Download - Nutrition
NUTRITION
Ma. Victoria J. Recinto RN, USRN
University of the Philippines Manila
Philippine General Hospital
Macronutrient: CHO
Preferred source of energy Includes sugars, starches, cellulose 4 cal/g Promote N fat metabolism, spare CHON,
enhance LI function Major food source: milk, grains, fruits &
vegies
Food Sources: CHO Cellulose
ApplesBeansBranCabbage
FructoseFruitsHoney
LactoseMilk
Glucose Carrots, corn, dates, grapes,
oranges Starch
Barley, beets, carrots, peas, corn, oats, potatoes, pasta, rye, wheat
Sucrose Apricots, granulated table sugar,
honeydew, cantaloupe, molasses, peaches, peas, corn, plums
Macronutrient: FATS
Concentrated source & a stored form of energy Protect internal organs & maintain body T Enhance absorption of fat-soluble Vit 9 cal/g Inadequate intake: cold sensitivity, skin lesions,
risk for infection, amenorrhea High fat diet: obesity, CV disease, CA
Food Sources: FATS Cholesterol
Animal productsEgg yolksLiver & organ meats
MonosaturatedDuck & gooseEggsOlive & peanut oils
PolyunsaturatedCorn, safflower &
sunflower oils Saturated
BeefButterHard yellow cheesesLuncheon meats
Macronutrient: CHON Critical to all aspects of growth & dev’t of body tissues Build & repair tissues, regulate fluid & acid-base
balance, produce Ab, provide energy, produce enzymes & hormones
4 cal/g Essential (Complete) AA: required in the diet because
the body cannot manufacture them (eggs, dairy products, meat, fish, poultry)
Inadequate intake: PEM, severe wasting of fat & muscle tissue
Food Sources: CHONBread & cereal productsDairy productsDried beansMeats
Micronutrient: Vitamins Facilitate metabolism of macronutrients Promote life & growth processes Maintain & regulate body functions Fat-soluble Vit: can be stored in the body: excess can
cause toxicity Water-soluble Vit: excreted in urine Vit K: catalyst for blood-clotting factors, esp. prothrombin Vit C: helps in the production of collagen, a vital
component of wound healing Vit A: maintains eyesight & epithelial linings
Food Sources: Vitamins Water-Soluble
Folic acid: green, leafy vegies; liver; beef; fish; legumes; grapefruit; oranges
Niacin: meats, poultry, fish, beans, peanuts, grains B1 (thiamine): pork & nuts, whole grain cereals,
legumes B2 (riboflavin): milk, lean meats, fish, grains B6 (pyridoxine): yeast, corn, meat, poultry, fish B12 (cobalamin): meat, liver C (ascorbic acid): citrus fruits, tomatoes, brocolli,
cabbage
Food Sources: Vitamins Fat-Soluble
A: liver, egg yolk, whole milk, green or orange vegies & fruits
D: fortified milk, fish oils, cerealsE: vegies oils, green leafy vegies,
cereals, apricots, apples & peachesK: green leafy vegies, cauliflower &
cabbage
Minerals Components of hormones, cells,
tissues & bones Acts as catalysts for chemical
reactions & enhancers of cell function
Deficient occurs in chronically ill or hospitalized pts
Food Sources: Minerals Na, Cl, K, Ca, PO4, Mg (see fluid &
electrolytes) Iron: breads & cereals, dark green
vegies, egg yolk, liver, meats Zinc: eggs, leafy vegies, meats,
CHON-rich foods
US Food Guide Pyramid Level 1 (Base): Bread, cereal, rice & pasta group
Daily recommendation: 6-11 servings Level 2: Vegies & fruit group
Vegies: 3-5 servingsFruit: 2-4 servings
Level 3: Milk, yogurt & cheese group; Meats, poultry, fish, dry beans, eggs & nuts groups2-3 servings for each group
Peak: Fats, oils & sweets groupEaten sparingly
US Food Guide Pyramid
Therapeutic Diets: Clear Liquid Relatively clear & liquid at room & body T Includes: water, bouillion, clear broth, carbonated
drinks, gelatin, hard candy, lemonade, popsicles, coffee & tea
Provides fluids & electrolytes to prevent dehydration
Initial feeding (after NPO, for malnourished, in diarrhea )
Bowel prep for surgery or test, Post-op diet Deficient in energy & most nutrients, no residue:
should not be maintained for a day or two
Therapeutic Diets: Full Liquid Clear & opaque liquids at room & body T Includes: clear liquids, plain ice cream,
sherbet, breakfast drinks, milk, pudding, custard, strained soups & vegies/fruit juices
Second diet after clear liquids post-op or for pt who is unable to chew or swallow
Deficient in energy & most nutrients
Therapeutic Diets: Soft DietRegular foods with soft
consistency; liquid, chopped, pureed foods
All food seasonings: allowedRaw fruits, vegies, fried
foods, whole grains & nuts or seeds: avoided
Therapeutic Diets: Soft Diet For pt with dental problems, poor fitting
dentures, difficulty chewing or swallowing, with stomatitis, s/p oral, head or neck surgery, with broken jaw, with dysphasia, had CVA, ulcerative colitis & Chron’s disease
If with stomatitis: serve cool foods If with salivation: suck on sour candy Provide plenty of fluids with meals Drinking from a straw is easier than from a
cup or glass
Therapeutic Diets: Bland Diet For pt with gastritis, ulcers, reflux
esophagitis, CHF, MI Less likely to form gas than regular diets Avoid foods that can stimulate gastric acid
secretions or irritating to the gastric mucosa: alcohol, caffeine (cola, cocoa, coffee, tea), fried foods, pepper & spicy foods
Therapeutic Diets: Low-residue/fiber Diet For pt with Chron’s disease, ulcerative
colitis, gut obstruction, diarrhea Least likely to form an obstruction Includes: white bread, cereals, pasta Avoid: raw fruits (except banana),vegies,
seeds, plant fiber & whole grains Dairy products: limited to 2 servings/day
Therapeutic Diets: High-residue/fiber Diet For pt with constipation, asymptomatic
diverticular disease, DM (diet regulates blood glucose), heart disease (diet regulates blood cholesterol)
Adds vol. & wt. to the stool, speeds bowel movement
Includes: fruits, vegies & whole grain products
Therapeutic Diets: Fat-controlled Diet
For pt with atherosclerosis, DM, hyperlipidemia, HTN, MI, nephrotic syndrome, RF
Reduces the risk of heart disease
Therapeutic Diets: High-calorie Diet For pt with severe stress, burns, CA,
HIV/AIDS, COPD, resp. failure Should be high in CHON to build lean
body mass Add fats & sugar to foods, nuts & raisins,
cereals Give high-calorie desserts, snacks in
between meals (milk shakes & instant breakfasts)
Therapeutic Diets: Na-restriction Diet For pt with HTN, CHF, kidney &
cardiac diseases, liver cirrhosis 2-4 g/day: mild 1g/day: moderate 500 mg/day: strict (seldom prescribed) Cereals allowed: dried or instant,
puffed wheat & rice, shredded wheat
Therapeutic Diets: Na-restriction Diet
Na-free spices & flavoringsallspice; bay leaves; caraway seeds; cinnamon; curry & mustard powder; garlic; ginger; almond, lemon & maple extract; marjoram; nutmeg
Therapeutic Diets: CHON-restriction Diet For pt with ARF, CRD, liver cirrhosis & hepatic
coma 40-60 g/day of essential (complete) CHON Adequate CHO & fat is critical to spare the
CHON as source of energy Special low-CHON products: pastas, bread,
cookies, wafers, gelatin made with wheat starch Powdered or liquid CHO, vegetables & fruits Limited milk, meat, bread & starch exchange
Therapeutic Diets: High-CHON Diet
For tissue building, burns, liver disease, older pt
Includes: meat, fish, fowl, dairy product, CHON supplements
Therapeutic Diets: Low-Ca Diet
To prevent renal calculiAvoid: whole grains, milk &
dairy products & green, leafy vegies
Therapeutic Diets: High-Ca Diet
For bone growth & to prevent osteoporosis
Includes: dairy products, supplements (esp. if lactose intolerant)
Therapeutic Diets: Low-purine DietFor gout (purine is the precursor
for uric acid that forms stones)Avoid: fish (anchovies, herring,
mackerel, sardines & scallops), glandular meats, gravies, meat extracts, wild game, goose & sweatbreads
Therapeutic Diets: High-iron DietFor anemic ptIncludes: organ meats, meat,
egg yolks, whole wheat products, leafy vegies, dried fruit, legumes
Therapeutic Diets for Diverticular DiseaseSymptomatic: low-residue/fiberAsymptomatic: high-residue/fiberForce fluids: 2.5-3 L/dayNo seeds & nuts, no gas forming
foods
Therapeutic Diets for Diverticular DiseaseGas forming foods
Apples, artichokes, barley, beans, bran, brocolli, brussels sprouts, cabbage, celery, cherries, coconuts, eggplants, figs, honey, melon, milk, mollases, onions, radishes, soybeans, wheat, yeast
Therapeutic Diets: Fluid-restriction
For pt with ARF, CRD, liver cirrhosis & hepatic coma, CHF, cardiac disease
Includes: limited/measured intake of clear and full liquids
Therapeutic Diets: CHO-controlled Diet
For pt with DM, hypoglycemia, lactose intolerance, galactosemia, dumping syndrome & obesity
Use Exchange System for Meal Planning (American Dietetic & Diabetes Associations)
Vegetarian Diets
Lacto-ovo: plant foods with dairy products & eggs, fish & occasional poultry
Lacto: plant foods with dairy products excluding eggs
Vegans: entirely plant foods
Vegetarian Diets
Eat a variety of foods to meet nutritional & energy needs
Vegetable CHON sources: whole grains, legumes, seeds, nuts
Enteral nutrition
Provides liquefied foods into GIT via a tube
When GIT is functional but oral intake is not feasible
For pt with swallowing problems, burns, major trauma, liver failure, severe malnutrition
TOTAL PARENTERAL NUTRITION
TPN Supplies necessary nutrients via veins Indications
Severely dysfunctional GIT (r/t surgery, trauma, obstruction enteral feeding intolerance)
Inadequate oral nutritionAIDS, CA, malnourished pt, receiving
chemotherapy
TPN: Components CHO
Dextrose 5% sol’n (peripheral) to 50-70% (central) Provide 60-70% caloric (energy) needs
CHON: AA 3-15% of total calories Lipids (fat emulsion): 30% of caloric needs Vitamins, minerals & trace elements Water Electrolytes Insulin (to control blood glucose) Heparin (to prevent clotting at the catheter tip)
TPN: IV sites Peripheral Parenteral Nutrition (PPN)
Used for short periods (5-7 days) Small concentrations of macronutrients Delivers isotonic or mildly hypertonic sol’ns (otherwise can
cause sclerosis, phlebitis or swelling) Central Parenteral Nutrition (CPN)
For large concentration of CHO (>10% glucose) Subclavian or internal jugular veins: <4 wks use PICC line, tunneled catheter or implanted vascular access
device: >4 wks use
TPN: Lipids (Fat Emulsion) Don’t use bottle if separation of emulsion into layers/fat
globules/froth is noted, return it to pharmacy Don’t put additives into lipids Use 1.2 m filter or larger for lipids to pass through, use
vented IV tubing Infuse initially at 1 ml/hr, monitor VS q 10 mins, WOF
adverse reaction for 30 mins (if noted, stop the infusion & notify MD)
Monitor serum lipids 4 hrs after d/c infusion Monitor liver function tests (liver metabolize lipids)
TPN: Lipids (Fat Emulsion)Adverse Reactions
Chest & back pain, chills, cyanosis, diaphoresis, dyspnea, fever, flushing, HA, N/V, pressure over the eyes, thrombophlebitis, vertigo
TPN: FiltersTo remove crystals from the solutionTPN without lipids: 0.22 mFor lipids: 1.2 mLipids: given via separate tubing below
the filter of the main TPN because particles are too large to pass through filters
TPN: ComplicationsPneumothorax
After catheter insertion: confirm placement through Chest X-ray before initiating TPN to r/o pneumothorax
S/Sx: (-) breath sounds, chest or shoulder pain, sudden SOB, tachycardia
TPN: Complications Air embolism
During tubing & cap changes:Instruct pt in Valsalva maneuverPlace the pt in head down position with head turned opposite the insertion site (to intrathoracic venous pressure)
Secure all tubing connections
TPN: Complications Air embolism
S/Sx: apprehension, chest pain, dyspnea, BP, loud churning pericardial sound, rapid & weak pulse, RR distress
If suspected: Clamp the IV catheter Position the pt in L side-lying, Trendelenburg position
to trap the air in the R side of the heart Notify MD Administer O2 as ordered
TPN: Complications Infection
Strict asepsis (glucose: medium for bacterial growth) WOF T, Check site for redness, swelling, tenderness or drainage Change TPN solution & tubing q 12-24 hrs, dressing at IV site q 48
hrs according to agency protocol If suspected:
Remove IV line & restarted at a different site Remove the catheter tip & send to lab for culture Prepare for blood cultures
S/Sx: T, chills, WBC, erythema or drainage at the insertion site
TPN: Complications Fluid Overload
If received solution too rapidlyAlways use an infusion pumpNever rate to “catch up” if IV infusion gets behindMonitor I/OWeigh OD (ideal wt gain: 1-2 lb/wk)S/Sx: bounding pulses, crackles, HA, HTN, JVD,
wt gain more than desired
TPN: Complications Hyperglycemia
Ask for hx of glucose intolerance, meds taken (esp. steroids)
Begin infusion slowly (usually 40-60 ml/hr) as prescribed
Monitor CBG q 4-6 hrs or as orderedAdminister regular insulin as orderedS/Sx: 3P’s + 1 g
TPN: ComplicationsThrombosis
S/Sx: Edema in the cath insertion site or arm, neck pain, JVD
Catheter displacementS/Sx: Leak at insertion site,
pain/discomfort during TPN infusion
TPN: Complications Hypoglycemia
Monitor CBG (esp. 1 hr s/p TPN)Gradually infusion before d/cIf hypertonic glucose is stopped, an infusion of
dextrose 10% is instituted & maintained for 1-2 hrs
Administer glucose as orderedS/Sx: TIRED
TPN: Additional Nursing Interventions Don’t give meds & blood through TPN If receiving heparin: check PT & aPTT Check e+, albumin, liver & renal
function studies If pt is severely malnourished: WOF
refeeding syndrome (rapid K, Mg & PO4 levels)
TPN should be refrigerated & administered within 24 hrs from the time prepared