NCLEX-RN: Nutritional Management

Nutritional Management: Macronutrients

Focus topic: Nutritional Management

Nutritional Management: Carbohydrates

Focus topic: Nutritional Management

 

A. Carbohydrates are the chief source of energy and contain carbon, hydrogen, and oxygen.

  • Carbohydrates include sugars, starches, and cellulose.
  • Simple sugars, such as fruit sugar, are easily digested.
  • Starches, which are more complex, require more sophisticated enzyme processes to be reduced to glucose.
  • One gram of carbohydrate provides 4 kilo calories.
  • Glucose, which is converted sugar or starch, appears in the body as blood sugar.
    a. It is “burned” as fuel by the tissues.
    b. Some glucose is processed by the liver, converted to glycogen, and stored by the liver for later use.

✦B. Ingesting too many carbohydrates crowds out other important foods; it prevents the body from receiving the necessary nutrients for healthy maintenance.
✦C. Ingesting too few carbohydrates leads to loss of energy, depression, ketosis; it also leads to a breakdown of body protein.
D. The amount and kind of carbohydrates that should be consumed for optimal health are determined by several factors.

  • Differences in body structure; energy expenditure; basal metabolism rate; and general health status.
  • The average American diet provides 45% of calories from carbohydrates; it is recommended that this proportion be increased to 50–65%.
  • Simple (refined) sugars should be limited to 10% total calories.

Nutritional Management: Fats or Lipids

Focus topic: Nutritional Management

A. Fats or lipids are the second important group of nutrients.

  • They provide energy.
  • When oxidized, they are the most concentrated sources of energy.
  • They furnish the calories necessary for survival; each fat gram provides 9 kilo calories.

B. Fats also act as carriers for the fat-soluble vitamins A, D, E, and K.
C. Consuming too much fat is unhealthy.

  • The average American diet provides 35–40% of calories from fat.
  • Fats should account for no more than 20–35% of daily calorie intake.

D. Fatty acids are the basic components of fat, and comprise two main groups.

  • Saturated fatty acids usually come from animal sources. It is recommended to substitute saturated fats with polyunsaturated and monounsaturated fats.
    a. Saturated fats should be less than 10% of calories.
    b. Cholesterol should be limited to 300 mg daily.
  • Unsaturated fatty acids primarily come from vegetables, nuts, or seed sources and are liquid at room temperature.
    a. This group contains three essential fatty acids.
    b. These acids are called essential because they are necessary to prevent a specific deficiency disease.
    c. The body cannot manufacture these acids. They are obtained only from the diet.
    d. These acids are called linoleic acid, arachidonic acid, and linolenic acid.
    e. A deficiency in this group would lead to skin problems, illness, and unhealthy blood and arteries.

Nutritional Management: Proteins

Focus topic: Nutritional Management

A. Proteins are complex organic compounds that contain amino acids.
B. Protein is critical to all aspects of growth and development of body tissues. It is necessary for the building of muscles, blood, skin, internal organs, hormones, and enzymes.
C. Each gram of protein provides 4 kilo calories.

  • The RDA for protein is 56 g/day for men and 45 g/day for women.
  • The optimal diet should be 10–12% protein rather than the 17% most Americans consume.

D. Protein is also a source of energy.

  • When there is insufficient carbohydrate or fat in the diet, protein is burned.
  • When protein is spared, it is either used for tissue repair and maintenance or converted by the liver and stored as fat.

E. When proteins are digested and broken down, they form 20 amino acids.

  • Amino acids are absorbed from the intestine into the bloodstream.
  • They are carried to the liver for synthesis into the tissues and organs of the body.

F. Amino acids are the chemical basis for life. If just one is missing, protein synthesis will decrease or even stop.

G. All but nine amino acids can be synthesized by the body. Eight are required by all humans; infants require one more—histidine.

  • These nine must be obtained from the diet.
  • If all nine are present in a particular food, the food is a complete protein.
  • Foods that lack one or more essential amino acids are called incomplete proteins.
  • Most meat and dairy products are complete proteins.
  • Most vegetables and fruits are incomplete proteins.
  • When several incomplete proteins are ingested, they should be combined carefully so that the result will be a balance yielding complete protein. For example, the combination of beans and rice is a complete protein food.

H. Protein deficiency can affect the entire body—organs, tissues, skin, and muscles, as well as certain body processes.

Nutritional Management: Water

Focus topic: Nutritional Management

A. While not specifically a nutrient, water is essential for survival.

  • Water is involved in every body process, from
    digestion and absorption to excretion.
  • It is a major portion of circulation and is the
    transporter of nutrients throughout the body.

B. Body water performs three major functions.

  • Water gives form to the body, accounting for 50–75% (average 60%) of the body mass.
  • It provides the necessary environment for cell metabolism.
  • It maintains a stable body temperature.

C. Almost all foods contain water that is absorbed by the body.
D. The average adult body (male weighing 70 kg) contains approximately 40 L of water and loses about 3 L per day.

  • If a person suffers severe water depletion, dehydration and salt depletion can result and can eventually lead to death.
  • A person can survive longer without food than without water.

Nutritional Management: Micronutrients

Focus topic: Nutritional Management

Nutritional Management: Vitamins

Focus topic: Nutritional Management

A. Vitamins are organic food substances and are essential in small amounts for growth, maintenance, and the functioning of body processes.
B. Vitamins are found only in living things—plants and animals—and usually cannot be synthesized by the human body.

C. Vitamins can be grouped according to the substance in which they are soluble.
D. The fat-soluble group includes vitamins A, D, E, and K.
E. The water-soluble vitamins include the B-complex vitamins, vitamin C, and the bioflavonoids.
F. Vitamins have no caloric value, but they are as necessary to the body as any other basic nutrient.

  • Currently, there are about 20 substances identified as vitamins.
  • Recent research is concerned with identifying even more of these substances because they are so essential to survival.

G. The most commonly used guidelines are the listings of the Recommended Dietary Allowances (RDA), based on standards established by the National Academy of Sciences.

Nutritional Management: Minerals

Focus topic: Nutritional Management

A. Minerals are inorganic substances, widely prevalent in nature, and essential for metabolic processes.
B. Minerals are grouped according to the amount found in the body. These are both major minerals and trace minerals.
C. Major minerals include calcium, magnesium, sodium, potassium, phosphorus, sulfur, and chlorine, all of which have a known function in the body.
D. Trace minerals include iron, copper, iodine, manganese, cobalt, zinc, fluorine, selenium, and molybdenum. Their function in the body remains unclear.
E. There remains another group of trace minerals found in scanty amounts in the body and whose function is also unclear.

Nutritional Management: Foods Rich in Fat and Water-Soluble Vitamins

Focus topic: Nutritional Management

Nutritional Management

Nutritional Management: Essential Body Nutrients

Focus topic: Nutritional Management

Nutritional Management

F. Minerals form 60–90% of all inorganic material in the body, and are found in bones, teeth, soft tissue, muscle, blood, and nerve cells.
G. Minerals act on organs and in metabolic processes.

  • They serve as catalysts for many reactions, such as controlling muscle responses, maintaining the nervous system, and regulating acid–base balance.
  • They assist in transmitting messages, maintaining cardiac stability, and regulating the metabolism and absorption of other nutrients.

H. Even though they are considered separately, all minerals work synergistically with other minerals, and their actions are interrelated.

  • A deficiency in one mineral will affect the action of others in the body.
  • Adequate minerals must be ingested because a mineral deficiency can result in severe illness.
  • Excessive amounts of minerals can throw the body out of balance and may be toxic to the body.

I. Adequate diet can supply sufficient minerals.

Nutritional Management: Assimilation of Nutrients

Focus topic: Nutritional Management

Nutritional Management: Gastrointestinal Tract

Focus topic: Nutritional Management

A. The main functions of the gastrointestinal system.

  • Secretion of enzymes and electrolytes to break down raw materials that are ingested.
  • Movement of ingested products through the system.
  • Complete digestion of nutrients.
  • Absorption of nutrients into the blood.
  • Storage of nutrients.
  • Excretion of the end products of digestion.

B. When nutrients reach the stomach, both mechanical and chemical digestive processes occur.

  • Nutrients are churned, and peristaltic waves move the material through the stomach.
  • At intervals, with relaxation of the pyloric sphincter, they move into the duodenum.
  • This chemical action creates hydrochloric acid, which provides a medium for pepsin to split protein into proteoses and peptones.
  • The digestive process produces other chemical actions.
    a. Lipase, a fat-splitting enzyme.
    b. Rennin, an enzyme that coagulates the protein of milk.
    c. The intrinsic factor, which acts on certain food components to form the antianemic factor.

C. Nutrients then move into the duodenum and the jejunum.

  • Intestinal juices provide a large number of enzymes.
    a. These break down protein into amino acids.
    b. They form and convert maltase to glucose.
    c. They split nucleic acids into nucleotides.
  • The large intestine provides for the absorption of nutrients and the elimination of waste products.
    a. Vitamins K and B12, riboflavin, and thiamine are formed.
    b. Water is absorbed from the fecal mass.

Nutritional Management: The Accessory Organs

Focus topic: Nutritional Management

A. The accessory organs of the gastrointestinal tract play an important role in the utilization of nutrients.
B. The liver plays a major role in the metabolism of carbohydrates, fats, and proteins.

  • Liver converts glucose to glycogen and stores it.
  • It reconverts glycogen to glucose when the body requires higher blood sugar.
  • The process of releasing carbohydrates (end products) into the bloodstream is called glycogenolysis.
  • Fats are metabolized through the process of oxidation of fatty acids and the formation of acetoacetic acid.
  • Lipoproteins, cholesterol, and phospholipids are formed, and carbohydrates and protein are converted to fats.
  • Proteins are metabolized in the liver, and deamination of amino acids takes place.
  • The formation of urea and plasma proteins is completed.
  • The interconversions of amino acids and other compounds occur in the liver.

Nutritional Management: Major Enzymes of Digestion

Focus topic: Nutritional Management

Nutritional Management

C. The gallbladder’s primary function is to act as a reservoir for bile.

  • Bile emulsifies fats through constant secretion.
  • Secretion rate is 500–1000 mL every 24 hours.

D. The pancreas secretes pancreatic juices that contain enzymes for the digestion of carbohydrates, fats,and proteins.

  • Enzymes are secreted as inactive precursors that do not become active until secreted into the intestine.
  • In the intestine, the enzyme trypsin acts on proteins to produce peptones, peptides, and amino acids.
  • Pancreatic amylase acts on carbohydrates to produce disaccharides.
  • Pancreatic lipase acts on fats to produce glycerol and fatty acids.

Nutritional Management: Gastrointestinal Dysfunctions

Focus topic: Nutritional Management

A. Dysphagia (difficulty swallowing) occurs in 60% of stroke clients and 50% of clients with Parkinson’s disease.

  • Dysphagia may also occur in cerebral palsy, multiple sclerosis, polio, and myasthenia gravis.
  • Most serious complication is aspiration of liquid or food into lungs.

B. Gastrointestinal hemorrhage may cause a rise in serum ammonia, which may lead to altered neurologic function.
C. Intestinal obstruction—cessation of peristalsis (ileus) results in altered GI movement and absorption.

Nutritional Management: Nutritional Concepts

Focus topic: Nutritional Management

Nutritional Management: Normal and Therapeutic Nutrition

Focus topic: Nutritional Management

A. Normal nutrition.

  • A guide for determining adequate nutrition is the U.S. Department of Agriculture recommended daily dietary allowances.
    a. The guide is scientifically designed for the maintenance of healthy people in the United States.
    b. The values of the caloric and nutrient requirements given in the guide are used in assessing nutritional states.
    c. Stress periods in the life cycle, which require alterations in the allowances, should be considered during the planning of menus.
  • The basic food groups are described in the My Plate Food Guide 2011. (See Appendix 4-2, MyPlate Food Guide 2011).
    a. Choices in these food groups are offered to meet the nutrient recommendations during the life cycle. (Caloric requirements are not included.)
    b. The basic nutrients in each food group should be related to dietary needs during the life cycle when menus are planned for each age group.

B. Therapeutic nutrition.

  • The therapeutic or prescription diet is a modification of the nutritional needs based on the disease condition and/or the excess or deficit nutrition state.
  • Combination diets, which include alterations in minerals, vitamins, proteins, carbohydrates, and fats, as well as fluid and texture, are prescribed in therapeutic nutrition.
  • Although not all such diets will be included in this review, study of the selected diet concepts will enable you to combine two or more diets when necessary.

C. Normal and therapeutic nutrition considerations.

  • Cultural, socioeconomic, and psychological influences, as well as physiological requirements, must be considered for effective nutrition.
  • In any given situation, the nutrition requirements must be considered within the context of the biopsychosocial needs of an individual.

Nutritional Management: Diet Related to Heart Disease Risk

Focus topic: Nutritional Management

A. The lipid hypothesis, introduced in the 1950s, suggested diet and cholesterol (especially saturated fat) presented risk for heart disease.

  • Total cholesterol over 200 and ratio of high-density lipoproteins (HDL), the “good” cholesterol, to low-density lipoproteins (LDL) or “bad” cholesterol, predict risk.
  • Goal is to reduce saturated fat in diet.

B. High concentration of homocysteine in blood is also associated with risk for heart disease.

  • An amino acid forms when diet has a high concentration of meat and dairy products.
  • Excess levels damage artery walls, causing the blood vessel to trap circulating cholesterol.
  • Increasing daily intake of B vitamins (folic acid, pyridoxine and B12) will reduce homocysteine levels.

Nutritional Management: Nutritional Problems in the Hospital

Focus topic: Nutritional Management

A. Nutrition is frequently neglected as a viable component of client management.
B. For clients who seem to be stable on admission and give no history of nutritionally related food problems, the usual hospital diet is adequate.

  • These clients must be reassessed periodically to prevent nutritional problems from developing.
  • A periodic assessment is especially important for clients hospitalized for a long period of time. (See Appendix 4-1, Nutritional Assessment Parameters.)
  • Studies conducted at various medical centers support the claim that as many as 50% of hospitalized clients suffer from malnutrition and become more malnourished the longer they remain in a hospital.

C. For clients identified as having a nutritional problem, a client care plan must be developed.

  • The cause of depletion must be determined.
  • Research indicates that poor food intake is the leading cause of malnutrition.
  • Reasons for poor food intake.
    a. The client may feel fear, anxiety, or depression prior to or during hospitalization.
    b. Some clients may not be capable of feeding themselves or may have poor-fitting dentures.
    c. Treatment and therapy may limit the capability of a client to eat or interfere with a client’s appetite.
    d. Although the desire for food is present, shortly after eating a certain food a client may have cramps, pain, gas, or diarrhea or feel nauseous and/or vomit.

D. As clients become more and more malnourished, they lose the ability to handle foodstuffs metabolically.

  • As intake decreases below nutritional requirements, the body cannot generate the epithelium of the gastrointestinal tract from the crypt cells.
  • The villi and microvilli needed to metabolize and absorb food flatten and become ineffective.
  • This condition leads to malabsorption, resulting in malnutrition.

E. Malabsorption––the osmotic gap.

  • The management of clients with malabsorption and maldigestion can be complex. It consists of treatment of the underlying disease, management of accompanying symptoms, and correction of nutritional deficits.
  • Because many diseases may lead to malabsorption, there is no one nonspecific or generally recommended treatment. As a result, knowing the exact diagnosis is essential for successful therapy
  • Most clients presenting with malabsorption have only mild or moderate weight loss. If the underlying disease causing the malabsorption can be treated, most clients can continue with normal or slightly modified dietary intake.
  • Dietary restrictions in some diseases leading to malabsorption can result in full restoration of mucosal function and nutritional status of the client.

Nutritional Management: Instituting Therapeutic Regimens

Focus topic: Nutritional Management

A. Check that a complete nutritional assessment has been completed on the client. (See Appendix 4-1, Nutritional Assessment Parameters.)
B. Evaluate the status of the client’s gastrointestinal tract to determine if modifications in nutrients are necessary.

  • Can the client split intact protein into the peptides and amino acids needed for absorption?
  •  Can the client tolerate the osmotic load of monosaccharides or disaccharides?
  • Is the client fat intolerant, or does the client need special fat? Is the client lactose intolerant?

C. Check that therapeutic diet is ordered.
D. Be aware of compliance by the client.

  • The nurse can best determine the client’s actual intake.
  • The nurse should ensure that the client is not receiving inappropriate foods from other sources.
  • The nurse should check that the client is actually eating the foods prescribed.

E. If the prescribed diet is not meeting the client’s needs, consider an alternative method of feeding.

  • If oral feedings prove inadequate, then alternative methods such as nasogastric, nasoduodenal, or nasojejunal tube feeding should be considered.
  • A variety of delivery systems and methods of enteral feeding are now available for adequate care of the client.
  • When other methods have failed, parenteral nutrition may be the management of choice.
    a. This can be administered peripherally, using isotonic concentrations of glucose, crystalline amino acids, and fats.
    b. It can be administered through a central, high-flow vein in which hypertonic glucose is given, supplemented with crystalline amino acids, fats, electrolytes, vitamins, and trace elements.

F. Be alert to clients’ nutritional needs so that no client becomes or remains malnourished or developsany kind of nutritional problem.

  • Elicit food preferences from the client.
  • Send request to the diet kitchen for the specific diet and keep diet sheets or diet requests up to date.
  • Check all diet trays before serving to ensure the diet provided is the one ordered.
  • Ensure that hot food is hot and cold food is cold.
  • Keep food trays attractive. Avoid spilling liquids on tray.
  • Position the client in a chair or up in bed (unless otherwise ordered) to assist in feeding.
  • Assist the client with cutting meat and opening milk cartons as needed.
  • Feed the client if necessary.

G. Administer ordered fluids and tabulate fluid intake.

Nutritional Management: Nutritional Guidelines for Managing Clients

Focus topic: Nutritional Management

A. An adequate diet must include carbohydrates, fats, proteins, vitamins, and minerals.

  • Carbohydrates are the chief source of energy,and diets not sufficient in carbohydrates lead to a low energy level, use of protein for energy, and ketosis.
  • Fats provide the most concentrated source of energy and are carriers for fat-soluble vitamins.
  • Proteins are essential for building body tissue and are necessary for tissue repair.
  • Vitamins are essential for growth, maintenance, and functioning of body processes.
  • Minerals are essential for metabolic processes.

Nutritional Management: Recommended Nutrient Requirements For Healing*

Focus topic: Nutritional Management

Nutritional Management

B. Digestion takes place throughout the gastrointestinal tract.

  • The gastrointestinal system breaks down raw materials through the secretion of enzymes and electrolytes.
  • Mechanical and chemical digestive processes are necessary for nutritional synthesis.
  • Nutrients are absorbed through the large intestine.
  • The liver plays a major role in nutritional metabolism.

C. Nutritional needs are based on a client’s disease condition and excess or deficit of a nutritional state.

  • Therapeutic diets are used to alter health status.
  • Combination diets, which include alteration of all the major nutrients, are prescribed for certain disease conditions.

D. Alternative methods of providing nutrients must be instituted when clients are unable to ingest or assimilate foods orally.

  • Enteral feedings provide life-sustaining nutrients when other oral methods cannot be utilized.
  • Parenteral nutrition may be administered peripherally, using isotonic concentrations, or centrally with intravenous catheter placement.

Nutritional Management

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