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Nutrition

Nutrition. Teresa V. Hurley. MSN, RN. Physical — geographic location, food technology, income Physiologic — health, hunger stage of development. Psychosocial — culture, religion, tradition, education. Factors Affecting Food Habits. Psycho/Social. Developmental.

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Nutrition

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  1. Nutrition Teresa V. Hurley. MSN, RN

  2. Physical — geographic location, food technology, income Physiologic — health, hunger stage of development Psychosocial — culture, religion, tradition, education Factors Affecting Food Habits

  3. Psycho/Social

  4. Developmental

  5. Human Growth and Development • Infants through School-Age -rapid growth with high protein, vitamin, mineral and energy demand; infant doubles birth weight in 4-5months; triples weight at 1 year Breast Feeding encouraged -reduces allergy risks What other factors?

  6. Infants • Formula • Cow’s milk causes GI bleeding • Kidney’s unable to handle • Research: milk in 1st and the development of Type I Diabetes later in life • Honey and corn syrup maybe be source of botulism

  7. Introduction of Solid Food • 4 to 6 months of age • Introduce one at a time 4 to 7 days apart to identify allergies

  8. Toddlers • Picky eaters around 18 months of age • 3 meals and 3 snacks • Calcium and phosphorous for bone growth Hot dogs, candy, nuts, grapes, raw veggies, popcorn frequently lead to choking deaths

  9. School Age • Growth slower and steadier • Check for protein, vitamins A and C • High fat, sugar and salt intake lead to childhood obesity compounded by sedentary lifestyle

  10. Adolescents • Energy needs increase to meet the increase metabolic demands of growth • protein., calcium, iron (females) and muscle growth (males) • Fad dieting, oral contraceptive use, fast foods, skipping meals • Eating disorders anorexia nervosa and bulimia nervosa

  11. Young and Middle-Age • Energy demands less • Fetal development affected by mother’s nutritional status and weight at time of conception; protein, calcium, iron, folic acid • Lactation: protein, calcium, Vitamins A, C, B; avoid caffeine, alcohol and drugs

  12. Older Adults • Lifestyle • Income • Lack of teeth, dentures, thirst sensation less with resultant dehydration (confusion, weakness, hot dry skin, rapid pulse • Nutrient dense foods: peanut butter, cheese, eggs, cream and meat-based soups

  13. Cultural

  14. Alternative Food Patterns • Vegetarian • Ovolactovegetarian (no meat, fish and poultry but will have milk and eggs) • Lactovegetarians (drink milk but no eggs) • Vegans (plant foods) -A Zen vegan eats brown rice, grains, herb teas -Fruitarians eat only fruits, nuts, honey and olive oil

  15. Religious Dietary Restrictions • Islam (no pork, caffeine, ritual slaughter of animals; Ramadan fasting sunrise to sunset for a month) • 7th day Adventists (no pork, shellfish, alcohol, vegetarianism encouraged) • Hinduism (no meats) • Latter Day Saints (no alcohol, tobacco , caffeine)

  16. Developmental factors State of health Alcohol abuse Medications Megadoses of nutrient supplements Risk Factors for Poor Nutritional Status

  17. Anorexia Anorexia -poor appetite related to ketosis an appetite suppressant Surgical Procedures with resultant pain Diagnostic testing (NPO, bowel evacuations)

  18. Promoting Appetite • Keep environment free of odors • Oral hygiene • Insulin, glucosteriods, thyroid hormones affect metabolism • Antifungals alter taste • Psychotropics affect appetite, nausea, alter taste

  19. Nursing Interventions • Risk for Aspiration • Assess LOC • Decrease or absent gag or cough reflex • Surgical procedures • Neuromuscular impairments • Sensory impairments

  20. Nursing Interventions • Upright position • Food placed stronger side of mouth • Thickening agents • Rate of eating slower to provide for chewing and swallowing • Use clock as guide to identify food location for visually impaired • Use assistive devices (padded forks, spoons etc)

  21. Nursing Interventions • Client to direct order and preferences of food items to eat

  22. Therapeutic Diets • NPO nothing by mouth • Clear Liquid: broth, bouillon cubes, tea, carbonated beverages, clear fruit juices, popsicles • Full Liquid: add to clear liquid diet smooth textured dairy products as custard, refined cooked cereals, pureed veggies, all fruit juices

  23. Diets Continued • Pureed ( continue to add to the previous) scrambled eggs, pureed meats, veggies, fruits, mashed potatoes and gravy • Mechanical Soft (add to the previous) ground or diced meats, flaked fish, cottage cheese, cheese, rice, potaotes, pancakes, light breads, cooked vegetables and fruits, canned fruits, bananas, soups, peanut butter

  24. Diets Continued • Soft Low Residue: add pastas, casseroles, moist tender meats, canned cooked fruits and vegetables, desserts, cakes, cookies without nuts or coconut • High Fiber: add fresh uncooked fruits, steamed veggies, bran, oatmeal, dried fruits • Low Sodium: 4g (no added salt) 2gm to 500mg Na diets require selective choices

  25. Medications • Stimulate appetite • Periactin • Megace • Marinol’

  26. Diets Continued • Low Cholesterol 300mg/day in accordance with AHA guidelines for serum lipid reduction • Diabetic: Food exchanges with balanced intake of protein, CHO and fats and vary according to energy demands as exercise, pregnancy, illness • Regular NO restrictions

  27. Short-term nutritional support Nasogastric nasointestinal route Long-term nutritional support Enterostomal tube created into stomach (gastrostomy) Percutaneous endoscopic gastrostomy (PEG) jejunum (jejunostomy) Enteral Nutrition

  28. Enteral Nutrition (EN) • Nutrients given via the GI tract • Formula given via NGT,PEG, PEJ • Initial tube placement verified by x-ray which is the most accurate indicator • Traditional Method for placement • Measure distance from tip of nose to earlobe to xiphoid process of sternum • Water soluble lubricant • Insert through naris toward posterior nasopharynx • Flex head toward chest after passage through posterior nasopharynx • Have client mouth breathe and swallow small sips of water • Stop advancing if client choking, coughing, cyanotic

  29. Types of Tubes • Naso-Gastric Salem Sump

  30. Types of Tubes Gastrostomy Tube Jejunostomy Tube

  31. Tube Placement

  32. Evidence Based Research • X-ray verification most accurate • X-ray method not feasible, the next best method is pH testing of gastric aspirate with readings between 0-4. • pH of 6 or more placement in lung, intestine • Ausculatory method should not be used but in some agencies still in use

  33. Gastrostomy or Jejunostomy Tube • HOB elevated 45 degrees • Auscultate for bowel sounds • Verify placement by testing pH of gastric aspirate • Check gastric residual • If over 100 ml notify MD • Would you replace the gastric contents? • Would you stop the feeding?

  34. Some Complications of Feeding • Aspiration • Tube displacement • Cramping from using cold formula • Diarrhea • Impaired skin integrity • Nosocomial infections

  35. Total parenteral nutrition (TPN) Partial parenteral nutrition (PPN) Parenteral Nutrition

  36. Total Parenteral Nutrition TPN- Total Parenteral Nutrition • complete form of nutrition • protein • CHO • fat • vitamin • minerals =

  37. Indications for TPN • Inability to eat • Ventilator dependency • Additional surgery • Altered mental status affecting ability to eat • Diminished nutrient intake • Anorexia • Dyspepsia from medications • Gastrointestinal problems including nausea, vomiting, diarrhea, and distention • Increased nutrient requirements • Hyper metabolism • Nitrogen loss caused by surgery and corticosteroid administration • Malabsorption

  38. TPN ACCESS DEVICES

  39. Insertion problems Infection Metabolic alterations Fluid, electrolyte, and acid-base imbalances Phlebitis Complications of Parenteral Nutrition

  40. PN Complications • Electrolyte and Mineral imbalances: refeeding syndrome -high concentrations of glucose leads to endogeneous insulin production which leads to -cations moving from inter to intracellular (potassium, magnesium and phosphorus) which leads to cardiac dysarrthymias, CHF. Respiratory distress, convulsions, coma, death

  41. Complications of PN • Rapid administration of hypertonic dextrose leads to osmotic diuresis and dehydration • DO NOT SPEED UP IF BEHIND • DO NOT STOP LEADS TO HYPOGLYCEMIA

  42. Glucose Testing • Diabetes is a metabolic disorder • Inadequate insulin production by pancreatic beta cells or • Insulin resistance whereby glucose unable to cross sell membrane • Cellular starvation • Fluid and electrolyte imbalances

  43. Diabetes • Hypoglycemia: pancreas secretes glucagon • Hyperglycemia: pancreas secretes insulin • Polyuria • Polydyspia • Polyphagia • Glycosuria • Ketones

  44. Hypoglycemia • Rapid onset with BS 80 or below • Cool, pale, diaphoretic skin • Disorientation---coma • Shaky, dizzy, agitated • Pulse maybe tachy • B/P maybe high • Seizures common • Treat with PO or IV Glucose

  45. Hyperglycemia • Gradual onset with BS 200 or above • Skin warm, dry, flush • Awake, lethargic • Hungry, blurred vision • Deep, rapid respirations • Pulse, weak, rapid • B/P maybe low • Breath: fruity odor • Dehydrated • Polyuria • Polydyspia • Treatment: IV, insulin and K

  46. Glucose Monitoring • ac and at hs • Range 70-110 mg • Insulin Coverage • Regular Insulin (Rapid Acting) 3-4 hr • NPH/reg (Fast Acting) 30 min---24hr • Lente, NPH (Intermediate Acting) 1-3 hr---18-28 hr • Ultra-lente (Long Acting) 4-6 hr---36 hr

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