Fundamentals of Nursing: Nutrition Study Notes

Fundamentals of Nursing: Chapter 45 - Nutrition

Scientific Knowledge Base

Nutrients: Biochemical Units of Nutrition

• Carbohydrates: Essential for energy.

• Proteins: Crucial for tissue repair, growth, and enzyme production.

• Fats: Provide concentrated energy, absorb fat-soluble vitamins, and insulate the body.

• Water: Vital for all bodily functions, making up a significant portion of body weight.

• Vitamins:

  • Fat-soluble vitamins: A, D, E, K (stored in the body).

  • Water-soluble vitamins: C and B-complex (not stored, require regular intake).

• Minerals: Inorganic elements necessary for various physiological processes.

Anatomy and Physiology of the Digestive System

• Digestion: The process of breaking down food into absorbable units.

• Absorption: The passage of digested food from the gastrointestinal (GI) tract into the blood and lymph.

• Metabolism and storage of nutrients: Chemical processes occurring within a living organism to maintain life, including nutrient utilization and storage.

• Elimination: The excretion of undigested food and waste products from the body.

Organ-Specific Functions in Digestion

• Mouth:

  • Breaks up food particles through mastication.

  • Assists in producing spoken language.

• Pharynx:

  • Facilitates swallowing.

• Salivary glands:

  • Saliva moistens and lubricates food.

  • Amylase digests carbohydrates, initiating chemical digestion.

• Esophagus:

  • Transports food from the pharynx to the stomach via peristalsis.

• Stomach:

  • Stores and churns food.

  • Hydrochloric acid (HCI) activates enzymes, breaks up food, and kills germs.

  • Mucus protects the stomach wall from acid.

  • Limited absorption occurs here.

• Liver:

  • Breaks down and builds up many biological molecules.

  • Stores vitamins and iron.

  • Destroys old blood cells.

  • Detoxifies poisons.

  • Produces bile to aid in fat digestion.

• Gallbladder:

  • Stores and concentrates bile produced by the liver.

• Pancreas:

  • Hormones regulate blood glucose levels (e.g., insulin, glucagon).

  • Bicarbonates neutralize stomach acid as chyme enters the small intestine.

• Small intestine:

  • Completes digestion of carbohydrates, proteins, and fats.

  • Mucus protects the gut wall.

  • Absorbs most nutrients and water.

• Large intestine:

  • Reabsorbs some water, ions, and vitamins.

  • Forms and stores feces.

• Rectum:

  • Stores and expels feces.

• Anus:

  • Opening for elimination of feces.

Dietary Guidelines

• Dietary Reference Intakes (DRIs): A set of nutrient-based reference values for healthy people.

• Food guidelines: Recommendations for healthy eating patterns (e.g., MyPlate).

• Daily values: Nutritional information on food labels, expressed as a percentage of the recommended daily intake.

Nursing Knowledge Base

Factors Influencing Nutrition

• Environmental factors: Food availability, socioeconomic status, access to healthy options, food deserts.

• Developmental needs: Nutritional requirements change across the lifespan.

  • Infants through school age:

    • Breastfeeding: Recommended for optimal infant nutrition.

    • Formula: Alternative for infants when breastfeeding is not possible.

    • Introduction to solid foods: Gradual introduction of age-appropriate foods.

  • Adolescents: High energy and nutrient needs due to rapid growth.

  • Young and middle adults: Maintenance of healthy weight and prevention of chronic diseases.

    • Pregnancy: Increased caloric and nutrient needs to support fetal growth.

    • Lactation: Further increased caloric and nutrient needs for milk production.

  • Older adults: Reduced caloric needs, but continued or increased need for certain nutrients.

Alternative Food Patterns

• Vegetarian diet: A diet that excludes meat.

  • Ovolactovegetarian: Includes eggs ($ext{ovo}$) and milk products ($ext{lacto}$).

  • Lactovegetarian: Includes milk products but no eggs.

  • Vegan: Excludes all animal products, including meat, dairy, eggs, and honey.

Critical Thinking in Nursing

• Understanding Rationale: Knowing how digestion and absorption work is crucial for understanding a patient's nutritional problems and developing effective interventions.

• Patient-Centered Care: When developing meal plans, consider:

  • Patient's preferences

  • Culture

  • Socioeconomic status

  • Environment

  • Religious practices

Elements of Clinical Decision Making in Nutrition

• Knowledge Base:

  • Normal nutrients, food sources, and nutritional alterations.

  • Anatomy and physiology of the gastrointestinal system.

  • Patient assessment findings.

  • Cultural beliefs and influences affecting nutrition.

  • Developmental factors affecting nutrition.

  • Effects of medications on nutrition.

  • Patient-centered communication principles.

  • Effects of illness/disability on nutritional practices, energy needs, dietary intake, and ability to prepare meals.

• Attitudes:

  • Be open-minded about patient's nutritional practices during assessment.

  • Display confidence when collecting data (culture, socioeconomic status, physical functioning, dietary restrictions, preferences).

• Standards:

  • ANA Standards and Scope of Nursing Practice.

  • Clinical Practice Guidelines and Standards of Practice (e.g., Dietary Reference Intakes, MyPlate, Healthy People $2030$, Dietary Guidelines for Americans).

  • Intellectual standards in measurement (accuracy, completeness, significance in health history).

  • Agency policies and procedures.

  • Professional, standards of care, and ethical standards.

• Environment:

  • Impact of nutritional feeding devices on time and task complexity.

  • Resources from other health professionals (e.g., registered dietitian/nutritionist).

  • Interruptions during feedings and feeding tube insertion/care.

• Experience:

  • Caring for patients with altered nutrition.

  • Observation of nutritional practices of friends and family.

  • Personal assessment of nutritional practices.

Nursing Process Applied to Nutrition

Assessment (Recognize Cues)

• Through the patient's eyes: Understand their perception and experience of nutrition.

• Screening: Identify patients at nutritional risk.

• Anthropometry: Measurement of the human body (e.g., height, weight, BMI, skinfold thickness).

• Laboratory and biochemical tests: Blood tests (e.g., albumin, prealbumin, hemoglobin A1c) to assess nutritional status and related conditions.

• Diet history and health history: Comprehensive review of dietary intake, eating patterns, medical conditions, and medications.

• Environment: Assess factors like food access, living situation, and support systems.

• Physical examination: Observe signs of malnutrition (e.g., skin integrity, hair, nails, muscle wasting).

• Dysphagia: Assess difficulty swallowing, a common nutritional alteration.

Analysis and Nursing Diagnosis (Analyze Cues, Prioritize Hypotheses)

• Examples of Nursing Diagnoses:

  • Risk for Aspiration: Due to impaired swallowing or decreased level of consciousness.

  • Overweight: Excess body fat for age and height.

  • Impaired Low Nutritional Intake: Inadequate intake of nutrients for metabolic needs.

  • Impaired Self-Feeding: Difficulty manipulating utensils or bringing food to the mouth.

  • Impaired Swallowing: Difficulty passing food or fluids from the mouth to the stomach.

Planning and Outcomes Identification (Generate Solutions, Plan)

• Outcomes: Specific, measurable, achievable, relevant, and time-bound goals for nutritional improvement.

• Setting priorities: Address immediate and critical nutritional needs first.

• Teamwork and collaboration: Work with dietitians, physicians, speech therapists, and other healthcare professionals.

Knowledge Base, Attitudes, Standards, Environment, and Experience in Planning

• Knowledge Base:

  • Role of registered dietitians/nutritionists.

  • Effect of community support groups/resources.

  • Effect of therapeutic diets versus poor diets.

  • Patient assessment findings and nursing diagnoses.

  • Delegation principles.

• Attitudes:

  • Display confidence in selecting interventions.

  • Creatively adapt interventions for patient's physical limitations, culture, personal preference, budget, and home care needs.

• Standards:

  • ANA Standards, Clinical Practice Guidelines (USDA, FDA, WHO).

  • Agency policies, patient-centered outcomes, intellectual standards, professional, standards of care (ADA, AHA for therapeutic diets), ethical standards.

• Environment:

  • Time management for collaboration with patient and family.

  • Communication with healthcare team.

  • Availability of assistive personnel.

• Experience:

  • Previous patient responses to planned nursing interventions.

  • Experience with dietary change strategies (what worked/didn't).

Implementation (Take Action)

Health Promotion

• Education on balanced diets, healthy weight management, and lifestyle choices.

Acute Care

• Advancing diets: Progressing from clear liquids to a regular diet as tolerated.

• Promoting appetite: Addressing factors that decrease appetite (pain, nausea, environment).

• Assisting patients with oral feeding: Providing assistance for those with physical limitations.

• Enteral tube feeding: Delivering nutrients directly to the stomach or small intestine via a tube.

  • Types of tubes: Levin tube, Weighted feeding tube, Salem sump tube.

• Parenteral nutrition (PN): Intravenous administration of nutrients.

  • Initiating parenteral nutrition: Strict aseptic technique and careful calculations.

  • Preventing complications: Monitoring for infection, fluid imbalances, metabolic issues.

• Blood glucose monitoring: Essential for patients receiving parenteral nutrition or those with diabetes.

Restorative and Continuing Care

• Medical Nutrition Therapy (MNT): Nutritional counseling and dietary modifications for specific conditions.

  • Gastrointestinal diseases: (e.g., Crohn's, ulcerative colitis, celiac disease).

  • Diabetes mellitus: Blood glucose control through carbohydrate management.

  • Cardiovascular diseases: Diet low in saturated fats, cholesterol, and sodium.

  • Cancer and cancer treatment: Managing side effects, maintaining weight, and supporting immune function.

  • Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS): Addressing wasting, malabsorption, and opportunistic infections.

Evaluation (Evaluate Outcomes)

• Checking through the patient's eyes: Their satisfaction, understanding, and perceived improvement.

• Patient outcomes: Assessing whether set goals were met (e.g., weight gain/loss, improved lab values, symptom resolution).

Knowledge Base, Attitudes, Standards, Environment, and Experience in Evaluation

• Knowledge Base:

  • Characteristics of normal nutritional status.

  • Potential impact of patient adherence to therapeutic diet.

  • Patient's clinical condition and treatments.

  • Patient nursing diagnoses and assessment findings.

• Attitudes:

  • Use discipline to objectively analyze patient data to determine intervention success.

  • Be creative in designing innovative interventions.

  • Demonstrate responsibility by following through with evaluation and counseling.

• Standards:

  • ANA Standards, Clinical Practice Guidelines, intellectual standards, agency policies, expected outcomes, professional, standards of care, ethical standards.

• Environment:

  • Modifiable environmental factors for time management and task complexity (enteral/parenteral feedings).

  • Availability of adaptive equipment for feeding.

  • Effectiveness of healthcare resources (speech-language pathologist, registered dietitian/nutritionist, occupational therapy, adaptive equipment).

• Experience:

  • Previous patient responses to planned interventions.

  • Personal experiences with dietary change strategies.

Safety Guidelines for Nursing Skills

• Nasal Tube Placement Risks: Anticoagulation and bleeding disorders pose a risk for epistaxis (nosebleed). Nasal tubes are associated with sinusitis, otitis, vocal cord paralysis, and medical device-related pressure injuries to the nose.

• ENFit Connectors: Use ENFit connectors for all enteral nutrition sets, syringes, and feeding tubes to prevent misconnections.

• Aseptic Technique: Use aseptic technique when preparing and delivering enteral feedings to prevent infection.

• Labeling Enteral Equipment: Label all enteral equipment clearly.

• "Right Patient, Right Formula, Right Tube, Right ENFit Adapter": Practice these $5$ Rights for safe enteral feeding administration.

• Patient Positioning: Position the patient upright or elevate the head of the bed (unless medically contraindicated) for patients receiving enteral feedings to prevent aspiration.

• Trace All Lines: Trace all lines and tubing back to the patient to ensure only enteral-to-enteral connections.

• No Food Coloring/Dye: Do not add food coloring or artificial dyes to enteral nutrition, as it can mask aspiration.

• Hang Time: Refer to manufacturer guidelines to determine the appropriate hang time for enteral feedings.

• Parenteral Nutrition (PN) IV Infusion: Follow standard Aseptic Non-Touch Technique (ANTT®) practices when manipulating parts of the IV infusion for PN.

• Infusion Pumps: Always use the appropriate type of infusion pump for continuous enteral feedings and PN.

• Aspiration Monitoring: Be alert for signs of aspiration during oral feedings and when enteral nutrition is administered.

• Blood Glucose Meter Cleaning: Clean and disinfect a point-of-care (POC) blood glucose testing meter after each patient use to prevent cross-contamination.