Nutrition

Foundations & Clinical Applications

A Nursing Approach

Today’s Plan

• Review Strategies for Success in NRS 220

• Test Dates

• Assignment(s) Dates

• Web CT & E-mail contact

• Syllabus Questions

Objectives• Dimensions of health

• Role of Nutrition

• Positive life style behaviors

• Disease prevention

• Role of nutrients

• RDA’s & DRI’s

• Tools for assessment

HealthPhysical : function, immunity, meeting

energy requirements

Intellectual: learning & adaptation to change

Emotional: express or suppress appropriately

Social: interactions & relationships

Spiritual: beliefs that give purpose

Nutrition & Health• Review definitions on page 4 of the text

( blue box)

• Primary role is: building blocks for efficient functioning

• Nutrition is the corner stone

for all of the dimensions

of health

Physical Health• Obesity causes multiple autonomic

dysfunctions. Examples?

Laederach-Hofmann, K., Muggsay, L., Ruddel, H. (2002). Autonomic

cardiovascular regulation in obesity. Journal of Endocrinology. 164, 59-66.

Suggested reading only; think of other examples as well.

Physical Health• Fracture risk in patients with anorexia

nervosa, bulimia nervosa, and EDNOS

• Increased risk for fracture risk in AN clients one year after diagnosis– Lasting deficit in bone mineral– Anorexic state left permanent skeletal

damage, augmented by age

Physical Health• Increased risk for fractures exists for ten

years prior to actual diagnosis in Bulimic disorders.

• WHY?

• B.N. often goes undiagnosed for years as this group of clients does not present with alarming obvious weight loss symptoms.

Intellectual HealthCogitative control increased with decreased

feelings of hunger and irritability.

Insulin stimulates sympathetic nervous system activity ( Flack Sowers 1991)

Emotional Health• Reference

Laederach-Hofmann, K., Kupferschmid, S., & Mussgay, L.( 2002). Links between body mass index, total body fat,cholesterol, high density lipoprotein, and insulin sensitivity in patients with obesity related to depression, anger and anxiety. International Journal of Eating Disorders 32(1)

Suggested; not required

Emotional Health• Correlations between body fat and anger

• Correlations between body fat and aggression

• Overweight often leads to depression & feelings of worthlessness especially in women

Emotional Health

• Binge eating is a “marker” for psychiatric obesity

• Associated with greater increased risk for lifetime depression, panic disorder, phobias and alcohol dependence

• Associated with higher neuroticism, dependency and lower self-esteemBulik, C.M. Sullivan P.F. & Kendler K.S. (2002)

Social HealthEating in isolation, eating with

groupsQuality of relationships may

affect food intake in multiple ways

Whom you choose to eat with may affect your actual intake

Spiritual HealthJudaism, pork restriction

Islamic or Muslims, can eat meat

Catholics, food restrictions and fasting

Hindu, vegetarians

Rituals and feasts may also affect eating patterns

Health Promotion• HP 2010 20 nutrition related objectives• Reduce the intake of dietary fat to less than

30%• Page 8 of text specifies the category and

details of all 20 objectives• Take note of the goal regarding growth

objectives, nutrient consumption, anemia, counseling & food security

DefinitionsWellness: a lifestyle that enhances each of the

five dimensions of health

Lifestyle: pattern of behaviors

Disease Prevention: specific actions or changes in behavior that can reduce a threat to health

Categories of Prevention

• Primary- advert the development of poor health

• Secondary-early intervention to minimize or reduce the effects of a disease, illness, or treatment undertaken for a disease.

• Tertiary-minimize further complications and assist in restoring health

Nutrients• Carbohydrates

• Minerals

• Fats (lipids)

• Vitamins

• Protein

• Water

Foods provide energy and nutrients

Essential Nutrients for Humans

Carbohydrates

Complex

Simple

Fiber

Protein(Animal and plants)

Lipids/Fats

Essential fatty acids: linoleic & linolenic acids

Saturated Fat Unsaturated Fat

Vitamins

Minerals/Elements

Water

Energy• Carbohydrates

• Proteins

• Lipids

Organic, therefore they contain energy. Molecular structure contains carbon hydrogen and water.

Energy• Energy & work are closely related concepts

• Energy derives its importance from two sources – It is a conserved quantity– It is a key concept in all areas of science

Energy is “The ability to do work”Many types of energy are noted:

KINETIC GRAVITATIONAL POTENTIAL

Work• What is accomplished by the action of a

force when it makes an object move through a distance.

• W=Fd

ENERGY• Kinetic

• Gravitational

• Potential

• Electric

• Nuclear

• Thermal

• Chemical

Energy stored in food and fuel can be regarded as

POTENTIAL energy stored by virtue of theRelative position of the atoms

within a molecule.OR

The Chemical Bonds

Using EnergyChemical reactions are necessary to release the

energy in food.Enzymes in the body allow the release of

energy from foodAnalogy: Compression Spring-when released-

does workSpark plug- spark allows the mixture of gasoline & air to react

Transformation of Energy

• Potential energy can be transformed into kinetic energy

• Transfer of energy is accompanied by the performance of work

Waste of Energy• Alcohol 7 kilocalories per gram

• Provides energy, but is not a nutrient

• Body treats alcohol as a toxin/poison

• Breaking down alcohol is stressful to the body & uses nutrients that could be used for nourishment

Sources of Energy• Carbohydrates- Major source

• Simple & Complex

• Simple: Azucar, leche, fruto

• Complex: Cereal, pastas, vendura

Glucose is the most efficient

form

Sources of Energy• Proteins- Provide energy AND

– Bone structure, muscle, enzymes, hormones, blood, immune system & cell membrane

• Twenty amino acids are required to create proteins essential for life– Proteins are formed

by linking amino acids

Sources of Energy• Fats-Dense form of energy

– Component of all cell structures, protects body organs, hormones

• Lipids– Triglycerides, phospholipids, sterols

• HP 2010 Objective

Sources of Energy• Vitamins

– Digestion, absorption & excretion– 13 vitamins are necessary

• Categories– Fat soluble: A,D,E,K--

– Water soluble: B complex and C---

Sources of Energy• Minerals

– Bone & teeth, structural function, muscles and CNS

• Major minerals & trace– Both are equally important, but required

quantities vary.

Sources of Energy• Water

– Key to reformulation of substances– Transport medium

• Critical for survival– 8-10 cups per day

Dietary Reference Intake

• Planning meals for large groups

• Creating standards

• Interpreting information of populations

• Meeting National Goals

• Developing new productsReview page 16 for abbreviations

Assessment• Process of determining nutritional status

– Deficiencies or excesses

• Levels of assessment– Intake & quantities– Consumption for growth & maintance of

health

Balance of Intake• Undernutrition- underconsumption base on

RDA/RDI values, not enough food or wrong types of food

• Overnutrition- Too much nutrients- FAT’s

• Malnutrition- Excess of nutrients, imbalance with energy expenditure– Absorption issues, ETOH, illness, or treatment

Assessment tools• 24 hr. diet recall

• Clinical analysis

• Biochemical analysis- – blood tests, urine screens

• Anthropometric measurements,– BMI, height, weight circumference– Bone density

Personal Nutrition• Responsibility

• Food Selection

• Food Preferences

• Palatability-genetic determination of taste

• Food Choices- convenient options

• Food Likes

Community Nutrition

• Economics- WIC

• Dietary related diseases – Heart disease, hypertension, cancer, diabetes,

osteoporosis, obesity,

• Excesses of: saturated fat, sodium cholesterol and azucar

Lifestyle Applications

• Whole grains in the morning, fruit

• Health selections from vending machines

• Low fat items from fast food places

• High quality grazing foods

Food Pyramid

Fats, Oils and Sweets

Use sparingly

Milk, Yogurt and Cheese Group

2-3 ServingsVegetable Group

3-5 Servings

Meat, Poultry, Fish, Dry Beans,

Eggs and Nuts Group

2-3 ServingsFruit Group

2 – 4 Servings

Bread, Cereal, Rice

and Pasta Group 6 –11

Servings

Food Trends• Fresh & processed fruit & vegetable

consumption is increasing

• Flour & cereal consumption is decreasing

• Meat poultry & fish, all have increased

• Egg & dairy has decreased

Technology affects availability

Implications• Learning to prepare a wider variety of foods

• Ethnic cuisines have increased options

• Buying style:– Budget– Whom is included– Special needs– Shopping frequency & location

Consumer information

• Labeling

• Food descriptors

• Health Claims

Safety Decisions

• Zero risk standard of the Delaney Clause

• Functional additives

• Foodborne Illness– Sushi, sashimi, ahi– Cider – Listeria

• See table 2.6, page 50 for additional notations on FBI

Safety Practices Clean areas

Hand washing

Clean surface area for cooked food

Correct temperatures for Hot/ Cold items

Damaged containers

Tasting & cooking

Positive Nutrition• Making a plan

• Knowledge of the relationship between nutrition & disease

• Disease prevention goal

• Choices based on nutrients not on taste alone

Groups at risk for malnutrition

•Pregnant & breastfeeding women

•Infants

•Children

•Frail elderly

•Ill

•Poor/Inadequate health care

Adequacy + Variety + Balance = Healthy

There are no good or bad foods

There are good or bad diets.

Variety, moderation, adequacy and balance are key to healthy diet

Nutrient Density

BREAK

• I will be available for questions after class

Nutrition in Nursing • Nutritional status:

– the state of balance between nutrient supply (intake) and demand (requirement)

– imbalance between intake and requirement can result in overnutrition or undernutrition

• Nurse’s Role and the Nursing Process

Nurse’s role in facilitating nutritional care

• Communicate with the registered dietitian (RD)

• Serve as a liaison between the physician and the RD

• Identify clients who may benefit from programs such as Meals on Wheels

• Request a referral to a speech therapist• Confer with the discharge planner, social

services worker, and physical or occupational therapist

Nutritional assessment

• Nutritional assessment: an in-depth analysis of a person’s nutritional status

• In the clinical setting, nutritional assessments focus on moderate- to high-risk patients with suspected or confirmed protein-energy malnutrition

Nutritional screening

• Nutritional screen: a quick look at a few variables to judge a client’s relative risk for nutritional problems

• Can be custom designed for a particular population (e.g., pregnant women) or for a specific disorder (e.g., cardiac disease)

Nutritional history

• Through a routine history and physical, nurses can identify who may be at nutritional risk

• Chronic or acute changes in health can impact nutritional status by altering intake, digestion, metabolism, or excretion of nutrients

Nutritional risk

• A client may be at nutritional risk because of what he/she does or does not eat

• Ask open-ended, non-leading questions to ascertain usual intake

• Neither BMI nor “ideal” body weight may reliably assess health risk related to weight if muscle mass is large or edema is present

Physical S&S and medications

• Significant weight loss increases the risk of poor nutrition even if the weight loss was intentional

• Medications and nutritional supplements should be evaluated for their potential impact on nutrient intake, absorption, utilization, or excretion

• Physical signs and symptoms of malnutrition are nonspecific, subjective, and develop slowly--suggestive but not diagnostic

Physical S&S of malnutrition:

• Hair is dull, brittle, dry, or falls out easily

• Swollen glands of neck and cheeks

• Dry, rough, or spotty skin • Poor or delayed wound

healing or sores• Thin appearance with

lack of subcutaneous fat

• Muscle wasting • Edema of lower

extremities• Weakened hand grasp• Depressed mood• Abnormal heart

rate/rhythm, BP• Enlarged liver or spleen• Loss of balance,

coordination

Nursing diagnoses related to nutrition

• Nursing diagnoses relate directly to nutrition when the client’s intake of nutrients is too much or too little for body requirements

• Many other nursing diagnoses relate indirectly to nutrition because nutrition contributes to the problem or solution

Nursing diagnoses with nutritional relevance

• Altered nutrition: more than body requirements• Altered nutrition: less than body requirements• Altered nutrition: risk for more than body

requirements• Constipation• Diarrhea• Fluid volume excess• Fluid volume deficit

Nursing diagnoses with nutritional relevance (cont’d)

• Risk for aspiration• Altered oral mucous membrane• Altered dentition• Impaired skin integrity• Noncompliance • Impaired swallowing• Knowledge deficit• Pain• Nausea

Nutrition priorities• A nutrition priority for all clients is to

obtain adequate calories and nutrients based on individual needs

• Sometimes it is necessary to prioritize nutrient needs

• Help the client to formulate nutrition goals that are measurable, attainable, and specific

Short-term nutrition goals

• attain or maintain adequate weight and nutritional status

• avoid nutrition-related symptoms and complications of illness (as appropriate)

Long-term nutrition goals

• to promote healthy eating to avoid chronic diet-related diseases such as heart disease, hypertension, obesity, and type 2 diabetes

How to promote adequate intake• Reassure clients who are apprehensive about eating• Encourage a big breakfast if appetite deteriorates

throughout the day• Advocate discontinuation of intravenous therapy as

soon as feasible• Replace meals withheld for diagnostic tests• Promote congregate dining if appropriate• Question diet orders that appear inappropriate

How to promote adequate intake (cont’d)

• Display a positive attitude when serving food or discussing nutrition

• Order snacks and nutritional supplements• Request assistance with feeding or meal

setup• Get patient out of bed to eat if possible• Encourage good oral hygiene• Solicit information on food preferences

How to facilitate client/family teaching

• Listen to client’s concerns and ideas

• Encourage family involvement if appropriate

• Reinforce importance of obtaining adequate nutrition

• Help client to select appropriate foods

• Counsel client about drug--nutrient interactions

• Avoid using term “diet”• Emphasize things “to do”

instead of things “not to do”

• Keep message simple• Review written handouts

with client• Advise client to avoid any

foods not tolerated

Diet: a four letter word• The term diet inspires negative feelings

in most people

• Replace it with eating pattern, eating style, or foods you normally eat to avoid negative connotations

Nutrition recommendations for clients

• Keep in mind that – intake recommendations are not always

appropriate for all persons

– clients’ needs change

– what is recommended in theory may not work for an individual

– clients may revert to comfort foods during periods of illness or stress

Nutrition counseling• Counseling = teaching + brainstorming

• Help client understand and implement intake recommendations

• Nurses can reinforce nutrition counseling done by the dietitian and initiate counseling for clients with low or mild risk

Nutrition counseling (cont’d)• Use preprinted lists of “do’s and don’ts”

only if absolutely necessary such as in the case of celiac disease

• For most people, actual food choices should be considered in view of how much and how often they are eaten rather than as foods that “must” or “must not” be consumed

How to stay on top of client’s nutrition

• Observe intake whenever possible to judge adequacy

• Document appetite and take action when client does not eat

• Order supplements if intake is low or needs are high

• Request a nutritional consult• Assess tolerance (i.e., absence of side

effects)• Monitor progress (e.g., weight gain)

How to stay on top of client’s nutrition (cont’d)

• Monitor progression of clients on restrictive diets:– NPO

– clear liquid diet

– receiving enteral or parenteral nutrition

• Monitor client’s grasp of information and motivation to change