Kozier Ch 47 Nutrition

•Water

• •Macronutrients
• –Carbohydrates
• •Simple, Starch, Complex (fiber)
• –Protein
• •Essential amino acids (not made by body)
• •Nonessential amino acids (body can make)
• •Pro. Metabolism- anabolism, catabolism, nitrogen
• balance
• –Lipids (Room temp: Fats- solid, Oil- liquid
• •Fatty acids (sat & unsat), monounsat & polyunsat
• •Triglycerides
• •Cholesterol

• •Micronutrients
• –Vitamins- not made by body
• •Water-soluble: not stored- C, B complex
• •Fat soluable: stored- A,D,E,K
• –Minerals
• •Macrominerals- over 100mg /day: Ca, P, Na, K, Mg, Cl, sulfur
• Micromineral- less than 100 mg: iron, zinc, iodine, etc

•Relationship between the energy derived from food and the energy used by the body

• •Caloric value is the amount of energy that nutrients or foods supply to the body
• –CHO: 4 calories/gram
• –Pro: 4 calories/gram
• –Fat: 9 calories
• –Alcohol: 7 calories/gram

•Basal metabolic rate (BMR): the rate at which the body metabolizes food to maintain the energy requirements of a person who is awake and at rest

• •Resting energy expenditure (REE): amount of energy required to maintain basic body functions & maintain life
• –1 cal/kg of body wt/hr for men
• –0.9 cal/kg of body wt/hr for women

•Balance between the expenditure of energy and the intake of nutrients

•Ideal body weight (IBW): the optimal weight recommended for optimal health

• •Body mass index (BMI): considered to be
• the more reliable indicator of a person’s healthy weight

• •IBW = Ideal Body Weight (Box 47-1 page 1236)
• Female: 100 lbs for 5 feet + 5 lbs for each additional inch

• Male:106 lbs for 5 ft. + 6 lbs for each additional inch
• + or – for body frame based on wrist size

Actual wt x 100 = % IBW <70% severe malnut. IBW

• •BMI = Body Mass Index < 18.5 underwt.
• Wt. In Kg 18.5-24.9 normal
• Ht. In meters 2 (squared) 25-29.9 overwt.
• 30-34.9 mild obese
• 35-39.9 moderate obese
• > 40 extremely obese
• •1 kg = 2.2 lb
• •1 meter = 39.6 inches

• •Can measure body mass by measuring % of fat
• •Underwater weighing
• •DEXA- expensive test
• •Waist circumference- greater waist = greater risk of
• Diabetes
• •Skinfold testing
• •Bioelectrical impedance analysis (BIA)- on some
• scales. Electrical signal passes thro the body

• •Developmental considerations
• •Gender
• •Ethnicity and culture
• •Beliefs about food
• •Personal preferences
• •Religious practices
• •Lifestyle
• •Economics
• •Medications and therapy
• •Health
• •Alcohol consumption
• •Advertising
• •Psychologic factors

• •Young adults
• –Females- iron intake, 18 mg of iron/day
• –Calcium is needed to maintain bones and help
• decrease the chances of developing osteoporosis in later life.
• –Adequate vitamin D is needed for the calcium absorption.
• –Low-fat and/or low-cholesterol diets play a significant role in both the prevention and treatment of cardiovascular disease.
• –Prevent obesity- risk for HTN & CV disease

• •Middle age 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

• •Older adults
• –Require the same basic nutrition as the younger adult
• –Fewer calories are needed by elders because of the
• lower metabolic rate & the decrease in physical activity
• –Some may need more carbohydrates for fiber &
• bulk, but most nutrient requirements remain relatively unchanged
• –Physical changes as tooth loss & impaired sense of taste and smell may affect eating habits
• –Decreased saliva, gastric juice secretion, decreased
• intestinal absorption may also affect nutrition
• –Psychosocial factors may also contribute to nutritional problems

• •Healthy People 2020 (www.healthypeople.gov)
• •Americans with a healthful diet:
• –Consume a variety of nutrient-dense foods within and across the food groups, especially whole grains, fruits, vegetables, low-fat or fat-free milk or milk products, and lean meats and other protein sources.
• –Limit the intake of saturated and trans fats,
• cholesterol, added sugars, sodium (salt), and alcohol.
• –Limit caloric intake to meet caloric needs.
• •All Americans should avoid unhealthy weight gain, and those whose weight is too high may also need to lose weight.

• •2010 Dietary Guidelines for Americans (USDA)
• –Nutrient dense food
• –Maintain healthy wt
• –Engage in physical activity
• –Eat fruit, veges, grains, milk
• –Keep fat 20-35% of total calories
• –Decrease sodium to <2,300/day
• –Drink alcohol in moderation

• •The Food Pyramid- USDA picture
• –Anatomy of MYPyramid- designed to be simple
• –Food Pyramid for children
• –Food Pyramid for Older Adults

• Overweight/ Obesity: Consuming nutrients
• •In excess of metabolic demands
• •More than needed for activity, gender, height, and
• weight
• •Overweight = BMI >25 but <29.9
• •Obesity = BMI >30
• Interventions
• •Food diary
• •Teach balanced diet and kcal content of food, fat substitutes
• •Weigh weekly
• •Increase physical activity

• Underweight/Undernutrition:
• •Insufficient intake of protein, fat, vitamins, minerals
• •Consuming less calories than needed according to activity, gender, height, and weight
• •Underweight: BMI < 18.5 Interventions
• •Offer high calorie & high protein foods
• •Consult with dietician
• •Weigh 1-2x/week
• •Offer high protein supplements
• •Community resources

• Malnutrition
• –Lack of necessary food substances

• Protein-calorie Malnutrition- severe malnutrition
• from long-term caloric deficiency. There is weight & fat loss. Also proteins stores are affected- skeletal muscle (wasting) & visceral proteins (hemoglobin, albumin) - low albumin indicates low protein

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

• Medical
• –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

• Medications- pages 1253 & 1239
• –Increase appetite (prednisone & antidepressants)
• –Decrease in appetite – many meds
• –Electrolyte loss- K from diuretics
• –Grapefruit- doesn’t mix with certain meds
• –Vit K- decreases affect of Coumadin

• •Age & gender
• •Activity level
• •Any difficulty eating
• •Condition of mouth, teeth, dentures
• •Changes in appetite and weight
• •Physical disabilities affecting purchasing, preparing &
• eating food
• •Ethnicity/religion/income

• •What & how much is eaten
• •Living arrangements
• •General health status
• •Food allergies
• •Medical conditions
• •Medication history
• •Do a 24 hour food recall/diary

• •Clinical Manifestations of Malnutrition (p.1257)
• -red beefy tongue
• •Calculating % of weight loss
• –There is a formula
• •Calculate usual body weight (UBW)
• •Calculate current weight
• –Looking for the amount of weight change
• loss of 5% in one month - cancer?

• Proteins- types have different half lives
• Albumin- is 60% of total body protein, used to measure prolonged depletion
• Prealbumin – fluctuates daily, marks acute change
• Transferrin – a protein that binds with iron, responds quickly to protein depletion
• Lymphocytes –WBCs, low is leukopenia Hemoglobin – heme (iron), globulin (serum protein)

• Urea nitrogen
• End product of protein metabolism, excreted by
• kidney.
• Reflects intake & breakdown of dietary protein
• Creatinine –
• End product skeletal muscle metabolism
• As skeletal muscle atrophies, creatinine decreases

• Imbalanced Nutrition : More than Body Requirements
• Imbalanced Nutrition:
• Less than Body Requirements
• Risk for imbalanced nutrition
• Impaired swallowing
• •Risk for infection
• •Constipation related to inadequate fluid intake
• •Low self-esteem related to obesity
• •Activity intolerance
• Impaired dentition

• •Maintain optimal nutritional status
• –Client will ingest 2000kcal/day
• –Client will gain/lose 1-2 lbs./month until IBW
• –Client will demonstrate understanding of the
• nutritional requirements for meal planning by end of shift

Regular diet- as tolerated, no restriction

• Clear liquid- short term for surgery or tests.
• Coffee/tea, carbonated beverages, bouillon/fat free
• broth, clear fruit juices (apple, cranberry, grape), gelatin, popsicles, sugar, honey, hard candy

• Full liquid- GI distrubances.
• Clear liquids plus items liquid at room temp. Soups, milk, puddings, custards, yogurt/ice cream.

• Mechanical Soft- easy to chew & digest
• •difficulty swallowing or chewing , missing teeth, jaw problems.
• All items on full liquid plus soft vegetables, chopped, ground or shredded meat. Can cook food extensively or blend & grind to alter texture. This diet is full of nutrients but low in fiber. Constipation is a risk.

• Pureed- type of soft. Blended diet. Any food can be
• eaten, liquid is added

• •Calorie restricted: - obesity
• •Fat restricted: - High cholesterol, or tryglycerides, weight loss
• •Sodium restricted: BP or fluid balance problems
• •DASH diet: for hypertention - high in grains, low in salt
• •ADA diet:
• •Renal:

• Dysphagia DIet - difficulty swallowing
• -elders, stroke, radiation to neck, nerve damage
• - Gag reflex not reliable, done through x-ray

• –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
• –Help client choose food he/she likes
• –Monitor the client’s appetite and food intake
• –Administer enteral and parenteral feedings
• –Consult with primary care provider and dietician
• about nutritional problems

• •Clients who are NPO (nothing by mouth)
• –Assist with oral hygiene, ice chips, hard candy, chewing gum
• •Stimulating a person’s appetite – Box 47-10 pg 1263
• •Providing Client Meals – Box 47-11 pg 1264
• •Special Community Nutritional Services
• –Meals on wheels

• •Alternative methods to get nutrients needed
• •Enteral (EN)- Directly into the GI tract via tube
• •Parenteral- directly through a vein
• –Intravenous hyperalimentation

• •Enteral nutrition:
• ¡Enteral access devices
• –Nasogastric tube
• –Nasoenteric tube
• –Gastrostomy/jejunostomy
• –PEG/PEJ
• ¡Test for placement
• ¡Aspirate stomach contents
• ¡Test pH- stomach higher than intestines & lungs
• ¡Feedings- different formulas
• ¡Procedure Inserting & removing- learn in lab

• •Aspiration
• –Prevent- HOB 30 or above
• –Check lung sounds
• •Diarrhea/constipation/flatulence
• •Assessing the client receiving feedings
• –Check how much remains in stomach. Check hosp.
• policy for 100 ml
• •Skin breakdown around insertion site
• •Prevent clogged tubes- flush
• •Prevent infection
• –Change formal every 8-12 hours

• •Unable to meet nutritional needs
• •Shortened small bowel due to disease or injury
• •Used in addition to oral to meet caloric & nutritient needs
• •Severly malnourished
• •Burns or trauma
• •Conditions that require resting the GI tract
• •Because TPN solutions are hypertonic, they must administered in a large, high flow vein.
• •Subclavian vein is site of choice
• •High flow through the vessel causes rapid dilution of the concentrated TPN preventing vessel damage.

• •10-50% concentrations of dextrose in H2O with amino acids
• •Vitamins
• •Minerals
• •Trace elements
• •Standard solutions or custom
• •Lipid emulsions/fatty acids and triglycerides are also admin. weekly

• • Supplied in Liter batches
• • Must be refrigerated to prevent bacterial growth
• •Cannot hang for more than 12 hours
• • TPN line used only for TPN
• •Because the line is central, infection at the site can lead rapidly to sepsis.
• •Surgical asepsis used when changing solution, tubing, and dressing
• •Begin infusion slowly to decrease potential for hyperglycemia
• •May require insulin during therapy to facilitate absorption of glucose
• •Therapy must be discontinued slowly to decrease potential for hypoglycemia