Nursing 120 - Exam 3

Lab Data to Evaluate Protein:

* It takes more than 1 lab test to evaluate a person's nutritional status! ---> Pre-Albumin: accurate view of current protein metabolism. - half-life is 2-3 days. - normal value = 18-36 - severe depletion = 0-5 - moderate depletion = 5-10 - mild depletion = 10-15 ---> Albumin: main protein in blood. - levels decrease with malnutrition, burns, hemorrhage, kidney disease, & chronic disease. - normal value = 3.1-4.3 (ATI says 3.5-5) ---> Transferrin: - half-life is 8 days. - normal value = 240-360 mg/dl - responds quickly to changes in protein intake. - increases with iron deficiency. - decreases with protein deficiency.

Mineral sources:

1) Calcium is found in: - milk, yogurt, fish, green leafy vegetables. 2) Sodium is found in: - table salt, processed foods. 3) Potassium is found in: - fruits, veggies, nuts, legumes. 4) Magnesium is found in: - nuts, whole grains, dried fruits. 5) Phosphorus is found in: - fish, milk, cheese, dried beans, nuts. 6) Iron is found in: - liver, red meats, grains, lentils/beans, iron cookware. 7) Iodine is found in: - iodized salt, seafood. 8) Fluoride is found in: - fluorinated water, toothpaste, dental treatments. 9) Zinc is found in: - shellfish, meats, liver, eggs, whole grains. 10) Selenium is found in: - seafood, whole grains, meat.

nutrition across the lifespan:

1) Infants: start introducing solid foods at 4-6 months old. 2) Toddlers/preschoolers: drinking whole milk until 2 years old. 3) School age children: important for children to have a health breakfast. 4) Adolescent: eating disorders often develop, important for family/friends support; caloric needs depend on activities, athlete vs. non-athlete. 5) Adults: need nutrition for energy, maintenance & repair; lack of physical activity & decreased metabolism can lead to obesity. 6) Pregnancy: good nutrition important before & during pregnancy; during lactation, need more kcals than normal. 7) Older Adults: decreased metabolic rate, & need less calories; however, vitamin & mineral requirements stay the same.

nutrient density

refers to the proportion of essential nutrients to the number of kilocalories.

Which action can a nurse delegate to assistive personnel (AP)?

- performing glucose monitoring every 6 hours on a patient.

Factors affecting nutrition:

- lifespan. - lifestyle/culture. - disease. - economics. - preferences. - medications.

key recommendations for a healthy eating plan:

*** A healthy eating plan... - consume a variety of fruits & veggies. - consume grains, half of which being "whole grains". - fat free or low-fat dairy products; soy substitute. - variety of protein sources: lean meat, seafood, eggs, poultry, legumes, nuts, seeds, soy. - use healthy oils instead of solid fats like butter, lards, or shortening. *** A healthy eating plan limits saturated fats, trans fats, added sugars, & sodium... - less than 10% of calories per day from added sugars. - less than 10% of calories per day from saturated fats (no limit on total fat intake). - less than 2300 mg of sodium per day. - no more than 1 alcoholic drink for women per day. - no more than 2 alcoholic drinks for men per day.

Which statement made by the parents of a 2 month old infant requires further education by the nurse?

- "I'm going to alternate formula with whole milk, starting next month."

Fat Soluble Vitamin sources:

- A, D, E, K - they require the presence of fats to be absorbed. - they are stored in fats, & excess can lead to toxicity -----> hypervitaminosis! --> Vitamin A is found in... - liver, deep yellow & green leafy vegetables, fruits. --> Vitamin D is found in... - sun exposure, milk, fatty fish, cereal. --> Vitamin E is found in... - plant oils, whole grain breads, wheat germ, sweet potatoes. --> Vitamin K is found in... - egg yolk, liver, green leafy vegetables.

Nutritional Assessment:

- Adequate nutrition/malnutrition. - Protein status. - vitamins/minerals. - diet history. - 24 hour recall of intake. - food frequency. - keeping a food journal; use of phone Apps. - nutrient composition method; consider food allergies, economics, culture, ethnicity.

Physical Activity Recommendations:

- Americans of all ages should meet the physical activity guidelines for Americans to promote health & prevent disease. --> Adults: 2.5 hours per week of moderate activity; 1 hour & 15 mins per week of vigorous activity. - aerobic activity should be at least 10 minutes. - additional health benefits by increasing to 5 hours per week of moderate activity, & 2.5 hours per week of vigorous activity. - adults should incorporate muscle strengthening activities involving 2 or more major muscle groups 2 or more days a week.

Diet & Disease Prevention: Immune Function & Infection

- B6, B12, folic acid, niacin, vitamin E & C, iron, & zinc. - consuming adequate protein. - keep cold foods cold, hot foods hot: to appropriate room temperature. - food safe measures to prevent bacterial contamination, food borne illness.

Diet Modifications:

- NPO: nothing by mouth; Dr.'s orders. - Clear Liquids: apple juice, coffee, water; NO pulp juices. - Full Liquids: soups, juices with pulp. - Pureed: consistency of baby food. - Mechanical Soft: regular food that is softened. - Regular: normal diet. - Disease Specific: a diet that is special for cardiac, renal, or diabetic patients.

A nurse sees an assistive personnel (AP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse?

- Placing client supine while giving a bath.

Factors affecting nutritional absorption:

- alcohol consumption. - liver function. - renal function. - decreased GI peristalsis. - decreased HLC & digestive enzymes. - GI disorders. - polypharmacy & chronic medication use. - diseases/pathological processes.

Vitamin C

- also known as ascorbic acid. - biosynthesis of collagen, protein metabolism, wound healing, epinephrine/norepinephrine, & steroid hormones. - it's an antioxidant; builds up the immune system to fight infection & disease. - vitamin c deficiency can cause bruising, petechiae, bleeding gums, scurvy. - at risk for vitamin c deficiency if smoker, poor fruit & veggie intake, alcoholic, stress, illness, & oral contraceptives. * water-soluble. * can reduce the risk of stress from certain diseases such as cancers & cardiovascular disease.

A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection?

- change the dressing using sterile technique. - change the TPN tubing every 24 hours.

Carbohydrates

- composed of carbon, hydrogen, and oxygen. - main source of energy in your diet. - 45-65% of our total daily intake. - each gram of carbohydrate produces 4 kcal/g. - glucose is the end product of carbohydrate metabolism. - simple carbs = monosaccharides & disaccharides. - complex carbs = polysaccharides, starch, fiber, glycogen. - serves as the main source of fuel for brain, skeletal muscles during exercise, erythrocyte & leukocyte production, & cell function of renal medulla.

A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume in 4 hours was 125 mL. What is the priority nursing intervention?

- continue the feedings; this is normal gastric residual for this feeding.

Respiratory Disease & Nutrition:

- decreased nutritional intake related to fatigue, poor appetite, discomfort, shortness of breath, smoking alters taste buds. - requires increased calories related to increased work of breathing. - often in a catabolic state, which could cause anorexia. - could have GI distress: malnutrition, decreased GI muscle mass, decreased GI structure & decreased peristalsis. - normally, we need 36-72 kcal to breathe. - late stage COPD patients need up to 430-720 kcal to breathe. - respiratory patients retain CO2, so the goal is to reduce CO2: fat calories produce less CO2 than carbs, so a higher fat diet is recommended for these patients.

nutrients

- elements necessary for the normal function of numerous body processes.

A client who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What should be the nurse's priority action?

- have the patient turn on the left side and perform a Valsalva maneuver.

Energy balance

- in order to have a stable body weight, you must have an equal energy balance. - energy content in food is measured by kilocalories. - REE/BMR (kilocalories needed to maintain all of the body's functions at rest). - energy allowances (how much extra energy you need) is affected by physical activity, growth spurts, pregnancy, or illness.

Other Diet Modifications:

- lactose free. - vegetarian, vegan, pescatarian. - cancer. - high fiber. - gluten free. - renal diets: help monitor protein intake; chronic kidney disease, renal calculi. - high protein. - low sodium. - low cholesterol. - peptic ulcer. - low residue: good for irritable bowel syndrome patients. - consistent carbohydrate diet: ADA diabetic.

Proteins

- provide a source of energy. - 1 gram = 4 kcal/g. - essential for the growth, to build muscle, & repair damaged muscle tissue. - collagen, hormones, enzymes, immune cells, DNA, & RNA are all made of protein. - blood clotting, fluid regulation, & acid-base balance requires proteins. - proteins transport nutrients & many drugs in the blood. - recommended daily allowance (RDA) varies 10-35%: -> women 46 g/day. -> men 56 g/day. - healthy adults = 0.8/kg of ideal body weight (IBW). - 9 essential amino acids (AA) need to be consumed: -> incomplete proteins = lack one or more essential AA. -> complete proteins = contain all 9 AA. - maintains nitrogen balance: -> you go into negative balance (anabolic metabolism) with burns, fever, starvation, head injury, & trauma. -> you go into positive balance (catabolic metabolism) with growth spurts, etc.

Metabolism

- regulated by hormones in the thyroid. - biochemical reactions within the cells (2 types): 1) Anabolic (building): - uses energy to build protein, triglycerides, & glucose. 2) Catabolic (breaking): - break down of large molecules in order to release energy.

The nurse is caring for a client with pneumonia, who has severe malnutrition. The nurse should assess the patient for which of the following assessment findings?

- sepsis. - hemorrhage. - skin breakdown.

The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition?

- serum total protein. - serum BUN.

The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention?

- stop feeding her.

Lipids

- the most calorie dense element. - 1 gram = 9 kcal. - necessary for energy, transport of fat-soluble vitamins, & promotes absorption of nutrients. - recommended daily allowance (RDA) is 20-30%; only 10% of that should be saturated fat. - Cholesterol: -> LDL (low density, "bad cholesterol"). -> HDL (high density, "good cholesterol"). ---> TYPES... 1) Unsaturated fat: - mono = one carbon to one carbon double bond. - poly = multiple carbon to carbon double bonds (omega 3, & omega 6 fatty acids). 2) Saturated fat: - solid at room temperature. - no carbon to carbon double bonds. 3) Hydrogenated fat. 4) Trans fatty acids.

A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request a discontinuation of parenteral nutrition?

- when 75% of the patient's nutritional needs are met by the tube feedings.

USDA Dietary Guidelines:

---> 5 main focuses: 1) follow a healthy eating pattern throughout the lifespan. 2) focus on food variety, nutrient density & quantity. 3) limit calories from added fats, sugars, & sodium intake. 4) shift to healthier food & beverage choices. 5) create & support healthy eating for all.

Disease Prevention Diet: Cardiovascular Disease

---> Cardiovascular Disease - CAD (coronary artery disease): - weight control, increase lean body mass = exercise. - consume omega-3 fatty acids: salmon, flaxseed, walnuts, almonds, soy. - consume vitamins E & C, Lipoic acid. - reduce saturated fats: choose nonfat dairy; avoid fried food, high fat packaged food, & solid fats. - consume monosaturated fats: olive oil, canola oil. - consume 4-8 ounces red grape juice/wine daily. - consume fiber: legumes, oats, barley apples, broccoli. - consume complex carbohydrates. - consume dark chocolate: at least 70% cacao.

Labs to Indicate O2 Carrying Ability:

---> Hemoglobin (HGB): - decreased in iron deficiency & other anemias. - may drop after surgery, trauma, & other illnesses. - patient will need a blood transfusion if < 7, or if patient is symptomatic. ---> Hematocrit (HCT): - % of red blood cells in the blood. - can be a function of nutrition, especially protein intake. ---> Serum Iron: - amount of iron bound to transferrin. - decreases with iron deficiency. ---> Total Iron Binding Capacity: - measurement of proteins available to bind with iron.

Nutritional Supplements:

---> Oral: - Ensure shakes - Nephro shakes - Boost - Glucerna shakes: for diabetic - Magic Cup: high protein ice cream ---> Enteral (j/g tube, PEG, small bored feeding tube (DHT)): - Jevity - Osmolite - Nutren ---> Parental (PPN, TPN): - nutrition that goes through an IV. - special blend of amino acids, proteins, & fats prepared in pharmacy. - appropriate for patients that have loss of GI function.

Disease Prevention Diet: Cancer

---> Risk Factors: - fat, alcohol, pickled & smoked foods, cooking meat at high temperatures. - chemical exposure from cooking in plastic containers, plastic wrap, Styrofoam, BPA. - pesticides, toxins. - mercury levels & toxins in seafood. ---> Protective Factors: - vitamin A, C, E, carotene. - selenium calcium. - fiber, fruits, cruciferous vegetables. - soy, lycopene, green tea.

Other Lab Indicators to Determine Nutrition:

---> Total Lymphocyte Count: - decreases with protein depletion. ---> Blood Urea Nitrogen (BUN): - a measurement of nitrogen (N2) breakdown. - urea is the breakdown of amino acids. - normal value = 8-18 - may be decreased with inadequate protein intake. ---> Ketones: - measured in urine or blood. - presence of ketones indicates anaerobic metabolism & breakdown of muscle, proteins. - found in low carb diets & diabetics that have an insulin deficiency.

Vitamins & Minerals

---> VITAMINS: - organic substances found in small amounts in food. - essentail to normal metabolism. - 2 types; fat-soluble & water-soluble. * Fat-soluble = stored in fatty areas of the body; have to be careful because they can build up in mega doses, known as hypervitaminosis; A, D, E, K. * Water-soluble = body does not store them; they are needed daily; C, B-complex (made of 8 vitamins). ---> MINERALS: - inorganic elements that act as catalysts to initiate biochemical reactions in the body. - present in variety of food; often foods are fortified with extra minerals. - too much can cause toxicity. - deficiency in minerals can cause enlarged thyroid (goiter), osteoporosis, muscle weakness. - minerals can interact; an excess of one can cause a deficiency of another! * Micro-minerals ( > 100 mg/day).

Mediterranean Diet:

---> a contemporary approach to delicious, healthy eating. - a variety of fruits, veggies, whole grains, olive oils, beans, nuts, legumes, seeds, herbs & spices as the basis for the diet. - fish & seafood often, & lots of water. - poultry, eggs, cheese, yogurt, & wine in moderation. - limiting meats & sweets.

Dash Diet:

---> a dietary approach to stop hypertension. - focus is on consuming fruits & veggies, then grains. - switching to low fat dairy & lean meats. - using healthy oils. - limiting sweets.

Vitamin B sources:

---> support the body's metabolism & help produce energy. --> 8 well known B vitamins... 1) B6: - helps produce insulin, fight infection, & create non-essential amino acids. 2) Folate: - also called folic acid. - reduces the risk for spine & brain deformities. - important for before & during pregnancy. 3) B12: - helps create red blood cells. - deficiency can cause anemia. 4) Thiamin. 5) Niacin. 6) Riboflavin. 7) Pantothenic Acid. 8) Biotin. * water-soluble vitamins. * found in yogurt, milk, breads, cheeses, lean meats, eggs, almonds, peanut butter. * vegans/vegetarians may have to take additional supplements, specifically B12.

Insulin Resistance:

---> when both blood glucose & insulin levels increase. - insulin puts glucose into the cells, & cells become resistant due to the lack of receptors or faculty sites. - caused by inactivity & obesity. - is a risk factor for all cancers, type 2 diabetes, & coronary artery disease. - having an apple shaped body increases the risk.

Digestion

--> Breakdown of food substances into simpler forms that can be absorbed and used. * starts in the GI tract - each part has a function! 1) Mechanical process of breaking down food: - mastication & swallowing. - peristalsis. 2) Chemical processes: - enzymes (protein like substances). - secretions (saliva). 3) End products: - carbohydrates (monosaccharides). - fat (fatty acids, glycerol). - proteins (amino acids).

Other Nutrient Requirement Calculations:

--> Grams of Protein/day = IBW in kg x 0.8 --> Grams of Carbs/day = (kcal/day x 0.55) / 4 --> Grams of Fat/day = (kcal/day x 0.3) / 9 *requirements may increase with metabolic needs!

Harris Benedict Equation: Resting Energy Expenditure (REE) & Total Energy Expenditure (TEE)

--> Harris Benedict Equation: used to calculate kilocalorie needs for hospitalized/non-hospitalized patients. * Step 1: find the REE... - Male formula = 66 + 13.7 (weight in kg) + 5 (height in cm) - 6.8 (age) - Female formula = 655 + 9.6 (weight in kg) + 1.7 (height in cm) - 4.7 (age) * Step 2: TEE (REE x AF)... - multiply the REE by an activity factor! ~ light or no activity = 1.2 ~ light activity = 1.375 ~ moderate activity = 1.55 ~ very active = 1.9 * Step 3: multiply (REE x AF x SF)... - multiply REE by AF by stress factor! ~ surgery = 1.1-1.3 sf ~ anabolism = 1.5-1.75 sf ~ fever; each degree over 98.6 = 1.07 sf ~ cancer = 1.6 sf ~ soft tissue trauma = 1.14-1.37 sf ~ long bone fracture; depends on % of bone broken = 1.6-1.85 sf ~ peritonitis = 1.2-1.5 sf ~ major sepsis = 1.4-1.8 sf ***only use stress factor for the hospitalized & acutely ill patient!!!

Drug & Nutrition Interactions:

--> Patients at risk for these interactions include... - polypharmacy patients. - those with poor nutrition. - chronic drug users. - alcohol users. - high potency vitamin/mineral supplement users. - the elderly. *** JCAHO requires that patients receive info on medications that have nutrition interactions, & that a nutritional screen is performed.

Anthropometric Measurements:

--> Use height/weight to get ideal body weight (IBW) = rule of 5's for women, rule of 6's for men... - ex: women 5 feet tall = 100 lbs, add 5 lbs for every inch (5'3 woman = 115 lbs). - ex: men 5 feet tall = 106 lbs, add 6 lbs for every inch (5'3 man = 124 lbs). --> Body Mass Index (BMI) = weight in kg/(height in meters)^2 --> Skinfold measurements (use of calipers) = used on triceps & abdomen. --> Mid-upper arm circumference measurements. --> Waist to Hip ratio (inches) = > .8 women & > .95 in men increases the risk for cardiovascular disease. --> Waist Circumference (inches) = > 35 women & > 40 men increases risk for cardiovascular disease. *** in regards to the body, 500 mL of water = 1 lb! *** rapid weight loss/gain = can mean fluid shifts within a patient's body.

Plant Stanols (PSter) & Sterols (Pstan):

--> cholesterol like compounds derived from plant-based foods. - also known as phytosterols. - includes vegetable oils, vegetable oil-based spreads such as smart balance butter, some orange juices, foods enriched with PSS. * research shows that these foods can help level LDL (bad cholesterol) levels.

Nutrition health promotion:

--> food guide pyramid 2020; dietary guidelines for Americans. - promotes weight management, healthy eating patterns, exercise, understanding food labels. - educates about disease prevention/management; DASH diet, Mediterranean diet.

Absorption

--> movement of the end products of digestion into the circulatory & lymphatic systems. * Small Intestine (ileum) is the primary absorption site: - villi & microvilli help digestion move along. - 85-95% of water is absorbed in the small intestine. * some minerals, electrolytes, & water are absorbed in the large intestine.

Essential Nutrients:

--> nutrients not produced by the body, but are needed for life function: 1) carbohydrates 2) proteins 3) fats 4) minerals 5) vitamins

Resting energy expenditure (REE) or resting metabolic rate

--> the amount of energy you need to consume over a 24 hour period for your body to maintain all of its internal working activities while at rest. --> the energy needed at rest to maintain life sustaining activities (breathing, circulation, heart rate, temperature) for a specific amount of time. * also known as basal metabolic rate (BMR). - BMR / REE are affected by age, gender, growth, body size/composition, genetics, climate, thermic effect.

Total Energy Expenditure (TEE)

--> total amount of energy used by the body each day. TEE = resting energy expenditure + physical activity

Mifflin-St. Joer: Alternative REE Calculation:

-A = age in years -W = weight in kilograms -H = height in centimeters --> formula for men: REE = (9.99 x W) + (6.25 x H) - (4.92 x A) + 5 --> formula for women: REE = (9.99 x W) + (6.25 x H) - (4.92 x A) - 161 **once REE is calculated, multiply by activity & stress factors!

How many calories do we need each day?

1) Newborn: 100-120 kcal/kg/day. 2) Infant: 90-110 kcal/kg of body weight. 3) Children: Preschool = about 1300-1500 kcal/day. 6-8 years old = 1800 kcal/day. 4) Adolescents (adjusted by gender after 9 years old): Female = 2000 kcal/day. Male = 3000-4000 kcal/day. 5) Adults: age 19-30 females = 2000 kcal. age 19-30 males = 2400 kcal. age 31-50 females = 1800 kcal. age 31-50 males = 2200 kcal. age 51+ females = 1600 kcal. age 51+ males = 2000 kcal.

food security

A condition in which all members of a household have access to sufficient, safe, and nutritious food that meets their dietary needs for an active and healthy lifestyle.

Medications that may cause specific symptoms: MEDICATIONS: 1. Decongestants, Stimulants, antihistamines, antineoplastic, bulk forming laxatives. 2. Corticosteroids, antidepressants, megace. 3. Lithium, ACE inhibitors, antibiotics. 4. NSAIDS, ASA, Fe, antibiotics. 5. Laxatives. 6. K+ replacement, antacid use, H2/gastric pump inhibitors. 7. Lipid lowering agents, mineral oil. 8. Anti-gout, antineoplastics, methotrexate, alcohol. 9. corticosteroids. 10. warfarin, antibiotics. 11. opioids, antipsychotics. 12. corticosteroids, oral contraceptives.

SYMPTOMS THEY CAUSE: 1. decreased appetite. 2. increased appetite. 3. smell, taste changes. 4. gastric irritation. 5. luminal changes, increased peristalsis. 6. luminal changes, gastric pH. 7. luminal changes, complex. 8. damaged mucosa. 9. alterations in metabolism. 10. interfere with vitamin metabolism. 11. decrease peristalsis, increase cholesterol absorption. 12. depletion of ascorbic acid.

BMI & Kcal/day example:

You have a 45 year old female, she is 135 lbs (61.3 kg), she is 5'5" (165.1 cm; 65 inches), she is moderately active. Calculate her BMI & Kcals/day... --> BMI = weight in kg / (height in meters)^2 SO 65 inches x .025 = 1.63 meters THEN 61.3 kg / (1.63 meters)^2 = 23 BMI --> Female REE = 655 + 9.6 (weight in kg) + 1.7 (height in cm) - 4.7 (age) SO 655 + 9.6 (61.3 kg) + 1.7 (165.1 cm) - 4.7 (45 years old) = 1,312.65 REE THEN 1,312.65 x 1.6 moderate activity = 2,100 kcal/day

Example: calculating grams of protein, carbs, & fat / day

You have a 50 year old female, she is 5'6" (167.6 cm), she is 140 lbs (63.6 kg), her IBW is 130 lbs (59.1 kg). Calculate her required grams of protein, carbs, & fat / day... ---> Grams of protein/day = IBW in kg x 0.8 SO 59.1 kg x 0.8 = 47.3 g protein/day ---> Grams of carbs/day = (kcal/day x 0.55) / 4 SO (2105 kcal/day x 0.55) / 4 à1,158 / 4 = 289 g carbs/day ---> Grams of fat/day = (kcal/day x 0.3) / 9 SO (2105 kcal/day x 0.3) / 9 à631.5 / 9 = 70.2 g fat/day