Nutrition

NUTRITION

OBJECTIVES

Explain the importance of a balance between energy intake and output.
Discuss the importance of carbohydrate, protein, and lipid metabolism.
Explain the significance of saturated, unsaturated, and polyunsaturated lipids in nutrition.
Describe the basic food groups and their value in planning meals for good nutrition.
Teach dietary guidelines and review patient education.
Discuss the major areas of nutritional assessment (diet history, medication history) across the lifespan.
Identify nutritional problems, and describe a patient at risk for these problems.
Establish a plan of care to meet the nutritional needs of a patient.
Discuss methods for feeding patients who require assistance with oral intake.
Describe the procedure for initiating and maintaining enteral tube feedings.
Describe the procedure for initiating and maintaining parenteral nutrition.

PRINCIPLES OF NUTRITION

Role of Food

The body requires food to provide nutrients for:
  - Growth and development
  - Organ function
  - Cellular metabolism
  - Movement
  - Synthesis/repair of tissues
  - Maintenance of body temperature

Nutrients

Carbohydrates:
   - Provide energy
   - Includes:
     - Starches and sugars
     - Fiber (soluble or insoluble)
Proteins:
   - Needed for tissue growth, maintenance, repair
   - Composed of amino acids
   - Nitrogen balance can be:
     - Positive (intake > output)
     - Negative (intake < output)
Fats:
   - Saturated Fats:
     - Solid at room temperature
     - Triglycerides composed of three fatty acids attached to a glycerol
   - Unsaturated Fats:
     - Liquid at room temperature
     - Divided into:
       - Monounsaturated
       - Polyunsaturated
   - Includes essential fatty acids
Vitamins:
   - Organic substances present in small amounts in foods and essential for life
   - Antioxidants (e.g., Vitamins A, C, E) neutralize free radicals, preventing oxidative damage to body cells and tissues
   - Types of vitamins:
     - Water soluble:
       - Vitamins C, B (stored temporarily, absorbed in GI tract, daily replacement needed)
     - Fat soluble:
       - Vitamins A, D, E, K (stored for longer periods in the body)
Minerals:
- Macrominerals: daily requirement is 100 mg or more (e.g., calcium, chloride, magnesium, phosphorus, potassium, sodium, sulfur)
- Microminerals: trace elements (< 100 mg, e.g., chromium, copper, fluoride, iodine, iron, manganese, molybdenum, selenium, zinc)
Water:
   - Functions include:
     - Transporting nutrients and waste products
     - Providing structure to large molecules
     - Promoting metabolic reacti ons
     - Serving as a solvent, lubricant, and cushion
     - Regulating body temperature
     - Maintaining blood volume

Functions of the GI Tract

Digestion
Absorption
Elimination
Metabolism
Storage

DIETARY GUIDELINES

Dietary Reference Intakes (DRI)

Composed of four components:
  1. Estimated Average Requirement (EAR)
  2. Recommended Dietary Allowances (RDAs)
  3. Adequate Intakes (AIs)
  4. Tolerable Upper Intake Levels (ULs)
MyPlate Guidelines
Healthy People 2020 initiative

NURSING KNOWLEDGE BASE

Nutritional requirements depend on:
  - Stage of development
  - Body composition
  - Activity levels
  - Pregnancy
  - Presence of disease

ALTERNATIVE FOOD PATTERNS

Special patterns of food intake:
  - Vegetarian Diet: consists predominantly of plant foods
     - Ovolactovegetarian: consumes eggs and milk
     - Lactovegetarian: consumes milk
     - Ovovegetarian: consumes eggs
     - Vegan: strictly plant foods

DEVELOPMENTAL NEEDS

Infants through School Age:
  - Breastfeeding
  - Formula feeding
  - Introduction to solid food
Adolescents
Young and Middle-age Adults
Pregnancy and Lactation
Older Adults

OVERWEIGHT AND OBESITY

Contributing Factors to Obesity

Calories: Excessive intake without expenditure (e.g., sedentary lifestyles)
Genetics
Metabolic and lifestyle factors
Body Mass Index (BMI):
  - Recommended range: $18.5$ to $24.9$
  - Overweight: > 24.9
  - Obese: > 29.9
Childhood obesity

CRITICAL THINKING

Knowledge:
- Nutrition principles
- Basic and social sciences
Experience:
- Personal and clinical
Attitudes:
- Integrity, discipline, and perseverance
Standards:
- Include DRIs, USDA’s MyPlate, dietary guidelines, and Healthy People 2020 objectives, as well as other professional standards

NURSING PROCESS: ASSESSMENT

Screening

Part of the initial assessment
Malnutrition Universal Screening Tool (MUST)

Nutrition Assessment

Components include:
  - Diet history
  - Medication history
  - Special considerations for older adults
  - Mini Nutritional Assessment (MNA)

Patients at Risk for Nutritional Problems

Physical examination
Anthropometry
Laboratory values
Dysphagia: screening for swallowing difficulties
Patient expectations

NURSING PROCESS: DIAGNOSIS

Identified diagnoses include:
  - Deficient Knowledge (Nutrition)
  - Diarrhea
  - Feeding Self-Care Deficit
  - Imbalanced Nutrition: Less than Body Requirements
  - Impaired Swallowing
  - Obesity
  - Risk for Aspiration
  - Readiness for Enhanced Nutrition

NURSING PROCESS: PLANNING

Goals and Outcomes

Goals focus on improving nutritional status
- Can be both short term and long term

Setting Priorities

Anticipate what is most important to help your patient achieve good nutrition

Collaborative Care

Involves:
- Patient and family
- Professionals: Dieticians, Speech Therapists (ST), Occupational Therapists (OT), Pharmacists

NURSING PROCESS: IMPLEMENTATION

Health Promotion

Meal planning aligned with diagnosis
Weight loss plans
Dietary Approaches to Stop Hypertension (DASH)
Food safety practices

Acute Care

Providing a comfortable environment for patients
Assisting patients with feeding, especially those who have dysphagia or disabilities

INTERVENTIONS FOR THOSE UNABLE TO MEET NUTRITIONAL NEEDS ORALLY

Enteral Tube Feedings

Initiating tube feedings
Gastrostomy tube placement
Jejunostomy tube placement
Displacement issues

PARENTERAL NUTRITION

Risks and Administration

Increased risk of infection with parenteral nutrition
Individualized formula formulation
Central PN:
- Solutions that contain $10 ext{ ext{ ext{percent}}}$ dextrose or greater
- Administered through a central venous catheter
Peripheral PN:
- Solutions with osmolality greater than $900 ext{mOsm}$
- Administered through peripheral veins
Need for PN is evaluated daily

Initiating PN

Patient care considerations
Preventive measures for infection
Maintenance of the PN system
Prevention of complications
Meeting nutritional and fluid needs
Evaluating continued need for PN
Planning for home PN and providing support

SAFETY GUIDELINES

Verify tube position to ensure accuracy
Label enteral equipment properly
Confirm “right patient, right formula, right tube”
Elevate the head of the bed a minimum of $30$ to $45$ degrees during feeding
Trace all lines and tubing back to the patient for compliance
Monitor tube placement regularly
Promote food safety throughout care
Refer to manufacturer guidelines to determine hang time for enteral feedings
Prevent clogging of feeding tubes
Medications administered via the feeding tube should be in liquid form whenever possible or well crushed and adequately diluted
Administer continuous enteral nutrition (EN) and parenteral nutrition (PN) with an infusion pump

RESTORATIVE AND CONTINUING CARE

Focus on diet therapy in disease management
Medical nutrition therapy
Home care considerations
Education and troubleshooting in case of issues
Transitioning patients back to oral intake when indicated

NURSING PROCESS: EVALUATION

Patient Outcomes

Compare patient data to expected outcomes
Regular reassessment of the patient and revision of goals as needed

Patient Expectations

Individualize the nutrition care plan centered on the patient's needs and allow informed choices