nutrition exam 1

treatment and weight loss

A modest weight loss of 5% to 10% of initial body weight is associated with significant improvements in blood pressure, cholesterol and plasma lipid levels, and blood glucose levels!!! i. More attainable goals ii. Easier to maintain over time iii. Sets the stage for subsequent weight loss

when is enteral nutrition appropriate

Appropriate when gut is functioning!!!!! i. Accessible and safe to use when patient is unable or unwilling to consume adequate nutrients/kilocalories orally ii. Physiologic benefits: maintaining gut integrity/function

what labs to monitor that indicate water content

BUN and creatinine

complications of obesity

Insulin resistance, type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, stroke, gallstones and cholecystitis, sleep apnea, respiratory dysfunction, and increased incidence

Malnutrition of fat may contribute to

Malnutrition may contribute to multiple organ dysfunction syndrome, sepsis, and death.

before surgery

NPO to prevent aspiration

example of drug-nutrient interactions effecting absorption

Vit C helps to increase the absorption of iron

1. About bulimia

a. An eating disorder characterized by recurrent episodes of bingeing and purging. b. Lack sense of control regarding eating c. Fear of being overweight d. Usually being adolescence and young adulthood- more common in males e. Wt can be normal or slightly above normal f. Swollen salivary glands in cheeks, sores, calluses, and scars on knuckles or hands, dental erosion g. Arrhythmias

Eating disorders not otherwise specified

a. At least as common as AN and BN-- This group represents subacute cases of AN or BN... Clients may or may not meet all AN criteria b. Binge eating disorder... Bingeing that occurs w/o purging

about binge eating disorder

a. BED patients do not purge. b. Associated with history of dieting or depression c. Cognitive behavior therapy and medication are main treatment options.

dumping

a. High sugar, high fat, n and v, sweating

Goals of treatment of obesity

a. Ideally, treatment would "cure" overweight and obesity b. In reality, this ideal is seldom achieved

how is stress a vicious cycle

a. Impaired immunity leads to increased risk of disease, disease compromises nutritional status, and compromised nutritional status further impairs immunity. b. Recovery requires that this cycle be broken. We can't stop cycle until we identify what the problem is!!!!!!

the risk complications increase when

a. Increases the risk of complications during and after surgery i. May be hard to get them out of anesthetics

1. Systemic inflammatory response syndrome

a. Inflammatory response that occurs in infection, pancreatitis, ischemia, burns, multiple trauma, shock, and organ injury ~Use enteral nutrition more often because it decreases risk for infection~

starvation

a. Involuntarily going without food is called starvation. b. Fasting withholding food from ourselves.

reminder about genetics and obesity

a. Just because they have a predisposed position of their family being obese, doesn't mean that that person will be obese. But it does put them at a higher risk

food-drug interactions

a. Knowledge of all types of potential interactions between food, nutrients, and drugs helps make patient care more comprehensive.

what happens during starvation

a. Liver glycogen is used first to maintain normal blood glucose levels and to provide energy for brain and blood cells- usually depleted in 24hrs b. Lipid (triglyceride) stores begins and as the amount of liver glycogen decreases free fatty acids are mobilized for energy- use fat for energy c. After about 24 hours without intake, the prime source of glucose is from gluconeogenesis. d. During early starvation, the brain uses glucose from muscle protein. (By day 2 or 3 of starvation, about 75 g of muscle protein is catabolized each day!! Not good. Less protein, less healing the body) e. Ketone bodies produced if starvation prolonged.... They are from fatty acids. Will cause bodies demand for glucose to decrease! Will see a lot of neurologic deficits to increase

what also might people who have an eating disorder suffer from

a. May suffer from a coexisting depression, anxiety, impulse control, or substance abuse disorder.

cultural considerations for nutrition

a. Meaning of food and eating b. What types of foods c. Usual timing and sequencing of meals d. Who shops for food and who prepares the client's meals e. Client's choice of a particular practice such as vegetarianism f. Cultures eat at different times, types of food, and eat at different speeds

Specific care--- things to remember for nurses who work closely with patients who got bariatric surgery

a. Measure amounts of liquid intake to avoid dumping syndrome b. No liquids with solid food c. Avoid concentrated sweets d. Vomiting is not uncommon e. Should eat at scheduled times f. Meals should take at least 30 minutes g. Should participate in physical activity most days of the week. h. Need to work with a nutritionist-- High risk of vitamin deficiencies, diarrhea, anemia i. Continue psychological support

metabolic response to stress

a. Metabolic changes occur as a reaction to stress b. Uncomplicated stress is present when patients are at nutritional risk. c. Severe stress is linked with trauma, disease, and some types of surgery

Bariatric Surgery

a. Most effective treatment for severe obesity b. Appropriate for clients whose BMI is 35 to 39.9 who have major comorbidities or BMI > 40 c. Failure to lose weight by nonsurgical means d. Absence of contraindications e. Motivated and well informed

blockage

a. N and V, abdominal pain

what do nurses do on the collaborative team

a. Nurses help identify patients in need of nutrition services. We are at the front line because we are with the patient all day Ask questions early to identify about nutrition deficiency!!

external nutrition

a. Nutrition for patients who are unable to consume an adequate oral intake and have at least a partially functional GI tract. b. May augment an oral diet or may be the sole source of nutrition

about obesity and social concerns

a. Obesity presents psychological and social disadvantages b. Negative social consequences such as social isolation-- Stereotyping, discrimination

nutritional supplements (boost, ensure)

a. Some patients are unable or unwilling to eat enough food to meet their requirements b. Benefits to liquid supplements-- Serve cold c. Either once a day or twice a day

inflammation response

a. When the immune system is depressed b. To maintain homeostasis, the body responds to physiologic or psychologic stress. c. Hormonal and metabolic changes subdue the immune system's ability to protect the body.

intensity of the stress response depends on what

a. depends to some extent on the cause and/or severity of the initial injury

risk factors for eating disorders

abnormal eating patterns, early childhood eating, GI problems, abuse, low self-esteem, and sexual abuse

stress hormones

aldosterone antidiurectic hormone adrenocorticotropic hormone catecholamines

complications of enteral feeding

aspiration diarrhea clogged tube

Initial feeds begin at what rate

at 10-40 mL/hr. for adults

N/V

a. Too much too fast or not chewing well

Food and nutrition therapy- vitamin and mineral requirements

a. Vitamin and mineral requirements also increase- tissue will repair quicker i. VIT C ii. ZINC iii. CALCIUM iv. MAGNESIUM v. Manganese vi. COPPER

what do the doctors do on the collaborative team

doctors write orders, including diet

if they have calories count

don't take the food try out of the room before you document

Risks to monitor

dumping dehydration N/V constipation blockage

what kind of therapy is most effective for eating disorders

group therapy

A genetically modified organism (GMO)....

has had its DNA altered or modified in some way through genetic engineering ~Drawback is that some people could have an allergic reaction to the modified food item~

3rd degrees burns

i. (full-thickness injury): destruction of entire epidermis, dermis, and underlying subcutaneous tissue; do not heal, and skin grafts required Severe burns= most severe form of metabolic stress!!

how much moderate intensity physical activity to do to sustain weight loss

i. 200-420 mins/wk of moderate intensity physical activity-sustained weight loss

a role of nutrition

i. A number of nutrients affect immune function. ii. Components affected include mucous membranes, skin, gastrointestinal (GI) tract (microvilli here... help with immune system), T-lymphocytes, macrophages, granulocytes, and antibodies. iii. Mucus will decrease antibody secretion. Need adequate hydration

diet as tolerated

i. Allows for postoperative diet progression on the basis of the patient's tolerance ii. Start on the lowest spectrum and work that patient up to a regular diet based on how good their tolerance is iii. Check gag reflex and then start them on clear liquid diet as they progress upward they cannot experience N/V

how to check tube placement

i. Aspirate GI contents (pH) 1. < 5mL usually but check your policy! 2. Regularly for continuous 3. Anytime there is a concern 4. Before any bolus feed

Laparoscopic Sleeve Gastrectomy

i. Bariatric surgery that removes 80% of the stomach ii. Increase in gut hormone levels- induced satiety increase insulin sensitivity and slow gastric emptying iii. People say they feel full quicker iv. Gaining popularity due to similar benefits as RYGB- Lower cost, lower morality, less complications, fewer metabolic complications. v. Least amount of restrictions and problems with it

Oral Diet for burn pts

i. Burns covering <20% TBSA- high protein, high calorie diet ii. Include small frequent meals of calorie and protein dense foods iii. Oral supplements iv. Daily calorie counts are helpful

food allergy

i. Caused by the release of histamine and serotonin ii. Most common symptoms are diarrhea, nausea, vomiting, cramping, abdominal distention, and pain. iii. 8 foods with major triggers for adults (eggs, milk, wheat, soy, fish, shellfish, peanuts, and tree nuts). iv. People who have food allergies may not be able to consume certain types of food. v. People who have food allergies may not be able to consume certain types of food.

Diet modification

i. Cornerstone of most weight loss programs ii. Few calories iii. Macronutrient composition iv. Nutrition Therapy

Physical Activity dietary guidelines

i. Dietary Guidelines recommend adults engage in approximately 60-90 mins of moderate- to vigorous-intensity activity on most days of the week to prevent weight gain. -Walking, cycling, swimming -Impacts metabolic rate

glucose in PN

i. Difference percentage amount of glucose in these bag based off the patients nutritional needs.

what should the nurse know about food service delivery of the pt

i. Does the patient have a specific diet? ii. Is the patient diabetic--- need to give them their insulin before eating... Communicate with patient about their meal time insulin

effects of drugs ON FOOD AND NUTRIENTS

i. Drug absorption rate may increase or decrease in the presence of food in the gastrointestinal tract. ii. Drugs, including alcohol, may alter food intake, nutrient absorption, metabolism, and excretion. iii. Drugs may alter mineral levels, causing depletion or overload. iv. Drugs may act as appetite suppressants or stimulants. v. Effects of food on drug action may produce uncomfortable side effects.

dysphagia diets

i. Dysphagia- signs of swallowing difficulty, including drooling, pocketing of food, choking, gagging, and taking longer than 2-10 seconds to swallow food. ii. Food consistency altered only to the degree needed.

binge eating disorder is characterized by

i. Eating more quickly than normal ii. Eating alone or when not hungry and eat until extremely full iii. Feelings disgusted, depressed, or guilty about overeating

Effect of stress on fat metabolism

i. Fat from adipose stores is mobilized for energy. ii. Fat stores are rapidly depleted if hypermetabolic patients are not fed during this time-- Fat will go quicker iii. Resulting malnutrition increases susceptibility to infection.

Nutrition care for burn pt

i. First 24 to 48 hours dedicated to fluid and electrolyte replacement 1. Fluid needs based on age, weight, and extent of burn 2. Total body surface area (TBSA) used to estimate extent of burn: RULE OF NINES

behavior modification

i. Focuses on changing the client's eating and exercise behaviors

effects of food and nutrients ON DRUGS

i. Food intake and composition: affect drug absorption ii. Timing of drug administration in relation to meals: significant iii. Tube-feeding effects

clear liquid diets

i. Foods that are clear and liquid at room or body temperature ii. Inadequate in energy and almost all nutrients except water iii. Deficient in nutrients iv. Used to maintain hydration during an illness v. Should not be used for more than 8 to 24 hours vi. Used commonly pre and post op surgery and procedures vii. Diabetes may have problem with hyperglycemia because of the high sugar intake

full liquid diet

i. Foods that are liquid at room temperature ii. Often prescribed if patients have difficulty chewing or swallowing solid foods iii. Can supply adequate energy and nutrients iv. Assess for signs of dysphagia

Roux-en-Y gastric bypass (RYGB)

i. Gold standard procedure for obesity, but highest rate of complications ii. Bypass various portions of the small intestine so that less food is absorbed. iii. People who have a lot of comorbidities get this iv. Dumping syndrome v. Most common micronutrients deficiencies after RYGB includes calcium, Iron, folate, vitamin b12, thiamine and vitamin D vi. Major complication is anastomotic leak! Can make patient deathly ill vii. Weight loss of 35% at 1-2 years and 30% at 10 years.

rule of nines (%)

i. Head and each arm 9% ii. Back and chest each 18% iii. Each leg 18% iv. Perineum 1%

carbohydrate metabolism

i. Hepatic glucose production increased ii. Insulin levels and glucose use increased iii. Should provide 60%-70% of total calories.-- NEED MORE CARBS. Might have elevation in glucose... then need more insulin

effects of herbs on food, nutrients, and drugs

i. Herbs may significantly affect bioavailability of foods, nutrients, and drugs ii. Herb and drug interactions may occur

high risk surgical procedures

i. Hip replacement, open heart surgery, and prostatectomy are high-risk procedures. ii. Patient at high risk for malnutrition have significantly longer lengths of hospital stay and higher mortality rates-- Need to be on strict diet

how are genetics involved

i. How likely a person is to gain or lose weight ii. Where body fat is distributed iii. Response to overeating

Ebb phase (early phase)

i. Immediately after injury ii. Decreased oxygen consumption, hypothermia, lethargy, decrease insulin levels iii. Major concern is maintain cardiovascular effectiveness and tissue profusion.

what is the purpose of GMO foods

i. Increase food supply ii. Make foods more shelf-stable iii. Improve quality

Effect of stress on fluid/hydration status

i. Increased fluid losses possible from fever, increased urine output, diarrhea, draining wounds, or diuretic therapy ii. Fluid requirements average 30 to 40 mL/kg of body weight. iii. Monitor!!

nutritional needs for pt with multiple organ dysfunction syndrome

i. Increased needs for kilocalories and protein ii. Early enteral feedings appear to maintain gut integrity if GI tract is functioning iii. If GI tract is not functioning, then use parenteral nutrition

safety measures with enteral feeding

i. Initiate Aspiration Precautions HOB 30-45 ii. Always check for proper placement iii. Change tubing and tube feeding bag every 24 hours iv. Do not hang feedings for longer than 4-8 hours v. Always document when feedings were hung

Weight maintenance after loss

i. Keeping weight off is even harder than losing it. ii. Diets that lead to weight loss are not necessarily effective for maintaining weight loss. iii. Single best predictor of who will be successful at maintaining weight loss is how long someone has kept his or her weight off.

why would nutrients need to be modified

i. Low-sodium diet is used to lower blood pressure. ii. Carbohydrates are restricted for diabetes management.-- Depends on how severe their diet is

indications for enteral nutrition

i. Malnutrition risk: 5 days or longer of inadequate or reduced oral intake ii. Severe dysphagia, major burns, short gut, intestinal fistulas. iii. Are in a coma iv. Have an increased nutrient requirement

Parenteral nutrition and IV medications

i. Medications that are added to the PN (such as heparin or insulin) must be done by the pharmacy ii. Most often, the IV port should only be used for PN and not other IV medications iii. Blood work should not be drawn from the PN port

Burns benefit of early enteral nutrition

i. Meets nutrient needs ii. Improves feeding tolerance iii. Decreases incidence of bacterial translocation iv. Decreases number of infectious episodes v. Decreases need for antibiotic therapy vi. Improves nitrogen balance vii. Reduces urinary catecholamines viii. Diminishes serum glucagon ix. Suppresses hypermetabolic response x. Enhances visceral protein status

Genetics and environment and obesity

i. More than 300 genes have been linked to obesity ii. About 30% to 40% of the variance in BMI is attributed to genetics iii. About 60% to 70% is attributable to environment iv. Linked to how fast they will gain or lose weight

feeding route for enteral nutrition nasogastric esophagostomy gastrostomy juejunostomy

i. Nasogastric: tube is passed through nose to stomach. ii. Esophagostomy: tube is surgically inserted into neck and extends to stomach. iii. Gastrostomy: tube is surgically inserted in stomach. iv. Jejunostomy: tube is surgically inserted into small intestine. (PEG)

Effect of stress on vitamins and minerals metabolism

i. Need for most vitamins and minerals increases. ii. If kilocalorie needs are met, patients probably receive adequate amounts of most vitamins and minerals. iii. Special attention should be given to vitamins C and A, beta carotene, and zinc: will aid in patient outcomes iv. The following supplements are recommended: 500 to 1000 mg of vitamin C daily, 220 mg of zinc sulfate daily.

food intolerance

i. Non-allergic reaction to foods. ii. Dose responsive, occurring after large amount is consumed. iii. Lactose or gluten intolerance most common

Food and nutrition therapy- protein requirements

i. Normal: 0.8 g/kg body weight ii. Moderate stress: 1.0 to 1.5 g/kg body weight iii. Severe stress: 1.5 to 2.0 g/kg body weight

what does the registered dietitian/nutritionist do

i. Nutrition care process ii. Detailed nutrition assessments iii. Nutrition diagnosis iv. Intervention: provision of specific nutrition therapies (Nurse can help identify) v. Monitoring and evaluation of outcomes (Like daily weight) vi. Will make recommendations to what kind of diets they should be on

Significant considerations of burn patient care:

i. Pain management, wound care, infection control, and nutrition support

nutritional therapy for bulimia

i. People with BN tend to have fewer serious medical complications than people with AN because their undernutrition is less severe-- Do not always look malnourished ii. Nutritional counseling focuses on identifying and correcting food misinformation and fears iii. Structured and relatively inflexible to promote the client's sense of control iv. Initial meal plans may consist of low calories to prevent overwhelming client. v. 1500 cal diet distributed among 3 balanced meals plus a snack may be used.

pharmacotherapy is recommended for who

i. People with a BMI ≥30 ii. People with a BMI ≥27 with comorbid conditions iii. People with waist circumference > 35 inches (women) and 40 inches (men) are also candidates for pharmacotherapy **if comorbidities are present**

parenteral delivery

i. Prefer a centrally placed catheter: Subclavian-(short-term), Hickman catheter or Port-A-Cath, PICC ii. Can use a peripheral catheter but ONLY if a low concentration of dextrose is used-- This is not ideal! D10 or less only

residuals

i. Prior to feeding for a bolus and during continuous feeds ii. Give them back residual-- Keep pulling up residual until you no longer have it iii. put bed up to prevent aspiration

Effect of stress on protein metabolism

i. Protein (skeletal muscle) mobilized for energy ii. Glutamine used as fuel source for intestinal cells; also plays role in maintaining intestinal immune function and enhancing wound repair iii. Body is getting rid of more protein than it is getting in iv. Meat and beans are high in protein

nutritional therapy for anorexia

i. Provide support, monitor eating in a respectful way ii. Step-by-step goals of nutrition therapy iii. Good to develop a trusting relationship with client iv. Want to reward the client based on the number of calories consumed, not the amount of weight gained.

drug and nutrient interactions have the potential to

i. Reduce drug efficacy or absorption ii. Interfere with disease control iii. Foster nutritional deficiencies iv. Influence food intake, absorption, and metabolism v. Provoke toxic reaction

about nutrition screening

i. Required by the Joint Commission within 48 hours of hospital admission. ii. Identifies whether patients have malnutrition or nutritional risk. iii. Conducted by RN, RD, DTR, MD, other trained personnel. iv. Long-Care residents screening and assessments w/in 14 days v. Referral if necessary for further assessment. vi. Will help you identify who else needs to be a part of this team for the patient

bariatric surgery works by

i. Restricting the stomach's capacity ii. Creating malabsorption of nutrients and calories iii. A combination of both

a. Laparoscopic adjustable gastric banding (LAGB)

i. Restrictive surgery that reduces the size of the stomach ii. Feel full quicker iii. Stomach and intestine digest and absorb food normally iv. Risk of anemia or deficiencies is lower v. Adverse effects band slippage, erosion, reflux esophagitis vi. Decrease rate of wound infection vii. Weight loss is more gradual

environmental obesity

i. Rise in obesity without change in gene pool ii. Root cause is lifestyle and environment, not biology

regular or general diet

i. Serves as the basis for modified diets ii. They can eat whatever they want to eat

nutritional clinical assessment

i. Sources of data: medical history, social history, and physical examination ii. Features associated with nutritional deficiencies iii. Always review the chart so you have full information about the patient

medication administration during enteral feeding

i. Stop infusion ii. Flush tubing with 20mL before and after iii. Give the medication (meds must be in liquid form) iv. Never crush time released, liquid capsules, or enteric coated meds-- Call pharmacy if you run into this problem v. Check med compatibility before mixing multiple meds together

What needs to be done to determine safety and risk of aspiration

i. Swallowing evaluation needed before any oral feeding to determine safety and risk of aspiration ~patient may need to be on tube feeding (enteral feeding)~

what do Dietetic technicians, registered (DTRs)- "assistant to registered dietitian" do

i. Take diet histories. ii. Collect information for nutrition screening and assessment. iii. Work directly with patients who are having problems with their meals. iv. Provide basic nutrition education. v. Should not be asked to counsel patients about modifications for complex disease. vi. Basic amount of nursing education to that patient

complications of parenteral nutrition

i. Technical: pneumothorax most common. Avoid by doing proper technique ii. Septic: catheter-related sepsis iii. Metabolic: hyperglycemia most common

Supplements we need during stress and what they do for the body

i. Vitamin C- Collagen formation and wound healing. ii. Vitamin A and Beta Carotene - Healing process/ antioxidants. iii. Zinc- Protein synthesis and wound healing iv. Vitamin K- Clotting v. Iron- RBC formation

fats in PN

i. concentrated energy source to prevent essential fatty acid deficiency- infuse early in the morning to give the body time to adjust the fatty acids in case lipid panel needs to be drawn

amino acids in PN

i. mixture of essential and nonessential crystalline amino acids.

diarrhea

i. slow tube feeding down if you notice this 1. Bacteria? Too fast? Too much fiber? Too cold? 2. Too high Osmolarity? 3. Nausea (too much volume?, intolerance?) 4. Bloating/Distention (too much fat?) 5. Dehydration (too much electrolyte? Protein?) 6. Fluid overload (too dilute? Too much flush?) 7. Constipation (dehydrated? Too little fiber?) 8. Social implications (lack of satisfaction? Loss of control? Body image?)

what to watch on patient to find out if that calorie count is appropriate for that patient

input and output

carbs in PN

most common carb used is dextrose monohydrate.

immune system is

one of the first body functions to be affected by impaired nutritional status... which leads to malnutrition affecting the immune system

after surgery

oral intake resumed

medications

orlistat lorcaserin qsymia Naltrexone-bupropion SR Liraglutide

hypermetabolic stress

patient has increase in metabolism rate a. Formulas exist to determine the energy needs of patients experiencing hypermetabolic stress

eating stragies

portion control, eliminating sweeteners, eating frequency, and including breakfast

Antidiuretic hormone

promotes conservation of water and salt to support circulating blood volume

Verify initial tube placement

radiography.

oral diets

regular or modified consistency-- Easiest and most preferred method of providing nutrition

micronutrient needs for burn patients

special attention to vitamins A and C

Catecholamines (epinephrine and norepinephrine):

stimulate hepatic glycogenolysis, fat mobilization, gluconeogenesis

Calorie density of a product determines

the volume of formula needed 1. Routine formulas provide 1.0 to 1.2 cal/mL 2. High-calorie formulas provide 1.5 to 2.0 cal/mL 3. Adults usually have 1000-1500 ml/day of TF

is obesity considered to be a major contributor to preventable deaths in the United States

yes

orlistat

~Less potent version. All is OTC~ 1. Decreases the absorption of fat from the GI system 2. Bloating, fatty stools, and abdominal pain

obesity definition

~Obesity is defined as having a BMI ≥30~ i. Generally assumed to be related to an excessive amount of body fat ii. Factor in bone, muscle mass, water as well

overweight definition

~Overweight is defined as having a BMI ≥25 or > 85% for a child~ i. Related to an excessive body weight, not necessarily excessive body fat

trauma

~Patients with traumatic brain injury (TBI) are severely hypermetabolic and catabolic~ a. More severe the injury, higher amounts of catecholamine's and cortisol b. Patients with spinal cord injury (SCI) and those with multiple traumas in addition to SCI may have higher nutritional needs. c. Over months, recovering patients with TBI and SCI need lower calorie intake to prevent excessive weight gain.

nursing education for physical activity

~Reducing barriers to exercise may increase exercise adherence.~ a. Exercise at home versus a gym b. Exercise in multiple short bouts instead of a long session c. Adopt a more active lifestyle -Walk -Take stairs -Walk while talking on the phone -Burn approximately 5 calories/min walking

water content

~Varies with caloric concentration~ 2. 1.0 cal/mL provide 850 mL of water/Liter 3. High-calorie formulas are lower at 690 to 720m>/L 4. Adults generally need 30-40mL/kg/day 5. Need for additional free water?!?!?

Thermal injury wounds

~heal only when patient is in anabolic state~ i. Feedings should be initiated as soon as patient is hydrated. ii. Very early enteral feeding (within 4 to 12 hours) may decrease hypercatabolic response. iii. MUST START OUT WITH FLUID AND ELECTROLYTE REPLACEMNT !!!!

Physical assessment and obesity

~look at different components to see if they are at increase risk for any chronic conditions~ a. Lab values (ie , glucose) b. Blood pressure (htn?) c. BMI and categorize it (>30) d. Dietary assessment of intake (24 hr recall for calorie count) e. Assessment of client goals for weight f. Any cultural or religious preferences-- Like Hispanics eat a lot of rice and beans... high in carbs g. Allergies or intolerances? h. Medical diagnoses?-- Chronic conditions... like arthritis (because of the pain they don't want to exercise) i. Vit D deficiency? Less available vit D when obese-- Puts them at higher risk for bone fractures

Food and nutrition therapy- fluid needs

~really based off patients age~ i. Adults younger than 55 years: 35 to 40 mL/kg body weight ii. Adults 55 to 65 years: 30 mL/kg body weight iii. Adults older than 65 years: 25 mL/kg body weight

Standard-intact formulas (polymeric):

~require a normally functioning GI tract. WHAT YOU TYPICALLY USE~ 1. Blenderized food 2. Milk based 3. High kilocalories, lactose free 4. Normocaloric, lactose-free (isotonic, hypertonic, high-nitrogen, and fiber containing) 5. Modified nutrients (carbohydrate, fat, protein, vitamins, minerals)

menus of food service delivery...

~selective and nonselective~ i. Nonselective tray is when the dietary office picks choices of food items to be delivered. These patients will get their tray regardless of if they called of not

aspiration

~the most serious potential problem! (can still aspirate with a PEG)~ 1. Check placement 2. Patients HOB up 30 to 45 degrees 3. Minimizing transport of patients 4. High risk/intolerant patients switched to continuous 5. Avoid narcotics or reduce when possible 6. Agents to increase motility may be beneficial 7. Consider diverting the tube to a small intestine placement 8. Turn feed off if moving patient around a lot

for diagnosis of Systemic inflammatory response syndrome...

~the site of infection is established along with at least two of the following: i. Temperature: >38° C or <36° C ii. Heart rate: >90 bpm iii. Respiratory rate: >20 breaths/min iv. Partial pressure of arterial carbon dioxide (PaCO2): <32 mm Hg (hyperventilation) v. WBC count: >12,000/mm3 or <4000/mm3

cyclic administration

~variation of continuous feedings~ a. Given a constant rate over 8-20hrs. often at bedtime b. Used from home parenteral nutrition c. Oral during the day and at night they receive the tube feeding for 4-8 hours

components of parenteral nutrition

carbs, amino acids, fats, glucose

Adrenocorticotropic hormone (ACTH):

causes release of cortisol to mobilize amino acids from skeletal muscles

aldosterone

corticosteroid that causes renal sodium retention

flow phase

(36 to 48 hours after injury) i. Increased oxygen consumption, hyperthermia, increased nitrogen excretion and catabolism ii. Lasts for days, weeks, or months until injury healed

1st degree burns

(partial-thickness injury): reddening of the area with no injury to dermal or subcutaneous tissue; take 3 to 5 days to heal without scarring

2nd degree burns

(superficial partial-thickness injury and deep partial-thickness injury): reddening and blistering; take weeks to months to heal- will effect dermis to epidermis

calorie counts- dietary intake assessment

1. Identify all the calories eaten for the day 2. Energy and protein intakes are most often quantified. 3. Information gathered is used to determine the adequacy of patients' daily oral intake or to document need for nutrition support. 4. Used in acute and long term setting 5. Look at the percentage of food item they had. And count mL of liquids they had

insulin injection why necessary

1. Insulin may be added if glucose running high

nutrition therapy explained

1. Low fat diet-- Make sure the diet they pick won't cause any more problems to the chronic issues they have 2. High protein 3. Dietary pattern 4. Meal replacement 5. Very-low calorie (less than 1000 calories per day)

post surgery nursing care

1. Monitor for electrolyte complications 2. Pulmonary complications 3. DVT wear stockings!! 4. HOB elevated to reduce pressure on abdomen 5. Early ambulation 6. Monitor skin 7. Evaluate pain....considerable abdominal pain after surgery 8. If NG tube is in place....evaluate placement and if needs repositioned→ notify surgeon-- Careful with irrigation of it because stomach pouch is small

about Peripheral Parenteral Nutrition (PPN)

1. Must be isotonic; limited kilocalories and protein 2. Most often used when short-term nutrition support is needed 3. Dextrose concentration contains 5%-10% and 3%-5% amino acids and electrolytes.

clogged tube

1. Often result of not routinely flushing tube with sterile water or not flushing before/after medications-- Flush with 30-50 mL of warm water 2. check for a kink 3. attempt to draw back 4. follow institutional policy

pre-surgery nursing care

1. Patients often undergo a several month period of evaluation 2. Involves diet intervention, PT, psychological evaluation 3. Evaluation of cardiac risks

concerns with full liquid diet

1. Potential problem with lactose intolerance- issue because a lot of milk based products 2. Concern with high saturated fat and cholesterol 3. Safety concern: avoid use of raw eggs

food record- dietary intake assessment

1. Records food for at least 7 days

key behavior modification strategies

1. Self-monitoring 2. Goal setting: 1-2 weight loss per week 3. Stimulus control-- Avoiding or changing that queues trigger undesirable behaviors 4. Problem solving-- identifying problem and implementing alternative behavior 5. Cognitive restructuring-- positive self-talk 6. Relapse prevention

why do we modify diets

-Therapy may require texture changes to liquefied or pureed foods. -Nutrients may also be modified -If they are having a specific procedure, may need to modify their diet

then advance the rate by what

1. Advance by 10-20 mL/hour every 8-12 hours or as tolerated GRADUALLY INCREASE FEEDING

Qsymia

1. Combination of Topamax (Topirimate) seizure medication and Phentermine which is an appetite suppressant 2. Use if BMI >= 30 or BMI >= 27 with a comorbidity such as HTN

basic nutrition screening

1. Decreased appetite 2. Unintentional weight loss 3. Age and medical history (Older patients are the most at risk for nutritional deficiency) 4. Hydration status and illness severity -Check for turgor (not always accurate) -Check cap refill -Check mucous membranes

lorcaserin

1. Decreases appetite and cravings.

Naltrexone-bupropion SR

1. Decreases appetite and fewer

nursing education for diet modification

1. Eat smaller portions at meals and snacks 2. Good carbs such as fruits, vegetables, whole grains, and legumes that are higher in fiber (versus bad carbs such as sugars) 3. Healthy fat—unsaturated fats found in poultry, fish, nuts, and cooking oils. 4. Increase fiber 5. Bake, broil, roast 6. Proteins may make them feel fuller 7. Modify recipes for lower caloric content 8. Read labels 9. How to eat out without over eating. 10. Distribute calories through the day

teaching for Laparoscopic adjustable gastric banding (LAGB) should include

1. Eating small meals a couple times per day, eating slowly, chewing thoroughly and progressing diet slowly

special formulas

1. Elemental formulas (predigested or hydrolyzed): composed of partially or fully hydrolyzed nutrients 2. Modular formulas: single macronutrients added to other foods or enteral products 3. Specialty formulas: designed to meet specialized nutrient demands for specific disease states

example of drug-nutrient interactions influencing food intake, absorption, and metabolism

1. Especially GI disorders... look at the medicines they are taking and how the food affects it

mechanically altered

1. For patients with chewing or swallowing difficulty 2. Regular diet altered from natural consistency 3. Tips to make food appealing 4. Foods are chopped, grounded, pureed or soft 5. Easier to chew and swallow

what is the best nursing interventions for a person who has dysphagia

1. Get involved with registered dietitian to do a swallow test

bolus-variation of intermitted feeding administration

1. Goes much fast than intermittent. a. Large volume delivered quickly- can cause dumping syndrome b. Volumes infused range from 250-500 mLs c. No more than two feedings should be allowed

Environmental influences include—

1. Growing portion size of restaurant meals 2. Low levels of physical activity 3. Increases in television watching 4. Widespread use of electronic devices in the home, such as computers and video games 5. ***All lead to sedentary lifestyle which increases our weight

heparin injection why necessary

1. Heparin may be added to reduce fibrinogen build up on catheter tip

what are the step by step goals

1. To prevent further weight loss 2. To gradually reestablish normal eating behaviors (gradually eat more calories) 3. To gradually increase weight (1-2lbs per week) 4. To maintain agreed-upon weight goal

tolerance of feeding and malnourished

1. Tolerance can be problematic for malnourished, severe stressed or patients who have not eaten in a long time.

i. Liraglutide

1. Used to treat diabetes then approved for weight loss. 2. Injectable medication that they get once a week

soft diets

1. Whole foods, low in fiber and lightly seasoned (bananas, mashed potatoes) 2. Transition diet 3. Constipation!!!!!

24 hr recall- dietary intake assessment

1. first assess orientation 2. writing down everything they put into their mouth in 24 hr

continuous administration

1. given at constant rate over 24 hour period 2. Recommended for critically ill patients

intermittent administration

1. given throughout the day in 3-6 feedings- don't necessarily need to be on the pump a. Resembles a normal intake and allows for freedom between feedings. b. Delivered by gravity over 30 to 60 minutes.

what could refeeding syndrome lead to

Cardiac sufficiency heart failure, respiratory distress, convulsions, coma, or death!

How much is too much residual?

Depends on patient, type of delivery, and situation!!! 1. 200 ml on two successive occasions call doctor to hold the tube feedings 2. More than half of the previously infused amount 3. Refeed residual check

precipitating factors for eating disorders

Onset of puberty, divorce, death and ridicule of being

Oral intake for first 3 days and then how is it continued

Oral intake is less than 75% of estimated need for more than 3 days, EN should be used for total (24 hr continuous tube feeding) or supplemental (cyclic feedings) nutrition-- Cyclic feedings or total EN nutrition

example of drugs that act as appetite suppressants or stimulants

Specifically diabetic medications... insulin, metformin

what is the usual max rate

Usual max rate for adults is 125 mL/hr.

what to consider when helping an obese patient

a. "Are they ready to lose weight?"- helps you to understand if they are motivated to lose weight. We want to encourage them but we can't make them be ready

dehydration

a. 48-64 oz. a day, sips throughout day-- to prevent bloating and GI distress

About anorexia

a. A condition of self-imposed fasting or severe self-imposed dieting. b. Compulsive thinning, fear of becoming fat c. Usually develops during adolescence or young adulthood d. 90-95% female population e. BMI< 17.5 or less f. Lanugo (fine black hair), dry skin, brittle nails, cold intolerance, & severe constipation g. Low HR, Low BP orthostatic BP, hypotensive, bradycardic h. Protein-calorie malnutrition

specific pulmonary complications

a. Body stores anesthetic agents in adipose tissue and these can reenter the blood stream b. Can cause issues with pneumonia

Burns (thermal injury)

a. Causes may be thermal or nonthermal (chemical, electrical, or radioactive)

The stress response

a. Chain reaction involving central nervous system and hormones that affects entire body b. "Fight or flight" response, or general adaptation syndrome-- see elevation in stress hormones during flight or fight

lifespan- pediatric interventions

a. Counsel non obese patients to establish weight friendly and healthy lifestyle b. Breast feed first 6 months and continue for at least the first year. c. Five or more fruits and veggies a day d. Limit sugar sweetened beverages e. Prepare more meals at home f. Eat at the table as a family 5-6 times a week with TV off. g. Healthy breakfast every day h. Involve the whole family in lifestyle changes Parents avoid overly restricted

1. Eating disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS)

a. Defined psychiatric illnesses that can have a profound impact on nutritional status and health b. Generally characterized by abnormal eating patterns and distorted perceptions of food and body weight

constipation

a. Fiber intake may be low

goal for people with binge eating disorder

a. Goal is to normalize eating behaviors: make awareness that if they aren't hungry they don't need to eat

transitioning to oral diet from enteral feeding

a. Goal of diet intervention is to ensure an adequate nutritional intake while promoting an oral diet b. Stop enteral feed 1 hour before oral feeding!!!!!!!!! c. Should be able to tolerate bolus feedings first d. Gradually increase meal frequency until 6 small oral feedings are accepted e. Some may eat oral by day and feeds at night: cyclic

Surgery and nutrition

a. Patients who are malnourished or in danger of malnutrition must be identified early so that corrective action may be arranged. b. Undernutrition can lead to decreased protein synthesis, weakness, multiple organ dysfunction syndrome, and even death. c. Have increased risk for nutritional deficiency! Inadequate nutritional status

refeeding syndrome

a. Physiologic and metabolic complications associated with reintroducing nutrition to quickly. b. SO START OFF SLOW AND GRADUALLY WORK UP c. Seen more with PN than EN feedings d. Can lead to glucose and electrolyte shifts e. Thorough nutritional assessment is important. f. Monitor for fluid retention= daily weights. g. Provide adequate phosphorus, potassium, and magnesium daily.

therapeutic diets

a. Preventing or treating an illness (DASH, Low fat, etc.) b. Based off of patient disease process c. Therapeutic diets differ from a regular diet

Multiple organ dysfunction syndrome

a. Progressive decline of two or more organ systems at the same time b. If not correct, can lead from one failure to the next c. May follow trauma, severe burns, infection, or shock d. Usually results from uncontrolled inflammatory response-- Can progress to organ failure and death

Parenteral Nutrition

a. Provides energy and nutrients intravenously. two kinds: i. Central Parenteral Nutrition (CPN) ii. Peripheral Parenteral Nutrition (PPN)

the stress response

a. The body's attempt to promote healing and resolve inflammation when homeostasis is disrupted b. Hormonal and Inflammatory responses cause changes that account for metabolic stress