Nutrition Flashcards
What is Nutrition?
It is the “study of food and how it affects the human body and influences health”
What are nutrients?
are biochemical substances that affect growth, development, reproduction, activity, health maintenance, and the body’s ability to recover from illness and injury
What is metabolism?
Metabolism is the “process by which the body converts food into energy”
Recommended Dietary Allowance (RDAs): Nutrition guidelines to meet nearly all healthy people
The Guidelines:
- Follow a healthy eating pattern across the lifespan
- Food and beverage choices matter
- Choose a calorie intake appropriate to maintain healthy body weight, support nutrient adequacy, and reduce the risk of chronic disease
- Focus on variety with all food groups that are nutrient-dense
- Limit calories from added sugars and saturated fats and reduce sodium intake
- Support healthy eating patterns in multiple settings nationwide, from home to school to work to communities
6 Classes of Nutrients:
Essential nutrients: Nutrients that must be supplied in diet or supplements:
1-Carbohydrate
2-Protein
3-Fat
These 3 above are macro-nutrients that provide energy to the body.
1-Vitamins
2-Minerals
3-Water
These 3 above are micro-nutrients: they regulate the body’s processes.
Non-Essential nutrients: Not essential for body function or are synthesized (made) in adequate amounts by the body
Energy balance = ?
Total energy intake - Total daily expenditure.
The amount of energy a person requires is dependent: on age, sex, activity level, weight, height, and health conditions
How is energy measured?
Energy is measured in Kcal (kilocalorie)
1 gram of carbohydrate = 4 Kcal
1 gram of protein = 4 Kcal
1 gram of fat = 9 Kcal
Daily caloric requirements: Several formulas are available. Simplest:
20 to 35 kcal/kg body weight
Glycogenesis:
excess glucose stored in form of glycogen in the liver
Carbohydrates and proteins are converted to fat in excess and stored as triglycerides in the liver or fat cells (adipose tissue)
Glycogenolysis
When glycogen is broken down into glucose for energy
Carbohydrates (CHO)
CHO: the primary source of energy
CNS relies exclusively on glucose for energy
Chief protein-sparing energy source
Easier and faster to digest than proteins and fats
All CHO converted to glucose for transport in the blood
Glucose transported to GI tract →portal vein → liver for storage
Glycogenesis: excess glucose stored in form of glycogen in the liver
Carbohydrates and proteins are converted to fat in excess and stored as triglycerides in the liver or fat cells (adipose tissue)
Glycogenolysis: When glycogen is broken down into glucose for energy
Blood glucose is regulated by the hormones insulin and glucagon
The body completely metabolizes glucose (unlike fats and proteins which leaves behind ketones - toxic byproduct)
What are Monosaccharides (simple)?
Single-stranded sugar molecule
Glucose
Fructose
Found in fruits and honey
What are Disaccharides (simple)?
Disaccharides (simple)
Double-stranded sugar molecule
Sucrose (table sugar)
Maltose (malted grains)
Lactose (milk)
Complex carbohydrates (polysaccharides)?
Starches such as cereal grains, starches, and legumes
Ideal amounts of carbs a day?
Ideally 45% to 65% of daily caloric needs
Should include 14 g of fiber/1000 kcal
How many variations of amino acids do proteins have?
Made of 22 variations of amino acids which are the basic building blocks for life:
Proteins are essential for?
Essential for the formation of all body structures:
1-genes
2-enzymes
3-muscle
4-bone matrix
5-skin and blood.
What are the 2 types of proteins?
- Complete proteins
- Incomplete proteins
Complete proteins:
Contains all essential amino acids to support growth
Animal proteins: eggs, dairy, meat
Incomplete proteins:
Lacks one or more amino acids
Plant proteins: grains, legumes, vegetables (some exceptions: soy, buckwheat, hemp, etc. )
10% to 35% of daily caloric needs
Protein Metabolism
Protein metabolism:
Ingested protein → broken down to amino acids by pancreatic enzymes in small intestine → absorbed by GI mucosa → liver→recombined into new proteins or release into bloodstream for protein synthesis by tissues and cells
Excess converted to fatty acids or used for fuel
*Breaking down protein for energy forms ketones which is toxic for kidneys in excess
Body in constant flux between tissue breakdown (catabolism) and tissue rebuilding (anabolism)
Nitrogen balance compares protein intake vs protein excretion (loss via urine, stool, hair, nails, skin) Nitrogen is a fundamental component of amino acids, which are the molecular building blocks of protein. Therefore, measuring nitrogen inputs and losses can be used to study protein metabolism.
Positive nitrogen balance (intake > excretion) occurs in growth spurts, pregnancy, lactation, illness recovering
Negative nitrogen balance (intake < excretion) occurs with starvation, and conditions such as surgery, illness, trauma, stress when the body is overwhelmed
Fats (Lipids)
A major source of energy
Insoluble in water and blood
95% of lipids in diet are triglycerides
5% are phospholipids and cholesterol
Carriers of essential fatty acids and fat-soluble vitamins
20% to 35% of total daily caloric intake (<10% from saturated and trans fat)
9 kcal/g
Unhealthy fats
Saturated fat and trans fat
Lacks double bonds between carbons leading to solid form at room temp
Animal source
Raises serum cholesterol
Healthy fats
Unsaturated fat: Mono-and poly-unsaturated fats
Contains at least one double bond between carbons; liquid at room temp
Olive oil, salmon, avocado
Lowers serum cholesterol
Where is fat metabolized?
In the small intestine
Fat metabolism process?
Occurs in the small intestine
Bile secreted by the gallbladder emulsifies fat for pancreatic lipase to break down fat more efficiently
Most fats are absorbed in the lymphatic system and transported to the liver
Only 3% of fats eaten are excreted in the stool
the body has to burn off excess fat
What is cholesterol?
Cholesterol sources: produced by the liver and consumption of animal foods
Essential for cell membrane, the precursor of steroid hormones and Vitamin D, synthesizes bile acids
LDL (low-density lipoprotein)
The “bad” cholesterol
High levels lead to plaque buildup → atherosclerosis
HDL (high-density lipoprotein
The “good” cholesterol
Carries LDL away from body to liver for processing
Triglyceride
Most common type of fat
Liver converts excess CHO as glycogen or converted to triglycerides and stored in adipose tissue
What are vitamins?
Organic compounds are required for normal metabolism and prevention of diseases related to deficiency
- Not made by the body; must be consumed
Water soluble: vitamin C and B-complex? B for blood stream
absorbed directly by the small intestine and into the bloodstream
Not stored; excess excreted in the urine
Fat-soluble: vitamins A, D, E, K
Inadequate amounts lead to deficiency syndromes
Vit C deficiency →Scurvy
Vit D deficiency →Rickets in children; osteomalacia in adults
Folate (Folate is the natural form of vitamin B9) and Iron → Anemias
Absorbed with fat and carried in the lymphatic circulation; must be attached to a protein to be transported in the blood
Excess stored in the liver and adipose tissue
What are Minerals?
- Inorganic elements found in nature (food and supplements)
- For tissue building, nerve impulse, fluid regulation, bone and blood health
- Not broken down by body
- Major minerals (macrominerals)
Required in amounts of > 100 mg/day
e.g. Calcium, phosphate, sodium, potassium, magnesium - Trace minerals (microminerals)
Essential but in low amounts < 100 mg/day
e.g. Iron, Zinc, Iodine, fluoride
2 Major types of minerals?
- Major minerals (macrominerals)
Required in amounts of > 100 mg/day
e.g. Calcium, phosphate, sodium, potassium, magnesium - Trace minerals (microminerals)
Essential but in low amounts < 100 mg/day
e.g. Iron, Zinc, Iodine, fluoride
Water?
Water is more vital to life than any other nutrient
- Major body constituent in every body cell
- Accounts for 50-60% of an adult’s body weight
* ⅔ in intracellular space
* ⅓ in extracellular space
- Average adult requirement: 2.2 -3L/day
- Water balance and levels in the body are affected by :
* renal function
* fever, perspiration, tachypnea, severe burns
* diarrhea, vomiting
* Draining fistulas and drainage tubes
* Hemorrhage
* Prolonged open abdominal surgery
Water source: fluid and food intake and produced during the metabolism of CHO, protein, fat
- Water depletion through urine, stool, insensible loss (breathing and perspiration)
Special Diets:
Vegetarian
Lacto-Ovo vegetarians
Vegans
Vegetarian Diet?
Exclusion of meat from the diet
Need a well-planned diet to avoid vitamin, protein, and iron, deficiencies
Lacto-ovo vegetarian Diet ?
Plant food diet and occasional dairy products and eggs
Risk for vitamin and mineral deficiencies
Iron deficiency
Vegan diet ?
Exclusive plant foods
Can develop megaloblastic anemia and neurologic signs of deficiency
Require fortified foods with Cobalamin (vitamin B12)
Cardiac diet?
2g of Na a day only (Cardiac diet)
Renal diet?
low K and Na
NPO vs strict NPO
?
Npo a secas you can take some medicine and ice chips.
Diabetic diet?
low carbohydrate and sugar-free
Dysphagia diet? difficulty swallowing
- For patients with difficulty swallowing or increased risk of aspiration
- Need to thicken thin liquids or puree. Thicker consistency like pudding is recommended
Fluid restriction?
common for patients with heart failure or SIADH)
The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a disorder of impaired water excretion caused by the inability to suppress the secretion of antidiuretic hormone (ADH) [1]. If water intake exceeds the reduced urine output, the ensuing water retention leads to the development of hyponatremia (low sodium)
Diarrhea – BRAT (Banana, Rice, Apple sauce, Toast/Tea)?
Important also to assess for adequate fluid intake for patients having diarrhea
No longer recommended for it is unnecessarily restrictive
Factors Affecting Nutrition?
- Cultural preferences
- Integrate culture foods into meals if not contraindicated
- Be mindful about including foods with herbal supplements because they have chemicals that actually act like medicine.
- Religious practices
- Dietary restrictions during sacred holidays
- Hindus do not eat beef
- Kosher diet in the Jewish religion
- Developmental age
- Periods of growth, pregnancy, and lactation require high caloric intake and vitamins
- Fad diets
- Food insecurity/Food Access
- Medication effects
- Alcohol consumption
- Eating disorders
- Health disorders
- anemia
- short gut syndrome
- Trauma, surgery, burns
- Chronic disorders: DM, CAD, cancer
- Elderly
Chronic Ethanol Consumption ETOH?
- Hypertension
- Cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body)
- Dyslipidemia (s the imbalance of lipids such as cholesterol, low-density lipoprotein cholesterol, (LDL-C), triglycerides, and high-density lipoprotein (HDL). )
- Pancreatitis
- Obesity
- Hepatic dysfunction (ASH)
- Fetal alcohol syndrome
- Addiction
Chronic Fructose Consumption?
Hypertension
Myocardial infarction
Dyslipidemia
Pancreatitis
Obesity
Hepatic dysfunction (NASH: Nonalcoholic fatty liver disease)
Fetal insulin resistance
Habituation, if not addiction
Age-Related Changes Affecting Nutrition?
Altered ability to chew (edentulus or poor dentition)
Loss of sense of taste or smell
Decrease peristalsis
GERD (Gastroesophageal reflux disease: A digestive disease in which stomach acid or bile irritates the food pipe lining)
Lower glucose tolerance
Reduction in appetite and thirst sensation
Physical disability
* arthritis pain, gout
Social isolation and depression
Food access
Osteoporosis → ↑ risk of osteoporosis and fractures
Nutrition Assessment
Interview
-Recent weight loss or gain
-Appetite and special diets
-Chronic conditions
-Exercise pattern
-Nutrition/food access
Assessment
-Measure height and weight person for BMI
-Assess dysphagia → indication of high aspiration risk
-Nutritional lab studies: albumin, prealbumin, transferrin, Hg, Fe, blood glucose, lipid panel
Prealbumin ?
A protein synthesized by the liver
half-life of 2-3 days
Better indicator of recent or current nutritional status
Most accurate in identifying early protein or calorie malnutrition
Albumin:
Albumin value lags behind actual protein changes by > 2 weeks (20-22 days)
Not a good indicator of acute changes in nutritional status
Check Table 9.6 power point
Nutrition Assessment
Diagnosis
Imbalanced nutrition less than body requirement r/t… food security, chronic illness, poor appetite, etc.
Readiness for enhanced nutrition as e/b desire to lose weight, reduce alcohol consumption, etc.
Planning
Collaborate with dietician
Consult social worker for etoh cessation programs
Monitor daily nutritional labs and blood gluocose
Implementation
Social worker and dietician ordered for consult
Daily nutritional labs drawn and blood sugar checks before meals
Assisted patient with menu selection
Evaluation
Evaluate results of planned interventions
Routes of Nutrition?
Enteral
Oral
Gastrointestinal
Parenteral
Intravenous (peripheral or central)
Oral Feeding
- When patient has normal swallowing reflexes (+ cough and gag)
- Completely awake, alert, follows commands
- Sit up at 90 degree; preferably in chair
- Follow ordered diet
- Sit up for at least 30 min after meals
- For patients with nutritional deficit:
- High-calorie supplements
-Milkshakes
- Ensure, Glucerna for DM patients,
-Nepro for renal failure patients - Consult dietician
Enteral Nutrition?
Often referred to as tube feeding
Administration of nutritionally balanced liquified food or formula through a tube inserted into:
Stomach
Duodenum
Jejunum
- Also inserted for medication administration in a sedated/comatosed patient
- Provides nutrients alone or is a supplement to oral or parenteral nutrition
Enteral vs Parenteral nutrition
Maintains gut function
Easily administered
Infection risk: Enteral < Parenteral route
Physiologically more efficient than parenteral
Less expensive than parenteral
Indications for Enteral Nutrition. Meaning when is it used
- Indications include those with:
1- Anorexia
2- Frequent aspirations
3- Orofacial fractures
4- Head/neck cancer
5- Burn victims
6- Nutritional deficiencies
7- Neurologic conditions
8- Psychiatric conditions
9- Chemotherapy
Percutaneous Endoscopic Gastrostomy (PEG)
When longer-term enteral feeding is anticipated:
More comfortable
Tube replaced every few months
Laparoscopically (a type of surgical procedure that allows a surgeon to access the inside of the abdomen ) placed in interventional radiology
Percutaneous Endoscopic Jejunostomy
A J-tube is considered in the following circumstances:
-Gastroparesis (a condition that affects the normal spontaneous movement of the muscles (motility) in your stomach)
-GERD
-High-risk aspiration
-If surgery is needed on
stomach/esophagus at a later point
Insertion of Feeding Tube
Nasogastric and nasointestinal tubes:
- Inserted through the nasal cavity directly to the GI tract
- Confirmed by x-ray prior to use
- Tube can be inadvertently placed in lungs or sinuses
- Observe for cough, change in voice, respiratory distress
- ↓ the likelihood of regurgitation and aspiration when placed post-pyloric
- Nasogastric feeding tube is the best choice to use if the tube feeding plan is < 6 weeks
Nasogastric/Nasointestinal Tubes
Insertion:
- Measure from nose to earlobe to tip of xiphoid process (approximates position of stomach)
- Most tubes have cm markings so note approximately how far the tube should go
- Ask the patient to flex chin to chest
- Ask patient to swallow once the tube passes the nasopharynx to the epiglottis
- Insert gently and never force if obstruction is met
- Advance the tube as the patient swallows
- May be necessary to change the angle and rotate the tip as it is inserted
- Observe the patient closely
***Prior to feeding, X-ray confirmation must be done and nursing order ”ok to use”
Do not rely on auscultation of abdomen or pH strips
Record and documented insertion length; use sharpie to mark if tube has no measurement marking
**Follow individual hospital policy and procedures for feeding tube placement
and maintenance
Check slide 38
Complications of feeding tube and nasogastric tube?
- Aspiration pneumonia (most serious)
*Insert post pyloric - HOB (head of bed)>30-45°, maintain upright for at least 30 min- 1° after
bolus feed - Check tube placement and residual
- Tube migration: by vigorous vomiting or coughing
- Clogged tube
*Flush tube with sterile water per policy
*Crush meds finely - Nasal or gastrointestinal erosion (Erosive gastritis causes both inflammation and erosion (wearing away) of the stomach lining.)
- Check skin under securement
- Diarrhea
- Do not hang more than 4° worth of modular formula and 8° vol of pre-packaged formula; change system Q 12-24°
- Stoma infection -assess skin and cleanse around the stoma
Nursing Responsibilities: Enteral Nutrition meaning feeding tube and nasogastric tube.
- Assess for residual per hospital policy (generally every 4-8hrs)
- Insertion length verified and documented every shift
- Securement tape should also be changed every day to assess skin
- Eyeball for same marking before administration of feeding/meds
- Check for protocols such as hanging D10 when tube feed nutrition interrupted to prevent hypoglycemia
- Will need MD order to restart tube feeding
Nursing Responsibilities Enteral Nutrition 2.0
- Patient position:
- Patient should be sitting or with HOB at 30 to 45° if in bed
- HOB remains elevated for 30 to 60 minutes for intermittent delivery
- Continuous feedings administered on the feeding pump
- Aspiration precautions
- Tube patency
- Flush with sterile water before/after each feeding, drug administration, and after residual checks
- Flush with 5mL of sterile water between meds
- Depending on order: usual residual withhold order is >250- 400mL
- If residual is less than hold order, simply document feeding and refeed residual
Enteral Nutrition Delivery modes?
- Continuous infusion by pump
- Intermittent by gravity or syringe
- NEW PRACTICE per JCAHO
Delivery mode continuous infusion by pump:
Usually gradual increase in rate every 8-12hrs
until patient reaches ordered goal rate
Delivery mode Intermittent by gravity or syringe
Vol usually 200 to 500 mL per feeding
Remember to flush with 30mL water before after feeding so tube does not clog
Cyclic feedings by an infusion pump (feeding by electric enteral feeding pump over a period of )
Delivery mode NEW PRACTICE per JCAHO (Joint Commission on Accreditation of Healthcare Organizations)
Flush 30 ml of sterile water before and after med administration / Feeding
Flush 5 ml of sterile water in between meds
10 ml sterile water to dissolve meds
Meds are never combined; not a Nursing scope of practice – considered compounding meds
Enteral Nutrition: Nursing Considerations?
- Daily weights
- Assess bowel sounds and abdominal distention
- Monitor bowel movements
- Accurate intake/output
- Check the order for free water boluses (for patients with hypernatremia) coz if there is very low levels of water sodium levels can increase dangerously
- Refeeding syndrome (the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding)
- Dehydration
- More calorically dense, less water
contained in formula - High protein content
- Initial glucose checks
-Label enteral bag with patient name, formula type, date and time started - Enteral bags changed every 12-24h
- Wear gloves when hanging feeding
Pathophysiology: Refeeding Syndrome
Starvation of nutrients for many consecutive days or metabolically stressed d/t critical illness leads to:
-Depletion of intracellular minerals, especially phosphate
- Using fatty acids and amino acids for fuel
- Insulin (decreases blood sugar levels) secretion is suppressed; glucagon (a hormone)release increase (Glucagon increases your blood sugar level )
When “refeeding”:
- Insulin secretion resumes in response to sugar sources
- Glycogen, fat and protein synthesis require phosphate, mag, and potassium which are already depleted leads to further decrease
- Hallmark of refeeding syndrome leading to Hypophosphatemia
- Fluid retention and electrolyte imbalances ensues
Check slide 45
Preventing feeding syndrome:
Identify individuals at risk
Correct depleted electrolytes before refeeding
Initiate nutrition support at approximately 25% of the estimated goal. 3-5 days before reaching the goal rate.
Serum electrolytes and vital signs monitored carefully after initiation
Preventing feeding syndrome:
Identify individuals at risk
Correct depleted electrolytes before refeeding
Initiate nutrition support at approximately 25% of the estimated goal and advance over 3-5 days to the goal rate
Serum electrolytes and vital signs monitored carefully after initiation
Enteral Nutrition: Complications continue
Gastrostomy or jejunostomy tubes:
-Skin irritation around the tube
*Skin assessment and care
*Tube dislodgement
*Teach patient/family about feeding administration, tube care, and complications
-Fistulas -entero-cutaneous (is an abnormal connection that develops between the intestinal tract or stomach and the skin)
-Infections: skin, fasciitis (inflammation of the fascia), peritonitis ( peritoneum: the serous membrane lining the cavity of the abdomen and covering the abdominal organs)
-Abdominal wall or intraperitoneal bleeding and bowel perforation
-Obstruction or erosion of the gastric wall
-Gastric mucosa hypertrophy (overgrowth of the cells that make up the mucosa.)
Enteral Nutritiongerontologic Considerations?
- More vulnerable to complications
*Fluid and electrolyte imbalances
*Glucose intolerance
*Decreased ability to handle large volumes
*Increased risk of aspiration
Parenteral Nutrition Parenteral nutrition (PN)
-Administration of nutrients by route other than GI tract (i.e. Intravenously)
-Used when
* GI tract cannot be used for ingestion, digestion, and absorption of essential nutrients
Parenteral Nutrition indications and composition:
Indications:
Chronic or intractable diarrhea and vomiting
Complicated surgery or trauma Post GI surgery
GI obstruction
GI tract anomalies and fistulae
Sepsis (the body’s extreme response to an infection)
Severe malnutrition
Malabsorption
Pancreatitis
Composition:
Base solutions contain dextrose and protein in the form of amino acids
Prescribed electrolytes, vitamins, and trace elements are added to customize the patient need
IV fat emulsion is added to complete the nutrients
*Different from crystalloid solutions in that crystalloids do not contain amino acids or vitamins
Parenteral Nutrition: Administration Method. Central Parenteral Nutrition: (large vein. vena cava)
Base Solution 20-25% dextrose
- May only be infused via central access due to the risk of thrombophlebitis (blood clot) caused by hypertonic (too much glucose ) solution of TPN (total parenteral nutrition )
- Tip of catheter lies in superior vena cava where vesicant and irritant solutions are safe to be administered
*Central catheter to internal jugular vein to superior vena cava
*Peripherally inserted central catheters (PICCs) - For longer term nutrition support
Parenteral Nutrition: Administration Method. Peripheral Parenteral Nutrition:
The base solution must be < 20% dextrose
-Through the peripherally inserted catheter
-Short-term
-When lower protein and calorie content is required
Parenteral Nutrition: Complications?
Hyperglycemia and hypoglycemia
Fluid, electrolyte, and acid base imbalances
Hyperlipidemia when lipids used
Phlebitis (inflammation of a vein)
Infection and bacteremia
Gallbladder and liver disease
Thrombosis (occurs when blood clots block veins or arteries)
Parenteral Nutrition: Nursing Management/Care
- Vital signs every 4 to 8 hours
- Daily weights
- Regular blood glucose monitoring
**Check initially every 4 to 6 hours - Check labs: Electrolytes, BUN, Creatinine, CBC, liver function enzymes
- Assess the central access site
*Site assessment for phlebitis
*Dressing change every 7 days or as needed
*Use sterile technique with dressing changes
*Assess for refeeding syndrome
*Infusion pump must be used
Parenteral Nutrition: Nursing Management 2
Before administering, check label and ingredients against order
Examine bag for signs of contamination, leaks, color, particulate matter, clarity, cracking
- MUST replace solution and tubing every 24 hours even if the bag hanging is not empty
- If the solution is not available, hang D10W to prevent hypoglycemia
Tubing with filter is required for TPN
Do not abruptly discontinue TPN
- Decrease rate by half for one hr then stop. Check blood sugar in an hr.
- Monitor for infection and bacteremia:
*Local infection
*Erythema
*Tenderness
*Exudate at catheter insertion site
- Systemic Infection – High risk associated with TPN
*Fever, chills
*Nausea/vomiting
*Malaise
Parenteral Nutrition: Nursing Management
Before administering, check label and ingredients against order
Examine bag for signs of contamination, leaks, color, particulate matter, clarity, cracking
- MUST replace solution and tubing every 24 hours even if the bag hanging is not empty
- If the solution is not available, hang D10W to prevent hypoglycemia
Tubing with filter is required for TPN
Do not abruptly discontinue TPN
- Decrease rate by half for one hr then stop. Check blood sugar in an hr.
- Monitor for infection and bacteremia:
*Local infection
Erythema
Tenderness
Exudate at catheter insertion site
*Systemic Infection – High risk associated with TPN
Fever, chills
Nausea/vomiting
Malaise
Parenteral Nutrition: Nursing Management continues
- Perform DTTP (differential time to positivity) blood cultures when systemic infection is suspected
Differential time to positivity
Differentiates infection likely source from catheter or blood
Samples must be drawn no more than 15 min apart and collect same amount of blood for each sample
If the sample from catheter grows bacteria < 2hrs before peripheral sample, the likely source of infection is from catheter - Chest X-ray: To check changes in pulmonary status
- Urinalysis and Urine culture
When 60% of caloric needs met orally, then can discontinue PN or EN nutrition
Malnutrition?
Deficit, excess, or imbalance in essential components needed for a balanced diet
Under-nutrition:
Poor nourishment due to inadequate consumption or disease process
Over-nutrition:
Ingestion of more food than body requires
Malnutrition: Etiology
- Starvation-related malnutrition
Primary protein-caloric malnutrition (PCM)
Nutritional needs not being met
Chronic starvation without inflammation
Anorexia nervosa - Disease or injury-related malnutrition
Secondary Protein Calorie Malnutrition (SCM)
Sustained mild to moderate inflammation
Conditions including organ failure, cancer, rheumatoid arthritis, and other autoimmune disorders, obesity, and metabolic syndrome
Ex: Major infections, burns, trauma, closed head injury
Malnutrition 2.0
-Contributing factors
*Socioeconomic factors – food insecurity
*Physical illnesses
Illness, surgery, injury, hospitalization
Malabsorption syndrome
Fever
Incomplete diets, vitamin deficiencies
-Impaired absorption of nutrients from the GI tract as a result of:
*pancreatitis: ↓ digestive enzymes
*Drug side effects
* short gut syndrome: ↓ bowel absorption
Malnutrition: Pathophysiology?
- Initially during the starvation process, there is a decreased BMR, sparing of skeletal muscle, and decreased protein breakdown
- In inflammatory states, alterations in expression of proinflammatory (interleukin-6) and antiinflammatory cytokines (interleukin-10).
- Cytokine changes result in:
Increased protein and skeletal muscle breakdown
Increased BMR
Decreased protein (albumin, prealbumin) production
Increased C-reactive protein production
Malnutrition: Pathophysiology 2.0?
- Starvation process
*Prolonged starvation: 97% of calories from fat and protein
*Fat stores depleted in 4 to 6 weeks, depending on amount available - Once fat stores used, body protein no longer spared
- Liver function impaired
- Protein synthesis diminished
- Low albumin leads to ↓ plasma oncotic pressure
*Fluid shifts from vascular space into interstitial space - Na+/K+ pump fails due to deficiency in calories and proteins
Malnutrition: Clinical Manifestations?
Mild to emaciation:
*Skin dry and scaly, brittle nails, hair loss
*Mouth and tongue: crusting and ulceration,
*Muscles-wasting, decreased mass and weakness
*CNS -mental status changes such as confusion and irritability
*Fatigue
*Increased susceptibility to infection
*Anemia related to deficiencies in iron and folic acid, chronic dx
Malnutrition: Nursing Management of Imbalanced Nutrition < Body Requirements
-Daily calorie count
-High-protein, high-calorie foods or feedings
-Multiple, small feedings
-Supplements
-Appetite stimulants such as Megace and Marinol
-Regular weight schedule
-Diet diary
-Dietitian consult
-Social work consult for help with purchasing food/meal preparation
-Discharge instructions
Diabetes Mellitus?
-A chronic multisystem disease related to abnormal insulin production, impaired insulin utilization, or both
-Affects 25.8 million people; incidence Type II DM on the rise and affecting children
-7th leading cause of death
-Leading cause of
*Adult blindness
*End-stage kidney disease
*Nontraumatic lower limb amputations
-Major contributing factor
*Heart disease
*Stroke
*Hypertension
HYPERGLYCEMIA signs and causes?
Elevated BG (>180mg/dl)
Increase in urination
Increased in Thirst
Increase appetite
Glycosuria
Weakness
Fatigue,
Headache
Nausea
Abdominal cramps
Blurred vision
Progression to DKA or HHS
DKA- Daibetic Ketoacidosis
HHS- Hyperosmolar Hyperglycemic Syndrome
HYPERGLYCEMIA CAUSES?
Intake > expenditure
Illness, Infection
Corticosteroids
Improper diabetic management
Inactivity
Emotional or physical stress
HYPERGLYCEMIA TREATMENT/INTERVENTIONS
Insulin
Oral Antidiabetic Agents
Frequent blood glucose checks
Check blood/ urine for ketones
Fluid replacement
HYPOGLYCEMIA SIGNS AND SYMPTOMS?
BG <70mg/dl
Cool Clammy Skin
Hunger
Numbness of fingers, toes mouth
Rapid Heartbeat
Irritability
Headache
Faintness, shakiness
Dizziness, unsteady gait
slurred speech,
Changes in vision
Seizure, coma
Hypoglacimia CAUSES ?
Inadequate food consumption
Alcohol abuse
Overmedication of diabetic medication
Strenuous exercise without adequate food intake
Loss of weight without change in dose of medication
Use of Beta Adrenergic Blockers – interfering with recognition of symptoms
TREATMENT/INTERVENTIONS for hypoglycemia.
Conscious patient:
Eat or drink 15 grams of quick acting carbohydrate
Orange Juice or Regular soda
4-6 oz
Hard candy/Glucose tabs
Wait 15 min then recheck blood
glucose level
Once stable, give longer acting carbs
Worsening symptoms, or unconscious pt:
SQ or IM of 1mg Glucagon
IV administration (IVP) of 25-50 ml of 50% Glucose / Dextrose
(also for pts unable to eat or drink)
Collaborative Care for DM?
- Goals of diabetes management
*Decrease symptoms
*Promote well-being
*Prevent acute complications
*Delay onset and progression of long-term complications
-Need to maintain blood glucose levels as near to normal as possible
-Patient teaching
*Nutritional therapy
*Drug therapy
*Exercise
*Self-monitoring of blood glucose
-Diet, exercise, and weight loss may be sufficient for patients with type 2 diabetes
-All patients with type 1 require insulin
Oral Hypoglycemic Agents
-Metformin (Glucophage) most commonly used
-Reduces glucose production by liver
-Enhance insulin sensitivity
-Improve glucose transport
-May cause weight loss
-Also used in prevention of type 2 diabetes
-Least likely to cause hypoglycemia
-Hold med if patient is undergoing surgery or radiologic procedure with contrast medium
*24-48 before procedure and at least 48 hours after
*Monitor serum creatinine
-Contraindications
*Renal, liver, cardiac disease
*Excessive alcohol intake
Nutritional Therapy
ADA healthy food choices for improved metabolic control
*Maintain blood glucose levels to as near normal as safely possible
*Normal lipid profiles and blood pressure
*Prevent or slow complications
*Maintain pleasure of eating
*Consistent carbohydrate diet
-Meal plan is based on individual’s usual food intake and is balanced with insulin and exercise patterns
-Day-to-day consistency important for patients using conventional, fixed insulin regimens
-More flexibility with rapid-acting insulin, multiple daily injections, or insulin pump
Health Promotion
- Ambulatory and home care
*Assess patient’s ability to perform BG injection and insulin injection
*Assess patient/caregiver knowledge and ability to manage diet, medication, and exercise therapy
*Teach manifestations/treatment of hypoglycemia and hyperglycemia
What is Glycogenesis?
Glycogenesis: excess glucose stored in form of glycogen in the liver
Carbohydrates and proteins are converted to fat in excess and stored as triglycerides in the liver or fat cells (adipose tissue)
What is Glycogenolysis?
Glycogenolysis: When glycogen is broken down into glucose for energy
Blood glucose is regulated by the hormones insulin and glucagon
The body completely metabolizes glucose (unlike fats and proteins which leaves behind ketones - toxic byproduct)
