Nutrition and nursing NRSG 200 CSULB School of Nursing Introduction Basic component of health

É normal growth & development É tissue repair & maintenance É cellular metabolism É organ function

Disease Prevention Objectives É Promote health & reduce diseases

related to diet & weight É Nurses need to understand the nutrition

requirements needed to promote health, wellness & healing

Scientific knowledge base: nutrients Nutrients for body processes & functions

É Carbohydrates – starches & sugars É Proteins – amino acids É Fats – saturated, monounsaturated &

polyunsaturated É Water – cells depend on a fluid

environment É Vitamins – water & fat soluble É Minerals – catalysts for biochemical

reactions Basal Metabolic Rate - BMR Resting Energy Expenditure - REE The Digestive System Dietary Guidelines

Ò Dietary Reference Intake É Requirements of amounts of vitamins & nutrients to

avoid deficiencies or toxicities for age & gender groups Ò Food Pyramid Guide

É guide for buying food & meal preparations Ò Daily Values

É Needed protein, vitamins, minerals, fats, cholesterol, carbohydrates, fiber, sodium, & potassium Nutrition During Human Growth & Development

Ò Infants through school age Ò Adolescents Ò Young & middle adults Ò Older adults

Ò Factors affecting nutritional status Ò Age related changes Ò Chronic diseases Ò SES, IADLs Ò Ethnicity, religion Ò Cognitive status

Alternative Food Patterns Ò Based on religion, cultural, ethics, health beliefs, preference

Ò Vegetarian diets Ò Christian diet Ò Kosher diet Ò Islam diet restrictions

NUTRITIONAL SCREENING & ASSESSMENT Nursing history Ask questions like: Are you able to chew or swallow effectively? What is your intake? Give me a 24-hour diet recall and then ask if this is typical for them. Do they have a good budget for meals? Ask them if they eat alone. Those that eat alone usually don’t have nutritious meals and tend to eat less. If you are dealing with female who has been pregnant or is pregnant, you want to look at how close these pregnancies are. The closer they are, the higher chance of poor nutrition. Also people who have high amount of alcohol intake tend to drink and not eat. These individuals have anemias. Banana bag is rich in vitamin B because pt who drink tend to be deficient in vitamin B. So we give them banana bag with folic acid and vitamin B in the bag. Most have 1 banana bag a day for their alcoholism. Common is to have 125 mL an hour and takes 8 hours to put in 1 L of fluid. For the next 16 hours we put something else up like normal saline or D5 ½, whatever the individual needs. Also people with extensive oral or gastrointestinal disease or surgery. Individuals with radiation to neck area makes it more difficult for good nutrition. Any fluctuations in weight. Weight change not

intended is a bad thing especially if it is weight loss. We always want to rule out some type of malignancy because most individuals do not lose weight unintentionally. You know how difficult it is to lose it intentionally. We are concerned if there is weight loss. Also any medications they might be on. Some chemotherapy medications make foods or anything they put their mouth to have metallic taste so pt does not want to eat. As we age we lose 80% of our taste buds. So food does not taste as well either. People who smoke cigarettes also tend to not taste as well either. Physical examination

Look at general appearance. Do they look tired or fatigued or pale or fissures on lips, skin, hair, and tongue (roughened papillae) but some have smooth glossy tongue or gummy/spongy appearance (signs of nutritional deficiencies). DTR- deep tendon reflexes- people tend to have decreased response in reflexes who have poor nutritional intake Dietary history 24- hour food recall is good. Ask questions like who prepares the meals? Who buys the food? Allergies to food? How does the food taste? Chewing problems or bad taste? Laboratory data There is no 1 specific lab test that will tell us if individual is malnourished. We can look at album and prealbumin, but those are highly relied to if the liver is functioning adequately. Also look at

hemoglobin and hematocrit. Do they have enough nutrition to make those RBCs. We can look at vitamin levels, folate, calcium. But unfortunately nothing like BUN and Creatinine that tells us for the kidney status, that will tell us our nutritional status. Anthropometric measurements These are measurements that are done and help us to look at size and makeup of the body. We do trending. Done more in children where we measure head circumference. We look at BMI and BSA (body surface area) for adults

Nanda Nursing Diagnosis Appropriate for people with nutritional problems. Risk for aspiration r/t impaired swallowing or problems with GI tract Constipation r/t decreased activity, narcotic intake or dehydration Diarrhea r/t anxiety, alcoholism, infection Health seeking behavior Imbalanced nutrition more or less than body requirements Readiness for enhanced nutrition Feeding self care deficit Planning Plan outcomes & set goals with individual Prioritize according to needs Consider Daily nutritional intake what is required of them (how many kilocalories?) Providing optimal nutrition We can have physician order Ensure or Replete. They should not drink ensure first. Make sure they eat protein and eggs, bacon and oatmeal first. Ensure and Replete are not a replacement of the meal, they are addition to it. So save the Ensure and replete (for kidney problem) at around 10. That way they eat meal and drinking the extra supplement. Also some pt who do not have good intake get an order for that because some individuals will say that that’s what they have more a meal at home because they have problems with digestion or swallowing. So you need to individualize them. Education & counseling on appropriate diet and counsel on disease process and how to maintain healthy weight Health promotion sitting in chair when eating and getting out of bed. Implementation Promote appetite Try to get it to look as good as you can. Usually take off that piece of wilted parsley. They should be in the chair and rinse their mouth with mouth wash or water beforehand. Open lid to food before you bring it to pt who might be nauseous to get rid of that smell because lids have been on for 3-45 minutes. Also give medications to promote appetite (Marinol and Megastrol- both THC derivatives) When you have THC intake people tend to get the munchies. These drugs make you feel like you are hungry. No side effects of THC like the euphoria or open-mindedness. These drugs are also very good in increasing appetite in older pt who have failure to thrive. Advancing diets We do a gradual progression and we want to advance it as tolerated. We want physician’s order to advance the diet as tolerated. So we don’t want to

call the physician every time we want to change it from a clear liquid diet to full liquid diet to soft diet. So ideally advance as tolerated, as the nurse can make judgment with pt. 150 types of diet: gluten free, carb control, renal diet (low potassium, low phosphate, low protein), cardiac diet, mechanical soft diet, and puree diet, low fiber diet, regular diet. Be aware of different types of diets and progress them slowly. Please do not leave pt on clear or full liquid for a period of time because liquids tend to be salty and sugary and a lot of pt have heart failure who are in low sodium and lots of pt with diabetes so pt complain of too salty and sweet because the yare used to eliminating those foods with their diet. They also have very low satiety because they give low satiety and they do not feel like they are full and not very nutritious. So try to get them off of the liquid diet as long as there is nothing going with GI tract as quickly as you can. Assisting with meals

Some pt have risk for aspiration with the tracheal bronchial so ideally they should rest 30 minutes before they eat. Do not give them a bed bath or walk them around before they eat. These pt need to go into their meal feeling rested. Ideally put them into a chair, or bed 90 degrees and make sure knees are pressing up on their abdomen because it will

make them feel fuller than they are. Also instruct pt to put their chin down when swallowing which makes it easier to swallow for some patients with risk of dysphagia or aspiration need thicker viscosity of fluids, like the white powder should be mixed with the water and juice to get the correct viscosity. When things are too thin like water, we don’t have much control over swallowing. So sometimes there are orders where there should be no straws. Straws push everything to the back and they were not using the cheeks and tongues so much to help with the swallowing. Also very small bites for these individuals. Cut up the food for them. Those with visual impairments, put the plate in front of them and tell them that your scrambled eggs is at 3 o clock, the fruit is at 6 o clock. So make a picture for them so you are not encouraging them to be dependent on us to feed them. Keep them independent by letting them feed themselves. When pt do have problems with aspiration you will notice they are coughing when swallowing, have a voice change after the swallow and also sometimes they pocket their food under tongues and cheeks. So these are things you watch for. Some will have silent aspiration and this can be as high as 70% of people after stroke. Bedside swallow evaluation nurses can do and a swallow evaluation that speech therapy can do and have them swallow barium under fluoroscopy while they are swallowing to see if there are any fistulas. Health promotion Incorporate health promotion during the mealtime, especially pt who are on a special diet. If on carb control diet, count carbs with pt and let them know that if you can eat this in the hospital then you can eat this at home. Hopefully they will change their diet and start incorporating it into their lifestyle. Charting Meal Intake Estimate of food that we are charting. You can either check from ranges of 75-100% or 50-75% of meal intake OR specific percentages like 8% of meal eaten. 50% is on main dish and Milk is 20% and Coffee, Tea and Soda have 0%. Enteral Tubes

Nasoenteric – Salem sump, small boar NG tube, gastrostomy tube and jejunostomy tube.

Naso or oral gastric       NGT or OGT Put these in the nose or mouth and they end up in the stomach. Usually put it in the nose so they can talk to us. Some pt have endotracheal tube (breathing tube) that goes in orally. Then we put these tubes in orally as well. When you have NGT in it increases risk of getting sinus infection. Pt have gotten pressure sores from the tubes on the inside of their nares.

Ideally, we would put them in orally, bit it prohibits them from talking and it is much more likely to get displaces especially if they are moving around Gastrostomy   PEG it has an inflated balloon like the foley catheter to keep it in place. The phalange will move and pull it all the way back for someone with a thicker abdominal wall. There are two ports on there. One port to inflate or deflate balloon and the other part is where you flush it, where you put medications or tube feedings as well. Jejunostomy

  PEJ This portion is much longer than PEG tube because this end is in the jejunum. Three ports: 1 for balloon, the other for inside the stomach (gastric) and 1 in the jejunum- so we can still put food in stomach area or put food thru here.

This is what it looks like from the outside- so we don’t know where the distal end is- it could be in the stomach, jejunum or duodenum so we get rapport to know where it is. Or if pt with X ray done on the abdomen, we can see where the end is. If this were to ever come out, we take a foley catheter and put the foley catheter thru the track and call physician and tell them that the feeding tube is out of place. So you just want something to keep the track open. You won’t put anything in that foley catheter but you are just waiting and keeping that hole open. We must also clean the skin around this area. Put a 4x4 gauze with a slit in it. You need gauze so the phalange wont cause skin breakdown. Enteral Tube Feeding interventions

     

  HOB > 30o or higher to prevent aspiration Check placement & residual Q4H & prior to medication administration To check placement take a 60 mL syringe. There is a catheter tip syringe and a luer lock syringe. You need cath tip syringe to get into the salem sump and you need luer lock syringe to get into a different one. Use appropriate type of syringe to access whatever tube oyu have. To check placement put about 20-30 mL of air into syringe and put the syringe on the end of that tube and push the air in rather quickly with the end of your diaphragm at the end of the pt stomach and you will hear that blurp to verify placement. That 30mL of air you are putting there is not intake, it is just gas. If you are uncertain, reposition stethoscope and do it again. To check

residual you pull back. If you have a small boar NG tube it is very difficult to get an accurate residual because it is so tiny. Ideally, you should not have more than 2hours worth of food residuals. So let’s say your tube feeding is 45 an hour, we should not have more than 90mL of food 2 hr worth of food in their stomach. That means they are not digesting and it is not passing on. Medication that is pro-kinetic for the GI tract who had high residuals is Reglan. A lot of pt are on this drug to prevent tube feeding flowing downstream and we don’t get high residuals. High residuals lead to aspiration and then pneumonia and then death. If your pt is pulling around, itching it and if there is a question abut the placement, check again so that you don’t wait for that 4H. Flush with 30ml of H2O Q4H to help keep them patent. These new pumps will do the flushing for us. This is set up at 45 an hour. Down here is 0 fed because no food has gone in down there. Flush 0 mL and put up to flush 30mL and make the machine do 30mL every 4H for me. But I should always check the residual and placement. Different types of food formula- jevity, ensure, replete, just like we have different types of diet. Jevity 1 cal and Jevity 2 cal is higher calories. You have to put up what is ORDERED. You cannot just pick up whatever type of tube feeding, you have to have the right type. Then you get this bag with two little extensions that come off of it. This bigger one- you have to take off this purple lid and the other one who looks graduated will go into the tube. Put tap water. Some of you working for oncology or pt who are immunocompromised, you must put sterile water, but for most pt you can put tap water in bag up, tubes feedings over here, and hey are in a Y connecting and goes into pt. So tube feeding 45mL an hour and every 4H you have the flush of 30mL. This needs to be changed every 24H. You change the whole system because it is full of nutrition and microorganisms will love it. On this container you can put Pt name, date/time it was hooked, and your initials. That way nurse coming in after you knows when it is hung and knows when to change it. Parenteral Nutrition  

Pt’s whom we could not use their GI tract to feed them. Ideally, we want to use GI tract. But if we can’t because they had cancer or hyperemesis gravitarum (pregnant women can’t take fluids so we feed them via vein) Parenteral nutrition is feeding via the vein. TPN- Total parenteral nutrition or we can do PPN- partial parenteral nutrition. With the TPN you need to have a central line, a central line being a PICC line a triple lumen catheter is a line that the physician will put in. The reason for this is that the TPN have high amount of amino acids and dextrose. High enough so that the person can get their total nutritional intake from the TPN. With the PPN- partial or peripheral enteral nutrition- you are not getting total nutrition with this one. You will use a peripheral IV that the nurses put in. Since it is a peripheral line. If you look at this one with the blue and red- this is a catheter used for hemodialysis and an extra port called VIP (venous infusion port) These two are

central lines so you can use a TPN. This one is ppn- pink- does not have high enough amino acids or dextrose to give full nutrition because you cannot give that high of amino acids or dextrose through the veins in the hands because it will cause phlebitis and be painful. You could put PPN in a central line but you cannot reverse it. Also usually have lipids as well. Lipids have fat in it that we need. Yellow is the TPN or PPN and the lipids are w  hite. They are usually in two separate bags. Also you should have a dedicated IV line for this. You should not use the IV line to push morphine or

dilaudid to give your ancef in. Ideally a ddicatd line for TPN and lipids and one other IV line for other medications. This pt may have a lot of IV lines for their medications because they are not using their GI. This is hard on your liver, so before we start this we can do a liver profile, coagulation, CBC and chem 7. Look at magneiusm, phosphorous and ionized calcium and we do these labs regularly. Also, because of the high dextrose, we are bypassing the GI tract so the pancreas does not know to secrete insulin. So for these pt we check blood sugar very 6H or whatever ordered and we give these pt insulin. The pt will ask if they are a diabetic, but we must reassure them that the

reason we are giving them insulin is because it is bypassing their gut. Usually after a day or 2. We hand this once a day at 4 o clock in the afternoon. Everytime we hang a new bag, we change the tubing. With the TPN, or PPN, you have to have an inline filter wit this. Look at tubing or pixus system and you’ll see that they need a primary line with a filter. Usually after a day or 2, we know where their blood sugars are and the pharmacist will put insulin in the TPN or PPN so that way we don’t have to give them as much SQ insulin.

Ò Administered to clients who are unable to digest or absorb enteral nutrition

Ò Peripheral or through a central line Ò Initiating & discontinuing parenteral nutrition Ò Preventing complications

Evaluation Ò Measures the effectiveness of nutritional interventions…

hopefully pt did not have any weight loss and tolerating at least 75% of meals.

Ò Ascertain if client has met goals & outcomes Ò Amend nursing interventions if necessary

Review Questions A nurse is caring for a patient with continuous NGT feedings via a pump. The nurse identifies that the patient is having

difficulty breathing & is restless. What should the nurse do first? Most pt will have continuous feeding. You will sometimes see bolus tube feedings- meaning oyu will take a can of formula and give them about 240-360 mL 4x per day. Keep HOB up during their feeding and put head back down after feeding. So know continuous as well as bolus feedings both via a pump.

A. Use a nasal cannula to provide oxygen B. Activate the hold button the feeding pump you know that they

have difficulty breathing and that they are restless and that they have tube feeding. That tube feeding, NGT, has come out of place. Instead of the food going into the stomach, that food is going into the lungs. This is why they are having difficulty breathing and restless. So turn the damn thing off first and then put their head up, cough, suctioning, and after that you check their pulse ox and give them oxygen and then call the physician. NG Tubes are morel likely to become displaced than a PEG.

C. Raise the head of the bed to high fowlers D. Notify the primary care provider

A nurse is caring for a patient that is receiving parenteral nutrition. Which of the following are essential nursing actions when caring for this patient? We don’t know if it is TPN or PPN, but it is one of those two

A. Use tubing with an in-line filter B. Monitor blood glucose regularly C. Obtain a daily weight We do this because we are giving these

pt a lot of fluid. So we want an accurate I&O. We do I&O for a lot of pt in the hospital.

D. Hang dextrose 10% if the infusion runs out Because this has a high amount of dextrose in it. We don’t know if it is TPN or PPN. But we do know that it is parenteral. But if this runs out and it does have a high amount of dextrose, you cannot just cut of the pt’s dextrose. So yes, if it were to run out, you have to call physician to get a new bag soon. When we discontinue TPN or PPN, we have to ween it off. Start at 80 mL/hr then go down to 60 then 40 then 30 to get body used to lower amounts of dextrose.

E. Use a dedicated IV site A nurse is caring for a patient who is receiving enteral feedings. Which nursing measure intervention is important to help prevent the patient from experiencing diarrhea?

A. Flush the tube with 30mL of H2O every 4 hours & Keep the HOB at 30 degrees No because flushing the tube with 30 mL will make sure the tube stays patent and keeping HOB at 30 degrees will decrease risk of aspiration. So this doesn’t make sense

B. Check the residual every 4 hours No because that won’t decrease diarrhea. If there is a high residual, hopefully I can prevent them from aspirating.

C. Elevate the HOB to 30 degrees Will not decrease diarrhea, like in option A

D. Use unopened containers when priming the tubing & change the bag every 24 hours