Chapter 37: Nutrition

TUBE FEEDING INTERVENTIONS!!!

Patients with increased nutritional requirements, those who are unable to meet their nutritional requirements orally, and those who will be NPO for more than 48 to 72 hours may require nutritional support from Enteral nutrition, administering nutrients directly into the stomach, or Parenteral nutrition (PN), providing nutrition via intravenous (IV) therapy, based on individual circumstances.

Short term nutritional support

●       Using the nasogastric or nasointestinal route

●       Confirming NG feeding tube placement: This decreases the risk that the tip of the tube is situated in the stomach or intestine, preventing inadvertent administration of substances into the wrong place. A misplaced feeding tube in the lungs or pulmonary tissue places the patient at risk for aspiration, pneumonia, and even death. Radiographic examination, measurement of tube length and measurement of tube marking, measurement of aspirate pH, and monitoring of carbon dioxide have been suggested to confirm feeding tube placement.

●       Radiographic examination: Radiographic examination (x-ray) is the standard procedure to verify initial placement of a feeding tube as it allows the visualization of the entire course and the location of the tip of the tube

●       Assessment of aspirate pH

●       Measurement of tube length and tube marking

●       Carbon dioxide monitoring: Monitoring for carbon dioxide to determine nasogastric tube position and/or dislodgement involves the use of a colorimetric end-tidal CO2 detector to detect the presence of carbon dioxide, which would indicate tube positioning in the patient’s airway.

●       Confirming nasointestinal tube placement: After an initial x-ray for placement, the nurse can validate that the tube is still in the small intestine by checking the pH of the aspirate (pH ≥ 6) and observing the aspirate appearance. During fasting, gastric fluid is typically clear and colorless or grassy green; small-bowel secretions are typically bile-stained, ranging in color from light to golden yellow or brownish green

Nasointestinal (NI) tube is passed through the nose and into the upper portion of the small intestine (nasoduodenal and nasojejunal). NI may be indicated for a patient with high risk for aspiration or who have shown intolerance to gastric EN

Long term nutritional support

●       An enterostomal tube may be placed through an opening created into the stomach (gastrostomy) or into the jejunum (jejunostomy) (4-6 weeks) artificial openings ( may have had a stroke, multiple scelorisis,

●       A gastrostomy is the preferred route to deliver enteral nutrition in the patient who is comatose

●       Placement of a tube into the stomach can be accomplished by a surgeon or gastroenterologist via a percutaneous endoscopic gastrostomy (PEG) or a surgically (open or laparoscopically) placed gastrostomy tube (37.9-11

ASPIRATION, EVALUATE PT, ARE THEY TOLERATION, ARE THEY DISTENDED, ARE THEY FULL?.

A gastrostomy may be used for patients who have impaired chewing and swallowing related to neurologic diseases (stroke, multiple sclerosis) or obstruction of the upper respiratory and/or digestive tract, as in head and neck cancers; patients with oncologic health problems associated with malnutrition; and patients with other health issues that lead to malnutrition, such as chronic renal failure, cystic fibrosis, or Crohn disease.

The use of a PEG tube is the preferred and most common method of gastrostomy tube insertion for long-term enteral nutrition. PEG usually does not require general anesthesia and has lower rate of major complications, such as blocking and dislodgement

In long-term feeding situations in which gastric problems exist, the jejunostomy is an alternate method through which nutrition can be delivered. The small bowel may also be used for feeding for patients at high risk for aspiration

Enteral feeding 

●       Feeding schedule and formulas, and pumps: Enteral feedings are administered by bolus, intermittent continuous, or continuous infusion. Bolus formula administration involves administering a 200- to 400-mL volume over a 15- to 60-minute period, depending on patient tolerance, using a 50-mL syringe (no feeding pump)

●       Monitor for tolerance

●       Gastric residual volume (GRV)

●       Promote patient safety

●       Monitor for complications

●       Provide comfort measures

●       Provide education

Criteria to consider when evaluating patient feeding tolerance include:

●       Absence of nausea, vomiting

●       Absence of diarrhea and constipation

●       Absence of abdominal pain and feelings of fullness

●       Absence of distention

●       Presence of bowel sounds within normal limits

●       Achievement of target goal nutrition administration

Evidence related to definition, measurement, monitoring, and management of Gastric residual volume (feeding remaining in the stomach; GRV) varies. GRV has been used to monitor for tolerance of EN; however, there is little support for this intervention as routine measurement for most patients and is not considered best practice and should not be used as part of routine care to monitor EN

Promote patient safety:

Check tube placement before administering any fluids, medications, or feeding, using multiple techniques: x-ray, external length, external verification marking, pH testing , and carbon dioxide monitoring. Consistent inability to withdraw fluid from tube may indicate displacement of the tube from the stomach into the esophagus.

●       Assess for signs of respiratory distress; coughing, choking, dyspnea may occur when a tube is inadvertently positioned in the airway

Feeding tubes should be flushed with at least 30 mL of water before starting and after completion of bolus feedings; every 4 to 8 hours during continuous feeding, and before and after medication administration

Sterile water should be used for tube flushes in immunocompromised or critically ill patients, and for reconstituting powdered enteral formula

Make sure the patient is as upright as possible during feeding. Keep the head of the bed elevated at 30 to 45 degrees at all times during administration of enteral feedings and for 1 hour afterward to prevent reflux, aspiration, and pneumonia, unless contraindicated (

Provide comfort measures

●       Administer oral hygiene frequently (every 2 to 4 hours) to prevent drying of tissues and to relieve thirst. Offer the patient the opportunity to rinse the mouth with warm water and mouthwash solution frequently. Lubricate the lips generously.

●       Keep the nares clean, especially around the tube, where secretions tend to accumulate. Using a lubricant after cleaning the nares is recommended.

●       Help control local irritation from the tube in the throat. Analgesic throat lozenges or anesthetic sprays may be effective.

●       Encourage the patient, if able, to verbalize concerns about tube feeding and presence of the tube. A visit from another person who has learned to cope with this alternate feeding method may prove helpful.

●       Secure the nasogastric tube to the patient’s nose and cheek, based on facility policy, to prevent tension and tugging on the tube, causing trauma to the nares, and inadvertent displacement or dislodgement

Provide education

●       Information about the administration of feedings, amount of fluid to be administered, operation of the pump, formula, instructions regarding rate and frequency and how to check for tube placement, as well as what to do if the tube becomes blocked or dislodged

●       How to administer medications through the tube

●       Care of the tube insertion site and possible complications that need to be communicated to the health care team

●       Proper preparation, cleaning, and disposal of equipment

●       Emergency telephone numbers, including the number for the home health care facility and the appropriate members of the health care team

●       Arrangements for follow-up from the home health care nurse as soon as possible after discharge

Use of the enteral route is preferred to the parenteral route for nutrition support whenever feasible>>>

Parenteral Nutrition (PN)

 (IV CENTRAL VENOUS CATHETER, HYPERTONIC SOLUTION ) (INTESTINAL FAILURE, INFLAMMATORY BOWEL DISEASE, INTESTINAL OBSTRUCTION , SEVERE ACUTE PANCREATITIS, CHEMO PT. MONITOR AND PREVENT COMPLICATION (INFECTION) , ESPECIALLY THE LINE TO THAT CENTRAL VENOUS CATHETER, AT RISK FOR BONE DISEASE, BLOOD CLOTS,  ( we use a PICC LINE or a central venous catheter – central line)

●       Contains the three primary components necessary to maintain nutrition: amino acids, carbohydrates, and lipids

●       Highly concentrated, hypertonic nutrient solution

●       Given intravenously through a central venous access device

●       Monitor for and prevent complications

PN is a highly concentrated, hypertonic nutrient solution. PN provides calories; restores nitrogen balance; and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements. PN can also promote tissue and wound healing and normal metabolic function. It provides the bowel a chance to heal and reduces activity in the gallbladder, pancreas, and small intestine. PN meets the patient’s nutritional needs by way of nutrient-filled solutions administered intravenously through a central venous access device, such as a tunneled, multilumen, or nontunneled catheter into the subclavian vein or a peripherally inserted central catheter (PICC).

●       We need to check their glucose levels.

When is Parenteral Nutrition Typically Initiated? (chat gpt)

PN is typically considered when:

●       The patient’s gastrointestinal tract cannot be used for digestion and absorption.

●       Enteral feeding (through a tube) is either not possible or not effective.

●       Nutritional needs cannot be met by oral intake alone, and the patient requires an alternative means to receive nutrition.

Important considerations: Parenteral nutrition carries risks, such as infection (from the central line or catheter), metabolic disturbances (e.g., electrolyte imbalances), and liver dysfunction with long-term use, so it is usually reserved for patients who are unable to eat or absorb nutrients via the GI tract for an extended period.

Complication of TPN

●       Complications related to the use of central venous access devices, such as pneumothorax, thromboembolism (inflammation of a blood vessel and formation of a thrombus [blood clot]), and air embolism

●       Infection and sepsis (central line–associated blood stream infections [CLABSIs])

●       Metabolic alterations, such as hyperglycemia or hypoglycemia

●       Fluid, electrolyte, and acid–base imbalances

●       Hyperlipidemia

●       Liver and gallbladder disease

●       Refeeding syndrome (life-threatening complication related to overfeeding carbohydrates in nutritionally debilitated patients, characterized by metabolic and physiologic shifts of fluid, electrolytes, and minerals from the extracellular fluid to intracellular fluid)

●       Insertion problems

●       Discard after 24 hours, because of bacterial growth.

Risk of Hyperglycemia (High Blood Sugar):

➢     Parenteral nutrition often contains significant amounts of glucose (dextrose) to provide energy. This can raise blood sugar levels, particularly in patients who have compromised glucose metabolism or those who are insulin-resistant (e.g., in patients with diabetes or critically ill patients).

➢     Hyperglycemia can lead to various complications, including:

○       Increased risk of infections: High blood sugar impairs immune function, making it harder for the body to fight infections.

○       Electrolyte imbalances: Elevated blood glucose levels can cause dehydration and imbalances in electrolytes like sodium, potassium, and calcium.

○       Harm to blood vessels: Chronic hyperglycemia can contribute to long-term complications like vascular damage.

○       Potential for diabetic ketoacidosis (DKA) in diabetic patients if blood glucose is not properly controlled.

2. Risk of Hypoglycemia (Low Blood Sugar):

●       Abrupt discontinuation or a rapid reduction in the glucose infusion rate of parenteral nutrition can cause hypoglycemia. This is especially concerning if the patient’s body is used to receiving a steady supply of glucose from the PN and the body cannot adjust to a sudden drop in glucose levels.

●       Hypoglycemia can lead to:

○       Confusion

○       Shaking

○       Sweating

○       Severe cases can cause seizures, loss of consciousness, or even death.

Fecal impaction is a condition where a large mass of stool becomes firmly lodged in the colon or rectum, making it difficult or impossible for a person to pass stool normally.

STIMULATING APPETITE!! ( 2 Q’S)

Stimulating appetite: Pain, illness, anxiety, and medications can contribute to anorexia and poor intake when in a healthcare facility or in the home.

●       Serve small, frequent meals to avoid overwhelming the person with large amounts of food.

●       Solicit food preferences and encourage favorite foods from home or prepared when at home, if possible.

●       Provide encouragement and a pleasant eating environment.

●       Be sure that any prepared food looks attractive.

●       Schedule procedures and medications at times when they are least likely to interfere with appetite.

●       Control pain, nausea, or depression with medications.

●       Offer alternatives for items that a person cannot or will not eat.

●       Encourage or provide good oral hygiene. Ensure that the patient’s dentures are well-fitting and in place, if applicable.

●       Remove clutter from the eating area.

●       Keep eating area free from irritating odors.

●       Arrange food tray so that a person can easily reach food.

●       Provide a comfortable position.

●       Ask about any rituals during mealtimes at home and include them if possible.

●       If patients are absent from their rooms during mealtime, order a late food tray or keep food warm until they return.

●       Do not disturb mealtime; don’t interrupt patients for nonurgent procedures during mealtime.

DAILY NUTRITIONAL INTAKE

Carbs – All carbohydrates provide 4 calories per gram, regardless of the source. It is recommended that carbohydrates provide 45% to 60% of total calories for adults, focusing on complex carbohydrates, such as whole grains.

➢     Sugars and starches; organic compounds composed of carbon, hydrogen, and oxygen

➢     Serve as the structural framework of plants; The only animal source of carbohydrate in the diet is lactose, the sugar present in milk.

➢     Most abundant and least expensive source of calories in the world

○       Intake often correlated to income: as income increases, carbohydrate intake decreases, protein intake increases.

➢     Classified as simple or complex sugars

➢     Primary function is to supply energy

➢     Recommended as 45% to 60% of total calories for adults

Grains, bread, pasta, oatmeal, apples , bananas, mango

Dairy – milk, legumes, peas , potatoes

●       More easily and quickly digested than protein and fat

●       90% of carbohydrate intake is ingested

●       Converted to glucose for transport through the blood or for use as energy.

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

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

●       Liver stores glucose and regulates entry into the blood

●       Hormones, especially insulin and glucagon, are responsible for keeping serum glucose levels fairly constant during both feasting and fasting.

●       Cells oxidize (burn)  glucose to provide energy, carbon dioxide, and water

Protein:

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

●       Complete proteins contain sufficient essential amino acids to support growth

●       Incomplete proteins are deficient in one or more essential amino acids

●       Animal proteins are complete (eggs and chicken have all essential amino acids) ; plant proteins are incomplete (except that soy and quinoa are complete)

●       Vegetarians, who do not eat animal protein, can combine different plant proteins to supply a complete protein

Yogurt, almonds, salmon, tune, chickpeas, shrimp

●       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

●       Excess amino acids are converted to fatty acids, ketone bodies, or glucose and are stored or used as metabolic fuel.

●       Protein tissues are in a constant state of flux. Tissues are continuously being broken down (catabolism) and replaced (anabolism)

●       RDA for adults is 0.8 g/kg of body weight, 10% to 35% total calorie intake

Fats:

●       Insoluble in water and blood; composed of carbon, hydrogen, and oxygen

●       95% of lipids in diet are triglycerides

●       Contain mixtures of saturated (raise cholesterol levels) and unsaturated (lower cholesterol levels) fatty acids

●       Most animal fats are saturated

●       Most vegetable fats are unsaturated

●       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

●       Most concentrated source of energy in the diet, providing 9 calories for every gram.

●       Recommended intake: limit saturated fats to less than 10% of daily calories and intake of trans fats to as low as possible

Vitamins

●       Organic compounds needed by the body in small amounts; do not provide calories

●       Needed for metabolism of carbohydrates, protein, and fat

●       Fresh foods are higher in vitamins than processed

●       Water soluble: C, B-complex vitamins; not stored in body  (They are absorbed through the intestinal wall directly into the bloodstream. Although some tissues are able to hold limited amounts of water-soluble vitamins, they usually are not stored in the body. Deficiency symptoms are apt to develop quickly when intake is inadequate; therefore, a daily intake is recommended.) Absorbed through the intestinal wall directly into bloodstream, Consume in excess excreated through urine

●       Fat soluble: A, D, E, K (into lympatic system, stores mostly in liver and adipose tissue

●                         Vitamin A retinol ,

●       Like fat, they must be attached to a protein to be transported through the blood. Secondary deficiencies of the fat-soluble vitamins can occur anytime fat digestion or absorption is altered, such as during malabsorption syndromes and pancreatic and biliary diseases.

●       The body stores excesses of the fat-soluble vitamins mostly in the liver and adipose tissue. Because they are stored, a daily intake is not imperative and deficiency symptoms may take weeks, months, or years to develop. Excessive intake, particularly of vitamins A and D, is toxic.

●       For example, folate (folic acid) supplementation prior to conception and during pregnancy reduces the risk of neural tube defects

Chicken hint: fat soluble vitamins think of “ A DECK” OF fat cards “A D E K

Minerals

●       inOrganic elements found in all body fluids and tissues in the form of salts (e.g sodium chloride) or combined with organic compounds (e.g., iron in hemoglobin).

●       Some function to provide structure in the body, others help regulate body processes

●       Contained in the ash that remains after digestion

●       Amount greater than 5 grams in the body include: Microminerals calcium, phosphorus (phosphates), sulfur (sulfate), sodium, chloride, potassium, and magnesium

●       Trace elements are minerals present in the body in amounts less than 5 g; Microminerals include iron, zinc, manganese, chromium, copper, molybdenum, selenium, fluoride, and iodine

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 excretion

Through evaporation from the skin, water helps to regulate body temperature. As a lubricant, water is needed both for mucous secretions and for movement between joints.

Water is also produced through the metabolism of carbohydrates, protein, and fat. It leaves the body through urine, feces, expired air, and perspiration. Water intake (an average of 2,600 mL/day for adults

Water balance may be seriously affected when intake (such as in older adults or people in comatose states) or output (such as in patients with altered renal function, profuse perspiration, diarrhea, vomiting, fistulas, drainage tubes, hemorrhage, severe burns) is altered.

●       Food labeling: Diets higher in vitamin D and potassium can reduce the risk of osteoporosis and high blood pressure, respectively. Calcium and iron are also included on the label because Americans do not always get the recommended amounts. Diets higher in calcium and iron can reduce the risk of osteoporosis and anemia, respectively

Fiber???

BMR (1391)

Basal Metabolic Rate which refers to the amount of energy (or calories) your body requires to perform basic life-sustaining functions while at rest. BMR is energy (number of calories) required to fuel the involuntary activities of the body at rest after 12 hour fast, energy needed to sustain metabolism activities of cells and tissues. These activities include actions such as maintaining body temperature and muscle tone, producing and releasing secretions, propelling food through the gastrointestinal (GI) tract, inflating the lungs, and contracting the heart muscle.

➢     Males have a higher BMR

○       BMR is about 1 cal/kg of body weight per hour for men

○       BMR is about 0.9 cal/kg of body weight per hour for women

➢     Factors that increase BMR

○       Growth, infections, fever, emotional tension, extreme environmental temperatures, elevated levels of certain hormones, especially epinephrine and thyroid hormones.

➢     Factors that decrease BMR

○       Aging, prolonged fasting, and sleep

●       Gender, age, growth, infections, activity level, body fat is affected by BMR

BMI

The Body mass index (BMI) is a ratio of weight (in kilograms) to height (in meters squared). The BMI provides an estimate of body fat and can be used as an initial assessment of nutritional status.

●       What is the BMI of a 5-foot, 11-inch (1.8 m) male client who weighs 81 kg?

●       25

●       BMI = weight in kg/height in m²

●       BMI is (body weight in kilograms) divided by (body height in meters squared). (weight in kg) (height in meters) (height in meters) 81/1.81.8=25

BMI below 18.5 is underweight,

BMI of 18.5 to 24.9 is a healthy weight,

BMI of 25 to 29.9 indicates an overweight person,

BMI of 30 to 39.9 indicates Obesity

BMI of 40 or greater indicates extreme obesity

BMI also provides an estimation of relative risk for diseases that can occur with more body fat, such as heart disease, type 2 diabetes, hypertension, and certain cancers

NUTRITIONAL ASSESSMENT

Components of nutritional assessment

●       History taking

●       Dietary, medical, socioeconomic data

●       Physical assessment

●       Anthropometric and clinical data

●       Biochemical data (37.5

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

Anthropometric measurements (measurement of the size and proportion of the human body) are used to determine body dimensions. In children, anthropometric measurements are used to assess growth rate and weight gain; in adults, they can give indirect measurements of body protein and fat stores.

Assess for physical barriers to eating. Dysphagia (difficulty swallowing or the inability to swallow) can be the result of poor dental health, cancer, or a neurologic disease, such as stroke, Parkinson disease, or dementia, and may reduce the patient’s nutritional intake. Dysphagia also is associated with an increased risk for Aspiration, the misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract

Hemoglobin, the oxygen-carrying protein of the red blood cells, and hematocrit, the volume of red blood cells packed by centrifugation in each volume of blood, are measures of plasma protein that also reflect a person’s iron status. Protein status can also be determined by measuring serum prealbumin and transferrin levels and by a total lymphocyte count

Urea, a breakdown product of amino acids, can be measured in the urine and blood. It reflects protein intake and the body’s ability to detoxify and excrete this metabolic byproduct. Creatinine levels are directly proportional to the body’s muscle mass; a reduction in this value reflects severe malnutrition

CLIENT W/ PUREED DIET

Puree diet  – difficulty swallowing and chewing, pt who just had a stroke.

A pureed diet (also called a blended diet) consists of foods that have been blended or mashed into a smooth, pudding-like consistency. This diet is often prescribed for individuals who have difficulty chewing or swallowing, due to conditions such as dysphagia (difficulty swallowing), mouth or throat surgery, or certain neurological conditions that affect the muscles involved in swallowing. The goal of a pureed diet is to provide nutrition in a form that is easier and safer to swallow, while still providing necessary calories, proteins, fats, vitamins, and minerals.

●       Pureed chicken, turkey, beef, or pork (often mixed with broth or gravy to achieve the proper texture).

●       Pureed fish or shellfish.

●       Tofu or scrambled eggs.

●       Ground or pureed meatloaf or meatballs.

●       Pureed fruits like applesauce, mashed bananas, or canned peaches or pears (without skins or seeds).

●       Yogurt (plain or flavored, without fruit chunks).

●       Smooth cottage cheese (blended if needed).

●       Pudding or custard (without solid pieces).

●       Smooth gelatins or ice creams (without nuts or fruit pieces).

Patient teaching, complications

TYPES OF ORAL NUTRITION

NORMAL OR HOUSE DIETS: designed to achieve or maintain optimal nutritional status by providing adequate amounts of all nutrients. The diet’s actual composition and nutritional value varies with the quantity and types of food selected by the patient. No foods are excluded

VEGETARIAN DIETS: Because fewer or no animal products are consumed, vegetarians consume less saturated fat, cholesterol, and animal protein and greater amounts of carbohydrates, fiber, and other important nutrients. Vitamin B12, vitamin A, and iron are nutrients that may require supplementation in some vegetarian diets, but most vegetarian diets are not deficient in any nutrients.

●      

●       Providing long-term nutritional support

●       Modified consistency diets

Liquid diets are used most often as transitional diets when eating resumes after acute illness, surgery, or parenteral nutrition. Because clear-liquid diets are inadequate in calories, protein, and most nutrients, progression to more nutritious alternatives is recommended as soon as possible. Full-liquid diets contain all the items on a clear-liquid diet. Additional items allowed include milk and milk drinks, puddings, custards, plain frozen desserts, pasteurized eggs, cereal gruels, vegetable juices, and milk and egg substitutes. A full-liquid diet contains liquids that can be poured at room temperature. High-calorie, high-protein supplements are recommended if a full-liquid diet is used for more than 3 days.

MYPLATE FOOD GUIDE!!!!

MyPlate food guidance graphic is part of a communication initiative based on the Dietary Guidelines for Americans to help consumers make better food choices to follow a healthy heating pattern across the lifespan. the goals of the recommendations are to balance calories by encouraging consumers to enjoy food, but eat less, and avoid oversized portions. Consumers are also advised to increase the intake of a variety of nutrient-dense foods across and within all food groups. Consumers are encouraged to reduce sodium consumption by comparing sodium in foods such as soup, bread, and frozen meals and choose foods with lower numbers. MyPlate also encourages the consumption of water instead of sugary drinks.

●       MyPlate food guide: The importance of activity and exercise are also emphasized, including the recommendations for children and adolescents to be physically active for 60 minutes or more a day and adults to engage in activity that requires moderate effort, such as brisk walking for 2 1/2 hours or more a week