Nutrition Ch.38 Flashcards
1
Q
Basal Metabolism (basal metabolic rate[BMR])
A
the energy (number of calories) required to fuel involuntary activities of the body at rest after a 12-hour fast–the energy needed to sustain the metabolic activities of cells and tissues
ex:
- maintaining body temp. and muscle tone
- producing and releasing secretions
- propelling food through the GI tract
- inflating the lungs
- contracting the heart muscle
2
Q
Body mass index (BMI)
A
the ratio of weight (in kilograms) to height (in meters squared)
- provides an estimate of body fat and can e used as an initial assessment of nutritional status
- provides an estimation of relative risk for diseases that can occur with more body fat (such as heart disease, type-2 diabetes, hypertension, and certain cancers)
3
Q
Table 37.1 - Know the categories used for BMI
A
4
Q
Box 37.2 Key Recommendations of the Dietary Guidelines for Americans 2020-2025
A
A healthy eating pattern includes:
- a variety of vegetables
- Fruits
- Grains, at least half of which are whole grains
- Fat-free or low-fat dairy
- A variety of protein foods
- Oils
A healthy eating pattern limits
- Saturated fats, trans fats, added sugars, and. sodium
- Calories/day from added sugars to <10%
- Calories/day from saturated fats to <10%
- Sodium to less than 2,300 mg/day
- Alcohol to moderate consumption
Guidelines for activity include:
- Engage in regular PA and reduce sedentary activities to promote health, psychological well-being, and a healthy body weight
- to achieve and maintain a healthy body weight, adults should do the equivalent of 150 to 300 minutes of moderate-intensity aerobic actives each week. If necessary adults should increase their weekly minutes of aerobic physical activity gradually over time and decrease calorie intake to a point at which they Cana achieve calorie imbalance and a healthy weight. Adults should also infuse muscle-strengthening activities, such as lifting weighs or doing push-ups, at lease 2 days each week
5
Q
Factors affecting nutrition
A
- Physiologic and physical influence nutrient requirements (stage of development, state of health, medications)
6
Q
What happens to your patient’s nutritional needs when they are ill or injured?
A
nutritional requirements vary with the intensity and duration of stress
- fevers - increase need for calories and water
- trauma - to preserve or replenish body nutrient stores and promote healing and recovery nutrient requirements increase dramatically in the adaptive phase after stress
- chronic disorder can. alter nutrient requirements by influencing nutrient intake, digestion, absorption, metabolism, utilization, or excretion
- mental health problems such as depression and confusion can cause a patient to forget to eat or lack the motivation to eat –> malnutrition
7
Q
Physical, Sociocultural, and Psychosocial Factors that influence Food choices
A
- social determinant of health
- religion
- meaning of food
- culture
8
Q
Box 37-3
How will you care for patients from cultural backgrounds different from yours?
A
- Acquire basic information about health beliefs and practices of various cultural groups in your health care setting. This provides a basis for assessing patients’ beliefs and practices. Recognize, however, that within all cultures and ethnic groups, there are members who do not hold all the values of the group.
- Ask specifically about the use of folk or home remedies prescribed by a nontraditional healer.
- Determine the patient’s language preferences for spoken and written communication.
- Utilize printed or audiovisual information that is in the language spoken by your patients.
- Promote healthy food choices by identifying healthy traditional food practices and encourage their use.
- Encourage cultural sensitivity in health care workers in your particular setting.
- Recognize that diversity exists within cultural groups. For example, the Hispanic/Latino population includes Mexican American, Mexican, Cuban, Puerto Rican, and other groups.
- Emphasize threads or messages in health teaching that are common to all cultures (e.g., concern about family, faith, home).
- Help culturally diverse patients to value and understand the importance of communicating concerns and asking questions about prescribed dietary practices.
9
Q
Anorexia
A
a general term that involves lack of appetite that may be related to systemic and local diseases; numerous physiological causes, such as fear anxiety, depression, or pain; and impaired ability to smell and taste; or may occur secondary to drug therapy or medical treatments
10
Q
Anorexis nervosa
A
an eating disorder that involves varied issues including extreme weight loss, muscle wasting, arrested sexual development, refusal to eat, and bizarre eating habits
11
Q
What are some reason reasons for decreases intake of food for your patients?
A
- anorexia
- difficulty chewing pr swallowing
- those who experience chronic GI problems or undergo certain surgical procedures
- those with certain chronic illnesses (such as cancer)
- inadequate food budgets
12
Q
Food Diaries/Calorie Counts is an assessment you will participate in as a bedside nurse. What is a calorie count?
A
a recording/documentation of everything the patient had to eat or drink including portion size
- may provide a better overall picture of nutrient intake
13
Q
Dysphagia
A
difficulty swallowing or the inability to swallow
14
Q
Aspiration
A
dysphagia is associated with an increased risk for aspiration –the misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract; WHEN FOOD CONTENTS OR FLUIDS ACCIDENTALLY ENTER THE LUNGS
15
Q
Signs and Symptoms and Risk Factors for Dysphagia
A
Signs and Symptoms
- Difficulty swallowing foods or fluids: may only be certain foods or liquids
- Coughing or choking when eating or drinking
- Unintentional weight loss
- Frequent throat clearing
- Wet gurgling voice after eating
- Feeling of food or liquids “stuck” in throat
- Leakage of food or saliva from mouth
Risk Factors
- Neurologic condition (ex; stroke, head injury, brain injury, progressive neurologic disorder [Parkinson’s disease, multiple sclerosis])
- Dementia
- Obstructive condition (ex; head and neck cancer, gastroesophageal reflux disease)
- COPD
- Aging
- Malnutrition
- Childhood syndromes (es; Down syndrome, cerebral palsy)
16
Q
Normal Hemoglobin for Adults
A
12-18 g/dL
decreased–> anemia
17
Q
Normal Hematocrit for Adults
A
46-52%
decreased –> anemia
18
Q
Enteral nutrition
A
administering nutrients directly into the stomach
19
Q
Parenteral nutrition (PN)
A
providing nutrition via intravenous (IV) therapy, based on individual circumstances
20
Q
What may your patient eat if they are prescribed a normal or regular diet?
A
they are designed to achieve or maintain optimal status by providing adequate amounts of all nutrients
- the diet’s composition and nutrition values varies with quantity and types of food selected by the patient
- no foods are excluded
- portion sizes are not limited
21
Q
What will you need to ask your patient who follows a vegetarian diet?
A
22
Q
What is a clear liquid diet? How long should your patient be on it?
A
composed of only clear fluids or foods that become fluid at. body temperature; requires minimal digestion and leaves minimal residue
includes:
- clear broth
- coffee
- tea
- clear fruit juices (apple, cranberry, grape)
- gelatin
-popsicles
- commercially prepared clear liquid supplements
indications:
preparation for bowel surgery and lower endoscopy; acute gastrointestinal disorders; initial postoperative diet
23
Q
What can your patient have on a full-liquid diet that was not allowed on clear liquids?
A
Contains all items on a clear-liquid diet including:
- milk/ milk drinks
- puddings
- custards
- plain frozen desserts
- pasteurized eggs
- cereal gruels
- vegetable juices
- milk and egg substitutes
24
Q
Table 37-4 Modified Consistency Diets
A
- Clear liquid diet - Composed only of clear fluids or foods that become fluid at body temperature. Requires minimal digestion and leaves minimal residue. Includes clear broth, coffee, tea, clear fruit juices (apple, cranberry, grape), gelatin, popsicles, commercially prepared clear liquid supplements.
Indications: Preparation for bowel surgery and lower endoscopy; acute gastrointestinal disorders; initial postoperative diet
- Puree diet - Also known as a blenderized liquid diet because the diet is made up of liquids and foods blenderized to liquid form. All foods are allowed.
Indications: After oral or facial surgery; chewing and swallowing difficulties
- Mechanically altered diet - Regular diet with modifications for texture. Excludes most raw fruits and vegetables and foods with seeds, nuts, and dried fruits. Foods are chopped, ground, mashed, or soft.
Indications: Chewing and swallowing difficulties; after surgery to the head, neck, or mouth
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Table 37-3 Selected Therapeutic Diets
Can I connect these diets to the patient problem?
1. Consistent-carbohydrate diet: Total daily carbohydrate content is consistent; emphasizes general nutritional balance. Calories based on attaining and maintaining healthy weight. High-fiber and heart-healthy fats encouraged; sodium and saturated fats are limited.
Indications: Type 1 and type 2 diabetes, gestational diabetes, impaired glucose tolerance
2. Fat-restricted diet: Low-fat diets are intended to lower the patient’s total intake of fat.
Indications: Chronic cholecystitis (inflammation of the gallbladder) to decrease gallbladder stimulation; cardiovascular disease, to help prevent atherosclerosis
3. High-fiber diet: Emphasis on increased intake of foods high in fiber.
Indications: Prevent or treat constipation; irritable bowel syndrome; diverticulosis
4. Low-fiber diet: Fiber limited to <10 g/day.
Indications: Before surgery; ulcerative colitis; diverticulitis; Crohn disease
5. Sodium-restricted diet: Sodium limit may be set at 500–3,000 mg/day
Indications: Hypertension; heart failure; acute and chronic renal disease, liver disease
6. Renal diet: Reduce workload on kidneys to delay or prevent further damage; control accumulation of uremic toxins. Protein restriction 0.6–1 g/kg/day; sodium restriction 1,000–3,000 mg/day; potassium and fluid restrictions dependent on patient situation
Indications: Nephrotic syndrome; chronic kidney disease; diabetic kidney disease
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17. Box 37.7 Special Considerations and Interventions for Feeding Patients With Dysphagia
--Provide at least a 30-minute rest period prior to mealtime. A rested person will likely have less difficulty swallowing.
--Sit the patient upright, preferably in a chair. If bedrest is mandatory, elevate the head of the bed to a 90-degree angle. Maintain upright position for 30 minutes after the meal.
--Provide mouth care immediately before meals to enhance the sense of taste.
--Avoid rushed or forced feeding.
--Provide small, frequent meals to help maximize intake.
--Adjust the rate of feeding and size of bites to the patient’s tolerance. Allow patient to control the eating process if possible.
--Collaborate to obtain a speech therapy consult for swallowing evaluation.
--Initiate a nutrition consult for appropriate diet modification such as chopping, mincing, or pureeing of foods and liquid consistency (thin, nectar-thick, honeylike, spoon-thick).
--Keep in mind that some patients may find thickened liquids unpalatable and thus drink insufficient fluids.
--Reduce or eliminate distractions at mealtime so that the patient can focus attention on swallowing; discourage chatting during the meal.
--Alternate solids and liquids.
--Assess for signs of aspiration during eating: sudden appearance of severe coughing; choking; cyanosis; voice change, hoarseness, and/or gurgling after swallowing; frequent throat clearing after meals; or regurgitation through the nose or mouth.
--Inspect oral cavity for retained food.
--Avoid or minimize the use of sedatives and hypnotics since these agents may impair the cough reflex and swallowing.
27
What is an oral nutrition supplement (ONS)?
foods rich in energy, protein, and macro- and micronutrients
28
What can a patient have to eat or drink if they are prescribed NPO?
- ice chips or sips of water
- patients who will be NPO for more than 48-72 hours may require support from enteral nutrition (EN) or parenteral nutrition (PN)
29
For enteral feeding formulas undestand that they are prescribed and must be checked and administered as carefully as medication
30
26. Monitoring Tolerance of Enteral Nutrition
What does the nurse asses for?
What is gastric residual volume (GRV)?
Is it a good tool?
If you are required to do it, what volume would lead you to turn off the feeding?
1. Patient tolerance of the volume and type of formula
- Absence of nausea, vomiting
- Absence of diarrhea and constipation
- Absence of abdominal pail and feelings of fullness
- Absence of distention
- Presence of bowel sounds within normal limits
- Achievement of target nutrition administration
2/3. feeding remaining in the stomach; is NOT a suitable parameter to determine feeding intolerance
4. autonomic cessation should be avoided for GRVs <500 mL in the absence of other signs of intolerance
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27. Promoting Patient Safety
1. What should the nurse do before giving something through the tube?
2. What signs of respiratory distress should the nurse watch for?
3. Feeding tubes should be ___ with ___ before and after bolus feedings and med admin.
4. How should the patient be positioned?
5. Should you turn off the feeding when putting the patient flat for a short time?
6. How do you reduce the risk for formula contamination?
7. T or F It's okay to mix meds with formula or with other meds when giving by the tube?
1. Check the tube placement; consistent inability to withdraw fluid from tube may indicate displacement of the tube from the stomach into the esophagus
2. coughing, choking, dyspnea
3. flushed with at least 30 mL of water; every 4 to 8 hours during continuous feeding; and before and after med admin. based on patient's fluid needs and restrictions
4. as upright as possible during feeding. Keep the head of the bed elevated at 30 to 45 degrees at all times during administration of enteral feedings and for 1 hour afterward to prevent reflux, aspiration, and pneumonia, unless contraindicated
5. There is no benefit from stopping feedings during short periods of lowering of the head of the bed. If a prolonged procedure will require lowering of the head of the bed, feedings should be stopped during this period; feedings should be promptly restarted when the procedure is ended or as feasible.
6.
- Maintain the integrity of the feeding system and using proper technique.
- Closed systems, consisting of a sterile, prefilled, ready-to-hang container, reduce the opportunity for bacterial contamination of the feeding formula.
- An open system exists when formula from a can or bottle is added to a feeding setup.
- Always check the expiration date of formula.
- Perform hand hygiene and put on nonsterile gloves before preparing, assembling, and handling any part of the feeding system
- Disinfect the opening and rim of any cans to be opened before opening.
- Label all equipment with the patient’s name, date, and time the feeding was hung, and cap or cover any disconnected tubing
- Clean a reusable feeding system with soap and hot water every 24 hours
- replace a disposable feeding apparatus for open systems every 24 hours.
7. False
Do not mix medications together; administer each medication separately and dilute appropriately prior to administration
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27. Complications
Table 37-5 Know the complications and interventions
Complications:
Aspiration
Clogged Tube
Nasal erosion with nasogastric or nasointestinal tubes
Diarrhea
Other GI symptoms
Unplanned extubation
Gastrostomy site infection
What are some interventions for these complications?
Complication: Aspiration
Intervention:
- Use appropriate measures to check tube placement.
- Elevate head of bed at least 30–45 degrees during feeding and for 1 hour afterward.
- Give small, frequent feedings.
- Avoid over sedation of patient.
- Check residual volume per policy
Complication: Clogged Tube
Interventions:
- Flush tube before and after feeding, every 4 hours during continuous feeding, and after withdrawing aspirate.
- Sterile water should be used for tube flushes in immunocompromised or critically ill patients
- Attach a 30- or 60-mL piston syringe to the feeding tube and pull back the plunger to help dislodge the clog. Then, fill the syringe with warm water and attempt to flush. If met with resistance, use gentle back and forth motion of the plunger to help loosen the clog. If necessary, clamp the tube to allow the warm water to penetrate the clog for up to 20 minutes and then attempt to flush
Complication: Nasal erosion with nasogastric or nasointestinal tubes
Interventions:
- Check nostrils every shift for signs of pressure.
- Clean and moisten nares every 4–8 hours.
- Secure tube to avoid pulling or pressure
Complication: Diarrhea
Interventions:
- Prevent contamination in both open and closed systems.
- Change delivery set every 12–24 hours according to facility policy.
- Refrigerate opened cans of formula and discard after 24 hours.
- Limit hang time to 4 hours when using open system.
- Use aseptic technique for patients who are immunosuppressed or acutely ill.
- Assess for fecal impaction.
Complication: Other GI symptoms (nausea, vomiting, distention)
Interventions:
- Avoid oversedating patient (delays gastric emptying).
- Administer GI motility medications, as prescribed.
Complication: Unplanned extubation
Interventions:
- Anchor tube appropriately with commercial device, bridle, or tape.
- Check on patient frequently.
- Measure external length of tubing at regular intervals.
Complication: Gastrostomy site infection
Interventions:
- Cleanse stoma and peristomal skin with sterile saline and gauze 24 hours after placement and every day for the first week
- Stoma and peristomal skin may be cleansed with skin cleanser/mild soap and warm water 7–10 days after placement
- Avoid the use of creams or powders around the stoma
- Assess for signs of infection.
Request a consult with a wound care specialist, as needed.
33
27. Comfort measures
What actions should the nurse take to increase patient comfort during enteral nutrition?
Patients with nasogastric tubes often experience discomfort related to irritation to nasal and throat mucosa and drying of the oral mucous membranes
- Administer oral hygiene frequently (every 2 to 4 hours) to prevent drying of tissues and to relieve thirst. Offer the patient the opportunity to rinse the mouth with warm water and mouthwash solution frequently. Lubricate the lips generously.
- Keep the nares clean, especially around the tube, where secretions tend to accumulate. Using a lubricant after cleaning the nares is recommended.
- Help control local irritation from the tube in the throat. Analgesic throat lozenges or anesthetic sprays may be effective.
- Encourage the patient, if able, to verbalize concerns about tube feeding and presence of the tube. A visit from another person who has learned to cope with this alternate feeding method may prove helpful.
- Secure the nasogastric tube to the patient’s nose and cheek, based on facility policy, to prevent tension and tugging on the tube, causing trauma to the nares, and inadvertent displacement or dislodgment. Displacement or dislodgment of a tube can lead to aspiration, pneumonia, and sepsis. Use of a commercial securement device is recommended
- Secure the gastrostomy tube to the patient’s abdomen in a way that stabilizes the tube and avoids excessive traction. Excessive friction may result in development of peristomal hypergranulation tissue. Excessive traction may contribute to enlargement of the stoma and the development of leakage around the tube.
34
Parenteral Nutrition (PN)
Define?
Why is it used?
What is it delivered through?
the administration of nutritional support via the intravenous route
- Use of the enteral route is preferred to the parenteral route for nutrition support whenever feasible
- patients who cannot meet their nutritional needs by the oral or enteral routes may require intravenous nutritional supplementation
- Intravenous supplementation may be prescribed for high-risk patients under specific circumstances, when enteral nutrition is not feasible or sufficient to meet energy or protein goals. PN may be considered for patients already on EN only after 7 to 10 days, when unable to meet >60% of energy and/or protein requirements by the enteral route alone
PN provides calories; restores nitrogen balance; and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements. PN can also promote tissue and wound healing and normal metabolic function. It provides the bowel a chance to heal and reduces activity in the gallbladder, pancreas, and small intestine. PN meets the patient’s nutritional needs by way of nutrient-filled solutions administered intravenously through a central venous access device, such as a tunneled, multilumen, or nontunneled catheter into the subclavian vein or a peripherally inserted central catheter (PICC).
35
28. Bad things that can happen when a patient is on PN
- Complications related to the use of central venous access devices, such as pneumothorax, thromboembolism (inflammation of a blood vessel and formation of a thrombus [blood clot]), and air embolism
- Infection and sepsis (central line–associated blood stream infections [CLABSIs])
- Metabolic alterations, such as hyperglycemia or hypoglycemia
- Fluid, electrolyte, and acid–base imbalances
- Hyperlipidemia
- Liver and gallbladder disease
- Refeeding syndrome (life-threatening complication related to overfeeding carbohydrates in nutritionally debilitated patients, characterized by metabolic and physiologic shifts of fluid, electrolytes, and minerals from the extracellular fluid to intracellular fluid)
36
29. Guidelines for Nursing Care 37-2
nursing actions that can help prevent those complications^
- Use the same catheter lumen for administration of parenteral nutrition each time the tubing is changed.
- Use an electronic infusion device to administer infusion of parenteral nutrition.
- Infusion rate changes are made incrementally to avoid severe hyperglycemia or hypoglycemia. Taper infusion rates gradually
- Discard unused parenteral nutrition solution within 24 hours of starting its administration.
- Check vital signs every 4 hours to monitor for development of infection or sepsis.
- Monitor blood glucose levels as appropriate based on the patient’s clinical status.
- Use aseptic technique when changing solution, tubing, filter, or dressings according to facility policy.
- Infusion administration sets should include an in-line filter. Change infusion administration sets every 24 hours.
- Avoid blood sampling via the venous access device used for PN when feasible
- Change site dressings according to facility protocol. Transparent semipermeable dressings are changed once per week. Gauze dressings do not allow for inspection of exit site without dressing removal and should be changed every 48 hours. In addition, change dressings immediately if they become wet, soiled, or nonocclusive.
- Check that all connections are securely taped, catheter is clamped before opening the system, and insertion site is covered with sterile dressing.
- Compare the patient’s daily weight to fluid intake and output. Total weight gain should not be greater than 3 lb per week. Weight gain greater than 1 lb per day indicates fluid retention.
- Assess serum protein and electrolyte levels for signs of imbalance.
37
Page 1398, read about MyPlate if you are not familiar with this resource
The goals of the recommendations are to balance calories by encouraging consumers to enjoy food but eat less, and avoid oversized portions . (MyPlate :Vegatables biggest portion, then grains , then protein, then fruit)
38
Factors affecting Nutrition
- culture
- religion
-food ideology (the meaning of the food for the individual)
- economic stability
- neighborhood environment
39
Note how each category affects dietary intake (physical, sociocultural, and Psychosocial factors)
psychosocial - language barriers, knowledge of nutrition, literacy, lack of caregiver or social support, social isolation, limited access to food market and ability to obtain food (food deserts), lack of or inadequate cooking and or food preparation arrangements
sociocultural- Dietary restrictions associated with religions might affect a patient's nutritional requirements
Culture influences what is eaten or considered edible, how it is prepared, and what combinations of food are permitted
physical-
40
How will you care for patients from cultural backgrounds different from yours?
- acquire basic information about health beliefs and practices of various cultural groups in your health care setting. This provides a basis for assessing patient's beliefs and practices.
- promote healthy food choices by identifying healthy traditional food practices and encouraging their use
-help culturally diverse patients to value and understand the importance of communicating concerns and asking questions about prescribed dietary practices
-utilize printed or audiovisual information that is in the language spoken by your patients
- ask specifically about the use of folk or home remedies prescribed by a nontraditional healer
41
Look over the MNA on page 1405, This is a common screening tool for nutrition
42
Clinical observations for nutritional assessment (37-2)
Body area (general appearance)
43
WHat is a calorie count
food diaries and calorie counts require documentation of actual intake for a specific period of time. In an outpatient setting, ask the client to record everything the patient has had to eat or drink, including the portion size, over a set of period of time. These tools help provide a better overall picture of nutrient intake because all food and beverages consumed in a specified period are recorded.
44
List the other problems related to nutrition in the last paragraph
impaired swallowing/ neuromuscular impairment: food seems to get suck
impaired nutritional status/ insufficient dietary intake: food just doesn't taste good anymore
body weight problem
45
aging impacts nutrition a great deal
change/ strategies
- altered ability to chew related to loss of teeth, ill-fitting dentures / encourage and instruct patient to care for and retain own teeth and dentures, encourage proper tooth brushing and use of special toothpaste if gums and teeth are sensitive
- loss of senses of smell and taste/ serve food that is attractive and at the proper temperature
-decreased peristalsis in the esophagus/ avoid cold liquids, avoid emotional upsets and stress-producing situations
- low income/ use coupons, buy specials when available at food stores, use generic brands
- malnutrition/ eat essential foods first, encourage eating by planning special events, select nutrient-dense foods
- increased risk for drug-nutrient interactions/ avoid unnecessary drugs; monitor for polypharmacy, be aware of drug actions and interactions
-physical disability/ open cartons and assist with setup of meal, arrange for home-delivered meals, provide transportation and assistance to obtain food
46
read stimulating appetite on page 1413. Know these interventiions
- provide a comfortable position
- keep eating area free from irritating odors
- remove clutter from the eating area
-be sure that any prepared food looks attractive
- provide encouragement and a pleasant eating environment
- serve small, frequent meals to avoid overwhelming the person with large amounts of food
-solicit food preferences and encourage favorite foods from home or prepared when at home, if possible
- control pain, nausea, or depression with medications
- arrange food trays so that a person can easily reach food
- encourage or provide good oral hygiene. Ensure that the patients dentures are well fitting and in place if applicable
47
read assisting with eating on page 1413. Know these interventions
- provide appropriate drinks
- place. a napkin, not a bib, over the persons clothes for protection
- provide supervision as needed
- use straws for beverages, if not contraindicated by the presence of dysphagia
- place foods and sites in similar locations at each meal
- ensure that if a person wears dentures, hearing aids, or glasses, they are in place before mealtime
- engage the person in pleasant conversations to ease tension
-sit at the patient's eye level and make eye contact to create a more relaxed, person-centered atmosphere
48
for enteral feeding formulas, understand that they are prescribed and must be checked and administered as carefully as a medication
