Medical SU NUR 2301 Exam 1 Nutrition, Obesity, GI Periop- Portage Learning

Nutrition  Foods high in iron
o Breads/cereals, Grains – 2/3c
Optimal nutrition results from a balanced diet, micronutrients, o Meat, poultry, fish – 3oz (deck of cards);
water, and physical activity
1/2c soybeans
Caloric requirements are based on body type, age, gender,
medications, activity, and presence or absence of disease
Vitamins – organic compounds needed in small amounts for
Mifflin-St. Jeor equation = caloric needs based on BMR proper amino acid, fat, and carbohydrate metabolism

Simpler = 20-25cal/kg to lose, 25-30cal/kg to maintain, 30-  Water-soluble – C, B-complex
35cal/kg to gain  Fat-soluble – ADEK
o Can be stored and cause toxicity
Carbohydrates = 4cal/g o Contains upper limits
 A- retinol
 Simple = monosaccharides (glucose, fructose; fruit
o 900mcg(M), 700mcg(F)
and honey) and disaccharides (maltose, sucrose,
lactose; table sugar) o Dry, scaly skin; increased susceptibility for
 Complex = polysaccharides (starches; potatoes, infection; night blindness; anorexia; eye
cereal) irritation; keratinized resp/GI mucosa;
 Chief protein-sparing ingredient bladder stones; anemia
 DRI = 45-65%  D
 14g fiber/1000cal; 28g fiber/2000 o 600IU (adults 19-70)
o Fruits, veggies, whole grains o 800IU (adults >70)
o Muscle weakness, excessive sweeting,
Fats = 9cal/g diarrhea, bone pain, active/healed rickets,
osteomalacia
 Adipose tissue and abdominal cavity
 E
 Carrier of essential fatty acids and fat-soluble
o 15mg
vitamins
o Neuro deficits
 Cause the feeling of satiety
 No more than 20-35% daily caloric intake  K
 Harmful = saturated and trans o 120mcg(M),90mcg(F)
 Healthier = monounsaturated, polyunsaturated o Blood coag issues
(omega-3*)  B1 – thiamine
 Consume less than 10% cal from saturated fatty o 1.2mg(M), 1.1mg(F)
acids (~20g total fat/day in 2000cal diet) o Anorexia, fatigue, nervous irritability,
constipation, paresthesia, insomnia
Protein = 4cal/g  B6 – pyridoxine
o 1.3-1.7(M), 1.3-1.5(F)
 Tissue growth, repair, maintenance
 10-35% daily caloric needs (45-65g/d) o Seizures, dermatitis, anemia, neuropathy
 0.8-1g/kg with motor weakness, anorexia
 22 total amino acids  B12 – cobalamin
 Body can produce nonessential amino acids; body o 2.4mcg
cannot produce 9 essential amino acids o Mega.anemia, anorexia, glossitis, sore
 Complete proteins – contain all essential amino mouth/tongue, pallor, neuro problems, wt
acids loss, nausea, constipation
o Eggs  C
o Fish o 90mg(M), 75mg(F)
o Meat o Bleeding gums, loose teeth, easy bruising,
o Milk/milk prod pour wound healing, scurvy, dry itchy skin
o Poultry
 Incomplete proteins – lack one or more essential  Folate – folic acid
amino acids o 400mcg
o Grains (corn) o Impaired cell division/protein synthesis,
o Legumes (soybeans, peas) mega.anemia, anorexia, fatigue, sore
o Nuts/seeds tongue, diarrhea, forgetfulness
 Vegetarian (plant based) protein is acceptable but Mineral salts
often lacks nutrients; combination of plant proteins
can improve nutritional value  Mg, Fe, Ca
o Primary deficiency = B12; obtained from  4% total body weight
animal protein  Required for building and repair of tissues,
 Megaloblastic anemia, CNS regulation of body fluids, and assisting in other
changes functions
o Others – Vit A/D, Ca, Zn  Major minerals – require more than 100mg/d
o Ca, Cl, Mg, P, K, Na S

,  Trace elements – require minute amounts  resulting plasma glucose continues metabolic
o Chromium, Copper, Fluoride, Iodine, Fe, processes
Manganese, Molybdenum, Selenium, Zn o Often leads to negative nitrogen balance
 Some can be stored and lead to toxicity  5-9d later – body uses fat for 97% of calories to
conserve protein
o Depleted within 4-6wks
Malnutrition  Depleted fat stores – visceral proteins from organs
and plasma
 Deficit, excess, or imbalance of essential nutrients; o Rapid depletion as it is the only remaining
can occur with or without inflammation source of energy
 Prevalence in hospital settings = 30-50%  Stress response is superimposed on starvation
 Older adults based on MNA = 3-30% (higher for response
long-term/rehab settings)  Liver function becomes impaired and protein
 Primary (starvation-related) = nutritional needs are synthesis decreases  lowered plasma oncotic
not met; chronic starvation without inflammation pressure
 Secondary (chronic-disease related) = conditions o Albumin = maintains osmotic pressure of
that ave sustained mild-mod inflammation, and blood
intake does not meet tissue needs but would under o Decreases causes fluids to shift from
normal conditions (i.e., organ failure, cancer, RA, vascular space to interstitial compartment 
obesity) albumin then leaks to interstitial space
 Acute-disease related = injury related; acute o Edema forms in face/legs and often masks
disease/injury with marked inflammation (burns, muscle wasting
trauma, surgery)  Total blood vL drops = dry wrinkly skin
 Contributing factors o Na increases within cell; K and Mg increase
o Socioeconomic – limited financial resources in extracellular space
leading to food insecurity (inadequate o Na-K ump requires 20-50% of all cal.
access to quality and quantity; often leads to ingested  deficit = pump failure
choosing less nutritious/higher fat foods for  Liver loses most mass during starvation  gradual
cheap) infiltration of fat due to decreased synthesis of
o Physical illness – hospitalization, trauma, lipoproteins with death rapidly ensuring
injury; undernutrition often worsens  Inflammation
pathological condition or is exacerbated o Changes in proinflammatory and cytokines
under illness or injury if already existing result in increased protein and skeletal
(sepsis, wound drains, burn, fractures, muscle breakdown, BMR, glucose turnover,
immobilization) positive acute phase protein (CRP), and
o Malabsorption syndrome – decreased decreased negative acute phase protein
digestive enzymes or surface area to allow (albumin/prealbumin)
for proper absorption; can be caused by  Clinical manifestations
several drugs such as AB (change gut flora; o Skin – dry, patchy hair loss, brittle nails,
unable to make biotin [complex B-vit]) rashes
o Fever – each degree raises BMR by 7%; o Mouth – crusting and ulcerations around
once temp returns to normal, rate of protein tongue
breakdown and resynthesis may stay o Muscles – decreased mass/strength
increased for several weeks
o CNS – AMS, confusion, irritability
o Incomplete diets – vit deficiencies are rare in
o Speed at which this occurs depends on
developed countries but usually involve
protein intake, caloric value, illness and pt
multiple vit when present; resected TI
age
impaired absorption of fat-soluble vitamins
o Delayed wound healing
and gastrectomy pt often need B12
injections o Impaired phagocytosis
o Drug-nutrient interactions – incompatibilities o Susceptibility to infection (B/T-cells are both
or altered drug effectiveness can lead to impaired)
malabsorption; decreased taste and o Anemia due to lack of iron/folic acid (building
appetite, nausea blocks of RBCs)
 Lab studies
o Serum albumin – 1/2life of 20-22d; poor
indicator of nutrition since it lags by ~2wks
Pathophysiology of Starvation
o Prealbumin – 1/2life of 2d; good indicator of
 Initially – body uses carbs (glycogen) to meet recent/current nutritional status
metabolic needs; found in liver/muscles  Alb/prelab.are both negative acute
o Totally depleted within 18hr phase proteins
 Next – body converts skeletal protein to glucose for  Liver decreases synthesis of these
energy; alanine and glutamine are the first aminos during inflammation
used in gluconeogenesis (liver formation of glucose)  Low/below normal levels can
indicate inflammation

, o CRP – positive acute phase proteins; o Neuro – decreased reflexes, tremor,
increases during inflammation confusion, irritability, syncope
o High CRP + low alb/prealb = inflammation o MS – decreased mass and tone, bow-
o Elytes change legged, knock-knees, chest deformity,
o RBC and HgB indicate anemia level prominent bony structures
o Total lymphocyte = decreases with o Anthropometric measures – ht, wt, girth,
malnutrition; calculated by %lymph times BMI, waist circumference/hip-to-waist ratio
total WBC  Arm-demi span = unable to obtain
o LFTs may increase standing height  midline at
o Fat/water-soluble vitamins decrease suprasternal notch to web between
 Steatorrhea = low fat-soluble levels middle and ring fingers
 Diagnosis of malnutrition – determined by body Nutritional Assessment
comp, thorough history of wt loss, intake, measures
of functional status  Anthropometric measurements
o Wt/ht
o BMI
Nursing Assessment
o Rate of wt change
 Subjective data o Amount of wt loss
o Past health history – severe burns, traumas, o Midarm muscle circumference and skinfold
hemorrhage, draining, fractures, renal/liver thickness (most reflective of body fat = over
disease, cancer, malabsorption syndrome, bicep/tricep, below scapula, above iliac
RA crest, over upper thigh)
o Medications (*chemo, corticosteroids, diet  Physical exam
pills, herbs) o Appearance
o Sx or other treatments o Muscle mass/strength
o Functional health (smoking/drinker) o Dental and oral health
o Nutritional-metabolic – wt changes or  Health history
problems, changes in appetite, typical o Personal and family
intake, dry mouth, dysphagia o Acute/chronic illnesses
o Elimination patters (urine and stool) o Medications
o Activity levels o Cognitive status
o Cognitive-perceptual – pain in mouth,  Diet history
paresthesia, loss of position and vibratory o Chewing/swallowing ability
sense o Changes in appetite or taste
o Role-relationship – change in family/financial o Intake
status o Availability of food
o Sexual-reproductive – amenorrhea,  Lab data
impotence o Glucose
o Intentional or unintentional wt loss? o Elytes
 More than 5% over 6mo = critical o Lipid panel
indicator o BUN
 <5% = 0 o Albumin, Prealbumin, CRP
 5-10% = 1
 Functional status
 >10% = 2
o ADLs
 Objective
 Katz Index, Lawton Scale
o General appearance
o Handgrip
o Eyes – pale/red/gray (Bitot’s spots)
o Performance test (timed gait, chair test)
conjunctiva, dry/split cornea, fissured eyelid
corners Nursing Diagnoses
o Skin – dry, brittle, sparse hair, color
changes, alopecia, scaly lips, fever blisters,  Impaired nutritional status
cheilosis, decreased tone/elasticity  Impaired nutritional intake
o Respiratory – decreased RR, vital capacity,  Fluid imbalance
crackles or weak cough  Risk for impaired tissue integrity
o CV – increased/decreased HR, drop in BP,
Planning
dysrhythmias
o GI – glossitis, hypertrophic/atrophic papillae,  Goals = obtain appropriate wt, consume adequate
cavities, absent/loose teeth, discolored calories on diet, have no AE related to malnutrition
enamel, bleeding gums, ulcers, or nutritional therapies
distended/tympanic abdomen, ascites,
hepatomegaly, decreased bowel sounds, Implementation
steatorrhea  Health promotion

, o Teach/reinforce healthy eating patterns o Milkshakes, puddings, Ensure/Boost
o MyPlate – half fruit/veggies, half  Enteral Nutrition (EN)
grains/protein, small dairy o Delivered directly into GI tract; must be
 Balance calories functional
 Enjoy food but eat less o Anorexia, orofacial fractures, head/neck
 Avoid oversizing cancer, neuro or psych conditions, extensive
 Consume more fruits, veggie, whole burns
grain, 1%/fat-free milk o Wide variety; most are lactose free and 1-
 Half plate = F/V 2cal/mL (standard = 1-1.5cal/mL)
 Switch to fat-free/low-fat dairy  More calorie dense = less water
 Half grains = whole grains  Less water = lower osmolality
 Eat less solid fat, added sugar, salt, o No high Na for CV prob; no high fat for short
fatty meats bowel/ileocecal resection
 Compare sodium in foods o EN with protein greater than 16% =
 Drink water supplemental fluids through feeding tube or
 Acute care PO if able
o ID pt with malnutrition and implement o Continuous or intermittent feeding via pump
appropriate therapies  Critically ill = continuous
o Increased stress = more calorie demands  Pt improving or at home = bolus
o Malnourished pt may need several weeks of o Depends on
therapy before having sx  Anticipated length of use
o Record daily I&O and wt  Risk of aspiration
o PO = obtain daily calorie count and diet  Pt clinical status
diary 3d at a time for healthful eating pattern  Adequate digestion/absorption
reinforcement  Pt anatomy
 High cal, high protein  OG/NG and Nasointestinal Tubes
o Oral/hand hygiene o Short-term feedings (<4wk)
o Add oral liquid supplements with med admin o Nasoduodenal/jejunal = transploric tubes;
to contribute adequate consumption require feeding below pyloric sphincter
o Appetite stims may be necessary  Decreases risk of regurgitating
 Ambulatory Care gastric content into esophagus +
o Teach about cause of undernourishment and aspiration
how to avoid it o Polyurethane or silicone feeding tubes =
o Assess ability to follow instructions, previous long and thin, flexible; decreased risk for
eating habits, religious preferences, income, damage from long placement
resources, state of current health o Stylet = comatose p tbc swallow is not
o Ensure proper f/u (home health nurses, required
outpatient dietician)  Increased risk for perforation
o Smaller tubes are easily clogged, require
Evaluation flushing before//after med admin, GRV is
 Achieve and maintain optimal body wt harder to check, vomiting/coughing can
 Consume well-balanced diet occlude tube
 No AE related to malnutrition  Gastrostomy/Jejunostomy Tubes
 Maintain optimal physical functioning o Extended times (>4wks)
o Functional, intact GI tract
o PEG = esophageal lumen has to be wide
enough to fit endoscope
Geriatrics  Radiologically placed = fewer risks
than surgically placed
 Low/fixed income
o J-Tube = chronic reflux and reduced risk of
 Changes in taste/saliva prod
aspiration; endo/laparoscopically placed
 Dysphagia
o G-J Tube = simultaneous decompression
 Dementia
 Poor wound healing, pressure injuries, infection, and small bowel feeding
decreased strength  **Know which port is gastro and
 Ensure proper protein and adequate vitD which is jejunal
 Consult with social worker for post-discharge if pt is o Most enteral feedings can begin within 24hr
unable to obtain food for themselves of surgical placement; otherwise PEG
feedings begin within 4hr
Specialized Feedings o Safety – aspiration, dislodged tubes,
accidental removal
 Oral Feeding
o Admin in adjunct to PO meals; do not use as Nursing Management – Enteral Nutrition
meal replacement
o Admin as snacks between meals  Maintaining EN Infusion