Unit 12 Altered Nutrition

1 lb

500 mL fluid

EN aspiration

A serious complication associated with enteral feedings is aspiration of formula into the tracheobronchial tree. Aspiration of enteral formula into the lungs irritates the bronchial mucosa, resulting in decreased blood supply to affected pulmonary tissue. This leads to necrotizing infection, pneumonia, and potential abscess formation. Some of the common conditions that increase the risk of aspiration include coughing, gastroesophageal reflux disease (GERD), nasotracheal suctioning, an artificial airway, decreased level of consciousness, and lying flat. Keep the head of the bed elevated a minimum of 30 degrees, preferably 45 degrees, unless medically contraindicated.

Electrolyte and mineral imbalances of PN

Administration of concentrated glucose accompanies an increase in endogenous insulin production, which causes cations (potassium, magnesium, and phosphorus) to move intracellularly. Monitor blood glucose levels every 6 hours to assess for hyperglycemia and administer supplemental insulin as needed. If an infusion falls behind schedule, do not increase the rate in an attempt to catch up. Sudden discontinuation of a solution can cause hypoglycemia. Usually it is recommended to infuse 10% dextrose when discontinuing PN solution suddenly.

Older Adults

Adults 65 years and older have a decreased need for energy because their metabolic rate slows with age. However, vitamin and mineral requirements remain unchanged from middle adulthood. Difficulty chewing, missing teeth, having teeth in poor condition, and oral pain result from poor oral health. These often contribute to malnutrition and dehydration in older adult. Symptoms of dehydration in older adults include confusion; weakness; hot, dry skin; furrowed tongue; rapid pulse; and high urinary sodium.

ketones

All body cells except red blood cells and neurons oxidize fatty acids into ketones for energy when dietary carbohydrates (glucose) are not adequate.

food security

All members of a household have access to sufficient, safe, nutritious food to maintain a healthy lifestyle

glycogenesis

Anabolism of glucose into glycogen for storage

Verification of Feeding Tube Placement

Auscultation is not effective in distinguishing between gastric and intestinal placement for feeding tubes. The measurement of pH of secretions withdrawn from the feeding tube helps to differentiate the location of a tube . At present the most reliable method for verification of placement of small-bore feeding tubes is x-ray film examination.

Medical Nutrition Therapy: CV Diseases

Balance caloric intake and exercise. Maintain a healthy body weight. Diet rich in fruits, vegetables, and complex carbohydrates. Limit foods and beverages high in sugar and salt. Limit trans-saturated fat to less than 1%. Eat fish twice per week.

indispensable amino acids

Because the body does not synthesize indispensable amino acids, we need these to be provided in our diet.

Medical Nutrition Therapy: HIV/AIDS

Body wasting and severe weight loss Severe diarrhea, GI malabsorption, altered nutrient metabolism Maximize kilocalories and nutrients. Encourage small, frequent, nutrient-dense meals with fluid in between.

Diet History and Health History

Box 45-6 lists some specific assessment questions to ask in the diet history. The diet history focuses on a patient's habitual intake of foods and liquids and includes information about preferences, allergies, and other relevant areas such as the patient's ability to obtain food.

gluconeogenesis

Catabolism of amino acids and glycerol into glucose for energy

glycogenolysis

Catabolism of glycogen into glucose, carbon dioxide, and water

Peptic ulcer disease

Caused by H. pylori, stress, and/or acid overproduction Peptic ulcer treatments: Avoid caffeine. Avoid spicy foods. Avoid aspirin, NSAIDs. Consume small, frequent meals.

Assisting Patients with Oral Feeding

Clear the table or over-bed tray of clutter. Patients at high risk for aspiration have decreased level of alertness, decreased gag and/or cough reflexes, and difficulty managing saliva. Patients with dysphagia are at risk for aspiration and need more help with feeding and swallowing. Provide a 30-minute rest period before eating and position the patient in an upright, seated position in a chair or raise the head of the bed to 90 degrees. Have the patient flex the head slightly to a chin-down position to help prevent aspiration. If the patient has unilateral weakness, teach him or her to place food in the stronger side of the mouth. Thicker fluids are generally easier to swallow.

Planning Goals and Outcomes

Educate your patients about the therapeutic diet prescribed, specifically on how it controls their illnesses and if there are any implications. When planning care, be aware of all factors that influence a patient's food intake. Individualized planning is essential.

Crohn's and ulcerative colitis

Elemental diets - simple nutrients that are easily absorbed Parenteral nutrition Vitamins and iron supplements Fiber increase Fat reduction Large meal avoidance Lactose and sorbitol avoidance

DASH Diet

Emphasizes dietary alterations to reduce BP(hypertension); Diet plan emphasizes fruits, vegetables, fat-free or low-fat milk products, whole grains, fish, poultry, beans, seeds, and nuts; Avoids intake of red meat, salt, sweet

Adolescents

Energy needs increase to meet greater metabolic demands of growth. Daily requirement of protein also increases. Calcium is essential for the rapid bone growth of adolescence, and girls need a continuous source of iron to replace menstrual losses. Boys also need adequate iron for muscle development. Iodine supports increased thyroid activity, and use of iodized table salt ensures availability. B-complex vitamins are necessary to support heightened metabolic activity.

Enteral Tube Feeding

Enteral nutrition (EN) provides nutrients into GI tract. It is physiological, safe, and economical nutritional support. Types: Nasogastric, Nasointestinal Gastrostomy, Jejunostomy PEG - percutaneous endoscopic gastrostomy PEJ - percutaneous endoscopic jejunostomy Priority is prevent Aspiration!!

unsaturated fatty acid

Fatty acid in which an unequal number of hydrogen atoms are attached and the carbon atoms attach to one another with a double bond.

saturated fatty acid

Fatty acid in which each carbon in the chain has an attached hydrogen atom

Enteral Access Tubes

Feeding tubes are inserted through the nose (nasogastric or nasointestinal), surgically (gastrostomy or jejunostomy), or endoscopically (percutaneous endoscopic gastrostomy or jejunostomy [PEG or PEJ]). If EN therapy is for less than 4 weeks, total, nasogastric, or nasojejunal feeding tubes may be used. Surgical or endoscopically placed tubes are preferred for long-term feeding (more than 6 weeks) to reduce the discomfort of a nasal tube and provide a more secure, reliable access. Most health care settings use small-bore feeding tubes because they create less discomfort for a patient. Adult patients typically have an 8- to 12-Fr tube that is 36 to 44 inches (90 to 110 cm) long. It is now standard to use an enteral-only connector (ENFit) designed for the specific enteral tube.

chyme

Food leaves the antrum, or distal stomach, through the pyloric sphincter and enters the duodenum. Food is now an acidic, liquefied mass

Food Safety

Foodborne bacteria can occur from improper food cleaning, preparation, or poor hygiene practices of food workers.

Patients with visual deficits also need special assistance

For example, identify the food location on a meal plate as if it were a clock (e.g., meat at 9 o'clock and vegetable at 3 o'clock). Tell the patient where the beverages are located in relation to the plate. Patients with impaired vision and those with decreased motor skills are more independent during mealtimes with the use of large-handled adaptive utensils.

Health Promotion

Incorporating knowledge of nutrition into patients' lifestyles serves to prevent the development of many diseases. Early identification of potential or actual problems is the best way to avoid serious problems. Often a simple tip is helpful in meal planning such as avoiding grocery shopping when hungry.

Diverticulitis

Inflammation of diverticula Low- to moderate-residue diet for infection High-fiber diet for chronic conditions (to prevent constipation)

Medical Nutrition Therapy: Cancer

Malignant cells compete with normal cells for nutrients. Anorexia, N/V, and taste distortions are common. Radiation causes anorexia, stomatitis, severe diarrhea, intestinal strictures, and pain. Maximize fluid and nutrient intake. Individualize diet choices to patient's needs, symptoms, and situation. Encourage small, frequent meals and snacks that are easy to digest.

Young and Middle Adults

Mature adults need nutrients for energy, maintenance, and repair. Energy needs usually decline over the years.

Screening

Nutrition screening tools gather data on the current condition, stability of the condition, assessment of whether it will worsen, and if the disease process accelerates. These tools typically include objective measures such as height, weight, weight change, primary diagnosis, and the presence of other co-morbidities. Several standardized nutritional screening tools are available for use in outpatient and inpatient settings: Subjective Global Assessment (SGA) uses the patient history, weight, and physical assessment data to assess nutritional status The Mini Nutritional Assessment (MNA) (Figure 45-4) screens older adults in home care programs, nursing homes, and hospitals. Malnutrition screening tools (MSTs) are an effective way to measure nutritional problems for patients in a variety of health care settings.

Parenteral Nutrition

Patients who are unable to digest or absorb EN benefit from PN. Patients in highly stressed physiological states such as sepsis, head injury, or burns are candidates for PN therapy (see Box 45-11). The goal to move toward use of the GI tract is constant. The addition of fat emulsion to a PN solution is called a 3-in-1 admixture or total nutrient admixture. The patient receives it over a 24-hour period. Do not use the admixture if you observe oil droplets or an oily or creamy layer on the surface of the admixture. This observation indicates that the emulsion has broken into large lipid droplets that cause fat emboli if administered. IV fat emulsions are white and opaque.

Advancing Diets

Patients with decreased immune function (e.g., from cancer, chemotherapy, human immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], or organ transplants) require special diets that decrease exposure to microorganisms and are higher in selected nutrients. Table 45-6 provides an overview of the immune system, the impact of malnutrition, and beneficial nutrients. In addition, patients who are ill, who have had surgical procedures, or who were NPO for an extended time have specialized dietary needs.

malnutrition

Screening a patient is a quick method for identifying; is a MEDICAL DIAGNOSIS

intravenous fat emulsions

Soybean- or safflower oil-based solutions that are isotonic and may be infused with amino acid and dextrose solution through a central or peripheral line.

Sample of Drug-Nutrient Interactions

TABLE 45-2 pg1061

Enteral Tube-Feeding Complications

TABLE 45-7 pg1076

Medical Nutrition Therapy: Diabetes

Type 1: insulin and dietary restrictions Type 2: exercise and diet therapy initially Carbohydrate monitoring is key Saturated fat less than 7% Cholesterol intake less than 200 mg/dL Protein intake 15% to 20% of diet Primary goal: Normal to near-normal glucose levels

Advancing the Rate of Tube Feeding

Typically tube feedings start at full strength at slow rates (Box 45-12). Increase the hourly rate every 8 to 12 hours per health care provider's order if no signs of intolerance appear (high gastric residuals, nausea, cramping, vomiting, and diarrhea).

Parenteral Nutritional Support

Used if unable to digest or absorb enteral nutrition; Composition: Calories, protein, electrolytes, vitamins, and trace elements Delivered via PICC or other central line: Confirm placement by X-ray before initiating TPN Monitor for complications: Infection Metabolic problems Mechanical problems

Elimination

Water absorbs in the mucosa as feces move toward the rectum. The longer the material stays in the large intestine, the more water is absorbed, causing the feces to become firmer. Exercise and fiber stimulate peristalsis, and water maintains consistency.

Water

Water is critical because cell function depends on a fluid environment. Water makes up 60% to 70% of total body weight. An ill person has an increased need for fluid (e.g., with fever or gastrointestinal [GI] losses). By contrast, he or she also has a decreased ability to excrete fluid (e.g., with cardiopulmonary or renal disease), which often leads to the need for fluid restriction.

kilocalories (kcal)

When the kilocalories ingested exceed our energy demands, we gain weight. Likewise, if the kilocalories ingested fail to meet our energy requirements, we lose weight.

Fiber

a polysaccharide, is the structural part of plants that is not broken down by our digestive enzymes

Simple carbohydrates

classification for both monosaccharides and disaccharides; they are found primarily in sugars

Fatty acids

composed of chains of carbon and hydrogen atoms with an acid group on one end of the chain and a methyl group at the other

Triglycerides

composed of three fatty acids attached to a glycerol

macrominerals

daily requirement is 100 mg or more

DAT

diet as tolerated

Dysphagia

difficulty swallowing; Complications include aspiration pneumonia, dehydration, decreased nutritional status, and weight loss. Dysphagia leads to disability or decreased functional status, increased length of stay and cost of care, increased likelihood of discharge to institutionalized care, and increased mortality

There are four levels of diet

dysphagia puree, dysphagia mechanically altered, dysphagia advanced, and regular

ideal body weight (IBW)

estimate of what a person should weigh

Measure gastric residual volumes (GRVs)

every 4 to 6 hours in patients receiving continuous feedings and immediately before the feeding in patients receiving intermittent feedings; Delayed gastric emptying is a concern if 250 mL or more remains in a patient's stomach on two consecutive assessments (1 hour apart) or if a single GRV measurement exceeds 500 mL.

Parenteral nutrition (PN)

form of specialized nutrition support provided intravenously. A basic PN formula is a combination of crystalline amino acids, hypertonic dextrose, electrolytes, vitamins, and trace elements. Total PN (TPN), administered through a central line, is a 2-in-1 formula in which administration of fat emulsions occurs separately from the protein and dextrose solution

S and S hyperglycemia

frequent urination, thirsty, dizzy, lethargic

Healthy People 2020

guidlelines for nutritional needs and promotion for general population

outpatient setting

have a patient keep a 3- to 7-day food diary

Monounsaturated fatty acids

have one carbon double bond

polyunsaturated fatty acids

have two or more double carbon bonds

microminerals or trace elements

less than 100 mg is needed daily

Body mass index (BMI)

measures weight corrected for height and serves as an alternative to traditional height-weight relationships. Calculate BMI by dividing a patient's weight in kilograms by height in meters squared: weight (kg) divided by height*2 (m2)

Acute Care

often a patient must refrain from eating or drinking anything by mouth (NPO) as he or she prepares for or recovers from a diagnostic test. Frequent interruptions during mealtimes occur in the health care setting, or patients have poor appetites. Patients often are too tired or uncomfortable to eat.

Vitamins

organic substances present in small amounts in foods that are essential to normal metabolism. They are chemicals that act as catalysts in biochemical reactions; Antioxidant vitamins include beta-carotene and vitamins A, C, and E

malabsorption

poor absorption, syndromes such as celiac disease includes a gluten-free diet. Gluten is present in wheat, rye, barley, and oats. Short-bowel syndrome results from extensive resection of bowel, after which patients suffer from malabsorption caused by lack of intestinal surface area.

Enteral nutrition (EN)

provides nutrients into the GI tract. It is the preferred method of meeting nutritional needs if a patient is unable to swallow or take in nutrients orally yet has a functioning GI tract. EN provides physiological, safe, and economical nutritional support

The North American Summit on Aspiration in the Critically Ill Patient

recommends the following: (1) stop feedings immediately if aspiration occurs; (2) withhold feedings and reassess patient tolerance to feedings if GRV is over 500 mL; (3) routinely evaluate the patient for aspiration; and (4) use nursing measures to reduce the risk of aspiration if GRV is between 250 and 500 mL

S and S of hypoglycemia

shaky, diaphoresis

Feeding a patient with dysphagia

slowly, providing smaller-size bites. Allow him or her to chew thoroughly and swallow the bite before taking another.Allow the patient time to empty the mouth after each spoonful, matching the speed of feeding to the patient's readiness. If he or she begins to cough or choke, remove the food immediately.

Glycogen

synthesized from glucose, provides energy during brief periods of fasting (e.g., during sleep). It is stored in small reserves in liver and muscle tissue.

Catabolism

the breakdown of biochemical substances into simpler substances and occurs during physiological states of negative nitrogen balance

Anabolism

the building of more complex biochemical substances by synthesis of nutrients

Vegetarianism

the consumption of a diet consisting predominantly of plant foods. Some vegetarians are ovolactovegetarian (avoid meat, fish, and poultry but eat eggs and milk), lactovegetarians (drink milk but avoid eggs), or vegans (consume only plant foods). Zen macrobiotic (primarily brown rice, other grains, and herb teas) and fruitarian (only fruit, nuts, honey, and olive oil) diets are nutrient poor and frequently result in malnutrition.

Nutrients

the elements necessary for the normal function of numerous body processes. We meet energy needs through the intake of a variety of nutrients: carbohydrates, proteins, fats, water, vitamins, and minerals.

basal metabolic rate (BMR)

the energy needed at rest to maintain life-sustaining activities (breathing, circulation, heart rate, and temperature) for a specific amount of time

nitrogen balance

the intake and output of nitrogen are equal

lipids

the most calorie-dense nutrient, providing 9 kcal/g. Fats are composed of triglycerides and fatty acids; We also classify fatty acids as essential or nonessential. Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans. Linolenic acid and arachidonic acid, another type of unsaturated fatty acids, are important for metabolic processes. The body manufactures them when linoleic acid is available. Deficiency occurs when fat intake falls below 10% of daily nutrition.

nutrient density

the proportion of essential nutrients to the number of kilocalories

Enzymes

the protein-like substances that act as catalysts to speed up chemical reactions

Medical nutrition therapy (MNT)

the use of specific nutritional therapies to treat an illness, injury, or condition. It is necessary to help the body metabolize certain nutrients, correct nutritional deficiencies related to the disease, and eliminate foods that may exacerbate disease symptoms.

The four levels of liquid

thin liquids (low viscosity), nectarlike liquids (medium viscosity), honeylike liquids (viscosity of honey), and spoon-thick liquids (viscosity of pudding)

TPN

total parenteral nutrition

Hypervitaminosis

toxicity is possible when a person takes large doses of fat-soluble vitamins results from megadoses (intentional or unintentional) of supplemental vitamins, excessive amounts in fortified food, and large intake of fish oils.

water-soluble vitamins

vitamin C and the B complex (which is eight vitamins). The body does not store water-soluble vitamins; thus we need them provided in our daily food intake.

Gold standard for EN placement

x-ray, and then content pH

fat-soluble vitamins

(A, D, E, and K) are stored in the fatty compartments of the body

Laboratory and Biochemical Tests

Common laboratory tests used to study nutritional status include measures of plasma proteins such as albumin, transferrin, prealbumin, retinol-binding protein, total iron-binding capacity, and hemoglobin. After feeding, the response time for changes in these proteins ranges from hours to weeks. The metabolic half-life of albumin is 21 days, transferrin is 8 days, prealbumin is 2 days, and retinol-binding protein is 12 hours. Factors that affect serum albumin levels include hydration; hemorrhage; renal or hepatic disease; large amounts of drainage from wounds, drains, burns, or the GI tract; steroid administration; exogenous albumin infusions; age; and trauma, burns, stress, or surgery. Albumin level is a better indicator for chronic illnesses, whereas prealbumin level is preferred for acute conditions. A positive 2- to 3-g nitrogen balance is necessary for anabolism. By contrast, negative nitrogen balance is present when catabolic states exist.

Preventing Complications of PN

Complications of PN include catheter-related problems and metabolic alterations (Table 45-8). In relation to PN, pneumothorax most often occurs during CVC placement. Monitor a patient with a CVC for the first 24 hours for signs and symptoms of pulmonary distress. An air embolus possibly occurs during insertion of the catheter or when changing the tubing or cap. Turn the patient into a left lateral decubitus position and have him or her perform a Valsalva maneuver (holding the breath and "bearing down") during catheter insertion to help prevent air embolus. Catheter occlusion is present when there is sluggish or no flow through the catheter. Temporarily stop the infusion and flush with saline or heparin per protocol or orders. Suspect catheter sepsis if a patient develops fever, chills, or glucose intolerance and has a positive blood culture. To prevent infection, 1080change the TPN infusion tubing every 24 hours. Do not hang a single container of PN for more than 24 hours or lipids more than 12 hours. Change the administration system every 72 hours when infusing a 2-in-1 solution and every 24 hours for a 3-in-1 solution. PN solutions contain most of the major electrolytes, vitamins, and minerals. Patients also need supplemental vitamin K as ordered throughout therapy. Synthesis of vitamin K occurs by the microflora found in the jejunum and ileum with normal use of the GI tract; however, because PN circumvents GI use, patients need to receive exogenous vitamin K.

Renal Diet

Dietary changes to decrease stress on kidneys; Consists of restricted amounts of: Protein (if not on dialysis) Sodium (2 to 4 Gm/day) Potassium Phosphate Fluids - may be as little as 500 mL/day

Setting Priorities

For example, managing a patient's oral pain will be a priority over the intervention of diet education to improve nutrition if the patient is unable to swallow and maintain adequate food intake. The priority of care is to provide optimal preoperative nutrition support in patients with malnutrition. The priority for the resumption of food intake after surgery depends on the return of bowel function, the extent of the surgical procedure, and the presence of any complications. The priority of care is to first provide comfort and pain control. Then address nutritional priorities and plan care to maintain nutrition that does not cause pain or injury to the healing tissues.

Celiac disease

Gluten-free diet (omit wheat, rye, barley, oats)

Dietary reference intakes (DRIs)

Information on each vitamin or mineral to reflect a range of minimum-to-maximum amounts that avert deficiency or toxicity. There are four components to the DRIs. The estimated average requirement (EAR) is the recommended amount of a nutrient that appears sufficient to maintain a specific body function for 50% of the population on the basis of age and gender. The recommended dietary allowance (RDA) is the average needs of 98% of the population, not the exact needs of the individual. The adequate intake (AI) is the suggested intake for individuals based on observed or experimentally determined estimates of nutrient intakes and used when there is not enough evidence to set the RDA. The tolerable upper intake level (UL) is the highest level that likely poses no risk of adverse health events.

Short bowel syndrome

Intestinal surface decrease Lifetime enteral or parenteral nutrition

Administering Enteral Feedings

Keep HOB elevated 30° at all times Check for correct placement (Box 45-14, p. 1078) Check for gastric residual Administer formula as ordered Infuse slowly and monitor for complications Administer water as ordered Prevent excessive air from entering tube - at all times Medications can also be given via feeding tube

Enteral Tube Feeding

Patients with enteral feedings receive formula via nasogastric, jejunal, or gastric tubes. Patients with a low risk of gastric reflux receive gastric feedings; however, if there is a risk of gastric reflux, which leads to aspiration, jejunal feeding is preferred. Box 45-11 lists indications for tube feeding. After insertion of an enteral tube, it is necessary to verify tube placement by x-ray film examination. An enteral formula is usually one of four types. Polymeric(absorbs whole nutrients) (1 to 2 kcal/mL) includes milk-based blenderized foods prepared by hospital dietary staff or in a patient's home. Modular formulas (3.8 to 4 kcal/mL), are single macronutrient (e.g., protein, glucose, polymers, or lipids) preparations and are not nutritionally complete. You can add this type of formula to other foods to meet your patient's individual nutritional needs. Elemental formulas (1 to 3 kcal/mL), contain predigested nutrients that are easier for a partially dysfunctional GI tract to absorb. Finally, specialty formulas (1 to 2 kcal/mL) are designed to meet specific nutritional needs in certain illness (e.g., liver failure, pulmonary disease, or HIV infection).

Initiating Parenteral Nutrition

Patients with short-term nutritional needs often receive IV solutions of less than 10% dextrose via a peripheral vein in combination with amino acids and lipids. Patients receiving PN at home frequently administer the entire daily solution over 12 hours at night. This allows the patient to disconnect from the infusion each morning, flush the central line, and have independent mobility during the day.

Environmental Factors

Proposed contributing factors for obesity are sedentary lifestyle, work schedules, and poor meal choices often related to the increasing frequency of eating away from home and eating fast food. Environmental factors can limit a person's likelihood of healthy eating and participation in exercise or other activities of healthy living. Lack of access to full-service grocery stores, high cost of healthy food, widespread availability of less healthy foods in fast-food restaurants, widespread advertising of less healthy food, and lack of access to safe places to play and exercise are environmental factors that contribute to obesity

Proteins

Proteins provide a source of energy (4 kcal/g); they are essential for the growth, maintenance, and repair of body tissue. Collagen, hormones, enzymes, immune cells, deoxyribonucleic acid (DNA), and ribonucleic acid (RNA) are all made of protein. In addition, blood clotting, fluid regulation, and acid-base balance require proteins. Proteins transport nutrients and many drugs in the blood. Ingestion of proteins maintains nitrogen balance. A complete protein, also called a high-quality protein, contains all essential amino acids in sufficient quantity to support growth and maintain nitrogen balance. Examples of foods that contain complete proteins are fish, chicken, soybeans, turkey, and cheese. Incomplete proteins are missing one or more of the nine indispensable amino acids and include cereals, legumes (beans, peas), and vegetables. Complementary proteins are pairs of incomplete proteins that, when combined, supply the total amount of protein provided by complete protein sources.

Promoting Appetite

Providing an environment that promotes nutritional intake includes keeping a patient's environment free of odors, providing oral hygiene as needed to remove unpleasant tastes, and maintaining patient comfort. Offering smaller, more frequent meals often helps. In addition, certain medications affect dietary intake and nutrient use. Assess patients for the need for pharmacological agents to stimulate appetite. Mealtime is often a social time, so company may help.

Infants Through School-Age

The American Academy of Pediatrics strongly supports breastfeeding for the first 6 months of life and breastfeeding with complementary foods from 6 to 12 months. Breastfeeding has multiple benefits for both infant and mother, including fewer food allergies and intolerances; fewer infant infections; easier digestion; convenience, availability, and freshness; temperature always correct; economical because it is less expensive than formula; and increased time for mother and infant interaction. Infant formulas contain the approximate nutrient composition of human milk. Cow's milk is too concentrated for an infant's kidneys to manage, increases the risk of milk-product allergies, and is a poor source of iron and vitamins C and E. Adding foods to an infant's diet depends on the infant's nutrient needs, physical readiness to handle different forms of foods, and the need to detect and control allergic reactions. Introducing foods that have a high incidence of causing allergic reaction such as wheat, egg white, nuts, citrus juice, and chocolate should happen later in the infant's life. In addition, caregivers should introduce new foods one at a time, approximately 4 to 7 days apart to identify allergies. It is best to introduce new foods before milk or other foods to avoid satiety

dispensable amino acids

The body synthesizes dispensable amino acids.

Pregnancy

The energy requirements of pregnancy relate to the mother's body weight and activity. The quality of nutrition during pregnancy is important, and food intake in the first trimester includes balanced parts of essential nutrients with emphasis on quality. Protein intake throughout pregnancy needs to increase to 60 g daily. Calcium intake is especially critical in the third trimester, when fetal bones mineralize. Providing iron supplements to meet the mother's increased blood volume, fetal blood storage, and blood loss during delivery is important. Folic acid intake is particularly important for DNA synthesis and the growth of red blood cells. Inadequate intake can lead to fetal neural tube defects, anencephaly, or maternal megaloblastic anemia. Women of childbearing age need to consume 400 mcg of folic acid daily, increasing to 600 mcg daily during pregnancy.

Implementation

The focus of health promotion is to educate patients and family caregivers about balanced nutrition and to help them obtain resources to eat high-quality meals. In acute care your role as a nurse is to manage acute conditions that alter patients' nutritional status and help in ways to promote their appetite and ability to take in nutrients. In the restorative care setting you help patients learn how to follow the therapeutic diets necessary for recovery and treatment of chronic health conditions.

Nursing Diagnoses: Nutrition

The following are nursing diagnoses applicable to nutritional problems: • Risk for Aspiration • Diarrhea • Overweight • Imbalanced Nutrition: Less Than Body Requirements • Readiness for Enhanced Nutrition • Feeding Self-Care Deficit • Impaired Swallowing • Obesity

The Goal of PN Feeding

The goal is to move patients from PN to EN and/or oral feeding. Once patients are meeting one third to one half of their kilocalorie needs per day, health care providers usually decrease PN by half the original volume and increase EN feedings to meet the patient's nutritional needs. Patients who make the transition from PN to oral feedings typically have early satiety and decreased appetite. Gradually decrease PN in response to increased oral intake. When meeting 75% of nutritional needs by enteral feedings or reliable dietary intake, it is usually safe to discontinue PN therapy.

Lactation

The lactating woman needs 500 kcal/day above the usual allowance because the production of milk increases energy requirements. Protein requirements during lactation are greater than those required during pregnancy. There is an increased need for vitamins A and C. Daily intake of water-soluble vitamins (B and C) is necessary to ensure adequate levels in breast milk. Excretion of caffeine, alcohol, and drugs occurs through breast milk.

amino acid

The simplest form of protein

Warning Signs for Dysphagia

They include cough during eating; change in voice tone or quality after swallowing; abnormal movements of the mouth, tongue, or lips; and slow, weak, imprecise, or uncoordinated speech. Abnormal gag, delayed swallowing, incomplete oral clearance or pocketing, regurgitation, pharyngeal pooling, delayed or absent trigger of swallow, and inability to speak consistently are other signs of dysphagia. Patients with dysphagia often do not show overt signs such as coughing when food enters the airway.

Anthropometry

a measurement system of the size and makeup of the body. Nurses obtain height and weight for each patient on hospital admission or entry into any health care setting. If you are not able to measure height with the patient standing, position him or her lying flat in bed as straight as possible with arms folded on the chest and measure him or her lengthwise. Serial measures of weight over time provide more useful information than one measurement. Weigh the patient at the same time each day, on the same scale, and with the same type of clothing or linen. Rapid weight gain or loss is important to note because it usually reflects fluid shifts. One pint or 500 mL of fluid equals 1 lb (0.45 kg). For example, for a patient with renal failure, a weight increase of 2 lbs (0.90 kg) in 24 hours is significant because it usually indicates that the patient has retained 1 L (1000 mL) of fluid. These include the ratio of height-to-wrist circumference, mid-upper arm circumference (MAC), triceps skinfold (TSF), and mid-upper arm muscle circumference (MAMC). An RD compares values for MAC, TSF, and MAMC to standards and calculates them as a percentage of the standard.

Metabolism

all of the biochemical reactions within the cells of the body. Metabolic processes are anabolic (building) or catabolic (breaking down).

Carbohydrates

are the main source of energy in the diet; Each gram of carbohydrate produces 4 kcal/g and serves as the main source of fuel (glucose) for the brain, skeletal muscles during exercise, erythrocyte and leukocyte production, and cell function of the renal medulla. We obtain carbohydrates primarily from plant foods, except for lactose (milk sugar).

Silent aspiration

aspiration that occurs in patients with neurological problems that lead to decreased sensation. It often occurs without a cough, and symptoms usually do not appear for 24 hour. Silent aspiration accounts for most of the 51% to 78% of aspiration in patients with dysphagia following stroke

daily values

based on percentages of a diet consisting of 2000 kcal/day for adults and children 4 years or older; he FDA first established two sets of reference values. The referenced daily intakes (RDIs) are the first set, comprising protein, vitamins, and minerals based on the RDA. The daily reference values (DRVs) make up the second set and consist of nutrients such as total fat, saturated fat, cholesterol, carbohydrates, fiber, sodium, and potassium. Combined, both sets make up the daily values used on food labels

saccharides

carbohydrate units

Dysphagia screening

includes medical record review; observation of a patient at a meal for change in voice quality, posture, and head control; percentage of meal consumed; eating time; drooling or leakage of liquids and solids; cough during/after a swallow; facial or tongue weakness; palatal movement; difficulty with secretions; pocketing; choking; and a spontaneous dry cough. A number of validated screening tools are available such as the Bedside Swallowing Assessment, Burke Dysphagia Screening Test, Acute Stroke Dysphagia Screen, and Standardized Swallowing Assessment

Minerals

inorganic elements essential to the body as catalysts in biochemical reactions; Macrominerals help to balance the pH of the body

Key Points

• Ingestion of a diet balanced with carbohydrates, fats, proteins, vitamin, and minerals provides the essential nutrients to carry out the normal physiological functioning of the body throughout the life span. • Through digestion food is broken down into its simplest form for absorption. Digestion and absorption occur mainly in the small intestine. • Guidelines for dietary change recommend reduced fat, saturated fat, sodium, refined sugar, and cholesterol and increased intake of complex carbohydrates and fiber. • Because improper nutrition affects all body systems, nutritional assessment includes a review of total physical assessment. • Enteral feedings are for patients who are unable to ingest food but are able to digest and absorb food in the gastrointestinal tract. • EN protects intestinal structure and function and enhances immunity. • TPN supplies essential nutrients in appropriate amounts to support life through the administration of a concentrated nutrient solution into the superior vena cava near the right atrium of the heart. • MNT is a recognized treatment modality for both acute and chronic disease states. • One of the most important responsibilities of a nurse administering enteral feedings is to take precautions to prevent patients from aspirating feeding formula. • Special diets alter the composition, texture, digestibility, and residue of foods to suit the patient's particular needs.

Safety Guidelines for Nursing Skills

• Verify that the appropriate ENFit connector is attached to the enteral tube when administering tube feedings. • Use aseptic technique when preparing and delivering enteral feedings. Check agency policy for wearing gloves when handling feedings. • Label enteral equipment with patient name and room number; formula name, rate, and date and time of initiation; and nurse initials. • Practice "right patient, right formula, right tube, right ENFit adaptor" by matching formula and rate to feeding order and verifying that enteral tubing set connects formula to a feeding tube. • Position the patient upright or elevate the head of the bed a minimum of 30 (preferably 45) degrees unless medically contraindicated for patients receiving enteral feedings. • Trace all lines and tubing back to the patient to ensure only enteral-to-enteral connections (Stewart, 2014). • Do not add food coloring or dye to EN because the use of dye has been linked to hypotension, metabolic acidosis, and death. • Refer to manufacturer guidelines to determine hang time for enteral feedings. Maximum hang time for formula is 8 hours in an open system and 24 to 48 hours in a closed, ready-to-hang system (if it remains closed). There is increased risk of bacterial growth in feedings that exceed the recommended hang time. • Always use an infusion pump for continuous enteral feedings and PN.