GUIDE FOR STUDYING FOR TEST 3 Disclaimer: The following information is only a guide for studying. Be sure to read the assigned chapters, review the chapter slides, and review notes taken during class. Additional materials that review the content related to Test 3 include: *Recordings of the lectures Chapter 13: Nutrition Care and Assessment Describe how disease and its treatment can impact nutritional status and how malnutrition can impact disease. Illnesses and there treatment may lead to malnutrition by: o Reducing Food Intake o Impairing digestion or absorption o Altering Metabolism o Altering Excretion o Malnutrition over or under can lead to malnutrition o Hospital malnutrition occurs in 40-60% of patients hospitalized with acute illnesses Identify members of the health care team who have unique roles in nutrition care of patients. Physicians/ Nurse Practitioners- Write diet orders, also include referrals for nutrition assessment and dietary counseling. Registered Nurses-Screen, assess, develop care plans, provide direct nutrition care and education. Responsible for admin tube and IV feedings. In facilities that do not employ registered dietitians, nurses assume much of the nutrition care. Registered Dietitians- provide medical nutrition therapy(MNT), which includes assessing nutritional status/assessment, diagnose nutritional problems,
Transcript
GUIDE FOR STUDYING FOR TEST 3
Disclaimer: The following information is only a guide for studying. Be sure to read the assigned chapters, review the chapter slides, and review notes taken during class.
Additional materials that review the content related to Test 3 include:*Recordings of the lectures
Chapter 13: Nutrition Care and Assessment
Describe how disease and its treatment can impact nutritional status and how malnutrition can impact disease.
Illnesses and there treatment may lead to malnutrition by:o Reducing Food Intakeo Impairing digestion or absorptiono Altering Metabolismo Altering Excretiono Malnutrition over or under can lead to malnutritiono Hospital malnutrition occurs in 40-60% of patients hospitalized with acute
illnesses
Identify members of the health care team who have unique roles in nutrition care of patients.
Physicians/ Nurse Practitioners- Write diet orders, also include referrals for nutrition assessment and dietary counseling.
Registered Nurses-Screen, assess, develop care plans, provide direct nutrition care and education. Responsible for admin tube and IV feedings. In facilities that do not employ registered dietitians, nurses assume much of the nutrition care.
Registered Dietitians- provide medical nutrition therapy(MNT), which includes assessing nutritional status/assessment, diagnose nutritional problems, develop nutrition care plans, provide nutrition counseling/education, plan and improve menus. May also manage food and cafeteria services in healthcare institutions.
Registered Dietitic Technicians- Assists RD in implementing and monitoring of nutrition services.
Other Professionals-Pharmacists, speech therapists, social workers, occupational therapist, certified laboratory specialist, PCA’s..- can alert dieticians or nurses on nutritional problems.
Identify risks for malnutrition.
To identify risk of nutrition a nutrition screening is conducted within 24hrs of a patients admission, and routinely every 7-14 days.
Describe each of the five components of the nutrition care process (i.e. nutrition screening, assessment, diagnosis, intervention, and monitoring/evaluation).
Nutrition Screening- A tool for quickly identifying patients most likely to be at risk for malnutrition.
o Allows for prevention strategies and early intervention. Identifies need for complete nutrition assessments.
Assessment-involves the collection and analysis of health-related data in order to identify specific nutrition problems and their underlying causes.
o Info may be obtained from medical record, physical examination, lab analysis, medical procedure, interviews.
Diagnosis- includes specific nutrition problem, etiology or cause, and signs and symptoms that provide evidence of the problem.
o EX: unintentional weight loss(the problem), related to insufficient kcaloric intake(the etiology or cause), evidenced by a 10 pound weight loss in the past few months(sign or symptom)
Intervention-May include counseling or education about appropriate dietary and lifestyle practices, a change in meds or other treatment, or adjustments in meals. To be successful intervention should consider an individuals food habits lifestyles, and personal habits.
Monitoring and Evaluation- patients progress should be monitored closely, and updated assessment data or diagnoses may require adjustments in goals or outcome measures. The nutrition care plan must be flexible enough to adapt to new situations.
Describe each of the four components of nutrition assessment and the limitations of each.
Medical History- Includes family history. May also reveal genetic susceptibilities for diseases that can potentially be prevented with dietary and lifestyle changes.
Medication and Supplement History- A number of meds can have detrimental effects on nutrition status, and some dietary components can alter absorption or metabolism of drugs.
Personal and Social History-This can influence food choices as well as a persons ability to manage health and nutrient problems. Ex: cultural/religious beliefs, financial concerns, individuals who live alone, tobacco and illegal drugs.
Food and Nutrition History- A detailed account of persons dietary practices. It includes info of food intake, lifestyle habits, food allergies. This includes a 24 hour food recall, and a survey about food choices.
Explain the advantages and disadvantages of each tool to determine food intake and eating habits.
24-hour dietary recall- guided interview of what a patient has consumed in the last 24 hrs.
o Advantages: results are not dependent on literacy, interview occurs after food is consumed so does not influence dietary choices, quick method, does not require reading/writing
o Disadvantage: Relies on memory, underestimation/overestimations of food is common, food items that cause embarrassment may be omitted, data from a single day is not accurate, seasonal variations may not be addressed, skill of interviewer affects outcome.
Food Frequency Questionnaire-Written survey of food consumption during a specific period of time
o Advantages: Process examines long-term food intake, so day-to-day/seasonal variability should not affect results, method does not influence food choices, inexpensive
o Disadvantage: relies on memory, food lists often only includes common foods, serving sizes are often difficult for respondent to evaluate without assistance, calculated nutrient intakes are may not be accurate, food list for general population are of limited value in special populations, method not effective for short-term changes in food.
Food Record- Written account of food consumed during a specific period.o Advantages: does not rely on memory, recording foods as consumed
improves accuracy, process is useful for controlling intake of foodso Disadvantages: recording process influences food intake,
underreporting/portion size errors are common, time-consuming, requires literacy/ability to see, seasonal changes in diet may not be taken into account.
Direct Observation- observation of meal trays or shelf inventories before and after eating, possible only in residential facilities.
o Advantages: does not rely on memory, does not influence food intake, can be used to evaluate acceptability of a prescribed diet.
o Disadvantages: possible only in residential situations, is labor intensive.Chart on pg.387
Identify the amount of weight loss over specified periods of time that indicate risk of malnutrition. (NUMBERS)
> 2% in 1 week > 5% in 1 month > 7.5% of weight loss in 3 months > 10% of weight loss in 6 months
chart bottom of pg.392
Compare and contrast the use of percent ideal body weight and percent usual body weight in adults. (NUMBERS)
%UBW- 85-95%, %IBW- 80-90% Risk of mild malnutrition %UBW- 75-84%, %IBW-70-79% Risk Of Moderate malnutrition
%UBW- <75, %IBW- <70% Risk of severe malnutrition***UBW is more effective than IBW for interpreting weight changes that occur in underweight, overweight, or obese individuals.***
Chart bottom pg. 391
Using the quick method, calculate ideal body weight. (NUMBERS)
Females: 100lbs + 5 lbs for every inch over 60” Males: 106lbs + 6 lbs for every inch over 60”
Discuss the pros and cons of tests used for the evaluation of serum protein status.
Albumin- most abundant serum proteino Insensitive index of early malnutrition due to long half-life of 14-20 dayso Slow to react to changes in health statuso May reflect chronic malnutrition(PEM)- albumin levels remain normal for
a long period despite significant protein depletion, and levels fall only after prolonged malnutrition.
o Albumin is not a sensitive indicator of effective treatment Transferrin- An iron transport protein and its concentration responds to iron
status, PEM, and various illnesses.o More sensitive marker with an 8-10 day half-lifeo Dependent on iron status
Prealbumin/Retinol Binding Protein- decrease rapidly during PEM and respond quickly to improved protein intakes. These proteins are very sensitive.
o More expensive than albumin so not routinely included during nutrition assessment.
o Use is limited b/c they are affected by a number of different factors such as metabolic stress, zinc deficiency, and various medical conditions.
Identify the physical signs of malnutrition.
Hair: dull, brittle, dry, corkscrew hair Eyes: pale membranes, spots, dryness, night blindness Lips: dry, cracked, sore in corners of lips Mouth and Gums: bleeding gums, smooth or magenta tongue, poor taste sensation Skin: poor wound healing, dry, rough, lack of fat, bruising/bleeding, pale Nails: ridged nails, spoon shaped, pale Other: dementia, peripheral neuropathy. Swollen glands, bowed legs
Chart on bottom pg.395
Discuss fluid imbalance and its effect on weight and blood test results.
Edema- signs include: weight gain, facial puffiness, swelling limbs, and abdominal distention.
o May indicate malnutrition, cardiovascular disease, renal/liver disease. Dehydration- signs include: thirst, dry skin mouth, reduced skin tension, dark
colored urine with low volume. Occurs more rapidly in Infants and elderly.o May be caused by fever, sweating, vomiting, diarrhea, diuresis, or burns
Chapter 14: Nutrition Intervention and Diet-Drug Interactions
Describe methods of nutrition intervention, including counseling for behavior change.
Food and/or nutrient delivery- Providing appropriate nutrients via foods, supplements, and nutrition support
Nutrition Education- Providing tailored nutrition information to increase knowledge and skills
Nutrition counseling- providing assistance in developing goals and plans for behavior changeChart on bottom pg.404
State the definitions of diet prescription, diet manual, and medical nutrition therapy.
Diet Prescription- MDs and NPs prescribe diets for patients; RDs and RNs can ask for modification or clarification of diets.
Diet Manuel- Describes the foods included and excluded on modified diets, the rationale for use of each diet, and sample menus
Medical Nutrition Therapy(MNT)- Nutrition care; includes assessing nutritional status, diagnosing nutrition problems, devising diet plans, and providing education/counseling
Differentiate between regular and modified diets.
Regular Diet(standard or house diet)- diet that includes all foods and meets the nutrient needs of healthy persons
Modified diet(therapeutic diet)- diet adjusted to meet medical needs. Contains foods altered in texture, consistency, or nutrient content or that includes or omits specific foods.
Differentiate between foods allowed on clear liquid and full liquid diets.
Clear Liquid diet- contains clear fluids or foods that are liquid at room temp and leave minimal residue in the colon. Provides fluids and electrolytes. Includes:
o Strained orange juiceo Flavored gelatino Ginger aleo Coffee/tea
o Bouilliono Flavored gelatino Apple/grape juiceo Soft drinks
Chart on pg.411 Full Liquid diet- opaque and transparent liquids/semi-liquids. Deficient in energy
Describe the components and uses of a diet progression.
Diet Progression- Progress diet from clear liquids to regular diet as tolerated.Ex: pt given clear liquids and then gradually weaned onto beverages or other solid foodsEx: diet progresses from smaller meals to larger meals
Explain the different ways in which drugs and diet can interact, and identify specific examples of each as shown on slides
Drugs can alter Food Intake by:o reducing appetiteo increasing appetiteo Interfering with tasteo Causing/reducing nausea and vomitingo Causing mouth dryness, inflammation, lesions
Drugs can alter nutrient absorption by:o Changing acidity of stomacho Changing GI transit timeo Damaging intestinal mucosao Competing for carriers/absorption siteso Binding with nutrients
Diet can alter drug absorption by:o Changing acidity in the stomacho changing gastric emptying rateo competing for carriers/absorption siteso binding with drugs
Drugs can alter Nutrient Metabolism by:
o Inhibiting or enhancing activity needed for nutrient metabolismo Competing for enzymes due to being a structural analogo Altering hormones
Diet can alter drug metabolism by:o Inactivating enzymes needed for drug’s metabolism, thus increasing blood
concentrations od drug toxicityo Acting as structural analogs
Drugs can alter nutrient excretion by:o Reducing nutrient reabsorptiono Increasing nutrient reabsorption in the kidneyso Causing diarrhea and vomiting
Diet can alter drug excretion by:o Decreasing urinary excretion which increases drug toxicityo Increasing urinary excretion which increases drug excretiono Changing urinary pH which can increase or decrease drug excretion
Diet-Drug Interactions & Toxicityo Increasing side-effectso Increasing drug action to excessive levels
Ex: Tyramine is a food component and if combined with MAO inhibitors it can be fatal.Ex: caffeine enhances effect of amphetamines, but limits effects of barbiturates.
Chapter 15: Enteral and Parenteral Nutrition Support
Describe characteristics of standard formulas, elemental formulas, specialized formulas, and modular formulas.
Standard Formulas: also called polymeric formulaso Provided to individuals who can digest and absorb nutrients w/out
difficulty. They contain intact proteins extracted from milk or soybeans (called protein isolates) or a combo of such proteins
o The carbohydrates sources include hydrolyzed cornstarch, glucose polymers (such as maltodextrin and corn syrup solids), and sugars. A few commercial formulas, called blenderized formulas, are produced from a mixture of whole foods such as chicken, vegetables, fruits, and oil, along with some added vitamins and minerals
Elemental Formulas: also called hydrolyzed, chemically defined, or monomeric formulas
o Prescribed for patients who have compromised digestive or absorptive functions
o Contains proteins and carbohydrates that have been partially or fully broken down to fragments that require little (if any) digestion
o The formulas are often low in fat and may provide fat from medium-chain triglycerides (MCT) to ease digestion and absorption
Specialized Formulas: also called disease-specific or specialty formulaso Designed to meet the specific nutrient needs of patients with particular
illnesseso Products have been developed for individuals w/ liver, kidney, and lung
diseases; glucose intolerance; severe wounds; and metabolic stresso Generally expensive and their effectiveness is controversial
Modular Formulas:o Created from individual macronutrient preparations called modules, are
sometimes prepared for patients who require specific nutrient combinations to treat illnesses
o Vitamin and mineral preparations are also included in these formulas so that they can meet all of a person’s nutrient needs
o In some cases one or more modules are added to other enteral formulas to adjust their nutrient composition
Explain factors that should be considered in selecting an appropriate formula.
Formula is selected after careful assessment of the patient’s medical problems, fluid & nutrition status, and ability to digest and absorb nutrients. The formula chosen should meet the patient’s medical and nutrient needs w/ the lowest risk of complications and the lowest cost
The vast majority of patients can use standard formula but a person w/ functional, but impaired GI tract may require an elemental formula. Factors that influence formula selection include:
o Nutrient and energy needs: as w/ patients consuming regular diets, an adjustment in macronutrient & energy intakes may be necessary for tube-fed patients. For ex. Pt’s with diabetes may need to control carb intake, critical care pt’s may have high protein and energy requirements, and pt’s w/ chronic kidney disease may need to limit their intakes of protein and several minerals
o Fluid Requirements: High nutrient needs must be met using the volume of formula a patient can tolerate. If fluids are restricted, the formula should have adequate nutrient content and energy density to provide the required nutrients in the volume prescribed
o The need for fiber modifications: the choice of formulas is narrower if fiber intake needs to be high or low. Formulas that provide fiber may be helpful for managing diarrhea, constipation, or hyperglycemia in some patients; other patients may need to avoid fiber due to an increased risk of bowel obstruction
o Individual tolerances (food allergies and sensitivities): most formulas are lactose free b/c many patients who need enteral formulas have some degree of lactose intolerance. Many formulas are also gluten free and can accommodate the needs of individuals w/ celiac disease (gluten sensitivity)
Describe how enteral formulas are used orally as supplemental nutrition, and ways to help patients accept oral formulas.
Patients who are weak or debilitated may find it easier to consume oral supplements than to consume meals
A patient who can improve nutrition status w/ supplements may be able to avoid the stress, complications, and expense associated w/ tube feedings
Hospitals usually stock a variety of nutrient-dense formulas, milkshakes, fruit drinks, puddings, gelatin desserts, and snack bars to provide to patients who are at risk of becoming malnourished
When a pt. uses an oral supplement, taste becomes an important consideration Allowing patients to sample different products & select the ones they prefer helps
to promote acceptance Other ways to help pt accept oral formula:
o Serve supplements attractively. For ex, a formula offered in a glass on an attractive plate may be more appealing than a formula served from a can w/ an unfamiliar name
o Try keeping the formula in an ice bath so that it is cool and refreshing when the pt. drinks it
o If the pt. finds the smell unappealing, it may help to cover the top of the glass w/ plastic wrap or a lid, leaving just enough room fro a straw
o For pt’s w/ little appetite, offer the formula or snack food in small amounts that are easy to tolerate, and serve it more frequently during the day
o Provide easy access, so keep the supplement close to the pt. bed where it can be reached w/ little effort and w/in sight so the pt. is reminded to consume it
o If the pt. stops enjoying a particular product, suggest an alternative Oral supplements are sold in pharmacies and grocery stores for home use; ex:
ensure, boost, and carnation instant breakfast These are used sometimes as convenient meal replacements or supplements by
healthy individuals
Describe characteristics of candidates for tube feedings.
Severe swallowing disorders Impaired motility in the upper GI tract GI obstructions and fistulas that can be bypassed w/ a feeding tube Certain types of intestinal surgeries Little to no appetite for extended periods, especially if the patient is malnourished Extremely high nutrient requirements Mechanical ventilation Mental incapacitation due to confusion, neurological disorders, or coma Contraindications for tube feedings include severe GI bleeding, high-output
fistulas, intractable vomiting or diarrhea, complete intestinal obstruction, and severe malabsorption
Several clinical studies have suggested that tube feedings are not always effective in some of the patient populations in which they are routinely used; thus the decision to use tube feedings should be considered in light of the most recent research evidence
Describe the appropriate techniques to prepare formulas to prevent contamination.
Hands should be carefully washed before handling formulas and feeding containers. Some facilities require that nonsterile gloved be worn whenever formulas are handled. The following steps can reduce the risk of contamination for open feeding systems:
o Before opening a can of formula, clean the lid w/ a disposable alcohol wipe and wash the can opener w/ detergent and hot water. If you do not use the entire can at one feeding, label the can w/ the date and time it was opened
o Store opened cans or mixed formulas in clean, closed containers. Refrigerate the unused portion of formula promptly. Discard unlabeled or improperly labeled containers and all opened containers of formula that are not used w/in 24 hours
o Hang no more than an 8-hr supply of formula ( or a 4-hr supply for newborn infants) when using liquid formula from a can. Formulas prepared from powders or modules should hang no longer than 4 hrs. Discard any formula that remains, rinse out the feeding bag and tubing, and add fresh formula to the feeding bag
o Use a new feeding container and tubing (except for the feeding tube itself) every 24 hrs
o For closed feeding systems, the hang time should be no longer than 24-48 hrs. Contamination is more likely w/ the longer time periods
Describe the different ways formulas can be administered to patients.
When preparing a tube feeding:o Discuss w/ patient and familyo Check initial placement w/ X-rayo Monitor its position throughout the dayo Elevate the upper body during and after feeding: elevate to a 30-45 degree
angle during the feeding and for 30-60 minutes after the feeding to prevent aspiration
Intermittent Feedings: delivering relatively large amounts of formula several times per day, has more side effects
o Best tolerated when they are delivered into the stomach (not the intestine)o Generally, a total of about 250-400 milliliters of formula is delivered over
30-45 minutes using a gravity drip method or an infusion pumpo Due to the relatively high volume of formula delivered at one time,
intermittent feedings may be difficult for some patients to tolerate, and the risk of aspiration may be higher than w/ continuous feedings
o An advantage is that they are similar to the usual pattern of eating and allow the patient freedom of movement between meals
o May start w/ 60-120 milliliters at the initial feedings and be increased by 60-120 milliliters at each feeding until the goal volume is reached
Continuous Feedings: delivered slowly and at a constant rate over a period of 8-24 hours
o Are used to deliver intestinal feedings and are generally recommended for critically ill patients b/c the slower delivery rate may be easier to tolerate
o May also be recommended for patients who cannot tolerate intermittent feedings
o An infusion pump is required to ensure accurate and steady flow rates; consequently, the feedings can limit the patients freedom of movement and are also more costly
o Usually start at rates of about 40-60 milliliters per hour and be raised by 20 milliliters per hour until the goal rate is reached
Bolus Feedings: rapid delivery of a large volume of formula into the stomach (250 to 500 milliliters over 5-15 minutes)
o May be given every 3-4 hrs using a syringeo Convenient for patients and staff b/c they are rapidly administered, do not
require an infusion pump, and allow greater independence for patientso Can cause abdominal discomfort, nausea, and cramping in some patients,
and the risk of aspiration is greater than with the other methods of feedingo For these reasons, bolus feedings are used only in patients who are not
critically ill If the patient cannot tolerate an increased rate of delivery, the feeding rate is
slowed until the person adapts. Goal rates can usually be achieved over 24-36 hours. In some patients, formula delivery can be started at the goal rate immediately
Slower rates of delivery may be better tolerated by critically ill patients, when concentrated formulas are used, or in patients who have undergone an extended period of bowel rest due to surgery, intestinal disease, or the use of parenteral nutrition
Discuss meeting water needs with tube feedings.
May adults require about 2000 mL of water daily Additional water is required in pt’s w/ severe vomiting, diarrhea, fever, excessive
sweating, high urine output, fistula drainage, high-output ostomies, blood loss, or open wounds. Fluids may be restricted in persons w/ kidney, liver, or heart disease
Enteral formulas contain about 70-85% water or about 700-850 mL of water per liter of formula
In addition to the water in formulas, water can be provided by flushing water separately through the feeding tube
Water flushes are also conducted to prevent feeding tubes from clogging; the tubes are flushed w/ about 30mL of warm water about very 4 hrs during continuous feedings and before and after each intermittent feeding
The water used for routine flashes should be included when estimating fluid intakes
Describe guidelines for delivering medications through feeding tubes.
Continuous feedings are ordinarily stopped for 15 minutes before and after medication administration so that the components of enteral formulas do not interfere w/ the medications absorption
Some meds may require a longer formula-free interval; for example, feedings need to stopped for at least one hour before and after administering phenytoin, a med that controls seizures. In such cases, the formula’s delivery rate needs to be increased so that the correct amount of formula can be delivered
Meds are a major cause of diarrhea that frequently accompanies tube feedings. Diarrhea is associated w/ the administration of sorbitol-containing meds, laxatives, and some types of antibiotics
The high osmolality of many liquid meds can also cause diarrhea, so dilution of hypertonic meds may be helpful
Guidelines:o Do not mix meds w/ enteral formulas. Do not mix meds togethero Before administering meds, ensure that the feeding tube is placed
correctly, that it is not clogged, and that the gastric residual volume is not excessive
o Position the patient in a semi-upright position (30 degrees) or higher) to prevent aspiration
o Flush the feeding tube w/ 30 mL of warm water before and after administering a med. When more than one med is administered, flush the feeding tube w/ water btw meds
o Use liquid forms of meds whenever possible. Dilute viscous or hypertonic fluid meds w/ at least 30 mL of water before administering them through the feeding tube
o If tablets are used, crush tablets to a fine powder and mix w/ about 30mL of warm water before administering
Identify major causes of tube feeding complications and ways to prevent or correct them. For full list of preventions/corrections go to table 15-2 on page 446 Aspiration of formula
o Caused by inappropriate tube placement, delayed gastric emptying and excessive sedation
o Prevented/corrected by ensuring correct placement of feeding tube; elevating head of bed during and after feeding, decreasing formula delivery rate if gastric residual volume is excessive, consider using intestinal feedings in high-risk patients; minimize use of meds that cause sedation
Clogged feeding tubeo Caused by excessive formula viscosity and improper administration of
medso Prevented/corrected by ensuring tube is appropriate, flushing tube w/
water etc; using oral, liquid, or injectable meds whenever possible, flush tubing w/ water before and after each med is given etc
Constipationo Caused by inadequate dietary fiber, dehydration, lack of exercise and
medication side effecto Prevented/corrected by using a formula w/ appropriate fiber content;
providing additional fluids; encouraging walking and other activities if appropriate; consult physician about minimizing or replacing meds that cause constipation
Diarrheao Caused by medication intolerance, infection in GI tract, formula
contamination, excessively rapid formula administration and lactose or gluten intolerance
o Prevention/corrected by diluting hypertonic meds before administering; consulting a physician about specific diagnosis & appropriate treatment; review safety guidelines for formula preparation; decreased formula delivery or use continuous feedings; use lactose-free or gluten-free formula in pts. w/ intolerances
Fluid & Electrolyte imbalanceso Caused by diarrhea, inappropriate fluid intake or excessive losses,
inappropriate insulin, diuretic, or other therapy, inappropriate nutrient intake
o Prevented/corrected by monitoring daily weights, intake and output records; ensuring that med doses are appropriate; use a formula w/ appropriate nutrient content
Nausea and vomiting, crampso Caused by Delayed stomach emptying, formula intolerance, medication
intolerance and response to disease or disease treatmento Prevented/corrected by decreasing formula delivery rate or use continuous
feedings; ensure that formula is at room temp; consult physician about replacing meds that are poorly tolerated; consider use of meds that control nausea and vomiting
Describe the appropriate way to transition from tube feedings to table foods. (NUMBER) After the pt’s condition improves, the volume of formula can be tapered off as the
patient gradually shifts to an oral diet Individuals using continuous feedings are often switched to intermittent feedings
initially Swallowing function may be evaluated in some patients before oral feedings
begin Pt’s receiving elemental formulas may begin the transition by using a standard
formula, either orally or via tube feeding
If the pt. has not consumed lactose for several weeks, a diet w/ minimal lactose may be better tolerated
Oral intake equal to 2/3 of nutrient needs before discontinuing the tube feeding
Describe the advantages and potential risks of parenteral nutrition. Advantage is short term support Peripheral veins can be damaged by overly concentrated solutions and phlebitis
can occur which is characterized by redness, swelling, and tenderness at the infusion site. To prevent this keep osmolarity of solution to less than 900 milliosmoles per liter
Compare and contrast the composition, purpose, and uses of peripheral parenteral nutrition versus TPN by central vein.
Peripheral Parenteral Nutrition o Delivered using only the peripheral veinso Often used in patients who require short-term nutrition support (about 7-
10 days) and do not have high nutrient needs or fluid restrictionso The use of PPN is not possible if the peripheral veins are too weak to
tolerate the procedure and in some cases clinicians must rotate venous access sites to avoid damaging veins
Total Parenteral Veino Most patients meet their nutrient needs using the larger, central veins,
where blood volume is greater and nutrient concentrations do not need to be limited
o B/c the central veins carry a large volume of blood, the parenteral solutions are rapidly diluted
o Used for long-term supporto For patients w/ high nutrient needs or fluid restrictions
Explain the proper way to administer TPN solutions.
Only qualified physicians can place catheters directly into central veins. Patients may be awake for the procedure and given local anesthesia
Make sure to explain procedure to patient beforehand To reduce the risk of complications, nurses should use aseptic techniques when
inserting catheters, changing tubes, or changing a dressing that covers the catheter site
Describe the appropriate way to transition from parenteral feedings to enteral feedings. (NUMBER)
The patient must have adequate GI function before they can be tapered off and enteral feedings begin
Clear liquids are generally the first foods offered and are given in small amounts to determine tolerance
Later feedings include beverages and solid foods that are unlikely to cause discomfort
Once about 65-75 percent of nutrient needs can be provided enterally, the intravenous infusions may be discontinued
Describe the metabolic complications associated with parenteral nutrition.
Hyperglycemiao Most often occurs in patients who are glucose intolerant, receiving excess
energy or dextrose, or undergoing severe metabolic stresso Provide insulin w/ feedings or decrease dextroseo Dextrose infusions are generally limited to less than 5 mg per kilo of body
weight per minute so that the carbohydrate intake does not exceed the maximum glucose oxidation rate
Hypoglycemiao Occurs when parenteral nutrition is interrupted or discontinued of if
excessive insulin is giveno In patients at risk such as young infants, infusions may be tapered off over
several hours before discontinuation or infuse dextrose at the same time that the parenteral solution is discontinued
Hypertriglyceridemiao May develop in critically ill patients who cannot tolerate the amount of
lipid emulsion suppliedo Patients at risk include those w/ sever infection, liver disease, kidney
failure, or hyperglycemia and those using immunosuppressant or corticosteroid meds
o If blood triglyceride levels exceed 500 mg per deciliter, lipid infusions should be reduced or stopped
Refeeding Syndromeo Severely malnourished patients who are fed aggressively may develop thiso It is characterized by electrolyte and fluid imbalance & hyperglycemiao These effects occur b/c dextrose infusions raise circulating insulin levels,
which promote anabolic processes that quickly remove phosphate, potassium, and magnesium from the blood
o Generally develops within two weeks of beginning parenteral infusionso To prevent this start parenteral infusions slowly and carefully monitor
electrolyte and glucose levels May lead to liver failure Gallbladder disease
o Sludge builds up, leading to gallstoneso Give meds to stimulate gallbladder or remove gallbladder
Metabolic bone diseaseo Lowers bone densityo Alterations in calcium, phosphorus, magnesium & sodium metabolism
Identify the benefits of home nutrition support.
Current medical technology allows for the safe administration of nutrition support in home settings, and insurance coverage often pays a substantial portion of the costs
Medical equipment providers and home infusion companies can provide the supplies, enteral formulas or parenteral solutions, and necessary services for home nutrition care
Patients using these services can continue to receive specialized care while leading normal lives
Chapter 16: Nutrition in Metabolic and Respiratory Stress
Describe the body's immune system and hormonal responses to stress and related clinical signs and symptoms.
The stress response is mediated by several hormones, which are released into the blood soon after injury
The catecholamines (epinephrine & norepinephrine) often called fight or flight hormones, stimulate heart muscle, raise blood pressure and increase metabolic rate
Epinephrine also promotes glucagon secretion from the pancreas, prompting the release of nutrients from storage
Glucagon increases the breakdown of glycogen, triglycerides and amino acids Cortisol increases breakdown of glycogen, triglycerides, and amino acids. Over
time, depletes protein throughout body (muscle wasting); causes insulin resistance; reduces immunity
Aldosterone & antidiuretic hormone maintain blood volume by increasing reabsorption of sodium and water via the kidneys
Explain how hypermetabolic illnesses affect nutrition status and lead to malnutrition.
A disruption in the body’s chemical environment due to the effects of disease or injury
Metabolic stress is characterized by changes in metabolic rate, heart rate, blood pressure, hormonal status, and nutrient metabolism
Can result from uncontrolled infections or extensive tissue damage, such as deep, penetrating wounds or multiple broken bones
Describe how hypermetabolism and protein depletion associated with stress can lead to multiple organ failure.
Hypermetabolism: a higher than normal metabolic rate
Hypermetabolism and negative nitrogen balance can lead to wasting, which may impair organ function and delay recovery
Explain how severe stress worsens nutritional status.
Severe stress worsens nutritional status and can cause diseases: Chronic Obstructive Pulmonary Disease
o Chronic bronchitis: chronic inflammation & mucus secretion in main airways
o Emphysema: progressive damage to bronchioles & alveoli Symptoms: difficulty breathing, dyspnea, coughing, fatigue, muscle wasting,
decreased physical activity, weight loss; may lead to heart/respiratory failure Causes: smoking and genetics Treatment: smoking cessation, meds such as bronchodilators, corticosteroids,
oxygen therapy, physical activity to increase endurance and LBM, high-calorie, high-protein diet (unless overweight); small frequent meals; adequate liquids btw meals; liquid supplements
Goals: prevent progression of disease; manage symptoms, maintain healthy weight and lean body mass, prevent or correct malnutrition
Respiratory failureo Impaired gas exchange leads to: o hypoxemia (low blood O2) and hypoxia (low tissue O2) cell death,o hypercapnia (high blood CO2) acidosis,o cyanosis, headache, confusion, arrhythmias, comao Treatment varies according to cause:o Oxygen support,o Mechanical ventilation if needed,o Diuretics for fluid in lungs; anti-inflammatory drugs,o Adequate energy & protein- but not excessive!,o Enteral or parenteral nutrition
Identify immediate concerns about stress and possible measures that might be taken by the health care team.
In patients hospitalized w/ acute stress, initial treatments include restoring fluid and electrolyte balances and treating infections and wounds
Metabolic stress can result in hypermetabolism, negative nitrogen balance, hyperglycemia, and wasting. The objectives of nursing care are to preserve muscle tissue, maintain immune defenses, and promote healing
To determine energy needs for acute stress, RMR values may be modified using disease-specific stress factors
Micronutrient needs may be increased during acute stress Enteral and parenteral nutrition support or oral supplements may be used to help
meet the high nutrient needs of acutely stressed patients
Identify the goals of nutrition support following stress.
Initial goal: correct fluid and electrolyte imbalance with IV solution Additional goals
o Address hypermetabolism, negative nitrogen balance, & hyperglycemiao Preserve lean tissues and promote immunity & healingo Deliver adequate calories & protein
Balance overfeeding and underfeeding Permissive underfeeding? – recommended for critically ill obese
patients. So you will underfeed them by reducing calories. Be fed only 70% of their energy needs
The method of delivering calories and nutrients depends on the GI function and nutrient needs:
o High-calorie, high-protein diet w/ an oral supplemento Enteral nutrition: for these feedings started in the first 24-48 hours after
hospitalization are associated w/ fewer complications and shorter hospital stays compared w/ delayed feedings
o If enteral nutrition is not possible, malnourished patients may receive parenteral nutrition support soon after admission to the hospital. In previous healthy patients, potential parenteral nutrition support may be withheld during the first seven days of hospitalization to avoid the risk of infectious complications
Using quick methods, estimate the energy, protein, and fluid needs of patients. (NUMBERS)
Energyo 30 kcal/kg/day for weight maintenance (typically a range of 25 to 35
kilocalories/kilogram as seen in the book) For weight loss: 20-25 kcal/kg/day For weight gain: 35-40 kcal/kg/day For critically ill patients: 20-30 kcal/kg/day
Proteino Healthy adult: 0.8 g/kg/dayo Elderly person: 0.8 to 1.0 g/kg/dayo Critically ill person: 1.2 to 2.0 g/kg/dayo Severe burns 2.0 to 3.0 g/kg/day
Fluidso 30 ml/kg body weight or 1 ml/kcal of RMR
Describe how refeeding syndrome develops. Occurs when aggressively feeding a malnourished person Results in electrolyte and fluid imbalances and hyperglycemia Increased electrolyte requirements due to preexisting deficiencies and rapid
intracellular uptake
Describe how a practitioner would decide on the nutrient and best route of delivery of nutrients following stress.
A practitioner would decide by looking at the patient. It’s subjective and all depends on the patients condition
Chapter 17: Nutrition and Upper GI Disorders List conditions that may interfere with chewing and swallowing.
o Dry mouth (Xerostomia): caused by reduced salivary flow Side effect of many medications Associated with many diseases and disease treatments
Ex: antidepressants, antihistamines, antihypertensives, antieoplastics, bronchodilators, and other medications
Sjögren’s syndrome: condition that directly affects salivary gland function Radiation therapy may permanently damage salivary function
o Dysphagia Oropharyngeal: involves mouth and pharynx; muscles in mouth and
tongue propel bolus through the pharynx into esophagus Neuromuscular disorder upsets swallowing reflex or impairs the
mobility of the muscles involved with swallowing Inhibits transfer of food from the mouth and pharynx to the
esophagus Common in elderly people Frequently follows strokes
Esophageal: swallowing, peristalsis forces the bolus through the esophagus, and lower esophageal sphincter relaxes to allow passage of the bolus into the stomach
Interferes with passage of materials through esophageal lumen and into the stomach, and usually caused by an obstruction in the esophagus or a motility disorder
Obstruction can be caused by stricture (abnormal narrowing), tumor, or compression of esophagus surrounding tissues
Prevents passage of solid foods Motility disorder hinders passage of solids and liquids Achalasia: most common motility disorder; degenerative nerve
condition affecting the esophagus; characterized by impaired peristalsis and incomplete relaxation of the lower esophageal sphincter when swallowing
May cause malnutrition, weight loss, and risk of dehydration If aspiration occurs, it may cause choking, airway obstruction, or
respiratory infections, including pneumonia***Table 17-2
o Gastroesophageal disease Describe the nutrition therapy required for patients with chewing difficulties.
o Foods should be easy-to-manage textures and consistencieso Physically modified foods/beverages
Explain how to improve acceptance of pureed foods.o Help to stimulate appetite by preparing favorite foods and foods with pleasant
smells. Enliven food flavors with aromatic spices and seasonings
o Substitute brightly colored vegetables for white vegetables; for example, replace mashed potatoes with mashed sweet potatoes. If serving more than one vegetable, place contrasting colors side by side or swirl the two together
o Shape pureed and ground foods so they resemble traditional dishes; for example, meats can be flattened to form a patty or rounded to resemble meatballs. Use food molds to restore slurried breads and pureed meats to their traditional shapes
o Try layering ingredients so that the food looks like a fancy casserole or popular hors d’oeuvre. For example, food items can resemble lasagna, moussaka, tamales, or sushi
o Use attractive plates and silverware to improve the visual appeal of a meal. Colorful garnishes can add interest and eye appeal
Discuss the dangers, signs, and diet therapy for dysphagia.o Dangers
Dehydration Malnutrition and weight loss Aspiration Airway obstruction Choking Respiratory infections
o Signs Oropharyngeal Dysphagia
Inability to initiate swallowing, coughing during or after swallowing (due to aspiration), and nasal regurgitation
Gurgling noise after swallowing, hoarse or “wet” voice, or speech disorder
Esophageal Dysphagia Main symptom: sensation of food “sticking” to esophagus after it
is swallowedo Diet Therapy (Table 17-3)
Level 1: Pureed Foods should be pureed or well mashed, homogeneous and
cohesive For patients with moderate to severe dysphagia and poor oral or
chewing ability Ex: cream of wheat, slurried muffins/pancakes, plain or vanilla
yogurt, well-mashed bananas, pureed meat or poultry, chocolate pudding, pureed carrots or green beans
Avoid dry breads and cereals, oatmeal, fruit yogurt, cheese, peanut butter, nuts and seeds, beverages with pulp
Level 2: Mechanically Altered Foods should be moist, cohesive, and soft textured and should
easily form a bolus For patients with moderate to severe dysphagia Some chewing ability is required
Ex: moist oatmeal, cornflakes, moist pancakes/muffins, well-cooked pasta with moist meatballs and meat sauce, baked potato with gravy
Avoid dry or coarse foods; breads and cereals with nuts/seeds/dried fruits, hard-cooked eggs, pizza, sliced cheese cabbage, celery, brussel sprouts
Level 3: Dysphagia Advanced Foods should be moist and in bite-sized pieces when swallowed;
foods with mixed textures included For patients with mild dysphagia and adequate chewing ability Ex: cereal with milk, moist eggs/pancakes, chicken noodle soup,
moistened crackers/bread, fruit yogurt, coffee or tea, fresh fruit (pealed) or berries
Avoid fruit with skin/seeds/stringy textures, popcorn, chewy candies, breads and cereals with nuts/seeds/dried fruit, corn and clam chowders
Liquid Consistencies Thin: watery fluids; may include milk, coffee, tea, juices,
carbonated beverages Nectarlike: fluids thicker than water that can be sipped through a
straw; may include buttermilk, eggnog, tomato juice, cream soups Honeylike: fluids that can be eaten with a spoon but do not hold
their shape; may include honey, some yogurt products, tomato sauce
Spoon-thick: thick fluids that must be eaten with a spoon and can hold their shape; may include milk pudding, thickened apple sauce
Identify the potential causes, symptoms, & consequences of GERD as well as the medical treatments & lifestyle changes for managing it.
o Causes (Figure 17-1 & Table 17-4) Weak lower esophageal sphincter High stomach pressures Inadequate acid clearance from esophagus Obesity Pregnancy Hiatal hernia: portion of the stomach protrudes above the diaphragm Medications Nasogastric tubes in tube feedings Large meals
o Symptoms Heartburn or acid indigestion
o Consequences Reflux esophagitis: occurs when gastric acid remains in the esophagus
long enough to damage the esophageal lining Severe and chronic inflammation may lead to esophageal ulcers with
bleeding
Esophageal stricture may be caused due to healing and scaring of ulcerated tissue that may narrow the inner diameter of the esophagus
Slowly progressive dysphagia for solid foods; swallowing occasionally becomes painful
Pulmonary disease may occur if gastric contents aspirate into the lungs Chronic reflux associated with Barrett’s esophagus (condition in which
damaged cells are gradually replaced by cells that resemble those in gastric or intestinal tissue
Such changes increase the risk of developing esophageal cancer May damage tissues in the mouth, pharynx, and larynx, resulting in
eroded tooth enamel, sore throat, cough, laryngitiso Medical Treatments
Proton-pump inhibitors (PPI) used for rapid healing and as a maintenance treatment
Histamine-2 receptor blockers (H2 blockers) Antacids: used to relieve occasional heartburn for short-term
Not necessarily appropriate because they may cause nutrient deficiencies when used long-term
Surgery in severe cases that are unresponsive to medication and lifestyle changes (fundoplication)
o Lifestyle Changes Consume only small meals and drink liquids between meals so that the
stomach does not become overly distended, which can exert pressure on the lower esophageal sphincter
Limit foods that weaken lower esophageal sphincter pressure or increase gastric acid secretion; these include chocolate, fried and fatty foods, spearmint and peppermint, coffee (caffeinated and decaffeinated), and tea
During periods of esophagitis, avoid foods and beverages that may irritate the esophagus, such as citrus fruits and juices, tomato products, garlic, onions, pepper, spicy foods, carbonated beverages, and very hot or very cold foods (depending on indiv. tolerances)
Avoid eating bedtime snacks or lying down after meals; meals should be consumed at least 3 hours before bedtime
Reduce nighttime reflux by elevating the HOB on 6-inch blocks, inserting a foam wedge under the mattress, or propping pillows under the head and upper torso
Avoid bending over and wearing tight-fitting garments; both can cause pressure in the stomach to increase, heightening the risk of reflux
Avoid cigarettes and alcohol; both relax the lower esophageal sphincter Avoid using NSAIDS such as aspirin, naproxen, and ibuprofen, which can
damage the esophageal mucosa Explain the appropriate nutrition therapy for individuals with: vomiting, reflux
esophagitis, hiatal hernia, gastritis, and ulcers.o Vomiting
Eat and drink slowly Small meals
Clear cold beverages Dry starchy foods (crackers, pretzels) Foods cold or at room temperature
o Reflux esophagitis (inflammation in the esophagus related to the reflux of acidic stomach contents)
Refer to lifestyle changes of GERDo Hiatal hernia
Refer to lifestyle changes of GERD o Gastritis
In asymptomatic cases, no dietary adjustments needed If pain/discomfort is present, patient should avoid irritating foods and
beverages (alcohol, coffee, cola beverages, spicy foods, and fried/fatty foods)
If consumption increases pain or causes nausea and vomiting, food intake should be avoided 24 – 48 hours
o Ulcers Correct nutrient deficiencies Avoid consumption at least 2 hours before bedtime Avoid dietary items that increase acid secretion or irritate the GI lining
(alcohol, coffee, caffeine-containing beverages, chocolate, and pepper) Avoid large meals Don’t smoke
List ways to prevent indigestion.o Eat small mealso Avoid spicy or fatty foodso Avoid foods that may trigger symptoms
Discuss common nutritional problems and related therapies associated with gastric surgery.
o Common nutritional problems Dumping Syndrome
Rapid gastric emptying Related therapy
Limit meal size Limit amount of food reaching the intestine Eat slowly Reduce foods that increase hypertonicity Eat fiber-rich foods Limit amount of fluid included in meals Avoid foods and beverages that are high in sugar
Fat malabsorption Deficiencies of fat-soluble vitamins & some minerals Related therapy
Supplemental pancreatic enzymes sometimes provided to improve fat digestion
Bone disease Malabsorption of calcium and vitamin D
Osteoporosis and osteomalacia Related therapy
Calcium and vitamin D supplements Anemia
Impaired iron & vitamin B12 absorption due to decreased hydrochloric acid
Related therapy Iron and vitamin B12 supplements
Describe the post-gastrectomy diet. (Table 17-6)o Progress to 6-8 small meals & snacks/dayo Avoid sweets and sugarso Soluble fiber to delay stomach emptyingo Avoid irritating foodso May need to avoid milk products (lactose intolerance)o Liquids between meals
Describe the major types of bariatric surgeries, potential candidates for surgery, and post-surgery nutrition therapy to prevent or manage complications.
o Major types of bariatric surgeries (Figure 17-3) Partial gastrectomy (Vertical Sleeve Gastrectomy) Gastric bypass
Small gastric pouch constructed that reduces stomach capacity and restricts meal size
Pouch connected directly to jejunum (causes significant nutrient malabsorption)
Usually permanent surgery Clinical studies suggest that it is more effective than gastric
banding Gastric banding (LAP band)
Gastric pouch created using fluid-filled inflatable band; adjusting band’s fluid level can tighten or loosen the band and alter size of opening to the rest of the stomach
Smaller opening slows the pouch-emptying rate and prolongs sense of fullness after a meal
Fully reversible procedureo Potential candidates for surgery
Severe obese (BMI 35-40 with severe weight-related problems or BMI >40)
Obese accompanied with weight-related problems (diabetes mellitus, hypertension, or debilitating osteoarthritis)
Patient should have attempted nonsurgical weight-loss measures (ex: dietary adjustments, exercise, medications, and behavior modification) prior to seeking surgery
o Post-surgery nutrition therapy to prevent/manage complications First two days: only sugar-free, noncarbonated clear liquids and low-fat
broths provided
4 – 6 weeks: initial liquid diet high in protein, low sugars and fat; followed by pureed foods and then solid food; 3 – 6 small meals/day
Protein intake recommended 1 – 1.5 grams/kg body weight Advance 3 – 6 small meals/day Recommend vitamin-mineral supplement
Vitamin B12, vitamin D, iron and calcium Avoid foods that may obstruct the gastric outlet [doughy/sticky breads and
pasta products, melted cheese, fibrous vegetables (asparagus, celery), foods with seeds, peels or skins, nuts, popcorn, and tough chewy meats]
Control food portions; avoid foods high in sugars; and consume liquids between meals to avoid dumping syndrome
Chapter 18: Nutrition and Lower GI Disorders Discuss the causes and treatments of constipation and diarrhea.
multiple sclerosis Pregnancy Medications and dietary supplements (opiate-containing
analgesics, tricyclic antidepressants, anticonvulsants, calcium channel blockers, aluminum-containing antacids, iron and calcium supplements)
Treatments Gradual increase in fiber intake to at least 25 grams/day High-fiber diet (wheat bran, fruits, and vegetables) Fiber supplements Laxatives (increase stool weight, increase water content of stool, or
stimulate peristaltic contractions) Consuming adequate fluids (1.5 – 2 liters/day) Enemas and suppositories (distend and stimulate the rectum or
lubricate stool) Medications (prokinetic agents for severe constipation that
stimulate colonic contractions)o Diarrhea
Causes May be induced by infections, medications, or dietary substances Inadequate fluid reabsorption in the intestines Osmotic diarrhea: unabsorbed nutrients or other substances attract
water to the colon and increase fecal water content; the usual
causes include high intakes of poorly absorbed sugars (such as sorbitol, mannitol, or fructose), lactase deficiency (which causes lactose malabsorption), and ingestion of laxatives that contain magnesium or phosphates
Secretory diarrhea: fluid secreted by the intestines exceeds the amount that can be reabsorbed by intestinal cells
Foodborne illnesses Intestinal inflammation Irritating chemical substances
Motility disorders Treatments
Correcting underlying problem Antibiotics for intestinal infections Different drug prescribed if medication is the problem Certain foods omitted from diet that may be responsible Bulk-forming agents; psyllium (Metamucil) and methylcellulose
(Citrucel) can help reduce liquidity of stool Antidiarretics may be prescribed in chronic diarrhea Probiotics (infectious diarrhea) BRAT diet (bananas, rice, applesauce, and toast) Low fiber, fat, sugar alcohols and fructose foods Lactose and caffeine free foods
Identify foods likely to produce gas.o High-fiber dietso Carbohydrates
Fructose Sugar alcohols Beans Some grains and potatoes
Identify the causes and effects of bacterial overgrowth.o Causes
Impaired intestinal motility Reduced gastric secretions Atrophic gastritis, use of acid-suppressing medications, and some
gastrectomy procedureso Effects
Disrupts fat digestion and absorption (may lead to fat malabsorption) May develop fat-soluble vitamin (A, D, E) & vitamin B12 deficiencies
Describe symptoms of lactose intolerance and the appropriate nutrition therapy.o Symptoms
Diarrhea and gaso Nutrition Therapy
Lactose-free diet May not need to avoid lactose completely; may be able to tolerate
some dairy products Enzymes prior to consuming dairy products
Identify the cause of malabsorption in pancreatitis and the appropriate nutrition therapies for acute and chronic pancreatitis.
o Acute pancreatitis Causes
Gallstones, alcohol abuse, high triglycerides, toxins Nutrition therapies
Pain control and IV hydration Withhold food and fluids until patient is pain free and no longer
experiences vomiting or nausea Nutrient supplements needed until food intake can meet nutritional
Nutrition therapies Remove pancreas NPO Small frequent meals Low fat diet Avoid alcohol and cigarettes
Discuss the impact of cystic fibrosis on nutrition status, and how it is treated.o Effect on nutrition status
Lung disease Hypermetabolism may cause impaired nutrition status due to
greater energy cost of labored breathing and anorexia Pancreatic disease
Malabsorption of protein, fat and fat-soluble vitamins Thickened pancreatic secretions obstruct pancreatic ducts May lead to diabetes or glucose intolerance
Salt losses in sweat (increases risk of dehydration)o Treatment
Energy needs = 120 – 150% of DRI High-calorie, high-fat foods Frequent meals and snacks Pancreatic enzyme replacement Liberal use of table salt
Describe characteristics of a gluten-restricted diet for the treatment of celiac disease. (Table 18-6)
o Gluten-free diet for life No wheat, rye, barley (oats) Avoid lactose-containing foods in lactose deficiency is suspected Check food labels
Differentiate between the characteristics of Crohn's disease and ulcerative colitis, and their appropriate nutrition therapy.
o Crohn’s disease (Table 18-8) Characteristics
May occur anywhere in intestine Most cases involve ileum and/or large intestine
May lead to nutrient malabsorption Tissue damage, bleeding, diarrhea Lesions may develop along intestine, with normal tissue separating
affected regions Ulcerations, fissures, and fistulas Loop of intestines may become matted together Malnutrition due to poor food intake, malabsorption, nutrient
losses, surgical resections that shorten small intestine If the ileum is affected, bile acids may become depleted, causing
malabsorption of fat, fat-soluble vitamins, calcium, magnesium, and zinc (the minerals bind to the unabsorbed fatty acids)
Possible vitamin B12 deficiency Anemia due to bleeding, inadequate absorption of nutrients (iron,
folate, and vitamin B12) involved in cell formation, or metabolic effects of chronic illness
Anorexia due to abdominal discomfort Nutrition therapy
Aggressive dietary management Specific measures depend on functional status of GI tract High calorie, high protein diets to prevent malnutrition or promote
healing Oral supplements to promote weight gain and increase energy
intake Vitamin and mineral supplements (calcium, iron, magnesium, zinc,
folate, vitamin B12, vitamin D) Tube feedings
o Ulcerative colitis Characteristics
Involves large intestine Tissue damage, rectal bleeding, diarrhea, constipation, abdominal
pain Erosion or ulceration affects mucosa and submucosa In early stages, the mucosa appears reddened and swollen;
advanced stages may feature mucosal atrophy, thin colon walls, and, in some cases, colon dilation
Frequent, urgent bowel movements that are small in volume and contain blood and mucus
Weight loss, fever, and weakness Anemia, dehydration, and electrolyte imbalances in severe cases
Nutrition therapy Restore fluid and electrolyte balances
Adequate protein, energy fluid, and electrolytes need to be provided)
Describe the nutrition therapy for irritable bowel syndrome.o Gradually increase fiber intake from food or supplements to relieve constipation
and improve stool bulko Psyllium supplementation (patients with constipation)o Specific to each patiento Peppermint oil (under investigation)
Differentiate between diverticulosis and diverticulitis and the appropriate nutrition therapy for each.
o Diverticulosis Presence of pebble-sized herniations (outpockets) in intestinal mucosa Prevalence increases with age High-fiber diet can be preventative May need to avoid nuts, popcorn, & seeds Nutrition therapy
Treatment necessary only if symptoms exist Increase fiber intake to relieve constipation Avoid nuts, seeds, and popcorn
o Diverticulitis Inflammation or infection Most common complication of diverticulosis Persistent abdominal pain, fever, alternating constipation and diarrhea Nutrition therapy
Antibiotics, pain medication Clear liquid diet or bowel rest Surgery
Describe important components of nutrition support for ostomies.o Depends on length of colon removed and portion of ileum that remainso Dietary adjustments are individualized according to surgical procedure and
symptomso Colostomy & ileostomyo Temporary or permanento Chew food thoroughly to prevent obstructionso Foods that cause unpleasant odors
