CHAPTER 37: NUTRITION Study Guide

CHAPTER 37: NUTRITION

NUTRITION OVERVIEW: MACROS

  • Nutrition = Energy for the body
    • Carbohydrates
    • Required for brain function and energy.
    • Carbohydrates are converted to glucose in the body.
    • Insulin and Glucagon help stabilize glucose levels.
    • Importance of Fiber: essential for digestive health.
    • Proteins
    • Required for the formation of all body structures (e.g., muscle, skin, enzymes).
    • Excess protein can place a burden on the kidneys, highlighting the need for careful protein management, particularly in individuals with renal concerns.
    • Fats
    • Aid in the absorption of fat-soluble vitamins (A, D, E, K) and are crucial for hormone production.
    • Types of fats:
      • Saturated vs Unsaturated Fats.
      • Trans Fats increase the risk of heart disease and stroke; they should be avoided.
      • Fun Fact: The body synthesizes cholesterol, which is vital for creating cell membranes, particularly for brain and nerve cells.

NUTRITION OVERVIEW: MICROS

  • Water vs. Fat Soluble Vitamins
  • Electrolytes: Essential minerals such as iron, copper, zinc, and iodine, among others.
  • Minerals: Inorganic substances that play critical roles in various bodily functions.

FACTORS AFFECTING NUTRITION: AGE

  • Older Adults
    • Loss of lean body mass can result in weakness.
    • Loss of teeth can create chewing difficulties, impacting nutrient intake.
    • Decreased peristalsis can lead to constipation.
    • Diminished sensation of thirst increases the risk of dehydration.
    • Loss of independence may hinder the ability to prepare food, leading to malnutrition.
    • Comorbidities may require dietary restrictions, complicating nutritional management.
    • Fixed incomes may limit access to nutritious food options.

FACTORS AFFECTING NUTRITION: SOCIAL DETERMINANTS OF HEALTH

  • Economic Resources: Limited financial resources can restrict access to nutritious foods.
  • Lack of Caregiver or Social Support: This may affect the ability to obtain or prepare food.
  • Food Deserts: Areas where access to affordable and nutritious food is limited, impacting dietary choices.
  • Religion: Specific dietary practices or restrictions tied to religious beliefs can influence food intake.
  • Personal Preference: Individual tastes and preferences directly affect what foods are consumed.

FOOD INTAKE

  • Decreased Food Intake:
    • Anorexia: Lack of appetite that can lead to malnutrition, anemias, heart conditions, and loss of bone and muscle mass.
  • Increased Food Intake:
    • May result in overweight or obesity, leading to malnutrition, cardiovascular diseases, strokes, and sleep apnea, along with increased healthcare bias against individuals with obesity.

ASSESSMENT

  • 24-Hour Diet Recall: Tools for assessing nutritional intake.
  • Food Diaries or Calorie Counts: Keeping records of food intake to monitor diet.
  • Weight Monitoring: Tracking weight changes to assess nutritional status.
  • Health History:
    • Understanding medical conditions that could alter nutrient intake or absorption.
    • Notably, DYSPHAGIA (difficulty swallowing) significantly impacts food intake.
  • Intake and Output Monitoring: Tracking overall fluid intake vs. output.
  • Lab Data: Utilizing laboratory tests to assess nutritional needs and deficiencies.

DIAGNOSIS

  • Actual Diagnoses:
    • Impaired Nutritional Status
    • Impaired Swallowing
    • Body Weight Imbalance: Can be either overweight or underweight.
  • Risk Diagnoses:
    • Risk for Electrolyte Imbalance: Need for monitoring electrolyte levels.
    • Patient goals include:
    • Maintain Body Weight
    • Eat a Diet to Meet Nutritional Needs
    • Follow the Appropriate Modified Diet
    • Avoid Aspiration: Important for individuals with swallowing difficulties.

PLANNING

  • Implementation:
    • Provider Orders: Include therapeutic dietary orders, dietary consultations, and 24-hour calorie counts.
    • Nutritional Support:
    • Parenteral vs. Enteral Nutrition
      • Used for patients who are NPO for more than 48-72 hours.
    • Lab Orders: Critical to monitor nutritional status based on lab findings.
  • Nursing Interventions:
    • Educate patients on dietary choices that support health and prevent condition exacerbation.
    • Screening for nutritional risk.
    • Monitoring intake and output with particular attention to weight.
    • Evaluating swallowing abilities in patients at risk for aspiration:
    • Elevate HOB (Head of Bed) >60º while Eating
    • Assist with eating as necessary.
    • Provide oral hygiene.
    • Maintain NG or G-tube as needed to ensure nutritional delivery.

A NOTE ABOUT CHARTING

  • When charting weights, always document in kg.
  • When documenting intake and outputs (I&Os), always use mL.
  • Common conversions to remember for accuracy:
    • 1 mL = 1 cc
    • 1 kg = 2.2 pounds
    • 30 mL = 1 ounce
    • 1 kg = 1000 grams
    • 1000 mL = 1 liter
    • 1 gram = 1000 mcg.

THERAPEUTIC DIETS: TABLES 37 – 3 AND 37 – 4

  • Various types of diets can be prescribed to accommodate patient needs:
    • Consistent Carb Diet (diabetic diet)
    • Heart Healthy Diet
    • Low Sodium Diet
    • Renal Diet
    • Low Protein Diet (especially for liver concerns)
    • Modified Consistency Diets: Includes clear liquids vs. full liquids.
    • Mechanically Altered Diets: Adjusted for patients with swallowing difficulties.
    • NPO with Exceptions: NPO, or not eating, except for medication intake.

ENTERAL NUTRITION

  • Administered via the gastrointestinal (GI) system, representing the most efficient method of nutrition delivery when indicated.
    • Options include NG tube or PEG tube for patients unable to swallow.
    • NG Tube: Short-term solution for delivering nutrition.
    • PEG or J Tube: Long-term nutrition delivery methods.
    • It is vital to maintain Head of Bed (HOB) at >30º to prevent aspiration risk.

ENTERAL NUTRITION – UH OH

  • NG Tubes: Require frequent assessment as they can easily become dislodged.
    • For instance, if the NG tube was inserted to 55 cm, the nurse should confirm it is at the same length upon each entry into the patient's room.
    • If the tube is found to be at 30 cm, feeding should cease immediately until the situation is reassessed.

ENTERAL NUTRITION

  • Bolus vs. Continuous Feeds: The nursing staff must understand patient needs and provider's orders regarding nutrition delivery methods.
  • Follow-Up Assessments:
    • Monitoring for nausea and vomiting, consistency and frequency of bowel movements (BM), bowel sounds, and abdominal pain.
    • Trace the feeding line to ensure proper placement.
    • Assess for potential complications at the insertion site.

PARENTERAL NUTRITION

  • Definition: Nutrition delivered via the venous route, indicated when the enteral route is contraindicated.
    • Must always be administered through an IV pump to ensure proper dosage and administration.
  • Types of Parenteral Nutrition:
    • TPN (Total Parenteral Nutrition): Requires central venous access through a central line; higher risk of infection due to this method.
    • PPN (Peripheral Parenteral Nutrition): Delivered via peripheral lines; associated with high risks of phlebitis and infection.

Comparison of Enteral vs Parenteral Nutrition

  • Enteral Nutrition (EN)

    • Route: GI tract (via tube: NG, NJ, PEG, or G-tube)
    • Indications: Functioning GI tract but unable to eat (e.g., dysphagia, stroke)
    • Delivery Site: Stomach or small intestine
    • Cost: Less expensive
    • Infection Risk: Lower, as GI tract defenses remain intact
    • Metabolic Complications: Fewer; more physiologic nutrient absorption
    • GI Function: Helps maintain gut integrity, prevents atrophy
    • Monitoring Needs: Check tube placement, residuals, tolerance
    • Advantages: Safer, more physiologic, supports gut health
    • Disadvantages: Risk of aspiration, tube dislodgment

  • Parenteral Nutrition (PN)

    • Route: IV route
    • Indications: Non-functioning GI tract (e.g., bowel obstruction, ileus)
    • Delivery Site: Bloodstream (superior vena cava for TPN; peripheral vein for PPN)
    • Cost: More expensive
    • Infection Risk: Higher due to central line infections and sepsis risk
    • Metabolic Complications: More common (hyperglycemia, hyperlipidemia, electrolyte imbalances)
    • GI Function: Bypasses GI tract; no direct GI stimulation
    • Monitoring Needs: Frequent laboratory tests (glucose, triglycerides, electrolytes, liver function)
    • Advantages: Life-saving when GI tract can’t be used
    • Disadvantages: Risk of central line complications, metabolic disturbances

EVALUATION

  • Assessment of Interventions: Determining if the implemented nursing actions were effective in addressing the identified problems.
  • Re-evaluation: If interventions did not work, explore modifications required in care. Consider:
    • For patients with impaired swallowing, evaluate progress in swallowing ability after interventions.
    • For patients experiencing weight loss due to poor dentition, evaluate any changes in weight or nutritional status post-intervention.