ALTERATIONS IN NUTRITION Jennifer B. Cowley, RN, MSN.

ALTERATIONS IN NUTRITION

Jennifer B. Cowley, RN, MSN

Objectives:

* Who’s at risk?* Labs? Diagnostic tests?* Assessment - What do they look like?

* Nursing Diagnoses - What’s the problem?

* Therapeutic diets - What should they eat?

* Nursing interventions - What should you do?

* Enteral & parenteral nutrition - What are the nursing implications?

Clients with Nutritional Problems: Who’s at Risk?

Dietary history

Medical history

Lab Values

Serum hemoglobin & hematocrit

– “H&H”

Serum albumin

Serum pre-albumin

Hemoglobin & Hematocrit

Hgb - iron-containing pigment of the RBC’s– Normal lab values:• female - 12-16 g/100 ml

• male - 14-18 g/100 ml

Hct - % of whole blood occupied by RBC’s– Normal lab values:

• female - 37-47%

• male - 40-54%

Albumin

Synthesized in the liver from amino acids

Accounts for > 50% total serum proteins

Indicator of prolonged protein depletion

Normal lab value:

– 3.5-5 g/dl

Pre-albumin

A precursor to albumin

Determines protein depletion in acute

conditions

Normal lab values:

– 15-36 mg/kl

Diagnostic Tests

Gastroscopy– direct visualization

Upper Gastrointestinal Series (UGI)– indirect x-ray exam

Manifestations of Major

Nutritional Deficiencies…Harkreader, p.703, Table 30-1

The nursing assessment enables the nurse to determine

whether actual or potential nutritional problems exist.

NANDA Nursing Diagnoses

Altered Nutrition: Less than Body Requirements

Altered Nutrition: More than Body Requirements

Risk for Altered Nutrition: More than Body Requirements

Examples of Examples of SecondarySecondary Nursing Nursing Diagnosis for Clients with Nutritional Diagnosis for Clients with Nutritional ProblemsProblems

Activity Intolerance r/t insufficient energy from

protein depletion

Altered Oral Mucous Membranes r/t oral intake

Constipation r/t inadequate dietary intake and fiber

Self-Esteem Disturbance r/t obesity

Risk for Impaired Skin Integrity r/t intake of

proteins, vitamins, and minerals

Commonly Prescribed Therapeutic Diets

Regular Diet– Who?

• Clients who do not have special needs

– What? • 2500 cal/day, variety of food groups

Diets: NPO

Nothing by Mouth (NPO)

– Who? • Prior to surgery/certain diagnostic test

• To rest the GI tract

• When problem has not been identified

– What?• NPO

Diets: Clear Liquid

Clear Liquid Diet

– Who? • Surgical clients

– What?• Only liquids that keep the GI tract empty (no

residue) - i.e., apple juice, broth, carbonated beverages, gelatin. No dairy products

Diets: Full Liquid

Full Liquid Diet

– Who?

• Primarily postoperative clients

– What?

• Consists of liquids or foods that turn to liquid at

body temperature

Diets: Soft

Soft Diet

– Who?• For clients experiencing difficulty in chewing and

swallowing; also for those with impaired digestion/absorption

– What?• Avoid nuts, sees, raw fruits/vegetables, fried foods,

whole grain.

Diets: Mechanical Soft

Mechanical Soft Diet

– Who?• For clients experiencing difficulty chewing - i.e.,

poorly fitting dentures

– What?• Similar to soft; however, allows clients variation -

permitting foods with different tastes, such as chili beans

Diets: Pureed

Pureed Diet

– Who?• For clients with dysphagia

– What?• Food that has been blenderized to a smooth

consistency

Diets: Low-Residue

Low-residue Diet– Who?

• Clients that need minimal GI irritation (diverticulitis, ulcerative colitis, Crohn’s disease)

– What?• Has reduced fiber and cellulose. Avoid raw fruits

(except bananas), vegetables, seeds, plant fiber, and whole grains. Limited dairy products (2 servings/day)

Diets: High-Fiber

High-fiber Diet

– Who?

• To increase elimination

– What?

• Opposite of low-residue

Diets: Bland

Bland Diet

– Who?

• Clients with gastritis and ulcers

– What?

• Eliminates chemical and mechanical food irritants,

such as fried and spicy foods, alcohol and caffeine

I don’t think so!

Diets:Fat-Controlled

Low-Fat Diet

– Who? • Clients with heart disease, atherosclerosis, and

obesity

– What?• Decreased saturated fats (replace with

mono/polyunsaturated fats) and restricting cholesterol

Uh-oh!

Diets: Sodium-Controlled

Low-Sodium Diet– Who?

• Clients with hypertension, heart failure, myocardial infarction/MI (heart attack), renal failure

– What?• Mild - 2-3 g

• Moderate - 1000 mg

• Strict - 500 mg

• Severe - 250 mg

Diets: American Diabetic Association (ADA)

Diabetic Diet

– Who?• Diabetics (of course!)

– What?

• Specified number of calories, amount of fat,

carbohydrates, and protein at each meal, with snacks

included. No concentrated sweets (NCS).

A no-no!

Any diet is only as good as the client’s willingness to follow it.

Meal plans should be individualized and developed in collaboration

with the client.

Monitoring Intake & Output/ “I&O”

Purpose: To monitor client’s fluid status over a 24 hour period

Who should be on I&O?

Medical vs. nursing decision?

Check clinical agency policy

Inaccuracies of I&O

I&O: Intake

Oral fluids Ice chips Foods that become liquid at room

temperature Tube feedings Intravenous fluids/medications Catheter/tube irrigants

I&O: Output

Urine

Diarrhea

Vomitus (emesis)

Tube drainage

I&O: Nursing Responsibilities

Client/family teaching

Documentation

Relay to others that client is on I&O

Look for trends over 48-72 hours

The Malnourished Client: Nursing Interventions

Stimulate the appetite

Assist the client with eating

Initiate client/family counseling

Assisting the Client with Feeding

ENTERAL NUTRITIONENTERAL NUTRITION

If the client will not,

should not, or cannot eat,

enteral nutrition may be provided

with nasogastric, gastric

or jejunal tubes.

Feeding tubes: Placement

Nasoenterally Surgically

– Gastrostomy

– Jejunostomy

Endoscopically– Percutaneous endoscopic gastrostomy

(PEG)

Placement of Enteral Nutrition

Tubes

Nasoenteral Feeding Tubes: Types

Large-bore

Small-bore

– 90-95% of clients in hospital have small bore

– more flexible, comfortable

– stylet inserted into lumen

Nasoenteral:Small-bore Feeding Tube

Short term

RN performs blindly at the bedside

X-ray the only reliable method of placement verification

Nasogastric, nasoduodenal, or nasojejunal

Small bowel usually preferred over stomach in acutely ill clients

Feeding Tube: Who does what?

MD orders:

– Type of tube

– Rate and type of formula

RN:

– Inserts feeding tube

– Administers/monitors tube feeding

Enteral Feeding Tube: Confirmation of Tube Placement

Radiologic confirmation

Bedside methods:

– Auscultatory method

– Aspiration of gastric contents

– pH method

Gastrostomy/Jejunostomy:“G-tube/J-tube”

Long term MD performs in OR Incision through abdominal wall creating an

artificial fistula More cosmetically appealing/more

comfortable Larger lumen allows more flexibility for

feeding/medication administration

Percutaneous endocscopic gastrostomy:“PEG” tube

Long term

MD performs at bedside or in endoscopy

room

Does not require surgery, therefore less

risky and expensive than G/J tube insertion

Percutaneous Endoscopic Gastrostomy Tube

PARENTERAL NUTRITIONPARENTERAL NUTRITION

Total Parenteral Nutrition

“TPN”

Total Parenteral Nutrition

Candidates for

What’s in

Tonicity of

Complications r/t

Lipids given with

TPN

That’s All, Folks!