NUTRITI ON

Essential nutrients and sources

• Water
• Carbohydrates
• Protein
• Fats
• Micronutrients
o Vitamins
o Minerals

Digestion, Absorption and metabolism

CARBOHYDRATES
• Major enzymes include ptyalin (salivary amylase), pancreatic amylase, and the disaccharidases
• End products are monosaccharides
• Absorbed by the small intestine in healthy people
• Body break down carbohydrates into glucose
o Maintain blood levels
o Provide readily available source of energy

PROTEIN
• Digestion begin in the mouth with enzyme pepsin
• Most protein digested in the small intestine
• Pancreas secretes the proteolytic enzymes trypsin, chymotrypsin, and carboxypeptidase
• Glands in intestinal wall secrete amino peptidase and dipeptidase w/c break protein into amino acids
• Amino acids absorbed by active transport through small intestines
• Anabolism, catabolism, nitrogen balance

LIPIDS AND FATS

• Digestion begins in the stomach, but mainly digested in the small intestine
• Digestion primarily by bile, pancreatic lipase, and enteric lipase
• End products of lipid digestion are glycerol, fatty acids, and cholesterol
• Reassembled inside the intestinal cells into triglycerides and cholesterol esters
• Small intestine an d the liver convert these into soluble compounds called lipoprotein
• Converting fat into useable energy occurs through lipase that breaks down triglycerides in adipose cells releasing glycerol and fatty acids
into the blood

Energy balance
• Relationship between the energy derived from food and the energy used by the body
• Caloric value is the amount of energy that nutrients or food supply to the body
• BMR is the rate which the body metabolizes food to maintain the energy requirements of a person who is awake and at rest
• Resting energy expenditure (REE) is the amount of energy required to maintain basic body functions (calories required to maintain life)

Healthy body weight

• Balance between the expenditure of energy and the intake of nutrients
• IBW (Ideal Body Weight) is the optimal weight recommended for optimal health
• BMI (Body Mass Index)is considered to be more reliable indicator by health professionals
• Other indirect body mass measures
o Percent body fat
o Waist circumference
o Skinfold circumference
o Near-infrared interactance
o Bioelectrical inpedance analysis (BIA)

Factors influencing nutrition

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

Alterations in Nutrition

Ove rweight is an energy imbalance in which more food is consumed than is needed, causing a storage of fat.
Overweight indicates a positive energy balance and is defined as weight 10% to 20% above average; obesity refers to weight 20% above average.
Overweight may result from one or more factors: genetic, psychological, social, cultural, economic, or physiological. Genetically linked factors, such
as a low BMR, excess fat distribution, and obese parents, place the person at risk for obesity. Some people overeat in response to emotional stress
or whenever food is available rather than in response to hunger.

 Socio cultural norms influence eating habits

 Cultures place a high value on excess weight.
 Hormonal imbalances, such as decreased thyroxin levels, can lower the BMR, causing weight gain if food intake remains constant.

Underweight , a negative energy balance, is weight at least 10% to 15% below average. Being underweight decreases the individual’s resistance
to infection and increases susceptibility to fatigue and sensitivity to cold environments. Family dynamics and a fear of fatness are psychological
conditions that can contribute to eating disorders.
 Anore xia ne rvosa (self-starvation) disrupts metabolism because of inadequate calorie intake and results in hair loss, low blood
pressure, weakness, amenorrhea, brain damage, and even death (Townsend & Roth, 1999).
 Bu li mia ner vosa refers to food-gorging binges followed by purging of food, usually through self-induced vomiting or laxative abuse.
 Underweight can also be caused by long-term conditions that deplete the body’s resources, such as fever, infection, and cancer, or that
prevent nutrient absorption, as occurs with diarrhea, metabolic or GI disorders, and laxative abuse. Other causes of underweight are
hyperthyroidism and poverty.

Developmental nutritional considerations

• Neonate to 1 yr
o Fluid and nutritional needs are met by breast milk or formula
o Addition of solid food to the diet between 4 and 6 months of age
o By the age of 1, most infants can be completely fed on table food, and milk intake is about 20 ounces per day

• Toddler
o Can eat most foods and adjust to 3 meals / day
o Able to bite and chew adult table food

• Preschooler
o Eat adult foods
o Very active and often require snacks between meals
o Cheese, fruits, yogurt, raw vegetables, and milk are good choices

• School aged
o Require a balanced diet including 2400 Kcal/day
o Eat 3 meals a day and one or two nutritious snacks
o Need a protein rich food at breakfast to sustain the prolonged physical and mental effort required at school

• Adolescent
o Increased need for nutrient and calories during growth spurts
o Adequate calcium intake (1200 to 1500mg/day)
 o Health snacks and limits on junk foods
o Anorexia nervosa and bulimia may occur

• Adults
o Continue to eat a healthy diet, with special attention to protein, calcium, and limiting cholesterol and caloric intake
o 2 or 3 liters of fluid should be included in the daily diet
o Postmenopausal women need to ingest sufficient calcium and vitamin D to reduce osteoporosis
o Antioxidants such as vitamin A, C, and E may be helpful in reducing the risks of heart disease in women

• Elders
o Require the same basic nutrition as the younger adult
o Fewer calories are needed by elders because of the lower metabolic rate and the decrease in physical activity
o Some may need more carbohydrates for fiber and bulk, but most nutrient -------inc--------
o Physical changes as tooth loss and impaired sense of taste and smell may affect eating habits

Food Pyramids
• Fats and sweet - eat less
• Milk group - 2-3 servings
• Veg. Groups - 2-3 servings
• Grain group - 6-7 servings
• Meat groups - 2 servings
• Fruit groups - 2 servings

Nutritional Screening and assessment

• Purposes
o Assessment performed to identify clients at risk for malnutrition
o Clients found to be at moderate or high risk are followed with a comprehensive assessment by a dietician
o Nursing homes residents whose percent of meals eaten falls below 75% receive a full nutritional assessment by a nurse
o Nursing history; factors influencing nutrition
o PE; signs of malnutrition
o Calculating percentage of weight loss
o Dietary history
o Anthropometric measurements
o Lab data
o Measuring skinfold

Malnutrition risk factors

• Diet history
o Chewing and swallowing difficulties
o Inadequate food budget, food intake, preparation and storage facilities
o IV fluids
o Living and eating alone
o No intake for greater than 7 days
o Physical disabilities
o Restricted or FAD diet
• Medical history
o Adolescent pregnancy or closely spaced pregnancies
o Alcohol/substance abuse
o Catabolic or hypermetabolic conditions
o Chronic illnesses
o Dental problems
o Neurologic or cognitive impairments
o Oral and GI surgeries
o Unintentional weight loss or gain
o Medications
• Antacids
  Antidepressants
 Antihypertensive
 Anti-inflammatory
 Antineoplastic
 Aspirin
 Digitalis
 Diuretics
 Laxatives
 Potassium chlorides
Nursing Process applications

1. Assessment

The goals of a nursing assessment are to collect subjective and objective data regarding the client’s nutritional status and to determine what type of
nutritional support is needed. Nurses are in a unique position to recognize
Ma lnutr it ion or alterations related to inadequate intake, disorders of digestion or absorption, and overeating

a. Nursing historyThe nutritional history of clients experiencing alterations in nutrition and metabolism is of critical importance in the development of
the plan of care. Several methods can be used in collecting these subjective data: 24-hour recall, food frequency questionnaire, food record, and diet
history

24-Hour Reca ll
The 24-hour recall requires client identification of everything consumed in the previous 24 hours. It is performed easily and quickly by asking
pertinent questions. However, clients may be unable to recall their intake accurately or anything atypical for their diet. Family members can often
assist with these data, if necessary.
Food-Fr eque nc y Quest ionnai re
The food-frequency method gathers data relative to the number of times per day, week, or month the client eats particular foods. The nurse can tailor
the questions to particular nutrients, such as cholesterol and saturated fat. This method helps to validate the accuracy of the 24- hour recall and
provides a more complete picture of foods consumed.
Food Record
The food record provides quantitative information regarding all foods consumed, with portions weighed and measured for three consecutive days.
This method requires full client or family member cooperation.
Diet H is tor y
The diet history elicits detailed information regarding the client’s nutritional status, general health pattern, socioeconomic status, and cultural factors.
This method incorporates information similar to that collected by the 24-hour recall and food frequency questionnaire. Inform the client that the
history might require more than one interview because of the amount of data to be collected. Although the history data may indicate adequate
nutrition, clients must be reassessed periodically to prevent nutritional problems from occurring. Fear, anxiety, or depression before or during
hospitalization may lead to poor food intake, which is the leading cause of malnutrition.

b. Physical examination

A physical assessment requires decision making, problem solving, and organization This section presents the physical assessment findings that
suggest nutrient imbalance. “The nurse should be aware of rapidly proliferating tissues such as hair, skin, eyes, lips, and tongue that usually show
nutrient deficiencies sooner than other tissues”(Hammond, 1999, p. 355)..
Intake and Output (I &O)
Intake and output measurements and daily weights are critical components of a nutritional assessment;
Anth ropometr ic M easu rements
Anth ropometr ic m easu rements (measurement of the size, weight, and proportions of the body) evaluate the client’s calorie-energy expenditure
balance, muscle mass, body fat, and protein reserves based on height, weight, skin folds, and limb and girth circumferences.
The body ma ss i ndex ( BM I) determines whether a person’s weight is appropriate for height and is calculated using a simple formula: For
example, a person who weighs 65 kg and is 1.6 m tall would have a BMI of or greater indicates obesity.

Sk in fo ld m easure ment indicates the amount of body fat. This information is beneficial in promoting health and determining risks and treatment
modalities associated with chronic illness and surgery. A special caliper is used to measure skin folds. The caliper should grasp only the
subcutaneous tissue, not the underlying muscle. Measurements can be taken of the triceps, subscapular, biceps, and suprailiac skinfolds.
1. To measure the triceps fold, locate the midpoint of the upper arm. Grasping the skin on the back of the upper arm, place the calipers 1 cm
below your fingers (Figure 38-10), and measure the thickness to the nearest millimeter.
2. For a subscapular skinfold measurement, grasp the skin below the scapula with three fingers, angle the fold about 45° laterally to the
scapula, place the caliber 1 cm above your fingers, and read the measurement. It is essential to document the skin fold sites, the type of
caliper used, and the measurement in millimeters.

Diagnost ic and Laborator y Data

Biochemical data assessment is another essential source of objective data. Trends revealed in laboratory results can be used to detect alterations in
nutrition and metabolism before clinical symptoms are assessed in the examination.
Pr otein Ind ice s
Several tests that reflect protein synthesis can also reflect nutritional status. Serum levels of albumin and transferrin are used to identify protein-
calorie malnutrition.
Se rum Album in
Albumin is synthesized in the liver from amino acids. Serum albumin plays an important role in fluid and electrolyte balance and the transport of
nutrients, hormones, and drugs. However, serum albumin has a half life of 21 days and fluctuates according to the level of hydration; therefore, it is
not a good indicator of acute alterations in protein status. Clinically, this blood test is used to measure prolonged protein depletion that

Hemog lobin Leve l

The hemoglobin test measures the oxygen- and iron carrying capacity of the blood; the normal level is 12 to 15 g/100 ml. Decreased hemoglobin
may indicate some form of anemia, such as microcytic iron deficiency anemia, or blood loss.
Tota l L ymphoc yte Count
Another test that may be used to measure protein depletion is total lymphocyte count. Protein deficiency may cause a depression in the immune
system, with a resultant decrease in the total lymphocyte count; this can occur with severe debilitating diseases, such as cancer or renal disease.
Ni trogen B alan ce
Nitrogen balance studies indicate the degree to which protein is being depleted or replaced in the body. The blood urea nitrogen (BUN) is increased
with severe dehydration, malnutrition, starvation, excessive protein intake, and most commonly in kidney disease (the kidneys fail to excrete urea). A
decreased BUN results from
a diet low in protein-rich foods.
Ur ine Creat inine E xc ret ion
During skeletal muscle metabolism, creatinine is released at a rate in proportion to the total body mass. A 24-hour urine test is done to measure the
total amount of creatinine excreted by the kidneys. In malnutrition, the creatinine level is decreased as a result of muscle atrophy.

Upper GI s er ies , also upper gastro intest inal (GI ) tra ct rad iography , is aradiologic examination of the upper gastrointestinal tract. It
consists of a series of X-ray images of the esophagus, stomach and duodenum. The most common use for this medical testing is to look for signs
of ulcers, acid reflux disease, uncontrollable vomiting, or unexplained blood in the stools (hematochezia or positive fecal occult blood).

Ba riu m Swa ll ow is a medical imaging procedure used to examine the upper GI (gastrointestinal) tract, which includes the esophagus and, to a
lesser extent, the stomach.

Es opha gogast rodu odenoscopy (EGD)

is a diagnostic endoscopicprocedure that visualizes the upper part of the gastrointestinal tract up to the duodenum. It is considered a minimally

invasive procedure since it does not require an incision into one of the major body cavities and does not require any significant recovery after the

procedure (unlesssedation or anaesthesia has been used). A sore throat is also common.

Li ver func tion tes ts (LFTs or LFs), which include liv er enz yme s, are groups of clinical biochemistry laboratory blood assays designed to give
information about the state of a patient's liver. Most liver diseases cause only mild symptoms initially, but it is vital that these diseases be detected
early. Hepatic (liver) involvement in some diseases can be of crucial importance. This testing is performed by a medical technologiston a patient's
serum or plasma sample obtained by phlebotomy. Some tests are associated with functionality (eg. albumin); some with cellular integrity
(eg. transaminase) and some with conditions linked to the biliary tract (gamma-glutamyl transferase and alkaline phosphatase).

Li ver B iop sy Is The Biopsy (Removal Of A Small Sample Of Tissue) From The Liver. It Is A Medical Test That Is Done To Aid Diagnosis Of Liver
Disease, To Assess The Severity Of Known Liver Disease, And To Monitor The Progress Of Treatment. Liver Biopsies May Be
Taken Percutaneously (Via A Needle Through The Skin), Transvenously (Through The Blood Vessels) Or Directly Duringabdominal Surgery. The
Sample Is Examined By Microscope, And May Be Processed Further By Immunohistochemistry, Determination Of Iron Andcopper Content,
And Microbiological Culture If Tuberculosis Is Suspected

Nursing interventions for optimal nutrition

• Hospitalized client
o Provided in collaboration with the primary care provider and the dietician
o Reinforce information presented by dietician
o Create an atmosphere that encourages eating
o Provide and assist with eating
o Monitor the client's appetite and food intake
o Administer enteral and parenteral feedings
o Consult with primary care provider and dietician about nutritional problems
• Community setting
o Education
• Home setting
o Refer clients at risk to appropriate resources
o Instruct clients about enteral and parenteral feedings
o Offer nutritional counseling as needed
o Assist clients with special diet
o Stimulating the appetite

NANDA nursing diagnosis

• Related to nutritional problems
o Imbalance nutrition: more than body requirements
o Imbalance nutrition: less than body requirements
o Readiness for enhanced nutrition
o Risk for imbalanced nutrition: more than body requirements
o Activity intolerance
o Constipation
o Low self-esteem
o Risk for infection
• Desired outcomes
o Maintain or restore optimal nutritional status
o Promote healthy nutritional practices
o Prevent complications associated with malnutrition
o Decrease weight
o Regain specified weight
GUYS DON’T LET OTHER SECTIONS HAVE COPIES OF MY LECTURE NOTES. TNX------JNT