Basic Nutrition and Nutritional Therapy Foundations of Nursing

Basic Nutrition and Nutritional Therapy Foundations of Nursing Christensen Kockrow Mosby 5 th edition Sharon Kinley-Schwing BSN Pacific College 2006

Prevention = nutrition one of the most important parts of health care. Nutrition is the total of all processes involved in the taking in and utilization of food substances for proper growth, functioning, and maintenance of health. Nutrition plays a role directly or indirectly in all body processes, and disease states. Proper nutrition may help prevent or delay onset of many diseases. Nutrition is the most over looked part of healthy living.

Role of the Nurse in Promotion Nutrition The nurse can promote good nutrition by: – Helping the patient understand the importance of the diet and encouraging dietary compliance. – Serving meal trays to patients in a prompt and positive manner. – Assisting some patients with the eating process. – Taking and recording patient weight. – Recording patient intake. – Observing clinical signs of poor nutrition and reporting them. – Serving as a communication link. – Nurse can apply nutrition to their personal lives, what a better reason to understand nutrition for your own health.

NUTRITION All of the processes involved in consuming and utilizing food for energy, maintenance, and growth. These processes are ingestion, digestion, absorption, metabolism, and excretion.

INGESTION The taking of food into the digestive tract, generally through the mouth. In special circumstances, ingestion occurs directly into the stomach, through a feeding tube.

DIGESTION Mechanical and chemical processes converting nutrients to a physically absorbable state: – Mastication–chewing – Deglutition–swallowing – Peristalsis–rhythmic, coordinated, serial contractions of smooth muscles of GI tract

ABSORPTION The process whereby the end products of digestion pass through the epithelial membranes in small and large intestines and into blood or lymph systems. Villi–small finger-like projections that line the small intestine. Most nutrients are absorbed directly through the villi.

METABOLISM The conversion of nutrients into energy. Anabolism–the constructive process of metabolism, requires energy. Catabolism–the destructive process of metabolism, releases energy. Basal metabolism–the energy needed to maintain essential physiologic functions.

EXCRETION The process of eliminating or removing waste products from the body.

NUTRIENTS The body must have six types of nutrients to function efficiently and effectively: Water Proteins Carbohydrates Vitamins Fats Minerals

Dietary Guidelines for Americans: These guidelines form the foundation of U. S. federal nutrition policy and directly affect federal nutrition programs such as food stamps, school breakfast and lunch programs, and the Special Supplemental Program for Women, Infants, and Children (WIC). These guidelines have been developed to address the importance of adequate nutrition, as well as the prevention of over nutrition and disease. Dietary Reference Intakes: This is a set of nutrient-based values that can be used for both assessing and planning diets. They form the basis for daily values used in the Nutrition Facts labels on foods. The DRIs are intended to help individuals optimize their health, prevent disease, and avoid consuming too much of a nutrient.

Essential Nutrients – Basic Functions: Essential nutrients are those that our bodies cannot make in amounts necessary for good health. The six classes of essential nutrients are carbohydrates, fats, proteins, vitamins, minerals, and water. Provide energy – Carbohydrates and proteins: 4 kcal/g – Fat: 9 kcal/g Build and repair tissue – Protein, calcium, phosphorus, iron, and fat Regulate body processes – Metabolism: the combination of all chemical processes that take place in living organisms

CARBOHYDRATES Made of the elements carbon, hydrogen, and oxygen (CHO) Constitute the chief source of energy for all body functions. Requirements are 50– 60% of total kcal intake per day.

Carbohydrates: Simple Carbohydrates: Complex Carbohydrates: Digestion and Metabolism of Carbohydrates:

CARBOHYDRATE FUNCTIONS Primary source of energy for the body. About half-day supply stored in liver and muscles for use as needed. Spares proteins from being used for energy. Needed to oxidize fats and for synthesis of fatty acids and amino acids.

Carbohydrate Absorption & Storage Digestion begins in mouth, little takes place in the stomach, is completed in the small intestine. Leave no waste for kidneys to eliminate. Absorption takes place in the villi. Excess converted to glycogen and stored in the liver or stored as fat.

DEFICIENCY AND EXCESS Mild deficiency can cause weight loss and fatigue. Serious deficiency can cause ketosis. Excess can cause obesity, tooth decay, irritate the lining of the stomach, or flatulence.

FATS Most concentrated energy source in diet. Provides 9 kcal per gram. Also known as lipids. Composed of carbon, hydrogen, and less oxygen than carbohydrates. Recommended: no more than 25– 30% of daily intake.

Fats (Lipids) Lipids: Saturated fatty acids: Unsaturated fatty acids: Trans Fatty Acids: Cholesterol: Digestion and Metabolism of fat:

Summary of Fatty Acid Classification Saturated Monounsaturated: Polyunsaturated: Trans:

Classification of LDL, Total HDL, Cholesterol LDL Cholesterol: Total Cholesterol: HDL Cholesterol:

Functions of Fat Provides concentrated source of energy. Needed to absorb fat-soluble vitamins. Major component of cell membranes and myelin sheaths. Improves flavor, delays emptying time. Protects and helps hold organs in place. Insulates the body.

CLASSIFICATION Triglycerides (true fats) are composed of one glycerol molecule attached to three fatty-acid molecules. Phospholipids (lipoids) are composed of glycerol, fatty acids, and phosphorus. Cholesterol (sterol) liver produces over 1000 mg every day.

Absorption and Storage No breakdown occurs in the mouth, very little digestion occurs in the stomach. Digestion begins in the small intestine. Final products of fat digestion are fatty acids and glycerol. 95% absorbed in small intestine. Excess fats stored as adipose tissue.

Deficiency and Excess Deficiency occurs when fats provide less than 10% of the total daily kcal requirement. May result in eczema, retarded growth, weight loss. Excess can lead to overweight and heart disease.

Sources of Fat Animal fats–lard, butter, milk, cream, egg yolks, meat, poultry, and fish. Plant fats–corn oil, safflower oil, olive oil, cottonseed oil, peanut oil, palm oil, and coconut oil, nuts, and avocado.

Protein Amino Acids: Complete proteins: Incomplete proteins: Vegetarian diets: Digestion and Metabolism of Protein: Protein-Kilocalorie malnutrition:

Proteins Made of carbon, hydrogen, oxygen, and nitrogen (CHON). The only nutrient that can build, repair, and maintain body tissues. Daily requirement for average adults is 0. 8 g of protein for each kilogram of body weight.

Functions Of Proteins Provide amino acids, needed to build, repair, and maintain body tissues. Assist in regulating fluid balance. Vital part of enzymes, hormones, blood plasma. Used to build antibodies. Can be converted to glucose, for energy.

Protein Digestion and absorption Begins in the stomach. Most digestion takes place in small intestine. End product is amino acids, absorbed into the blood by the villi in the small intestine. Excess amino acids are converted to glucose, glycogen, or fat for storage.

Sign of Deficiency and Excess Muscle wasting. Edema. Lethargy and depression. Marasmus and Kwashiorkor. Excess can contribute to heart disease, and may be linked to colon cancer, osteoporosis, and kidney damage.

Vitamins and Minerals They are needed in small amounts; toxicity may occur with over consumption. They are best received from a balanced, varied diet. Vitamins can be destroyed by heat, light, and exposure to air. Minerals cannot be destroyed because they are single elements rather than compounds. Both vitamins and minerals can be lost when foods are cooked in water.

VITAMINS Organic compounds essential to life and health. Regulate body processes, needed in very small amounts. No fuel value but required for metabolism of fats, carbohydrates, proteins. Functions are unique to each vitamin.

–Fat soluble: A, D, E, and K. Usually carried in the fatty portion of food. Can be stored by the body. –Water soluble: B vitamins and C. Not stored in the body; excesses excreted in the urine.

Digestion of Vits Vitamins do not require digestion. Fat-soluble vitamins are absorbed into the lymphatic system, excesses are stored in the liver and adipose tissue. Water-soluble vitamins are absorbed directly into the circulatory system, and excesses are excreted in urine.

Deficiency/ Excess Vitamin deficiencies can occur and result in disease. Vitamins consumed in excess amounts can be toxic to the body.

Minerals Inorganic elements that help regulate body processes and /or serve as structural components of the body. Major minerals–more than 100 mg/day. Trace minerals–less than 100 mg/day. Functions are unique to each individual mineral.

Classification and Sources Classified as major minerals or trace minerals. Found in water and in unprocessed foods. Some foods are enriched—some vitamins are added to them. Supplements may be needed during growth periods, some clinical situations.

Digestion The amount of a mineral absorbed by the body is influenced by: Type of food Need of body Health of absorbing tissue

Deficiency and Excess Deficiency signs unique to each mineral. Excesses can lead to toxicity. Concentrated forms of minerals should be used only on advice of a physician. Excesses can cause hair loss, changes in the blood, hormones, bones, muscles, and nearly all tissues.

Vitamins Antioxidant vitamins: Vitamin A: Vitamin C: Vitamin D: Vitamin E:

Vitamin K: Folate Acid: Thiamine: Vitamin B 12: Riboflavin: Niacin:

Vitamin B 6: Biotin: Choline: Pantothenic Acid: Vitamin C:

Mineral Calcium Phosphorus: Magnesium: Sulfur: Sodium:

Potassium: Chloride: Iron: Zinc: Iodine: Selenium:

Copper: Fluoride: Chromium: Manganese:

WATER ! Nutrient most vital to life. Makes up approximately 60% of adult body weight and 80% of infant weight. Provides form and structure to body tissues.

Acts as a solvent; necessary for most chemical processes. Transports nutrients and other substances. Lubricates and protects moving parts of the body. Lubricates food and aids in digestion. Regulates body temperature

SOURCES OF WATER FOR THE BODY Liquids consumed, including water, coffee, juice, tea, milk and soft drinks. Foods consumed, especially vegetables and fruits. Metabolism, which produces water when oxidization occurs.

WATER DIGESTION/ ABSORPTION, /STORAGE Water is absorbed, not digested. It is not stored and is excreted daily. Sensible loss–aware of loss of water. Insensible loss–not aware of loss of water. Urine, feces, perspiration, and respiration are the four ways the body loses water.

SIGNS OF Dehydration: – Deficiency of water, can cause death. – Occurs from profuse sweating, vomiting, diarrhea, hemorrhage, wound drainage, fever, and edema. Positive water balance when more water taken in than used or excreted.

Selected Foods with Vit. C: Selected Foods with Vit. D: Factors that affect Calcium Absorption and Excretion: Factors that affect iron Absorption:

Basic Nutrition

Diet Planning Guides A number of guidelines have been established in the US to help guide Americans in healthy and balanced eating. – My Pyramid: Bread, cereal, rice, and pasta group. Vegetable group. Fruit group. Milk, yogurt, and cheese group. Meat, poultry, fish, dried beans, eggs, and nuts group. Fats, oils, and sweets.

My. Pyramid, a personalized guide to daily food choices and number of servings. (From US Department of Agriculture, Washington, DC, 2005, US Government Printing Office. )

My. Pyramid U. S. Department of Agricultures, Pyramid symbolizes a personalized approach to health eating and physical activity. My. Pyramid emphasizes key concepts in physical activity and eating. Moderation is represented by the narrowing of each food group. The wider base stands for food with little or no solid fats or added sugars. The Narrower top area is food with more added sugars and solid fats. Varity and proportionality is shown by different widths of food groups. This pyramid can be personalized at www. mypyramid. gov.

Life Cycle Nutrition

Life Cycle Changes Nutritional needs change as a person grows and develops. Changes generally based on growth needs, energy needs, nutrient utilization. Nutritional assessment should be conducted to ascertain the nutritional needs of the individual.

Pregnancy and Lactation Nutrient needs during period of intensive growth, such as pregnancy and infancy are greater than any other time in life. Evidence has proven that optimal nutrition during pregnancy reduce risk of complications during pregnancy and delivery. Health diets and avoid alcohol and caffeine play an important role prior to and after pregnancy.

Concerns in Pregnancy Weight gain: Discomforts and complications: Practices to avoid: Lactation:

Infancy

The time from birth to 1 year of age is one of the rapid growth and development. The average infant birth weight triples by the first birthday. Nutrition is important for proper growth and development.

Breast Milk: Regular cow’s milk: Solid foods: Single-ingredient foods : Food high in iron: Commercially prepared baby foods: Juice for infants younger than 6 months: Children having juice bottles/cups/box:

Childhood This is a critical time to instill good dietary habits.

– This is a critical time for instilling good dietary habits. – At 1 year of age, appetite generally tapers off, growth slows for now. – Children still need adequate nutrition. – The younger the child, the smaller the portions needed. – If children are offered nutritious foods in pleasant surroundings and in non-threatening ways. – The parents should decide which foods to serve at what time; the child should be able to decide what and how much to eat. – However this is also the time children test their independence.

Encouraging Good Dietary Habits Meals at the table at regular times. Relaxed and enjoyable. Variety of foods. Do not force children to eat or clear plates. Small servings. New foods. Nutritious snacks. Limit sweets. Encourage physical activity. Adults are to set good eating habits.

Adolescence These years are of both physical and emotional growth.

Diets are often filled with kilocalorie-rich and nutrient-poor snack foods. Common dietary inadequacies include iron and calcium. Many teenagers experiment with alcohol and drugs, which have detrimental effects on nutrition. Obesity is a common problem; weight reduction diets should be attempted only under the advice of a physician and with the guidance of a dietitian.

Adult With energy, activity decreasing, weight gain increasing: Nutritional needs start to decrease.

Older Adult Considerations Aging may affect the eating process. Aroma and taste of food may change. Changes in the digestion process. Kilocalorie needs decrease. Numerous medications. Social and mental changes. Chronic medical conditions.

Nutritional Concerns of Adults in Long Term Care Facilities Malnutrition is a common problem among nursing home residents and profoundly influences physical health and quality of life. Residents should be offered familiar foods that taste good. Fluids should be offered to residents at all meals and between meals. Dehydration is very common and easily corrected in long term care facilities.

Nurses must understand the value of mealtime as a pleasant, social experience. Cultural and personal preferences should be considered. Many residents need assistance or encouragement. Lack of adequate staffing play a large role in patient nutrition. Many patients are on restricted diets. Pressure sore due to lack of mobility, and nutrition. Nutrient-Drug interactions.

Caffeine: Drug Central nervous system stimulant and diuretic. Nervousness Irritability Anxiety Insomnia Heart arrhythmias Palpitations See Caffeine Content of Selected Beverages and Foods.

Common Medications and Their Effect on Nutrition Antacids. Antibiotics. Anticoagulants. Aspirin. Diuretics. Laxatives.

Medical Nutrition Therapy and Therapeutic Diets These diets are specific nutrition as needed to treat an

Purpose of Diet Therapy The dietary prescription is written for one or more of the following purposes: Provide the client with nutrients needed for maintenance or growth. Prepare a client for diagnostic tests. Treat the client with a disease or condition.

DIET THERAPY The treatment of a disease or disorder with a special diet. A client must not be given anything to eat or drink without an order.

The Vegetarian Diet Lacto-ovo vegetarians–use dairy products and eggs but no meat, poultry, or fish. Lacto vegetarians–use dairy products but no meat, poultry, or eggs. Vegans–avoid all animal foods.

Factors Influencing Diet Culture Religion Socioeconomics Fads Superstitions

BASIC NUTRITIONAL ASSESSMENT Nutritional status Height and weight Meal and snack pattern Food allergies Physical activity Cultural, ethnic, and family influences Use of vitamin/mineral supplements

NUTRITION AND HEALTH Primary nutritional disease–occurs when nutrition is the cause of the disease. Secondary nutritional disease– occurs as a complication of another disease or condition.

WEIGHT MANAGEMENT Based on relationship between intake and use of kcal. Overweight: 11%– 19% above Obesity: 20% or more above Underweight: 10%– 15% under

FOOD LABELING Required on virtually all retail food products. Labels must follow the approved uniformat and use standard serving sizes and household measurements.

FOOD QUALITY AND SAFETY Proper storage, preparation, sanitation, and cooking are necessary to help prevent or reduce the risk of food-borne illnesses.

Consistency, Texture, and Frequency Modifications Liquid Diets: Clear Liquids Full Liquids Soft and Low-Residue Diets. High Fiber Diets. Meal Frequency Modification.

Kilocalorie Modifications Basal Metabolic Rate (BMR). High-Kilocalorie and High Protein Diets. Anorexia. Kilocalorie-Controlled and Low-Kilocalorie Diets. Obesity Measurements of Obesity BMI Body Composition Waist circumference Treatment of Obesity

Eating Disorders Anorexia Nervosa: Self-imposed starvation. Individuals have an intense drive for thinness, an intense fear of gaining weight or becoming fat, and a distorted body image. Bulimia Nervosa: Periods of binge eating followed by purging (self-induced vomiting, emetics, laxatives, enemas, or diuretics). Often normal weight or overweight. Binge / Purge:

Comparison of Eating Disorders Diagnoses Body weight and other physical indicators. Eating behaviors. Compensatory behaviors (purging). Psychologic indicators.

Carbohydrate-Modified Diets Diabetes Mellitus: A disease in which the body does not produce or properly use insulin. Insulin convert sugar, starches, and other food into energy needed for daily life. Two major types of diabetes: Type 1 Type 2

Primary goals for medical nutrition therapy: – Improve metabolic control by achieving and maintaining optimal blood glucose. – Provide adequate energy for maintenance of a reasonable body weight. – Prevent acute and chronic complications of diabetes. – Improve overall health through optimal nutrition

Carbohydrate intake should be monitored and controlled. Diabetic diet tools: – Exchange lists for meal planning – Carbohydrate counting Other nutritional considerations: – Hypoglycemia: consumption of inadequate carbohydrates causes the blood sugar to drop.

Carbohydrate-Modified Diets (continued) – Dumping Syndrome: It may occur after surgery in which a portion or all of the stomach is removed. – Lactose Intolerance: Intolerance occurs as a result of a lack of the digestive enzyme lactase.

Special Diets Low-residue diet High-fiber diet Liberal bland diet Fat-controlled diet Sodium-restricted diet

Fat Modified Diet These diets are beneficial in reducing the risk of atherosclerosis. Lowering dietary fat may assist in disease treatment and control.

Fat-Controlled Diets: Limits total fat, saturated fat, and trans -fatty acids. Low-Fat Diets: All fats limited, regardless of saturation.

Lowering Fat/Saturated Fat/Trans Fatty Acids/Cholesterol Food Groups: Choose: Go Easy on:

Protein/Electrolyte and Fluid-Modified Diets Increased protein facilitate healing. Defects in protein is seen in liver/renal disease.

Sodium-Restricted Diets: pg 649 box 21 -9 Potassium-Modified Diets: Fluid-Modified Diets: Fluid Restrictions Fluid Increase

Patient Teaching Fluid restrictions: Explain the rationale. Indicated if restriction is temporary or permanent. Educate, discuss different sources of water. Teach how to count fluids. Show the patient how much fluid is allowed. Suggest ways to alleviate thirst without drinking. Discuss the consequences of over consumption of fluids.

Nutritional Support

Nutritional Support Enteral nutrition–includes both the ingestion of food orally and the delivery of nutrients through a GI tube. Parenteral nutrition–the infusion of a solution of nutrients directly into a vein to meet the client’s daily requirements.

Tube Feedings – Administration of nutritionally balanced liquefied foods or formula though a tube inserted into the stomach, duodenum, or jejunum by way of a nasogastric tube or a feeding ostomy. – Indicated when a patient is unable to chew or swallow, has no appetite, or refuses to eat. – Tube feeding used only when all or at least part of the GI tract is functioning. – Feeding given continuously or intermittently.

Figure 21 -7 Tube feeding sites. (From Potter, P. A. , Perry, A. G. [2005]. Fundamentals of nursing. [6 th ed. ]. St. Louis: Mosby. )

Nasogastric Tube Feedings Checking for placement of a feeding tube before administering medication or tube feeding is critical to safe patient care. Tube may be accidentally placed in the lung, esophagus, or even the stomach when it should be in the small bowel. To test, use chest x-ray, test p. H of aspirated fluid, or use auscultatory method.

Administering Nasogastric Tube Feedings

Skill 21 -1: Step 10 a(1) (From Elkin, M. K. , Perry, A. G. , Potter, P. A. [2004]. Nursing interventions and clinical skills. [3 rd ed. ]. St. Louis: Mosby. ) Administering nasogastric tube feedings.

Skill 21 -1: Step 10 a(2) (From Potter, P. A. , Perry, A. G. [2005]. Fundamentals of nursing. [6 th ed. ]. St. Louis: Mosby. ) Administering nasogastric tube feedings.

Skill 21 -1: Step 10 b (From Potter, P. A. , Perry, A. G. [2005]. Fundamentals of nursing [6 th ed. ]. St. Louis: Mosby. ) Administering nasogastric tube feedings.

Administering nasogastric tube feedings. (From Elkin, M. K. , Perry, A. G. , Potter, P. A. [2004]. Nursing interventions and clinical skills. [3 rd ed. ]. St. Louis: Mosby. )

Administering nasogastric tube feedings. (From Elkin, M. K. , Perry, A. G. , Potter, P. A. [2004]. Nursing interventions and clinical skills. [3 rd ed. ]. St. Louis: Mosby. )

Parenteral Nutrition Support – Parenteral nutrition (hyperalimentation): Intravenous feedings. May be administered through peripheral veins. – Total parenteral nutrition (TPN): Administration of hypertonic solution into a large central vein. Composed of glucose, amino acids, vitamins, minerals, and electrolytes; fats also given as a supplement to the main formula. Indicated for the patient with a nonfunctioning or dysfunctional GI tract.

Figure 21 -8 (Courtesy of Rolin Graphics. ) Central venous catheter placement during administration of parenteral nutrition.

Nursing Assessment Must be performed in a logical fashion and should include a nutritional history, physical examination, and the results of laboratory tests.

Nursing Diagnosis Imbalanced nutrition: – Less than body requirements – More than body requirements Risk for imbalanced nutrition: more than body requirements Disturbed body image Ineffective breastfeeding

Impaired dentition Deficient knowledge (specify) Impaired oral mucous membrane Pain Feeding self-care deficit Chronic low self-esteem Risk for impaired skin integrity

Planning / Outcome A plan should be formulated by the nurse and client to achieve mutually agreed-upon goals. The plan is individualized to meet the client’s specific needs.

Implementation Interventions to accomplish the goals may include diet therapy, assistance with meals, weight and intake monitoring, and nutritional support.

Questions ?