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NUTRITION FOR NURSING I

Nutrition for Nursing REVIEW MODULE EDITION 7.0

Contributors Honey C. Holman, MSN, RN

Debborah Williams, MSN, RN

Sheryl Sommer, PhD, RN, CNE

Janean Johnson, MSN, RN, CNE

Brenda S. Ball, MEd, BSN, RN

Peggy Leehy, MSN, RN

Consultants Penny Fauber, PhD, MS, BSN, RN

Maria Sheilla Membrebe, MSN/Ed., RN, ONC, CMSRN, CBN

INTELLECTUAL PROPERTY NOTICE ATI Nursing is a division of Assessment Technologies Institute®, LLC.

The reproduction of this work in any electronic, mechanical or other means, now known or hereafter

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property rights or licenses held by Assessment Technologies Institute, LLC, one of its affiliates, or by

third parties who have licensed their materials to Assessment Technologies Institute, LLC.

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II CONTENT MASTERY SERIES

IMPORTANT NOTICE TO THE READER Assessment Technologies Institute, LLC, is the publisher of this publication. The content of this publication is for

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NUTRITION FOR NURSING USER’S GUIDE III

User’s Guide Welcome to the Assessment Technologies Institute® Nutrition for Nursing Review Module Edition 7.0. The mission of ATI’s Content Mastery Series® Review Modules is to provide user-friendly compendiums of nursing knowledge that will: ● Help you locate important information quickly. ● Assist in your learning efforts. ● Provide exercises for applying your nursing knowledge. ● Facilitate your entry into the nursing profession as a

newly licensed nurse.

This newest edition of the Review Modules has been redesigned to optimize your learning experience. We’ve fit more content into less space and have done so in a way that will make it even easier for you to find and understand the information you need.

ORGANIZATION This Review Module is organized into units covering principles of nutrition, clinical nutrition, and alterations in nutrition. Chapters within these units conform to one of two organizing principles for presenting the content. ● Nursing concepts ● Nutritional considerations for specific disorders

Nursing concepts chapters begin with an overview describing the central concept and its relevance to nursing. Subordinate themes are covered in outline form to demonstrate relationships and present the information in a clear, succinct manner.

Nutritional considerations for specific disorders chapters include an overview describing nutritional needs of clients who have the given disorder. These chapters cover assessments and data collection, nutritional guidelines, nursing interventions, and complications, if applicable.

ACTIVE LEARNING SCENARIOS AND APPLICATION EXERCISES

Each chapter includes opportunities for you to test your knowledge and to practice applying that knowledge. Active Learning Scenario exercises pose a nursing scenario and then direct you to use an ATI Active Learning Template (included at the back of this book) to record the important knowledge a nurse should apply to the scenario. An example is then provided to which you can compare your completed Active Learning Template. The Application Exercises include NCLEX-style questions, such as multiple-choice and multiple-select items, providing you with opportunities to practice answering the kinds of questions you might expect to see on ATI assessments or the NCLEX. After the Application Exercises, an answer key is provided, along with rationales.

NCLEX® CONNECTIONS To prepare for the NCLEX, it is important to understand how the content in this Review Module is connected to the NCLEX test plan. You can find information on the detailed test plan at the National Council of State Boards of Nursing’s website, www.ncsbn.org. When reviewing content in this Review Module, regularly ask yourself,

“How does this content fit into the test plan, and what types of questions related to this content should I expect?”

To help you in this process, we’ve included NCLEX Connections at the beginning of each unit and with each question in the Application Exercises Answer Keys. The NCLEX Connections at the beginning of each unit point out areas of the detailed test plan that relate to the content within that unit. The NCLEX Connections attached to the Application Exercises Answer Keys demonstrate how each exercise fits within the detailed content outline. These NCLEX Connections will help you understand how the detailed content outline is organized, starting with major client needs categories and subcategories and followed by related content areas and tasks. The major client needs categories are: ● Safe and Effective Care Environment

◯ Management of Care ◯ Safety and Infection Control

● Health Promotion and Maintenance ● Psychosocial Integrity ● Physiological Integrity

◯ Basic Care and Comfort ◯ Pharmacological and Parenteral Therapies ◯ Reduction of Risk Potential ◯ Physiological Adaptation

An NCLEX Connection might, for example, alert you that content within a unit is related to:

● Basic Care and Comfort ◯ Nutrition and Oral Hydration

■ Manage the client who has an alteration in nutritional intake.

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IV USER’S GUIDE CONTENT MASTERY SERIES

QSEN COMPETENCIES As you use the Review Modules, you will note the integration of the Quality and Safety Education for Nurses (QSEN) competencies throughout the chapters. These competencies are integral components of the curriculum of many nursing programs in the United States and prepare you to provide safe, high-quality care as a newly licensed nurse. Icons appear to draw your attention to the six QSEN competencies.

Safety: The minimization of risk factors that could cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others.

Patient-Centered Care: The provision of caring and compassionate, culturally sensitive care that addresses clients’ physiological, psychological, sociological, spiritual, and cultural needs, preferences, and values.

Evidence-Based Practice: The use of current knowledge from research and other credible sources, on which to base clinical judgment and client care.

Informatics: The use of information technology as a communication and information-gathering tool that supports clinical decision-making and scientifically based nursing practice.

Quality Improvement: Care related and organizational processes that involve the development and implementation of a plan to improve health care services and better meet clients’ needs.

Teamwork and Collaboration: The delivery of client care in partnership with multidisciplinary members of the health care team to achieve continuity of care and positive client outcomes.

ICONS Icons are used throughout the Review Module to draw your attention to particular areas. Keep an eye out for these icons.

This icon is used for NCLEX Connections.

This icon indicates gerontological considerations, or knowledge specific to the care of older adult clients.

This icon is used for content related to safety and is a QSEN competency. When you see this icon, take note of safety concerns or steps that nurses can take to ensure client safety and a safe environment.

This icon is a QSEN competency that indicates the importance of a holistic approach to providing care.

This icon, a QSEN competency, points out the integration of research into clinical practice.

This icon is a QSEN competency and highlights the use of information technology to support nursing practice.

This icon is used to focus on the QSEN competency of integrating planning processes to meet clients’ needs.

This icon highlights the QSEN competency of care delivery using an interprofessional approach.

This icon appears at the top-right of pages and indicates availability of an online media supplement, such as a graphic, animation, or video. If you have an electronic copy of the Review Module, this icon will appear alongside clickable links to media supplements. If you have a hard copy version of the Review Module, visit www.atitesting.com for details on how to access these features.

FEEDBACK ATI welcomes feedback regarding this Review Module. Please provide comments to [email protected].

As needed updates to the Review Modules are identified, changes to the text are made for subsequent printings of the book and for subsequent releases of the electronic version. For the printed books, print runs are based on when existing stock is depleted. For the electronic versions, a number of factors influence the update schedule. As such, ATI encourages faculty and students to refer to the Review Module addendums for information on what updates have been made. These addendums—which are available in the Help/FAQs on the student site and the Resources/eBooks & Active Learning on the faculty site— are updated regularly and always include the most current information on updates to the Review Modules.

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NUTRITION FOR NURSING TABLE OF CONTENTS V

Table of Contents

NCLEX® Connections 1

UNIT 1 Principles of Nutrition CHAPTER 1 Sources of Nutrition 3

Carbohydrates and fiber 3

Proteins 4

Lipids 4

Vitamins 5

Minerals and electrolytes 7

Water 9

Phytonutrients 9

CHAPTER 2 Ingestion, Digestion, Absorption, and Metabolism 11

CHAPTER 3 Nutrition Assessment/Data Collection 15

Obesity 16

CHAPTER 4 Guidelines for Healthy Eating 21

CHAPTER 5 Food Safety 27

CHAPTER 6 Cultural, Ethnic, and Religious Influences 31

CHAPTER 7 Nutrition Across the Lifespan 37

Pregnancy and lactation 37

Infancy 39

Childhood 41

Adolescence 43

Adulthood and older adulthood 44

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VI TABLE OF CONTENTS CONTENT MASTERY SERIES

NCLEX® Connections 49

UNIT 2 Clinical Nutrition CHAPTER 8 Modified Diets 51

CHAPTER 9 Enteral Nutrition 55

CHAPTER 10 Total Parenteral Nutrition 61

NCLEX® Connections 65

UNIT 3 Alterations in Nutrition CHAPTER 11 Barriers to Adequate Nutrition 67

CHAPTER 12 Cardiovascular and Hematologic Disorders 71

CHAPTER 13 Gastrointestinal Disorders 77

CHAPTER 14 Renal Disorders 85

CHAPTER 15 Diabetes Mellitus 89

CHAPTER 16 Cancer and Immunosuppression Disorders 93

Active Learning Templates A1 Basic Concept A1

Diagnostic Procedure A3

Growth and Development A5

Medication A7

Nursing Skill A9

System Disorder A11

Therapeutic Procedure A13

Concept Analysis A15

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NUTRITION FOR NURSING NCLEX® CONNECTIONS 1

NCLEX® Connections

When reviewing the following chapters, keep in mind the relevant topics and tasks of the NCLEX outline, in particular:

Health Promotion and Maintenance AGING PROCESS Provide care and education for the newborn, infant, and toddler client from birth through 2 years.

Provide care and education for the adult client ages 65 years and over.

ANTE/INTRA/POSTPARTUM AND NEWBORN CARE: Provide prenatal care and education.

HEALTH PROMOTION/DISEASE PREVENTION: Educate the client on actions to promote/maintain health and prevent disease.

HEALTH SCREENING: Perform targeted screening assessments.

Basic Care and Comfort NUTRITION AND ORAL HYDRATION Consider client choices regarding meeting nutritional requirements and/or maintaining dietary restrictions, including mention of specific food items.

Initiate calorie counts for clients.

Apply knowledge of mathematics to client nutrition.

Physiological Adaptation FLUID AND ELECTROLYTE IMBALANCES: Manage the care of the client with a fluid and electrolyte imbalance.

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2 NCLEX® CONNECTIONS CONTENT MASTERY SERIES

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NUTRITION FOR NURSING CHAPTER 1 SOURCES OF NUTRITION 3

UNIT 1 PRINCIPLES OF NUTRITION

CHAPTER 1 Sources of Nutrition Nutrients absorbed in the diet determine, to a large degree, the health of the body. Deficiencies or excesses can contribute to a poor state of health. Essential nutrients are those that the body cannot manufacture, and the absence of essential nutrients can cause deficiency diseases.

Components of nutritive sources are carbohydrates and fiber, protein, lipids (fats), vitamins, minerals and electrolytes, and water. Carbohydrates, fats, and proteins are all energy-yielding nutrients. A healthy eating pattern includes foods that provide all essential nutrients, and allows a broad assortment of food sources.

DIETARY REFERENCE INTAKES Dietary Reference Intakes (DRIs) are developed by the Institute of Medicine’s Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. ● DRIs are useful in understanding the food intake

patterns of large groups, planning nutrition program standards (Supplemental Nutrition Assistance program [SNAP]), and helping individuals.

● DRIs are comprised of the following reference values. ◯ Recommended Dietary Allowances (RDAs): The

amount of a particular nutrient that most healthy people in a similar life-stage and sex will need to decrease the risk of chronic disease.

◯ Estimated Average Requirement (EAR): The amount of a nutrient required to meet basic requirements for half of the people in a particular population. This reference is often used by researchers and policy makers, and is used to help determine RDAs.

◯ Adequate Intake (AI): The amount of a nutrient that most people in a group or population consume. This is helpful when there is not enough data to establish an RDA for a nutrient.

◯ Tolerable Upper Intake Level (UL): The upper limit on the amount of a particular nutrient, or the maximum an individual should consume. ULs are used when a nutrient is known to have adverse effects.

◯ Acceptable Macronutrient Distribution Ranges (AMDRs): The recommended percentages of intake for energy-yielding nutrients (carbohydrates, fat, protein).

● Clients can use DRIs as a guide for nutrition intake, but should also consider individual factors that increase nutrient needs (disease, injury).

Carbohydrates and fiber All carbohydrates are organic compounds composed of carbon, hydrogen, and oxygen (CHO). The main function of carbohydrates is to provide energy for the body.

● The average minimum amount (DRI) of carbohydrates needed to fuel the brain is 130 g/day for adults and children. Median carbohydrate intake is 305 g/day for males aged 20 years and older, and 228 g/day for adults, children, and females in the same age range. The AMDR for carbohydrates is 45% to 65% of calories.

● Carbohydrates provide energy for cellular work, and help to regulate protein and fat metabolism. Adequate amounts of protein in the diet creates a protein-sparing effect, which results in protein being spared from energy use to perform its other essential functions. Brain and nervous system tissue require carbohydrates for maximum effective functioning.

TYPES OF CARBOHYDRATES (1.1) Carbohydrates are classified according to the number of saccharide units making up their structure.

Monosaccharides: simple carbohydrates (glucose, fructose, and galactose) Disaccharides: simple carbohydrates (sucrose, lactose, and maltose) Polysaccharides: complex carbohydrates (starch, fiber, and glycogen)

CONSIDERATIONS ● The liver converts fructose and galactose into glucose,

which is then released in the bloodstream. This elevates blood glucose levels, which causes the release of insulin from the pancreas. With insulin production, glucose is moved out of the bloodstream into cells in order to meet energy needs.

● The body digests 95% of starch within 1 to 4 hr after ingestion. Digestion occurs mainly in the small intestine using pancreatic amylase to reduce complex carbohydrates into disaccharides.

● Glycogen is the stored carbohydrate energy source found in the liver and muscles. It is a vital source of backup energy, but is only available in limited supply.

● To maintain glucose levels between meals, glucose is released through the breakdown of liver glycogen.

● Digestible carbohydrates provide 4 cal/g of energy and make blood glucose levels more stable.

CHAPTER 1

1.1 Carbohydrates at a glance

EXAMPLE (SOURCES) FUNCTION

Monosaccharides Glucose (corn syrup), fructose (fruits), galactose (found in milk) Basic energy for cells

Disaccharides Sucrose (table sugar), lactose (milk sugar), maltose (malt sugar)

Energy, aids calcium and phosphorus absorption (lactose)

Polysaccharides

Starches (grains, legumes, root vegetables), fiber (whole grains, fruits, vegetables)

Energy storage (starches), digestive aid (fiber)

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4 CHAPTER 1 SOURCES OF NUTRITION CONTENT MASTERY SERIES

FIBER Fiber is categorized as a carbohydrate. ● Dietary fiber is the substance in plant foods that

is indigestible. Types are pectin, gum, cellulose, and oligosaccharides.

● Fiber is important for proper bowel elimination. It adds bulk to the feces and stimulates peristalsis to ease elimination.

● Fiber helps to lower cholesterol and lessen the incidence of intestinal cancers. It has also been shown to help keep blood glucose levels stable by slowing the rate of glucose absorption.

● Total fiber AI is 25 g/day for females and 38 g/day for males.

● The fermentation and metabolization of fiber in the colon provides 1.5 to 2.5 cal/g of energy, depending on the type.

Proteins Proteins are provided by plant and animal sources. They are formed by linking amino acids in various combinations for specific use by the body.

TYPES OF PROTEINS There are two types of proteins. Each is obtained from the diet in various ways.

Complete proteins , from animal sources and soy, contain sufficient amounts of all nine essential amino acids.

Incomplete proteins , generally from plant sources, can contain an insufficient number or quantity of amino acids, which limits the ability for protein synthesis. ● Complementary proteins are incomplete proteins

that, when combined, provide a complete protein. It is not necessary to consume complementary proteins at the same time to form a complete protein; instead, consuming a variety of complementary proteins over the course of the day is sufficient.

● Examples of incomplete protein pairs that provide complete protein include black beans with rice and hummus with crackers.

CONSIDERATIONS ● Proteins have many metabolic functions.

◯ Tissue-building and maintenance ◯ Balance of nitrogen and water ◯ Backup energy ◯ Support of metabolic processes

■ Nitrogen balance ■ Transportation of nutrients, other vital substances

◯ Support of the immune system ◯ Facilitating acid-base, fluid, and electrolyte balance ◯ Formation of neurotransmitters, enzymes

antibodies, peptide hormones, breast milk, mucus, histamine, and sperm

● Three main factors influence the body’s requirement for protein. ◯ Tissue growth needs ◯ Quality of the dietary protein ◯ Added needs due to illness

● The RDA of protein is 0.8 g/kg for healthy adults. Protein’s acceptable macronutrient distribution range (AMDR) for adults is 10% to 35% of total calories.

● Underconsumption can lead to protein energy malnutrition (PEM). Kwashiorkor and marasmus are two disorders caused by extreme PEM. These serious disorders are caused by a lack of protein ingestion.

● Protein provides 4 cal/g of energy.

Lipids ● The chemical group of fats is called lipids, and they are

available from many sources. ◯ Dark meat ◯ Poultry skin ◯ Dairy foods ◯ Added oils (margarine, butter, shortening, oils, lard)

● Fat is an essential nutrient for the body. It serves as a concentrated form of stored energy for the body and supplies important tissue needs.

◯ Hormone production ◯ Structural material for cell walls ◯ Protective padding for vital organs ◯ Insulation to maintain body temperature ◯ Covering for nerve fibers ◯ Aid in the absorption of fat-soluble vitamins

TYPES OF FATS Fats are divided into three categories: triglycerides, phospholipids, and sterols. Triglycerides are further comprised of fatty acids, which include saturated fatty acids and unsaturated fatty acids.

Triglycerides

Triglycerides total 95% of fat in food. They combine with glycerol to supply energy to the body, allow fat-soluble vitamin transport, and form adipose tissue that protects internal organs. ● Saturated fatty acids are solid at room temperature, and

are found primarily in animal sources. ● Unsaturated fatty acids, including monounsaturated

and polyunsaturated fatty acids, are usually from plant sources and help reduce health risks. ◯ Sources of monounsaturated fatty acids include

olives, canola oil, avocado, peanuts, and other nuts. ◯ Sources of polyunsaturated fatty acids include corn,

wheat germ, soybean, safflower, sunflower, and fish. ● Essential fatty acids, made from broken down fats,

must be supplied by the diet. Essential fatty acids, including omega-3 and omega-6, are used to support blood clotting, blood pressure, inflammatory responses, and many other metabolic processes.

Phospholipids

Phospholipids (e.g., lecithin) are important to cell membrane structure, as well as the transport of fat-soluble substances across the cell membrane.

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NUTRITION FOR NURSING CHAPTER 1 SOURCES OF NUTRITION 5

Sterols

Sterols (e.g., cholesterol) are found in the tissues of animals, and are not an essential nutrient because the liver is able to produce enough to meet needs.

If cholesterol is consumed in excess, it can build up in the tissues, causing congestion and increasing the risk for cardiovascular disease.

CONSIDERATIONS ● The AMDR for fats is approximately 20% to 35% of total

calories. 10% or less of total calories should come from saturated fat sources.

● A low intake of dietary cholesterol is associated with reduced risks of cardiovascular disease (CVD) and obesity.

● A diet high in fat is linked to CVD, hypertension, and diabetes mellitus.

◯ The exception is for children under 2 years of age, who need a higher amount of fat to form brain tissue.

◯ Conversely, a diet with less than 10% of fat cannot supply adequate amounts of essential fatty acids and results in a cachectic (wasting) state.

● The majority of lipid metabolism occurs after fat reaches the small intestine, where the gallbladder secretes concentrated bile, which acts as an emulsifier and enables the breakdown of fat down into smaller particles for digestion. At the same time, the pancreas secretes pancreatic lipase, which breaks down fat. Intestinal cells absorb the majority of the end products of digestion, with some being excreted in the feces.

◯ Very-low-density lipoproteins (VLDL) carry triglycerides to the cells.

◯ Low-density lipoproteins (LDL) carry cholesterol to the tissue cells.

◯ High-density lipoproteins (HDL) remove excess cholesterol from the cells, and transport it to the liver for disposal.

● Lipids provide 9 cal/g of energy and are the densest form of stored energy.

Vitamins Vitamins are organic substances required for many enzymatic reactions. The main function of vitamins is to be a catalyst for metabolic functions and chemical reactions.

● There are 13 essential vitamins, each having a specialized function.

● There are two classes of vitamins. ◯ Water-soluble: Vitamins C and B-complex ◯ Fat-soluble: Vitamins A, D, E, and K

● Vitamins yield no usable energy for the body, but they are needed for energy to be metabolized.

WATER-SOLUBLE VITAMINS

Vitamin C

Vitamin C (ascorbic acid) aids in tissue building and metabolic reactions (healing, collagen formation, iron absorption, immune system function). ● Vitamin C is found in citrus fruits (oranges,

lemons), tomatoes, peppers, green leafy vegetables, and strawberries.

● Stress and illness, as well as cigarette smoking, increases the need for vitamin C. Cigarette smokers are advised to increase Vitamin C intake by 35 mg/day due to increased oxidative stress and metabolic turnover.

● Severe deficiency causes scurvy, a hemorrhagic disease with diffuse tissue bleeding, painful limbs/joints, weak bones, and swollen gums/loose teeth. While scurvy can be fatal, it can also be cured with moderate doses of vitamin C for several days.

B-complex vitamins

B-complex vitamins have many functions in cell metabolism. Each one has a varied duty. Many partner with other B vitamins for metabolic reactions. Most affect energy, metabolism, and neurologic function. Sources for B vitamins almost always include green leafy vegetables and unprocessed or enriched grains.

Thiamin (B1) functions as a coenzyme in energy metabolism, promotes appetite, and assists with muscle actions through its role in nerve functioning. ● Deficiency results in beriberi (ataxia, confusion, anorexia,

tachycardia), headache, weight loss, and fatigue. ● Food sources are widespread in almost all plant and

animal tissues, especially meats, grains, and legumes.

Riboflavin (B2) works as a coenzyme to release energy from cells.

● Deficiency results in cheilosis (manifestations include scales and cracks on lips and in corners of the mouth), smooth/swollen red tongue (also called glossitis), and dermatitis of the ears, nose, and mouth.

● Dietary sources include milk, meats, and dark leafy vegetables.

Niacin (B3) aids in the metabolism of fats, glucose, and alcohol, and synthesis of steroid hormones, cholesterol, and fatty acids. ● Deficiency causes pellagra (manifestations include

sun-sensitive skin lesions, and gastrointestinal issues with impaired food digestion and excretion, as well as nutrient absorption and neurologic findings [anxiety, insomnia, confusion, paranoia]).

● Sources include meats, legumes, milk, whole grain and enriched breads and cereals.

Pyridoxine/Vitamin B6 is needed for cellular function and synthesis of hemoglobin, neurotransmitters, and niacin.

● Deficiency causes macrocytic anemia and CNS disturbances.

● High intake of supplements can cause sensory neuropathy. ● Widespread food sources include meats, grains,

and legumes.

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6 CHAPTER 1 SOURCES OF NUTRITION CONTENT MASTERY SERIES

Pantothenic acid is involved in the metabolism of carbohydrates, fats, and proteins as part of coenzyme A.

● Deficiency is extremely rare, but results in generalized body system failure.

● Rich sources include meats, whole grain cereals, dried peas and beans.

Biotin serves as a coenzyme used in fatty acid synthesis, amino acid metabolism, and the formation of glucose. ● Deficiency is rare, but results in neurologic findings

(depression, fatigue), hair loss, and scaly red rash. ● Widespread food sources include eggs, milk, and dark

green vegetables.

Folate is required for hemoglobin and amino acid synthesis, new cell synthesis, and prevention of neural tube defects in utero. (Folic acid is the synthetic form.)

● Deficiency causes megaloblastic anemia, CNS disturbances, and fetal neural tube defects (spina bifida, anencephaly). It is important that all clients of child-bearing age get an adequate amount of folate due to neural tube formation occurring early in gestation, often before a client knows they are pregnant.

● Folate occurs naturally in a variety of foods including liver, dark-green leafy vegetables, orange juice, and legumes.

Cobalamin (B12) is necessary for folate activation and red blood cell maturation. ● Deficiency causes pernicious anemia and is seen mostly

in clients who follow a strict vegan diet (B12 is found solely in foods of animal origin), and those who have an absence of intrinsic factor needed for absorption of B12.

● Sources include meat, shellfish, eggs, and dairy products.

FAT-SOLUBLE VITAMINS ● All fat-soluble vitamins have the possibility for toxicity

due to their ability to be stored in the body for long periods of time.

● Absorption of fat-soluble vitamins is dependent on the body’s ability to absorb dietary fat. Fat digestion can be interrupted by any number of conditions, particularly those that affect the secretion of fat-converting enzymes, and conditions of the small intestine. Clients who have cystic fibrosis, celiac disease, Crohn’s disease, or intestinal bypasses are at risk for deficiencies.

● Clients who have liver disease should be careful not to take more than the daily recommendations of fat-soluble vitamins, as excess is stored in the liver and adipose tissue.

Vitamin A

Vitamin A (retinol, beta-carotene) contributes to vision health, tissue strength and growth, and embryonic development. Retinoids are found in animal foods and are the active form of vitamin A. Carotenoids are found in plants and are a precursor form of vitamin A, which the body converts to the usable form as needed.

● Care should be taken when administered to pregnant clients as some forms have teratogenic effects on the fetus.

● Deficiency results in vision changes, xerophthalmia (dryness and hardening of the cornea), GI disturbances, and hyperkeratosis.

● Food sources include fatty fish, egg yolks, butter, cream, and dark yellow/orange fruits and vegetables (carrots, yams, apricots, squash, cantaloupe).

● Toxicity can result from retinoids, and is more common in clients who are taking vitamin A supplements.

1.2 Water-soluble vitamins at a glance

MAJOR ACTIONS MAJOR SOURCES DEFICIENCY

Vitamin C (ascorbic acid)

Antioxidant, tissue building, iron absorption

Citrus fruits and juices, vegetables

Scurvy, decreased iron absorption, bleeding gums

Thiamin (B1) Muscle energy, energy metabolism Meats, grains, legumes

Beriberi, headache, weight loss, fatigue

Riboflavin (B2) Assists with releasing energy from cells

Milk, meats, dark leafy vegetables

Skin eruptions, cracked lips, red swollen tongue

Niacin (B3)

Metabolism of fat, glucose, and alcohol; synthesis of fatty acids, cholesterol, and steroid hormones

Liver, nuts, legumes Pellagra, skin lesions, GI and CNS findings, dementia

Pantothenic acid Carbohydrate, fat, and protein metabolism

Meats, whole grain cereals, dried peas and beans.

Rare Generalized body system failure

Pyridoxine (B6) Cellular function, heme and neurotransmitter synthesis

Meats, grains, and legumes

Macrocytic anemia, CNS disturbances, poor growth

Folate

Synthesis of amino acids and hemoglobin, formation of fetal neural tube

Liver, green leafy vegetables, legumes

Megaloblastic anemia, CNS disturbance

Cobalamin (B12) Folate activation, red blood cell maturation

Meats, clams, oysters, eggs, dairy products

Pernicious anemia, GI findings, poor muscle coordination, paresthesia of the hands and feet

Biotin Fatty acid synthesis, amino acid metabolism, glucose formation

Eggs, milk, dark green vegetables

Rare; scaly rash, hair loss, depression, fatigue

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NUTRITION FOR NURSING CHAPTER 1 SOURCES OF NUTRITION 7

Vitamin D

Vitamin D assists in the absorption of calcium and phosphorus, and aids in bone mineralization. ● Sunlight enables the body to synthesize vitamin D

in the skin. ● Deficiency results in bone demineralization, and

extreme deficiency can cause rickets and osteomalacia. Excess consumption can cause hypercalcemia.

● Food sources include fatty fish, eggs, and fortified products (ready-to-eat cereals, milk, orange juice).

Vitamin E

Vitamin E is an antioxidant that helps to preserve lung and red blood cell membranes.

● Deficiency rare, but results in anemia and can cause edema and skin lesions in infants.

● Food sources include vegetable oils and certain nuts.

Vitamin K

Vitamin K assists in blood clotting and bone maintenance. ● Deficiency results in increased bleeding time. ● Used as an antidote for excess anticoagulants (warfarin). ● Vitamin K is found in carrots, eggs, and dark green

vegetables (spinach, broccoli, asparagus).

Minerals and electrolytes Minerals are inorganic elements, are available in an abundance of food sources, and are used at every cellular level for metabolic exchanges. Minerals are divided into major and trace.

Electrolytes are electrically-charged minerals that cause physiological reactions that maintain homeostasis. Major electrolytes include sodium, potassium, and chloride.

MAJOR MINERALS Major minerals occur in larger amounts (more than 5 g) in the body, and 100 mg or more is required through dietary sources each day. The seven major minerals are calcium, phosphorus, sodium, potassium, magnesium, chloride, and sulfur.

Sodium (Na)

MAJOR ACTIONS: Maintains fluid volume, allows muscle contractions, contributes to nerve impulses

MAJOR SOURCES: Table salt, added salts, processed foods

FINDINGS OF DEFICIENCY: Muscle cramping, memory loss, anorexia

FINDINGS OF EXCESS: Fluid retention, hypertension, disorientation

NURSING ACTIONS: Monitor level of consciousness, edema, and blood pressure.

Potassium (K)

MAJOR ACTIONS: Maintains fluid volume inside cells, muscle action

MAJOR SOURCES: Oranges, dried fruits, tomatoes, avocados, dried peas, meats, broccoli, bananas, dairy products, meats, whole grains, potato

FINDINGS OF DEFICIENCY: Dysrhythmias, muscle cramps, confusion

FINDINGS OF EXCESS: Dysrhythmia, muscle weakness, irritability, confusion, numbness in extremities

NURSING ACTIONS: Monitor cardiac status and ECG. Give oral preparations (tabs, elixirs) with meals to minimize GI irritation.

Chloride (Cl)

MAJOR ACTIONS: Assists with intracellular and extracellular fluid balance, and aids acid-based balance and digestion

MAJOR SOURCES: Table salt, added salts, processed foods

FINDINGS OF DEFICIENCY: Rare; muscle cramps, anorexia

FINDINGS OF EXCESS: Vomiting

NURSING ACTIONS: Monitor sodium levels.

1.3 Fat-soluble vitamins at a glance

MAJOR ACTIONS MAJOR SOURCES DEFICIENCY

Vitamin A Normal vision, tissue strength, growth and immune system function

Orange/yellow fruits and vegetables, fatty fish, dairy

Reduced night vision, dry/thick corneas, mucosa changes

Vitamin D Maintain blood calcium and phosphorus, aid in bone development

Fish, fortified dairy products, egg yolks, sunlight

Low blood calcium, fragile bones, rickets, osteomalacia in adults

Vitamin E Protects vitamin A from oxidation Vegetable oils, grains, nuts, dark green vegetables

Anemia, edema and skin lesions in infants

Vitamin K Essential for prothrombin synthesis, aids in bone metabolism Green leafy vegetables, eggs Increased bleeding times

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8 CHAPTER 1 SOURCES OF NUTRITION CONTENT MASTERY SERIES

Calcium (Ca)

MAJOR ACTIONS: Bones/teeth formation, blood pressure, blood clotting, nerve transmission

MAJOR SOURCES: Dairy, broccoli, kale, fortified grains

FINDINGS OF DEFICIENCY: Tetany, positive Chvostek’s and Trousseau’s signs, ECG changes, osteoporosis in adults, poor growth in children

FINDINGS OF EXCESS: Constipation, renal stones, lethargy, depressed deep-tendon reflexes

NURSING ACTIONS: Monitor ECG and respiratory status. Give PO tabs with vitamin D.

Magnesium (Mg)

MAJOR ACTIONS: Bone formation, catalyst for many enzyme reactions, nerve/muscle function, smooth muscle relaxation

MAJOR SOURCES: Green leafy vegetables, nuts, whole grains, tuna, halibut, chocolate

FINDINGS OF DEFICIENCY: Weakness, dysrhythmias, convulsions, increased blood pressure, anorexia

FINDINGS OF EXCESS: Diarrhea, nausea, muscle weakness, hypotension, bradycardia, lethargy

NURSING ACTIONS: Follow seizure precautions, and monitor level of consciousness and vital signs.

Phosphorus (P)

MAJOR ACTIONS: Energy transfer of RNA/DNA, acid-base balance, bone and teeth formation

MAJOR SOURCES: Dairy, peas, meat, eggs, legumes

FINDINGS OF DEFICIENCY: Unknown

FINDINGS OF EXCESS: Decreased blood calcium levels

NURSING ACTIONS: Evaluate the use of antacids (note type) and the use of alcohol (alcohol impairs absorption).

Sulfur (S)

MAJOR ACTIONS: A component of vitamin structure, by-product of protein metabolism

MAJOR SOURCES: Proteins

FINDINGS OF DEFICIENCY: Only seen in severe protein malnourishment

FINDINGS OF EXCESS: Toxicity does not result in any health issues

NURSING ACTIONS: Sulfur levels are not usually monitored.

TRACE MINERALS Trace minerals, also called micronutrients, are required by the body in amounts of less than 5 g, and 20 mg or less is required through dietary sources each day. The nine trace elements are iron, iodine, zinc, copper, manganese, chromium, selenium, molybdenum, and fluoride.

Iodine

Iodine is used for synthesis of thyroxine, the thyroid hormone that helps regulate metabolism. Iodine is taken up by the thyroid. When iodine is lacking, the thyroid gland enlarges, creating a goiter. Too much iodine can result in thyrotoxicosis.

● Grown food sources vary widely and are dependent on the iodine content of the soil in which they were grown.

● Seafood provides a good amount of iodine. Table salt in the U.S. is fortified with iodine, so deficiencies are not as prevalent.

● The RDA is 150 mcg for adults.

Iron

Iron is responsible for oxygen distribution to hemoglobin and myoglobin. ● The body recycles unused iron from dying red blood

cells and stores it for later use. ● Iron in food consists of two forms: heme iron found in

meat, fish, and poultry and non-heme iron found in grains, legumes, and vegetables.

● Iron supplements can cause constipation, nausea, vomiting, diarrhea, and teeth discoloration (liquid form). They can be taken with food to avert gastrointestinal manifestations, and nurses should encourage fresh fruits, vegetables, and a high-fiber diet.

● Supplements that are unneeded can become toxic. ● Vitamin C increases the absorption of iron. ● Clients during the menstruating years, older infants

and toddlers, and pregnant clients are at risk for iron deficiency anemia.

● Toxicity can occur when there is too much iron stored in the body.

Fluoride

Fluoride forms a bond with calcium and thus accumulates in calcified body tissue (bones and teeth). Water with added fluoride protects against dental cavities.

● Deficiency can result in dental caries, and increase the risk for osteoporosis.

● Toxicity can result in fluorosis, itching, and chest pain.

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NUTRITION FOR NURSING CHAPTER 1 SOURCES OF NUTRITION 9

Water Water is the most basic of nutrients. The body can maintain itself for several weeks on its food stores of energy, but it cannot survive without water/hydration for more than a few days. Water makes up the largest portion of our total body weight and is crucial for all fluid and cellular functions.

● Fluid balance is essential for optimum health and bodily function.

● The balance of fluid is a dynamic process regulated by the release of hormones.

● Water leaves the body via the kidneys, skin, lungs, and feces. The greatest elimination is through the kidneys. Other loss factors include bleeding, vomiting, and rapid respirations.

● To maintain a balance between intake and output, intake should approximate output. Healthy adults lose approximately 1000 mL of water daily through insensible losses (respirations, skin, fecal), and to get rid of metabolic wastes needs to excrete at least 500 mL of urine daily. Therefore, the minimum daily amount of water intake needed is 1,500 mL.

● Most water intake is from drinking fluids; water is also present in solid sources (lettuce, gelatin, soup, melons). Under normal conditions, the AI for adult water intake for females is 2.7 L/day, of which 2.2 L should be from fluids; and for males 3.7 L/day, of which 3 L should be from fluids.

● Additional hydration can be required for athletes, persons with fever/illness (vomiting, diarrhea), and those in hot climate conditions. Fluid replacement can occur orally, enterally, or IV.

● Young children and older adults dehydrate more rapidly. ● Assessment for proper hydration should include skin turgor,

mental status, orthostatic blood pressures, urine output and concentration, and moistness of mucous membranes.

● Thirst is a late indicator of the need for hydration, especially in older adults.

● Some individuals can have an aversion to drinking water, and should be encouraged to explore other options (fresh fruits, fruit juices, flavored gelatin, frozen treats, soups).

● Caffeinated drinks have a mild diuretic effect. However, tolerance develops in clients who regularly consume caffeinated beverages, which results in little to no effect on fluid volume.

Phytonutrients Also called phytochemicals, phytonutrients occur naturally in plants. They can have positive health effects (detoxifying the body, stimulating the immune system, promoting hormone balance, serving as antioxidants).

● They are found in fruits, vegetables, green tea, legumes, whole grains, and broccoli.

● No recommendations for intake of phytonutrients exists at this time.

Active Learning Scenario

A school nurse is conducting a nutritional class for a group of athletes. Use the ATI Active Learning Template: Basic Concept to complete this item.

RELATED CONTENT ● Describe two types of protein. ● Describe complimentary proteins. ● Describe three main factors influencing

the body’s requirement for protein.

Application Exercises

1. A nurse is educating a client who has anemia about dietary intake of iron. Which of the following is a non-heme source of iron? A. Ground beef B. Dried beans C. Salmon D. Turkey

2. A nurse is discussing foods that are high in vitamin D with a client who is unable to be out in the sunlight. Which of the following should be included in the teaching? A. 1 cup steamed long-grain brown rice B. 6 medium raw strawberries C. ½ cup boiled Brussels sprouts D. 2 large, poached eggs

3. A nurse is reviewing dietary recommendations with a group of clients at a health fair. Which of the following information should the nurse include? A. “Fats should be 5% to 15% of daily calorie intake.” B. “Make protein 10% to 35% of

total calories each day.” C. “Consume 1,500 mL of water from

liquids and solids daily.” D. “The body needs 40 mg of iron each day.”

4. A nurse is conducting a nutritional class on minerals and electrolytes. The nurse should include which of the following foods is a major source of magnesium? A. Tuna B. Tomatoes C. Eggs D. Oranges

5. A nurse is discussing health problems associated with nutrient deficiencies with a group of clients. Which of the following conditions is associated with a deficiency of vitamin C? (Select all that apply.) A. Dysrhythmias B. Scurvy C. Pernicious anemia D. Megaloblastic anemia E. Bleeding gums

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10 CHAPTER 1 SOURCES OF NUTRITION CONTENT MASTERY SERIES

Application Exercises Key

1. A. Ground beef is an animal product, which provides heme iron.

B. CORRECT: Dried beans provide non-heme iron, as do other legumes, vegetables, and grains.

C. Salmon is an animal product, which provides heme iron. D. Turkey is an animal product, which provides heme iron.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

2. A. Long-grain brown rice does not contain vitamin D. B. Strawberries do not contain vitamin D. C. Brussels sprouts do not contain vitamin D. D. CORRECT: Include eggs as a food that is high in vitamin D.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

3. A. Fats should be 20% to 35% of daily calorie intake. B. CORRECT: The recommendation for protein

intake is 10% to 35% of total daily calories. C. Recommended water intake from liquids or solids is

2.7 L/day for females and 3.7 L/day for males. D. Iron is a trace mineral, which means the

body needs 20 mg or less daily.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

4. A. CORRECT: Tuna and halibut are major sources of magnesium.

B. Green, leafy vegetables are a good source of magnesium. C. Nuts are a major source of magnesium. D. Chocolate is a major source of magnesium.

NCLEX® Connection: Physiological Adaptation, Fluid and Electrolyte Imbalances

5. A. Dysrhythmias are associated with a potassium deficiency. B. CORRECT: Scurvy is associated with a vitamin C deficiency. C. Pernicious anemia is associated a deficiency of vitamin B12. D. Megaloblastic anemia is associated

with a deficiency of folate. E. CORRECT: Bleeding gums is a condition that

results from vitamin C deficiency.

NCLEX® Connection: Physiological Adaptation, Illness Management

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT ● Traditional foods

◯ Grains: rice, corn ◯ Tropical fruits and vegetables ◯ Protein: nuts, legumes, eggs, cheese, seafood, poultry

● Acculturation ◯ Increased milk use ◯ Decreased vegetable consumption ◯ Replacement of corn by wheat in tortillas and breads ◯ Decreased bean use and change in rice

preparation to plain boiled rice ◯ Added fats in the form of butter or salad dressings

on cooked vegetables and side salads ◯ Replacement of fruit-based drinks by sugar-laden drinks

NCLEX® Connection: Psychosocial Integrity, Cultural Awareness/ Cultural Influences on Health

Application Exercises Key

1. A. Asking the client about some favorite foods choices demonstrates sensitivity to the client’s food preferences.

B. Calling the dietitian to fill out the menu does not demonstrate sensitivity to the client’s food preferences. However, it is not an example of an ethnocentric approach.

C. CORRECT: Recommending one’s own favorite foods is an example of ethnocentrism, which is the belief that one’s own cultural practices are the only correct behaviors/beliefs.

D. Having the family fill out the menu does not demonstrate sensitivity to the client’s food preferences. However, it is not an example of an ethnocentric approach.

NCLEX® Connection: Psychosocial Integrity, Cultural Awareness/Cultural Influences on Health

2. A. Encourage plant-based foods to increase nutrients in the diet.

B. Encourage raw fruits in the client’s diet to increase vitamin intake.

C. CORRECT: The preparation of foods using sodium places the client at risk for hypertension. Many spices in the Asian diet contain sodium, or it is used as a preservative. The client should reduce sodium consumption.

D. Encourage the consumption of shellfish because it is a good source of protein and vitamins.

NCLEX® Connection: Health Promotion and Maintenance, High Risk Behaviors

3. A. This is generally not a practice of Roman Catholics. Caffeinated beverages are often not consumed by Mormons and Muslims because caffeine is a stimulant.

B. CORRECT: Most clients who practice Orthodox Judaism do not eat meat with dairy products.

C. Most clients who follow the teachings of Islam eat only the protein of animals that are slaughtered under strict guidelines.

D. Most clients who practice Hinduism believe dairy products enhance spiritual purity.

NCLEX® Connection: Health Promotion and Maintenance, High Risk Behaviors

4. A. CORRECT: Asian traditions can include balancing yin and yang forces within the body, and foods are grouped into those categories.

B. African culture has influenced development of the soul food diet, but individual preferences differ widely.

C. Roman Catholicism includes few laws related to fasting on holidays or from certain foods.

D. CORRECT: Hispanic/Latinx cultural traditions can include balancing hot and cold forces within the body, and foods are grouped into those categories.

E. Buddhism has recommendations for eating foods in a manner that do not cause harm.

NCLEX® Connection: Psychosocial Integrity, Cultural Awareness/Cultural Influences on Health

36 CHAPTER 6 CULTURAL, ETHNIC, AND RELIGIOUS INFLUENCES CONTENT MASTERY SERIES

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NUTRITION FOR NURSING CHAPTER 7 NUTRITION ACROSS THE LIFESPAN 37

UNIT 1 PRINCIPLES OF NUTRITION

CHAPTER 7 Nutrition Across the Lifespan

Nutritional needs change as clients pass through the stages of the lifespan, reflecting physiological changes.

Nurses must address nutritional needs across the lifespan and have a thorough understanding of how needs change. This includes planning and implementing dietary plans that meet clients’ specific needs and assist in health promotion.

Major stages of the lifespan that have specific nutritional needs include pregnancy and lactation, infancy, childhood, adolescence, and adulthood and older adulthood.

Pregnancy and lactation ● Prepregnancy nutrition is highly significant and plays an

important role, because early fetal development occurs before a client might realize they are pregnant. A client should be well-nourished and within the normal weight range prior to conception. Low levels of folate prior to conception increases the likelihood of neural tube defects.

● Good nutrition during pregnancy is essential for the health of the unborn child.

● Maternal nutritional demands are increased for the development of the placenta, enlargement of the uterus, formation of amniotic fluid, increase in blood volume, and preparation of the breasts for lactation.

● A daily increase of 340 calories is recommended during the second trimester of pregnancy, and an increase of 452 calories is recommended during the third trimester of pregnancy.

● The nutritional requirements of clients who are pregnant or lactating involves more than increased caloric intake. Specific dietary requirements for major nutrients and micronutrients should be met.

DIETARY GUIDELINES ● Achieving an appropriate amount of weight gain during

pregnancy prepares a client for the energy demands of labor and lactation, and contributes to the delivery of a newborn of normal birth weight.

● The recommended weight gain during pregnancy varies for each client depending on their body mass index (BMI) and weight prior to pregnancy. (7.1)

● Lactating clients require an increase in daily caloric intake. If the client is breastfeeding during the postpartum period, an additional daily intake of 330 calories is recommended during the first 6 months, and an additional daily intake of 400 calories is recommended during the second 6 months.

MAJOR AND MICRONUTRIENT REQUIREMENTS

● Dietary requirements for major nutrients ◯ Protein should comprise 20% of the daily total calorie intake. The Dietary Reference Intake (DRI) for protein during pregnancy is 71 g/day. Protein is essential for rapid tissue growth of maternal and fetal structures, amniotic fluid, and extra blood volume. Clients who are pregnant should be aware that animal sources of protein might contain large amounts of fats.

◯ Fat should be limited to 30% of total daily calorie intake. ◯ Carbohydrates should comprise 50% of the total daily calorie intake. Ensuring adequate carbohydrate intake allows for protein to be spared and available for the synthesis of fetal tissue.

● The need for most vitamins and minerals increases during pregnancy and lactation. Vitamins are essential for blood formation, absorption of iron, and development of fetal tissue. TABLE 7.2 lists the comparative DRIs of major vitamins for clients age 19 to 30 during nonpregnancy, pregnancy, and lactation.

CHAPTER 7

7.1 Recommended weight gain during pregnancy

FIRST TRIMESTER: Recommended weight gain is 1.1 to 4.4 lb.

SECOND AND THIRD TRIMESTERS: Recommended weight gain is 2 to 4 lb/month.

● Normal weight client (BMI 18.5-24.9): 1 lb/week for a total of 25 to 35 lb.

● Underweight client (BMI < 18.5): just more than 1 lb/week for a total of 28 to 40 lb.

● Overweight client (BMI 25-29.9): 0.66 lb/week for a total of 15 to 25 lb.

● Obese client (BMI > 30): 0.5 lb/week for a total of 11 to 20 lb.

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38 CHAPTER 7 NUTRITION ACROSS THE LIFESPAN CONTENT MASTERY SERIES

ADDITIONAL DIETARY RECOMMENDATIONS

Fluid: 2,000 to 3,000 mL fluids daily from food and drinks. Preferred fluids include water, fruit juice, and milk. Carbonated beverages and fruit drinks provide little or no nutrients.

Alcohol: It is recommended that clients abstain from alcohol consumption during pregnancy. There is no safe recommendation for alcohol use during pregnancy.

Caffeine: Caffeine crosses the placenta and can affect the movement and heart rate of the fetus. However, moderate use (less than 200 mg/day) does not appear to be harmful.

Vegetarian diets: Well-balanced vegetarian diets that include dairy products can provide all the nutritional requirements of pregnancy.

Folic acid intake: It is recommended that 600 mcg/ day of folic acid be taken during pregnancy. Current recommendations for lactating clients include 500 mcg/ day folic acid. It is necessary for the neurologic development of the fetus and to prevent birth defects. It is essential for maternal red blood cell formation. Clients who have had a child born with a neural tube defect should consume 4 mg daily of folic acid during pregnancy. Food sources include green leafy vegetables, enriched grains, and orange juice. ● Folic acid is the synthetic form of folate and is absorbed

better by the body. Folic acid is found in supplements and in fortified foods.

● Folate is found in natural foods.

Iron: The DRI for iron increases by 50% during pregnancy to support the increase in maternal blood volume and to provide iron for fetal liver storage. Iron can be obtained from meats, eggs, leafy greens, enriched breads, and dried fruits. Consuming foods high in vitamin C aids in the absorption of iron. It is recommended that pregnant clients take a supplement of 27 to 30 mg iron daily to assure adequate intake.

Nonnutritive sweeteners: Several nonnutritive sweeteners have been approved for use during pregnancy. Occasional use is not considered harmful, but it is not known if they are beneficial.

Fish: The FDA has issued advisories regarding fish and shellfish consumption during pregnancy due to the risk of mercury levels. Mercury can be toxic to developing fetal brain tissue. Fish are a good source of omega 3 fatty acids, which are important for fetal brain and eye development.

● Limit albacore tuna to 6 oz/week. ● Avoid tilefish, shark, swordfish, marlin, orange roughy,

and king mackerel due to mercury content. ● Limit weekly consumption of seafood to 12 oz.

DIETARY COMPLICATIONS Nausea and constipation are common during pregnancy. ● For nausea, eat dry crackers, toast, and salty or tart

foods. Avoid alcohol, caffeine, fats, and spices. Avoid drinking fluids with meals, and do not take medications to control nausea without checking with the provider.

● For constipation, increase fluid consumption (at least 8 cups per day) and include extra fiber in the diet. Fruits, vegetables, and whole grains contain fiber.

● Regular physical activity can minimize or prevent constipation.

Maternal phenylketonuria (PKU) is a maternal genetic disease in which high levels of phenylalanine pose danger to the fetus.

● It is important for a client to start the PKU diet at least 3 months prior to pregnancy, and continue the diet throughout pregnancy.

● The diet should include foods low in phenylalanine. Foods high in protein (fish, poultry, meat, eggs, nuts, dairy products) must be avoided due to high phenylalanine levels.

● The client’s blood phenylalanine levels should be monitored during pregnancy.

● These interventions will prevent fetal complications (intellectual disability, behavioral problems).

ASSESSMENT/DATA COLLECTION AND INTERVENTIONS

● Nursing assessments should include a complete profile of the client’s knowledge base regarding nutritional requirements during pregnancy.

● Nurses should review with the client the recommended dietary practices for pregnant and lactating clients, while providing materials containing this information.

7.2 DRIs of major vitamins

NUTRIENT NONPREGNANT PREGNANT LACTATING Protein 46 g 71 g 71 g Vitamin A 700 mcg 770 mcg 1,300 mcg Vitamin C 75 mg 85 mg 120 mg Vitamin D* 15 mcg 15 mcg 15 mcg Vitamin E 15 mcg 15 mcg 19 mcg Vitamin K* 90 mcg 90 mcg 90 mcg Thiamin 1.1 mg 1.4 mg 1.4 mg Vitamin B6 1.3 mg 1.9 mg 2.0 mg Folic acid 400 mcg 600 mcg 500 mcg Vitamin B12 2.4 mcg 2.6 mcg 2.8 mcg Calcium* 1,000 mg 1,000 mg 1,000 mg Iron 18 mg 27 mg 9 mg

*Values represent adequate intakes.

Source: Office of Dietary Supplements. National Institutes of Health, ods.od.nih.gov

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NUTRITION FOR NURSING CHAPTER 7 NUTRITION ACROSS THE LIFESPAN 39

Infancy ● Growth rate during infancy is more rapid than any other

period of the life cycle. It is important to understand normal growth patterns to determine the adequacy of an infant’s nutritional intake.

● Birth weight doubles by 4 to 6 months and triples by 1 year of age. The need for calories and nutrients is high to support the rapid rate of growth.

● Appropriate weight gain averages 0.15 to 0.21 kg (5 to 7 oz) per week during the first 5 to 6 months.

● An infant grows approximately 2.5 cm (1 in) per month in height during the first 6 months, and approximately 1.25 cm (0.5 in) per month during the second 6 months.

● Head circumference increases rapidly during the first 6 months at a rate of 1.5 cm (0.6 in) per month. The rate slows to 0.5 cm/month for months 6 to 12. By 1 year, head size should have increased by 33%. This is reflective of the growth of the nervous system.

● Breast milk, infant formula, or a combination of the two is the sole source of nutrition for the first 6 months of life.

● Semisolid foods should not be introduced before 6 months of age to coincide with the development of the gastrointestinal system, head control, ability to sit, and the back-and-forth motion of the tongue.

● Gestational iron stores begin to deplete around 4 months of age, so iron supplementation is recommended after this time for infants who are exclusively fed breast milk. Once solid foods are introduced, iron-fortified cereal is a good source of iron.

● Cow’s milk should not be introduced into the diet until after 1 year of age because protein and mineral content stress the immature kidney. A young infant cannot fully digest the protein and fat contained in cow’s milk.

MEETING NUTRITIONAL NEEDS Additional information about feeding is available in MATERNAL NEWBORN CHAPTER 25: NEWBORN NUTRITION and NURSING CARE OF CHILDREN CHAPTER 3 : HEALTH PROMOTION

OF INFANTS (2 DAYS TO 1 YEAR).

BREASTFEEDING ● The American Academy of Pediatrics (AAP), World

Health Organization (WHO), Department of Health and Human Services (HHS), and American College of Obstetricians and Gynecologists recommend that infants receive breast milk for the first 6 to 12 months of age (exclusive breast feeding) followed by breastfeeding with the introduction of complementary foods until at least 12 months of age, then continuation of breastfeeding for as long as the parent and infant desire. Even a short period of breastfeeding has physiological benefits.

● Donor milk can be considered in certain circumstances. ◯ The choice to feed an infant human milk from a source other than the infant’s parent should be made in consultation with the provider, because the nutritional needs of each infant depend on many factors, including the infant’s age and health.

◯ The FDA recommends that if an infant is to be fed human milk from a source other than the infant’s parent, use only milk from a source that has screened its donors and take other precautions to ensure the safety of the milk.

● The AAP recommends that for the first 6 months, infants should receive no water or formula except in cases of medical indication or informed parental choice. In the hospital, no water or formula should be given to a breastfed infant unless prescribed by a provider.

Nutritional advantages of breast milk ● Carbohydrates, proteins, and fats in breast milk are

predigested for ready absorption. ● Breast milk is high in omega-3 fatty acids. ● Breast milk is low in sodium. ● Iron, zinc, and magnesium found in breast milk are

highly absorbable. ● Calcium absorption is enhanced, as the

calcium-to-phosphorous ratio is 2:1.

Breastfeeding teaching points ● The newborn is offered the breast immediately after

birth and frequently thereafter. There should be eight to 12 feedings in a 24-hr period.

● Instruct the client to demand-feed the infant and to assess for hunger cues. These include rooting, suckling on hands and fingers, and rapid eye movement. Crying is a late indicator of hunger.

● The newborn should nurse up to 15 min per breast. Findings that indicate the newborn has completed the feeding include the slowing of newborn suckling, a softened breast, or sleeping. Eventually, the infant will empty a breast within 5 to 10 min, but might need to continue to suck to meet comfort needs.

● Do not offer the newborn any supplements unless indicated by the provider.

● Frequent feedings (every 2 hr can be indicated) and manual expression of milk to initiate flow can be needed.

● Awaken the infant to feed every 3 hr during the day and every 4 hr at night.

● Encourage clients to express breast milk for supplementation if extra fluids or calories are required.

● Expressed milk can be refrigerated in sterile bottles or storage bags and labeled with the date and time the milk was expressed. It can be maintained in the refrigerator for 24 hr or frozen in sterile containers for 3 months.

● Thaw milk in the refrigerator. It can be stored for 24 hr after thawing. Defrosting or heating in a microwave oven is not recommended because high heat destroys some of milk’s antibodies, and can burn the infant’s oral mucosa.

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40 CHAPTER 7 NUTRITION ACROSS THE LIFESPAN CONTENT MASTERY SERIES

● Do not refreeze thawed milk. ● Unused breast milk must be discarded. ● Limit alcohol and caffeine while breastfeeding. ● Begin manual expression of the breast or use an electric

breast pump if the infant is unable to breastfeed due to prematurity or respiratory distress.

FORMULA FEEDING Can be used in place of breastfeeding, as an occasional supplement to breastfeeding, or when exclusively breastfed infants are weaned before 12 months of age.

● Commercial infant formulas provide an alternative to breast milk. They are modified from cow’s milk to provide comparable nutrients. However, breast milk is superior to any formula and even more crucial for a premature infant.

● If formula-fed, an iron-fortified formula is recommended for at least the first 12 months of life or until the infant consumes adequate solid food.

● Fluoride supplements can be required if an adequate level is not supplied by the water supply.

● Precisely follow the manufacturer’s mixing directions. ● Bottles of mixed formula or open cans of liquid formula

require refrigeration. Do not use if the formula has been left at room temperature for 2 hr or longer. Do not reuse partially emptied bottles of formula.

● Formula can be fed chilled, warmed, or at room temperature. Always give formula at approximately the same temperature.

● The infant should not drink more than 32 oz formula per 24 hr period unless directed by a provider.

BOTTLE FEEDING ● Hold the infant during feedings with the head slightly

elevated to facilitate passage of formula or breast milk into the stomach. Tilt the bottle to maintain liquid in the nipple and prevent the swallowing of air.

● Do not prop the bottle or put an infant to bed with a bottle. This practice promotes tooth decay.

INTRODUCING SOLID FOOD ● Indicators for readiness include voluntary control of the

head and trunk, hunger less than 4 hr after vigorous nursing or intake of 8 oz of formula, and interest of the infant.

● New foods should be introduced one at a time over a 5- to 7-day period to observe for indications of allergy or intolerance, which can include fussiness, rash, upper respiratory distress, vomiting, diarrhea, or constipation. The order of introduction of new foods is no longer considered important, and meat can be introduced first due to its iron and zinc content.

● The infant can be ready for three meals per day with three snacks by 8 months of age.

● Homemade baby food is an acceptable feeding option. Do not use canned or packaged foods that are high in sodium. Select fresh or frozen foods, and do not add sugars or other seasonings.

● Open jars of infant food can be stored in the refrigerator for up to 24 hr.

● By 9 months of age, the infant should be able to eat table foods that are cooked, chopped, and unseasoned.

● Do not feed the infant honey due to the risk of botulism. ● Appropriate finger foods include ripe bananas, toast

strips, graham crackers, cheese cubes, noodles, and peeled chunks of apples, pears, or peaches.

NUTRITION-RELATED PROBLEMS

Colic

Colic is characterized by persistent crying lasting 3 hr or longer per day. ● The cause of colic is unknown, but usually occurs in the

late afternoon, more than 3 days per week for more than 3 weeks. The crying is accompanied by a tense abdomen and legs drawn up to the belly.

● If breastfeeding, eliminate cruciferous vegetables (cauliflower, broccoli, and Brussels sprouts), cow’s milk, onion, and chocolate, and limit caffeine and nicotine.

● Burp the infant in an upright position.

Lactose intolerance

Lactose intolerance is the inability to digest significant amounts of lactose (the predominant sugar of milk) and is due to inadequate lactase (the enzyme that digests lactose into glucose and galactose).

● Lactose intolerance has an increased prevalence in individuals of Asian, Native American, African, Latino, and Mediterranean descent.

● Findings include abdominal distention, flatus, and occasional diarrhea.

● Soy-based or casein hydrolysate formulas can be prescribed as alternative formulas for infants who are lactose intolerant.

Failure to thrive

Failure to thrive is defined as inadequate gains in weight and height in comparison to established growth and development norms (weight-for-length less than 5th percentile or weight for age below the 3rd percentile). ● Assess for findings of congenital defects,

central nervous system disorders, or partial intestinal obstruction.

● Monitor for swallowing or sucking problems. ● Identify feeding patterns, especially concerning

preparation of formulas. ● Observe for psychosocial problems, especially impaired

caregiver-infant bonding, abuse/neglect. ● Provide supportive nutritional guidance. Usually a

high-calorie, high-protein diet is indicated. ● Provide supportive parenting guidance.

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NUTRITION FOR NURSING CHAPTER 7 NUTRITION ACROSS THE LIFESPAN 41

Diarrhea

Diarrhea is characterized by the passage of more than three loose, watery stools over a 24-hr period. ● Overfeeding and food intolerances are common causes

of osmotic diarrhea. ● Infectious diarrhea in the infant is commonly caused

by rotavirus. ● Mild diarrhea can require no specific interventions.

Check with the provider for any diet modifications. ● Treatment for moderate diarrhea should begin at

home with oral rehydration solutions. After each loose stool, an 8 oz solution should be given. Sports drinks are contraindicated.

● Educate parents about the findings of dehydration: listlessness, sunken eyes, sunken fontanels, decreased tears, dry mucous membranes, and decreased urine output.

● Breastfed infants should continue nursing. ● Formula-fed infants usually do not require diluted

formulas or special formulas. ● Contact the provider if findings of dehydration are

present, or if vomiting, bloody stools, high fever, change in mental status, or refusal to take liquids occurs.

Constipation

Constipation is the inability or difficulty to evacuate the bowels.

● Constipation is not a common problem for breastfed infants.

● Constipation can be caused by formula that is too concentrated.

● Stress the importance of accurate dilution of formula. ● Advise adherence to the recommended amount of

formula intake for age.

NURSING ASSESSMENT/DATA COLLECTION AND INTERVENTIONS

● Nursing assessments should include an assessment of knowledge base of the client regarding nutritional guidelines for infants, normal infant growth patterns, breastfeeding, formula feeding, and the progression for the introduction of solid foods.

● Additionally, nurses should provide education and references for the client regarding each of the assessments listed above.

Childhood ● Growth rate slows following infancy. ● ChooseMyPlate.gov is a food guidance system that offers

an Internet-based tool to provide clients with individualized recommendations for adequate nutrition. Children require the same food groups as adults, but in smaller serving sizes.

● Energy needs and appetite vary with the child’s activity level and growth rate.

● Generally, nutrient needs increase with age. ● Attitudes toward food and general food habits are

established by 5 years of age. ● Increasing the variety and texture of foods helps the

child develop good eating habits. ● Foods like hot dogs, popcorn, peanuts, grapes, raw

carrots, celery, peanut butter, tough meat, and candy can cause choking or aspiration.

● Inclusion in family mealtime is important for social development.

● Group eating becomes a significant means of socialization for school-age children.

TODDLERS: 1 TO 3 YEARS OLD

NUTRITION GUIDELINES ● Toddlers generally grow 2 to 3 inches in height and gain

approximately 5 to 6 lb/year. ● Limit 100% juice to 4 to 6 oz a day. ● The 1- to 2-year-old child requires whole cow’s milk to

provide adequate fat for the still-growing brain. ● Food serving size is 1 tbsp for each year of age. ● Exposure to a new food might be needed 15 to 20 times

before the child develops an acceptance of it. ● If there is a negative family history for allergies, cow’s

milk, chocolate, citrus fruits, egg white, seafood, and nut butters can be gradually introduced while monitoring the child for reactions.

● Toddlers prefer finger foods because of their increasing autonomy. They prefer plain foods to mixtures, but usually like macaroni and cheese, spaghetti, and pizza.

● Regular meal times and nutritious snacks best meet nutrient needs.

● Snacks or desserts that are high in sugar, fat, or sodium should be avoided.

● Children are at an increased risk for choking until 4 years of age.

● Avoid foods that are potential choking hazards. Always provide adult supervision during snack and mealtimes. During food preparation, cut small, bite-sized pieces that are easy to swallow to prevent choking. Do not allow the child to engage in drinking or eating during play activities or while lying down.

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42 CHAPTER 7 NUTRITION ACROSS THE LIFESPAN CONTENT MASTERY SERIES

NUTRITIONAL CONCERNS/RISKS

Iron ● Iron deficiency anemia is the most common nutritional

deficiency disorder in children. ● Lean red meats provide sources of readily

absorbable iron. ● Consuming vitamin C (orange juice, tomatoes) with

plant sources of iron (beans, raisins, peanut butter, whole grains) will maximize absorption.

● Milk should be limited to the recommended quantities (24 oz) because it is a poor source of iron and can displace the intake of iron-rich foods.

Vitamin D ● Vitamin D is essential for bone development. ● Recommended vitamin D intake is the same (5 mcg/day)

from birth through age 50. Children require more vitamin D because their bones are growing.

● Milk (cow, soy) and fatty fish are good sources of vitamin D.

● Sunlight exposure leads to vitamin D synthesis. Children who spend large amounts of time inside (watching TV, playing video games) are at an increased risk for vitamin D deficiency.

● Vitamin D assists in the absorption of calcium into the bones.

PRESCHOOLERS: 3 TO 6 YEARS

NUTRITION GUIDELINES ● Preschoolers generally grow 2 to 3 inches in height and

gain approximately 5 to 6 lb/year. ● Preschoolers need to consume 13 to 19 g/day of

complete protein. ● If the preschooler consumes foods from all five food

groups and height and weight are within expected reference ranges, supplemental vitamins/minerals might not be needed.

● Preschoolers tend to dislike strong-tasting vegetables (cabbage, onions), but like many raw vegetables that are eaten as finger foods.

● Food jags (ritualistic preference for one food) are common and usually short-lived.

● MyPlate guidelines are appropriate, requiring the lowest number of servings per food group.

● Food patterns and preferences are first learned from the family, and peers begin influencing preferences and habits at around 5 years of age.

NUTRITIONAL CONCERNS/RISKS Concerns include overfeeding; intake of high-calorie, high-fat, high-sodium snacks, soft drinks, and juices; and inadequate intake of fruits and vegetables. ● Be alert to the appropriate serving size of foods (1 tbsp

per year of age). ● Avoid high-fat and high-sugar snacks. ● Encourage daily physical activities. ● Can switch to skim or 1% low-fat milk after

2 years of age.

Iron deficiency anemia

Lead poisoning is a risk for children younger than 6 years of age because they frequently place objects in their mouths that can contain lead and have a higher rate of intestinal absorption. ● Feed children at frequent intervals because more lead is

absorbed on an empty stomach. ● Inadequate intake of calories, calcium, iron, zinc, and

phosphorous can increase susceptibility.

SCHOOL-AGE CHILDREN: 6 TO 12 YEARS

NUTRITION GUIDELINES ● School-age children generally grow 2 to 3 inches in

height and gain approximately 5 to 6 lb/year. ● Following MyPlate recommendations, the diet should

provide variety, balance, and moderation. ● Young athletes need to meet energy, protein, and

fluid needs. ● Educate children to make healthy food selections. ● Children enjoy learning how to safely prepare

nutritious snacks. ● Children need to learn to eat snacks only when hungry,

not when bored or inactive.

NUTRITIONAL CONCERNS/RISKS Not eating breakfast occurs in about 10% of children. ● Optimum performance in school is dependent on a

nutritious breakfast. ● Children who regularly eat breakfast tend to have an

age-appropriate BMI.

Overweight/obesity affects at least 20% of children. ● Greater psychosocial implications exist for children

than adults. ● Overweight children tend to be obese adults. ● Prevention is essential. Encourage healthy eating habits,

decrease fats and sugars (empty-calorie foods), and increase the level of physical activity.

● A weight-loss program directed by a provider is indicated for children who are overweight, or obese if they have comorbidity. Otherwise, efforts are directed at maintaining weight so the BMI will normalize as height increases.

● Praise the child’s abilities and skills. ● Never use food as a reward or punishment.

NURSING ASSESSMENT/DATA COLLECTION AND INTERVENTIONS

Nursing assessments should include the parent’s knowledge base of the child’s nutritional requirements, and nutritional concerns with regard to age. Nurses should provide education for the parent and child about nutritional recommendations.

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NUTRITION FOR NURSING CHAPTER 7 NUTRITION ACROSS THE LIFESPAN 43

Adolescence ● The rate of growth during adolescence is second only to

the rate in infancy. Nutritional needs for energy, protein, calcium, iron, and zinc increase at the onset of puberty and the growth spurt.

● The female adolescent growth spurt usually begins at 10 or 11 years of age, peaks at 12 years, and is completed by 17 years. Female energy requirements are less than that of males, as they experience less growth of muscle and bone tissue and more fat deposition.

● The male adolescent growth spurt begins at 12 or 13 years of age, peaks at 14 years, and is completed by 21 years.

● Eating habits of adolescents are often inadequate in meeting recommended nutritional intake goals.

NUTRITIONAL CONSIDERATIONS ● Energy requirements average 2,000 cal/day for a

12- to 18-year-old female and 2,200 to 2,800 cal/day for a 12- to 18-year-old male.

● The USDA reports that the average U.S. adolescent consumes a diet deficient in folate, vitamins A and E, iron, zinc, magnesium, calcium, and fiber. This trend is more pronounced in females than males.

● Diets of adolescents generally exceed recommendations for total fat, saturated fat, cholesterol, sodium, and sugar.

NUTRITIONAL RISKS Eating and snacking patterns promote essential nutrient deficiencies (calcium, vitamins, iron, fiber) and overconsumption of sugars, fat, and sodium.

● Adolescents tend to skip meals, especially breakfast, and eat more meals away from home.

● Foods are often selected from vending machines, convenience stores, and fast food restaurants. These foods are typically high in fat, sugar, and sodium.

● Carbonated beverages can replace milk and fruit juices in the diet with resulting deficiencies in vitamin C, riboflavin, phosphorous, and calcium.

Increased need for iron ● Females 14 to 18 years of age require 15 mg/day of iron

to support expansion of blood volume and blood loss during menstruation.

● Males 14 to 18 years of age require 11 mg/day of iron to support expansion of muscle mass and blood volume.

Inadequate calcium intake can predispose the adolescent to osteoporosis later in life.

● During adolescence, 45% of bone mass is added. ● Normal blood-calcium levels are maintained by drawing

calcium from the bones if calcium intake is low. ● Adolescents require at least 1,300 mg/day of calcium,

which can be achieved by three to four servings from the dairy food group.

Dieting ● The stigma of obesity and social pressure to be thin can

lead to unhealthy eating practices and poor body image, especially in females.

● Males are more susceptible to using supplements and high-protein drinks in order to build muscle mass and improve athletic performance. Some athletes restrict calories to maintain or achieve a lower weight.

● Eating disorders can follow self-imposed crash diets for weight loss.

Eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder) commonly begin during adolescence. These disorders are discussed further in the MENTAL HEALTH REVIEW MODULE, CHAPTER 19: EATING DISORDERS.

Adolescent pregnancy ● The physiologic demands of a growing fetus

compromise the adolescent’s needs for their own unfinished growth and development.

● Inconsistent eating and poor food choices place the adolescent at risk for anemia, pregnancy-induced hypertension, gestational diabetes, premature labor, miscarriage, and delivery of a newborn of low birth weight.

NURSING ASSESSMENT/DATA COLLECTION AND INTERVENTIONS

● Nursing assessments should include a determination of the following in the adolescent. ◯ Typical 24-hr food intake ◯ Weight patterns, current weight, and body mass

index (BMI) ◯ Attitude about current weight ◯ Use of nutritional supplements, vitamins,

and minerals ◯ Medical history and use of prescription medications ◯ Use of over-the-counter medications ◯ Use of substances (marijuana, alcohol, tobacco) ◯ Level of daily physical activity

● Assess for findings of an eating disorder. This can include an evaluation of the adolescent’s laboratory values.

● Nursing assessments should include strategies that promote health for the adolescent. ◯ Educate the adolescent on using MyPlate to meet

energy and nutrient needs with three regular meals and snacks.

◯ Stress the importance of meeting calcium needs by including low-fat milk, yogurt, and cheese in the diet.

◯ Educate the adolescent on how to select and prepare nutrient-dense snack foods: unbuttered, unsalted popcorn; pretzels; fresh fruit; string cheese; smoothies made with low-fat yogurt, skim milk, or reduced-calorie fruit juice; and raw vegetables with low-fat dips.

◯ Encourage participation in vigorous physical activity at least three times per week.

◯ Refer pregnant adolescents to the Women, Infant, and Children (WIC) nutrition subsidy program.

◯ Provide individual and group counseling for adolescents who have findings of eating disorders.

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44 CHAPTER 7 NUTRITION ACROSS THE LIFESPAN CONTENT MASTERY SERIES

Adulthood and older adulthood

● A balanced diet for all adults consists of 45% to 65% carbohydrates and 20% to 35% fat (with 10% or less from saturated fats).

● The recommended amount for protein is unchanged in adults and older adults. However, many nutrition experts believe that protein requirements increase in older adults.

● Older adults need to reduce total caloric intake. This is due to the decrease in basal metabolic rate that occurs from the decrease in lean body mass that develops with aging.

● Reduced caloric intake predisposes the older adult for development of nutrient deficiencies.

● Older adults can have physical, mental, and social changes that affect their ability to purchase, prepare, and digest foods and nutrients.

● Dehydration is the most common fluid and electrolyte imbalance in older adults. Fluid needs increase with medication-induced fluid losses. Some disease processes necessitate fluid restrictions.

● BMI should be between 18.5 and 24.9. There is an increased risk for both overweight and underweight older adult clients. Overweight adults are more prone to hypertension, diabetes mellitus, and stroke.

NUTRITIONAL CONCERNS ● A 24-hr dietary intake is helpful in determining the

need for dietary education. ● Older adults can have oral problems (ill-fitting dentures,

difficulty chewing or swallowing), and a decrease in salivation or poor dental health.

● Older adults have decreased cellular function and reduced body reserves, leading to decreased absorption of multiple vitamins and minerals as well as reductions in insulin production and sensitivity.

● Older adults have a decreased lean muscle mass. Exercise can help to counteract muscle mass loss.

● The loss of calcium can result in decreased bone density in older adults.

BALANCED DIET AND NUTRIENT NEEDS MyPlate suggests the following daily food intake for adults and older adults who get less than 30 min of moderate physical activity most days. (7.3)

Grains: Select whole grains.

Vegetables: Select orange and dark green leafy vegetables.

Fruits: Select fresh, dried, canned, or juices. Avoid fruits with added sugar.

Make half your plate vegetables and fruits.

Milk, yogurt, and cheese group: One cup of milk or plain yogurt is equivalent to 1 ½ oz of natural cheese or 2 oz processed cheese.

Protein foods group: Includes meat, fish, poultry, dry beans, eggs, soy products, seeds, and nuts. One ounce-equivalent equals 1 oz meat, fish, or poultry (baked, grilled, broiled); ¼ cup cooked beans; 1 egg; 1 tbsp peanut butter; or ½ oz nuts or seeds. Use lean meats.

Oils: Use vegetable oils (except palm and coconut). One tbsp of oil equals 3 tsp equivalent; 1 tbsp equals 2 ½ tsp dietary intake; and 1 oz nuts equals 3 tsp oils (except hazelnut, which equals 4 tsp).

Discretionary calories: 132 to 362 discretionary calories are permitted per day. These add up quickly and can be from more than one food group.

Minerals: Calcium requirements increase for older adults as the efficiency of calcium absorption decreases with age.

Vitamins: Vitamins A, D, C, E, B6, and B12 can be decreased in older adults. Supplemental vitamins are recommended.

7.3 MyPlate recommendations for adults

MALES FEMALES 19 TO 30 YEARS

31 TO 50 YEARS 51+ YEARS

19 TO 30 YEARS

31 TO 50 YEARS 51+ YEARS

Calories 2,400 2,200 2,000 2,000 1,800 1,600 Fruits 2 cups 2 cups 2 cups 2 cups 1 ½ cups 1 ½ cups Vegetables 3 cups 3 cups 2 ½ cups 2 ½ cups 2 ½ cups 2 cups Grains 8 oz 7 oz 6 oz 6 oz 6 oz 5 oz Protein 6 ½ oz-eq 6 oz-eq 5 ½ oz-eq 5 ½ oz-eq 5 oz-eq 5 oz-eq Milk 3 cups 3 cups 3 cups 3 cups 3 cups 3 cups Oils 7 tsp 6 tsp 6 tsp 6 tsp 5 tsp 5 tsp

Source: United States Department of Agriculture. ChooseMyPlate.gov. Retrieved December 22, 2015, from www.choosemyplate.gov

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NUTRITION FOR NURSING CHAPTER 7 NUTRITION ACROSS THE LIFESPAN 45

REGULAR EXERCISE ● All adults should exercise at a moderate or vigorous

pace for at least 150 min per week. Adults who cannot do 150 min of moderate activity should be as physically active as tolerated.

● Moderate activities include gardening/yard work, golf, dancing, and walking briskly.

● The loss of lean muscle mass is part of normal aging and can be decreased with regular exercise. The loss of lean muscle can be associated with a decrease in total protein and insulin sensitivity.

● Regular exercise can improve bone density, relieve depression, and enhance cardiovascular and respiratory function.

POTENTIAL EFFECT OF PHYSICAL, MENTAL, AND SOCIAL CHANGES

● Diseases and treatments can interfere with nutrient and food absorption, and utilization.

◯ Aging adults are at an increased risk for developing osteoporosis (decreasing total bone mass and deterioration of bone tissue). Adequate calcium and vitamin D intake with regular weight-bearing exercise is important for maximizing bone density.

◯ Musculoskeletal concerns, such as arthritis, cause pain that can interfere with the purchase and preparation of foods.

◯ Dementia can make shopping, storing, and cooking food difficult.

● Medications can cause electrolyte losses. ● Loss of smell and vision interfere with the interest in

eating food. ● Older adults can have difficulty chewing, in which case

mincing or chopping food is helpful. They can have difficulty swallowing food, and thickened liquids can decrease the risk for aspiration.

● Social isolation, loss of a partner, and mental deterioration can cause poor nutrition in adult and older adult clients. Encourage socialization and refer to a senior center or program.

● A fixed income can make it difficult for older adults to purchase needed foods. Refer to food programs, senior centers, and food banks. Meals on Wheels programs are available for housebound older adults.

FLUID INTAKE ● The long-held standard of consuming eight 8-oz glasses

of liquid per day has been tempered by evidence that dehydration is not imminent even when less than 64 oz of fluid is consumed.

● Solid foods provide varying amounts of water, making it possible to get adequate fluid despite low beverage intake.

● For healthy adults, it is generally acceptable to allow normal drinking and eating habits to provide needed fluids.

● Encourage water and natural juices, and discourage drinking only soda pop and other liquids that have caffeine.

NURSING ASSESSMENT/DATA COLLECTION AND INTERVENTIONS

● Nursing assessments should include a dietary profile of the adult or older adult. Medical history, medication regimen, mobility, social practices, mental status, and financial circumstances are important components of the assessment.

● Nurses should provide education about dietary practices for the adult and older adult, while additionally providing referrals to registered dietitians and community agencies when needed.

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46 CHAPTER 7 NUTRITION ACROSS THE LIFESPAN CONTENT MASTERY SERIES

Active Learning Scenario

A community health nurse is teaching a group of guardians the importance of adequate vitamin D intake for children. Use the ATI Active Learning Template: Basic Concept to complete this item.

UNDERLYING PRINCIPLES ● Explain why vitamin D is important for children. ● Identify at least two sources of vitamin D.

Application Exercises

1. A nurse at a community center is providing nutrition counseling for a group of older adult clients. Which of the following information should the nurse include? (Select all that apply.)

A. Increase protein to 50% of daily calories.

B. The need for vitamins and minerals can increase.

C. Up to 35% of daily calories should come from fat.

D. At least 45% of daily calories should come from carbohydrates.

E. Fruits and vegetables should make up one-third of each meal.

2. A nurse is assessing a 6-month-old infant who has a lactose intolerance. Which of the following findings should the nurse expect? (Select all that apply.)

A. Abdominal distention

B. Flatus

C. Hypoactive bowel sounds

D. Occasional diarrhea

E. Visible peristalsis

3. A nurse is educating the parents of a toddler about appropriate snack foods. Which of the following foods should the nurse include? (Select all that apply.)

A. Graham crackers

B. Apple slices

C. Raisins

D. Jelly beans

E. Cheese cubes

4. A nurse is teaching a group of clients who are pregnant about iron-rich foods. Which of the following foods should the nurse include? (Select all that apply.)

A. Beans

B. Fish

C. Dairy products

D. Lean red meats

E. Apples

5. A school nurse is teaching a group of adolescents about healthy snack food choices. Which of the following foods should the nurse include? (Select all that apply.)

A. Carrot sticks with low-fat dip

B. Cheese and crackers

C. Unbuttered popcorn

D. French fries

E. Hot dog

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NUTRITION FOR NURSING CHAPTER 7 NUTRITION ACROSS THE LIFESPAN 47

Application Exercises Key

1. A. Protein requirements do not increase during older adulthood.

B. CORRECT: Age-related changes can reduce the body’s ability to absorb vitamins and minerals.

C. CORRECT: Adult clients should obtain 20% to 35% of daily calories from fat.

D. CORRECT: Adult clients should obtain 45% to 65% of daily calories from carbohydrates.

E. Fruits and vegetables should make up one-half of each meal.

NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

2. A. CORRECT: Abdominal distention is a finding associated with a lactose intolerance.

B. CORRECT: Flatus is a finding associated with a lactose intolerance.

C. Hypoactive bowel sounds are not associated with a lactose intolerance.

D. CORRECT: Occasional diarrhea is a finding associated with a lactose intolerance.

E. Visible peristalsis is not associated with a lactose intolerance.

NCLEX® Connection: Health Promotion and Maintenance, Aging Process

3. A. CORRECT: Graham crackers are appropriate snack foods for toddlers.

B. CORRECT: Apple slices are appropriate snack foods for toddlers.

C. Raisins are difficult to chew and pose a choking hazard. D. Jelly beans are difficult to swallow, pose a choking

risk, and are high in sugar content. E. CORRECT: Cheese cubes are appropriate

snack foods for toddlers.

NCLEX® Connection: Health Promotion and Maintenance, Aging Process

4. A. CORRECT: Iron-rich foods include beans. B. CORRECT: Iron-rich foods include fish. C. Dairy products are not rich in iron. D. CORRECT: Iron-rich foods include lean red meats. E. Apples are not rich in iron.

NCLEX® Connection: Health Promotion and Maintenance, Ante/Intra/Postpartum and Newborn Care

5. A. CORRECT: Carrot sticks with low-fat ranch dip are a healthy snack selection.

B. CORRECT: Cheese and crackers are a healthy snack selection.

C. CORRECT: Unbuttered popcorn is a healthy snack selection. D. French fries are not a healthy food choice

because they are high in fat. E. Hot dogs are not a healthy food choice because

they are high in sodium and fat.

NCLEX® Connection: Health Promotion and Maintenance, Aging Process

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

UNDERLYING PRINCIPLES ● Vitamin D is essential for the development of healthy bones. It is important in children because their bones are newly formed and continually growing.

● Vitamin D aids in the absorption of calcium into the bones. Sunlight exposure, milk (cow’s, soy), and fatty fish are sources of vitamin D.

NCLEX® Connection: Health Promotion and Maintenance, Aging Process

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48 CHAPTER 7 NUTRITION ACROSS THE LIFESPAN CONTENT MASTERY SERIES

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NUTRITION FOR NURSING NCLEX® CONNECTIONS 49

NCLEX® Connections

When reviewing the following chapters, keep in mind the relevant topics and tasks of the NCLEX outline, in particular:

Basic Care and Comfort NUTRITION AND ORAL HYDRATION Manage the client’s nutritional intake.

Provide client nutrition through tube feedings.

Evaluate side effects of client tube feedings and intervene, as needed.

Monitor the client's nutritional status.

Pharmacological and Parental Therapies TOTAL PARENTERAL NUTRITION (TPN) Administer parenteral nutrition and evaluate client response.

Apply knowledge of nursing procedures and psychomotor skills when caring for a client receiving TPN.

Reduction of Risk Potential LABORATORY VALUES: Compare client laboratory values to normal laboratory values.

POTENTIAL FOR ALTERATIONS IN BODY SYSTEMS Identify client potential for skin breakdown.

Identify client potential for aspiration.

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50 NCLEX® CONNECTIONS CONTENT MASTERY SERIES

NUTRITION FOR NURSING CHAPTER 8 MODIFIED DIETS 51

UNIT 2 CLINICAL NUTRITION

CHAPTER 8 Modified Diets Therapeutic nutrition is the role of food and nutrition in the treatment of diseases and disorders. The basic diet becomes therapeutic when modifications are made to meet client needs. Modifications can include increasing or decreasing caloric intake, fiber, or other specific nutrients; omitting specific foods; and modifying the consistency of foods.

It is important to remember, however, that food meets both physiological and psychological needs and should be a pleasant experience for the hospitalized client. Nurses should collaborate with the dietitian for nutritional or dietary concerns.

TYPES OF MODIFIED DIETS

Regular diet (normal or house diet) ● Indicated for clients who do not need dietary

restrictions. The diet is adjusted to meet age specific needs throughout the life cycle.

● Many health care facilities offer self-select menus for regular diets.

● Modify the regular diet to accommodate individual preferences, food habits, and ethnic values.

Clear liquid diet ● Consists of foods or fluids that have no residue and are

liquid at room temperature. ● Primarily to prevent dehydration and relieve thirst,

the diet consists of water and carbohydrates. This diet requires minimal digestion, leaves minimal residue, and is non-gas-forming. It is nutritionally inadequate and should not be used long-term.

● Indications include acute illness, reduction of colon fecal material prior to certain diagnostic tests and procedures, acute gastrointestinal disorders, and some postoperative recovery.

● Acceptable foods are water, tea, coffee, fat-free broth, carbonated beverages, clear juices, ginger ale, and gelatin.

Full liquid diet ● Consists of foods that are liquid at room temperature

including plain ice cream and strained cereals. Some facilities include pureed vegetables.

● Offers more variety and nutritional support than a clear liquid diet but might require supplementation of protein and calories if used more than 3 days.

● Indications include a transition from liquid to soft diets, postoperative recovery, acute gastritis, febrile conditions, and intolerance of solid foods.

● Use cautiously with clients who have dysphagia (difficulty swallowing) unless liquids are thickened appropriately.

● Many dietary manuals have removed the full liquid diet, so it might be used infrequently.

Blenderized liquid (pureed) diet ● Consists of liquids and foods that are pureed to

liquid form. ● The composition and consistency of a pureed diet varies,

depending on the client’s needs. ● Modify with regard to calories, protein, fat, or other

nutrients based on the dietary needs of the client. ● Adding broth, milk, gravy, cream, soup, tomato sauce, or

fruit juice to foods in place of water provides additional calories and nutritional value.

● Each food is pureed separately to preserve individual flavor.

● Indications include clients who have chewing or swallowing difficulties, oral or facial surgery, and wired jaws.

Soft (bland, low‑fiber) diet ● Contains whole foods that are low in fiber, lightly

seasoned, and easily digested. ● Food supplements or snacks in between meals

add calories. ● Food selections vary and can include smooth, creamy, or

crisp textures. Raw fruits and vegetables, coarse breads and cereals, beans, and other potentially gas-forming foods are excluded.

● Indications include clients transitioning between full liquid and regular diets, and those who have acute infections, chewing difficulties, or gastrointestinal disorders.

● Predisposes clients to constipation.

CHAPTER 8

52 CHAPTER 8 MODIFIED DIETS CONTENT MASTERY SERIES

Mechanical soft diet ● A regular diet that is modified in texture. The diet

composition is altered for specific nutrient needs. ● Includes foods that require minimal chewing before

swallowing (ground meats, canned fruits, softly cooked vegetables).

● Butter, gravies, sugar, or honey can be added to increase calorie intake.

● Excludes harder foods (dried fruits, most raw fruits and vegetables, foods containing seeds and nuts).

● Indications include limited chewing ability; dysphagia, poorly fitting dentures, and clients who are edentulous (without teeth); surgery to the head, neck, or mouth; and strictures of the intestinal tract.

Dysphagia diet ● Prescribed when swallowing is impaired (following

a stroke). ● Manifestations of dysphagia are drooling, pocketing

food, choking, or gagging.

LEVELS OF SOLID TEXTURES ● Level 1: Pureed. Foods are totally pureed to a smooth

consistency with a pudding-like texture (pureed fruits, vegetables, meats, soups, scrambled eggs, pudding, custard, applesauce).

● Level 2: Mechanically altered. Soft-textured, moist, semi-solid foods that are easily chewed and swallowed (ground meat served with gravy, chicken or tuna salad, well-moistened pancakes with syrup, poached eggs, soft canned or cooked fruit).

● Level 3: Advanced. Near-normal textured foods that are moist (moist tender meats or casseroles, breads that are not crusty, moist potatoes, soups, rice, and stuffing). Hard, sticky foods are eliminated.

LEVELS OF LIQUID CONSISTENCIES ● Thin: Non-restrictive. Consists of all unthickened

beverages and supplements (clear juices, frozen yogurt, ice cream, milk, soda, and broth).

● Nectar-like: Liquids that are thin enough to sip through a straw but thicker than water. Consistency of a heavy syrup (nectars, cream soups, buttermilk, and thin milkshakes).

● Honey-like: Liquids that do not maintain their shape when poured but are thickened. They can be eaten with a spoon but cannot be sipped through a straw (honey, tomato sauce, and yogurt).

● Spoon-thick: Liquids thickened to maintain their shape and need to be eaten with a spoon (pudding, custard, hot cereals).

NURSING ASSESSMENT/DATA COLLECTION AND INTERVENTIONS

● Ongoing assessment parameters include daily weights, prescribed laboratory tests, and an evaluation of a client’s nutritional and energy needs and response to diet therapy.

● Observe and document nutritional intake. Perform a calorie count if needed to determine caloric intake and to evaluate adequacy.

● Provide education and support for diet therapy. ● A prescription for a diet as tolerated permits a client’s

preferences while taking into consideration the client’s ability to eat. Assess the client for hunger, appetite, and nausea when planning the most appropriate diet, and consult with a dietitian.

● Dietary intake is progressively increased (from nothing by mouth to clear liquids to regular diet) following a major surgery. Nurses should assess for the return of bowel function (as evidenced by auscultation of bowel sounds and the passage of flatus) before advancing a client’s diet.

NUTRITION FOR NURSING CHAPTER 8 MODIFIED DIETS 53

Active Learning Scenario

A nurse is planning care for a newly admitted client who has a prescription for a regular diet. Use the ATI Active Learning Template: Basic Concept to complete this item to include the following sections:

UNDERLYING PRINCIPLES: Identify the indication for a regular diet.

NURSING INTERVENTIONS ● Identify at least two assessments that are

appropriate to determine the need for dietary modifications to the regular diet.

● Identify at least two nursing actions that are appropriate to monitor the client’s response to diet therapy.

Application Exercises

1. A nurse is caring for a client following an appendectomy who has a postoperative prescription that reads “discontinue NPO status; advance diet as tolerated.” Which of the following are appropriate for the nurse to offer the client initially? (Select all that apply.)

A. Applesauce

B. Chicken broth

C. Sherbet

D. Wheat toast

E. Cranberry juice

2. A nurse is caring for a client who is to receive a Level 2 dysphagia diet due to a recent stroke. Which of the following dietary selections is most appropriate?

A. Turkey sandwich

B. Poached eggs

C. Peanut butter crackers

D. Granola

3. A nurse is performing dietary needs assessments for a group of clients. A blenderized liquid diet is appropriate for which of the following clients? (Select all that apply.)

A. A client who has a wired jaw due to a motor vehicle crash

B. A client who is 24 hr postoperative following temporomandibular joint repair

C. A client who has difficulty chewing due to oral surgery

D. A client who has hypercholesterolemia due to coronary artery disease

E. A client who is scheduled for a colonoscopy the next morning

4. A nurse is caring for a client who has multiple sclerosis and requires liquids with honey-like thickness. Which of the following foods can the client consume without adding a thickening agent?

A. Ice cream

B. Yogurt

C. Buttermilk

D. Cream of chicken soup

5. A nurse is assisting a client who has a prescription for a mechanical soft diet with food selections. Which of the following are appropriate selections by the client? (Select all that apply.)

A. Dried prunes

B. Ground turkey

C. Mashed carrots

D. Fresh strawberries

E. Cottage cheese

54 CHAPTER 8 MODIFIED DIETS CONTENT MASTERY SERIES

Application Exercises Key

1. A. Applesauce is appropriate once the client’s diet begins to advance. It is not appropriate as an initial postoperative selection.

B. CORRECT: Chicken broth is a clear liquid, which is appropriate as an initial selection for a client who is postoperative.

C. Sherbet is appropriate once the client’s diet begins to advance. It is not appropriate as an initial postoperative selection.

D. Wheat toast is appropriate once the client’s diet begins to advance. It is not appropriate as an initial postoperative selection.

E. CORRECT: Cranberry juice is a clear liquid, which is appropriate as an initial selection for a client who is postoperative.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

2. A. A Level 2 diet requires foods that are moist and semi-solid. A turkey sandwich would be too dry, and breads are not allowed on the Level 2 diet. This would be an appropriate choice for a client receiving a regular diet.

B. CORRECT: A Level 2 diet requires foods that are moist and semi-solid, such as a poached egg.

C. A Level 2 diet requires foods that are moist and semi-solid. Peanut butter crackers are too sticky and dry for a Level 2 diet. This would be an appropriate choice for a client who is receiving a regular diet.

D. A Level 2 diet requires foods that are moist and semi-solid. Granola is too hard and crunchy for a client receiving a Level 2 diet.

NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures

3. A. CORRECT: A blenderized liquid diet is appropriate for a client who has a wired jaw.

B. CORRECT: A blenderized liquid diet is appropriate for a client following oral surgery.

C. CORRECT: A blenderized liquid diet is appropriate for a client who has difficulty chewing.

D. The client’s history does not indicate a need for a blenderized liquid diet.

E. A client who is scheduled for a colonoscopy should receive a clear liquid, rather than a blenderized liquid, diet.

NCLEX® Connection: Reduction of Risk Potential, Potential for Alterations in Body Systems

4. A. Identify ice cream as a thin liquid that can place the client at risk for aspiration.

B. CORRECT: Identify yogurt as a honey-like liquid, because it can be eaten with a spoon but not sipped with a straw. This client can also safely receive spoon-thick liquids.

C. Identify buttermilk as a nectar-like liquid that can place the client at risk for aspiration.

D. Identify cream of chicken soup as a nectar-like liquid that can place the client at risk for aspiration.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

5. A. Dried fruits are excluded from a mechanical soft diet due to potential chewing difficulty.

B. CORRECT: Ground meats require minimal chewing before swallowing and are therefore appropriate for a mechanical soft diet.

C. CORRECT: Mashed carrots require minimal chewing before swallowing and are therefore appropriate for a mechanical soft diet.

D. Fresh strawberries are excluded from a mechanical soft diet due to seeds and potential chewing difficulty.

E. CORRECT: Cottage cheese requires minimal chewing before swallowing and is therefore appropriate for a mechanical soft diet.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

UNDERLYING PRINCIPLES: A regular diet is indicated for clients who do not need dietary restrictions.

NURSING INTERVENTIONS

Assessments to determine the need for dietary modification ● Individual preferences ● Food habits ● Ethnic values or practices

Assessments to monitor the client’s response to diet therapy ● Obtain daily weight ● Monitor laboratory values ● Monitor energy level ● Observe and document nutritional intake ● Evaluate understanding of diet therapy

NCLEX® Connection: Physiological Adaptation, Illness Management

NUTRITION FOR NURSING CHAPTER 9 ENTERAL NUTRITION 55

UNIT 2 CLINICAL NUTRITION

CHAPTER 9 Enteral Nutrition Enteral nutrition (EN) is used when a client cannot consume adequate nutrients and calories orally, but has a gastrointestinal (GI) system that functions at least partially. EN is contraindicated when the GI tract is nonfunctional (paralytic ileus or intestinal obstruction).

EN is administered when a client has a condition (burns, trauma, prolonged intubation, eating disorders, radiation therapy, chemotherapy, liver or renal dysfunction, infection, inflammatory bowel disease) that hinders nutritional status. EN is also administered when a client is neuromuscularly impaired and cannot chew or swallow food.

EN feeding or gavage feeding for an infant is used when an infant is too weak for sucking, unable to coordinate swallowing, and lacks a gag reflex. Gavage feeding is implemented to conserve energy when an infant is attempting to breast feed or bottle feed, but becomes fatigued, weak, or cyanotic.

EN consists of a commercial formula administered by a tube into the stomach or small intestine. Enteral feedings most closely utilize the body’s own digestive and metabolic routes. EN can augment an oral diet or be the sole source of nutrition.

ENTERAL FEEDING ROUTES A client’s medical status and the anticipated length of time that a tube feeding will be required determine the type of tube used.

Nasoenteric tubes

Nasoenteric tubes are short-term (less than 3 to 4 weeks). ● Nasogastric (NG) tubes are passed through the nose to

the stomach. ● Nasoduodenal tubes pass from the nose through the

stomach and end in the duodenum. ● Nasojejunal tubes pass from the nose through the

stomach and end in the jejunum. ● Nasoduodenal and nasojejunal tubes are used in clients

who are at risk for aspiration or who have delayed gastric emptying (gastroparesis).

● For an infant, a feeding tube is inserted from the nares or mouth into the stomach. This flexible tube can remain taped in place for up to 30 days.

Ostomies

Ostomies are placed for clients requiring long-term enteral feeding, who are at high risk for aspiration or when a nasal obstruction makes insertion through the nose impossible. An ostomy is a surgically created opening (stoma); ostomies can be used to deliver feedings directly into the stomach or intestines.

Gastrostomy tubes are endoscopically or surgically inserted into the stomach.

● A percutaneous endoscopic gastrostomy (PEG) tube is placed with the aid of an endoscope.

● An alternative to the PEG tube is a skin-level gastrostomy tube, which is known as a low-profile gastrostomy device. It is more comfortable, longer-lasting, and fully immersible in water. Checking for residual is more difficult with this device because of the close proximity of the button on the skin.

● Gastrostomy tube feedings are generally well-tolerated because the stomach chamber holds and releases feedings in a physiologic manner that promotes effective digestion. As a result, dumping syndrome is usually avoided.

Jejunostomy tubes are surgically inserted into the jejunal portion of the small intestine (jejunum).

ENTERAL FEEDING FORMULAS ● Commercial products are preferred over home-blended

ingredients because the nutrient composition, consistency and safety can be better insured.

● Standard and elemental formulas are the two primary types of enteral feeding formulas available. They are categorized by the complexity of the proteins included.

● Other formula types include disease-specific (COPD, kidney disease, immunocompromise) and modular formulas that typically contain a single nutrient (protein, carbohydrates, fat).

CHAPTER 9

56 CHAPTER 9 ENTERAL NUTRITION CONTENT MASTERY SERIES

Standard formulas ● Also called polymeric or intact, these formulas are

composed of whole proteins (milk, meat, eggs) or protein isolates.

● They require a functioning gastrointestinal tract. ● Most provide 1 to 2 cal/mL.

Elemental formulas ● These formulas are made up of nutrients that are

partially or fully hydrolyzed or broken down. ● These formulas are used for clients who have a

partially functioning gastrointestinal tract, or those who have an impaired ability to digest and absorb foods (inflammatory bowel disease, liver failure, cystic fibrosis, pancreatic disorders, and short-gut syndrome).

● Most provide 1.0 to 1.5 cal/mL. High-calorie formulas provide 1.5 to 2.0 cal/mL. Partially hydrolyzed formulas provide other nutrients in simpler forms that require little or no digestion.

PACKAGING Tube feedings can be packaged in cans or prefilled bags. ● Prefilled bags and administration tubing should be

discarded every 24 hr or according to facility policy, even if they are not empty.

● Cans can be used to add formula to a generic bag to infuse via a pump, or for feedings directly from a syringe.

DETERMINING APPROPRIATE FORMULA Caloric density determines the volume of the formula necessary to meet the caloric needs of a client (1.0 to 1.2 cal/mL).

Water content in formulas with 1.0 cal/mL should be 850 mL water per 1 L formula. Higher-calorie formulas have lower water content. The client might need additional free water to meet hydration needs.

Osmolality of the formula is determined by the amount of dissolved particles of sugars, amino acids, and electrolytes. ● Osmolality is increased if the formula contains more

digested protein. ● Hydrolyzed or partially hydrolyzed (predigested)

formulas are higher in osmolality than standard formulas. They are also lactose-free.

Fiber and residue content ● Standard formulas are low in residue which makes

them less likely to produce abdominal distention or gas. These products are optimal for clients who have been on bowel rest, are postoperative following bowel surgery, or have GI related disease processes. Hydrolyzed formulas are considered residue-free.

● Standard formulas that are enriched with fiber are recommended for clients who have constipation or diarrhea to normalize bowel movements.

The presence of other nutrients include fats and carbohydrates, which can be modified according to a client’s disease processes (respiratory disease, malabsorption, diabetes mellitus, kidney disease).

ENTERAL FEEDING DELIVERY METHODS The delivery method is dependent on the type and location of the feeding tube, type of formula administered, and the client’s medical status and GI function.

Continuous infusion method

Formula is administered at a continuous rate over a 24-hr period.

● Infusion pumps help ensure consistent flow rates. ● This method is recommended for critically ill clients

because of its association with smaller residual volumes, and a lower risk of aspiration and diarrhea.

● Many facilities require measuring every 4 to 6 hr. Other facilities are moving away from this practice, as there is insufficient evidence to support it.

● Feeding tubes should be flushed with 20 to 50 mL of warm water every 4 hr to maintain tube patency and provide hydration.

● Check facility policy regarding withholding feedings for high gastric residual volume (GRV). Typically, the amount is more than 250 mL on two consecutive measurements for an adult or more than one-fourth the prescribed volume for children.

Cyclic feeding ● Formula is administered at a continuous rate for 8 to

20 hr, often during sleeping hours. ● Often used for transition from total EN to oral intake.

Intermittent tube feeding

Formula is administered every 4 to 6 hr in equal portions of 250 to 400 mL, typically over a 30- to 60-min time frame, usually by gravity drip or an electronic pump. Feeding times can range from 20 to 90 min.

● This is often used for noncritical clients, home tube feedings, and clients in rehabilitation.

● Feeding resembles normal pattern of nutrient intake. ● Facilities might require measurement prior to initiating

the feeding and held if the amount is greater than the amount stated in facility policy or prescription.

Bolus feeding

A variation of intermittent feeding using a large syringe attached to the feeding tube. A large volume of formula (700 mL maximum, usual volume is 250 to 400 mL) is administered over a short period of time (5 to 30 min) four to six times daily. ● The rate of administration for a premature or small

infant should be no greater than 5 mL every 10 min, and 10 mL/min in older infants and children.

● Bolus feedings are delivered directly into the stomach; they are contraindicated for tubes placed into the jejunum or duodenum. They can be poorly tolerated and can cause dumping syndrome.

NUTRITION FOR NURSING CHAPTER 9 ENTERAL NUTRITION 57

NURSING ACTIONS

PREPARATION OF THE CLIENT ● Prior to instilling enteral feeding, tube placement

should be verified by radiography. The tube should then be marked with indelible ink or adhesive tape where it exits the nose and documented.

● Measure the tube each shift and prior to each feeding to ensure the tube has not migrated. Aspirating gastric contents and measuring pH levels are not considered reliable methods of verifying initial placement.

● Verify the presence of bowel sounds. ● To maintain feeding tube patency, it is flushed routinely

with warm water. ● Check gastric residuals if required by the facility,

typically every 4 to 6 hr. In some cases, policy or prescription will indicate whether to return the contents to the client’s stomach or to hold or reduce feedings.

◯ The volume that indicates a need for intervention for adults ranges from 100 to 500 mL in a single measurement, or at least 250 mL on two consecutive checks.

◯ Returning residual contents to the stomach prevents electrolyte and fluid imbalance. However, returning large volumes could increase the risk for complications.

● The head of the bed should be elevated at least 30º during feedings and for at least 30 to 60 min afterward to lessen the risk of aspiration.

● Burp the infant following the feeding if the infant’s condition allows.

● Begin with a small volume of full-strength formula. Increase volume in intervals as tolerated until the desired volume is achieved.

● Administer the feeding solution at room temperature to decrease gastrointestinal discomfort.

● Do not heat formulas in a microwave as this can result in uneven temperatures within the solution.

BASELINE PARAMETERS ● Obtain height, weight, and body mass index. ● Monitor blood urea nitrogen (BUN), albumin,

hemoglobin, hematocrit, glucose, and electrolyte levels. ● A registered dietitian will work with the provider to

evaluate nutritional and energy needs. ● Verify gastrointestinal function. Dysfunction of the GI

tract can indicate a need for alternate forms of nutrition.

ONGOING CARE ● Monitor daily weights and I&O. ● Obtain gastric residuals every 4 to 6 hr. ● Monitor electrolytes, BUN, creatinine,

minerals, and CBC. ● Monitor the tube site for manifestations of infection or

intolerance (pain, redness, swelling, drainage). ● Monitor the character and frequency of

bowel movements. ● When appropriate, administer medications through a

feeding tube. ◯ Feeding should be stopped prior to

administering medications. ◯ The tubing should be flushed with water (15 to 30 mL)

before and after the medication is administered, and between each medication if more than one is administered.

◯ Medications should only be dissolved in water. ◯ Liquid medications should be used when possible.

■ For an infant or child, the volume of water to flush is 1.5 times the amount predetermined to flush an unused feeding tube of the same size.

■ More water can be required to flush the tubing following some medications (suspensions).

INTERVENTIONS ● Weaning occurs as oral consumption increases. Enteral

feedings can be discontinued when the client consumes two-thirds of protein and calorie needs orally for 3 to 5 days.

● A client who is NPO will require meticulous oral care. ● A client can require nutritional support service at home

for long-term EN. A interprofessional team comprised of a nurse, dietitian, pharmacist, and the provider monitors the client’s weight, electrolyte balance, and overall physical condition.

● Transitioning from EN to an oral diet requires the client to receive adequate nutrition as food items are reintroduced. ◯ Begin the transition process by stopping the EN for

1 hr before a meal. ◯ Slowly increase the frequency of the meals until the

client is eating up to six small meals daily. ◯ When oral intake equals 500 to 750 cal/day, the

continuous tube feeding is administered only during the night.

Online Video: Enteral Tube Feeding

58 CHAPTER 9 ENTERAL NUTRITION CONTENT MASTERY SERIES

COMPLICATIONS

Gastrointestinal complications ● Constipation, diarrhea, cramping, pain, abdominal

distention, dumping syndrome, nausea, and vomiting. ● Dumping syndrome occurs due to rapid emptying of

the formula into the small intestine, resulting in a fluid shift. Manifestations include dizziness, rapid pulse, diaphoresis, pallor, and lightheadedness.

NURSING ACTIONS ● Consider a change in formula. ● Decrease the flow rate or total volume of the infusion. ● Increase the volume of free water if constipated. ● Administer the EN at room temperature. ● Take measures to prevent bacterial contamination.

Mechanical complications

Tube misplacement or dislodgement; aspiration; irritation and leakage at the insertion site; irritation of the nose, esophagus, and mucosa; and clogging of the feeding tube.

NURSING ACTIONS ● Confirm tube placement prior to feedings. ● Elevate the head of the bed at least 30º during

feedings and maintain the client in this position for approximately 60 min following completion of the feeding.

● Administer bolus feedings over a period of 15 to 30 min. ● Flush the tubing with 15 to 30 mL of warm water every 4 hr for continuous infusion, after measuring gastric residual, before and after bolus feedings, and between each medication administration.

● Unclog tubing using gentle pressure with 30 to 50 mL warm water in a 60 mL piston syringe. Carbonated beverages are not approved for fixing a clogged tube. Commercially-made products are available and have been shown to effectively dissolve clotted formula.

● Do not mix medications with the formula.

Metabolic complications

Include dehydration, hyperglycemia, electrolyte imbalances, fluid overload, refeeding syndrome, rapid weight gain

NURSING ACTIONS ● Provide adequate amounts of free water. ● Consider changing formula to one that is isotonic. ● Restrict fluids if fluid overload occurs. ● Monitor electrolytes, blood glucose, and weights. ● Monitor respiratory, cardiovascular, and

neurologic status. ● Administer insulin per prescribed protocol

for hyperglycemia.

Refeeding syndrome

A potentially fatal complication that occurs when a client who is in a starvation state is started on enteral nutrition. The risk is greater with parenteral nutrition than enteral.

Food poisoning

Can result due to bacterial contamination of formula

NURSING ACTIONS: Prevent bacterial contamination. ● Wash hands before handling formula or enteral products. ● Clean equipment and tops of formula cans. ● Use closed feeding systems. ● Cover and label unused cans with the client’s name,

room number, date, and time of opening. ● Refrigerate unused portions promptly for up to 24 hr. ● Replace the feeding bag, administration tubing, and any

equipment used to mix the formula every 24 hr. ● Fill generic bags with only 4 hr worth of formula.

NUTRITION FOR NURSING CHAPTER 9 ENTERAL NUTRITION 59

Active Learning Scenario

A nurse is providing information to a client on complications that can occur when administering an enteral nutrition. What information should the nurse include in the teaching? Use the ATI Active Learning Template: Basic Concept to complete this item to include the following.

RELATED CONTENT: Identify three complications. List two nursing interventions for each complication.

Application Exercises

1. A nurse is discussing the use of a low-profile gastrostomy device with the guardian of a child who is receiving an enteral feeding. Which of the following is an appropriate statement by the nurse?

A. “The device is usually comfortable for children.”

B. “Checking residual is much easier with this device.”

C. “This access requires less maintenance than a traditional nasal tube.”

D. “Mobility of the child is limited with this device.”

2. A nurse is teaching a client who is starting continuous feedings about the various types of enteral nutrition (EN) formulas. Which of the following should the nurse include in the teaching?

A. Formula rich in fiber is recommended when starting EN.

B. Standard formula contains whole protein.

C. Hydrolyzed formula is recommended for a full-functioning GI tract.

D. The high-calorie formula has increased water content.

3. A nurse is instructing a client on how to administer cyclic enteral feedings at home. Which of the following information should the nurse include?

A. “Give a feeding every 6 hours.”

B. “Set the feeding up before you go to bed.”

C. “Weigh yourself daily.”

D. “Flush the tube with a carbonated beverage to dislodge clogs.”

E. “Ensure your head is elevated to 15 degrees during administration.”

4. A nurse is administering bolus enteral feedings to a client who has malnutrition. Which of the following are appropriate nursing interventions? (Select all that apply.)

A. Verify the presence of bowel sounds.

B. Flush the feeding tube with warm water.

C. Elevate the head of the bed 20°.

D. Administer the feeding at room temperature.

E. Instill the formula over 60 min.

5. A nurse is preparing to administer intermittent enteral feeding to a client. Which of the following are appropriate nursing interventions? (Select all that apply.)

A. Fill the feeding bag with 24 hr worth of formula.

B. Discard feeding equipment after 24 hr.

C. Place any unused formula in open cans in the refrigerator.

D. Flush the feeding tube every 4 hr.

E. Elevate the head of the client’s bed for 15 min after administration.

60 CHAPTER 9 ENTERAL NUTRITION CONTENT MASTERY SERIES

Application Exercises Key

1. A. CORRECT: The gastrostomy device is more comfortable for children because of the close proximity of the button on the skin.

B. Checking for residual is more difficult with this device because of the close proximity of the button on the skin.

C. Instruct the guardian to provide regular stoma care, and give information about flushing the tube.

D. The mobility of the child is increased because of the close proximity of the button on the skin.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

2. A. Residual-free formula without fiber is recommended when starting EN to minimize abdominal distention from increased flatus.

B. CORRECT: A standard formula contains whole protein (milk, meat, eggs) and requires a full-functioning GI tract.

C. Hydrolyzed formula is recommended for a partially functioning digestive tract or for those who have impaired ability to digest and absorb foods.

D. Formula high in calories is low in water content.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

3. A. Include this instruction for a client who is prescribed intermittent feedings.

B. CORRECT: Many clients administer cyclic feedings during sleeping hours, so they are free during the daytime to do other things.

C. CORRECT: The client should obtain a daily weight while receiving enteral nutrition.

D. Have the client notify the provider if the tube is clogged to obtain a commercial remedy to dislodge the tube.

E. Tell the client to elevate the head 30º or more during administration.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

4. A. CORRECT: Verify the presence of bowel sounds prior to a bolus feeding to ensure the bowel is functioning.

B. CORRECT: Flush the feeding tube to ensure patency before administering a bolus feeding.

C. Elevate the client’s head of bed at least 30° prior to a bolus feeding to decrease the risk of aspiration.

D. CORRECT: Administer the bolus feeding at room temperature to prevent abdominal cramping.

E. Instill the formula in a shorter time period, typically 5 to 30 min.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

5. A. The feeding bag should be filled with only enough formula for 4 hr to prevent bacterial contamination.

B. CORRECT: Feeding equipment, such as the bag holding the formula and the tubing, should be discarded every 24 hr to prevent bacterial contamination.

C. CORRECT: The unused portion of formula should be refrigerated up to 24 hr to prevent bacterial contamination.

D. CORRECT: Flushing the feeding tube every 4 hr maintains patency.

E. Elevate the head of the client’s bed for 30 to 60 min following administration to prevent aspiration.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT

Infection and sepsis ● Monitor for manifestations of fever, chills, increased WBCs, and redness around catheter insertion site.

● Use aseptic technique when setting up the IV tubing and accessing or deaccessing the port.

● Use sterile technique when changing central line dressing and tubing. ● Change the PN bag and tubing set every 24 hr or per facility protocol.

Hyperglycemia ● Administer sliding scale insulin or plan for insulin to be added to the TPN solution.

● Monitor blood glucose.

Hypoglycemia ● Inform the provider and plan to give additional dextrose. ● Monitor frequent blood glucose.

Weight gain greater than 1 kg/day ● Inform the provider and anticipate a decrease in the concentration, rate of administration or volume of lipid emulsion.

● Monitor the client’s intake of oral nutrients.

NCLEX® Connection: Pharmacological and Parenteral Therapies, Nutrition and Oral Hydration

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NUTRITION FOR NURSING NCLEX® CONNECTIONS 65

NCLEX® Connections

When reviewing the following chapters, keep in mind the relevant topics and tasks of the NCLEX outline, in particular:

Health Promotion and Maintenance HEALTH PROMOTION/DISEASE PREVENTION Identify risk factors for disease/illness.

Educate the client on actions to promote/ maintain health and prevent disease.

HEALTH SCREENING: Perform targeted screening assessments.

HIGH-RISK BEHAVIORS: Assist the client to identify behaviors/risks that may impact health.

Basic Care and Comfort ELIMINATION: Assess and manage client with an alteration in elimination.

NUTRITION AND ORAL HYDRATION Provide nutritional supplements as needed.

Evaluate the impact of disease/illness on the nutritional status of a client.

Physiological Adaptation ALTERATIONS IN BODY SYSTEMS: Implement interventions to address side/adverse effects of radiation therapy.

ILLNESS MANAGEMENT: Educate the client about managing illness.

FLUID AND ELECTROLYTE IMBALANCES: Manage the care of the client with a fluid and electrolyte imbalance.

Reduction of Risk Potential POTENTIAL FOR ALTERATIONS IN BODY SYSTEMS: Identify client potential for aspiration.

SYSTEM SPECIFIC ASSESSMENTS: Assess the client for signs of hypoglycemia or hyperglycemia

07/24/15 March 27, 2019 10:08 AM rm_rn_2019_nut_unit3

66 NCLEX® CONNECTIONS CONTENT MASTERY SERIES

NUTRITION FOR NURSING CHAPTER 11 BARRIERS TO ADEQUATE NUTRITION 67

UNIT 3 ALTERATIONS IN NUTRITION

CHAPTER 11 Barriers to Adequate Nutrition

Many individuals have difficulty consuming a nutritional or prescribed diet due to factors that create a barrier. Medical, psychological, and social factors can all create nutritional barriers. Approximately 30% to 50% of clients in acute care facilities are malnourished upon admission or during part of their hospital stay.

It is important for nurses to recognize these factors as nutritional education will be ineffective if a client lacks the necessary resources to follow through on recommendations.

NUTRITIONAL BARRIERS AND NURSING INTERVENTIONS

Poor dentition

Poor dentition (dental caries, poorly fitting dentures) is a potential problem for clients across the lifespan.

● Children who do not have access to dental care or tools (toothbrush, toothpaste) can have caries that impair the ability to chew.

● Adults who have lost teeth or have teeth that need removal or repair have an impaired ability to chew.

● After an adult has teeth removed, it can be difficult to adjust to dentures.

NURSING CARE ● School screenings can help identify children who need

dental attention, and can facilitate the referral process. ● Provide children with information about healthy snacks

that are low in sugar. ● Advise children and adults to limit consumption of

processed carbohydrates, which can stick to teeth and increase the risk for dental caries.

● Encourage children and adults to use a fluoridated tooth paste and have fluoride applied to their teeth.

● Perform a basic dental screening for clients admitted to acute or long-term care facilities to identify issues that can affect the ability to properly eat.

● Consult a dietitian or nutritionist to assist with meal and diet planning, as well as for recommendations on nutritional supplements.

Low socioeconomic status and lack of access

The lack of money to purchase healthy foods or foods required for a specific diet can be a barrier to maintaining a proper diet. ● Nutritious foods (fresh fruit, vegetables) tend to be more

expensive than canned and boxed foods. ● Canned, boxed, and processed foods (lunch meats and

frozen meals) are usually high in calories and salt, and often contain a higher fat, sodium, and simple carbohydrate content. These are poor choices for clients on calorie- or sodium-restricted diets.

● The lack of money to purchase necessary food can lead to malnutrition or obesity if canned and boxed foods are selected.

● The lack of transportation to grocery stores is a barrier if the client does not have a car or is not licensed to drive.

● Food deserts occur in low-socioeconomic areas where a person lives more than 1 mile from a food source in the urban area, or more than 10 miles in a rural area.

NURSING CARE ● Refer the client to a dietitian who can discuss food

options and substitutions that are appropriate. ● Instruct the client that frozen fruits and vegetables can

be an affordable option, and are maintained longer in the freezer.

● Educate clients on how to read food labels to be aware of nutritional, caloric, and sodium values of the food they are consuming.

● Contact social services regarding the client’s access to food. Investigate the availability of a nutrition program that provides a meal for clients within a community.

Cognitive disorders

Cognitive disorders (dementia, Alzheimer’s disease [AD]) can have a significant impact on nutritional status. ● Clients who have dementia or AD can experience

impairments in memory and judgment, making shopping, food selection, and food preparation difficult.

● As dementia and AD progress, clients might refuse to eat or choose a small selection of food that might not provide adequate nutrition.

NURSING CARE ● If the client lives independently, encourage shopping with

a friend or family member and following a shopping list. ● Monitor for vitamin and mineral deficits, and evaluate

the need for nutritional supplements. ● Contact social services regarding the availability of food

or meal delivery to the client’s home. ● If the client lives in a care facility, provide a menu with

minimal but nutritious options. ● Serve meals at the same time and in the same location

surrounded by the same people. Keep environmental distractions to a minimum.

● Provide snacks in between meals if mealtime intake is inadequate.

● Cut food into small pieces if the client has difficulty chewing food. Remind the client to chew and then swallow. Lightly stroking the chin and throat can help promote swallowing.

CHAPTER 11

68 CHAPTER 11 BARRIERS TO ADEQUATE NUTRITION CONTENT MASTERY SERIES

Altered sensory perception

Clients who have an alteration in vision, smell, or taste can find it difficult to feed themselves or can find food unpalatable. ● Clients who have decreased vision might need

assistance shopping for food on a regular basis, and with food preparation.

● Clients in a health care or long-term care facility might need help with tray setup and location of food on the tray.

● Clients who have an altered sense of smell have an altered sense of taste.

● Clients who smoke might have a diminished sense of smell. ● Clients receiving chemotherapy and other types of

medications can experience taste alterations such as a metallic taste in their mouth, masking the real taste of food.

● Clients receiving radiation to the head and neck can experience altered or loss of taste (mouth blindness).

NURSING CARE ● Encourage the client who has decreased vision to

consider shopping with a friend or family member, or have groceries delivered to the house.

● Contact social services regarding availability of food or meal delivery to the client’s home.

● Recommend to the client who has a food aversion to eat foods that are served cool, as they are typically less aromatic and are less likely to precipitate nausea.

● Suggest consuming foods that are spicy or tangy to compensate for the decreased sense of taste.

● Recommend sucking on hard candies, mints, or chewing gum to counteract an unusual taste in the mouth.

● Instruct the client to avoid ingestion of empty calories. If an increase in calories and fluid is desired, milkshakes, juice, and supplements are good options.

Impairment in swallowing

Clients who have neurologic disorders (Parkinson’s disease, cerebral palsy, stroke) or had a surgical procedure done on their mouth, throat, epiglottis, or larynx can have difficulty managing food and swallowing without choking. ● Clients who have a neurologic disorder affecting the

muscles in the mouth and throat are at risk for aspiration due to delayed swallowing and/or inadequate mastication.

● Clients who have a history of oral cancer might have had part of their lip, tongue, and/or soft palate removed. This significantly affects the ability to masticate and coordinate the development of a bolus of food prior to swallowing.

● The larynx and epiglottis prevent food from entering the trachea. Clients who have had partial or total removal of these can easily aspirate food and fluids, unless special precautions are taken.

NURSING CARE ● Continually monitor clients who are at risk for

aspiration during meals, and have suction equipment immediately available.

● Consult a dietitian regarding an appropriate diet for the client. The National Dysphagia diet includes three levels of solid textures. ◯ Level 1: Pureed ◯ Level 2: Mechanically altered ◯ Level 3: Advanced

● Thicken thin fluids with a commercial thickener to the prescribed consistency of thin, nectar-like, honey-like, or spoon-thick.

● Allow adequate time for assisting the client who has dysphagia to eat. Have the client rest before meals.

● Teach clients who aspirate easily due to surgical alteration of their throat or upper tracheal structures to tuck their chins when swallowing. Arching the tongue in the back of the throat can help close off the trachea.

Mechanical fixation of the jaw

Disorders of the jaw requiring surgery include facial trauma and reconstruction.

● After fractured bones are realigned, the client’s upper and lower jaw might be wired together.

● The jaw can be immobilized for several weeks. ● The client is generally placed on a liquid diet during

this period.

NURSING CARE ● Encourage the intake of fluids. ● Help the client determine where to insert a straw

through the space between the jaws. ● Work with the dietitian to develop a liquid meal plan

that includes the necessary nutrients.

Lack of knowledge and misinformation about nutrition

Clients can be subject to overnutrition, undernutrition, and the ingestion of an inadequate intake of essential nutrients.

● Clients might not have basic knowledge about nutrition. ● Information about nutrition can be confusing

or misleading. ● Clients can be drawn to fad diets (which are generally

unhealthy) because quick results are promised. ● Clients can be misled by false advertising.

NURSING CARE ● Encourage clients to use dietary guidelines available from

government and health associations (MyPlate [www . choosemyplate . gov], American Heart Association, Office of Disease Prevention and Health Promotion Dietary Guidelines [https://health.gov/dietaryguidelines]).

● Assist clients in locating community resources that provide education on nutrition.

● Assess dietary intake. ● Instruct clients on how to read nutrition fact labels. ● Encourage the client to keep a journal of dietary intake. ● Provide clients with information on foods that are

healthy and portion sizes. ● Warn clients that advertisements can be fraudulent.

Medical conditions ● Clients who have medical conditions (cancer, COPD,

burns, severe trauma, or HIV/AIDS) are at increased risk for malnutrition due to anorexia, nausea, or stomatitis related to treatments, increased metabolic demands, or the inability to consume a diet.

● Clients who are undergoing diagnostic testing that require NPO status are potentially at risk.

● Clients who have comorbidities resulting in polypharmacy are at risk for malnutrition and medication nutrient interactions.

NUTRITION FOR NURSING CHAPTER 11 BARRIERS TO ADEQUATE NUTRITION 69

NURSING CARE ● Monitor diet prescriptions and laboratory results,

particularly for clients who are NPO or are receiving clear or full liquid diets for more than 24 hr. Refer the client to a dietitian for a complete evaluation of nutritional status.

● Monitor clients who have comorbidities for interactions between medications and nutrition. Refer the client to a pharmacist for a thorough evaluation of medication interactions and the impact upon nutritional intake.

● Offer several small meals or snacks through the day instead of three large meals if the client cannot tolerate large amounts at once.

● Provide oral care prior to and following meals. ● Discourage the use of alcohol-based mouthwashes for

clients who have stomatitis. ● Provide liquid supplements between meals to increase

nutrient intake.

Active Learning Scenario

A nurse is providing dietary teaching for a client who requests assistance for weight loss. The client states, “I’ve tried several fad diets but they don’t work for me.” Use the ATI Active Learning Template: Basic Concept to complete this item to include the following sections.

UNDERLYING PRINCIPLES: Identify the client’s barrier to nutrition.

NURSING INTERVENTIONS: Identify at least four interventions to address this client’s barrier to nutrition and to promote healthy weight loss.

Application Exercises

1. A nurse is caring for several clients in an extended care facility. Which of the following clients is the highest priority to observe during meals?

A. A client who has decreased vision

B. A client who has Parkinson’s disease

C. A client who has poor dentition

D. A client who has anorexia

2. A nurse is planning care for a client who is receiving treatment for malnutrition. The client is scheduled for discharge to their home where they live alone. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

A. Consult social services to arrange home meal delivery.

B. Encourage the client to purchase nonperishable boxed meals.

C. Advise the client to purchase frozen fruits and vegetables.

D. Recommend drinking a supplement between meals.

E. Educate the client on how to read nutrition labels.

3. A nurse is providing teaching for a client who has a new diagnosis of hypertension and a prescription for a low-sodium diet. Which of the following client statements indicate an understanding of the teaching? (Select all that apply.)

A. “I should select organic canned vegetables.”

B. “I need to read food labels when grocery shopping.”

C. “I will stop eating frozen dinners for lunch at work.”

D. “I know that deli meats are usually high in sodium.”

E. “I can refer to the American Heart Association’s website for dietary guidelines.”

4. A nurse is caring for a client who is transitioning to an oral diet following a partial laryngectomy. Which of the following actions should the nurse take to reduce the client’s risk for aspiration?

A. Request to have the client’s oral medications provided in liquid form.

B. Instruct the client to follow each bite of food with a drink of water.

C. Encourage the client to tuck the chin when swallowing.

D. Consult the dietitian about providing the client with a thin liquid diet.

5. A nurse is planning care for a client who has mechanical fixation of the jaw following a motorcycle crash. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

A. Thicken liquids to honey consistency.

B. Educate the client about the use of a nasogastric tube.

C. Assist the client to use a straw to drink liquids.

D. Ensure that the client receives ground meats.

E. Encourage intake of fluids between meals.

70 CHAPTER 11 BARRIERS TO ADEQUATE NUTRITION CONTENT MASTERY SERIES

Application Exercises Key

1. A. Observation of a client who has decreased vision is necessary to evaluate the client’s need for assistance. However, this client is not the highest priority to observe during meals.

B. CORRECT: A client who has Parkinson’s disease is at risk for aspiration. Due to this safety risk, this client is the highest priority to observe during meals.

C. Observation of a client who has poor dentition is necessary to evaluate the client’s need for assistance or a modified diet. However, this client is not the highest priority to observe during meals.

D. Observation of a client who has anorexia is necessary to evaluate the client’s intake. However, this client is not the highest priority to observe during meals.

NCLEX® Connection: Safety and Infection Control, Accident/ Error/Injury Prevention

2. A. CORRECT: Consult social services to arrange home meal delivery to promote adequate nutrition.

B. Boxed foods are usually high in calories and salt and are therefore not recommended to promote adequate nutrition.

C. CORRECT: Advise the client to purchase frozen fruits and vegetables to promote adequate nutrition.

D. CORRECT: Recommend a supplement between meals to promote adequate nutrition.

E. CORRECT: Educate the client on how to read food labels to promote adequate nutrition.

NCLEX® Connection: Physiological Adaptation, Illness Management

3. A. Canned foods, even if organic, are usually high in sodium and are therefore a poor choice for a client on a sodium-restricted diet.

B. CORRECT: Reading food labels provides the client with information about the food’s sodium content.

C. CORRECT: Frozen dinners are usually high in sodium and are therefore a poor choice for a client on a sodium-restricted diet.

D. CORRECT: Deli meats are usually high in sodium and are therefore a poor choice for a client on a sodium-restricted diet.

E. CORRECT: The American Heart Association is a recommended health association for continued client education on dietary guidelines related to cardiac disorders such as hypertension.

NCLEX® Connection: Physiological Adaptation, Illness Management

4. A. Providing medications in liquid form does not decrease the risk for aspiration.

B. Drinking thin liquids, such as water, increases the risk for aspiration.

C. CORRECT: Tucking the chin when swallowing helps to close off the trachea and reduces the risk for aspiration.

D. Thick, rather than thin, liquids help reduce the risk for aspiration.

NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures

5. A. Mechanical fixation of the jaw does not cause dysphagia. It is not necessary to thicken the client’s liquids.

B. Mechanical fixation of the jaw does not indicate the need for a nasogastric tube.

C. CORRECT: Recommend the use of a straw to drink liquids. Help the client determine where to insert the straw through the space between the jaws.

D. Mechanical fixation of the jaw indicates the need for a liquid diet rather than ground meats.

E. CORRECT: The client who has a mechanical fixation of the jaw will have the jaws wired shut and is only able to consume liquids. Encourage supplemental and nutrient-rich liquids to maintain adequate hydration and nutrition.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

UNDERLYING PRINCIPLES: The client’s barrier to nutrition is lack of knowledge and misinformation about nutrition. This barrier must be acknowledged to promote adequate nutrition.

NURSING INTERVENTIONS ● Encourage the client to use dietary guidelines such as MyPlate. ● Assist the client in locating community resources that provide education and nutrition to support healthy nutrition and weight loss.

● Advise the client that fad diets are generally unhealthy and often include false advertising.

● Perform an assessment of dietary intake. ● Encourage the client to keep a journal of dietary intake. ● Provide the client with information on healthy foods and portion sizes.

NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

NUTRITION FOR NURSING CHAPTER 12 CARDIOVASCULAR AND HEMATOLOGIC DISORDERS 71

UNIT 3 ALTERATIONS IN NUTRITION

CHAPTER 12 Cardiovascular and Hematologic Disorders

Nurses must have an awareness of nutritional needs for clients who have cardiovascular and hematologic disorders. It is important to explore dietary needs with the client and recommend modifications related to the disease process. Understanding the role of primary and secondary prevention is essential to successful treatment.

Cardiovascular diseases are the leading cause of death in the U.S. Coronary heart disease (CHD) is the single leading cause of death.

ASSESSMENT/DATA COLLECTION

Coronary heart disease

Hypercholesterolemia leads to atherosclerosis, a process of damage and cholesterol deposits on the blood vessels of the heart. Atherosclerosis is the cause of many cardiovascular disease complications (myocardial infarction, kidney failure, ischemic strokes). ● High-density lipoprotein (HDL) cholesterol is “good”

cholesterol because it removes cholesterol from the body tissue and takes it to the liver. Levels greater than or equal to 60 mg/dL for males and 70 mg/dL or greater for females provide some protection against heart disease.

● Low-density lipoprotein (LDL) cholesterol is “bad” cholesterol because it transports cholesterol out of the liver and into the circulatory system, where it can form plaques on the coronary artery walls. The optimal range for LDL is less than 130 mg/dL.

● Optimal total cholesterol level is less than 200 mg/dL.

RISK FACTORS ● NON-MODIFIABLE: increasing age, male sex, family

history of early CHD ● MODIFIABLE: high LDL cholesterol, low HDL cholesterol,

consuming a diet high in saturated fat, hypertension, diabetes mellitus, metabolic syndrome, obesity, sedentary lifestyle, nicotine use disorder

Metabolic syndrome

The presence of three of the five following risk factors. ● Abdominal obesity

◯ MALES: greater than or equal to 40-inch waist ◯ FEMALES: greater than or equal to 35-inch waist ◯ For Asian and non-European clients who have lived

predominantly outside the U.S., use population- or country-specific definitions.

● Triglycerides greater than or equal to 150 mg/dL or taking medications to treat high triglyceride levels

● Low HDL or taking medications to lower HDL-C ◯ MALES: less than or equal to 40 mg/dL ◯ FEMALES: less than or equal to 50 mg/dL

● Increased blood pressure or taking an antihypertensive medication ◯ Systolic greater than or equal to 130 mm/Hg ◯ Diastolic greater than or equal to 85 mm/Hg

● Fasting blood glucose greater than or equal to 100 mg/dL or taking medication to control blood glucose levels

ANEMIAS Iron deficiency anemia

RISK FACTORS ● Blood loss, deficient iron intake from diet, alcohol use

disorder, malabsorption syndromes, gastrectomy ● Metabolic increase caused by pregnancy,

adolescence, infection MANIFESTATIONS ● Fatigue ● Lethargy ● Pallor of nail beds ● Intolerance to cold ● Headache ● Tachycardia

! Children who have low iron intake can experience short attention spans and display poor intellectual performance before anemia begins.

Vitamin B12 deficiency anemia (macrocytic)

RISK FACTORS: Lack of meat or dairy consumption, small bowel resection, chronic diarrhea, diverticula, tapeworm, excess of intestinal bacteria

MANIFESTATIONS ● Pallor ● Jaundice ● Weakness ● Fatigue

GASTROINTESTINAL FINDINGS ● Glossitis (inflamed tongue) ● Anorexia ● Indigestion ● Weight loss

NEUROLOGIC FINDINGS ● Decreased concentration ● Paresthesia (numbness) of hands and feet ● Decreased proprioception (sense of body position) ● Poor muscle coordination ● Increasing irritability ● Delirium

CHAPTER 12

72 CHAPTER 12 CARDIOVASCULAR AND HEMATOLOGIC DISORDERS CONTENT MASTERY SERIES

Folic acid deficiency anemia

RISK FACTORS: Poor nutritional intake of foods containing folic acid (green leafy vegetables, citrus fruits, dried bean, nuts), malabsorption syndromes (Crohn’s disease), certain medications (anticonvulsants and oral contraceptives)

MANIFESTATIONS ● Fatigue ● Pallor ● Glossitis ● Irritability ● Diarrhea

Findings of folic acid deficiency anemia mimic those for vitamin B12 deficiency anemia except for the neurologic manifestations.

NUTRITIONAL GUIDELINES AND NURSING INTERVENTIONS

Coronary heart disease

PREVENTATIVE NUTRITION ● Consuming a diet that is limited in trans fats, saturated

fats, and cholesterol can reduce the risk of developing CHD. The Therapeutic Lifestyle Change (TLC) diet is designed to be a user-friendly eating guide to encourage dietary changes.

● Daily cholesterol intake should be less than 200 mg. ● Conservative use of red wine can reduce the risk of

developing CHD. ● Increasing fiber and carbohydrate intake, avoiding

saturated fat, and decreasing red meat consumption can decrease the risk for developing CHD.

● Increased intake of omega-3 fatty acids found in fish, flaxseed, soy beans, canola, and walnuts reduces the risk of coronary artery disease.

● Homocysteine is an amino acid. Elevated homocysteine levels can increase the risk of developing CHD. Deficiencies in folate and vitamins B6 and B12 increase homocysteine levels.

THERAPEUTIC NUTRITION ● Secondary prevention efforts for CHD are focused on

lifestyle changes that lower LDL. These include a diet low in cholesterol and saturated fats, a diet high in fiber, exercise and weight management, and cessation of nicotine use.

● Daily cholesterol intake should be less than 200 mg/day. Saturated fat should be limited to less than 7% of daily caloric intake.

● To lower cholesterol and saturated fats, instruct the client to do the following. ◯ Trim visible fat from meats. ◯ Limit red meats and choose lean meats

(turkey, chicken). ◯ Remove the skin from meats. ◯ Broil, bake, grill, or steam foods. Avoid frying foods. ◯ Use low-fat or nonfat milk, cheese, and yogurt. ◯ Use spices in place of butter or salt to season foods. ◯ Use liquid oils (olive or canola) in place of oils that are

high in saturated fat (lard, butter).

◯ Avoid trans fat, which increases LDL. Partially hydrogenated products contain trans fat.

◯ Increase consumption of oily fish (tuna, salmon, herring).

◯ Read labels. ● Encourage the client to consume a high-fiber diet.

◯ Soluble fiber lowers LDL. ◯ Oats, beans, fruits, vegetables, whole grains, barley, and flaxseed are good sources of fiber.

● Encourage the client to exercise. ◯ Instruct the client regarding practical methods for increasing physical activity. (Encourage the client to take the stairs rather than the elevator.)

◯ Provide the client with references for local exercise facilities.

● Instruct the client to stop all use of tobacco products. ● The recommended lifestyle changes represent a

significant change for many clients. ◯ Provide support to the client and family. ◯ Encourage the client’s family to participate in the changes to ease the transition for the client.

◯ Explain why the diet is important. ◯ Aid the client in developing a diet that is complementary to personal food preferences and lifestyle. A food diary can be helpful.

◯ Instruct the client that occasional deviations from the diet are reasonable.

Hypertension ● Hypertension is a significant risk factor for developing

CHD, myocardial infarction, kidney disease, and stroke. ● Hypertension is a sustained elevation in blood pressure

greater than or equal to 140/90 mm Hg for clients under the age of 60, 150/90 mm Hg for those older than 60.

RISK FACTORS FOR PRIMARY HYPERTENSION: family history, hyperlipidemia, smoking, obesity, physical inactivity, high sodium intake, low potassium intake, excessive alcohol consumption, stress, and aging. African-American people have the highest prevalence of hypertension. A client’s risk of hypertension increases after menopause.

THERAPEUTIC NUTRITION ● The Dietary Approaches to Stopping Hypertension

(DASH) diet is a low-sodium, high-potassium, high-calcium diet that has proven to lower blood pressure (systolic and diastolic) and cholesterol. ◯ Decrease sodium intake (initially a daily intake of less

than 2,300 mg is recommended, and should gradually be decreased to 1,500 mg for maximum benefit).

◯ Foods high in sodium include canned soups and sauces, potato chips, pretzels, smoked meats, seasonings, and processed foods.

◯ Include low-fat dairy products to promote calcium intake.

◯ Include fruits and vegetables rich in potassium (apricots, bananas, tomatoes, potatoes).

● Limit alcohol intake. ● Encourage the client to read labels and educate the

client about appropriate food choices. ● Other lifestyle changes include exercising, weight loss,

and smoking cessation.

NUTRITION FOR NURSING CHAPTER 12 CARDIOVASCULAR AND HEMATOLOGIC DISORDERS 73

Heart failure

Heart failure is characterized by the inability of the heart to maintain adequate blood flow throughout the circulatory system. It results in excess sodium and fluid retention, and edema.

RISK FACTORS: CHD, arrhythmias, previous MI, valve disorders, hypertension, obesity, diabetes, metabolic syndrome

THERAPEUTIC NUTRITION ● Reduce sodium intake to less than 3,000 mg per day for

mild-to-moderate heart failure and less than 2,000 mg/ day for severe heart failure.

● Monitor fluid intake (and possibly restrict 2 L/day). ● Increase protein intake to 1.12 g/kg. ● Use small, frequent meals that are soft,

easy-to-chew foods.

Myocardial infarction ● A myocardial infarction (MI) occurs when there is an

inadequate supply of oxygen to the myocardium. ● After an MI, it is necessary to reduce the myocardial

oxygen demands related to metabolic activity. ● Risk factors are the same as for CHD.

THERAPEUTIC NUTRITION ● A liquid diet is best for the first 24 hr after

the infarction. ● Caffeine should be avoided because it stimulates the

heart and increases heart rate. ● Small, frequent meals are indicated. ● Counsel the client about recommendations for a

heart-healthy diet.

Anemia

Anemia results from either a reduction in the number of red blood cells (RBCs) or in hemoglobin, the oxygen-carrying component of blood. Anemia can result from a decrease in RBC production, an increase in RBC destruction, or a loss of blood.

● The body requires iron, vitamin B12, and folic acid to produce red blood cells.

● Iron deficiency anemia is the most common nutritional disorder in the world. It affects approximately 10% of the U.S. population, especially older infants, toddlers, adolescent females, and pregnant clients.

● From childhood until adolescence, iron intake tends to be marginal.

● Pernicious anemia is the most common form of vitamin B12 deficiency. It is caused by lack of intrinsic factor, a protein that helps the body absorb vitamin B12.

SOURCES OF IRON ● Meat ● Fish ● Poultry ● Tofu ● Dried peas and beans ● Whole grains ● Dried fruit ● Iron-fortified foods

◯ Infant formula (alternative or supplement to breastfeeding)

◯ Infant cereal (usually the first food introduced to infants)

◯ Ready-to-eat cereals

VITAMIN C: Facilitates the absorption of iron (promote consumption).

! Medicinal iron toxicity is the leading cause of accidental poisoning in small children and can lead to acute iron toxicity.

NATURAL SOURCES OF VITAMIN B12 ● Fish ● Meat ● Poultry ● Eggs ● Milk

People older than 50 years are urged to consume most of their vitamin B12 requirement from supplements or fortified food.

People who follow a vegan diet need supplemental B12.

FOLIC ACID SOURCES ● Green leafy vegetables ● Dried peas and beans ● Seeds ● Orange juice ● Cereals and breads fortified with folic acid

If the client is unable to obtain an adequate supply of folic acid, supplementation can be necessary.

74 CHAPTER 12 CARDIOVASCULAR AND HEMATOLOGIC DISORDERS CONTENT MASTERY SERIES

Application Exercises

1. A nurse is teaching a client about dietary recommendations to lower high blood pressure. Which of the following statements by the client indicates understanding?

A. “My daily sodium consumption should be 3,000 milligrams.”

B. “I should consume foods low in potassium.”

C. “My limit is three cigarettes a day.”

D. “I should consume low-fat dairy products.”

2. A nurse is teaching a client about high-fiber foods that can assist in lowering LDL. Which of the following foods should the nurse include? (Select all that apply.)

A. Beans

B. Cheese

C. Whole grains

D. Broccoli

E. Yogurt

3. A community health nurse is assessing a client who reports numbness of the hands and feet for the past 2 weeks. This finding is associated with which of the following nutritional deficiencies?

A. Folic acid

B. Potassium

C. Vitamin B12

D. Iron

4. A nurse is reviewing a client health record that includes a report of abdominal obesity and laboratory findings of elevated blood glucose and elevated triglycerides. These findings meet the criteria of which of the following conditions?

A. Anemia

B. Metabolic syndrome

C. Heart failure

D. Hypertension

5. A nurse is providing teaching to a client who has vitamin B12 deficiency. Which of the following foods should the nurse instruct the client to consume? (Select all that apply.)

A. Meat

B. Flaxseed

C. Beans

D. Eggs

E. Milk

Active Learning Scenario

A nurse is providing teaching to a client who has hypertension. What should the nurse include in the teaching? Use the ATI Active Learning Template: System Disorder to complete this item to include the following sections.

ALTERATION IN HEALTH (DIAGNOSIS)

CLIENT EDUCATION: Describe the Dietary Approaches to Stopping Hypertension (DASH) diet and four nutrition teaching points to include.

NUTRITION FOR NURSING CHAPTER 12 CARDIOVASCULAR AND HEMATOLOGIC DISORDERS 75

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): Hypertension is a sustained elevation in blood pressure greater than or equal to 140/90 mm Hg in clients less than age 60 and 150/90 mm Hg in those older than 60.

CLIENT EDUCATION ● The DASH diet is a low-sodium, high-potassium, high-calcium diet that has been proven to lower blood pressure and cholesterol.

● Lower sodium intake (daily intake of less than 2,300 mg) is recommended.

● Foods high in sodium include canned soups and sauces, potato chips, pretzels, smoked meats, seasonings, and processed foods.

● Include low-fat dairy products to promote calcium intake. ● Include fruits and vegetables rich in potassium (apricots, bananas, tomatoes, potatoes).

● Limit alcohol intake.

NCLEX® Connection: Physiological Adaptation, Illness Management

Application Exercises Key

1. A. Daily sodium consumption should be 2,300 mg or less. This assists with lowering systolic and diastolic blood pressures as well as cholesterol.

B. Foods high in potassium should be encouraged. This assists with lowering systolic and diastolic blood pressures as well as cholesterol.

C. Smoking cessation should be encouraged. Smoking can increase blood pressure and should be avoided.

D. CORRECT: Low-fat dairy products should be encouraged. They promote calcium intake and assist with lowering systolic and diastolic blood pressures as well as cholesterol.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

2. A. CORRECT: Beans are high in fiber and should be included in the teaching.

B. Cheese is high in calcium and should not be included in the teaching.

C. CORRECT: Whole grains are high in fiber and should be included in the teaching.

D. CORRECT: Broccoli is high in fiber and should be included in the teaching.

E. Yogurt is high in calcium and should not be included in the teaching.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

3. A. Pallor, glossitis, and gastrointestinal distress are manifestations associated with folic acid deficiency.

B. Irritability, decreased respirations, muscle weakness, and gastrointestinal distress are manifestations associated with hypokalemia.

C. CORRECT: Numbness of the hands and feet are manifestations associated with vitamin B12 deficiency.

D. Fatigue, lethargy, pallor of nail beds, and intolerance to cold are manifestations associated with iron deficiency anemia.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

4. A. Fatigue, lethargy, pallor of nail beds, and intolerance to cold are manifestations associated with anemia.

B. CORRECT: Weight gain in the abdomen, elevated blood glucose, and elevated triglycerides are manifestations associated with metabolic syndrome.

C. Shortness of breath, fluid retention, and fatigue are manifestations associated with heart failure.

D. Headaches, tiredness, and dizziness are manifestations associated with hypertension.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

5. A. CORRECT: Meat is a food source that is high in vitamin B12.

B. Flaxseed is a good source of fiber. C. Beans are a good source of folic acid. D. CORRECT: Eggs are a food source that is high in vitamin B12. E. CORRECT: Milk is a food source that is high in vitamin B12.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

76 CHAPTER 12 CARDIOVASCULAR AND HEMATOLOGIC DISORDERS CONTENT MASTERY SERIES

NUTRITION FOR NURSING CHAPTER 13 GASTROINTESTINAL DISORDERS 77

UNIT 3 ALTERATIONS IN NUTRITION

CHAPTER 13 Gastrointestinal Disorders

Nurses must gain an awareness of nutritional needs for clients who have gastrointestinal (GI) disorders. It is important to explore dietary needs with the client and recommend modifications in relationship to the disease process. Understanding the role of primary and secondary prevention is essential to successful treatment.

Nutrition therapy for gastrointestinal disorders is generally aimed at minimizing or preventing manifestations. In some conditions (celiac disease), nutrition is the only treatment. For some GI disorders, nutrition therapy is the foundation of treatment.

ASSESSMENT/DATA COLLECTION ● Determine whether the client is experiencing any of

the following. ◯ Difficulty chewing or swallowing ◯ Nausea, vomiting, or diarrhea ◯ Bloating, excessive flatus, occult blood, steatorrhea,

abdominal pain or cramping, abdominal distention, pale, sticky bowel movements

◯ Changes in weight, eating patterns, or bowel habits ● Determine whether the client uses the following.

◯ Tobacco ◯ Alcohol ◯ Caffeine ◯ Over-the-counter medications to treat GI

conditions (many can have GI complications or be contraindicated with GI conditions)

◯ Nutritional supplements ◯ Herbal supplements for GI conditions or other

problems (some clients do not consider them to be medications, so they do not mention them to the provider)

NUTRITIONAL GUIDELINES AND NURSING INTERVENTIONS

General gastrointestinal considerations ● Monitor gastrointestinal parameters.

◯ Weight and weight changes ◯ Laboratory values ◯ Elimination patterns ◯ I&O

● Low-fiber diets avoid foods that are high in residue content (whole-grain breads and cereals, raw fruits and vegetables). ◯ Diets low in fiber reduce the frequency and volume of

fecal output and slow transit time of food through the digestive tract.

◯ Low-fiber diets are used short-term for clients who have diarrhea or malabsorption syndromes.

● High-fiber diets focus on foods containing more than 5 g of fiber per serving. A diet high in fiber helps: ◯ Increase stool bulk. ◯ Stimulate peristalsis. ◯ Prevent constipation. ◯ Protect against colon cancer.

Nausea and vomiting ● Potential causes of nausea and vomiting include

decreased gastric acid secretion; decreased gastrointestinal motility; allergy to food(s); bacterial or viral infection; increased intracranial pressure; liver, pancreatic, and gall bladder disorders; and adverse effects of some medications.

● The underlying cause of nausea and vomiting should be investigated. Assessing the appearance of the emesis will aid in diagnosis and treatment (coffee-ground emesis indicates the presence of blood; pale green indicates bile).

● Once manifestations subside, begin with clear liquids followed by full liquids, and advance the diet as tolerated.

● Easy-to-digest, low-fat carbohydrate foods (crackers, toast, oatmeal, pretzels, plain bread, bland fruit) are usually well-tolerated.

NURSING ACTIONS ● Promote good oral hygiene with tooth brushing, mouth

swabs, mouthwash, and ice chips. ● Elevate the head of the bed. ● Serve foods at room temperature or chilled.

CLIENT EDUCATION ● Avoid hot and spicy foods. ● Avoid liquids with meals, as they promote a feeling

of fullness. ● Avoid high-fat foods if they contribute to nausea

because they are difficult to digest.

CHAPTER 13

78 CHAPTER 13 GASTROINTESTINAL DISORDERS CONTENT MASTERY SERIES

Anorexia ● Anorexia is defined as a lack of appetite. It is a common

finding for numerous physical conditions and is an adverse effect of certain medications. It is not the same as anorexia nervosa.

● Anorexia can lead to decreased nutritional intake and subsequent protein and calorie deficits.

NURSING ACTIONS ● Decrease stress at meal times. ● Collect data regarding adverse effects of medications. ● Administer medications to stimulate appetite. ● Assess and modify environment for unpleasant odors. ● Remove items that cause a decrease in appetite

(soiled linens, garbage, emesis basins, bedpans, used tissues, clutter).

● Assess and manage anxiety and depression. ● Provide small, frequent meals and avoid high-fat foods to

help maximize intake. Beverages should be held at least 30 min before and after meals to prevent the client from feeling full before adequate intake of calories from food.

● Provide liquid supplements between meals to improve protein and calorie intake.

● Ensure that meals appear appealing. Serve larger meals early in the day.

● Assess for changes in bowel status (increased gastric emptying, constipation, diarrhea).

● Position to increase gastric motility. ● Provide mouth care before and after meals.

Constipation ● Clients who have constipation have difficult or

infrequent passage of stools, which can be hard and dry. ● Causes include irregular bowel habits, psychogenic factors,

inactivity, chronic laxative use, obstruction, medications, GI disorders (irritable bowel syndrome [IBS]), pregnancy, or secondary to genital/rectal trauma (sexual abuse or childbirth), and inadequate consumption of fiber and fluid.

● Encourage exercise and a diet high in fiber (25 g/day for females and 38 g/day for males), and promote adequate fluid intake to help alleviate constipation.

● If caused by medication, a change in the medication might be necessary.

NURSING ACTIONS ● Determine onset and duration of past and present

elimination patterns, what is normal for the client, activity levels, occupation, dietary intake, and stress levels.

● Collect data about past medical and surgical history, medication use (OTC, herbal supplements, laxatives, enemas, and prescriptions), presence of rectal pressure or fullness, and abdominal pain.

● Encourage client to gradually increase daily intake of fiber.

CLIENT EDUCATION ● Increase fluid intake to 64 oz/day unless contraindicated. ● An increase in fiber intake is the preferred treatment for

constipation. Avoid chronic use of laxatives.

Diarrhea ● Diarrhea can cause significant losses of potassium,

sodium, and fluid, as well as nutritional complications. ● Common causes of diarrhea include emotional and

physical stress, gastrointestinal disorders, malabsorption disorders, infections, and certain medications.

● Low-fiber diets might be recommended on a short-term basis to decrease bowel stimulation.

● Nutrition therapy varies with the severity and duration of diarrhea. A liberal fluid intake to replace losses is needed.

Dysphagia ● Dysphagia is an alteration in the client’s ability to swallow. ● Causes include obstruction, inflammation, and certain

neurologic disorders. ● Modifying the texture of foods and the consistency of

liquids can enable the client to achieve proper nutrition. ● Dry mouth can contribute to dysphagia. Evaluate

medications being taken to determine if this is a potential adverse effect.

● Clients who have dysphagia should be referred to a speech therapist for evaluation.

● Dietary modifications are based on the specific swallowing limitations experienced by the client.

● Nutritional supplements are beneficial if nutritional intake is deemed inadequate.

NURSING ACTIONS ● Clients who have dysphagia are at an increased risk of

aspiration. Place the client in an upright or high-Fowler’s position to facilitate swallowing.

● Provide oral care prior to eating to enhance the client’s sense of taste.

● Allow adequate time for eating, use adaptive eating devices, and encourage small bites and thorough chewing.

CLIENT EDUCATION ● Pills should be taken with at least 8 oz of fluid (can be

thickened) to prevent medication from remaining in the esophagus.

● Avoid thin liquids and sticky foods.

Dumping syndrome

Normally, the stomach controls the rate in which nutrients enter the small intestine. When a portion of the stomach is surgically removed, the contents of the stomach are rapidly emptied into the small intestine, causing dumping syndrome. ● Early manifestations typically occur 10 to 20 min

after eating. Early manifestations include a sensation of fullness, abdominal cramping, nausea, diarrhea, and vasomotor manifestations (faintness, syncope, diaphoresis, tachycardia, hypotension, flushing).

● Late manifestations occur 1 to 3 hr after eating. Late manifestations include diaphoresis, weakness, tremors, anxiety, nausea, and hunger.

● Manifestations resolve after intestine is emptied. However, there is a rapid rise in blood glucose and increase in insulin levels immediately after the intestine empties. This leads to hypoglycemia.

NUTRITION FOR NURSING CHAPTER 13 GASTROINTESTINAL DISORDERS 79

NURSING ACTIONS ● Monitor clients receiving enteral tube feedings and report

manifestations of dumping syndrome to the provider. ● Monitor the client for vitamin and mineral deficits (iron

and vitamin B12).

CLIENT EDUCATION ● Consume small, frequent meals. ● Consume protein and fat at each meal. ● Avoid food that contains concentrated sugars and

restrict lactose intake. ● Plan to consume liquids 1 hr after meals or between

meals (no sooner than 30 min after eating). ● Lie down after meals to delay gastric emptying. If reflux

is a problem, try a reclining position.

Gastroesophageal reflux disease ● Gastroesophageal reflux disease (GERD) occurs as the

result of the abnormal reflux of gastric secretions up the esophagus. This leads to indigestion and heartburn.

● Factors that contribute to GERD include hiatal hernia, obesity, pregnancy, smoking, some medications, and genetics.

● Long-term GERD can cause serious complications, including adenocarcinoma of the esophagus and Barrett’s esophagus.

● Manifestations include heartburn, retrosternal burning, painful swallowing, dyspepsia, regurgitation, coughing, hoarseness, and epigastric pain. Pain can be mistaken for a myocardial infarction.

CLIENT EDUCATION ● Avoid situations that lead to increased abdominal

pressure, such as wearing tight-fitting clothing. ● Avoid eating for 3 hr before lying down. ● Elevate the body on pillows instead of lying flat and

avoid large meals and bedtime snacks. ● Attempt weight loss if overweight or obese. ● Avoid trigger foods (citrus fruits and juices, spicy foods,

carbonated beverages). ● Avoid items that reduce lower esophageal sphincter

pressure (fatty foods, caffeine, chocolate, alcohol, cigarette smoke, all nicotine products, peppermint and spearmint flavors).

Acute and chronic gastritis ● Gastritis is characterized by inflammation of the gastric

mucosa. The gastric mucosa is congested with blood and fluid, becoming inflamed. There is a decrease in acid produced and an overabundance of mucus. Superficial ulcers occur, sometimes leading to hemorrhages.

● Acute gastritis occurs with excessive use of NSAIDs, bile reflux, ingestion of a strong acid or alkali substance, as a complication of radiation therapy, or as a complication of trauma (burns; food poisoning; severe infection; liver, kidney, or respiratory failure; major surgery).

● Chronic gastritis occurs in the presence of ulcers (benign or malignant), Helicobacter pylori, autoimmune disorders (pernicious anemia), poor diet (excessive caffeine, excessive alcohol intake), medications (alendronate, perindopril), and reflux of pancreatic secretions and bile into stomach.

● Manifestations include abdominal pain or discomfort (can be relieved by eating), headache, lethargy, nausea, anorexia, hiccuping (lasting a few hours to days), heartburn after eating, belching, sour taste in mouth, vomiting, bleeding, and hematemesis (vomiting of blood).

● Acute recovery typically occurs in 1 day, but can take 2 to 3 days. The client should eat a bland diet when able to tolerate food. IV fluid replacement therapy is indicated if the condition persists.

● When the condition occurs due to ingestion of strong acids or alkalis, dilution and neutralization of the causal agent is needed. Avoid lavage and emetics due to potential perforation and esophageal damage.

CHRONIC MANAGEMENT: Modify diet, reduce and manage stress, avoid alcohol and NSAIDs. If condition is persistent, the provider will prescribe an H2 receptor antagonist (ranitidine).

NURSING ACTIONS: Monitor for vitamin deficiency, especially of vitamin B12.

CLIENT EDUCATION ● Avoid eating frequent meals and snacks, as they

promote increased gastric acid secretion. ● Avoid alcohol, cigarette smoking, aspirin and other

nonsteroidal anti-inflammatory drugs (NSAIDs), coffee, black pepper, spicy foods, and caffeine.

Peptic ulcer disease ● Peptic ulcer disease (PUD) is characterized by an erosion

of the mucosal layer of the stomach or duodenum. This can be caused by a bacterial infection with H. pylori or the chronic use of NSAIDs (aspirin, ibuprofen).

● Some clients who have PUD do not experience manifestations. Others report dull, gnawing pain, burning sensation in the back or low midepigastric area, heartburn, constipation or diarrhea, sour taste in mouth, burping, nausea, vomiting, bloating, urea present in breath, and tarry stools. Eating can temporarily relieve pain. Anemia can occur due to blood loss.

● For PUD caused by H. pylori, the provider prescribes triple therapy (a combination of antibiotics and acid reducing medications) to be taken for 10 to 14 days.

CLIENT EDUCATION: Avoid coffee, alcohol, caffeine, aspirin and other NSAIDs, cigarette smoking, black pepper, and spicy foods.

Lactose intolerance ● Lactose intolerance results from an inadequate supply of

lactase in the intestine, the enzyme that digests lactose. ● The enzyme that converts lactose into glucose, and

galactose is absent or insufficient. Manifestations include distention, cramps, flatus, and osmotic diarrhea.

● Small amounts (4 to 6 oz) of milk taken during meals can be tolerated.

● Some dairy products (yogurt, aged cheeses) are low in lactate and can be better tolerated.

NURSING ACTIONS: Monitor for vitamin D and calcium deficiency.

80 CHAPTER 13 GASTROINTESTINAL DISORDERS CONTENT MASTERY SERIES

NURSING ACTIONS ● Avoid or limit intake of foods high in lactose (milk, soft

cheese, ice cream, cream soups, sour cream, puddings, coffee creamer).

● Ask the provider about the use of a lactase enzyme.

Ileostomies and colostomies

An ostomy is a surgically created opening on the surface of the abdomen from either the end of the small intestine (ileostomy) or from the colon (colostomy). ● Fluid and electrolyte maintenance is the primary

concern for clients who have ileostomies and colostomies.

● The colon absorbs large amounts of fluid, sodium, and potassium.

● Nutrition therapy begins with liquids only and is slowly advanced based upon client tolerance.

NURSING ACTIONS: Provide emotional support to clients due to the risk of altered body image.

CLIENT EDUCATION ● Consume a diet that is high in fluids (at least 1.9 to 2.4 L

[64 to 80 oz] per day) and soluble fiber. ● Avoid foods that cause gas (beans, eggs, carbonated

beverages), stomal blockage (nuts, raw carrots, popcorn), and foods that produce odor (eggs, fish, garlic).

● Increase intake of calories and protein to promote healing of the stoma site.

Diverticulosis and diverticulitis

Diverticula are pouches protruding through the muscle of the intestinal wall, usually from increased intraluminal pressure. They occur anywhere in the colon, but usually in the sigmoid colon. Unless infection occurs, diverticula cause no problems.

● Diverticulosis is a condition characterized by the presence of diverticula.

● Diverticulitis is inflammation that occurs when fecal matter becomes trapped in the diverticula.

● Manifestations of diverticulitis include abdominal pain, nausea, vomiting, constipation or diarrhea, and fever, accompanied by chills and tachycardia.

● The client receives antibiotics, anticholinergics, and analgesics. Clients who have severe manifestations are admitted to the hospital and dehydration is treated with IV therapy. Opioid analgesics are administered for pain. Complications (peritonitis, bowel obstruction, abscess) can warrant surgical intervention.

● A high-fiber diet can prevent diverticulosis and diverticulitis by producing stools that are easily passed, thus decreasing pressure within the colon.

● During acute diverticulitis, a clear liquid diet is prescribed until inflammation decreases, then a high-fiber, low-fat diet is indicated.

● Clients require instruction regarding diet adjustment based on the need for an acute intervention or preventive approach.

Inflammatory bowel disease (IBD) ● Crohn’s disease (regional enteritis) and ulcerative colitis

are chronic, inflammatory bowel diseases characterized by periods of exacerbation and remission.

● Manifestations include nausea, vomiting, abdominal cramps, fever, fatigue, anorexia, weight loss, steatorrhea, and low-grade fever.

● Nutrition therapy is focused on providing nutrients in forms that the client can tolerate.

● A low-residue, high-protein, high-calorie diet with vitamin and mineral supplementation is prescribed during exacerbation to minimize bowel stimulation. Fluid and electrolyte imbalances are corrected with IV fluids or oral replacement fluids.

● Enteral nutrition can be prescribed during exacerbations, especially if the client is reluctant to eat. Because parenteral nutrition is more costly with a relatively similar benefit, it is not used unless enteral nutrition is ineffective or contraindicated.

● When the client is not experiencing an exacerbation, the diet can be broadened based on the client’s specific disease process and triggers.

Additional therapy ● Complementary therapies including vitamin C and herbs

(flaxseed) ● Yoga, hypnosis, and breathing exercises ● Sedatives ● Antidiarrheal and antiperistaltic agents ● Aminosalicylate medications and corticosteroids to

reduce inflammation ● Immunomodulators to alter the immune response and

prevent relapse ● Surgery when other treatments are not effective

CLIENT EDUCATION: Avoid intake of substances that cause or exacerbate diarrhea, and avoid nicotine.

Cholecystitis ● Cholecystitis is characterized by inflammation of

the gallbladder. ● The gallbladder stores and releases bile that aids in the

digestion of fats. ● Manifestations include pain, tenderness, and rigidity

in upper right abdomen. Pain can radiate to the right shoulder or midsternal area. Nausea, vomiting, and anorexia also can occur. If the gallbladder becomes filled with pus or becomes gangrenous, perforation can result.

● In clients who have large stones or inability to control the condition with diet modifications, surgery is required.

● Pancreatitis and liver involvement can result from uncontrolled cholecystitis.

● Fat intake should be limited to reduce stimulation of the gallbladder.

● The diet is individualized to the client’s needs and tolerance.

NUTRITION FOR NURSING CHAPTER 13 GASTROINTESTINAL DISORDERS 81

Pancreatitis ● Pancreatitis is an inflammation of the pancreas, which

can be acute or chronic. In 70% of the acute cases, alcohol use and gallstones are major causes. Chronic pancreatitis can result from acute pancreatitis that does not resolve.

● The pancreas is responsible for secreting enzymes needed to digest fats, carbohydrates, and proteins.

● Nutritional therapy for acute pancreatitis involves reducing pancreatic stimulation. The client is prescribed nothing by mouth (NPO), and a nasogastric tube is inserted to suction gastric contents.

● TPN can be used until oral intake is resumed. ● Nutritional therapy for chronic pancreatitis usually

includes a low-fat, high-protein, and high-carbohydrate diet. It can include providing supplements of vitamin C and B-complex vitamins.

Liver disease ● The liver is involved in the metabolism of most nutrients. ● Disorders affecting the liver include cirrhosis, hepatitis,

and cancer. ● Malnutrition is common with liver disease. ● Protein needs are increased to promote a positive

nitrogen balance and prevent a breakdown of the body’s protein stores.

● Carbohydrates are generally not restricted, as they are an important source of calories.

● Caloric requirements might need to be increased based on an evaluation of the client’s stage of disease, weight, and general health status.

● Multivitamins (especially vitamins B, C, and K) and mineral supplements might be necessary.

● Alcohol, nicotine, and caffeine should be eliminated.

Celiac disease ● Celiac disease is also known as gluten-sensitive

enteropathy, celiac sprue, and gluten intolerance. ● It is a chronic, inherited, genetic disorder with

autoimmune characteristics. Clients who have celiac disease are unable to digest the protein gluten. They lack the digestive enzyme DPP-IV, which is required to break down the gluten into molecules small enough to be used by the body. In celiac disease, gluten is broken down into peptide strands instead of molecules. The body is not able to metabolize the peptides. If untreated, the client will suffer destruction of the villa and the walls of the small intestine. Celiac disease can go undiagnosed in both children and adults.

● Manifestations vary widely. Children who have celiac disease have diarrhea, steatorrhea, anemia, abdominal distention, impaired growth, lack of appetite, and fatigue. Typical manifestations in adults include diarrhea, abdominal pain, bloating, anemia, steatorrhea, and osteomalacia.

● Treatment for celiac disease is limited to avoiding gluten. However, eliminating gluten, which is found in wheat, rye and barley, is difficult because it is found in many prepared foods. Clients must read food labels carefully in order to adhere to a gluten-free diet. Some gluten-free products are unappealing to clients, and many are more expensive than other products. Prognosis is good for clients who adhere to a gluten-free diet.

NURSING ACTIONS ● Monitor for complications including bleeding (bruising)

due to inadequate vitamin K intake, manifestations of anemias (iron, folate, vitamin B12), and manifestations of osteoporosis.

● Collaborate with a dietitian to assist with food selection and label reading.

CLIENT EDUCATION ● Eat foods that are gluten-free (milk, cheese, rice, corn,

eggs, potatoes, fruits, vegetables, fresh meats and fish, dried beans).

● Read labels on processed products. Gravy mixes, sauces, cold cuts, soups, and many other products have gluten as an ingredient.

● Read labels and research nonfood products (lipstick, communion wafers, vitamin supplements), which also can have gluten as an ingredient.

Bariatric surgery

This is considered the most effective treatment for managing obesity and related conditions. Benefits include reduction of diabetes mellitus, hypertension, dyslipidemia, and mortality rates as well as improved quality of life. ● Bariatric surgery works best in combination with

diet and lifestyle changes. Nutritional counseling is essential. Protein intake of 60 g/day is required to prevent protein-calorie malnutrition.

● CLIENT EDUCATION: Dramatic changes in food intake and regular physical activity will be necessary for successful long-term weight control.

Adjustable gastric banding restricts stomach capacity to 15 to 30 mL with an inflatable band that encircles the uppermost portion of the stomach, similar to a belt to create an outlet that can be adjusted as needed.

● CLIENT EDUCATION ◯ Diet will gradually increase from liquids to pureed to soft foods.

◯ Chew foods thoroughly, slowly, and in small amounts.

Roux-en-Y gastric bypass: Ingested food bypasses 95% of the stomach, the duodenum, and a small portion of the proximal jejunum. Weight loss is achieved through malabsorption and dumping syndrome and the altering of the hormone ghrelin which decreases hunger. ● Possible postoperative complications include

anastomotic leaks, internal hernias, GI bleeding, stomal stenosis, gallstones.

● Micronutrient deficiencies are common long term.

Sleeve gastrectomy is a procedure in which a longitudinal portion of the stomach is removed to create a “sleeve” effect. This reduces production of the hormone ghrelin, which decreases hunger.

82 CHAPTER 13 GASTROINTESTINAL DISORDERS CONTENT MASTERY SERIES

Active Learning Scenario

A nurse is providing instructions to the guardian of a child who has lactose intolerance. What should the nurse include in the teaching? Use the ATI Active Learning Template: System Disorder to complete this item.

CLIENT EDUCATION ● Describe the underlying cause of lactose intolerance. ● Identify two manifestations of lactose intolerance. ● Identify three foods the child should limit or eliminate from their diet.

Application Exercises

1. A nurse is teaching a client who is recovering from pancreatitis about following a low-fat diet. Which of the following foods should the nurse recommend? (Select all that apply.)

A. Ribeye steak

B. Oatmeal

C. Ice cream

D. Canned peaches

E. Pretzels

2. A nurse is teaching a client who has constipation about a high-fiber, low-fat diet. Which of the following food choices by the client indicates understanding of the teaching?

A. Peanut butter

B. Peeled apples

C. Hardboiled egg

D. Brown rice

3. A nurse is assessing a client who is postoperative from a gastric bypass and who just finished eating a meal. Which of the following findings are manifestations of dumping syndrome? (Select all that apply.)

A. Bradycardia

B. Dizziness

C. Dry skin

D. Hypotension

E. Diarrhea

4. A nurse is collecting data from a client who has peptic ulcer disease (PUD). Which of the following findings should the nurse expect? (Select all that apply.)

A. Steatorrhea

B. Anemia

C. Tarry stools

D. Epigastric pain

E. Swollen lymph nodes

5. A nurse is instructing a client who has celiac disease about foods to avoid. Which of the following foods should the nurse include in the teaching?

A. Potatoes

B. Graham crackers

C. Wild rice

D. Canned pears

NUTRITION FOR NURSING CHAPTER 13 GASTROINTESTINAL DISORDERS 83

Application Exercises Key

1. A. Ribeye steak is not a low-fat food source. B. CORRECT: Oatmeal is a source of easily

digested carbohydrate that is low in fat. C. Ice cream is not a low-fat food source. D. CORRECT: Canned peaches are a source of easily

digested carbohydrate that is low in fat. E. CORRECT: Pretzels are a source of easily

digested carbohydrate that is low in fat.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

2. A. Peanut butter is high in fat. B. Unpeeled fruit is a better source of fiber. C. Egg yolk is high in fat. D. CORRECT: Brown rice is a good source

of fiber and is low in fat.

NCLEX® Connection: Basic Care and Comfort, Elimination

3. A. Tachycardia due to a decrease in circulating volume is a manifestation of dumping syndrome.

B. CORRECT: When a portion of the stomach is no longer available to serve as a reservoir, a large amount of food is rapidly dumped into the small intestine, and fluid shifts from general circulation into the intestine. Dizziness occurs due to a decrease in circulating volume.

C. Sweating is a manifestation of dumping syndrome. D. CORRECT: Hypotension occurs due to a

decrease in circulating volume. E. CORRECT: Diarrhea from increased peristalsis is

a manifestation of dumping syndrome.

NCLEX® Connection: Basic Care and Comfort, Elimination

4. A. Steatorrhea is a clinical finding in the presence celiac disease.

B. CORRECT: Iron deficiency anemia due to blood loss is a clinical finding of PUD.

C. CORRECT: Tarry stools due to intestinal bleeding is a clinical finding of PUD.

D. CORRECT: Epigastric pain described as a gnawing or burning sensation is a clinical manifestation of PUD.

E. Swollen lymph nodes are a clinical manifestation of many conditions and infections, but not of PUD.

NCLEX® Connection: Basic Care and Comfort, Elimination

5. A. Potatoes are gluten-free and a good choice for a client who has celiac disease.

B. CORRECT: Graham crackers are made from wheat flour. A client who has celiac disease should avoid products that are made from wheat flour.

C. Wild rice is gluten-free and a good choice for a client who has celiac disease.

D. Fruits and vegetables without a sauce are gluten-free and are good choices for a client who has celiac disease.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

CLIENT EDUCATION ● The underlying cause of lactose intolerance is an inadequate level of lactase. The enzyme that converts lactose into glucose and galactose is absent or insufficient.

● Manifestations ◯ Abdominal distension ◯ Cramps ◯ Flatus ◯ Diarrhea

● Foods to limit or avoid include milk, soft cheese, ice cream, cream soups, puddings.

NCLEX® Connection: Physiological Adaptation, Illness Management

84 CHAPTER 13 GASTROINTESTINAL DISORDERS CONTENT MASTERY SERIES

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NUTRITION FOR NURSING CHAPTER 14 RENAL DISORDERS 85

UNIT 3 ALTERATIONS IN NUTRITION

CHAPTER 14 Renal Disorders Nurses must understand nutritional needs of clients who have renal disorders. It is important to explore dietary needs with the client and recommend modifications related to the disease process. Understanding the role of primary and secondary prevention is essential to successful treatment.

The kidneys have two primary functions: maintaining blood volume and excreting waste products. Other functions include the regulation of acid-base balance, blood pressure, calcium and phosphorous metabolism, and red blood cell production. Kidney damage and/or loss of kidney function have profound effects on the client’s nutritional state. Urea is a waste by-product of protein metabolism, and urea levels rise with kidney disease. Monitoring protein intake is critical.

Short-term kidney disease requires nutritional support for healing rather than dietary restrictions. Dietary recommendations are dependent upon the stage of kidney disease.

Nutritional considerations included in this chapter are for chronic kidney disease and end-stage kidney disease, acute kidney injury, nephrotic syndrome, and nephrolithiasis (kidney stones).

Referral to and consultation with a registered dietitian to determine calories, protein, and other nutrients is essential for the client to decrease the risk of malnutrition.

ASSESSMENT/DATA COLLECTION Chronic kidney disease is distinguished by an increase in blood creatinine. Manifestations include fatigue, back pain, and appetite changes. It is a progressive disorder, characterized by five stages.

● Stage 1: at risk for CKD ● Stage 2: mild CKD ● Stage 3: moderate CKD ● Stage 4: severe CKD ● Stage 5: CKD requiring dialysis or transplant for

survival (end-stage kidney disease)

End-stage kidney disease (ESKD) manifestations include fatigue, decreased alertness, anemia, decreased urination, headache, and weight loss.

Acute kidney injury (AKI) manifestations include a decrease in urination, decreased sensation in the extremities, swelling of the lower extremities, and flank pain. It is characterized by rising blood levels of urea and other nitrogenous wastes.

Nephrotic syndrome’s most pronounced manifestations are edema and high proteinuria. Other manifestations include hypoalbuminemia, hyperlipidemia, and blood hypercoagulation.

Kidney stones are characterized by sudden, intense pain that is typically located in the flank and is unrelieved by position changes as the stone moves out of the kidney pelvis and down the ureter. Diaphoresis, nausea, and vomiting are common, and there can be blood in the urine. The majority of kidney stones are made of calcium oxalate.

NUTRITIONAL GUIDELINES AND NURSING INTERVENTIONS

General renal considerations ● Monitor kidney parameters for clients who have

renal disorders. ◯ Nurses should monitor weight daily or as prescribed. Weight is an indicator of fluid status, which is a primary concern.

◯ Monitor fluid intake, and encourage compliance with fluid restrictions.

◯ Nurses should monitor urine output. Placement of an indwelling urinary catheter might be necessary for accurate measurement.

◯ Monitor for manifestations of constipation. Fluid restrictions predispose clients to constipation.

● Explain why dietary changes are necessary. Alterations in the intake of protein, calories, sodium, potassium, phosphorus, and other vitamins are required.

● Provide support for the client and family.

Chronic kidney disease (stages 1 to 4) ● Stages 1 to 4 are predialysis and characterized by

increasing blood creatinine levels and a decreasing glomerular filtration rate (GFR).

THERAPEUTIC NUTRITION ● Goals of nutritional therapy

◯ Slow the progression of CKD. ◯ Control blood glucose and hypertension. ◯ Help preserve remaining kidney function by limiting the intake of protein, which results in decreased phosphorus levels.

● Restricting phosphorus intake slows the progression of kidney disease. High levels of phosphorus contribute to calcium and phosphorus deposits in the kidneys.

● Protein restriction is essential for clients who have stage 1 to 4 CKD.

◯ Slows the progression of kidney disease. ◯ Too little protein results in the breakdown of body

protein. Carefully determine protein intake.

CHAPTER 14

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86 CHAPTER 14 RENAL DISORDERS CONTENT MASTERY SERIES

DIETARY RECOMMENDATIONS ● Restrict sodium intake to maintain blood pressure. ● Restrict potassium intake to prevent hyperkalemia. ● The recommended daily protein intake is 0.8 to 1.0 g/kg/day of ideal body weight.

◯ Protein restrictions are decreased as the disease progresses to ESKD, and to decrease the workload on the kidneys.

◯ High biologic value proteins are recommended for clients who have CKD to prevent catabolism of muscle tissue. These proteins include eggs, meats, poultry, game, fish, soy, and dairy products.

● Limit meat intake to 5 to 6 oz/day for most males and 4 oz/day for most females.

● Limit dairy products to ½ cup per day. ● Limit high-phosphorus foods (peanut butter, dried

peas and beans, bran, cola, chocolate, beer, some whole grains) to one serving or less per day.

● Caution clients to use vitamin and mineral supplements only when recommended by a provider. Avoid high protein sports drinks, energy drinks, or meal supplements. Avoid herbal supplements that can affect bleeding time and blood pressure.

End-stage kidney disease

ESKD, or Stage 5 CKD, occurs when the GFR is less than 15 mL/min and the blood creatinine level steadily rises, and indicates complete kidney failure.

THERAPEUTIC NUTRITION ● The goal of nutritional therapy is to maintain appropriate

fluid status, blood pressure, and blood chemistries. ◯ A low-protein, low-phosphorus, low-potassium, low-sodium (2 to 3 g/day), fluid-restricted diet is recommended.

◯ Consume adequate calories (35 kcal/kg of body weight) to maintain body protein stores.

● Monitor potassium level and replace as needed. Sodium and fluid allowances are determined by blood pressure, weight, blood electrolyte findings, and urine output.

● Achieving a well-balanced diet based on the above guidelines is difficult. The National Renal Diet provides clients with a list of food choices.

● Protein needs increase from 0.6 to 1.0 g/kg before dialysis to 1.2 to 1.5 g/kg, depending on the type of dialysis, once dialysis has begun as protein and amino acids are lost in the dialysate.

◯ Fifty percent of protein intake should come from biologic sources (eggs, milk, meat, fish, poultry, soy).

● Restrict phosphorus (700 to 1,200 mg/day). ◯ A high protein requirement leads to an increase in

phosphorus intake. ◯ Foods high in phosphorus are milk products, beef liver, chocolate, nuts, and legumes.

◯ Phosphate binders (calcium carbonate, calcium acetate) are taken with all meals and snacks.

● Vitamin D deficiency occurs as the kidneys are unable to convert vitamin D to its active form.

◯ This alters the metabolism of calcium, phosphorus, and magnesium, leading to hyperphosphatemia, hypocalcemia, and hypermagnesemia.

◯ Calcium supplements will likely be required because foods high in phosphorus (which are restricted) are also high in calcium.

Acute kidney injury

AKI is an abrupt, rapid decline in kidney function caused by trauma, sepsis, poor perfusion, or medications, and usually is reversible. AKI can cause hyponatremia, hyperkalemia, hypocalcemia, and hyperphosphatemia. Fluid overload leading to pulmonary edema is a complication of AKI.

THERAPEUTIC NUTRITION ● Diet therapy for AKI is dependent upon the phase of AKI

and its underlying cause. Protein, calories, fluids, potassium, and sodium need to be individualized according to the three phases of AKI (oliguric, diuretic, recovery) and whether the client is receiving dialysis.

● Recommendation is to consume 20 to 30 cal/kg/day of body weight in clients who are in any stage of AKI to maintain energy and demands of stress.

● Simple carbohydrates, fats, oils, and low-protein starches are included in the diet. Provide nonprotein calories in an adequate amount to maintain the client’s weight.

● Protein intake can increase to 1 to 1.5 g/kg if the client is receiving dialysis, compared to 0.6 g/kg (40 g/day) for nondialysis clients.

● Potassium and sodium are dependent on urine output, blood values, and if the client is receiving dialysis.

◯ Potassium is restricted to 60 to 70 mEq/day when on dialysis.

◯ Sodium is restricted to 1 to 2 g/day if not receiving dialysis, and 2 to 4 g/day if receiving dialysis, which also depends on the phase.

◯ Calcium requirements are less than 2,000 mg daily if receiving hemodialysis or peritoneal dialysis.

● Fluids are restricted to the client’s daily urine output plus 500 mL during the oliguric phase. Fluid needs are increased during the diuretic phase.

Nephrotic syndrome ● Nephrotic syndrome results in the increased excretion of

proteins into the urine, resulting in hypoalbuminemia, edema, hyperlipidemia, and blood hypercoagulation. Prolonged protein loss leads to protein malnutrition, anemia, and vitamin D deficiency.

● Diabetes mellitus, kidney damage due to medications or chemicals, autoimmune disorders, and infections can cause nephrotic syndrome.

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NUTRITION FOR NURSING CHAPTER 14 RENAL DISORDERS 87

THERAPEUTIC NUTRITION ● Nutritional therapy goals include minimizing edema,

replacing lost nutrients, minimizing kidney damage, controlling hypertension, and preventing protein malnutrition that can lead to muscle catabolism.

● Dietary recommendations indicate sufficient protein and low sodium intake.

◯ Adequate amount of protein intake is 0.7 to 1.0 g/kg/day.

◯ Soy-based proteins can decrease protein losses and lower blood lipid levels.

◯ Low-sodium diet of 2,000 mg/day can help control edema and hypertension.

◯ Carbohydrates should provide the majority of the client’s daily calories.

◯ Cholesterol, trans fat, and saturated fats can be restricted to assist in controlling high lipid levels.

◯ Provide a multiple vitamin supplement to replace loss of vitamins with protein excretion. Replace loss of vitamin D with a supplement as needed.

Nephrolithiasis ● The most common type of kidney stone is made of

calcium oxalate. ● Contributing factors include inadequate fluid intake,

elevated urine pH, and excess excretion through the kidneys of oxalate, calcium, and uric acid.

● Kidney stone formation is more influenced by the amount of oxalate in the client’s system than calcium. A client who has an ileostomy has an increased risk of kidney stones.

PREVENTATIVE NUTRITION: Excessive intake of protein, sodium, calcium, and oxalates (rhubarb, spinach, beets) can increase the risk of stone formation.

THERAPEUTIC NUTRITION ● Increasing fluid consumption is the primary

intervention for the treatment and prevention of kidney stones. Daily fluid intake should be enough to produce at least 2 L of urine per day. Drink some fluid before bedtime because urine becomes more concentrated at night. This is particularly important for clients who have cystine stones, which requires an even greater daily fluid intake.

● Recommendation for calcium oxalate stone formation is to limit animal protein, excess sodium, alcohol, and caffeine use. Low potassium can contribute to calcium stone formation.

● Foods high in oxalates include spinach, rhubarb, beets, nuts, chocolate, tea, wheat bran, and strawberries, and should be limited in the diet. Avoid megadoses of vitamin C, which increase the amount of oxalate excreted.

● Recommendation for prevention of uric acid stones is to limit foods high in purines, which include lean meats, organ meats, whole grains, and legumes.

Active Learning Scenario

A nurse is reviewing teaching for a client who has nephrotic syndrome. What information should the nurse include? Use the ATI Active Learning Template: System Disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS)

COMPLICATIONS: List three.

CLIENT EDUCATION: Include five teaching points.

Application Exercises

1. A nurse is planning care for a client who has ESKD. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Monitor the client’s weight daily. B. Encourage the client to comply

with fluid restrictions. C. Evaluate intake and output. D. Instruct the client on restricting

calories from carbohydrates. E. Monitor for constipation.

2. A nurse is teaching a client who has stage 2 chronic kidney disease about dietary management. Which of the following information should the nurse include in the instructions? A. Restrict protein intake. B. Maintain a high-phosphorus diet. C. Increase intake of foods high in potassium. D. Limit dairy products to 1 cup/day.

3. A nurse is teaching a client about protein needs when on dialysis. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. Consume 35 kcal/kg of body weight

to maintain body protein stores. B. Take phosphate binders when

eating protein-rich foods. C. Increase biologic sources of protein

(eggs, milk, and soy). D. Increase protein intake by 50% of the

recommended dietary allowance (RDA). E. Consume daily protein intake in the morning.

4. A nurse is teaching about diet restrictions to a client who has acute kidney injury and is on hemodialysis. Which of the following recommendations should the nurse include in the teaching? A. Limit calcium intake to 2,500 mg/day. B. Decrease total fat intake to 45% of daily calories. C. Decrease potassium intake to 60 to 70 mEq/kg. D. Limit sodium intake to 4.5 g/day.

5. A nurse is completing discharge teaching about diet and fluid restrictions to a client who has a calcium oxalate-based kidney stone. Which of the following instructions should the nurse include in the teaching? A. Reduce intake of spinach. B. Decrease broccoli intake. C. Increase intake of vitamin C supplements. D. Limit consumption of purine substances.

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88 CHAPTER 14 RENAL DISORDERS CONTENT MASTERY SERIES

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): Nephrotic syndrome is a renal disorder in which there is increased excretion of proteins into the urine.

COMPLICATIONS ● Hypoalbuminemia ● Proteinuria

● Edema ● Hyperlipidemia

● Malnutrition ● Anemia

CLIENT EDUCATION ● Increase protein intake to prevent catabolism of muscle tissue. ● Limit sodium intake to control edema and hypertension. ● Consume foods low in trans fats and cholesterol. ● Consume foods high in carbohydrates to increase calorie intake. ● Take a vitamin supplement to replace vitamin

loss that occurs with protein excretion.

NCLEX® Connection: Physiological Adaptation, Illness Management

Application Exercises Key

1. A. CORRECT: Monitoring the client’s daily weight assists in determining fluid retention.

B. CORRECT: Implementing fluid restriction for a client helps to slow fluid retention.

C. CORRECT: Evaluating I&O helps to determine if there is an increase in fluid retention.

D. Carbohydrates are not restricted for a client who has ESKD. E. CORRECT: Constipation often occurs as

a result of fluid restrictions.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

2. A. CORRECT: Restricting protein intake decreases the risk for proteinuria and decreases the workload on the kidney.

B. A diet high in phosphorus is not recommended because it can contribute to calcium and phosphorus deposits on the kidney.

C. Eating foods low in potassium is recommended because hyperkalemia occurs with kidney disease.

D. Dairy products are a protein and sodium source, and are limited to 0.5 cup/day.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

3. A. CORRECT: To maintain protein stores, the client should consume 35 cal/kg of body weight.

B. CORRECT: Protein consumption increases phosphorus intake. Phosphate binders are recommended with meals.

C. CORRECT: Protein intake should include biologic sources of protein to include eggs, milk, meat, fish, poultry, and soy.

D. CORRECT: The recommended protein intake for a client on dialysis is 50% greater than the RDA because amino acids are lost in the dialysate.

E. The client should spread protein intake throughout the day to prevent excessive intake of phosphorous and potassium.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

4. A. The client receiving hemodialysis should limit calcium intake to less than 2,000 mg/day.

B. The client should limit total fat intake to 35% of daily calories.

C. CORRECT: The client should limit potassium intake to 60 to 70 mEq/kg.

D. The client should limit sodium intake to 1 to 4 g/day when receiving dialysis.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

5. A. CORRECT: The client should reduce intake of foods high in oxalate, such as spinach, which can cause calcium stone formation.

B. Broccoli is high in calcium but does not cause calcium stone formation and is not restricted in the diet.

C. Large doses of vitamin C supplements can cause calcium stone formation.

D. Foods that contain purine, such as organ meats and red wine, cause uric acid stone formation.

NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

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NUTRITION FOR NURSING CHAPTER 15 DIABETES MELLITUS 89

UNIT 3 ALTERATIONS IN NUTRITION

CHAPTER 15 Diabetes Mellitus Glucose is the body’s primary source of energy, and insulin is needed to assist the body in the breakdown of glucose to a form that is used for energy. Diabetes mellitus inhibits the body’s production and/or use of insulin. This results in elevated blood glucose levels. Complications of diabetes mellitus are characterized as macrovascular (cardiovascular and cerebrovascular disease) or microvascular (kidney, nerve, and vision problems). For clients who are pregnant, blood glucose control prevents maternal and fetal complications.

The nurse assists the client in identifying lifestyle changes necessary to manage diabetes mellitus, including diet and activity level.

TYPES OF DIABETES MELLITUS

Prediabetes ● Clients who have glucose levels that are elevated above

the expected range but below the diagnostic criteria for diabetes mellitus are said to have prediabetes.

● Clients who have prediabetes are encouraged to adopt lifestyle modifications to prevent the development of diabetes mellitus.

Type 1 diabetes mellitus ● Autoimmune disease is triggered by genetic links or a

viral infection. ● Damage to or destruction of beta cells of the pancreas

results in an absence of insulin production. ● Most often diagnosed before 18 years of age; can occur

at any age.

Type 2 diabetes mellitus ● Results from genetic and environmental factors ● Characterized by altered patterns of insulin secretion and

decreased cellular uptake of glucose (insulin resistance)

Gestational diabetes mellitus (GDM) ● Glucose intolerance that is recognized during pregnancy,

that typically resolves after delivery ● Clients who have a history of GDM have an increased

risk for developing diabetes mellitus type 2 later in life.

ASSESSMENT/DATA COLLECTION Hypoglycemia is a blood glucose level less than 70 mg/dL. It results from taking too much insulin, inadequate food intake, delayed or skipped meals, extra physical activity, or consumption of alcohol without food. ● Manifestations include mild shakiness, mental

confusion, sweating, palpitations, headache, lack of coordination, blurred vision, seizures, and coma.

Hyperglycemia is a blood glucose level above the expected reference range. It results from an imbalance with food, medication, and activity, combined with an inadequate amount of insulin production or cells that are insulin-resistant.

● Infection, other illness, and stress can cause an increase in blood glucose.

● Primary manifestations include polydipsia (excessive thirst), polyuria (excessive urination), and polyphagia (excess hunger and eating). As hyperglycemia progresses, ketones (which can be detected in the urine and other manifestations (hyperventilation [Kussmaul respirations], dehydration, fruity odor to the breath, headache, inability to concentrate, decreased levels of consciousness, seizures leading to coma) develop.

● The Somogyi phenomenon is morning hyperglycemia in response to overnight hypoglycemia. Providing a bedtime snack and appropriate insulin dose prevents this phenomenon.

● The dawn phenomenon is an elevation of blood glucose around 0500 to 0600. It results from an overnight release of growth hormone and is treated by increasing the amount of insulin provided during the overnight hours.

Metabolic syndrome is a cluster of factors that increase the risk for diabetes mellitus and cardiovascular complications. Factors include elevated glucose levels, central obesity, hyperlipidemia, hypertension, and low levels of HDL cholesterol. The presence of at least 3 factors indicates metabolic syndrome.

NUTRITIONAL GUIDELINES AND NURSING INTERVENTIONS

Hypoglycemia ● Clients who have hypoglycemia should take 15 to 20 g of

a readily absorbable carbohydrate. ◯ Two or three glucose tablets (5 g each) ◯ Six to ten hard candies ◯ ½ cup (4 oz) juice or regular soda ◯ 1 tbsp honey or 4 tsp sugar

● Retest the blood glucose in 15 min. If it is less than 70 mg/dL, repeat the above steps. Once levels stabilize, have the client take an additional carbohydrate and protein snack or small meal, depending on the severity of the hypoglycemic episode and whether the next meal is more than 1 hr away.

CHAPTER 15

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90 CHAPTER 15 DIABETES MELLITUS CONTENT MASTERY SERIES

Hyperglycemia ● Clients who have hyperglycemia should do the following.

◯ Notify the provider or go to the emergency department for difficulty concentrating, altered consciousness, or seizure activity.

◯ Take medication if forgotten.

GENERAL NUTRITIONAL GUIDELINES ● Coronary heart disease (CHD) is a frequent cause of

death among clients who have diabetes. Clients who have diabetes are encouraged to follow a diet that is high in fiber and low in saturated fat, trans fat, and cholesterol to prevent CHD.

● Dietary intake should be individualized according to the client’s individual needs, need for weight management, and lipid and glucose patterns. Clients should space food intake throughout the day (regular meals and a snack or snacks). General guidelines follow. ◯ Carbohydrates

■ Encourage the client to consume carbohydrates found in grains, fruits, legumes, and milk. Limit simple carbohydrates, which include refined grains and sugars.

■ Carbohydrates should be 45% to 65% of total daily caloric intake.

◯ Fats ■ Clients should eat less saturated and trans fats. ■ Polyunsaturated fatty acids are found in fish. Two

or more servings per week are recommended. ■ Consuming foods enriched with plant sterols or

stanols can reduce LDL cholesterol. ◯ Fiber

■ Promote fiber intake (beans, vegetables, oats, whole grains) to improve carbohydrate metabolism and lower cholesterol.

■ Recommendation for fiber intake includes at least 14 g per 1,000 calories.

◯ Protein: Protein from meats, eggs, fish, nuts, beans, and soy products should comprise 15% to 20% of total caloric intake. Reduce protein intake if needed in clients who have diabetes and kidney failure.

◯ Sodium: Limit to 2,300 mg/day. ● Encourage clients to eliminate all tobacco use due to the

increased risk of cardiovascular disease. ● Moderate alcohol intake can lower the risk for

cardiovascular disease. Clients should limit daily alcohol intake to one alcoholic beverage for females or two for males. ◯ To avoid hypoglycemia, the client should consume

alcohol with a meal or immediately after a meal. ◯ Alcoholic beverages should not replace food intake.

● Vitamin and mineral requirements are unchanged for clients who have diabetes. Supplements are recommended for identified deficiencies.

● Artificial sweeteners are acceptable (sucralose, aspartame, saccharin, acesulfame, potassium). Sugar alcohols (xylitol, mannitol, sorbitol) contain some sugar, but not as much as natural sweeteners. Sucrose (table sugar) can be included in a diabetic diet and should be counted in the total calories for the day to ensure antidiabetic medications are sufficient to cover intake.

● Cultural and personal preferences should be considered in planning food intake.

● According to the American Diabetes Association and the Academy of Dietetics and Nutrition, daily nutritional requirements are based on the needs of each client.

● A dietitian works with the client to develop meal planning that meets the client’s needs based on healthy food choices. The goal of therapy is to maintain blood glucose levels as close to the expected reference range as possible.

◯ The dietitian instructs the client on various dietary methods, including exchange list and carbohydrate counting.

● Using the Food Lists for Diabetes (formerly called Exchange Lists) as a guide for meal planning allows for the incorporation of three basic food groups: protein, carbohydrates, and fats.

◯ Each client has a recommended amount of daily exchanges within each group based on the client’s needs.

Carbohydrate counting

Carbohydrate counting focuses on counting total grams of carbohydrates in each food item. Many clients find it easier than exchange lists because of the simplicity and flexibility. It does not require the client to learn how much a portion size is. ● One serving equals 15 g of carbohydrates. Clients are

free to choose what carbohydrates to consume, but are encouraged to choose a variety of types and include consistent amounts of protein and fats in the diet. ◯ Foods that contain 15 g of carbohydrates

■ 1 slice of sandwich bread ■ 1/2 cup cooked pasta ■ 1/2 cup canned fruit in juice (not syrup) ■ 1/4 cup dried fruit ■ 3 cups raw vegetables ■ 1 1/2 cup cooked vegetables ■ 4 to 6 snack crackers ■ 1/2 cup regular ice cream

● With basic carbohydrate counting, a client consumes a specific amount or servings of carbohydrates at each meal and snack.

● With advanced carbohydrate counting, clients calculate mealtime insulin based on the amount of carbohydrates consumed. Clients must be able to perform basic math skills and be willing to check their glucose before each meal to provide a corrective insulin dose, if the glucose level is too high.

● Clients can exchange carbohydrate selections as long as the grams of carbohydrates are the same per serving. Food selections can vary in amount of additional calories from fat and protein each food can contain.

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NUTRITION FOR NURSING CHAPTER 15 DIABETES MELLITUS 91

OTHER NURSING INTERVENTIONS ● Provide instructions to the client on the following, and

discuss these at subsequent appointments. ◯ Self-monitoring of blood glucose ◯ Dietary and activity recommendations ◯ Manifestations and treatment of hypoglycemia and

hyperglycemia, to include the importance of taking medications as prescribed

◯ Long-term complications of diabetes ◯ Psychological implications ◯ Community organizations and support groups whose

focus is diabetes ● Children who have diabetes require parental support,

guidance, and participation. Dietary intake must provide for proper growth and development. Altered nutritional needs during times of growth and fluctuations in eating patterns and activity levels can make management complicated.

● For older adult clients, ask questions to determine the presence of deficits that impede adequate nutrition or safe medication administration (cognitive impairment, vision and hearing changes, altered dentition, anorexia, financial barriers).

● For pregnant clients, there must be a balance between maternal blood glucose goals and nutritional needs of pregnancy. Clients might have to monitor blood glucose more often (up to eight times daily).

● Teach proper calibration and use of the self-monitoring of blood glucose, record keeping, and reporting of levels to health care provider.

CLIENT EDUCATION ● Exercise as appropriate and when blood glucose levels

are within an acceptable range. Closely monitor blood glucose; decreased medication doses might be required with strenuous exercise to prevent hypoglycemia.

◯ Recommendations for adults who have diabetes mellitus includes exercising at least 3 days/week for 150 min total.

◯ Adult should not sit for more than 90 min at a time. ● Lose weight if appropriate. It is important for clients who

have type 2 diabetes mellitus and have a BMI greater than 25, as it can decrease insulin resistance, improve glucose and lipid levels, and lower blood pressure.

◯ Successful weight loss programs include managing calorie intake, exercising, and making lifestyle modifications.

● Be aware of the timing for antidiabetic medications in regard to food intake (before or with meals, or regardless of calorie intake). Take medications at the appropriate time for maximum therapeutic effect.

● Perform self-monitoring of blood glucose. Strict control of glucose can reduce or postpone complications (retinopathy, nephropathy, neuropathy).

● Obtain regular evaluations from the provider.

Application Exercises

1. A nurse is talking with a client who has a new diagnosis of diabetes mellitus type 2 and their caregiver. Which of the following sweeteners should the nurse include as a zero-calorie sweetener option? (Select all that apply.) A. Sucrose B. Aspartame C. Mannitol D. Xylitol E. Sucralose

2. A nurse is assessing a client who is has hypoglycemia. Which of the following findings should the nurse expect? A. Fruity breath odor B. Diaphoresis C. Ketones in urine D. Polyuria

3. A nurse is caring for a client who has diabetes mellitus and reports feeling shaky and weak. The client’s blood glucose is 53 mg/dL. Which of the following actions should the nurse take? A. Provide subcutaneous insulin for the client. B. Offer the client 120 mL (4 oz) fruit juice. C. Give the client IV potassium. D. Administer IV sodium bicarbonate.

4. A nurse is reinforcing dietary teaching to a client who has type 2 diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) A. “Carbohydrates should comprise

55% of daily caloric intake.” B. “Use hydrogenated oils for cooking.” C. “You can add table sugar to cereals.” D. “Eat something if you choose to drink alcohol.” E. “Use the same portion sizes to

exchange carbohydrates.”

5. A nurse is teaching a group of clients who have diabetes about meal planning. Which of the following client statements indicates understanding? A. “I will avoid having snacks.” B. “I should not eat anything containing sugar.” C. “I will not eat fruit canned in syrup.” D. “I will not eat more than 2,800 mg of sodium a day.”

Active Learning Scenario

A nurse is reviewing the discharge plan for a client who has type 1 diabetes mellitus. How should the nurse use interprofessional care in the plan? Use the ATI Active Learning Template: System Disorder to complete this item.

INTERPROFESSIONAL CARE: Describe the role of another member of the health care team.

CLIENT EDUCATION: Describe three teaching points offered by this member of the health team.

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92 CHAPTER 15 DIABETES MELLITUS CONTENT MASTERY SERIES

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

INTERPROFESSIONAL CARE: Dietitian: Development of meal planning based on healthy food choices to meet the client’s needs.

CLIENT EDUCATION ● Review of exchange list: Incorporate proteins, carbohydrates, and fats within each group based on the client’s needs.

● Review of carbohydrate counting: Consider the total grams of carbohydrates in each food item and the quantity needed for each meal and snack.

● Review information on food labels: Teach how to read food labels to identify amounts of carbohydrates contained in food.

NCLEX® Connection: Physiological Adaptation, Illness Management

Application Exercises Key

1. A. Common table sugar is sucrose, and it contains about 15 g of carbohydrates per tablespoon.

B. CORRECT: Aspartame is an artificial sweetener that can sweeten foods and beverages without adding calories.

C. Mannitol is a type of sugar alcohol, which has a low amount of calories (1.6 calories/g).

D. Xylitol is a type of sugar alcohol, which has a low amount of calories (2.4 calories/g).

E. CORRECT: Sucralose is an artificial sweetener that can sweeten foods and beverages without adding calories.

NCLEX® Connection: Physiological Adaptation, Illness Management

2. A. Fruity breath odor is a manifestation of hyperglycemia. B. CORRECT: A client who has hypoglycemia can

have diaphoresis and cool, clammy skin. C. Ketones in the urine is a manifestation of hyperglycemia. D. Polyuria (excessive urination) is a

manifestation of hyperglycemia.

NCLEX® Connection: Reduction of Risk Potential, System Specific Assessments

3. A. IV insulin is administered for hyperglycemia. B. CORRECT: The client has manifestations of

hypoglycemia. Offer the client 15 to 20 g of carbohydrate, such as 120 mL juice.

C. IV potassium is administered for hypokalemia. D. IV sodium bicarbonate is administered

for metabolic acidosis.

NCLEX® Connection: Reduction of Risk Potential, System Specific Assessments

4. A. CORRECT: Carbohydrates should be 45% to 65% of total daily calorie intake.

B. The client should avoid using hydrogenated oils for cooking because they contain trans fatty acids and increase the risk for hyperlipidemia.

C. CORRECT: The client can use table sugar as long as adequate insulin or other agents are provided to cover the sugar intake. The client should count the carbohydrates in the sucrose in the daily carbohydrate count.

D. CORRECT: The client can drink alcohol (one drink/day for females, two drinks/day for males) but should eat something to reduce the risk of hypoglycemia.

E. CORRECT: The client can exchange carbohydrates as long as the total grams of carbohydrates remains the same each day.

NCLEX® Connection: Physiological Adaptation, Illness Management

5. A. Inform the client that a small snack before bedtime might be required to prevent hypoglycemia during the night.

B. Instruct the client that it is okay to eat some foods containing sugar, but in moderation and included in daily carbohydrate counting.

C. CORRECT: To avoid extra carbohydrate intake, the client should eat fruit that was canned with water or juice rather than syrup, honey, or molasses.

D. Instruct the client to limit sodium intake to 2,300 mg/day.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

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NUTRITION FOR NURSING CHAPTER 16 CANCER AND IMMUNOSUPPRESSION DISORDERS 93

UNIT 3 ALTERATIONS IN NUTRITION

CHAPTER 16 Cancer and Immunosuppression Disorders

Nurses should be knowledgeable of nutritional needs for clients who have cancer and immunosuppression disorders. Cancer and cancer treatments can affect chewing, swallowing, satiety, digestion, taste, appetite, nutrient absorption, use of glucose, and stool formation (dependent on type).

Protein-calorie malnutrition and body wasting are common secondary diagnoses for clients who have cancer or immunosuppression disorders (HIV/AIDS). Nutritional deficits are a major cause of morbidity and mortality for these clients. Adverse effects of treatments compromise the nutritional status of affected clients. Immunosuppression disorders increase the body’s metabolic demands. Alterations in fat storage and metabolism are related to medications used in treatment of the disorder. While subcutaneous fat is lost in the face and extremities, fatty deposits occur in the liver and skeletal muscles.

The goals of nutritional therapy are to minimize the nutritional complications of disease, improve nutritional status, prevent muscle wasting, maintain weight, promote healing, reduce adverse effects, decrease morbidity and mortality, and enhance quality of life and overall effectiveness of treatment therapies. Nutritional plans are individualized for client needs.

ASSESSMENT/DATA COLLECTION ● Current illness and presence of other medical diagnoses ● Nutritional habits, food preferences, and restrictions ● Food allergies ● Height, weight, body mass index (BMI), weight trends

RISK FACTORS

Immunosuppression disorders ● Unprotected sex (HIV) ● Use of contaminated needles (injection substance

use [HIV]) ● Use of medications that have immunosuppressive

effects (cytotoxic medications, corticosteroids, disease modifying immunosuppressive medications)

● History of radiation treatment ● Congenital immune deficiencies

Cancer ● Obesity ● Excessive fat intake ● Sedentary lifestyle ● Consumption of processed meats, red meats,

refined grains ● Excessive alcohol intake ● Family history ● History of cigarette smoking

LABORATORY TESTS Albumin, ferritin, transferrin

NUTRITIONAL GUIDELINES AND NURSING INTERVENTIONS

Immunosuppression ● Monitor the effectiveness of nutrition (weight, BMI,

laboratory findings). ● Assist the client to set realistic goals for nutrition and

food consumption. ● Instruct the client on strategies to manage adverse

effects of treatment.

CLIENT EDUCATION ● Potential food sources of bacteria include raw fruits and

vegetables, and undercooked meat, poultry, or eggs. Wash fruits and vegetables. Cook foods thoroughly. Refrigerate perishable foods as soon as possible.

● Make food choices based on nutrition recommendations.

CHAPTER 16

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94 CHAPTER 16 CANCER AND IMMUNOSUPPRESSION DISORDERS CONTENT MASTERY SERIES

Cancer

Excess body fat stimulates the production of estrogen and progesterone, which can intensify the growth of various cell types and can contribute to breast, gallbladder, colon, prostate, uterine, and kidney cancers.

NURSING ACTIONS: Use semisolid, thickened foods for clients who have dysphagia, and instruct them to sit upright and tilt their head forward when swallowing.

CLIENT EDUCATION ● Eat more on days when feeling better (on “good” days). ● Consume nutritional supplements that are high in

protein and/or calories as between-meal snacks. When necessary, use as a meal replacement.

● Increase protein and caloric content of foods. ◯ Substitute whole milk for water in recipes. ◯ Add milk, cheese, yogurt, or ice cream to dishes. ◯ Use peanut butter as a spread for fruits. ◯ Use yogurt as a topping for fruit. ◯ Dip meats in eggs, milk, and bread crumbs

before cooking. ● Preventative nutrition

◯ Consume adequate dietary fiber (25 to 38 g/day depending on sex and age) to lessen the risk of colon cancer.

◯ Eliminate tobacco and exposure to loose asbestos to reduce the risk of lung cancer.

◯ Eat at least 2.5 cups of a variety of fruits and vegetables daily (linked to lowered incidence of many types of cancer and obesity, which affects the risk for cancer development). ■ Foods high in vitamin A (dark green, red, and

orange vegetables) ■ Foods high in vitamin C (citrus fruits) ■ Cruciferous vegetables (broccoli,

cauliflower, cabbage) ◯ Consume whole grains rather than processed or

refined grains and sugars. Low-fiber foods and foods high in fat can cause a variety of cancers (lung, esophageal, pancreatic, oral cavity, cervical, kidney, bladder, liver, stomach).

◯ Avoid meat prepared by smoking, pickling, charcoal and grilling, and use of nitrate-containing chemicals (possibly carcinogenic).

◯ Consume polyunsaturated and monounsaturated fats (found in fish and olive oil), which might be beneficial in lowering the risk of many types of cancer.

◯ Limit alcohol consumption (associated with many types of cancers).

● Therapeutic nutrition ◯ Cancer can cause anorexia, increased metabolism, and

negative nitrogen balance. ◯ Systemic effects result in poor food intake, increased

nutrient and energy needs, and catabolism of body tissues.

◯ An individualized plan is based on the following. ■ Increased caloric needs ranging from 25 to 35 cal/kg

(depending on metabolism, activity level, disease state, and ability to absorb nutrients).

■ Protein needs are increased to 1.0 to 2.5 g/kg. ■ Vitamin and mineral supplementation is based

upon the client’s needs.

HIV/AIDS

The body’s response to the inflammatory and immune processes associated with HIV increases nutrient requirements. Malnutrition is common and is one cause of death in clients who have AIDS. ● HIV infection, secondary infection, malignancies, and

medication therapies can cause manifestations and adverse effects that impair intake and alter metabolism.

● Decreased nutrient intake occurs due to physical manifestations (anorexia, nausea, vomiting, diarrhea). Psychological manifestations can include depression and dementia.

● Nutritional findings include rapid weight loss, gastrointestinal problems, inadequate intake, increased nutrient needs, food aversions, fad diets, and supplements.

● Poor nutritional status leads to wasting and fever, further increasing susceptibility to secondary infections.

● HIV-associated wasting is characterized by unintended weight loss of 10% and at least one concurrent problem (diarrhea, chronic weakness, or fever) for at least 30 days.

● Diarrhea and malabsorption are prominent concerns in clients who have AIDS.

Therapeutic nutrition ● Creating an individualized plan for the client who has

HIV/AIDS is based on reducing unintentional weight loss and wasting.

◯ Increased caloric needs ranges from 37 to 55 cal/kg. ◯ A high-protein diet is recommended with amounts varying from 1.2 to 2.0 g/kg/day.

◯ Intake of a multivitamin that meets 100% of the recommended daily servings is sufficient, unless a specific deficiency is identified.

● Enteral feedings are used if the client is unable to consume sufficient nutrients, calories, and fluid.

● Liberal fluid intake is extremely important to prevent dehydration.

CLIENT EDUCATION: Consume small, frequent meals that are composed of high-protein, high-calorie, nutrient-dense foods.

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NUTRITION FOR NURSING CHAPTER 16 CANCER AND IMMUNOSUPPRESSION DISORDERS 95

COMPLICATIONS

Early satiety and anorexia

CLIENT EDUCATION ● Eat small amounts of high-protein foods loaded with

calories and nutrients. ● Try to consume food in the morning when

appetite is best. ● Avoid food odors. ● Do not fill up on low-calorie foods (liquids, broth,

high-roughage foods containing water). ● Eat cool or room temperature foods.

Mouth ulcers and stomatitis

CLIENT EDUCATION ● Use a soft toothbrush to clean teeth after eating and

at bedtime. ● Avoid mouth washes that contain alcohol. ● Omit acidic, spicy, dry, or coarse foods. ● Include cold or room-temperature foods in the diet. ● Cut food into small bites. ● Try using straws. ● Replace meals with high-calorie/protein drinks. ● Use well-fitting dentures. ● Prepare foods that are cooked until tender and soft. ● Add gravies, broth, and a variety of mild sauces to

moistened prepared foods.

Fatigue

CLIENT EDUCATION ● Eat a large, calorie-dense breakfast when energy level is

the highest. ● Conserve energy by eating foods that are easy

to prepare. ● Use a meal delivery service.

Food aversions

CLIENT EDUCATION: Eat foods that are well-tolerated and liked prior to treatments (chemotherapy, radiation).

Taste alterations and thick saliva

CLIENT EDUCATION ● Try adding foods that are tart (citrus juices). ● Eat small, frequent meals. ● Try using sauces and seasonings for added flavor. ● Use plastic utensils for eating. ● Suck on mints, candy, or chew gum to remove bad

taste in mouth. ● Sweeten meat with apple or cranberry sauce.

Nausea, vomiting

CLIENT EDUCATION ● Eat cold or room-temperature foods. ● Try high-carbohydrate, low-fat foods. ● Avoid fried foods. ● Do not eat prior to chemotherapy or radiation. ● Take prescribed antiemetic medication. ● Sit up for 1 hr after a meal. ● Sip on fluids throughout the day. Try ginger ale or

ginger tea.

Diarrhea

CLIENT EDUCATION ● Ensure adequate intake of liquids throughout the day to

replace losses. ● Avoid foods that can exacerbate diarrhea (foods high

in roughage). ● Consume foods high in pectin to increase the bulk of

the stool and to lengthen transition time in the colon. ● Limit caffeine, hot or cold drinks, and fatty foods.

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96 CHAPTER 16 CANCER AND IMMUNOSUPPRESSION DISORDERS CONTENT MASTERY SERIES

Application Exercises

1. A nurse is teaching a client who has cancer about ways to increase protein and calories in foods. Which of the following actions should the nurse include? (Select all that apply.)

A. Use peanut butter as a spread on crackers.

B. Add water in place of milk in soups.

C. Top fruit with yogurt.

D. Dip chicken in eggs before cooking.

E. Sprinkle cheese on a baked potato.

2. A nurse is teaching a community program on nutritional guidelines for cancer prevention. Which of the following instructions should the nurse include? (Select all that apply.)

A. Eat foods high in vitamin A.

B. Add cruciferous vegetables.

C. Increase intake of red meats

D. Use oil high in saturated fat.

E. Consume refined grains.

3. A nurse in an oncology clinic is caring for a client who is undergoing treatment for cancer and reports difficulty eating due to inability to taste food. Which of the following interventions should the nurse recommend?

A. Avoid citrus juices.

B. Use plastic utensils to eat.

C. Eat foods that are warm.

D. Increase foods high in pectin.

4. A nurse is teaching a client who is undergoing cancer treatment about interventions to manage stomatitis. Which of the following statements by the client indicates understanding of the teaching?

A. “I will try chewing larger pieces of food.”

B. “I will avoid toasting my bread.”

C. “I will consume more food in the morning.”

D. “I will add more citrus foods to my diet.”

5. A nurse is collecting data from a client who has suspected HIV-associated muscle wasting. Which of the following findings supports this diagnosis?

A. BMI 26

B. Fecal impaction

C. Report of fever for 30 days

D. Report of high alcohol consumption

Active Learning Scenario

A nurse in an oncology clinic is reviewing dietary management with a group of clients who have cancer and are undergoing treatment. What instructions should the nurse include in this discussion? Use the ATI Active Learning Template: System Disorder to complete this item.

CLIENT EDUCATION ● Describe three effects of cancer on nutrition. ● Describe three nutritional needs. ● Describe three activities that promote improved nutrition.

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NUTRITION FOR NURSING CHAPTER 16 CANCER AND IMMUNOSUPPRESSION DISORDERS 97

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

CLIENT EDUCATION

Effects of cancer on nutrition ● Causes anorexia ● Increases metabolism ● Causes negative nitrogen balance

Nutritional needs ● Increased calories (25 to 35 cal/kg) ● Increased protein (1 to 2.5 g/kg) ● Vitamin and mineral supplementation

Activities ● Eat more on days when feeling better. ● Consume nutritional supplements that are high in protein and/ or calories between meals and/or use as meal replacement.

● Substitute whole milk for water in recipes. ● Add milk, cheese, yogurt, or ice cream to foods when cooking. ● Add peanut butter and yogurt as a spread/topping on fruits. ● Coat meats in eggs, milk, and bread crumbs before cooking. ● Treat cancer-associated complications (early satiety, anorexia, mouth ulcers, stomatitis, fatigue, food aversions, altered taste, thick saliva, nausea, vomiting, diarrhea).

NCLEX® Connection: Physiological Adaptation, Illness Management

Application Exercises Key

1. A. CORRECT: Peanut butter adds calories and protein to fruit slices or crackers.

B. The client should substitute whole milk, cream, and/or hard-boiled eggs to soups and sauces to increase protein and calories.

C. CORRECT: Yogurt adds protein and calories to fruit. D. CORRECT: Eggs add protein and calories

to chicken, fish, or meat. E. CORRECT: Cheese adds protein and calories to vegetables.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

2. A. CORRECT: Consuming foods high in vitamin A (apricots, carrots, leafy green vegetables) reduces the risk of cancer.

B. CORRECT: Consuming cruciferous vegetables, such as broccoli and cabbage, reduces the risk the risk of cancer.

C. Increased consumption of red meat can increase the risk for cancer.

D. The use of polyunsaturated and monounsaturated fats is beneficial in lowering the risk of many types of cancer, while foods high in saturated fats are associated with an increased risk of cancer.

E. Consuming whole grains reduces the risk for colon cancer.

NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

3. A. Add tart foods, such as citrus, to the diet to increase food taste and reduce the occurrence of a metallic taste.

B. CORRECT: The use of plastic utensils when eating can enhance taste sensations for the client undergoing cancer treatment and reduce the occurrence of a metallic taste.

C. Eating cold or room-temperature foods improves taste sensation.

D. Add pectin-rich foods to increase bulk of the stool and lengthen transition time in the colon.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

4. A. The client should be encouraged to cut food into small pieces to reduce irritation to mucous membranes.

B. CORRECT: Dry, coarse foods such as toast can worsen the manifestations of stomatitis.

C. This intervention is indicated for the client who has fatigue due to cancer treatment.

D. Acidic or spicy foods irritate the mucous membranes of the client who has stomatitis due to cancer treatment.

NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration

5. A. A BMI of 26 is within the expected reference range; a weight loss of at least 10% is one factor required to diagnose HIV-associated muscle wasting.

B. Diarrhea is common for a client who has HIV-associated muscle wasting.

C. CORRECT: Report of fever or other condition for 30 days, in addition to a specific weight loss, indicates HIV-associated muscle wasting.

D. Alcohol consumption is not a factor used to diagnose HIV-associated muscle wasting.

NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems

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NUTRITION FOR NURSING REFERENCES 99

References

Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb’s fundamentals of nursing: Concepts, process, and practice (10th ed.). Upper Saddle River, NJ: Prentice-Hall.

Burchum, J. R., & Rosenthal, L. D. (2019). Lehne's pharmacology for nursing care (10th ed.). St. Louis, MO.

Dudek, S. G. (2018). Nutrition essentials for nursing practice (8th ed.). Philadelphia: Wolters Kluwer.

Grodner, M., Escott-Stump, S., & Dorner, S. (2016). Nutritional foundations and clinical applications of nutrition: A nursing approach (6th ed.). St. Louis, MO: Mosby

Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing (14th ed.). Philadelphia: Wolters Kluwer.

Hockenberry, M. J., & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed.). St. Louis, MO: Mosby.

Ignatavicius, D. D., Workman, M.L., & Rebar, C. R. (2018). Medical-Surgical nursing: Concepts for Interprofessional collaborative care. (9th Ed). St. Louis, MO.

Pagana, K. D., & Pagana, T. J. (2018). Mosby’s manual of diagnostic and laboratory tests (6th ed.). St. Louis, MO: Elsevier.

Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier.

Touhy, T. A., & Jett, K. F. (2016). Ebersole & Hess’ toward healthy aging: Human needs and nursing response (9th ed.). St. Louis, MO: Elsevier.

United States Department of Agriculture (USDA). (2013). Sausages and food safety. Retrieved from https://www.fsis.usda.gov/wps/wcm/connect/fsis- content/internet/main/topics/food-safety-education/get-answers/food- safety-fact-sheets/meat-preparation/sausages-and-food-safety/ct_index

U. S. Food and Drug administration. (2016). Food labeling: Revision of the nutrition and supplement facts labels. https://www. regulations.gov/document?D=FDA-2012-N-1210-0875

U. S. Food and Drug administration. (2018). Refrigerator & freezer storage chart. Retrieved from https://www.fda.gov/downloads/ food/foodborneillnesscontaminants/ucm109315.pdf

U. S. Food and Drug administration. (2017). Surplus, salvaged, and donated foods: Safety tips. Retrieved from https://www.fda.gov/ Food/ResourcesForYou/Consumers/ucm197835.htm

U. S. Food and Drug administration. (2017). Safe food handling: What you need to know. Retrieved from https://www.fda.gov/downloads/Food/ FoodborneIllnessContaminants/BuyStoreServeSafeFood/UCM440123.pdf

U. S. Food and Drug administration. (2018). Produce: selecting and serving it safely. Retrieved from https://www.fda.gov/food/ foodborneillnesscontaminants/buystoreservesafefood/ucm114299.htm

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100 REFERENCES CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES BASIC CONCEPT A1

Basic Concept STUDENT NAME _____________________________________

CONCEPT ______________________________________________________________________________ REVIEW MODULE CHAPTER ___________

Related Content (E.G., DELEGATION, LEVELS OF PREVENTION, ADVANCE DIRECTIVES)

Underlying Principles Nursing Interventions WHO? WHEN? WHY? HOW?

ACTIVE LEARNING TEMPLATE:

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A2 BASIC CONCEPT CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES DIAGNOSTIC PROCEDURE A3

Diagnostic Procedure STUDENT NAME _____________________________________

PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________

Description of Procedure

Indications

Interpretation of Findings

CONSIDERATIONS

Nursing Interventions (pre, intra, post)

Potential Complications

Client Education

Nursing Interventions

ACTIVE LEARNING TEMPLATE:

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A4 DIAGNOSTIC PROCEDURE CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES GROWTH AND DEVELOPMENT A5

EXPECTED GROWTH AND DEVELOPMENT

Growth and Development STUDENT NAME _____________________________________

DEVELOPMENTAL STAGE _______________________________________________________________ REVIEW MODULE CHAPTER ___________

Health Promotion

Physical Development

Immunizations

Cognitive Development

Health Screening

Psychosocial Development

Nutrition

Age-Appropriate Activities

Injury Prevention

ACTIVE LEARNING TEMPLATE:

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A6 GROWTH AND DEVELOPMENT CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES MEDICATION A7

Medication STUDENT NAME _____________________________________

MEDICATION __________________________________________________________________________ REVIEW MODULE CHAPTER ___________

CATEGORY CLASS ______________________________________________________________________

PURPOSE OF MEDICATION

Expected Pharmacological Action

Complications

Contraindications/Precautions

Interactions

Medication Administration

Evaluation of Medication Effectiveness

Therapeutic Use

Nursing Interventions

Client Education

ACTIVE LEARNING TEMPLATE:

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A8 MEDICATION CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES NURSING SKILL A9

Nursing Skill STUDENT NAME _____________________________________

SKILL NAME ____________________________________________________________________________ REVIEW MODULE CHAPTER ___________

Description of Skill

Indications

Outcomes/Evaluation

CONSIDERATIONS

Nursing Interventions (pre, intra, post)

Potential Complications

Client Education

Nursing Interventions

ACTIVE LEARNING TEMPLATE:

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A10 NURSING SKILL CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES SYSTEM DISORDER A11

System Disorder STUDENT NAME _____________________________________

DISORDER/DISEASE PROCESS __________________________________________________________ REVIEW MODULE CHAPTER ___________

ASSESSMENT SAFETY CONSIDERATIONS

PATIENT-CENTERED CARE

Alterations in Health (Diagnosis)

Pathophysiology Related to Client Problem

Health Promotion and Disease Prevention

Risk Factors Expected Findings

Laboratory Tests Diagnostic Procedures

Complications

Therapeutic Procedures Interprofessional Care

Nursing Care Client EducationMedications

ACTIVE LEARNING TEMPLATE:

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A12 SYSTEM DISORDER CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES THERAPEUTIC PROCEDURE A13

Therapeutic Procedure STUDENT NAME _____________________________________

PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________

Description of Procedure

Indications

Outcomes/Evaluation

CONSIDERATIONS

Nursing Interventions (pre, intra, post)

Potential Complications

Client Education

Nursing Interventions

ACTIVE LEARNING TEMPLATE:

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A14 THERAPEUTIC PROCEDURE CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES CONCEPT ANALYSIS A15

Concept Analysis STUDENT NAME _____________________________________

CONCEPT ANALYSIS ____________________________________________________________________

Defining Characteristics

Antecedents (WHAT MUST OCCUR/BE IN PLACE FOR CONCEPT TO EXIST/FUNCTION PROPERLY)

Negative Consequences (RESULTS FROM IMPAIRED ANTECEDENT — COMPLETE WITH FACULTY ASSISTANCE)

Related Concepts (REVIEW LIST OF CONCEPTS AND IDENTIFY, WHICH CAN BE AFFECTED BY THE STATUS OF THIS CONCEPT — COMPLETE WITH FACULTY ASSISTANCE)

Exemplars

ACTIVE LEARNING TEMPLATE:

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A16 CONCEPT ANALYSIS CONTENT MASTERY SERIES