Nutrition RNSG 1413

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NutritionRNSG 1413

• Amy C. Chavarria, RN, MSN, MBA, HCM, CCE

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Essential Nutrients and Sources

• Water
• Carbohydrates
• Protein
• Fats
• Micronutrients
• Vitamins
• Minerals

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Carbohydrates
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Digestion, Absorption, and Metabolism
Carbohydrates

• Major enzymes include ptyalin (salivary amylase),
  pancreatic amylase, and the disaccharidases
• End products are monosaccharides
• Absorbed by the small intestine in healthy people
• Body breaks carbohydrates into glucose
• Maintain blood levels
• Provide a readily available source of energy

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Proteins
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Digestion, Absorption, and Metabolism Protein

• Digestion begins in the mouth with enzyme pepsin
• Most protein digested in the small intestine
• Pancreas secretes the proteolytic enzymes
  trypsin, chymotrypsin, and carboxypeptidase
• Glands in intestinal wall secrete aminopeptidase
  and dipeptidase which break protein into amino
  acids
• Amino acids absorbed by active transport through
  small intestines
• Anabolism, catabolism, nitrogen balance

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Lipids/Fats
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Digestion, Absorption, and Metabolism Lipids/Fats

• Digestion begins in the stomach, but mainly
  digested in the small intestine
• Digestion primarily by bile, pancreatic lipase,
  and enteric lipase
• End products of lipid digestion are glycerol,
  fatty acids, and cholesterol
• Reassembled inside the intestinal cells into
  triglycerides and cholesterol esters

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Digestion, Absorption, and Metabolism Lipids/Fats

• Small intestine and the liver convert these into
  soluble compounds called lipoprotein
• Converting fat into useable energy occurs through
  lipase that breaks down triglycerides in adipose
  cells releasing glycerol and fatty acids into the
  blood

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Micronutrients

• Vitamins
• Minerals

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VITAMIN A

• FUNCTIONS -maintenance of normal vision
  especially in dim light
• maintenance of healthy epithelium
• promotion of normal skeletal and teeth
  development
• promotion of cellular proliferation
• SOURCES liver, fish, liver oils, fortified milk
  and dairy products
• DEFICIENCY/IES Night blindness, Cessation of
  bone growth, Decreased mucous secretion of
  stomach and intestine, Dry eyes, scaly skin

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VITAMIN D

• FUNCTIONS - intestinal absorption of calcium
• mobilization of calcium and phosphorus from bone
• renal absorption of calcium
• SOURCES exposure to sunlight
• DEFICIENCY/CIES
• Rickets
• Osteomalacia
• Tetany

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VITAMIN E

• FUNCTIONS - antioxidant
• assists in maintaining the integrity of cellular
  membranes and protecting vitamin A from oxidation
• SOURCES vegetable oils, wheat germ, leafy
  vegetables, soybeans, corn, peanuts, margarine
• DEFICIENCY/CIES Rare-increase hemolysis of RBC
• poor reflexes

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VITAMIN K

• Intake of this vitamin is needed in the liver for
  the formation of prothrombin other clotting
  factors ----- blood coagulation
• SOURCES green leafy vegetables, cheese, egg
  yolk, liver
• DEFICIENCY/CIES Hemorrhage, Hemorrhagic Disease
  of the Newborn

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VITAMIN B1(THIAMINE)

• FUNCTIONS - aids in energy metabolism especially
  in carbohydrates metabolism
• provides normal nervous system functioning,
  normal appetite and digestion
• SOURCES pork, liver, organ meats, potatoes,
  eggs, nuts, legumes, milk, whole grains
• DEFICIENCY/CIES Beriberi characterized by
  neurological, cerebral and cardiovascular
  abnormalities
• S/S anorexia, indigestion, constipation, apathy,
  fatigue, muscle weakness, cardiac failure death
  may occur

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VITAMIN B2(RIBOFLAVIN)
FUNCTIONS - aids in protein and carbohydrate
metabolism and contributes to healthy skin and
normal vision SOURCES milk and dairy products,
organ meats, eggs, green leafy vegetables DEFICIEN
CY/CIES Cheilosis cracking and fissures at the
corners of the mouth Dermatitis inflammation of
the skin evidenced by itching, redness, and
various skin lesions Photophobia unusual
intolerance to light
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VITAMIN B3(NIACIN)
FUNCTIONS - involved in glycogen metabolism,
tissue regeneration and fat synthesis SOURCES
liver, fish, poultry, peanut butter, whole
grains DEFICIENCY/CIES Pellagra characterized
by 4Ds dermatitis, diarrhea, dementia, death,
headache, weight loss and abdominal pain
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VITAMIN B12(CYANACOBALAMIN)

• FUNCTIONS - formation of RBC and synthesis of
  DNA and RNA
• maintenance of nervous tissue
• blood formation
• SOURCES liver, meats, milk, eggs, cheese, shrimp
• DEFICIENCY/CIES Pernicious Anemia inadequate
  RBC formation due to lack of intrinsic factor
  from the stomach which is required for the
  absorption of Vitamin B12
• S/S numbness, confusion, depression, delusion,
  psychosis

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FOLIC ACID(FOLACIN)

• FUNCTIONS co-enzyme of in protein metabolism and
  cell growth
• RBC formation
• Note Important in early pregnancy which is
  essential for spine and spinal cord development
  in the fetus
• SOURCES green leafy vegetables, liver, organ
  meats, eggs, milk
• DEFICIENCY/CIES Glossitis, Anemia, Birth Defects
  (Neural tube defects)

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VITAMIN C

• FUNCTIONS - antioxidant
• protects against infection
• promotes healing
• aids in absorption of iron
• SOURCES citrus fruits, green peppers, broccoli,
  cabbage
• DEFICIENCY/CIES Scurvy characterized by small
  skin hemorrhages, sore gums

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MINERALS

• are inorganic substances found in nearly all body
  tissues and fluids
• Help build body tissue and regulate metabolism

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CALCIUM

• bone and teeth formation and maintenance
• conversion pf prothrombin to thrombin and other
  steps in coagulation process
• nerve impulse transmission
• contraction and relaxation of muscles
• regulation of materials in and out of cells
• DEFICIENCY/CIES
• Rickets
• Osteomalacia
• Osteoporosis

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IRON

• most iron in the body is found in hemoglobin
  is the red pigmented, iron containing protein
• Hemoglobin- carries oxygen from the lungs to the
  tissues and helps transport CO2 to the lungs
• DEFICIENCY/CIES Iron deficiency anemia

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SODIUM

• found primarily in the extracellular fluid in
  the body and as an ion, helps maintain the bodys
  fluid and acidbase balance

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POTASSIUM

• is found primarily in intracellular fluid and
  functions as protein synthesis, fluid balance,
  regulation of muscle contraction

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IODINE

• primarily located in the thyroid gland
• is a component of thyroid hormone
• regulates energy metabolism
• nervous and muscle cell functioning
• mental and physical growth
• DEFICIENCY/CIES Goiter, Cretinism
  characterized by muscle flabbiness, weakness, dry
  skin thick lips, skeletal retardation and severe
  mental retardation

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A P Review
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Digestion of protein foods begins in the mouth,
where the enzyme pepsin breaks protein down to
smaller units, however most protein is digested
in the small intestine The pancreas secrets the
proteolytic enzymes trypsin, chymotrypsin, and
carboxypeptidase. Glands in the intestinal wall
secrete aminopeptidase ad dipeptidase, which
break protein down into smaller molecules and
eventually into amino acids. Amino acids are
absorbed by active transport through the small
intestines into the portal blood
circulation Protein metabolism includes three
activities Anabolism (building
tissue) Catabolism (breaking down
tissue) Nitrogen balance (a measure of the degree
of protein anabolism and catabolism)
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Lipid digestion begins in the stomach, but they
are mainly digested in the small intestine,
primarily by bile, pancreatic lipase, and enteric
lipase. End products of lipid digestion are
glycerol, fatty acids, and cholesterol. They are
immediately reassembled inside the intestinal
cells into triglycerides and cholesterol esters,
which are not water soluble. The small intestine
and the liver must convert these into soluble
compounds called lipoproteins. Converting fat
into usable energy occurs through lipase that
breaks down triglycerides into adipose cells,
releasing glycerol and fatty acids into the
blood. Only the glycerol molecules in fat can be
converted to glucose
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Energy Balance

• Caloric value
• Basic Metabolic Rate (BMR)
• Resting Energy Expenditure (REE)

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Healthy Body Weight

• Balance between the expenditure of energy and the
  intake of nutrients
• Ideal Body Weight (IBW)
• Body Mass Index (BMI)
• less than 18.5 is considered underweight
• 18.5-24.9 normal
• 25-29.9 overweight
• 30-39.9 obesity
• Greater than 40 is extreme obesity

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Health Body Weight

• Other indirect body mass measures
• Percent body fat
• Waist circumference
• Skinfold testing
• Near-infrared interactance
• Bioelectrical impedance analysis (BIA)

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Nutrition assessment

• Nutrition assessment
• alert, responsive
• Skin normal tone turgor
• pink, moist mucous membranes gums
• healthy hair nails
• Laboratory findings
• hemoglobin, hematocrit
• plasma proteins - albumin

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Factors Influencing Nutrition

• Developmental considerations
• Gender
• Ethnicity and culture
• Beliefs about food
• Personal preferences
• Religious practices
• Lifestyle

• Economics
• Medications and therapy
• Health
• Alcohol consumption
• Advertising
• Psychologic factors

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Developmental Nutritional Considerations

• Neonate to 1 year
• Fluid and nutritional needs are met by breast
  milk or formula
• Addition of solid food to the diet between 4 and
  6 months of age
• By the age of 1, most infants can be completely
  fed on table food, and milk intake is about 20
  ounces per day

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Developmental Nutritional Considerations

• Toddler
• Can eat most foods and adjust to three meals each
  day
• By the age of 3 is able to bite and chew adult
  table food
• Caloric requirement is 900 to 1800 Kcal/day
• Need for adequate iron, calcium, and vitamins C
  and A are common deficiencies

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Developmental Nutritional Considerations

• Preschooler
• Eat adult foods
• Very active and often require snacks between
  meals
• Cheese, fruits, yogurt, raw vegetables, and milk
  are good choices

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Developmental Nutritional Considerations

• School-aged
• Require a balanced diet including 2400 Kcal/day
• Eat three meals a day and one or two nutritious
  snacks
• Need a protein-rich food at breakfast to sustain
  the prolonged physical and mental effort required
  at school

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Developmental Nutritional Considerations

• Adolescent
• Increased need for nutrient and calories during
  growth spurts
• Adequate calcium intake (1200 to 1500 mg/day)
• Health snacks and limits on junk foods

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Developmental Nutritional Considerations

• Adults
• Continue to eat a healthy diet, with special
  attention to protein, calcium, and limiting
  cholesterol and caloric intake
• Two or three liters of fluid should be included
  in the daily diet
• Postmenopausal women need to ingest sufficient
  calcium and vitamin D to reduce osteoporosis
• Antioxidants such as vitamin A, C, and E may be
  helpful in reducing the risks of heart disease in
  women

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Developmental Nutritional Considerations

• Elders
• Require the same basic nutrition as the younger
  adult
• Fewer calories are needed by elders because of
  the lower metabolic rate and the decrease in
  physical activity
• Some may need more carbohydrates for fiber and
  bulk, but most nutrient requirements remain
  relatively unchanged

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PREGNANCY LACTATION

• increase in calories, protein, calcium, folic
  acid(Folacin) and iron
• Pregnant women at particular risk for
  nutritional deficiencies are
• -adolescent, underweight women, obese women,
  women with chronic nutritional deficiencies
  chronic diseases such as diabetes/anemia , women
  who smoke, ingest alcohol or drugs

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LACTATING MOTHER

• diet should be increase in calcium, protein,
  fluid and calories

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Developmental Nutritional Considerations

• Elders continued
• Physical changes as tooth loss and impaired sense
  of taste and smell may affect eating habits
• Decreased saliva and gastric juice secretion may
  also affect nutrition
• Psychosocial factors may also contribute to
  nutritional problems

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Diets

• NPO
• Clear liquid
• Full liquid
• Soft
• DAT diet as tolerated
• Restrictive diets

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Food Pyramids
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Food Pyramids
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Food Pyramids
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Nutritional Screening and Assessment

• Purposes
• Assessment performed to identify clients at risk
  for malnutrition
• Clients found to be at moderate or high risk are
  followed with a comprehensive assessment by a
  dietician
• Nursing homes residents whose percent of meals
  eaten falls below 75 receive a full nutritional
  assessment by a nurse

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Nutritional Screening and Assessment

• Nursing history
• Physical examination
• Calculating percentage of weight loss
• Dietary history
• Anthropometric measurements
• Laboratory data
• Measuring skinfold

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Nutritional Screening and Assessment
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NUTRITIONAL STATUS

• Body Mass Index
• is the measure that describes a persons relative
  weight and height
• BMI wt in kg / (height in meters)2
• is calculated as weight in kilograms divided by
  height ( in meters) squared
• if pounds inches are being used, the formula
  is
• (weight in lbs) /(height in inches squared)
  x 704.5

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Guide for BMI Evaluation lt 16
Malnourished lt 18.5 Underweight 18.5
24.9 Normal 25.0 29.9 Overweight 30.0
34.9 Moderately 35.0 39.9 Severely
obese gt 40 Morbidly Obese
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IDEAL BODY WEIGHT

• is the estimated weight optimal for body
  functioning health
• introduced by Metropolitan Life Insurance
  Company in 1942 1943

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APPROXIMATING IDEAL BODY WEIGHT
Rule of Thumb Women - 5 feet
should weigh 100 lbs and for every additional
inch add 5 lbs Men- 5 feet should weigh 105 lbs
and for every additional inch add 6 lbs
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PHYSICAL STATUS

• General appearance
• Physical Assessment
• Skin
• Oral cavity
• Hair, nails
• Bones
• Muscles
• Normal reflexes

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NUTRITIONAL SCREENING

• is the process of uncovering the characteristics
  known to be associated with dietary or
  nutritional problems.
• Its purpose is to identify individuals who are at
  risk for nutritional problems or who have
  unrecognized malnutrition.

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Malnutrition
B
C
A
D
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Malnutrition Risk Factors

• Diet history
• Chewing and swallowing difficulties
• Inadequate food budget, food intake, preparation
  and storage facilities
• IV fluids
• Living and eating alone
• No intake for gt 7 days
• Physical disabilities
• Restricted or fad diets

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Malnutrition Risk Factors

• Medical history
• Adolescent pregnancy or closely spaced
  pregnancies
• Alcohol/substance abuse
• Catabolic or hypermetabolic conditions
• Chronic illnesses
• Dental problems
• Neurologic or cognitive impairments
• Oral and GI surgeries
• Unintentional weight loss or gain

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Malnutrition Risk Factors

• Medication history
• Antacid
• Antidepressants
• Antihypertensives
• Anti-inflammatory
• Antineoplastic
• Aspirin
• Digitalis
• Diuretics
• Laxatives
• Potassium chloride

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Nursing Interventions for Optimal Nutrition

• Hospitalized Client
• Provided in collaboration with the primary care
  provider and the dietician
• Reinforce information presented by dietician
• Create an atmosphere that encourages eating
• Provide and assist with eating
• Monitor the clients appetite and food intake
• Administer enteral and parenteral feedings
• Consult with primary care provider and dietician
  about nutritional problems

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Nursing Interventions for Optimal Nutrition

• Community Setting
• Education

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Nursing Interventions for Optimal Nutrition

• Home Setting
• Refer clients at risk to appropriate resources
• Instruct clients about enteral and parenteral
  feedings
• Offer nutritional counseling as needed
• Assisting clients with special diets
• Stimulating the appetite
• Assisting clients with meals
• Referring to special community nutritional
  services
• Providing enteral and parenteral nutrition

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Nursing Interventions

• Assisting with special diets
• Stimulating the appetite
• Referring to community nutritional services
• Providing enteral and parenteral nutrition

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NANDA Nursing Diagnoses

• Related to nutritional problems
• Imbalanced Nutrition More Than Body Requirements
• Imbalanced Nutrition Less Than Body Requirements
• Readiness for Enhanced Nutrition
• Risk for Imbalanced Nutrition More Than Body
  Requirements
• Activity Intolerance
• Constipation
• Low Self-Esteem
• Risk for Infection

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Desired Outcomes

• Maintain or restore optimal nutritional status
• Promote healthy nutritional practices
• Prevent complications associated with
  malnutrition
• Decrease weight
• Regain specified weight

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Planning and Evaluation

• Intervention selected to meet goals
• Evaluation based upon criteria set in outcomes

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Enteric Tube Feeding

• Intermittent
• Via nasogastric
• Via gastrostomy (PEG)
• Continuous
• Via small bore nasogastric
• Via jejunostomy
• Check placement
• Management

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COMMUNITY RESOURCES

• Home Delivered Meals such as Meals on Wheels
  homebound people
• Food Stamps and Food Banks
• Local Senior Center

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Happy eating!!