CH 45

Judaism Pork Predatory fowl Shellfish (eat only fish with scales) Rare meatsBlood (e.g., blood sausage) Mixing of milk or dairy products with meat dishesMust adhere to kosher food preparation methods24 hr of fasting on Yom Kippur, a day of atonement No leavened bread eaten during Passover (8 days) No cooking on the Sabbath from sundown Friday to sundown Saturday

Religious Dietary Restrictions

Muslim Pork AlcoholCaffeineRamadan fasting sunrise to sunset for a month Ritualized methods of animal slaughter required for meat ingestion

Religious Dietary Restrictions

Seventh-Day Adventists Church Pork Shellfish Fish Alcohol Caffeine Vegetarian or ovolactovegetarian diets encouraged

Religious Dietary Restrictions

A patient will have a _______ nursing diagnosis when assessment reveals risk factors. For example, Risk for Overweight can be identified by the presence of risk factors such as excessive alcohol consumption or high frequency of eating restaurant food and adult BMI approaching 25 kg/m . Be specific so you can direct interventions toward risk factors. Defining characteristics may also point to a health promotion diagnosis such as Readiness for Enhanced 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

risk

Absorption of carbohydrates, protein, minerals, and water-soluble vitamins occurs in the small intestine and are then processed in the liver and released into the portal vein circulation. Fatty acids are absorbed in the lymphatic circulatory systems through lacteal ducts at the center of each microvilli in the small intestine.

Absorption

The small intestine, lined with fingerlike projections called villi, is the primary absorption site for nutrients. Villi increase the surface area available for absorption. The body absorbs nutrients by means of passive diffusion, osmosis, active transport, and pinocytosis (Table 45-1).

Absorption

The body is unable to digest some polysaccharides because we do not have enzymes capable of breaking them down. Fiber, a polysaccharide, is the structural part of plants that is not broken down by our digestive enzymes. The inability to break down fiber means that it does not contribute calories to the diet. Therefore insoluble fibers, including cellulose, hemicellulose, and lignin, are not digestible. Soluble fibers dissolve in water and include barley, cereal grains, cornmeal, and oats.

Carbohydrates

Successful critical thinking requires a synthesis of knowledge, experience, information gathered from patients, critical thinking attitudes, and intellectual and professional standards. Clinical judgments require you to anticipate information, analyze the data, and make decisions regarding your patient's care. During assessment consider all elements that build toward making an appropriate nursing diagnosis (Figure 45-3). Integrate knowledge from nursing and other disciplines, previous experiences, and information gathered from patients and families regarding customary food preferences and recent diet history. Use of professional standards such as the DRIs, the USDA MyPlate dietary guidelines, and Healthy People 2020 objectives provide guidelines to assess and maintain patients' nutritional status. Other professional standards by the AHA (2010), the American Diabetes Association (ADA, 2012), The ACS (2015), and the American Society for Parenteral and Enteral Nutrition (National Guideline Clearinghouse, 2013) are available. These standards are evidence based and regularly updated for optimal patient care.

Critical Thinking

Schools, Work Sites, and Nutrition Counseling • Increase work-site nutrition-education and weight-management program offerings. • Offer nutrition assessment and individualized planning at primary care sites. • Increase the percentage of schools that offer nutritious foods and beverages outside of school meals. • Increase the number of states with nutrition standards for food and beverages provided to preschool-age children in child care.

Examples of Nutrition Objectives for Healthy People 2020

Food Security • Increase food security to 94% of households.

Examples of Nutrition Objectives for Healthy People 2020

Allergies • Are you allergic to any foods? • Which types of problems do you have with these foods? • How are these food allergies treated (e.g., EpiPen, oral antihistamines)?

Nursing Assessment Questions

Assess patients for malnutrition when they have conditions that interfere with their ability to ingest, digest, or absorb adequate nutrients. Use standardized tools to assess nutrition risks when possible. Congenital anomalies and surgical revisions of the GI tract interfere with normal function. Patients receiving only an IV infusion of 5% or 10% dextrose are at risk for nutritional deficiencies. Chronic diseases or increased metabolic requirements are risk factors for development of nutritional problems. Infants and older adults are at greatest risk.

Screening

Hinduism All meats Fish, shellfish with some restrictions Alcohol

Religious Dietary Restrictions

Gluten Free Eliminates wheat, oats, rye, barley and their derivatives

Diet Progression and Therapeutic Diets

Key Recommendations for the General Population • Adopt a healthy eating pattern at an appropriate calorie level with a variety of nutrient-dense food and beverages among all the food groups. • Maintain body weight in a healthy range. • Encourage physical activity and decrease sedentary activities. • Encourage fruits, vegetables, whole-grain products, seafood, and fat-free or low-fat milk. • Eat a variety of proteins, including lean meats, seafood, poultry, eggs, legumes, nuts, seeds, and soy products. • Limit saturated fats and trans fats, consuming less than 10% of calories per day from saturated fats. • Limit added sugar or sweeteners so that less than 10% of calories are from added sugars. • Consume less than 2300 milligrams (mg) of sodium per day. • Choose and prepare foods with little salt and eat potassium-rich foods. • Limit intake of alcohol to moderate use (i.e., one drink daily for women and two drinks daily for men). • Practice food safety to prevent bacterial foodborne illness. Use food-safety principles of Clean, Separate, Cook, and Chill.

2015-2020 Dietary Guidelines for Americans

An enteral formula is usually one of four types. Polymeric (1 to 2 kcal/mL) includes milk-based blenderized foods prepared by hospital dietary staff or in a patient's home. The polymeric classification also includes commercially prepared whole-nutrient formulas. For this type of formula to be effective, a patient's GI tract needs to be able to absorb whole nutrients. The second type, 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. The third type, 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). Typically tube feedings start at full strength at slow rates (see Skill 45-3 on pp. 1090-1094; 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). Studies have demonstrated a beneficial effect of enteral feedings compared with PN. Feeding by the enteral route reduces sepsis, minimizes the hypermetabolic response to trauma, decreases hospital mortality, and maintains intestinal structure and function (Khalid et al., 2010). EN is successful within 24 to 48 hours after surgery or trauma to provide fluids, electrolytes, and nutritional support. If the patient develops a gastric ileus, it prevents instituting nasogastric feedings. Nasointestinal or jejunal tubes allow successful postpyloric feeding because the formula instills directly into the small intestine or jejunum or beyond the pyloric sphincter of the stomach (Hodin et al., 2014).

An enteral formula

Approximately 85% to 90% of water is absorbed in the small intestine (McCance et al., 2013). The GI tract manages approximately 8.5 L of GI secretions and 1.5 L of oral intake daily. The small intestine resorbs 9.5 L, and the colon absorbs approximately 0.4 L. Elimination of the remaining0.1 L occurs via feces. In addition, electrolytes and minerals are absorbed in the colon, and bacteria synthesize vitamin K and some B-complex vitamins. Finally, feces form for elimination.

Absorption

An energy-dependent process whereby particles move from an area of greater concentration to an area of lesser concentration. A special "carrier" moves the particle across the cell membrane.

Active transport

The nutritional care of acutely ill patients requires a nurse to consider a variety of factors that influence nutritional intake. Diagnostic testing and procedures in the acute care setting disrupt food intake. 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. It is important to assess a patient's nutritional status continuously and adopt interventions that promote normal intake, digestion, and metabolism of nutrients. Patients who are NPO and receive only standard IV fluids for more than 4 to 7 days are at nutritional risk.

Acute Care

Sports and regular moderate-to-intense exercise necessitate dietary modification to meet increased energy needs for adolescents. Carbohydrates, both simple and complex, are the main source of energy, providing 55% to 60% of total daily kilocalories. Protein needs increase to 1 to1.5 g/kg/day. Fat needs do not increase. Adequate hydration is very important. Adolescents need to ingest water before and after exercise to prevent dehydration, especially in hot, humid environments. Vitamin and mineral supplements are not required, but intake of iron-rich foods is required to prevent anemia. Parents have more influence on adolescents' diets than they believe. Effective strategies include limiting the amount of unhealthy food choices kept at home; encouraging smart snacks such as fruits, vegetables, or string cheese; and enhancing the appearance and taste of healthy foods (Mayo Clinic Staff, 2015). Some ways to promote healthy eating include making healthy food choices more convenient at home and at fast-food restaurants and discouraging adolescents from eating while watching television or using the computer. Pregnancy occurring within 4 years of menarche places a mother and fetus at risk because of anatomical and physiological immaturity. Malnutrition at the time of conception increases risk to the adolescent and her fetus. Most teenage girls do not want to gain weight. Counseling related to nutritional needs of pregnancy is often difficult, and teens tolerate suggestions better than rigid directions. The diet of pregnant adolescents is often deficient in calcium, iron, and vitamins A and C. The American College of Obstetricians and Gynecologists recommends prenatal vitamin and mineral supplements.

Adolescents. Developmental Needs

Acute and chronic conditions affect a patient's immune system and nutritional status. 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. Health care providers order a gradual progression of dietary intake or therapeutic diet to manage patients' illness (Box 45-10).

Advancing Diets

Advancing the Rate of Tube Feeding Protocols for advancing tube feedings are commonly institution specific. Most of these protocols are untested for validity. There does not appear to be a benefit to slow initiation of enteral nutrition over days. Most patients are able to tolerate feeding 24 to 48 hours after initiation. Do not dilute formulas with water; this increases the risk of bacterial contamination (Stewart, 2014). Intermittent Start formula at full strength for isotonic formulas (300 to 400 mOsm) or at ordered concentration. Infuse bolus of formula over at least 20 to 30 minutes via syringe or feeding container. Begin feedings with a volume of 2.5-5 mL/kg 5 to 8 times per day. Increase by 60-120 mL per feeding every 8-12 hours to achieve needed volume and calories in four to six feedings (Stewart, 2014). Continuous Start formula at full strength for isotonic formulas (300 to 400 mOsm) or at ordered concentration. Begin infusion rate at designated rate typically at 10 to 40 mL/hr (Stewart, 2014). Advance rate slowly (e.g., 10 to 20 mL/hr every 8 to 12 hours) to target rate if tolerated (tolerance indicated by absence of nausea and diarrhea and low gastric residuals) (Stewart, 2014).

Advancing the Rate of Tube Feeding

Long before the FDA issued recommended allowances and guidelines, many people followed special patterns of food intake on the basis of religion (Table 45-3), cultural background (Box 45-5), health beliefs, personal preference, or concern for the efficient use of land to produce food. Such special diets are not necessarily more or less nutritious than diets based on the MyPlate or other nutritional guidelines because good nutrition depends on a balanced intake of all required nutrients.

Alternative Food Patterns

Anthropometry is 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. Document the patient's actual weight and compare height and weight to standards for height-weight relationships. An ideal body weight (IBW) provides an estimate of what a person should weigh. 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.

Anthropometry

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 height2 (m2). For example, a patient who weighs 165 lbs (75 kg) and is 1.8 m (5 feet 9 inches) tall has a BMI of 23.15 (75 ÷ 1.82 = 23.15). The website for the National Heart Lung and Blood Institute (http://www.nhlbi.nih.gov/) provides an easy way to calculate BMI. A patient is overweight if his or her BMI is 25 to 30. Obesity, defined by a BMI of greater than 30, places a patient at higher medical risk of coronary heart disease, some cancers, DM, and hypertension.

Anthropometry

Other anthropometric measurements often obtained by RDs help identify nutritional problems. 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. Changes in values for an individual over time are of greater significance than isolated measurements (Nix, 2012).

Anthropometry

During the assessment process thoroughly assess each patient and critically analyze findings to ensure that you make patient-centered clinical decisions required for safe nursing care. Early recognition of malnourished or at-risk patients has a strong positive influence on both short- and long-term health outcomes. Studies demonstrate a link between malnutrition in adult hospitalized patients and readmission rates, higher mortality rates, and increased cost (Tappenden et al., 2013). Patients who are malnourished on admission are at greater risk of life-threatening complications such as arrhythmia, sepsis, or hemorrhage during hospitalization.

Assessment

Feed a patient with dysphagia slowly, providing smaller-size bites. Allow him or her to chew thoroughly and swallow the bite before taking another. More frequent chewing and swallowing assessments throughout the meal are necessary. Allow the patient time to empty the mouth after each spoonful, matching the speed of feeding to the patient's readiness (see Skill 45-1). If he or she begins to cough or choke, remove the food immediately (Ellis and Hannibal, 2013). Sometimes it is necessary to have oral suction equipment available at the patient's bedside. Provide opportunities for patients to direct the order in which they want to eat the food items and how fast they wish to eat. Determine a patient's food preferences and, unless contraindicated, try to have these items included on his or her dietary tray. Ask the patient if the food is the right temperature. These seem like small acts, but they go a long way in maintaining the patient's sense of independence. Patients with visual deficits also need special assistance. Patients with decreased vision are able to feed themselves when given adequate information. 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. Be sure that other care providers set the meal tray and plate in the same manner. Patients with impaired vision and those with decreased motor skills are more independent during mealtimes with the use of large-handled adaptive utensils (Figure 45-7). These are easier to grip and manipulate.

Assisting Patients with Oral Feeding

When a patient needs help with eating, it is important to protect his or her safety, independence, and dignity. Clear the table or over-bed tray of clutter. Assess his or her risk of aspiration (see Skill 45-1). Patients at high risk for aspiration have decreased level of alertness, decreased gag and/or cough reflexes, and difficulty managing saliva (see Assessment section of this chapter). Patients with dysphagia are at risk for aspiration and need more help with feeding and swallowing. A speech-language pathologist (SLP) identifies patients at risk and provides recommendations for therapy (Ellis and Hannibal, 2013). 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 and the caregiver to place food in the stronger side of the mouth. With the help of an SLP, determine the viscosity of foods that the patient tolerates best using trials of different consistencies of foods and fluids. Thicker fluids are generally easier to swallow. The American Dietetic Association published the National Dysphagia Diet Task Force National Dysphagia Diet in 2010 to provide uniformity of diets provided to patients with dysphagia (NDDTF, 2010). There are four levels of diet: dysphagia puree, dysphagia mechanically altered, dysphagia advanced, and regular. The four levels of liquid include thin liquids (low viscosity), nectarlike liquids (medium viscosity), honeylike liquids (viscosity of honey), and spoon-thick liquids (viscosity of pudding) (NDDTF, 2010).

Assisting Patients with Oral Feeding

General appearance Weight Posture Muscles Nerve conduction and mental status Gastrointestinal function Cardiovascular function General vitality Hair Skin (general) Face and neck Lips Mouth, oral membranes Gums Tongue Teeth Eyes Neck (glands) Nails Legs, feet Skeleton

Body Area

Myogenic • Myasthenia gravis • Aging• Muscular dystrophy • Polymyositis

Causes of Dysphagia

Neurogenic • Stroke • Cerebral palsy • Guillain-Barré syndrome • Multiple sclerosis • Amyotrophic lateral sclerosis (Lou Gehrig disease) • Diabetic neuropathy • Parkinson's disease

Causes of Dysphagia

Obstructive • Benign peptic stricture • Lower esophageal ring • Candidiasis • Head and neck cancer • Inflammatory masses • Trauma/surgical resection • Anterior mediastinal masses • Cervical spondylosis

Causes of Dysphagia

Other • Gastrointestinal or esophageal resection • Rheumatological disorders • Connective tissue disorders • Vagotomy

Causes of Dysphagia

Carbohydrates, composed of carbon, hydrogen, and oxygen, 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). Carbohydrate classification occurs according to their carbohydrate units, or saccharides.

Carbohydrates

Monosaccharides such as glucose (dextrose) or fructose do not break down into a more basic carbohydrate unit. Disaccharides such as sucrose, lactose, and maltose are composed of two monosaccharides and water. Simple carbohydrates is the classification for both monosaccharides and disaccharides; they are found primarily in sugars. Polysaccharides such as glycogen make up carbohydrate units too (i.e., complex carbohydrates). They are insoluble in water and digested to varying degrees. Starches are polysaccharides.

Carbohydrates

Implications for Patient-Centered Care • Ask patient or family caregiver to identify the meaning that types of food have for each patient. • Lactose and other food intolerances unique to specific cultures require diet adaptation to meet nutrient, mineral, and vitamin daily intake requirements. • When patients use hot and cold foods as part of their cultural health practices, dietary modifications are necessary. Hot foods include rice, grain cereals, alcohol, beef, lamb, chili peppers, chocolate, cheese, temperate zone fruits, eggs, peas, goat's milk, cornhusks, oils, onions, pork, radishes, and tamales. By contrast, cold foods are beans, citrus fruits, tropical fruits, dairy products, most vegetables, honey, raisins, chicken, fish, and goat. • Ask patient or family caregiver if there are: • Specific conditions such as menstruation, cancer, pneumonia, earache, colds, paralysis, headache, and rheumatism, which are cold illnesses and require hot foods. • Other conditions such as pregnancy, fever, infections, diarrhea, rashes, ulcers, liver problems, constipation, kidney problems, and sore throats, which are hot conditions and require cold foods.

Cultural Aspects of Care

Nutrition Food patterns developed as a child, habits, and culture interact to influence food intake. Culture also influences the meaning of food not related to nutrition. Eating is associated with sentiments and feelings such as "good" and "bad." For example, children are often rewarded for "being good" with a treat such as candy. They then associate candy with "being good." Food frequently enhances interpersonal relationships and demonstrates love and caring. The incidence of lactose intolerance around the world occurs in the following ethnic or racial groups: Asian-Pacific, African and African-American, Native American, Mexican American, Middle Eastern, and Caucasians. The incidence is highest in Asian-Pacific populations and lowest in Caucasians. It affects nutrient absorption. Calcium deficiency often results, causing decreased bone mass density. The theory of hot and cold foods predominates in many cultures. The origin appears to be from Hippocratic beliefs concerning health and the four humors. Arabs were keepers of this knowledge during the Dark Ages and later influenced the Spanish to adopt this belief system in the later Middle Ages. The foundation of the theory is keeping harmony with nature by balancing "cold," "hot," "wet," and "dry." Some cultures believe that hot is warmth, strength, and reassurance; whereas cold is menacing and weak. Classification has nothing to do with spiciness but is a symbolic representation of temperature (Giger and Davidhizar, 2012). Different cultures also have beliefs about food and special dishes that should be eaten when sick (e.g., chicken soup during illness).

Cultural Aspects of Care

The U.S. Food and Drug Administration (FDA) created daily values for food labels in response to the 1990 Nutrition Labeling and Education Act (NLEA). The 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. Daily values did not replace RDAs but provided a separate, more understandable format for the public. Daily values are based on percentages of a diet consisting of 2000 kcal/day for adults and children 4 years or older.

Daily Values

Adolescents. During adolescence physiological age is a better guide to nutritional needs than chronological age. 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. Many factors other than nutritional needs influence the adolescent's diet, including concern about body image and appearance, desire for independence, eating at fast-food restaurants, peer pressure, and fad diets. Nutritional deficiencies often occur in adolescent girls because of dieting and use of oral contraceptives. An adolescent boy's diet is often inadequate in total kilocalories, protein, iron, folic acid, B vitamins, and iodine. Snacks provide approximately 25% of a teenager's total dietary intake. Fast food, particularly value-size or super-size meals, is common and adds extra salt, fat, and kilocalories. Skipping meals or eating meals with unhealthy choices of snacks contributes to nutrient deficiency and obesity (Hockenberry and Wilson, 2015). Furthermore, research on public school lunch programs demonstrates that adolescents have higher body mass indexes (BMIs) than students enrolled in private school lunch programs (Li and Hooker, 2010). Fortified foods (nutrients added) are important sources of vitamins and minerals. Snack food from the dairy, fruit, and vegetable groups are good choices. To counter obesity, increasing physical activity is often more important than curbing intake. The onset of eating disorders such as anorexia nervosa or bulimia nervosa often occurs during adolescence. Recognition of eating disorders is essential for early intervention (Box 45-3).

Developmental Needs

Breastfeeding. 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 (AAP, 2012). 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.

Developmental Needs

Formula. Infant formulas contain the approximate nutrient composition of human milk. Protein in the formula is typically whey, soy, cow's milk base, casein hydrolysate, or elemental amino acids. Infants with allergies or intolerant to cow's milk should consume soy protein-based formulas instead (Nix, 2012). Infants should not have regular cow's milk during the first year of life. It 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 (Nix, 2012). Furthermore, children under 1 year of age should never ingest honey and corn syrup products because they are potential sources of the botulism toxin, which increases the risk of infant death.

Developmental Needs

In the last 20 years the prevalence of overweight children has risen. The percent of obesity in children ages 6 to 11 years has doubled to 17%, and the percent of overweight adolescents has more than tripled to 17.6% (Li and Hooker, 2010). A combination of factors contributes to the problem, including a diet rich in high-calorie foods, food advertising targeting children, inactivity, genetic predisposition, use of food as a coping mechanism for stress or boredom or as a reward or celebration, and family and socioeconomic factors (Tuan et al., 2012). Childhood obesity contributes to medical problems related to the cardiovascular system, endocrine system, and mental health. With the increase in obesity, the incidence of type 2 diabetes in children is also increasing. Prevention of childhood obesity is critical because of its long-term effects. Family education is an important component in decreasing the prevalence of this problem. Promote healthy food choices and eating in moderation along with increased physical activity.

Developmental Needs

Infants Through School-Age. Rapid growth and high protein, vitamin, mineral, and energy requirements mark the developmental stage of infancy. The average birth weight of an American baby is 7 to lbs. (3.2 to 3.4 kg). An infant usually doubles birth weight at 4 to 5 months and triples it at 1 year. Infants need an energy intake of approximately 90 to 110 kcal/kg of body weight per day, with premature infants needing 105 to 130 kcal/kg per day (Nix, 2012). Commercial formulas and human breast milk both provide approximately 20 kcal/oz. A full-term newborn is able to digest and absorb simple carbohydrates, proteins, and a moderate amount of emulsified fat. Infants need about 100 to 120 mL/kg/day of fluid because a large part of total body weight is water.

Developmental Needs

Introduction to Solid Food. Breast milk or formula provides sufficient nutrition for the first 4 to 6 months of life. The development of fine-motor skills of the hand and fingers parallels an infant's interest in food and self-feeding. Iron-fortified cereals are typically the first semisolid food to be introduced. For infants 4 to 11 months, cereals are the most important nonmilk source of protein (Dunne, 2012). 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 (Nix, 2012). 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 (Hockenberry and Wilson, 2015).

Developmental Needs

School-age children, 6 to 12 years old, grow at a slower and steadier rate, with a gradual decline in energy requirements per unit of body weight. Despite better appetites and more varied food intake, you need to assess school-age children's diets carefully for adequate protein and vitamins A and C. They often fail to eat a proper breakfast and have unsupervised intake at school. High fat, sugar, and salt result from too-liberal intake of snack foods. Physical activity level decreases consistently; and high-calorie, readily available food increases in consumption, leading to an increase in childhood obesity (Hedwig et al., 2013).

Developmental Needs

The growth rate slows during toddler years (1 to 3 years). A toddler needs fewer kilocalories but an increased amount of protein in relation to body weight; consequently, appetite often decreases at 18 months of age. Toddlers exhibit strong food preferences and become picky eaters. Small, frequent meals consisting of breakfast, lunch, and dinner with three interspersed high nutrient- dense snacks help improve nutritional intake (Hockenberry and Wilson, 2015). Calcium and phosphorus are important for healthy bone growth.

Developmental Needs

Toddlers who consume more than 24 ounces of milk daily in place of other foods sometimes develop milk anemia because milk is a poor source of iron. Toddlers need to drink whole milk until the age of 2 years to make sure that there is adequate intake of fatty acids necessary for brain and neurological development. Avoid certain foods such as hot dogs, candy, nuts, grapes, raw vegetables, and popcorn because they present a choking hazard. Dietary requirements for preschoolers (3 to 5 years) are similar to those for toddlers. They consume slightly more than toddlers, and nutrient density is more important than quantity.

Developmental Needs

Anorexia Nervosa • Restriction of energy intake relative to requirements, leading to a significantly low body weight in relation to age, sex, developmental trajectory, and physical health • Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight • Disturbance in the way in which one's body weight, size, or shape is experienced; undue influence of body weight or shape on self-evaluation; or persistent lack of recognition of the seriousness of the current low body weight (e.g., the person claims to "feel fat" even when emaciated, believes that one area of the body is "too fat" even when obviously underweight)

Diagnostic Criteria for Eating Disorders

Bulimia Nervosa • Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time) • A feeling of lack of control over eating behavior during eating binges • Recurrent inappropriate compensatory behaviors to prevent weight gain, such as self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise • Binge eating and inappropriate compensatory behaviors that both occur, on average, at least once a week for 3 months • Self-evaluation unduly influenced by body shape and weight

Diagnostic Criteria for Eating Disorders

In addition to the general nursing history, use data from a more specific diet history to assess a patient's actual or potential nutritional needs. 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. Gather information about the patient's illness/activity level to determine energy needs and compare food intake. Your nursing assessment of nutrition includes health status; age; cultural background (see Box 45-5); religious food patterns (see Table 45-3); socioeconomic status; personal food preferences; psychological factors; use of alcohol or illegal drugs; use of vitamin, mineral, or herbal supplements; prescription or over-the-counter (OTC) drugs (see Table 45-2); and the patient's general nutrition knowledge.

Diet History and Health History.

Clear Liquid Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, popsicles

Diet Progression and Therapeutic Diets

Diabetic Nutrition recommendations by the American Diabetes Association: focus on total energy, nutrient and food distribution; include a balanced intake of carbohydrates, fats, and proteins; varied caloric recommendations to accommodate patient's metabolic demands

Diet Progression and Therapeutic Diets

Dysphagia Stages, Thickened Liquids, Pureed As for clear and full liquid, with addition of scrambled eggs; pureed meats, vegetables, and fruits; mashed potatoes and gravy

Diet Progression and Therapeutic Diets

Full Liquid As for clear liquid, with addition of smooth-textured dairy products (e.g., ice cream), strained or blended cream soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt

Diet Progression and Therapeutic Diets

High Fiber Addition of fresh uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits

Diet Progression and Therapeutic Diets

Low Cholesterol 300 mg/day cholesterol, in keeping with American Heart Association guidelines for serum lipid reduction

Diet Progression and Therapeutic Diets

Low Sodium 4-g (no added salt), 2-g, 1-g, or 500-mg sodium diets; vary from no-added-salt to severe sodium restriction (500-mg sodium diet), which requires selective food purchases

Diet Progression and Therapeutic Diets

Mechanical Soft As for clear and full liquid and pureed, with addition of all cream soups, ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs (not fried)

Diet Progression and Therapeutic Diets

Regular No restrictions unless specified

Diet Progression and Therapeutic Diets

Soft/Low Residue Addition of low-fiber, easily digested foods such as pastas, casseroles, moist tender meats, and canned cooked fruits and vegetables; desserts, cakes, and cookies without nuts or coconut

Diet Progression and Therapeutic Diets

Food Guidelines. The U.S. Department of Health and Human Services (USDHHS) and the U.S. Department of Agriculture (USDA) published the Dietary Guidelines for Americans 2015-2020 and provide average daily consumption guidelines for the five food groups: grains, vegetables, fruits, dairy products, and meats (Box 45-2). These guidelines are for Americans over the age of 2 years. As a nurse, consider the food preferences of patients from different cultural groups, vegetarians, and others when planning diets. The U.S. Department of Agriculture developed the ChooseMyPlate program to replace the My Food Pyramid program. ChooseMyPlate provides a basic guide for making food choices for a healthy lifestyle (Figure 45-2). It includes guidelines for balancing calories; decreasing portion size; increasing healthy foods; increasing water consumption; and decreasing fats, sodium, and sugars (USDA, 2011).

Dietary Guidelines

Dietary reference intakes (DRIs) present evidence-based criteria for an acceptable range of amounts of vitamins and nutrients for each gender and age-group (IOM, 2015). 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. It is not a recommended level of intake (Tolerable upper-level intake, 2010).

Dietary Guidelines Dietary Reference Intakes

Digestion begins in the mouth, where chewing mechanically breaks down food. The food mixes with saliva, which contains ptyalin (salivary amylase), an enzyme that acts on cooked starch to begin its conversion to maltose. The longer an individual chews food, the more starch digestion occurs in the mouth. Proteins and fats are broken down physically but remain unchanged chemically because enzymes in the mouth do not react with these nutrients. Chewing reduces food particles to a size suitable for swallowing, and saliva provides lubrication to ease swallowing of the food. The epiglottis is a flap of skin that closes over the trachea as a person swallows to prevent aspiration. Swallowed food enters the esophagus, and wavelike muscular contractions (peristalsis) move the food to the base of the esophagus, above the cardiac sphincter. Pressure from a bolus of food at the cardiac sphincter causes it to relax, allowing the food to enter the fundus, or uppermost part, of the stomach.

Digestion

Digestion of food is the mechanical breakdown that results from chewing, churning, and mixing with fluid and chemical reactions in which food reduces to its simplest form. Each part of the GI system has an important digestive or absorptive function (Figure 45-1). Enzymes are the protein- like substances that act as catalysts to speed up chemical reactions. They are an essential part of the chemistry of digestion.

Digestion

Food leaves the antrum, or distal stomach, through the pyloric sphincter and enters the duodenum. Food is now an acidic, liquefied mass called chyme. Chyme flows into the duodenum and quickly mixes with bile, intestinal juices, and pancreatic secretions. The small intestine secretes the hormones secretin and cholecystokinin (CCK). Secretin activates release of bicarbonate from the pancreas, raising the pH of chyme. CCK inhibits further gastrin secretion and initiates release of additional digestive enzymes from the pancreas and gallbladder.

Digestion

Manufactured in the liver, bile is then concentrated and stored in the gallbladder. It acts as a detergent because it emulsifies fat to permit enzyme action while suspending fatty acids in solution. Pancreatic secretions contain six enzymes: amylase to digest starch; lipase to break down emulsified fats; and trypsin, elastase, chymotrypsin, and carboxypeptidase to break down proteins.

Digestion

Most enzymes have one specific function. Each enzyme works best at a specific pH. For example, the enzyme amylase in the saliva breaks down starches into sugars. The secretions of the GI tract have very different pH levels. Saliva is relatively neutral, gastric juice is highly acidic, and the secretions of the small intestine are alkaline.

Digestion

Peristalsis continues in the small intestine, mixing the secretions with chyme. The mixture becomes increasingly alkaline, inhibiting the action of the gastric enzymes and promoting the action of the duodenal secretions. Epithelial cells in the small intestinal villi secrete enzymes (e.g., sucrase, lactase, maltase, lipase, and peptidase) to facilitate digestion. The major part of digestion occurs in the small intestine, producing glucose, fructose, and galactose from carbohydrates; amino acids and dipeptides from proteins; and fatty acids, glycerides, and glycerol from lipids. Peristalsis usually takes approximately 5 hours to pass food through the small intestine.

Digestion

The chief cells in the stomach secrete pepsinogen; and the pyloric glands secrete gastrin, a hormone that triggers parietal cells to secrete hydrochloric acid (HCl). The parietal cells also secrete HCl and intrinsic factor (IF), which is necessary for absorption of vitamin B12 in the ileum. HCl turns pepsinogen into pepsin, a protein-splitting enzyme. The body produces gastric lipase and amylase to begin fat and starch digestion, respectively. A thick layer of mucus protects the lining of the stomach from autodigestion. Alcohol and aspirin are two substances directly absorbed through the lining of the stomach. The stomach acts as a reservoir where food remains for approximately 3 hours, with a range of 1 to 7 hours.

Digestion

The mechanical, chemical, and hormonal activities of digestion are interdependent. Enzyme activity depends on the mechanical breakdown of food to increase its surface area for chemical action. Hormones regulate the flow of digestive secretions needed for enzyme supply. Physical, chemical, and hormonal factors regulate the secretion of digestive juices and the motility of the GI tract. Nerve stimulation from the parasympathetic nervous system (e.g., the vagus nerve) increases GI tract action.

Digestion

Be aware of 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. Silent aspiration is 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 (Sorensen et al., 2013).

Dysphagia

Dysphagia often leads to an inadequate amount of food intake, which results in malnutrition. Frequently patients with dysphagia become frustrated with eating and show changes in skinfold thickness and albumin. During the rehabilitation period patients experience longer adjustment periods regarding new dietary restrictions. Furthermore, malnutrition significantly slows swallowing recovery and may increase mortality (Jensen et al., 2013).

Dysphagia

Dysphagia refers to difficulty swallowing. The causes (Box 45-7) and complications of dysphagia vary. 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 (Ellis and Hannibal, 2013).

Dysphagia

Dysphagia screening quickly identifies problems with swallowing and helps you initiate referrals for more in-depth assessment by an RD or a speech-language pathologist (SLP) (see Skill 45-1 on pp. 1083-1085). Early and ongoing assessment of patients with dysphagia using a valid dysphagia- screening tool increases quality of care and decreases incidence of aspiration pneumonia. 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 (Edmiaston et al., 2010). The Acute Stroke Dysphagia screen is an easily administered and reliable tool for health care professionals who are not speech-language pathologists (SLPs). Screening for and treatment of dysphagia requires a multidisciplinary team approach of nurses, RDs, health care providers, and SLPs (Sorensen et al., 2013).

Dysphagia

Chyme moves by peristaltic action through the ileocecal valve into the large intestine, where it becomes feces (see Chapter 47). 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. Feces contain cellulose and similar indigestible substances, sloughed epithelial cells from the GI tract, digestive secretions, water, and microbes.

Elimination

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. 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. Either the nurse or a family caregiver can easily give enteral tube feedings in the home setting. After insertion of an enteral tube, it is necessary to verify tube placement by x-ray film examination. Confirmation of placement is needed before a patient receives the first enteral feeding (see Skill 45-2 on pp. 1085-1089).

Enteral Tube Feeding

Food and Nutrient Consumption • Decrease saturated fat intake in population 2 years and older. • Increase the variety of vegetables and fruit intake in the population 2 years and older. • Increase grain product intake and consumption of calcium in the population 2 years and older. • Reduce sodium daily intake in the population 2 years and older.

Examples of Nutrition Objectives for Healthy People 2020

Iron Deficiency and Anemia • Reduce prevalence of iron deficiency in children and childbearing women. • Reduce prevalence of anemia in pregnant women in third trimester to 20%.

Examples of Nutrition Objectives for Healthy People 2020

• Increase proportion of adults who are at a healthy weight (body mass index [BMI] 18.5 to 24.9). • Reduce the proportion of adults who are obese. • Reduce the proportion of children (2 to 11 years) who are overweight or obese.

Examples of Nutrition Objectives for Healthy People 2020 Weight and Growth

Goals and outcomes of care reflect a patient's physiological, therapeutic, and individualized needs. Nutrition education and counseling are important to prevent disease and promote health. 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. For example, patients with heart failure experience decreased hunger, dietary restrictions, fatigue, shortness of breath, and sadness, which influence their food intake.

Goals and Outcomes

Environmental Factors. Environmental factors beyond the control of individuals contribute to the development of obesity. Obesity is an epidemic in the United States. Presently 68.7% of Americans are overweight or obese (CDC, 2015). In the annual "F is for Fat" report, authored by the Robert Woods Johnson Foundation and the Trust for America's Health (2013), the adult obesity rate, which consistently increased for three decades, now has leveled off. 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 (Wang et al., 2013). 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 (Hedwig et al., 2013).

Factors Influencing Nutrition

The fat-soluble vitamins (A, D, E, and K) are stored in the fatty compartments of the body. With the exception of vitamin D, people acquire vitamins through dietary intake. Because the body has a high storage capacity for these vitamins, toxicity is possible when a person takes large doses of them. Hypervitaminosis of fat-soluble vitamins results from megadoses (intentional or unintentional) of supplemental vitamins, excessive amounts in fortified food, and large intake of fish oils.

Fat-Soluble Vitamins

Fats (lipids) are the most calorie-dense nutrient, providing 9 kcal/g. Fats are composed of triglycerides and fatty acids. Triglycerides circulate in the blood and are composed of three fatty acids attached to a glycerol. Fatty acids are 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. Fatty acids can be saturated, in which each carbon in the chain has two attached hydrogen atoms; or unsaturated, in which an unequal number of hydrogen atoms are attached and the carbon atoms attach to one another with a double bond. Monounsaturated fatty acids have one double bond, whereas polyunsaturated fatty acids have two or more double carbon bonds. The various types of fatty acids referred to in the dietary guidelines have significance for health and the incidence of disease.

Fats

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. Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids.

Fats

Factors Affecting Nutritional Status • Age-related gastrointestinal changes that affect digestion of food and maintenance of nutrition include changes in the teeth and gums, reduced saliva production, atrophy of oral mucosal epithelial cells, increased taste threshold, decreased thirst sensation, reduced gag reflex, and decreased esophageal and colonic peristalsis (Touhy and Jett, 2010). • The presence of chronic illnesses (e.g., diabetes mellitus, end-stage renal disease, cancer) often affects nutrition intake (CDC, 2015). • Adequate nutrition in older adults is affected by multiple causes such as lifelong eating habits, culture, socialization, income, educational level, physical functional level to meet activities of daily living (ADLs), loss, dentition, and transportation (Touhy and Jett, 2010). • Adverse effects of medications cause problems such as anorexia, gastrointestinal bleeding, xerostomia, early satiety, and impaired smell and taste perception (Burcham and Rosenthal, 2016). • Cognitive impairments such as delirium, dementia, and depression affect ability to obtain, prepare, and eat healthy foods.

Focus on Older Adults

Individualized planning is essential. Explore patients' feelings about their weight and diet and help them set realistic and achievable goals. Mutually planned goals negotiated among the patient, RD, and nurse ensure success. For the patient with heart failure described previously, an overall goal is "Patient will achieve appropriate BMI height-weight range or be within 10% of IBW." The following outcomes help to achieve this goal: • Patient's daily nutritional intake meets the minimal DRIs. • Patient's daily nutritional fat intake is less than 30%. • Patient removes sugared beverages and high carbohydrate foods from diet. • Patient refrains from eating unhealthy foods between meals and after dinner. • Patient loses at least to 1 lb (0.2 to 0.45 kg) per week. Meeting nutritional goals requires input from the patient and the interprofessional team. Knowledge of the role of each discipline in providing nutrition support is necessary to maximize nutritional outcomes. For example, collaboration with an RD helps develop appropriate nutrition treatment plans. Calorie counts are frequently ordered, and help is necessary to obtain accurate data. An effective plan of care requires accurate exchange of information among disciplines.

Goals and Outcomes

As a nurse you are in a key position to educate patients about healthy diet choices and good nutrition. Incorporating knowledge of nutrition into patients' lifestyles serves to prevent the development of many diseases. Outpatient and community-based settings are optimal locations for nursing assessment of nutritional practices and status. Early identification of potential or actual problems is the best way to avoid serious problems. Similarly, in other health care settings patients with nutritional problems such as obesity often require help in menu planning and compliance strategies. Your role as educator includes assessing the patient's and family's health literacy (i.e., how much do they understand regarding their nutritional need) and providing nutritional education and information about community resources. Telephone numbers of an RD or nurse for follow-up questions are always a part of counseling.

Health Promotion

Meal planning takes into account a family's budget and different preferences of family members. Choose specific foods on the basis of the dietary prescription and recommended food groups. For families on limited budgets, use substitutes. For example, bean or cheese dishes often replace meat in a meal, and the use of evaporated milk or dry skim milk when cooking is a low-cost nutritional supplement. Have patients modify the method of preparation when it is necessary to minimize certain substances. Baking rather than frying reduces fat intake, and patients can use lemon juice or spices to add flavor to low-sodium diets.

Health Promotion

Planning menus a week in advance has several benefits. It helps ensure good nutrition or compliance with a specific diet and helps a family stay within their allotted budget. Nurses or RDs need to check menus for content. Often a simple tip is helpful in meal planning such as avoiding grocery shopping when hungry, which can lead to impulsive purchases of more expensive or less nutritious foods that are not included in meal plans. The U.S. Department of Agriculture (USDA, 2011) provides sample weekly meal-planning services for a range of budgets on its website. Support individuals who are interested in losing weight. A high percentage of those who attempt to lose weight are unsuccessful, regaining lost weight over time. Diet and exercise compliance affects success with weight loss. Information on weight loss is available from multiple sources. Help patients develop a successful weight-loss plan that considers their preferences and resources and includes awareness of portion sizes and knowledge of energy content of food (AHA, 2010). Food safety is an important public health issue. Foodborne bacteria can occur from improper food cleaning, preparation, or poor hygiene practices of food workers. Health care professionals not only need to be aware of the factors related to food safety but also should provide patient education to reduce the risks for foodborne illnesses (Table 45-5; Box 45-9).

Health Promotion

Diet therapies are numerous and chosen on the basis of a patient's overall health status, ability to eat and digest normally, and long-term nutritional needs. 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. Patients who are ill or debilitated often have poor appetites (anorexia). Anorexia has many causes (e.g., pain, fatigue, and the effects of medications). Help patients understand the factors that cause anorexia and use creative approaches to stimulate appetite. In the restorative care setting you help patients learn how to follow the therapeutic diets necessary for recovery and treatment of chronic health conditions.

Implementation

Enteral Nutrition (Used with patients who have a functional gastrointestinal tract) • Cancer • Head and neck • Upper GI • Critical illness/trauma • Neurological and muscular disorders • Brain neoplasm • Cerebrovascular accident • Dementia • Myopathy • Parkinson's disease • GI disorders • Enterocutaneous fistula • Inflammatory bowel disease • Mild pancreatitis • Respiratory failure with prolonged intubation • Inadequate oral intake • Anorexia nervosa • Difficulty chewing, swallowing • Severe depression Parenteral Nutrition • Nonfunctional GI tract• Massive small bowel resection/GI surgery/massive GI bleed • Paralytic ileus• Intestinal obstruction• Trauma to abdomen, head, or neck• Severe malabsorption • Intolerance to enteral feeding (established by trial) • Chemotherapy, radiation therapy, bone marrow transplantation • Extended bowel rest • Enterocutaneous fistula • Inflammatory bowel disease exacerbation • Severe diarrhea • Moderate-to-severe pancreatitis • Preoperative total parenteral nutrition • Preoperative bowel rest • Treatment for co-morbid severe malnutrition in patients with nonfunctional GI tracts • Severely catabolic patients when GI tract not usable for more than 4 to 5 days GI, Gastrointestinal.

Indications for Enteral and Parenteral Nutrition

Nitrogen balance is important in determining serum protein status (see discussion of protein in this chapter). Calculate nitrogen balance by dividing 6.25 into the total grams of protein ingested in a day (24 hours). Use laboratory analysis of a 24-hour urine urea nitrogen (UUN) to determine nitrogen output. For patients with diarrhea or fistula drainage, estimate a further addition of 2 to4 g of nitrogen output. Calculate nitrogen balance by subtracting the nitrogen output from the nitrogen intake. A positive 2- to 3-g nitrogen balance is necessary for anabolism. By contrast, negative nitrogen balance is present when catabolic states exist.

Laboratory and Biochemical Tests

Appetite and Weight • Have you had a change in appetite? • Have you noticed a change in your weight? • Was this change anticipated (e.g., were you on a weight-reduction diet)?

Nursing Assessment Questions

No single laboratory or biochemical test is diagnostic for malnutrition. Factors that frequently alter test results include fluid balance, liver function, kidney function, and the presence of disease. 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. Use this information to determine the most effective measure of plasma proteins for your patients. 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 (Jensen et al., 2013).

Laboratory and Biochemical Tests

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. The need for calcium remains the same as 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. Fluid intake needs to be adequate but not excessive. Excretion of caffeine, alcohol, and drugs occurs through breast milk. Therefore lactating mothers need to avoid their ingestion.

Lactation

Metabolism refers to all of the biochemical reactions within the cells of the body. Metabolic processes are anabolic (building) or catabolic (breaking down). Anabolism is the building of more complex biochemical substances by synthesis of nutrients. It occurs when an individual adds lean muscle through diet and exercise. Amino acids are anabolized into tissues, hormones, and enzymes. Normal metabolism and anabolism are physiologically possible when the body is in positive nitrogen balance. Catabolism is the breakdown of biochemical substances into simpler substances and occurs during physiological states of negative nitrogen balance. Starvation is an example of catabolism when wasting of body tissues occurs.

Metabolism and Storage of Nutrients

Some of the nutrients required by the body are stored in tissues. The major form of body reserve energy is fat, stored as adipose tissue. Protein is stored in muscle mass. When the energy requirements of the body exceed the energy supplied by ingested nutrients, stored energy is used. Monoglycerides from the digested part of fats convert to glucose by gluconeogenesis. Amino acids are also converted to fat and stored or catabolized into energy through gluconeogenesis. All body cells except red blood cells and neurons oxidize fatty acids into ketones for energy when dietary carbohydrates (glucose) are not adequate. 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. Nutrient metabolism consists of three main processes: 1. Catabolism of glycogen into glucose, carbon dioxide, and water (glycogenolysis) 2. Anabolism of glucose into glycogen for storage (glycogenesis) 3. Catabolism of amino acids and glycerol into glucose for energy (gluconeogenesis)

Metabolism and Storage of Nutrients

abolism when wasting of body tissues occurs. Nutrients absorbed in the intestines, including water, transport through the circulatory system to the body tissues. Through the chemical changes of metabolism, the body converts nutrients into a number of required substances. Carbohydrates, protein, and fat metabolism produce chemical energy and maintain a balance between anabolism and catabolism. To carry out the work of the body, the chemical energy produced by metabolism converts to other types of energy by different tissues. Muscle contraction involves mechanical energy, nervous system function involves electrical energy, and the mechanisms of heat production involve thermal energy.

Metabolism and Storage of Nutrients

Minerals are inorganic elements essential to the body as catalysts in biochemical reactions. They are classified as macrominerals when the daily requirement is 100 mg or more and microminerals or trace elements when less than 100 mg is needed daily. Macrominerals help to balance the pH of the body, and specific amounts are necessary in the blood and cells to promote acid-base balance. Interactions occur among trace minerals. For example, excess of one trace mineral sometimes causes deficiency of another. Selenium is a trace element that also has antioxidant properties. Silicon, vanadium, nickel, tin, cadmium, arsenic, aluminum, and boron play an unidentified role in nutrition. Arsenic, aluminum, and cadmium have toxic effects.

Minerals

Dietary Intake and Food Preferences • What type of food do you like? • How many meals a day do you eat? • What times do you normally eat meals and snacks? • What portion sizes do you eat at each meal? • Are you on a special diet because of a medical problem? • Do you have any dietary religious or cultural food preferences? • Who prepares the food at home? • Who purchases the food? • How do you cook your food (e.g., fried, broiled, baked, grilled)?

Nursing Assessment Questions

Taste, Chewing, and Swallowing • Have you noticed any changes in taste? • Did these changes occur with medications or following an illness? • Do you wear dentures? Are the dentures comfortable? • Do you have any mouth pain or sores (e.g., cold sore, canker sores)? • Do you have difficulty swallowing? • Do you cough or gag when you swallow?

Nursing Assessment Questions

Unpleasant Symptoms • Which foods cause indigestion, gas, or heartburn? • Does this occur each time you have the food? • What relieves the symptoms?

Nursing Assessment Questions

Use of Medications • Which medications do you take? • Do you take any over-the-counter medications that your doctor does not prescribe? • Do you take any nutritional or herbal supplements?

Nursing Assessment Questions

Cluster all assessment data to identify appropriate nursing diagnoses (Box 45-8). A nutritional problem occurs when overall intake is significantly decreased or increased or when one or more nutrients are not ingested, completely digested, or completely absorbed. When identifying a problem-focused nursing diagnosis, you select the appropriate related factors (e.g., inability to digest food or reduced daily activity). Related factors need to be accurate so you select the right interventions. For example, Imbalanced Nutrition: Less Than Body Requirements related to economic disadvantage will require very different interventions than Imbalanced Nutrition: Less Than Body Requirements related to an inability to ingest food.

Nursing Diagnosis

Sociological, cultural, psychological, and emotional factors are associated with eating and drinking in all societies. We celebrate holidays and events with food, bring it to those who are grieving, and use it for medicinal purposes. We incorporate it into family traditions and rituals and often associate food with eating behaviors. You need to understand patients' values, beliefs, and attitudes about food and how these values affect food purchase, preparation, and intake to affect eating patterns. Nutritional requirements depend on many factors. Individual caloric and nutrient requirements vary by stage of development, body composition, activity levels, pregnancy and lactation, and the presence of disease. Registered dietitians (RDs) use predictive equations that take into account some of these factors to estimate patients' nutritional requirements.

Nursing Knowledge Base

Apply the nursing process and use a critical thinking approach in your care of patients. The nursing process provides a clinical decision-making approach for you to develop and implement an individualized plan of care.

Nursing Process

The body requires fuel to provide energy for cellular metabolism and repair, organ function, growth, and body movement. The basal metabolic rate (BMR) is the energy needed at rest to maintain life-sustaining activities (breathing, circulation, heart rate, and temperature) for a specific amount of time. Factors such as age, body mass, gender, fever, starvation, menstruation, illness, injury, infection, activity level, and thyroid function affect energy requirements. The resting energy expenditure (REE), or resting metabolic rate, is 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. Factors that affect metabolism include illness, pregnancy, lactation, and activity level.

Nutrients: The Biochemical Units of Nutrition

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. Numerous factors influence the nutritional status of the older adult (Box 45-4). Age-related changes in appetite, taste, smell, and the digestive system affect nutrition (Touhy and Jett, 2010). For example, older adults often experience a decrease in taste cells that alters food flavor and may decrease intake. Multiple factors contribute to the risk of food insecurity in the older adult. Income is significant because living on a fixed income often reduces the amount of money available to buy food. Health is another important influence that affects a person's desire and ability to eat. Lack of transportation or ability to get to the grocery store because of mobility problems contributes to inability to purchase adequate and nutritious food. Often availability of nutritionally adequate and safe foods is limited or uncertain.

Older Adults

Maintaining good oral health is significant throughout adulthood, particularly as an individual ages. 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 adults (Touhy and Jett, 2010). Poor oral hygiene and periodontal disease are potential risk factors for systemic diseases such as joint infections, ischemic stroke, cardiovascular disease, DM, and aspiration pneumonia (Borrelli and Talih, 2012).

Older Adults

The USDHHS Administration on Aging (AOA) requires states to provide nutritional screening services to older adults who benefit from home-delivered or congregate meal services. This program requires meals to provide at least one third of the DRI for an older adult and meet the Dietary Guidelines for Americans (American Dietetic Association, 2010a). Homebound older adults with chronic illnesses have additional nutritional risks. They frequently live alone with little or no social or financial resources to help obtain or prepare nutritionally sound meals, contributing to the risk for food insecurity. Approximately 19% of older adults experience some degree of food insecurity resulting from low income or poverty (American Dietetic Association, 2010a). Increased nutrition screening by the nurse results in early recognition and treatment of nutritional deficiencies. Undernourishment of older adults often results in health problems that lead to admission to acute care hospitals or long-term care facilities.

Older Adults

The older adult is often on a therapeutic diet; has difficulty eating because of physical symptoms, lack of teeth, or dentures; or is at risk for drug-nutrient interactions (Table 45-2). Caution older adults to avoid grapefruit and grapefruit juice because they alter absorption of many drugs. Thirst sensation diminishes, leading to inadequate fluid intake or dehydration (see Chapter 42). Symptoms of dehydration in older adults include confusion; weakness; hot, dry skin; furrowed tongue; rapid pulse; and high urinary sodium. Some older adults avoid meats because of cost or because they are difficult to chew. Cream soups and meat-based vegetable soups are nutrient-dense sources of protein. Cheese, eggs, and peanut butter are also useful high-protein alternatives. Milk continues to be an important food for older women and men who need adequate calcium to protect against osteoporosis (a decrease of bone mass density). Screening and treatment are necessary for both older men and women. Vitamin D supplements are important for improving strength and balance, strengthening bone health, and preventing bone fractures and falls. The diet of older adults needs to contain choices from all food groups and often requires a vitamin and mineral supplement. MyPlate for Older Adults addresses the specific nutritional needs for older adults and encourages physical activity (Tufts University, 2011).

Older Adults

Movement of water through a semipermeable membrane that separates solutions of different concentrations. Water moves to equalize the concentration pressures on both sides of the membrane.

Osmosis

The force by which particles move outward from an area of greater concentration to one of lesser concentration. The particles do not need a special "carrier" to move outward in all directions.

Passive diffusion

Food Safety Objective • Patient is able to verbalize measures to protect from foodborne illness. Teaching Strategies • Explain that food safety is an important public health issue. Populations particularly at risk are older and younger people and immunosuppressed individuals. • Instruct patients using the following four principles: 1. CLEAN • Wash hands with warm, soapy water before touching or eating food. • Wash fresh fruits and vegetables thoroughly. • Clean the inside of refrigerator and microwave regularly to prevent microbial growth. • Clean cutting surfaces after each use. • When possible, use separate surfaces for fruit, meat, poultry, fish 2. SEPARATE • Wash cooking utensils and cutting boards with hot soapy water. • Wash hands after handling foods, especially meats, poultry, and eggs. • Clean vegetables and lettuce used in salads thoroughly. • Wash dishrags, towels, and sponges regularly or use paper towels. 3. COOK • Use a food thermometer to verify that meat, poultry, and fish are cooked properly. • Do not eat raw meats or unpasteurized milk. 4. CHILL • Keep foods properly refrigerated at 40° F (4.4° C) and frozen at 0° F (−17.8 ̊ C). • Do not save leftovers for more than 2 days in refrigerator. Evaluation • Ask patient to verbalize measures to prevent foodborne illnesses. • Observe patient at home for safe practices if making home visit.

Patient Teaching

The physical examination is one of the most important aspects of a nutritional assessment. Because improper nutrition affects all body systems, observe for malnutrition during physical assessment (see Chapter 31). Complete the general physical assessment of body systems and recheck relevant areas to evaluate a patient's nutritional status. The clinical signs of nutritional status (Table 45-4) serve as guidelines for observation during physical assessment.

Physical Examination

Engulfing of large molecules of nutrients by the absorbing cell when the molecule attaches to the absorbing cell membrane.

Pinocytosis

Planning to maintain patients' optimal nutritional status requires a higher level of care than simply correcting nutritional problems. Often there is a need for patients to make long-term changes for nutrition to improve. Synthesis of patient information from multiple sources is necessary to create an individualized approach of care that is relevant to a patient's needs and situation (Figure 45-6). Apply critical thinking to ensure that you consider all data sources in developing a patient's plan of care. The accurate identification of nursing diagnoses related to patients' nutritional problems results in a care plan that is relevant and appropriate (see the Nursing Care Plan). Referring to professional standards for nutrition is especially important during this step, because scientific findings support current published standards.

Planning

Christianity Some faiths such as Baptists have minimal or no alcoholSome meatless days may be observed during the calendar year, commonly during Lent

Religious Dietary Restrictions

Church of Jesus Christ of Latter-Day Saints (Mormons) Alcohol Tobacco Caffeine such as teas, coffees, and sodas

Religious Dietary Restrictions

Poor nutrition during pregnancy causes low birth weight in infants and decreases chances of survival. Generally meeting the needs of a fetus is at the expense of the mother. However, if nutrient sources are not available, both suffer. The nutritional status of the mother at the time of conception is important. Significant aspects of fetal growth and development often occur before the mother suspects the 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 (Nix, 2012). Women of childbearing age need to consume 400 mcg of folic acid daily, increasing to 600 mcg daily during pregnancy. Prenatal care usually includes vitamin and mineral supplementation to ensure daily intakes; however, pregnant women should not take additional supplements beyond prescribed amounts.

Pregnancy

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. For example, medications such as insulin, glucocorticoids, and thyroid hormones affect metabolism. Other medications such as antifungal agents frequently affect taste. Some of the psychotropic medications affect appetite, cause nausea, and alter taste. You and the RD help patients select foods that reduce the altered taste sensations or nausea. Consult with an RD regarding using seasonings that improve food taste. In other situations medications need to be changed. Assessing patients for the need for pharmacological agents to stimulate appetite such as cyproheptadine, megestro, or dronabinol or to manage symptoms that interfere with nutrition requires health care provider consultation. Mealtime is usually a social activity. If appropriate, encourage visitors to eat with a patient. When patients experience anorexia, encourage other nurses or care providers to converse and engage them in conversation. Mealtime is also an excellent opportunity for patient education. Instruct a patient about any therapeutic diets, medications, energy conservation measures, or adaptive devices to help with independent feeding.

Promoting Appetite

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.

Proteins

Achieving nitrogen balance means that the intake and output of nitrogen are equal. When the intake of nitrogen is greater than the output, the body is in positive nitrogen balance. Positive nitrogen balance is required for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing. The body uses nitrogen to build, repair, and replace body tissues. Negative nitrogen balance occurs when the body loses more nitrogen than it gains (e.g., with infection, burns, fever, starvation, head injury, and trauma). The increased nitrogen loss is the result of body tissue destruction or loss of nitrogen-containing body fluids. Nutrition during this period needs to provide nutrients to put patients into positive balance for healing.

Proteins

Protein provides energy but, because its essential role is to promote growth, maintenance, and repair, a diet needs to provide adequate kilocalories from nonprotein sources. When there is sufficient carbohydrate in the diet to meet the energy needs of the body, protein is spared as an energy source.

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.

Proteins

The simplest form of protein is the amino acid, consisting of hydrogen, oxygen, carbon, and nitrogen. Because the body does not synthesize indispensable amino acids, we need these to be provided in our diet. Examples of indispensable amino acids are histidine, lysine, and phenylalanine. The body synthesizes dispensable amino acids. Examples of amino acids synthesized in the body are alanine, asparagine, and glutamic acid. Amino acids can link together. Albumin and insulin are simple proteins because they contain only amino acids or their derivatives. The combination of a simple protein with a nonprotein substance produces a complex protein such as lipoprotein, formed by a combination of a lipid and a simple protein.

Proteins

Analgesic (Type of drug) Acetaminophen - Decreased drug absorption with food; overdose associated with liver failure Aspirin - Absorbed directly through stomach; decreased drug absorption with food; decreased folic acid, vitamins C and K, and iron absorption Antacid (Type of drug) Aluminum hydroxide - Decreased phosphate absorption Sodium bicarbonate - Decreased folic acid absorption Antiarrhythmic (Type of drug) Amiodarone (Cordarone) - Taste alteration Digitalis - Anorexia, decreased renal clearance in older people Antibiotic (Type of drug) Penicillin - Decreased drug absorption with food, taste alteration Cephalosporin - Decreased vitamin K Rifampin (Rifadin) - Decreased vitamin B6, niacin, vitamin D Tetracycline - Decreased drug absorption with milk and antacids; decreased nutrient absorption of calcium, riboflavin, vitamin C caused by binding Trimethoprim/sulfamethoxazole - Decreased folic acid Anticoagulant (Type of drug) Warfarin (Coumadin) - Acts as antagonist to vitamin K Anticonvulsant (Type of drug) Carbamazepine (Tegretol) - Increased drug absorption with food Phenytoin (Dilantin) - Decreased calcium absorption; decreased vitamins D and K and folic acid; taste alteration; decreased drug absorption with food Antidepressant (Type of drug) Amitriptyline - Appetite stimulant Clomipramine (Anafranil) - Taste alteration, appetite stimulant Fluoxetine (Prozac) (selective serotonin reuptake inhibitors [SSRIs]) - Taste alteration, anorexia Antihypertensive (Type of drug) Captopril (Capoten) - Taste alteration, anorexia Hydralazine - Enhanced drug absorption with food, decreased vitamin B6 Labetalol (Normodyne) - Taste alteration (weight gain for all beta-blockers) Methyldopa - Decreased vitamin B12, folic acid, iron Antiinflammatory (Type of drug) All steroids - Increased appetite and weight, increased folic acid, decreased calcium (osteoporosis with long-term use); promotes gluconeogenesis of protein

Sample of Drug-Nutrient Interactions

Nutrition screening is an essential part of an initial assessment. Screening a patient is a quick method of identifying malnutrition or risk of malnutrition using simple tools (Holst et al., 2013). 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 (Holst et al., 2013). Combine multiple objective measures with subjective measures related to nutrition to adequately screen for nutritional problems. Identification of risk factors such as unintentional weight loss, presence of a modified diet, or the presence of altered nutritional symptoms (i.e., nausea, vomiting, diarrhea, and constipation) requires nutritional consultation.

Screening

Several standardized nutritional screening tools are available for use in outpatient and inpatient settings. The Subjective Global Assessment (SGA) uses the patient history, weight, and physical assessment data to assess nutritional status (Tsai et al., 2013). The SGA is a simple, inexpensive technique that is able to predict nutrition-related complications. The Mini Nutritional Assessment (MNA) (Figure 45-4) screens older adults in home care programs, nursing homes, and hospitals. The tool has 18 items divided into screening and assessment. If a patient scores 11 or less on the screening part, the health care provider completes the assessment part. A total score of less than 17 indicates protein-energy malnutrition (Guigoz and Vellas, 1999; Guigoz et al., 1996). In conclusion, malnutrition screening tools (MSTs) are an effective way to measure nutritional problems for patients in a variety of health care settings.

Screening

After identifying patients' nursing diagnoses, determine priorities to plan timely and successful interventions. 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. Deficient Knowledge regarding diet therapy will become a priority if it is necessary to promote long-term and effective weight loss for a patient being discharged from a hospital. During acute illness and surgery, food intake varies in the perioperative period. 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 (see Chapter 50). For example, when patients have oral and throat surgery, they chew and swallow food in the presence of excision sites, sutures, or tissue manipulated during surgery. 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. The patient and family must collaborate with the nurse in planning care and setting priorities. This is important because food preferences, food purchases, and preparation involve the entire family. The plan of care cannot succeed without their commitment to, involvement in, and understanding of the nutritional priorities.

Setting Priorities

Alert: responsive Weight normal for height, age, body build Erect posture; straight arms and legs Well-developed, firm; good tone; some fat under skin Good attention span; not irritable or restless; normal reflexes; psychological stability Good appetite and digestion; normal regular elimination; no palpable organs or masses Normal heart rate and rhythm; lack of murmurs; normal blood pressure for age Endurance; energy; sleeps well; vigorous Shiny, lustrous; firm; not easily plucked; healthy scalp Smooth and slightly moist skin with good color Uniform color; smooth, pink, healthy appearance; not swollen Smooth; good color; moist; not chapped or swollen Reddish-pink mucous membranes in oral cavity Good pink color; healthy and red; no swelling or bleeding Good pink or deep reddish color; no swelling; smooth, presence of surface papillae; lack of lesions No cavities; no pain; bright, straight; no crowding; well-shaped jaw; clean with no discoloration Bright, clear, shiny; no sores at corner of eyelids; moist and healthy pink conjunctivae; prominent blood vessels; no fatigue circles beneath eyes No enlargement Firm, pink No tenderness, weakness, or swelling; good color No malformations

Signs of Good Nutrition

Listless, apathetic, cachectic Obesity (usually 10% above ideal body weight [IBW]) or underweight (special concern for underweight) Sagging shoulders; sunken chest; humped back Flaccid, poor tone, underdeveloped tone; "wasted" appearance; impaired ability to walk properly Inattention; irritability; confusion; burning and tingling of hands and feet (paresthesia); loss of position and vibratory sense; weakness and tenderness of muscles (may result in inability to walk); decrease or loss of ankle and knee reflexes Anorexia; indigestion; constipation or diarrhea; liver or spleen enlargement Rapid heart rate (above 100 beats/min), enlarged heart; abnormal rhythm; elevated blood pressure Easily fatigued; no energy; falls asleep easily; tired and apathetic Stringy, dull, brittle, dry, thin, and sparse, depigmented; easily plucked Rough, dry, scaly, pale, pigmented, irritated; bruises; petechiae; subcutaneous fat loss Greasy, discolored, scaly, swollen; dark skin over cheeks and under eyes; lumpiness or flakiness of skin around nose and mouth Dry, scaly, swollen; redness and swelling (cheilosis); angular lesions at corners of mouth; fissures or scars (stomatitis)Swollen, boggy oral mucous membranes Spongy gums that bleed easily; marginal redness, inflammation; receding Swelling, scarlet and raw; magenta, beefiness (glossitis); hyperemic and hypertrophic papillae; atrophic papillae Unfilled caries; missing teeth; worn surfaces; mottled (fluorosis), malocclusion Eye membranes pale (pale conjunctivas); redness of membrane (conjunctival injection); dryness; signs of infection; Bitot's spots; redness and fissuring of eyelid corners (angular palpebritis); dryness of eye membrane (conjunctival xerosis); dull appearance of cornea (corneal xerosis); soft cornea (keratomalacia) Thyroid or lymph node enlargement Spoon shape (koilonychia); brittleness; ridges Edema; tender calf; tingling; weakness Bowlegs; knock-knees; chest deformity at diaphragm; prominent scapulae and ribs

Signs of Poor Nutrition

Patients who cannot tolerate nutrition through the GI tract receive total PN, a solution consisting of glucose, amino acids, lipids, minerals, electrolytes, trace elements, and vitamins, through an indwelling peripheral or central venous catheter (CVC) (see Chapter 42). The pharmacist is an expert who reviews medications to identify drug-nutrient interactions. Pharmacists are also experts in preparing mixtures of total PN (TPN).When patients have difficulty feeding themselves, occupational therapists work with them and their families to identify assistive devices. Devices such as utensils with large handles and plates with elevated sides help a patient with self-feeding. A speech-language pathologist (SLP) helps a patient with swallowing exercises and techniques to reduce the risk of aspiration. Occupational therapists also help patients maintain function in the home setting by rearranging food preparation areas in an effort to maximize a patient's functional capacity.

Teamwork and Collaboration

The care of a patient often extends beyond the acute hospital setting, requiring continued collaboration among members of the health care team. It is important that discharge planning include nutritional interventions as patients return to their homes or extended care facilities. Communicate patient goals and planned interventions to all team members to achieve expected patient outcomes. In addition, as nurses, consult with an SLP, RD, pharmacist, and/or occupational therapist about patients with dysphagia and those who need ongoing nutritional assessment and interventions to meet their nutritional needs. Administration of enteral tube feedings typically enters through the stomach or intestines via a tube inserted through the nose or a percutaneous access (see Skills 45-2 and 45-3 on pp. 1085-1094). These enteral feedings supplement a patient's oral nutritional intake in the home, acute care, extended care, or rehabilitation setting when they cannot meet their nutritional needs by mouth. Regardless of the setting, the RD assesses and monitors the patient's nutritional status and intake and makes recommendations for changes. RDs are expert in the choice of enteral formulas and dietary modifications required for specific disease states. Long-term management of nutritional problems is a challenge that requires collaboration among the patient, family, and health care team members.

Teamwork and Collaboration

Assess patients' nutritional status by using the nursing history to gather information about factors that usually influence nutrition. You are in an excellent position to recognize signs of poor nutrition and take steps to initiate change. Close contact with patients and their families enables you to observe physical status, food intake, food preferences, weight changes, and response to therapy. Always ask patients about their food preferences, values regarding nutrition, and expectations from nutritional therapy. In attempting to affect eating patterns, you need to understand patients' values, beliefs, and attitudes about food. Also assess family traditions and rituals related to food, cultural values and beliefs, and nutritional needs. Determine how these factors affect food purchase, preparation, and intake.

Through the Patient's Eyes

A common alternative dietary pattern is the vegetarian diet. Vegetarianism is 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). Through careful selection of foods, individuals following a vegetarian diet can meet recommendations for proteins and essential nutrients (Nix, 2012). 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. Knowledge related to complementary use of high and low biological value proteins is necessary. Children who follow a vegetarian diet are especially at risk for protein and vitamin deficiencies such as vitamin B12. Careful planning helps to ensure a balanced, healthy diet.

Vegetarian Diet

Vitamins are organic substances present in small amounts in foods that are essential to normal metabolism. They are chemicals that act as catalysts in biochemical reactions. When there is enough of any specific vitamin to meet the catalytic demands of the body, the rest of the vitamin supply acts as a free chemical and is often toxic to the body. Certain vitamins are currently of interest in their role as antioxidants. These vitamins neutralize substances called free radicals, which produce oxidative damage to body cells and tissues. Researchers think that oxidative damage increases a person's risk for various cancers. Antioxidant vitamins include beta-carotene and vitamins A, C, and E (Nix, 2012). The body is unable to synthesize vitamins in the required amounts. Vitamin synthesis depends on dietary intake. Vitamin content is usually highest in fresh foods that have minimal exposure to heat, air, or water before their use. Vitamin classifications include fat soluble or water soluble.

Vitamins

Water is critical because cell function depends on a fluid environment. Water makes up 60% to 70% of total body weight. Lean people have a greater percent of total body water than obese people do because muscle contains more water than any other tissue except blood. Infants have the greatest percentage of total body water because of greater surface area, and older people have the least. When deprived of water, a person usually cannot survive for more than a few days.

Water

We meet our fluid needs by drinking liquids and eating solid foods high in water content such as fresh fruits and vegetables. Digestion produces fluid during food oxidation. In a healthy individual fluid intake from all sources equals fluid output through elimination, respiration, and sweating (seeChapters 41 and 45). 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.

Water

The water-soluble vitamins are 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. Water- soluble vitamins absorb easily from the GI tract. Although they are not stored, toxicity can still occur.

Water-Soluble Vitamins

There is a reduction in nutrient demands as the growth period ends. Mature adults need nutrients for energy, maintenance, and repair. Energy needs usually decline over the years. Obesity becomes a problem because of decreased physical exercise, dining out more often, and increased ability to afford more luxury foods. Adult women who use oral contraceptives often need extra vitamins. Iron and calcium intake continues to be important.

Young and Middle Adults.