Level 2 Nutrition Notes

Level 2 Nutrition

Exemplars for Level 2 Nutrition

  • Heart Healthy Diet
  • Diabetic Diet
  • Malnutrition (Intro to Parenteral Nutrition)
  • Peptic Ulcer Disease (PUD)
  • Gastroesophageal Reflux Disease (GERD)
  • Malabsorption Syndromes
  • Infant & Elderly (Gastrostomy and Enteral Feedings)
  • Starvation – Failure to Thrive
  • Infant Nutrition (Breast/Bottle)

Daily Recommended Requirements

  • Percentages for Carbohydrates, Proteins, and Fats
  • Calories per kilogram for weight management (lose, maintain, gain).

Diabetic and Heart Healthy Diets

Heart-healthy diet - steps to benefit those with diabetes and cardiac disease:
  • Control portion sizes.
  • Eat more vegetables and fruits.
  • Select whole grains.
  • Limit simple carbs.
  • Limit unhealthy fats.
  • Choose low-fat protein sources.
  • Reduce sodium intake.
  • Plan ahead with daily menus.
  • Allow occasional treats.
Example Heart Healthy Diet
  • Breakfast:
    • 1 cup cooked oatmeal with 1 tablespoon chopped walnuts and 1 teaspoon cinnamon.
    • 1 banana.
    • 1 cup whole milk.
  • Lunch:
    • 1 cup low-fat (1 percent or lower) plain yogurt with 1 teaspoon ground flaxseed.
    • 1/2 cup peach halves, canned in juice.
    • 1/2 cup Fritos.
    • 1 cup raw broccoli and cauliflower.
    • 2 tablespoons low-fat cream cheese (plain or vegetable flavor) for crackers or vegetable dip.
    • Sparkling water.
  • Dinner:
    • 4 ounces salmon.
    • 1/2 cup green beans with 1 tablespoon toasted almonds.
    • 2 cups mixed salad greens with 2 tablespoons salad dressing.
    • 1 tablespoon sunflower seeds.
    • 1 cup skim milk.
    • 1 small orange.
  • Snack:
    • 1 cup skim milk.
    • 9 animal crackers.
Example Diabetic Diet
  • Breakfast (294 calories, 41 g carbohydrates):
    • 1/2 cup oats cooked in 1/2 cup each 2% milk and water.
    • 1 medium plum, chopped.
    • 4 walnut halves, chopped.
  • A.M. Snack (96 calories, 18 g carbohydrates):
    • 3/4 cup blueberries.
    • 1/4 non-fat, plain Greek yogurt.
  • Lunch (319 calories, 37 g carbohydrates):
    • Turkey & Apple Cheddar Melt:
      • 2 slices whole-wheat bread.
      • 2 tsp. whole-grain mustard, divided.
      • 1/2 medium apple, sliced.
      • 2 oz. low-sodium deli turkey.
      • 2 Tbsp. shredded Cheddar cheese, divided.
    • 1 cup mixed greens.
  • Dinner (417 calories, 54 g carbohydrates):
    • 2 1/2 cups canned vegetable soup.
    • 1 serving Goat Cheese Toast.
  • P.M. Snack (58 calories, 16 g carbohydrates):
    • 1/2 medium apple, sliced.
    • 1/2 tsp. honey.
    • Pinch of cinnamon.

Gastroesophageal Reflux Disease (GERD)

Pathophysiology of GERD
  • In a healthy individual, the lower esophageal sphincter (LES) remains closed, preventing stomach contents from refluxing into the esophagus.
  • In GERD, the LES is open, allowing reflux.
Risk Factors for GERD
  • Obesity: increases intra-abdominal pressure.
  • Age over 50: may cause delayed gastric emptying.
  • White race.
  • Low socioeconomic status.
  • Sleep Apnea
  • Nasogastric tube
  • Smoking
Contributing Factors to GERD
  • Hiatal hernia.
  • Increased abdominal pressure.
  • Increased gastric acid production.
  • Connective tissue disorders, such as scleroderma.
  • Prolonged abdominal distention.
  • Excessive consumption of foods that relax the LES.
  • Medications that relax the LES.
  • Lying flat.
Cues and Symptoms of GERD
  • Heartburn: A burning sensation in the chest, usually after eating, lasting 20 minutes to 2 hours, especially after consuming offending foods or liquids.
  • Indigestion (dyspepsia).
  • Chest pain: Retrosternal burning, radiating pain to the neck, jaw, or back, potentially mimicking a heart attack.
  • Pain relief: Relief almost immediately by drinking water, sitting upright, or taking antacids.
  • Throat irritation: Chronic cough, laryngitis.
  • Pain on swallowing (odynophagia).
  • Chronic GERD can lead to dysphagia.
  • Regurgitation of food: Bitter taste in mouth.
  • Increased flatus and burping (eructation).
  • Dental caries.
  • Sleep disturbances at night.
Diagnostic Tools for GERD
  • History and Physical (H&P).
  • Tests to rule out cardiac etiology if presenting with chest pain.
  • Esophagogastroduodenoscopy (EGD) or Upper GI Endoscopy with biopsy.
  • pH monitoring.
  • Barium Swallow.
  • Nursing actions.
Treatments for GERD
  • Lifestyle and diet modifications.
  • Antacids: Neutralize hydrochloric acid (HCl) acid (e.g., Tums, Alka-Seltzer, Mylanta).
  • H₂ Blockers: Block the action of histamine (e.g., Pepcid, Zantac 360).
  • Proton Pump Inhibitors (PPIs): Reduce acid production (e.g., Nexium, Prilosec, Prevacid).
  • Anti-ulcer medications: Provide a protective layer against acid (e.g., Carafate, Pepto-Bismol).
  • Pro-kinetic agents: Block the effect of dopamine (metoclopramide/Reglan).
  • Surgical modifications: Enhance the function of the LES.

Peptic Ulcer Disease (PUD)

Pathophysiology of PUD
Risk Factors for Ulcer Development
  • Helicobacter pylori (H. pylori) infection.
  • NSAID use.
  • Hypersecretory states.
  • Pepsin.
  • Lifestyle factors.
  • O Blood type.
  • Family tendency.
  • Pancreatic tumors.
  • Chronic pulmonary or kidney disease.
  • Pernicious anemia.
Clinical Manifestations
  • General: bloating, Nausea/Vomiting (N/V), and early fullness.
  • Ulcers can be SILENT and lead to serious complications.
  • Gastric, Duodenal, Esophageal.
Diagnostic Studies
  • Endoscopy: Determine presence and location of ulcer.
  • Tissue specimen for H. pylori.
  • Barium swallow study, if unable to have endoscopy.
  • Stool and breath testing for H. pylori.
  • Stool for occult blood.
  • Blood tests.
Plan of Care
  • Encourage rest periods.
  • Regular exercise.
  • Avoid or eliminate NSAIDs; if ASA needed, enteric coated may be given with misoprostol, PPI, or H₂ Blocker.
  • Smoking cessation.
  • Avoiding alcohol consumption.
  • Decreasing/managing stress.
  • Consume a balanced diet – avoid triggers.
  • Monitor for signs of perforation.
Drug Therapy
  • Goal of drug treatment:
    • Alleviate symptoms
    • Promote healing
    • Prevent complications
    • Prevent recurrence
  • Medication Classes:
    • Antibiotics – treat H. pylori
    • Antisecretory agents reduce acid secretion
    • PPIs
    • H₂ Receptor Antagonists
    • Mucosal Protectants
    • Antisecretory agents that enhance mucosal defenses
    • Antacids
    • Pro-kinetics
Surgical Therapy
  • Gastrectomy
  • Antrectomy
  • Gastrojejunostomy
  • Vagotomy
  • Pyloroplasty
  • Complications

Malnutrition

Malnutrition - a continuum
  • Undernutrition
  • Overnutrition
Malnutrition Risk Factors
  • Incomplete diets
  • Alcohol/drug abuse
  • Eating disorders/fad diets
  • Chronic Illness
  • Prior GI surgery
  • Socioeconomic factors
  • Food-Drug interactions
  • Malabsorption Syndrome
  • Burns
  • Trauma
  • Sepsis
Malnutrition Types
  • Undernourishment
  • Starvation
  • Failure to thrive
  • Malabsorption syndromes
Starvation
  • Pathophysiology of starvation
  • Cues of Starvation
Failure to Thrive
  • FTT is a term used in infants, children, and adults.
  • Causes: organic or inorganic.
  • Risk factors: depression, mental illness, post traumatic stress disorder, poor food availability, poor water supply, medical causes, chromosomal abnormalities, dysfunctional interrelationships with caregivers, maternal emotional state, and socio- economic factors.
Malabsorption Syndrome
  • Malabsorption syndrome, another malnutrition, is caused by impaired (insufficient) absorption of fats, carbs, proteins, minerals, and vitamins.
  • Most common cues: weight loss, diarrhea, and steatorrhea.
  • Affects all ages
Malnutrition - Malabsorption syndrome
  • BRISTOL STOOL CHART
    • Type 1: Separate hard lumps - Very constipated
    • Type 2: Lumpy and sausage like - Slightly constipated
    • Type 3: A sausage shape with cracks in the surface - Normal
    • Type 4: Like a smooth, soft sausage or snake - Normal
    • Type 5: Soft blobs with clear-cut edges - Lacking fibre
    • Type 6: Mushy consistency with ragged edges - Inflammation
    • Type 7: Liquid consistency with no solid pieces - Inflammation
Malnutrition - Lab work for Undernourishment
  • Serum albumin
  • Pre-albumin
  • C-reactive protein (CRP)
Malnutrition - Treatments for Undernourishment
  • megestrol acetate/Megace
  • dronabinol/Marinol
  • Balanced oral diet
  • Multivitamin supplement
  • Correction of fluid and electrolyte imbalances
  • Enteral or parenteral nutrition
  • The pathophysiology of the problem directs the treatments. Consider the patient’s environment, comfort level, and functional ability related to feeding and nutrition.
Supplemental Nutrition
  • Nasogastric tube and PEG feeding tube.
Enteral Nutrition
  • Goal: prevent or correct nutritional deficits with liquefied food or formula
  • Preserves the structure and function of the gastric mucosa and stops movement of gastric bacteria across the intestinal wall into the blood stream.
  • Nursing considerations.
Parenteral Nutrition
  • Used when the enteral route is contraindicated or will not provide adequate nutrition.
  • Paralytic ileus, diffuse peritonitis, intestinal obstruction, pancreatitis, GI ischemia, abdominal trauma or surgery, severe burns, anemia, and diarrhea, prolonged and severe illness, and short bowel syndrome.
Parenteral Nutrition
  • PN is an IV administration of a complex, highly concentrated solution containing nutrients and electrolytes formulated for specific patient needs.
  • Base solution contains dextrose and protein.
  • Pharmacy adds prescribed electrolytes, vitamins, and trace elements.
  • Calories mostly supplied from carbohydrates.
  • High Osmolality- TPN/Central Line-For long term
  • Low Osmolality- PPN/Peripheral Line-For short term
  • Administered directly into the blood stream
Parenteral Nutrition - Nursing considerations
  • REQUIRED TO BE CHECKED BY TWO NURSES!
Management of Parenteral Nutrition
  • Limit number of personnel involved to reduce possibility of infection
  • Verify label with the physician order prior to administration
  • Examine solution for particulate matter
  • Change filters (not used with lipids) and IV tubing every 24 hours and hang a new bag every 24 hours, label all lines
  • Give via an infusion pump, dedicate one line of multi-lumen catheter
  • Change dressing per facility protocol, observe site for infection, document
  • If bag empties prior to next solution is ready, hang 10% or 20% dextrose to prevent hypoglycemia
Refeeding Syndrome
  • Occurs in severely malnourished patients
  • Bodies response from going from starvation to fed
  • Greater risk with parenteral nutrition
  • Predisposed conditions: chronic alcohol use, cancer, trauma, IBD, major surgery
  • Hallmark lab: hypophosphatemia
  • Labs show- hyperglycemia, fluid retention, hypokalemia, and hypomagnesemia
  • Cues include edema, confusion, shallow respirations, heart failure, seizures, coma, and death.