Nutrition and Diet Therapy for Nurses - pearsonhighered.com · Nutrition and Diet Therapy for Nurses Second Edition ... Healthy People 2020: Objectives for the Nation 6 Nursing Process

Nutrition and Diet Therapy for NursesSecond Edition

Sheila Buckley Tucker, MA, RD, CSSD, LDNClinical Instructor, Connell School of Nursing and Woods College of Advancing Studies, Boston College

Vera Dauffenbach, EdD, MSN, RNAssociate Professor and Director of the RN to BSN Program, Bellin College, Green Bay, Wisconsin

A01_TUCK2877_02_SE_FM.indd 1 10/11/17 9:18 PM

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Library of Congress Cataloging-in-Publication Data

Names: Tucker, Sheila Buckley, author. | Dauffenbach, Vera, author.Title: Nutrition and diet therapy for nurses / Sheila Buckley Tucker, Clinical Instructor, ConnTell School of Nursing and Woods College of Advancing Studies, Boston College, Vera Dauffenbach, Associate Professor and Director of the RN to BSN Program, Bellin College, Green Bay, Wisconsin.Description: Second edition. | Boston : Pearson, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2017023975 (print) | LCCN 2017025831 (ebook) | ISBN 9780134454306 (ebook) | ISBN 0134454308 (ebook) | ISBN 9780134442877 | ISBN 0134442873Subjects: LCSH: Diet therapy. | Nutrition. | Nursing.Classification: LCC RM217 (ebook) | LCC RM217 .T83 2019 (print) | DDC 615.8/54—dc23LC record available at https://lccn.loc.gov/

2017023975

ISBN 10: 0-13-444287-3ISBN 13: 978-0-13-444287-7

1 17

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Nutritional Misinformation 31

■■ NURSING CARE PLAN: The Language of Nutrition 33Chapter Summary 34 • Critical Thinking in the Nursing Process 35 • NCLEX-style Questions 35 • References 35

SECTION II Principles of Nutrition 37

3 Carbohydrates 39

Did You Know? 40Key Terms 40

What are Carbohydrates? 40Simple Carbohydrates 40Complex Carbohydrates 41

Function of Carbohydrates 42

Digestion and Metabolism 43

Simple and Complex Carbohydrates in Foods 44Simple Sugars 44Complex Carbohydrates 45

Carbohydrate Recommendations 48Simple Sugars 48Complex Carbohydrates 49

Nonnutritive and Nutritive Sweeteners 51Nonnutritive Sweeteners 52Nutritive Sweeteners 52

Wellness Concerns 53Dental Health 53Obesity and Weight Management 53Behavior and Neurological Health 54Altered Digestion or Metabolism 54Fiber and Health 56

■■ NURSING CARE PLAN: Constipation 57Chapter Summary 59 • Critical Thinking in the Nursing Process 59 • NCLEX-style Questions 59 • References 60

4 Protein 63


Structure of Proteins 64Amino Acids 64

Physiological Functions of Protein 65Tissue Growth and Maintenance 65Protein Synthesis 66

Contents

About the Authors xiiThank You... xiiiPreface xvSpecial Features xvii

1 Nursing and Nutrition Care 1Did You Know? 2Key Terms 2

Nutrition and Health Promotion 2Nutrition Standards 2

Dietary Guidelines 3MyPlate Food Guidance System 4Food Labels 5Healthy People 2020: Objectives for the Nation 6

Nursing Process and Nutritional Health 6Assessment 6Nursing Diagnosis 10Planning 10Implementation 10Evaluation 10

■■ NURSING CARE PLAN: Nutrition for Weight Loss 11Chapter Summary 12 • Critical Thinking in the Nursing Process 12 • NCLEX-style Questions 12 • References 13

SECTION I Nutrition Recommendations, Guidelines, and Regulation 14

2 Nutrition Recommendations and Standards 16


What Is a Healthy Diet? 17

Nutrient-Specific Recommendations: Dietary Reference Intakes 18

Diet-Based Nutrition Recommendations 20Dietary Guidelines for Americans 21MyPlate 22Pyramids and Guidelines from around the World 22Fruit and Veggies—More Matters Program 25Disease Prevention Diet Pattern Guides 25

Food Labels 27Ingredient List 27Nutrition Facts Panel 27Nutritional Claims 29

v


vi Contents

Choosing a Vitamin Supplement 107

Vitamin Classification 107Fat-Soluble Vitamins 108Water-Soluble Vitamins 117

■■ NURSING CARE PLAN: Patient with Fatigue 128Chapter Summary 130 • Critical Thinking in the Nursing Process 131 • NCLEX-style Questions 131 • References 131

7 Minerals 134


Why Do We Need Minerals? 135What Affects Mineral Balance? 135

Mineral Classification 136What Are the Major Minerals? 136What Are Trace Minerals? 150Nonessential Trace Minerals 159

■■ NURSING CARE PLAN: Iron and a Vegan Diet in Children 160Chapter Summary 162 • Critical Thinking in the Nursing Process 162 • NCLEX-style Questions 162 • References 163

8 Fluid, Caffeine, and Alcohol 166


Water 167Function of Water 167Water Balance in the Body 167Recommended Intake 169Sources 169

Hydration Assessment 170Hypohydration/Dehydration 172Hyperhydration/Water Toxicity 174Wellness Concerns 175

Caffeine 175Sources of Caffeine 175Wellness Concerns 175

Alcohol 178Sources of Alcohol 179Wellness Concerns 179

■■ NURSING CARE PLAN: Nutrition and Dehydration 181Chapter Summary 183 • Critical Thinking in the Nursing Process 183 • NCLEX-style Questions 183 • References 184

9 Energy Balance 186


What Is Energy and Energy Balance? 187Energy Intake 188Energy Expenditure 188

The Regulatory Role of Proteins 67Immune Function 68Energy 69

Protein Metabolism 69Protein Digestion 70Amino Acid Catabolism 70

Protein from Food Sources 70Complete and Incomplete Proteins 70Protein and Satiety 71

Requirements for Dietary Protein 71

Wellness Concerns 72Inborn Errors of Protein Metabolism 72Protein Requirements in Illness or Injury 72Protein Deficiency 73High-Protein Diets 74Vegetarianism 75

■■ NURSING CARE PLAN: Protein for Athletic Enhancement 78Chapter Summary 80 • Critical Thinking in the Nursing Process 80 • NCLEX-style Questions 80 • References 81

5 Fats 84


What are Fats? 85Triglycerides 85Phospholipids 88Sterols 88Functions of Fats 88

Digestion and Absorption 88

Where are Fats in the Diet? 89

Recommendations for Fat Intake 92Strategies for Modifying Fat Intake 93Fat Substitutes 95

Wellness Concerns 97Obesity 97Cardiovascular Disease 97Cancer 97Fat Malnutrition 99

■■ NURSING CARE PLAN: Patient with High Blood Lipid Levels 99Chapter Summary 101 • Critical Thinking in the Nursing Process 101 • NCLEX-style Questions 101 • References 102

6 Vitamins 104


Vitamins in Health 105What Are Vitamins? 105Do All Vitamins Have a Recommended Dietary Allowance? 106Vitamin Deficiency and Toxicity 106


Contents vii

Nutrition in Health Promotion 239Guidelines and Resources for Nutrition and Health Promotion 239

Food Intolerances and Allergies 241

Food Safety 242Who Is in Charge of Food Safety? 242Why Should We Be Concerned About Food Safety? 243

■■ NURSING CARE PLAN: Safe Food Handling 250Chapter Summary 252 • Critical Thinking in the Nursing Process 252 • NCLEX-style Questions 252 • References 253

12 Cultural Considerations in Nutrition 255


Transcultural Nursing 256

Cultural Influences on Dietary Practices 257Food Practices 257Health Beliefs about Food and Dietary Habits 258Beliefs about the Relationship between Body Size and Health 259Beliefs about Healthcare Authority and Decision-Making 259

Guidelines for Culturally Sensitive Nutrition Care 259Cultural Humility 259Listen First 259Nutrition Care Plan Development 260Culturally Sensitive Nutritional Counseling 260

Cultural Background Influences Eating Patterns 261Acculturation and Health Risks 261

Traditional Diets of Selected Cultural Subgroups in the United States 263

Mexican or Mesoamericans 263Black or African American 264Asian Population 264Indian 267

Religious Considerations in Nutrition and Dietary Practices 269

Buddhism 269Christianity 270Hinduism 270Islam/Muslim 270Judaism 271Sikhism 271

■■ NURSING CARE PLAN: Culturally Sensitive Nutritional Care 271Chapter Summary 273 • Critical Thinking in the Nursing Process 273 • NCLEX-style Questions 273 • References 274

13 Nutrition in Sports 276


Introduction 277

Energy Balance 194

Recommendations for Energy Intake and Expenditure 195

Wellness Concerns 196Positive Energy Balance: Weight Gain 196Negative Energy Balance: Weight Loss 196Energy Balance in Critical Illness 198

■■ NURSING CARE PLAN: Patient in an Automobile Accident 198Chapter Summary 200 • Critical Thinking in the Nursing Process 200 • NCLEX-style Questions 200 • References 201

SECTION III Nutrition Assessment 203

10 Nutritional Assessment 205


Nutritional Health and Assessment 206

Nutrition History 207Diet Recall 207Food Frequency Questionnaire 210Food Record 210Focused Interview 210

Physical Assessment 211Anthropometric Measurements 211Physical Findings 220

Laboratory Assessment 223Plasma Proteins 223Immunocompetence 224Nitrogen Balance Assessment 224Laboratory Measures of Nutrient Status 225Laboratory Measurements Associated with Overnutrition 225

Cultural Considerations 225

Nutrition Screening and Assessment Tools 226Malnutrition Universal Screening Tool (MUST) 226Tools for Use in Older Adults 226

■■ NURSING CARE PLAN: Nutrition Assessment for Weight Management 228Chapter Summary 230 • Critical Thinking in the Nursing Process 230 • NCLEX-style Questions 230 • References 231

SECTION IV Community Nutrition and Health Promotion 233

11 Nutrition and Health Promotion 235


Creating Healthy Communities 236Why Are Community Nutrition and Health Promotion Important? 236Levels of Health Prevention 237


viii Contents

Fluids 335Development of the Feeding Relationship 335Wellness Concerns in Childhood 336

Later Childhood—The Preschooler 337

School-Age Children 337Mealtime Nutrition Influences 337Wellness Concerns 340

Adolescent Nutrition 344Nutrient Needs 344Adolescent Choices 345

■■ NURSING CARE PLAN: Nutrition and the Overweight Child 347Chapter Summary 349 • Critical Thinking in the Nursing Process 349 • NCLEX-style Questions 349 • References 350

16 Adult and Older Adult 354


Introduction 355

Nutrition in the Adult 355Preventive Nutrition in the Adult: What Are the Concerns? 356

Nutritional Health in the Older Adult 359How Does Aging Affect Nutrition? 359

Nutrition Recommendations for the Older Adult 362Nutrient Needs of the Older Adult 362Nutrition Challenges in the Older Adult 366

Treatment of Undernutrition in the Older Adult 368

■■ NURSING CARE PLAN: Nutrition and Unplanned Weight Loss in the Older Adult 371Chapter Summary 373 • Critical Thinking in the Nursing Process 373 • NCLEX-style Questions 373 • References 374

SECTION VI Clinical Nutrition and Diet Therapy 377

17 Nutrition Care and Support 379


The Nutrition Care Process in Acute and Subacute Care 380Hospital and Long-Term Care Nutrition Services 380

Malnutrition of the Hospitalized Patient 381How Is Malnutrition Treated? 384

Nutrition Support: Enteral and Parenteral Nutrition 386

Enteral Nutrition 388Parenteral Nutrition 392

Palliative Nutrition and End-of-Life Care 396

What Fuels Exercise? 277Energy Recommendations 278Carbohydrate Recommendations 280Protein Recommendations 282Fat Recommendations 285

Vitamins and Minerals 286

Hydration: Fluid and Electrolytes 286Fluid and Electrolyte Recommendations 288

Nutrition Considerations for Younger and Older Athletes 291

Sports Supplements and Ergogenic Aids 291Do Alcohol and Caffeine Affect Performance? 294

■■ NURSING CARE PLAN: Inadequate Carbohydrate Intake for Exercise 296Chapter Summary 298 • Critical Thinking in the Nursing Process 298 • NCLEX-style Questions 298 • References 299

SECTION V Nutrition in the Life Cycle 301

14 Pregnancy and Lactation 303


Prepregnancy and Pregnancy 304Nutritional Needs 304Symptom Management 313

Wellness Concerns 314Obesity 314Diabetes Mellitus and GestationalDiabetes Mellitus 314Eating Disorders 315Phenylketonuria 316

Lactation 316Nutritional Needs 317Wellness Concerns 319

■■ NURSING CARE PLAN: Adequate Weight Gain and Pregnancy 320Chapter Summary 322 • Critical Thinking in the Nursing Process 322 • NCLEX-style Questions 322 • References 323

15 Infants, Children, and Adolescents 325

Did You Know? 326

Key Terms 326

Introduction 326

Nutrition for Infants 326Nutrient Needs 326Infant Feeding Decisions 328Tracking Pediatric Growth 330Wellness Issues in Infancy 330

Early Childhood—Toddlers 333Nutrient Needs 334


Contents ix

Diet 448Physical Activity 452Behavior Modification 454Medications and Dietary Supplements 454

Metabolic Surgeries 456Types of Surgery 456Postoperative Nutrition Concerns 457Size Acceptance, Health at Every Size, and Sensitive Care of the Overweight 459

Eating Disorders 459What Is an Eating Disorder? 460What Causes an Eating Disorder? 460Eating Disorder Assessment and Treatment 461

■■ NURSING CARE PLAN: Nutrition and the Overweight Adult 466Chapter Summary 468 • Critical Thinking in the Nursing Process 468 • NCLEX-style Questions 469 • References 469

21 Cardiovascular Diseases and Lipid Disorders 473


Cardiovascular Disease and the Atherosclerotic Process 474

Reducing Risk of CVD: Targeting Diet and Nutrition 476

The Effects of Diet on Blood Cholesterol 476

Dietary Patterns for Heart Health 478Dietary Fat Recommendations 478Other Dietary Components and Cardiovascular Disease Risk 481Diet and Risk of CVD: Beyond Hyperlipidemia 484

Hypertension 485

Metabolic Syndrome 486Nutrition Therapy for Metabolic Syndrome 487

Heart Failure: Nutritional Concerns 487Medical Nutrition Therapy for Heart Failure 487

■■ NURSING CARE PLAN: Nutrition and Hyperlipidemia 490Chapter Summary 492 • Critical Thinking in the Nursing Process 492 • NCLEX-style Questions 492 • References 493

22 Diabetes Mellitus 496


What Is Diabetes? 497

How Is Diabetes Classified? 497Prediabetes 497Type 1 Diabetes 498Type 2 Diabetes 499Gestational Diabetes 499

■■ NURSING CARE PLAN: Nutrition and Home Enteral Feedings 397Chapter Summary 399 • Critical Thinking in the Nursing Process 399 • NCLEX-style Questions 400 • References 400

18 Food, Nutrient, and Drug Interactions 403


Introduction 404

How Do Drugs Interact with Food or Nutrients? 404Alteration in Bioavailability 406Alteration in Metabolism 409Alteration in Excretion 411Pharmacodynamic Effects 411

Drug Effects and Dietary Intake 413

Who Is at Risk for a Drug Interaction? 413

Medication Classes and Food/Nutrient Interactions 414

■■ NURSING CARE PLAN: Nutrition and Diuretic Use 415Chapter Summary 417 • Critical Thinking in the Nursing Process 418 • NCLEX-style Questions 418 • References 418

19 Dietary Supplements in Complementary Care 420


Nutrition and Complementary Care 421What Is a Dietary Supplement? 421

How Are Supplements Regulated? 422Labeling and Advertising Requirements 422

Who Uses Dietary Supplements? 424

Supplement Safety 426

Popular Dietary Supplements 436

■■ NURSING CARE PLAN: Nutrition and Dietary Supplements 437Chapter Summary 439 • Critical Thinking in the Nursing Process 439 • NCLEX-style Questions 439 • References 440

20 Weight Management 442


Overweight and Obesity 443What Causes Overweight and Obesity? 444Health Risks of Obesity 446

Medical and Nutritional Interventions for Overweight and Obesity 447

Assessment 447Treatment Options 447Lifestyle Modifications 448


x Contents

Liver Disease 535Fatty Liver 535Hepatitis 535Cirrhosis 536Hepatic Encephalopathy 537Hemochromatosis 537Wilson Disease 538

Pancreatic Conditions 538Pancreatitis 538Cystic Fibrosis and Pancreatic Insufficiency 539

Gallbladder Disease 539

■■ NURSING CARE PLAN: Nutrition and Irritable Bowel Syndrome 540Chapter Summary 542 • Critical Thinking in the Nursing Process 542 • NCLEX-style Questions 542 • References 543

24 Renal Disease 546


Kidney Function, Nutrition, and Renal Disease 547

Renal Failure 547Acute Kidney Injury 547Chronic Kidney Disease 548Treatment 549

Medical Nutrition Therapy for Renal Failure 551

Nutrition Support in Acute and Chronic Renal Failure 558

Malnutrition in Renal Failure 559

Renal Transplantation 560

Nephrotic Syndrome 561Nutrition Intervention 561

Kidney Stones 562Nutrition Intervention 562

Urinary Tract Infection 565

■■ NURSING CARE PLAN: Nutrition and Renal Failure 565Chapter Summary 567 • Critical Thinking in the Nursing Process 567 • NCLEX-style Questions 567 • References 568

25 Physiological Stress 571


What Is Physiological Stress? 572Physical Consequences of the Stress Response 572

Nutritional Needs During Critical Illness 573Energy Needs 574Protein Needs 577

Diabetes and Metabolism 500Carbohydrate Metabolism in Diabetes 500Fat Metabolism in Diabetes 500Protein Metabolism in Diabetes 500

Nutrition Therapy for Diabetes 500Carbohydrate Intake Recommendations 501Fat Intake Recommendations 504Protein Intake Recommendations 504Dietary Supplements 504Alcohol Intake 504Weight Management 505Hypertension in Diabetes 505Cardiovascular Risk Factors 506Diabetic Nephropathy 506Diabetic Neuropathies 507

Dietary Considerations for Special Populations 507Older Adults Type 2 Diabetes 507Children and Adolescents—Type 1 Diabetes 507Children and Adolescents—Type 2 Diabetes 508Cultural Considerations 509

■■ NURSING CARE PLAN: Nutrition in Type 2 Diabetes 510Chapter Summary 512 • Critical Thinking in the Nursing Process 512 • NCLEX-style Questions 512 • References 513

23 Disorders of the Gastrointestinal Tract, Liver, Pancreas, and Gallbladder 515


How Are Nutrients Digested and Absorbed? 516

Disorders of the Gastrointestinal Tract 516Dysphagia 516Nausea and Vomiting 519Gastroesophageal Reflux, Hiatal Hernia, and Ulcer Disease 520Eosinophilic Esophagitis and Gastroenteritis 521Dumping Syndrome 522Gastroparesis 522Lactose Intolerance 523Inflammatory Bowel Disease 523Short Bowel Syndrome 525Celiac Disease 528Nonceliac Gluten Sensitivity 530Irritable Bowel Syndrome 530Diverticular Disease 531Constipation 532Bloating and Intestinal Gas 532Diarrhea 532


Contents xi

Medical Nutrition Therapy and Cancer 598Disease-Related Nutrition Risk Factors 598Treatment-Related Nutrition Risk Factors 600

Nutrition Intervention in Cancer Care 600

Medical Nutrition Therapy and HIV Infection 604Virus-Related Nutrition Risk Factors 605Treatment-Related Nutrition Risk Factors 606Nutrition Intervention 609

■■ NURSING CARE PLAN: Nutrition during Chemotherapy 612Chapter Summary 614 • Critical Thinking in the Nursing Process 614 • NCLEX-style Questions 614 • References 614

Appendices A: Infant and Child Growth Charts 617B: Body Mass Index Table 623C: DRIs for Nutrients 624

Glossary 630

Answers 636

Fluid Needs 578Vitamin and Mineral Needs 579

Nutrition Care 580Surgery 581Trauma 583Infection and Sepsis 584Burns 585Pressure Ulcers 587

Pulmonary Disease and Mechanical Ventilation 587

■■ NURSING CARE PLAN: Nutrition and Trauma 589Chapter Summary 591 • Critical Thinking in the Nursing Process 591 • NCLEX-style Questions 591 • References 592

26 Cancer and Human Immunodeficiency Virus (HIV) Infection 595


Cancer Prevention and Nutrition 596

Nutrition Challenges with Cancer or HIV 598


xii

About the Authors

Sheila Buckley Tucker graduated with a BS in Food and Nutrition and an MA in Healthcare Administration from Framingham State College in Massachusetts. She is board certified in sports nutrition from the Academy of Nutri-tion and Dietetics. As a registered dietitian for more than 25 years, Sheila has provided clinical nutrition care to patients and clients in a variety of settings, including as an in-patient clinical dietitian specializing in critical care, nutrition support, renal nutrition, cancer care, and medi-cal/surgical care. She has also provided nutrition education as a consultant to corporate wellness programs and area colleges. She has more than 25 years of teaching experience at the undergraduate and graduate levels in several Bos-ton area colleges and nursing schools. At Boston College, Sheila recently made the transition to full-time faculty after decades of a combining an on-campus clinical nutrition practice as the University’s Executive Dietitian, Nutrition-ist for the Office of Health Promotion, and Performance Nutritionist for Athletics, along with teaching nutrition in the Connell School of Nursing. She is a contributing author to many nursing textbooks.

DedicationTo Lance, Victoria, and Emma with all my love

Vera DauffenBach has a bachelor’s degree from Macal-ester College and a master’s degree in nursing from Pace University. Her doctorate in educational leadership is from Western Michigan University. She has been a faculty member in the baccalaureate nursing programs at Grand View College in Des Moines and Maryville College (now University) in St. Louis. At present, she is an associate professor and director of the RN to BSN program at Bellin College in Green Bay, Wisconsin. She has broad classroom and clinical teaching experience on all levels of the under-graduate curriculum, with a special interest in nutrition and pediatrics. At the graduate level, she teaches research and evidence-based practice. Her research interests relate to critical thinking and leadership development. She has contributed extensive NCLEX-style test questions for nurs-ing textbooks. She is a past board member of the Wisconsin League for Nursing and president of the Kappa Pi-at-Large Chapter of Sigma Theta Tau International.

DedicationTo my husband, Wil Tabb, my daughter, Hilary Dauffenbach-Tabb, and my son-in-law, Mike Houston, all of whom are the light of my life. They are forever my inspiration and support as I pursue scholarly excellence in my commitment to the profession.


ReviewersWe extend sincere thanks to our colleagues from schools of nursing across the country who gave their time gener-ously to help create Nutrition and Diet Therapy for Nurses, 2e. These professionals helped us plan and shape our book and resources by reviewing the original proposal, chapters, art, and more.

Elizabeth Braun, MSN, RN, CPN, CNEAdjunct Clinical LecturerIndiana UniversityIndianapolis, Indiana

Diane Cohen, MSN, RNProfessor, Associate Degree NursingMassBay Community CollegeFramingham, Massachusetts

Gabrielle Davis, RN, MSNAssociate ProfessorAustin Community CollegeAustin, Texas

Lucinda Lynn Earle, MPH, RDNAdjunct ProfessorOld Dominion UniversityNorfolk, Virginia

Angela Erickson, MSN, RNCoordinatorAssistant Professor Associate Degree NursingMineral Area CollegePark Hills, Missouri

Karen Gibson, DCN, RDN, CD, CSSDProfessor, Nutrition and DieteticsViterbo UniversityLa Crosse, Wisconsin

Catherine Hutcheson, MSN, RNProfessor of NursingMineral Area CollegePark Hills, Missouri

Thank You…

We extend a heartfelt thanks to the contributors who gave their time, effort, and expertise generously to developing and writing chapters.

ContributorsJanet L. Donaldson, MSN, RN, RD, LDFaculty IIIBaptist Health Systems School of Health ProfessionsSan Antonio, Texas

Rachel C. Findley, MS, RD, LDNInstructor, Food and NutritionMeredith CollegeRaleigh, North Carolina

Lori Kerley DNPc, MSN, RNNursing DepartmentTexas A & M University-CommerceCommerce, Texas

Laura Moskaluk, MSN, RN, CNEMercer County Technical SchoolTrenton New Jersey

Julie Stefanski, MEd RDN CSSD CDEAdjunct ProfessorYork CollegeYork, Pennsylvania

Rachael Pohle-Krauza, PhD, RD, CDN/LDAssistant Professor of Food and NutritionDepartment of Ecology, Youngstown State UniversityYoungstown, Ohio

Charlotte Wisnewski, PhD, RN, BC, CDEAssistant Professor, University of Texas Medical BranchGalveston, Texas

Supplement ContributorsDawna Martich, MSN, RNNursing Education ConsultantSubject Matter ExpertPittsburgh, Pennsylvania

xiii


xiv Thank You...

Sharon E. Long, RN, MSN, FNP-BCNursing FacultyDavenport UniversityWarren, Michigan

Laura Monnin Moskaluk, MSN, RN, CNEFacultyMercer County Technical SchoolHamilton, New Jersey

Jacqueline Sly, RN, BSN, MSN, NP-CClinical Instructor / Family Nurse PractitionerBoston College / Charles River Medical AssociatesChestnut Hill, Massachusetts

Cynthia Wachtel, MSN, RN, CDENursing FacultySiena Heights UniversityAdrian, Michigan


xv

Preface

Nutrition and Diet Therapy for Nurses will be a staple in the library of nursing textbooks. It encompasses all aspects of nutrition, building from the foundation of nutrition prin-ciples up to the peak that is medical nutrition therapy to construct a solid, evidence-based approach to the practice of nutrition. Nutrition science is an evolving field—having come a long way from simply linking foods to prevention of nutrient deficiencies—and it is often difficult for the patient to sift through the media, marketing promotions, the neighbor’s advice, and Internet information to find the facts. Now, more than ever, it is crucial that nurses possess the knowledge and skills to translate the science of what we know about nutrition and its role in health maintenance and disease prevention and be a reliable resource to the patient. Nutrition is not just about vitamins and minerals anymore. Topics such as cultural competence in nutrition care, herbs, sports nutrition supplements, trendy weight loss diets, the effect of specific fatty acids on brain develop-ment, and drug interactions with foods or nutrients are ex-amples of the range of topics that are new to nutrition. This book was written because nurses in any field of practice need to understand the role nutrition has in the well-being of the patient or client and be able to apply that knowl-edge as part of a holistic nursing approach to patient care. Nutrition and Diet Therapy for Nurses provides the nurse with the tools and resources to integrate nutrition into the nursing care process and become a reliable source of nutri-tion information and care over an entire career.

Organization of This BookThis textbook is organized in a fashion that allows its use in a variety of nutrition classes or with varying curricula that integrate nutrition in different ways. Section 1, Nutrition Recommendations, Guidelines and Regulation, introduces nutrition as an aspect of total health and the role of the nurse in diagnoses, screening, and assessment. Section 2, Principles of Nutrition, lays the foundation of normal nu-trition, covering the macronutrients, vitamins, minerals, fluids, and energy balance. Section 3, Nutrition Assessment explores assessing nutrition history, physical findings, nor-mal and abnormal findings, and incorporating nutritional assessment into the nursing process. Section 4, Community Nutrition and Health Promotion, builds on the principles of nutrition and applies them to population groups, outlining

nutrition recommendations and standards and other topics such as sports nutrition, food safety, allergies, and cultur-ally competent nutrition care that are important in many settings. Section 5, Nutrition in the Life Cycle, applies the principles of nutrition to individual patient care and nutrition assessment. Normal nutritional needs are incor-porated into the recommendations that are unique for each lifespan group and are presented in a way that encourages the incorporation of this information into the nursing pro-cess. Section 6, Clinical Nutrition and Diet Therapy, covers a wide range of therapeutic nutrition topics following an outline that is based on body systems. As in other sections, evidence-based information is presented that can be incor-porated into the nursing process. Special features in all sec-tions streamline this approach and provide the nurse with cutting edge information for practice.

What’s New in the 2eThe second edition of Nutrition and Diet Therapy for Nurses includes chapter reorganization, expanded content, and a new feature on drug interactions woven throughout the book right from the foundation chapters through to the section on Clinical Nutrition and Diet Therapy.

The chapter Nutrition Recommendations and Standards has moved to Section 1: Nutrition Recommendations, Guidelines, and Regulation to reflect that this information is very much a part of the foundation of nutrition. By mov-ing this chapter earlier in the textbook, the nursing student will be able to build on this evidence-based body of science in later chapters on lifespan and clinical nutrition topics.

An entire chapter, Cultural Considerations in Nutrition, has been added to complement existing chapters in Section 2: Principles of Nutrition. Cultural competence involves lifelong learning and cultural humility and is a critical component in the nursing toolbox. The new chapter focuses on the development and expansion of cultural competence as it relates to nutrition care.

Expanded content can be found in the Fluid, Caffeine, and Alcohol and the Nutrition and Health Promotion chapters. Fluid, Caffeine, and Alcohol covers fluid balance and imbalances across the lifespan and the role of caffeine and alcohol in overall wellness, tackling such topics as the use of energy drinks by adolescents. Up-to-date and more comprehensive information on the nutrition management


xvi Preface

reflect current trends in dietary supplement use. The feature serves to reinforce the need to routinely assess and educate all patients regarding this clinically significant issue.

All new content in Evidence-Based Practice Research boxes outlines a current nutrition care question, reviews the available medical evidence on the topic, and presents a take-away message for the nurse to incorporate into practice. Critical Thinking Questions accompany each Evidence-Based Practice Research box to present a scenario for application of the evidence.

of food allergies can be found in Nutrition and Health Promotion.

Interaction Action is a new feature to the text, reflect-ing the need for the nurse to assess all patients for possible drug interactions with any component of nutrition, includ-ing food, nutrients, and dietary supplements. The feature is found throughout the book to help the nursing student de-velop foundational knowledge regarding well-known drug interactions with specific nutrients, such as divalent cation minerals and certain medications, as well as interactions that


Special Features

Special Features are an integral part of the entire text and offer the nurse snapshot views of the latest information on nutri-tion and nursing along with practical applications. Features include:

xvii

• Cultural Considerations integrate issues of cultural diversity and culturally competent care into each chapter. It is crucial that nurses realize the contribution that cultural beliefs and practices have on nutritional health.

Cultural ConsiderationsNutrition Recommendations around the WorldThe Healthy Living Plate and MyPlate are excellent diet-planning references. But many countries o�er healthy living advice using a variety of formats. Japan organizes the dietary advice from the Ministry of Health, Labor and Welfare and the Ministry of Agricul-ture, Forestry and Fisheries into a “spinning top” format, with grain dishes at the large end of the top and fruits and milk products at the lower pointed end that spins. The picture is di�erent, but the serving recommendations are very similar to the old USDA Food Guide Pyramid that has been replaced by MyPlate. The advice also recommends consuming local foods and reducing food waste (Food and Agriculture Organization, 2016).

The British Nutrition Society advocates the “eatwell plate,” a guide to both type of foods and amounts. The round plate shows visually (rather than by percentages) the amount of fruits and vegetables, bread and starches, meat, milk, and dairy products

that should be included in a healthy diet similarly to MyPlate but with graphics that emphasize fluid intake, healthy oils, and low intake of sweets (National Health Services, 2016).

Canada o�ers a food guide similar in format to the old USDA MyPyramid. It organizes the food groups into rows of di�erent types of foods and includes serving size suggestions. Additional materials are available for Canada’s First Nations, Inuit, and Metis populations to help tailor nutrition advice in a way that integrates their respective traditional dietary habits (Health Canada, 2016).

Another useful resource is the online availability of various healthy guides developed specifically for di�erent cultures. Some of the resources are o�ered in English but include foods that are famil-iar to the specific cultural group. Others are printed in the patient’s native language and include familiar foods. They can be viewed at the USDA Food and Nutrition Information Center’s website.

• Lifespan Boxes discuss the unique nutritional needs of specific age or life cycle groups in all chapters except those already specific to the life cycle. This feature is especially important in the section on Clinical Nutrition and Diet Therapy because of the influence of diseases and medical conditions on nutritional health in pediat-rics, pregnancy and lactation, and the older adult.

LifespanEstimating Height in Bedridden

There are three commonly accepted measurements that may be used to calculate standing height. These methods include knee height, forearm length, and demi-span.

• The knee height is measured from the heel of the foot to the top of the knee while the ankle and knee are held at 90-degree angles. A formula must be used to calculate height.

• The forearm length is measured from the elbow to the midpoint of the ulna at the wrist. The result is compared to a standardized height conversion table.

• The demi-span is measured as the distance from the middle of the sterna notch to the tip of the middle finger when the patient’s arm is held horizontal. A formula is then used to calculate height.

The chapter on nutrition assessment outlines these techniques in more detail.

Evidence-Based Practice Research

Is there an association between screen time and obesity in children?significantly more likely to be obese and living in poverty (Twarog, et al., 2015). Their analysis did not address physical activity. Finally, a meta-analysis of 14 studies found that each additional hour of television viewing was associated with a 13% greater risk of obesity (Zhang et al., 2016).

A systematic review of 25 studies was conducted by researchers interested in the association of screen time and dietary intake by adolescents (Fletcher et al., 2015). They found that the sedentary behavior associated with increased screen time was associated with adiposity, regardless of dietary intake. Vandewater and colleagues (2015) studied the relationship between sedentary behavior (television viewing and screen time), time with friends, and obesity. Their study of 1545 adolescents found that time with friends was a mediating factor in activity and obesity, such that the more time with friends the less likely an adolescent was to be obese or spend time engaged in screen activity. Data from 12,081 adolescents who participated in the Youth Risk Behaviors Survey were examined to determine the relationship between screen-based sedentary behavior and obe-sity (Kim, Barreira, & Kang, 2016). They found that adolescents who engaged in greater screen time were more likely to be obese than those who had less screen time, with greater odds of obesity with female adolescents.

Conclusion: The more time children and adolescents spend watching TV and using devices with screens—regardless of age—the greater risk they have of lower quality nutrient intake and of being overweight. Increased physical activity and time with friends lessens the risk of obesity.

Critical Thinking Question:

What suggestions could the nurse o�er to the mother who states “I am so tired by the time I get done with work and driving chil-dren to activities that all I can do is pick up something from a

Research Problem: Children now spend large amounts of time watching television or using computers and video games, rather than engaging in physical activity. Are children who have more screen time more likely to be overweight than those who have less screen time?

Evidence: Obesity rates are rising in children and adolescents; screen-based time is also increasing in the same age groups with devices even available for toddlers (Zhang et al., 2016). Several studies have examined the association between TV viewing and other screen time in preschool and school-aged children and their weight or body mass index (BMI). Two studies specifically examined whether the presence of a TV or electronic devices in the bedroom was associated with a risk of being overweight (Chaput et al., 2014; Ferrari et al., 2015). One study of 502 children found that a greater number of screens (2–3) in a child’s bedroom was associated with greater adiposity and poorer sleep quality (Chaput et al., 2014). Ferrari and colleagues (2015) studied 441 children in Brazil and found that activity levels were higher and BMI was lower in children who had no screens in their bedrooms. They noted this was regardless of gender or family income. Xu, Wen, and Rissel (2015) conducted a systematic review of literature with respect to parental influence on screen time and physical activity. Their review of 30 studies concluded that parents’ increase or decrease in screen time was mirrored by their children, thus suggesting that parental influence can have a major impact on the amount of time children spend in physical activity and screen time. Data from the National Health and Nutrition Examination Surveys (NHANES) were analyzed, and researchers found that preschool children

drive-through and have us eat it while we watch our favorite TV shows. At least we are spending time together.” What nursing diag-noses could be used to describe this family or parent?

• Evidence-Based Practice Research outline a current nutrition care question, review the available medical evidence on the topic and present a take-away mes-sage for the nurse to incorporate into practice. Critical Thinking Questions accompany each Evidence-Based Practice Research feature to present a scenario for application of the evidence.


• Practice Pearls call attention to quick ways the nurse can apply a nutrition concept directly to patient care.

PRACTICE PEARL Setting GoalsSetting realistic, achievable, and measurable nutritional goals is important for patients. When patients have short-term goals that can be readily achieved, they are more likely to develop confi-dence in their ability to set long-term goals that can have a lasting impact on their nutritional status.

• Hot Topics provide the nurse with an overview of trendy nutrition topics and present the latest research. Conclusions are explained that can be used to formu-late nursing interventions or serve as a basis for further research.

TopicWhen Nutrition Advertising Is Too Good to Be TrueIt is probably no surprise that false health claims for nutrition-al products cost unwary consumers billions of dollars a year. Unfortunately, if it sounds too good to be true, it probably is. But people who su�er from acute or chronic illnesses, especially those that are life-threatening, are particularly vul-nerable to unverified structure-function claims. In addition to delaying or interacting with proven health treatments, these treatments often carry safety risks for people because of contaminated compounds or medically active ingredients.

The FTC oversees advertising of food and dietary supple-ments to make sure that all types of advertising—print, tele-vision, or other types—are not misleading to the consumer or that food- and nutrition-related products are not adver-tised in a way that infers that they have drug-like properties that can treat medical conditions. Unfortunately, the process to screen and react to misleading advertisements happens after products are already on the market and is time-con-suming. The FTC has found that responsibility for decep-tive advertising is shared among many groups, including advertisers, media channels, marketing firms, and product endorsers. Following are some examples of bogus health claims for nutrition products on which the FTC has taken action.

• A Florida-based company was charged with marketing deceptive, unsubstantiated claims that its dietary supple-ment could be used to treat opiate addiction due to use of prescription or illegal drugs. The product promised that the consumer could permanently overcome drug withdrawal and feel results with the first dose.

• A company marketing through direct mail was charged with misleading advertising for claiming it had “clinical proof” and citing bogus references that its product pro-vided a “rapid fat meltdown” of up to 20 pounds in 16 days with just 4 pills.

• Several companies working together were charged with us-ing fake news websites and false weight loss claims to sell a green co�ee bean product. A $30 million judgment was imposed by the FTC.

• Other actions by the FTC have involved various products false-ly promising to improve childhood speech disorders, prevent and eliminate gray hair, and improve memory.

The nurse should note the significant settlement charges for some of these misleading claims and advertisements and realize that the amounts awarded are proportionate to the sales. Although some of the label claims outlined may seem far-fetched, a great number of consum-ers have purchased these products. The FTC seeks to protect consum-ers from health fraud, including that which arises from misleading nutri-tion claims. The nurse can use online resources available from the FTC to remain updated about bogus nutrition claims found in the marketplace.

Additionally, the adage “if it sounds too good to be true, it is” should be applied to nutrition-related advertising. Use these ideas to spot false claims:

• Be skeptical. If it sounds too good to be true, it is.

• Be cautious of products that o�er a quick cure-all for a variety of conditions such as pain, cancer, and heart problems.

• Avoid nutrition products or dietary supplements that promise to cure or treat a disease.

• Be wary of weight loss products that promise results with no changes needed in diet or exercise or that claim permanent weight loss even when no longer using the product.

• Think twice when words like “scientific breakthrough” and “miracle” are used or if there is an ancient or secret ingredient.

• Watch out for impressive medical jargon that really has no sci-entific meaning. An example is a product claiming to reset the “hunger stimulation point.”

• Use of testimonials and anecdotes as evidence should not be confused with scientific evidence.

• Economic warning signs of a product include promises of money-back guarantees (which most consumers are too embarrassed to seek) and the implication that there is a limited supply of the product warranting quick payment.

Source: Federal Trade Commission, 2011; Federal Trade Commission, 2014; Federal Trade Commission, 2015; Lellis, 2016

• Patient Education Checklists are quick reviews of the major patient teaching points presented in the chapter and serve as a guide to implementing patient educa-tion. It is meant as a stand-alone tool for patient educa-tion. The checklist is presented in steps outlining the intervention with specific examples given. The nurse can use the checklist to structure a teaching session and refer to it during teaching to make sure that all concepts are covered.

Patient Education Checklist

Increasing Fruit and Vegetable IntakeIntervention Example

Explain the role of fruits and vegetables in a balanced diet.

Fruits and vegetables provide vitamins, minerals, fiber, and phytochemicals (plant chemicals) believed to be beneficial in overall health and reduction of disease risk.

Outline dietary recommendations for intake.

At least 2 cups of fruits and vegetables are recommended. Some guidelines suggest daily intake of 8 servings or more.

Describe serving sizes. Dietary Guidelines for Americans describes servings in cups. Other guidelines consider a serving to be the following:1 piece of fruit1 cup chopped fruit1⁄2 cup 100% fruit juice1⁄4 cup dried fruit1 cup raw vegetable1⁄2 cup cooked vegetable or vegetable juice

Encourage choice of fruits and vegetables high in fiber.

Choose fruit and vegetables that are less processed—an unpeeled apple vs. apple juice is an example.Consume edible skins and seeds.

Modify existing intake to meet recommendations.

Replace low-fiber processed fruits and vegetables with less processed forms.

Add fruits and vegetables to existing dishes. Example: add peas to macaroni and cheese; have vegetable pizza; add fruit to a smoothie drink, yogurt, or cereal; add vegetables to plain casseroles; add spinach or dark greens to a sandwich.Try new fruits and vegetables to add to those already in the diet. Adding one per month makes it an easy idea.

Address existing barriers to adequate intake.

Cost: Purchase only seasonal fruits and vegetables or frozen. If canned are used, rinse before using.Dental problems: Cut or mash, use riper or softer forms that require less chewing (melon, banana, whipped squash, tomato sauce).Taste: Experiment with di�erent types and recipes.Convenience: Frozen fruits and vegetables retain more nutrition than canned and are convenient for when fresh produce is not available. Dried fruit is also an option.

xviii Special Features

• Interaction Action is focused on assessing patients for possible drug interactions with any component of nutrition, including food, nutrients, and dietary sup-plements. Found throughout the book, this feature reinforces the need to routinely assess and educate all patients regarding this clinically significant issue.

Interaction Action: Spotting Nutrients on the Food LabelSome types of medications are known to interact with nutrients, rendering the drug and/or the nutrient poorly absorbed. An example is calcium. Both the thyroid replacement hormone levothyroxin and certain antibiotics, called fluoroquinolones, are negatively a�ected by calcium consumed near

ingredient list for added nutrients and the Nutrition Fact Panel, a patient can learn whether there is a significant amount of calcium in the product.


Special Features xix

• Nursing Care Plans are included in each chapter to illustrate the nursing process. The case study pulls together key concepts from the chapter and allows the student to follow how the assessment, nursing diagno-ses, nursing interventions, and evaluations would be formulated by the nurse.

NURSING CARE PLANInadequate Carbohydrate Intake for Exercise

CASE STUDYPeter, 43, is a self-described “weekend warrior.” He works as an accountant for a large company. He typically works 8- to 10-hour days, skipping breakfast and eating just a sandwich from home at his desk for lunch. When he gets home, he helps his wife prepare dinner and has been reducing his intake of potato and other starches to try to lose a few pounds. In nice weather, he and his wife take a quick walk to talk over the events of the day and to have a little quiet time. Peter reports that on weekends, he makes up for all he could not do during the week: He goes to the gym to lift weights and uses the treadmill both days, he plays at least one round of golf, and he takes care of the house repairs and yard work. Lately, he has noticed that he cannot keep up the pace on the treadmill or do the usual number of reps with the weights and that he is worn out by the time the yard work is done. He has come to the clinic for a check-up and specifically wants to know if there are any natural supplements he could take to increase his strength and stamina.

APPLYING THE NURSING PROCESS 13.6 To formulate nursing interventions to promote

adequate intake of nutrients by physically active patients.

ASSESSMENT

Peter is 5 feet 10 inches (178 cm) tall and weighs 180 pounds (82 kg) with a BMI of 26. Vital signs are T 98.9, P 78, R 18; BP 128/88. He is pleasant and states that he has no health con-cerns beyond not having the stamina he used to have. He ad-mits to “not having the greatest diet” but states that he always takes his lunch to work and the family rarely eats out. He says he has to get more energy soon, or he is afraid he will turn into a “couch potato” like his overweight father. Lately, he has reduced his intake of carbohydrates based on a neighbor’s advice about how to lose weight.

DIAGNOSES

Deficient knowledge related to nutrient needs of athletes evidenced by questions about use of supplements and avoiding carbohydrates

Readiness for enhanced nutrition related to decreased stamina evidenced by questions about the e�ect of weight loss on stamina

Anxiety related to concern about consequences of not exer-cising evidenced by expressing concern about becoming a “couch potato”

EXPECTED OUTCOMES

Peter will develop a plan for energy expenditure realistic for age and nutrient intake

Identify facts and myths about both carbohydrates and supple-ments marketed to enhance strength

Develop a plan for nutrient intake that uses the principles of the U.S. Dietary Guidelines and MyPlate

INTERVENTIONS

Do a 24-hour food recall

Review lab data for iron deficiency

Suggest options for spreading exercise and activity throughout the week to maximize the benefits of those activities

Develop an individualized MyPyramid plan acceptable to Peter and his family that contains adequate carbohydrate sources

Discuss the role of supplements in enhancing physical fitness

EVALUATION

After 6 weeks, Peter reports feeling more rested and increased stamina. The family has agreed to eat dinner later one evening a week so Peter can go the gym for an hour. The children have enjoyed using the computer to see how foods that the family eats a�ect MyPlate and they have begun to plan weekly gro-cery lists. Peter tries to take a 15-minute walk at lunch with a colleague and finds he enjoys the socialization and has more energy to tackle work. He has improved his carbohydrate in-take with cereal and milk for breakfast and fruit along with his lunch. At dinner, he has a baked potato or a serving of rice or pasta. He sometimes buys skim milk from the vending ma-chine, but otherwise he drinks water. Peter was surprised to find that he lost 2 pounds by increasing his activity during the week and eating more balanced intake. He reviewed the edu-cational information and prices for supplements and decided that he would concentrate on eating more balanced meals and getting more regular exercise to improve strength and endur -ance instead of considering supplements. His hemoglobin was 15.1, so no interventions were indicated. Figure 13-2 outlines the nursing process for this case.

AssessmentData about the patient

Diagnosis

Subjective Objective

Example: Interest in improved nutrition

PlanningGoals stated in patient terms

Example: Long-term goal: Weight loss of one pound per week. Short-term goal: Use MyPlate as a guide to a balanced diet.

What the nurse observes;anthropometric and clinical data

Examples: Height, weight, weight history, labs

What the patient tells the nurseExample: “I need to lose weight and get in better shape.”

ImplementationNursing action to help patient achieve goals

Example: Use the “rule of 500” in planning weight loss diet

EvaluationWas the goal achieved or does the intervention

need to be modified?Example: Lost 5 pounds in 6 weeks.

Figure 1-3 Nursing Care Plan Process: Nutrition for Weight Loss

• Nursing Process Figures accompany each Nursing Care Plan to present a visual diagram of the nursing process used in the construction of the case study. This feature helps the visual learner picture the nursing process in addition to learning it through reading the case study.


• NCLEX-style Questions are included with each chap-ter and allow the student to become practiced with this style of testing. The correct answers, rationale, cogni-tion level, nursing process step, and category of client need are outlined for each question. This additional information is found at the back of the book.

• MyLab Nursing provides interactive activities, case studies, NCLEX-style Questions, and media links to websites that offer credible nutrition information to further learning on the topic. Many of the sites also feature patient education materials and other teaching tools.

NCLEX-style Questions1. A young mother asks the clinic nurse about DRIs

and why they are important. How should the nurse respond?

1. “They are guidelines for how many calories your child should consume.”

2. “They are the standards by which healthcare providers determine obesity.”

3. “They provide guidance about recommended in-take of nutrients, including vitamins and minerals.”

4. “They are used by dietitians to calculate calories and plan diets to treat diseases.”

2. The nurse who is teaching a patient about food product labels points out that a package of cookies labeled “low fat” contains cookies that have:

1. Very little fat per serving.

2. Half the fat calories of traditional cookies.

3. No saturated fat.

4. Fewer calories than traditional cookies.

3. What is the best explanation of nutrient density?:

1. The nutrient widely available in a variety of foods

2. The practice of consuming foods from each food group every day

3. Foods that contain a significant amount of specific nutrients for the least amount of calories

4. Those foods that make up the largest segment of MyPlate

4. The nurse uses the example of “milk builds strong bones” to explain which concept?

1. A nutrient content fact

2. A structure-function claim

3. A health claim

4. An exaggerated health claim

5. A patient expresses a desire to have a healthier diet. What could the nurse suggest as a first step?

1. Read the dietary reference intakes (DRIs).

2. Do a diet analysis using the MyPlate website.

3. Read current nutritional pamphlets from a health food section at the grocery store.

4. Check the United States Department of Agriculture (USDA) website.

• Critical Thinking Exercises accompany each Evidence-Based Practice Research box and Nursing Care Plan to allow the student to apply the concepts used in those features to actual practice and stimulate further learning. All Critical Thinking Exercises have answers available at the back of the book.

Critical Thinking in the Nursing Process1. For these questions refer back to the Nursing Care Plan-Nutrition

and Unplanned Weight Loss in the Older Adult. Laura was able to gain a small amount of weight by manipulating her diet and nutrient intake. What additional assessment might be indicated if she failed to gain any weight or lost more weight in 2 months?

2. What additional interventions might be necessary if Laura’s children were unable or unwilling to provide any extra financial assistance?

3. How might the use of nonprescription pain medications a�ect Laura’s appetite?

4. Even though Laura has episodes of urinary incontinence, the nurse has recommended drinking more water. Why was this recommendation made?

xx Special Features


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