Angelite Nurses

Basic Concepts


Principles

1. Essential nutrients: carbohydrates, fats, proteins, minerals, vitamins, and water that must be supplied to the body in specified amounts.
2. Foods: the sources of nutrients, provide energy to help build, repair, and maintain tissue and regulate body processes.
3. Malnutrition: results from deficiency, excess, or imbalance of required nutrients.

Carbohydrates (Sugars and Starches)

1. Major source of food energy; 4 kcal/g; composed of carbon, hydrogen, and oxygen
2. Classification
1. Monosaccharides: simplest form of carbohydrate
1. Glucose (dextrose): found chiefly in fruits and vegetables; oxidized for immediate energy
2. Fructose: found in honey and fruits
3. Galactose: not free in nature; part of milk sugar
2. Disaccharides: double sugars
1. Sucrose: found in table sugar, syrups, and some fruits and vegetables
2. Lactose: found in milk
3. Maltose: intermediate product in the hydrolysis of starch
3. Polysaccharides: composed of many glucose molecules
1. Starch: found in cereal grains, potatoes, root vegetables, and legumes
2. Glycogen: synthesized and stored in the liver and skeletal muscles
3. Cellulose, hemicellulose, pectins, gums, and mucilages: indigestible polysaccharides
4. Dietary fiber: includes several polysaccharides plus other substances that are not digestible by GI enzymes.
1. Dietary fiber (roughage) holds water so that stools are soft and bulky; increases motility of the small and large intestine and decreases transit time; reduces intraluminal pressure in the colon.
2. Sources: wheat bran, unrefined cereals, whole wheat, raw fruits and vegetables, dried fruits
3. Functions of carbohydrates
1. Cheapest and most abundant source of energy; only source of energy for central nervous system
2. To spare protein for tissue building when sufficient carbohydrate is present
3. Necessary for the complete oxidation of fats (to prevent ketosis)
4. Dietary sources: grains, fruits, vegetables, nuts, milk, sugars ("empty calories," contain few nutrients)

Lipids (Fats)

1. Most concentrated source of energy in foods; 9 kcal/g; contain carbon, hydrogen, oxygen
2. Include fats, oils, resins, waxes, and fatlike substances such as glycerides, phospholipids, sterols, and lipoproteins
3. Fatty acids
1. Saturated fatty acids: usually solid at room temperature; predominantly present in animal fats
2. Monounsaturated fatty acids: present in oleic acid found in olive oil, peanut oil
3. Polyunsaturated fatty acids: usually liquid at room temperature; predominantly present in plant fats and fish
4. Essential fatty acids: cannot be manufactured by the body (e.g., linoleic fatty acid)
5. Nonessential fatty acids: can be synthesized by the body
4. Functions of lipids
1. Most concentrated source of energy
2. Insulation and padding of body organs
3. Component of the cell membrane
4. Carrier of the fat-soluble vitamins A, D, E, K
5. Help maintain body temperature
5. Dietary sources: oil from seeds of grains, nuts, vegetables; milk fat, butter, cream cheese; fat in meat; lard, bacon fat; fish oil; egg yolk
6. Cholesterol: essential constituent of body tissues
1. A component of cell membranes
2. A precursor of steroid hormones
3. Can be manufactured in the body
4. Present in animal fats
5. Dietary sources: egg yolk, brains, liver, butter, cream, cheese, shellfish
7. Indications for low fat diet (see Related Link: Special Diets)
1. Cardiovascular disease
2. Gallbladder disease
3. Malabsorption syndromes, cystic fibrosis, pancreatitis

Proteins

1. Organic compounds that may be composed of hundreds of amino acids; 4 kcal/g; contain nitrogen in addition to carbon, hydrogen, and oxygen
2. Classification
1. Complete protein: contains all the essential amino acids; usually from animal food sources.
2. Incomplete protein: lacks one or more essential amino acids; usually from plant food sources
3. Amino acids
1. Essential amino acids: eight amino acids that cannot be synthesized in the body and must be taken in food.
2. Nonessential amino acids: 12 amino acids that can be synthesized in the body.
4. Functions of proteins
1. Necessary for growth and continuous replacement of cells throughout life
2. Play a role in the immune processes
3. Participate in regulating body processes such as fluid balance, muscle contraction, mineral balance, iron transport, buffer actions
4. Provide energy if necessary
5. Dietary sources: meat, fish, eggs, milk, cheese, poultry, grains, nuts, legumes (soybeans, lentils, peanuts, peanut butter)
6. Deficiencies
1. Conditions
1. Kwashiorkor
2. Hypoproteinemia
3. Marasmus (protein-kilocalorie malnutrition)
2. Manifestations
1. Generalized weakness
2. Weight loss
3. Lowered resistance to infection
4. Slow wound healing and prolonged recovery from illness
5. Growth failure
6. Brain damage to fetus or infant
7. Edema due to decreased albumin in blood
8. Anemia in severe deficiency
9. Fatty infiltration of liver and liver damage
3. Risk factors
1. Chronically ill
2. Elderly on fixed incomes
3. Low-income families
4. Strict vegetarians
7. Indications for high-protein diet
1. Burns, massive wounds when tissue building desired
2. Mild to moderate liver disease for organ repair when liver is still functioning
3. Malabsorption syndromes such as cystic fibrosis
4. Undernutrition
5. Pregnancy to meet needs of mother and developing fetus
6. Pregnancy-induced hypertension to replace protein lost in urine
7. Nephrosis to replace protein lost in urine
8. Deficiencies
8. Indications for low-protein diet
1. Liver failure (liver does not metabolize protein causing nitrogen toxicity to brain)
2. Kidney failure (kidneys can no longer excrete nitrogenous waste products causing toxic nitrogen levels in the brain)
9. Nursing interventions for clients needing low-protein diet
1. Increase carbohydrates so energy needs will be met by carbohydrates, not by breakdown of proteins
2. Protein intake that is allowed will be complete proteins (animal sources)

Energy Metabolism

1. Measurement of energy expressed in terms of heat units called kilocalories (kcal): amount of heat required to raise 1 kg water by 1°C
2. Energy expenditure
1. Basal metabolism
1. Amount of energy expended to carry on the involuntary work of the body while at rest
2. Factors influencing basal metabolic rate (BMR): body surface area, sex, age, body temperature, hormones, pregnancy, fasting, malnutrition
2. Physical activity: amount of energy expended depends upon the type of activity, the length of time involved, and the weight of the person
3. Factors determining total energy needs
1. Amount necessary for BMR
2. Amount required for physical activity
3. Specific dynamic action of food ingested
4. Growth
5. Climate

Minerals
Inorganic compounds that yield no energy; essential structural components involved in many body processes (see Table 4.2).


TABLE 4.2 Minerals

Vitamins
Organic compounds necessary in small quantities for cellular functions of the body; do not give energy; necessary in many enzyme systems (see Table 4.3).

1. Fat-soluble vitamins (A, D, E, K): can be stored in body; toxic in large amounts.
2. Water-soluble vitamins (B₁ [thiamin]; B₂ [riboflavin]; B₆ [pyridoxine]; B₁₂ [hydroxycobalamin]; C [ascorbic acid]; folacin; niacin): cannot be stored in body so must be ingested daily; dissolve in cooking water, toxicity unlikely.

TABLE 4.3 Vitamins

Water

1. Distribution: present in all body tissues; accounts for 50%-60% total body weight in adults and 70%-75% in infants.
1. Intracellular fluid: exists within the cells.
2. Extracellular fluid: includes plasma fluid, interstitial fluid, lymph, and secretions.
2. Functions: the medium of all body fluids
1. Necessary for many biologic reactions
2. Acts as a solvent.
3. Transports nutrients to cells and eliminates waste.
4. Body lubricant.
5. Regulates body temperature.
3. Sources
1. Ingestion of water and other beverages
2. Water content of food eaten
3. Water resulting from food oxidation
4. Recommended daily intake
1. Replacement of losses through the kidneys, lungs, skin, and bowel
2. Thirst usually a good guide
3. Approximately 48 oz/day of water from all sources is adequate; requirement is higher if physical activity is strenuous or if sweating is profuse.

Dietary Guides

1. Food Pyramid
1. New recommendations replace four food groups.
2. Foods are grouped by composition and nutrient value: grains; vegetable group; fruit group; meat, poultry, fish, dry beans, eggs and nut group; and milk, yogurt and cheese group.
3. Greater emphasis on fruits and vegetables with less emphasis on meats and fats than with basic four.
4. Recommends using fats and sweets sparingly (see Related Links: Special Diets).
2. Recommended daily allowances: established by the Food and Nutrition Board of the National Academy of Science; recommended nutrient intake is provided for infants, children, men, women, pregnant and lactating women; recommendations are stated for protein, kcal, and most vitamins and minerals.
3. Food composition tables: helpful in calculating the nutritive value of the daily diet; list nutrient content of foods.
4. Height and weight charts: ideal or desirable body weight for both men and women at specified heights with a small, medium, or large frame.
5. Exchange lists for meal planning
1. Foods are separated into six exchange lists.
2. Specific foods on each list are approximately equal in carbohydrate, protein, fat, and kcal content.
3. Individual foods on the same list may be exchanged for each other at the same meals.
4. Food lists are helpful in planning diets for weight control or diabetes (see Related Links: Special Diets).

Nutritional Assessment


Health History

1. Presenting problem
1. Weight changes
1. Usual body weight 20% above or below normal standards.
2. Recent loss or gain of 10% of usual body weight.
2. Appetite changes: may be increase or decrease from usual.
3. Food intolerances: allergies, fluids, fat, salt, seafood
4. Difficulty swallowing
5. Dyspepsia or indigestion
6. Bowel dysfunction: record frequency, consistency, color of stools.
1. Constipation
2. Diarrhea
2. Lifestyle: eating behaviors such as fast foods, "junk foods," and skipping meals; cultural/religious concerns (vegetarian, kosher foods, exclusion of certain food groups); alcohol, socioeconomic status, living conditions (alone or with family).
3. Use of medications: vitamin supplements, antacids, antidiarrheals, laxatives, diuretics, antihypertensives, immunosuppressants, oral contraceptives, antibiotics, antidepressants, digitalis, anti-inflammatory agents, catabolic steroids.
4. Medical history: gastrointestinal diseases; endocrine diseases; hyperlipidemia; coronary artery disease; malabsorption syndrome; circulatory problems or heart failure; cancer; radiation therapy; chronic lung, renal, or liver disease; food allergies; recent major surgery; eating disorders; obesity.
5. Family history: obesity, allergies, cardiovascular diseases, diabetes, thyroid disease.
6. Dietary history: Evaluation of the nutritional adequacy of diet
1. 24-hour recall
2. Food diary for a given number of days

Physical Examination

1. Assess for alertness and responsiveness
2. Record weight in relation to height, body build, and age
3. Inspect posture, muscle tone, skeleton for deformities
4. Elicit reflexes
5. Auscultate heart rate, rhythm; blood pressure
6. Inspect hair, skin, nails, oral mucosa, tongue, teeth
7. Inspect for swelling of legs or feet
8. Anthropometric measurements: indicators of available stores in muscle and fat compartments of body
1. Height/weight ratio
2. Midarm muscle circumference
3. Skinfold thickness (triceps, biceps, subscapular, abdominal, hip, pectoral, or calf)

Laboratory/Diagnostic Tests

1. Blood studies: serum albumin, iron-binding capacity, hemoglobin, hematocrit, lymphocyte count, blood sugar, total cholesterol, high-density lipids, low-density lipids, triglycerides, serum electrolytes
2. Urine studies, urinalysis, glucose, ketones, albumin, 24-hour creatinine
3. Nitrogen balance studies
4. Feces, hair
5. Intradermal delayed hypersensitivity testing

Analysis
Nursing diagnoses for the client with a nutritional dysfunction may include:

1. Alteration in nutrition: less than body requirements
2. Alteration in nutrition: more than body requirements
3. Alteration in nutrition: high risk for more than body requirements
4. Altered oral mucous membrane
5. Self-care deficit, feeding
6. Sensory/perceptual alterations: gustatory, olfactory
7. Actual or high risk for impairment of skin integrity
8. Impaired swallowing
9. Impaired tissue integrity
10. Activity intolerance
11. Body image disturbance
12. Constipation
13. Diarrhea
14. Fluid volume deficit
15. Fluid volume excess
16. Altered growth and development
17. High risk for infection
18. Knowledge deficit
19. Noncompliance

Planning and Implementation


Goals

1. Normal weight will be achieved and maintained.
2. Integrity of oral cavity will be maintained.
3. Client will feed self or receive help with feeding.
4. Normal skin integrity will be achieved/maintained.
5. Client will not aspirate.
6. Normal tissue integrity will be achieved/maintained.
7. Client will be able to exercise normally.
8. Client will maintain/develop satisfactory self-image.
9. Normal bowel functioning will be maintained.
10. Fluid and electrolyte balance will be achieved/maintained.
11. Client will have normal growth and development patterns.
12. Client will not develop infection.
13. Client will demonstrate knowledge of special dietary needs/prescriptions.
14. Client will comply with special diet.

Interventions


Care of the Client on a Special Diet

1. General information: therapeutic diets involve modifications of nutritional components necessitated by a client's disease state or nutritional status or to prepare a client for a procedure.
2. Nursing care in relation to special diets
1. Assess client's mental, emotional, physical, and economic status; appropriateness of diet to client's condition; and ability to understand diet and comply with it.
2. Maintain appropriate diet and teach client.
3. Changing diet means changing lifelong patterns.
4. Teach client importance of adhering to special diets that are long term.

Weight Control Diets

1. Underweight: 10% or more below individual's ideal weight
1. Causes: failure to ingest enough kcal, excess energy expenditure, irregular eating habits, GI disturbances, mouth sores, cancer, endocrine disorders, emotional disturbances, lack of education, economic problems.
2. Treatment: diet counseling, correction of underlying disease, nutritional supplements, behavioral therapy, social service referral.
2. Overweight: 10% or more above individual's ideal weight
3. Obesity: 20% or more above individual's ideal weight
1. Causes: overeating, underactivity, genetic factors, fat cell theory, alteration in hypothalamic function, endocrine disorders, emotional disturbances.
2. Treatment: diet counseling, nutritionally balanced diet, behavior modification, increased physical activity, medical treatment of any underlying disease, appropriate referrals.
4. Nursing care
1. Explain dietary instructions (see Related Links: Special Diets, 1500-Kilocalorie Diet).
1. Reducing fats and "empty calories" reduces caloric intake without sacrificing nutritional intake
2. Increasing exercise increases metabolism
2. Caution against fad diets that may be nutritionally inadequate.
3. Encourage support groups if indicated.

Diabetic Diet

1. Prescribed for clients with diabetes mellitus.
2. Purposes include: attain or maintain ideal body weight, ensure normal growth, maintain plasma glucose levels as close to normal as possible.
3. Principles
1. Distribution of kcal: protein 12-20%; carbohydrates 55-60%; fats (unsaturated) 20-25%.
2. Daily distribution of kcal: equally divided among breakfast, lunch, supper, snacks.
3. Use foods high in fiber and complex carbohydrates.
4. Avoid simple sugars, jams, honey, syrup, frosting.
4. Teach client to utilize exchange lists (see Related Links: Special Diets, Exchange Lists for Meal Planning).
5. New recommendations include low fat, high fiber diet.

Protein-modified Diets

1. Gluten-free diet
1. Purpose is to eliminate gluten (a protein) from the diet.
2. Indicated in malabsorption syndromes such as sprue and celiac disease.
3. Eliminate all barley, rye, oats, and wheat (BROW).
4. Avoid: cream sauces, breaded foods, cakes, breads, muffins.
5. Allow corn, rice, and soy flour.
6. Teach client to read labels of prepared foods.
2. PKU (Phenylketonuria) diet
1. Purpose is to control intake of phenylalanine, an amino acid that cannot be metabolized.
2. Diet will be prescribed until at least age 6 to prevent brain damage and mental retardation.
3. Avoid: breads, meat, fish, poultry, cheeses, legumes, nuts, eggs.
4. Give Lofenalac formula.
5. Teach family to use low-protein flour for baking.
6. Sugar substitutes such as Nutrasweet contain phenylalanine and must not be used.
3. Low-purine diet
1. Indicated for gout, uric acid kidney stones, and uric acid retention.
2. Purpose is to decrease the amount of purine, a precursor to uric acid.
3. Teach client to avoid: organ meats, other meats, fowl, fish and lobster, lentils, dried peas and beans, nuts, oatmeal, whole wheat.
4. Eggs are not high in purine.

Fat-restricted Diets (See Related Links: Special Diets, 20-Gram Fat-restricted Diet and Fat-controlled Diet)
Purpose is to restrict amount of fats ingested for clients with chronic pancreatitis, malabsorption syndromes, gallbladder disease, cystic fibrosis, and hyperlipidemia, and to control weight.

Consistency Modifications

1. Clear liquid diet
1. Purpose is to rest GI tract and maintain fluid balance.
2. Indications include difficulty chewing or swallowing; before certain diagnostic tests to reduce fecal material; immediate postoperative period (until bowel sounds have returned) to maintain electrolyte balance; and nausea, vomiting, and diarrhea.
3. Foods allowed: "see-through foods" include water, tea, broth, jello, apple juice, clear carbonated beverages, and frozen ice pops.
4. Not nutritionally adequate.
2. Full liquid diet
1. Used as a transition diet between clear liquid and soft diet; usually short term.
2. Foods allowed: clear liquids, milk and milk products, all fruit juices, cooked and strained cereals.
3. Can be nutritionally adequate.
3. Soft diet
1. Used as a transition diet between full liquid and regular diet.
2. Indications include postoperatively, mild GI disturbances, chewing difficulties from lack of teeth or oral surgery.
3. Foods allowed: foods low in fiber, connective tissue and fat (full liquid diet, pureed vegetables, eggs cooked any way except fried, tender meat, potatoes, cooked fruit).
4. Nutritionally adequate.
4. Bland diet (see Related Links: Special Diets, Bland Diet)
1. Promotes healing of the gastric mucosa and is chemically and mechanically nonstimulating.
2. Foods allowed: soft diet without spices.
5. Low-residue diet (see Related Links: Special Diets, Low-residue Diet)
1. Residue is the indigestible substances left in digestive tract after food has been digested.
2. Indications include colon, rectal, or perineal surgery to reduce pressure on the operative site; prior to examination of the lower bowel to enhance visualization; internal radiation for cancer of the cervix; Crohn's disease or regional enteritis; ulcerative colitis to reduce irritation of the large bowel; and diarrhea.
3. Teach client to avoid foods high in fiber, foods having skins and seeds, and milk and milk products.

Evaluation

1. Client's weight is within normal limits.
2. No lesions in oral cavity.
3. Client feeds self or receives needed assistance with feeding.
4. Skin and tissue integrity is maintained.
5. Client demonstrates ability to exercise.
6. Client makes positive statements about self-image.
7. Client's bowel functioning is normal.
8. Serum electrolytes are within normal limits.
9. Client will exhibit growth and development patterns appropriate for age.
10. Client shows no evidence of infection.
11. Client states reason for special diet.
12. Client describes foods allowed and not allowed on prescribed diet.
13. Client adheres to prescribed diet.

Enteral Nutrition
Preferred method for nutritional support for the malnourished client whose GI system is intact.

Oral Feeding

1. Always the first choice
2. Oral formula supplements may be used between meals to provide added kcal and nutrients.
1. Offer small quantities several times a day.
2. Vary flavors, avoid taste fatigue.
3. Chill and serve over ice.

Tube Feeding

1. Used for clients who have a functioning GI tract but cannot ingest food orally
1. Feeding tubes
1. Short term: nasogastric tube
2. Long term: esophagostomy, gastrostomy, or enterostomy tube
2. Formulas: nutritionally adequate, tolerated by client, easily prepared, easily digested, usual concentration 1 kcal/ml
3. Feeding schedules
1. Intermittent: usually 4-6 times/day, volumes up to 400 ml, by slow gravity drip over 30-60 minutes
2. Continuous: usually administered by pump through a duodenal or proximal jejunostomy feeding tube
4. Nursing responsibilities
1. Administer formulas at room temperature (refrigerate unused portion).
2. Gradually increase rate and concentration until desired amount is attained if there are no signs of intolerance (e.g., gastric residual greater than 120 ml, nausea, vomiting, diarrhea, distention, diaphoresis, increased pulse, glycosuria, aspiration).
3. Check tube placement and elevate head of bed (see also Nasogastric Tubes).
4. Monitor I&O, serum electrolytes, fractional urines, serum glucose, daily weights; keep a stool record as well as an ongoing assessment of tolerance.

Parenteral Nutrition
Nutrients are infused directly into a vein for clients who are unable to eat or digest food through the GI tract, who refuse to eat, or who have inadequate oral intake.

Total Parenteral Nutrition (TPN)

1. Involves the infusion of nutrients through a central vein catheter. A central vein is needed because its larger caliber and higher blood flow will quickly dilute the hypertonic hyperalimentation solution to isotonic concentrations.
2. Hyperalimentation solutions
1. Hypertonic glucose of 20%-70%, amino acids, water, vitamins, and minerals with lipid emulsions given in a separate solution.
2. Three-in-one solutions
1. Lipids mixed with dextrose and amino acids in pharmacy.
2. Comes in a three liter container and administered over 24 hours.
3. Nursing responsibilities
1. For details of nursing care of the client with a central venous line, see IV Therapy.
2. Inspect solution before hanging.
1. Check for correct solution and additives against physician's order.
2. Check expiration date.
3. Observe fluid for cloudiness or floating particulate matter.
3. Control flow rate of solution.
1. Calculate correct rate.
2. Administration via pump is preferable.
3. Monitor flow rate.
4. Never attempt to speed up or slow down infusion rate.
1. speeding up infusion causes large amounts of glucose to enter body, causing hyperosmolar state.
2. slowing down infusion can cause hypoglycemic state, as it takes time for the pancreas to adjust to reduced glucose level.
4. Monitor fluid balance.
5. Obtain fractional urines or Accu-checks every 6 hours.
6. Use Testape to detect hyperglycemia (some additives may cause false positive if Clinitest is used); cover with sliding scale insulin as ordered.
7. Provide psychologic support.
8. Encourage exercise regimen.

IV Lipid Emulsions

1. May be given through a central vein or peripherally in order to prevent essential fatty acid deficiency in long-term TPN clients, or to provide supplemental kcal IV.
2. Nursing care
1. Protect the stability of the emulsion.
1. Administer in its own separate IV bottle and IV tubing, and piggyback the emulsion into the Y connector closest to the catheter insertion. Follow hospital policy and manufacturer's recommendations for specific products.
2. Inspect solution for evidence of separation of oil, frothiness, inconsistency, particulate matter; discard solution if any of these signs of instability occur.
3. Do not shake the bottle; this might cause aggregation of fat globules.
4. Discard partially used bottles.
2. Control the infusion rate accurately and safely.
1. If using gravity method, lipid emulsion must hang higher than hyperalimentation to prevent back flow.
2. Pump is preferred but may not be possible due to viscous nature of emulsion.
3. Prevent and assess for adverse reactions.
1. Administer slowly according to package insert over first 30 minutes; if no adverse reactions, increase rate to complete infusion over the specified number of hours.
2. Obtain baseline vital signs; repeat after first 30 minutes, and then every 1-2 hours until completion.
3. Acute reactions may include: fever, chills, dyspnea, nausea, vomiting, headache, lethargy, syncope, chest or back pain, hypercoagulability, thrombocytopenia.
4. Evaluate tolerance and patient response.

Peripheral Vein Parenteral Nutrition (PPN)

1. Can be used for short-term support, when the central vein is not available, and as a supplemental means of obtaining nutrients. Client must be able to tolerate a relatively high fluid volume.
2. Solution contains the same components as central vein therapy, but lower concentrations (less than 20% glucose).
3. Care is the same as for the client receiving hyperalimentation centrally.
4. Phlebitis and thrombosis are common and IV sites will need frequent changing.