesity, diabetes, kidney, GI, or cardiac problems
-1800 cal ADA
-2G NA+ (sodium reduced...Cardiac)

mechanical soft

-If difficulty chewing/swallowing

­-Clear and full liquids plus foods that are diced or ground

clear liquid

-Clear liquid: A transitional diet often used after surgery, if has been NPO for a time, as a test prep, or if nausea present; gelatin, fat free broth, ice pops, clear juices, coffee, tea, ginger ale, and popsicles; inadequate in calories, protein, and most nutrients; can not be used long term

­-Clear at room temp, leave little residue, non-gas forming

­Ice = ½ mL

­-Primarily to prevent dehydration and relieve thirst

full liquid

-Clear liquids plus milk, puddings, custards, frozen desserts, eggs, cereals, vegetable juices. May need to use protein supplement if liquid diet used > 3 days.

NPO

Nothing by mouth; consider oral hygiene, swish and spit

low cholesterol

No more than 300 mg/day of dietary cholesterol; for patients dx with hypercholesterolemia (high cholesterol)

soft/low residue diet

-Low in fiber
-Easy to digest
-No fresh fruit/veggies
-Cooked veggies ok
-Often used in bowel/GI disease

complications from enteral feedings

-aspiration

-clogged tube

-nasal irritation

-stoma infections

-nausea, vomiting

-abdominal distention

-extubating

-large residual

-diarrhea/cramping

-skin irritation

-mouth discomfort

-dumping syndrome

aspiration comp from EF

-Hold feedings
-put on side
-suction airway
-provide O2
-monitor temp
-notify MD
-CXR

clogged tube comp from EF

-Flush
-milk the tube (use warm water - not juice or cola) or request order for pancreatic enzyme solution - Viokase tabs.

nasal irritation comp from EF

reposition, pad, switch to long term delivery device

stoma infections comp from EF

Keep site clean and dry, change tubing and solution q 24 hours, skin care, provide skin barrier, monitor temp, Abs, clean hub with ETOH prior to use

nausea, vomiting comp from EF

Hold feeding, notify MD, check for patency of tube, aspirate for residual, assess for bowel sounds

abdominal distention comp from EF

May be caused if clogged, or end of tube against bowel wall - change position, irrigate with tap water, slow rate

extubation comp from EF

-Can get lodged in pharynx or lung.
-Remove tube and notify MD

large residual comp from EF

-Residual should be <10-20% of hourly rate or under 100-200 cc if bolus, hold the feedings, Semi-Fowler's, recheck residual in 1 hour, notify MD
-There is a high risk of aspiration with large residual - must check regularly - q 4-6 hours with continuous and with each bolus feed.
-Ruby now saying do not check residual - see next slide.
-Digesting well=low residual

diarrhea/cramping comp from EF

-Simple nursing skills like warming tube feeds to room temp can help prevent major complications like cramping!
-3 or more times in 24 hours = notify MD, consult with dietician, provide skin care, monitor I/O

skin irritation comp from EF

provide barrier/skin care

mouth discomfort comp from EF

Oral care, lozenges, rinse mouth freq. Oral care q 2-4 hours!

dumping syndrome

-comp from EF

-Occurs with bolus feeds, hypertonic food enters jejunum and cause fluid shifts

-Signs and symptoms: Nausea, vomiting, diarrhea, cramping, pallor, sweating, heart palpitations, increased HR, fainting after feeding

enteral

within or by way of the intestines

parenteral

outside the GI system

TPN (total parenteral nutrition)

-Must be given through a central line

-THIS IS IV INFUSION!

-­Higher cost & risk than enteral feeding

­-Solution has PRO, CHO, fats, electrolytes, vitamins

-­Monitor I&O, wt., protein, electrolytes, blood sugar (giving concentrated sugar solution).

­-Don’t STOP abruptly! HYPOGLYCEMIA

­-Use aseptic technique (surgical asepsis at all times) & watch for inflammation and infection signs.

-change all equipment/bag/lines q 24 hrs. decrease risk for infections

-flush line with normal saline as ordered

anthroprometric meaures

-Indicate nutrition status & health risk due to body composition
-Height/weight by table or graph
-Body mass index (BMI): WT(kg)/[H(meters) squared]
-Skin-folds or electronic measurement of body fat (more accurate) or limb circumference. More accurate than measuring weight alone as it takes muscle mass into account.
-Waist measure of > 35 in for women & > 40 for men indicates health risk

body weight standards

-BMI = W(kg)/H^2(meters)
-Reliable indicator of total body fat in the general population
-Can estimate disease risk for heart disease, diabetes, HTN
-Not as accurate in athletes, dehydration, edema, older adults

underweight BMI

<18.5 kg/m2

Normal BMI

18.5-24.9 kg/m2

Overweight BMI

24.9-29 kg/m2

Obese BMI

30 - 39 kg/m2

morbidly obese BMI

40 + kg/m2

enteral med admin

-If the Enteral tube is to suction, you will need to clamp the tube for 30 minutes after medication administration.

-DON’T forget to hook back to suction as required.

-Liquid meds should be used.

-All meds should be diluted with sterile H2O.

-Don’t add meds to tube feeds.

-Administer one at a time with at least 15mls before and after.

­-Place patient 30-45 degree sitting position

­-Keep up to prevent aspiration for at least 30 minutes after med administration

­-Need to assess for correct tube placement and residual (??).

­-Liquid forms of meds are preferred OR must be crushable med.

­-Not sustained release or enteric coated, fluid filled or SL meds

­-Liquid meds at room temperature

-­Check compatibility of medications.

­-Use 30-60 ml syringe.

­-Crush each med separately and mix w/ 15-30 ml of sterile water.

­-Flush before/after each med w/ 30-60ml sterile water.

­-Flush w/ 30-60 ml sterile water when all done.

­-Don’t mix meds with tube feedings.

-­Sterile Water = Intake

metabolism

biochemical/physiologic processes by which body grows and maintains self

biochemical data

-hemoglobin (oxygen carrying protein)

-hematocrit (volume of RBC) reflect a persons IRON status

-serum albumin, transferrin, and total lymphocyte count=determine protein status/levels

-urine urea nitrogen

-urine creatinine

-creatinine

low albumin - biochem

-risk factor for poor nutrition

-­Serum albumin shows SLOW changes in protein levels (3.5-5 mg/dl)

­-Serum pre-albumin reflects ACUTE changes (16-35 mg/dl)

urine urea nitrogen + urine creatinine -biochem

excretions reflect protein intake and abilioty to excrete byproducts
-BUN goes up in renal disease..body cannot process protein

creatinine -Biochem

level directly relation to body's total muscle mass
-decreased in severe malunion

I&O

-intake and output
-Intake and output, needs to be a 1:1 ratio - what goes in should come out!
-Output should be at least 30 ml/hr.
-1 ounce is 30 ml.
-1 cup (8 ounces) is 240 ml.
-Ice is ½ the volume in ml.

A patient's shift total:
1 cup of ice
2 ½ cups of coffee
½ cup of milk
6 ounces of jello (clear liquid)
1 cup of broth
7 ounces of contrast dye

What was the total intake in ml?

120

240 240 120

120

6/8x240 = 180 or 6x30

240

7/8x240=210 or 7x30

1470ml

diabetes and nutrition

-Diabetes is an abnormal production of or use of insulin in the body.
-Insulin is a hormone that is needed to convert sugar, starches (glucose), and other food into energy needed for daily life.
-Insulin is needed to move the sugar into the cells for cellular energy and cellular processes.
-Diabetes is diagnosed by high blood sugar levels (at least 2 tests to confirm); must be fasting - reschedule if they have had food, juice, etc.

Type 2 Diabetes

is caused by either a normal or slowed production of insulin and/or an inability of body cells to use insulin (cellular resistance).
-causes=obesity, advanced age, inactivity, pancreatic disease.

Type 1 Diabetes

-is caused by a lack of production of insulin.
-causes=pancreatic cell destruction possibly by virus or bacteria, autoimmune
-s/s=polys, dehydration, blurred vision, fatigue, weight loss (type 1)

self care for diabetes

-Need lots of education on ways to stabilize blood sugar and prevent complications

-­Priority topic: Checking BG levels

­-Consistent carb counts at meals

­--Typical DM patient may need between 20-40g carbs each meal – requirements change with exercise!

­-Sick day insulin/med rules

­--When to take what meds if they can’t eat

-­Foot care

­--Cutting toenails – round not square

Blood Glucose

80-110

hypergylcemia

>110 fasting or >140 2 hrs pp

hypogylcemia

<80

S/S of hypoglycemia

-Shakiness
-Dizziness
-Sweating
-Confusion
-Headache
-Hunger
-Tingling around mouth
-Behavioral changes

S/S of hyperglycemia

-SOB
-Slowness
-N & V
-Fruity breath
-Dry mouth
-Fatigue
-Thirst

glucose monitoring

-Treat the numbers, not the symptoms

­--Know baseline.

­--Know when they last ate/ took anti-diabetic medications (insulin) or other meds that will increase blood sugar (STEROIDS).

­--Be aware of s/s of hyper/hypo.

nursing intervention for hypoglycemia

­-Confirmation glucose

­-Less than 70 for most facilities

­-Treat with 10-15 grams of carbs.

­-4 ounces of juice =15 carbs

­-3 glucose tabs=15 carbs

­-Do not dump sugar in orange juice!

-­Recheck in 15 minutes; repeat.

nursing intervention for hypergylcemia

-Confirmation glucose
-Greater than 400 for most facilities
-Insulin to treat
-Sliding scale or PRN order

NG tube feedings

-Check placement (verify with x-ray upon insertion) and residual (?? - RUBY new policy says no). Must document in EMR that tube has been cleared via X-RAY.
-HOB up 30-45 Degrees
-Monitor for aspiration.
-Monitor blood glucose.
-Monitor for dehydration (I/O).
-Monitor labs (BUN, creatinine, nitrogen can be high).
-Must be ordered by provider before placed by RN/LPN.

NG tube placement check

-Xray- upon initial insertion

-Check pH of stomach contents

­--Stomach 5.5

­--Meds can affect 4-6

­--Intestine 7 or higher

­--Lung 6 or higher

­--Aspiration of contents

­--Do not discard, return to the stomach

-Measurement of tube

-CO2 testing

-Air bolus not recommended

Jason, the RN, is assigned to care for a patient who is a high risk for aspiration. The provider has ordered an NG tube and bolus feeds for the patient. Jason is reviewing his notes on complications related to dumping syndrome. Jason would know that which of the following signs and symptoms experienced after a bolus feeding may indicate the patient is experiencing dumping syndrome: SELECT ALL THAT APPLY:

diarrhea, vomiting, abdominal cramping, fainting

Red meat is an incomplete protein. T or F

false - red meat is a complete protein

What is the name for the product that occurs when manufacturers partially hydrogenate liquid oils?

trans fat

Which one of the following vitamins affects visual acuity in dim light, formation and maintenance of skin and mucous membranes, and immune function?

Vit A

Food is more vital to life than water, because it provides the medium necessary for all chemical reactions and it is not stored in the body. T or F

false - Water is more vital to life than food, because it provides the medium necessary for all chemical reactions and it is not stored in the body.

postural reflexes

reflexes that help us maintain a normal upright posture
-labyrinthine sense
-proprioceptor or kinesthetic sense
-visual or optic refexes
-extensor or stretch reflexes

labyrinthine sense

Inner ear (position, orientation, movement)

proprioceptor or kinesthetic sense

Informs the brain of the location of limbs

visual or optic reflexes

Spatial relationships (how far from things)

extensor or stretch reflexes

Straightening of the joints

immobility

-Temporary, such as following knee arthroplasty
-Permanent, such as paraplegia
-Sudden onset, such as a fractured arm and leg following a motor-vehicle crash
-Slow onset, such as multiple sclerosis

effects of immobility on integumentary

-Increased pressure on skin, which is aggravated by metabolic changes
-Decreased circulation to tissue causing ischemia, which can lead to pressure ulcers

effects of immobility on respiratory

-Decreased respiratory movement resulting in decreased oxygenation and carbon dioxide exchange
-Stasis of secretions and decreased and weakened respiratory muscles, resulting in atelectasis and hypostatic pneumonia
-Decreased cough response

effects on immobility on cardiovascular

-Orthostatic hypotension
-Less fluid volume in the circulatory system
-Stasis of blood in the legs
-Diminished autonomic response
-Decreased cardiac output leading to poor cardiac effectiveness, which results in increased cardiac workload
-Increased oxygenation requirement
-Increased risk of thrombus development

effects on immobility on metabolic

-Altered endocrine system

-Decreased basal metabolic rate

-Changes in protein, carbohydrate, and fat metabolism

-Decreased appetite with altered nutritional intake

-Negative nitrogen balance

-Decreased protein resulting in loss of muscle

-Loss of weight

-Alterations in calcium, fluid, and electrolytes

-Resorption of calcium from bones

-Decreased urinary elimination of calcium resulting in hypercalcemia

effects of immobility on musculoskeletal

-Decreased muscle endurance, strength, and mass
-Impaired balance
-Atrophy of muscles
-Decreased stability
-Altered calcium metabolism
-Osteoporosis
-Pathological fractures
-Contractures
- Foot drop
-Altered joint mobility

effects of immobility on elmination

GENITOURINARY

-Urinary stasis

-Change in calcium metabolism with hypercalcemia resulting in renal calculi

-Decreased fluid intake, poor perineal care, and indwelling urinary catheters resulting in urinary tract infections

GASTROINTESTINAL

-Decreased peristalsis

-Decreased fluid intake

-Constipation, then fecal impaction, then diarrhea

Effects of Immobility on neurological/psychosocial

-Altered sensory perception
-Ineffective coping

effects of immobility on changes in emotional status

Depression, alteration in self-concept, and anxiety

effects of immobility on behavioral changes

Withdrawal, altered sleep/wake pattern, hostility, inappropriate laughter, and passivity

nursing intervention for immobility

-Identify patients at risk for pressure ulcer development.

-Position using corrective devices such as pillows, foot boots, trochanter rolls, splints, and wedge pillows.

-Turn every 1 to 2 hrs and use devices for support or per protocol.

-Teach patients who can move independently to turn at least every 15 min.

-Provide patients who are sitting in a chair with a device to decrease pressure.

-Limit sitting in a chair to 1 hr. Instruct patients to shift their weight every 15 min.

-Use a therapeutic bed or mattress for patients in bed for an extended time.

-Monitor nutritional intake.

-Provide skin and perineal care.

-DOCUMENT, DOCUMENT, DOCUMENT.

-Reposition every 1 to 2 hrs.

-Instruct patients to turn, cough, and breathe deeply every 1 to 2 hrs while awake.

-Instruct patients to yawn every hr while awake.

-Instruct patients to use an incentive spirometer 10 x an hour while awake.

-Remove abdominal binders every 2 hrs and replace correctly.

-Use chest physiotherapy.

-Auscultate the lungs to determine the effectiveness of chest physiotherapy or other respiratory therapy.

-Instruct patients to consume at least 2,000 mL fluid per day, unless intake is restricted.

-Monitor the ability to expectorate secretions.

-Use suction if unable to expectorate secretions

-Increase activity as soon as possible by dangling feet on side of bed or transferring to a chair.

-Instruct patients to perform isometric exercises to increase activity tolerance.

-Change position as often as possible.

-Move the patient gradually during position changes.

-Instruct patients to avoid the Valsalva maneuver.

-Give a stool softener to prevent straining.

-Teach range of motion (ROM) and anti-embolic exercises such as ankle pumps, foot circles, and knee flexion.