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