CHAPTER 47-NUTRITION

Nutrition - sum of all interactions between an organism and the food it consumes

- what a person eats and how the body uses it

Nutrients - organic and inorganic substances found in foods that are required for body functioning

Nutritive value - nutrient content of a specified amount of food

- no one food provides all essential nutrients

Three Major Functions:

- provide energy for body processes and movement

- provide structural material for body tissues

- regulate body processes

Essential Nutrients and Sources:

Macronutrients - needed in large amounts (hundred of grams)

- water

- carbohydrates - easily digestable

- protein

- fats - goes through emulsification process

- minerals and vitamins

Micronutrients - required in small amounts to metabolize energy providing nutrients (mg or micrograms)

- vitamins

- minerals

Carbohydrates - elements of Carbon, Hydrogen and Oxygen

Two Basic Types:

- simple carbohydrates - sugars

- monosaccharides

- disaccharides

- complex carbohydrates -starches and fibers

- starches - insoluble, nonsweet (grains and potatoes)

 - fibers - plants, bran, fruits and vegetables

Digestion, Absorption and Metabolism: Carbohydrates

- major enzymes: ptyalin (salivary amylase), pancreatic amylase, disaccharides

Enzymes - biological catalysts speeds up chemical reactions

- end product - monosaccharides

- absorbed by small intestine (villi)

- body breaks carbohydrates into glucose

- maintain blood vessels

- provide readily available source of energy

DAM: Protein (CHON)

- digestion begins in the stomach with enzyme pepsin

- pancreas secretes proteolytic enzymes trypsin, chymotrypsin and carboxypeptidase

- glands in intestinal wall secrete aminopeptidase and dipeptidase which breaks proteins to amino acids

- amino acids absorbed by active transport through small intestines

- Anabolism (building up of tissue)

- Catabolism (breaking down of tissue)

- Nitrogen Balance - measure of the degree of protein anabolism and catabolism

Lipids (CHOH) - organic substances that’s greasy and insoluble in water but soluble in alcohol or ether

Fats- lipids that are solid in room temperature

Oils - liquid in room temperature

Fatty Acids - basic structural unit of lipids

Saturated fatty acids - butter; animal products

Unsaturated fatty acids - linoleic acid (vegetable oil); plant products (olive, corn oils)

Cholesterol - fat-like substance produced by body and found from animal origin

Triglycerides - 3 fatty acids

- 90% of lipids in food and in the body

DAM: Lipids/Fats (CHOH)

- digestion begins in the stomach

- digested in the small intestine

 - digestion by bile, pancreatic lipase and enteric lipase

- end product: glycerol, fatty acids and cholesterol

- small intestine and the liver convert these into lipoprotein

- convert fat into useable energy occurs thru lipase that breaks down triglycerides in adipose cells releasing glycerol and fatty
acids into the blood

Micronutrients

- vitamin - organic compound cannot be manufactured by the body

- needed in small quantities

- water-soluble - vitamin C and B complex

- fat-soluble -vitamin ADEK

Energy Balance - relationship between energy derived from food and the energy used in the body

Caloric Value - amount of energy

that nutrients of foods supply to the
body

Calorie - unit of heat energy

Basal Metabolic Rate (BMR) - rate of

metabolism

Resting energy expenditure (REE) -

energy required to maintain basic
body functions

Metabolism - biochemical and

physiological processes by which
body grows and maintains

Health Body Weight - balance between expenditure of energy and the intake of nutrients

Ideal Body Weight (IBW) - optimal weight recommended

Body Mass Index (BMI) - person’s weight is appropriate for height

Other indirect body mass measures:

 - percent body fat

- waist circumference

Factors Affecting Nutrition:

Developmental Considerations:

Neonate to 1 year:

- fluid and nutritional needs are met by breast milk of formula

- addition of solid food to the diet (4-6 mos.)

- 1 year old, most infants can be completely fed on table food and milk intake is about 20 oz per day

- Demand feeding - means that the child is fed when hungry rather than on a set time schedule

- Regurgitation, or spitting up, during or after a feeding is a common occurrence during the first year

- Iron deficiency anemia is a form of anemia (decrease in red blood cells) caused by inadequate supply of iron for
synthesis of hemoglobin

- Bottle Mouth Syndrome - decay of the teeth caused by constant contact with sweet liquid from the bottle

Toddler:

- can eat most foods

- can adjust to three meals a day

Preschoolers:

- can eat adult foods

School Age:

- balanced diet (2400 kcal/day)

- 3 meals/day and additional one or two nutritious snacks

- protein-rich food at breakfast

Adolescent:

- increased need for nutrient and calories during growth spurts

- 1200-1500 mg/day (calcium intake)

- healthy snacks, limit junk foods

- anorexia nervosa and bulimia may occur

- Anorexia nervosa - characterized by a prolonged inability or refusal to eat, rapid weight loss, and emaciation in individuals
who continue to believe they are fat
 - Bulimia - uncontrollable compulsion to consume enormous amounts of food (binge) and then expel it by self-induced
vomiting or by taking laxatives (purge)

Adults:

- protein, calcium and limit cholesterol and caloric intake

- 2-3 liters of fluid intake

- antioxidants (Vitamins ACE) - reduce heart diseases in women

- postmenopausal women

Elders:

- same nutrition as adults

- fewer calories needed

- more carbohydrates for fiber and bulk

Food Pyramid:

- grain - 6 servings

- vegetables - 3 servings

- fruits - 2 servings

- water - 8 or more servings

- dairy - 3 or more servings

- beans, nuts, meats and fish - 2

or more servings

- fats/oils - eat less

Nutritional Screening and

Assessment:

- performed to identify client risk for

malnutrition

- Nursing History

- physical examination

-calculating percentage of weight loss

- dietary history

- anthropometric measurements

- laboratory data

- measuring skinfold
Malnutrition is commonly defined as the lack of necessary or appropriate food substances, but in practice includes both
undernutrition and overnutrition

Overnutrition refers to a caloric intake in excess of daily energy requirements, resulting in storage of energy in the form of adipose
tissue

A person is said to be overweight when the BMI is between 25 and 29.9 kg/m2 and obese when the BMI is >30 kg/m2

Undernutrition refers to an intake of nutrients insufficient to meet daily energy requirements because of inadequate food intake or
improper digestion and absorption of food.

Protein-calorie malnutrition (PCM), seen in starving children of underdeveloped countries, is now also recognized as a significant
problem of clients with long-term deficiencies in caloric intake (e.g., those with cancer and chronic disease)

Characteristics of PCM are depressed visceral proteins (e.g., albumin), weight loss, and visible muscle and fat wasting.

Risk factors for malnutrition: - antidepressants

Diet History: - antihypertensives

- chewing and swallowing difficulties - anti-inflammatory

- inadequate food budget and intake - antineoplastic

- IV fluids - aspirin

- living and eating alone - digitalis

- no intake for > 7 days - diuretics

- physical disabilities - laxatives

- restricted or fad diets (conformity to diets of other - potassium chloride

people)

Medical History:
Nursing Interventions for optimal nutrition:
- adolescent pregnancy
Hospitalized client:
- alcohol/substance abuse
- collaboration with primary care provider and dietician
- catabolic and hypermetabolic conditions
- atmosphere that encourages eating
- chronic illness
- provide and assist with eating
- dental problems
- monitor client’s appetite and food intake
- neurologic or cognitive impairments
- adm enteral and parenteral feedings
- oral and GI surgeries
- reinforce information presented by dietician
- unintentional weight loss or gain
Community setting:
Medication History:
- health education
- antacid
Home Setting:
 - refer to appropriate resources - instruct about enteral and parenteral feedings

Anthropometric measurements are noninvasive techniques that aim to quantify body composition

- Skinfold measurement - is performed to determine fat stores.

The most common site for measurement is the triceps skinfold (TSF). The fold of skin measured includes
subcutaneous tissue but not the underlying muscle. It is measured in millimeters using special calipers

- Mid-arm circumference (MAC) - is a measure of fat, muscle, and skeleton

-Mid-arm muscle area (MAMA) is then calculated by using reference tables or by using a formula that incorporates the TSF
and the MAC

The MAMA is an estimate of lean body mass, or skeletal muscle reserves

Food frequency record - checklist that indicated how often general food groups or specific foods are eaten

Food diary - detailed record of measured amounts (portion sizes) of all food and fluids a client consumes during a specified period,
usually 3-7 days

Diet history - comprehensive time-consuming assessment of a client’s food intake that involves an extensive interview by a
nutritionist or dietitian

Dysphagia - difficulty in swallowing

Enteral Nutrition (EN) - also referred to as total enteral nutrition (TEN); provided when the client cannot ingest foods or the upper GI
tract is impaired and the transport of food to the small intestine is interrupted

- adm through nasogastric and small-bore feeding tubes or through gastrotomy or jejunostomy tubes

Nasogastric tube - inserted through one of the nostrils, down the nasopharynx, and into the alimentary tract

Nasoenteric (nasointestinal) tube, a longer tube than the nasogastric tube (at least 40 cm [15.75 in.] for an adult), is inserted
through one nostril down into the upper small intestine

Gastrostomy and jejunostomy devices are used for long-term nutritional support, generally more than 6 to 8 weeks. Tubes are
placed surgically or by laparoscopy through the abdominal wall into the stomach (gastrostomy) or into the jejunum (jejunostomy)

A percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) is created by using an endoscope to
visualize the inside of the stomach, making a puncture through the skin and subcutaneous tissues of the abdomen into the stomach,
and inserting the PEG or PEJ catheter through the puncture
 Methods to check tube placement:

1. Aspirate GI secretions - gastric secretions

tend to be a grassy-green, off-white, or tan
color; intestinal fluid is stained with bile and has
a golden yellow or brownish green color

2. Measure the pH of aspirated fluid

- Gastric aspirates tend to be acidic and

have a pH of 1 to 4 but may be as high as 6 if the
client is receiving medications that control
gastric acid.

- Small intestine aspirates generally have a

pH equal to or higher than 6.

- Respiratory secretions are more alkaline

with values of 7 or higher. However, there is a
slight possibility of respiratory placement when
the pH reading is as low as 5.

3. Confirm length of tube insertion with the

insertion mark. If more of the tube is now
exposed, the position of the tip should be
questioned

Refeeding syndrome—a combination of fluid

and electrolyte shifts that can occur after a
lengthy period of malnutrition or starvation.
This syndrome can occur when the starving body converts from creating glucose from carbohydrates to creating it from protein
stores since carbohydrate was unavailable

Parenteral nutrition, also referred to as total parenteral nutrition (TPN) or intravenous hyperalimentation, is the IV infusion of
dextrose, water, fat, proteins, electrolytes, vitamins, and trace elements. Because TPN solutions are hypertonic (highly concentrated
in comparison to the solute concentration of blood), they are injected only into high-flow central veins, where they are diluted by the
client’s blood

Peripheral parenteral nutrition (PPN) is delivered into the smaller peripheral veins. PPN cannot handle as concentrated a solution as
central lines, but can accommodate lipids