Regents College Nursing


Study Guide Expanded Notes

I. Nutrition






I. Nutrition

A. Theoretical framework: basis for care

1. Principles related to normal nutrition (e.g.,
anatomy and physiology)

2. Components of normal nutrition: definitions, basic
function, common food sources, daily requirements
(e.g., from the food Guide Pyramid exchange lists)


Food provides the required nutrients that are required
for the body to build and maintain body tissue, and provides
the required energy for body activities. Nutrition is concerned
with the processes involved in the intake, metabolism and
utilization of food. Nutrients are those substances that are
needed by the body to maintain life.

There are approximately 40 essential nutrients that the
body must obtain from the food eaten because the body can
not make or can not make enough to satisfy the needs. Other
nutrients, the nonessential nutrients, come from the foods
eaten or made by the body in sufficient amounts.

The essential nutrients are carbohydrates, proteins, fats,
vitamins, minerals and water. Fiber is an important component
to successful function of the digestive tract.

Carbohydrates and fats are the richest source for energy,
with one gram of fat providing 9 calories and one gram of
carbohydrates providing 4 calories. Protein also provides 4
calories and may be used as an energy source, however, the
body prefers to use protein for the amino acids contained.
Calories are small units and are normally calculated in
kilocalories (kcal), with the common usage of a calorie being in
reality a kilocalorie. Adult males require an average total of
2000 to 3000 calories a day, with adult females requiring an
average of total 1400 to 300 calories a day.

Nutrition is not just concerned about the availability of
the various nutrients in the food, but also the quantity of
intake. As inadequate intake may cause health problems, so
will excessive intake. Many of the current western life style
diseases that consume much of the health care expenditure are
a result of intake excess, especially of food fats.

Food is not just the sum of its parts. There are many
other elements involved in providing nutrition in the health
care setting than simply nutritional content. Food is an
important element to the overall function of the individual and
society. Successful health care needs to consider the whole
patient in relationship to the nutritional needs and ensure that
various other factors such as religion and cultural needs are
considered. In the end, the consumption of food for humans is a
pleasurable social activity, and this needs to be reflected in the
health care environment.

Total Energy Requirement
Recommended Dietary Allowances (RDA)
Food Groups and Food Guide Pyramid
Food Exchange System
a. Carbohydrates

Provide 4 calories per gram
Starches, sugars and cellulose
Monosaccharides, Disaccharides, Polysaccharides

58% of the daily calories should come from
carbohydrates, with less than 10% of those from refined and
processes sugars, thus the remainder form complex
carbohydrates. Currently the average diet has 18% coming from
refined and processes sugars, and the overall diet having only
46% of the calories form carbohydrates. Needed is an increase
in overall percentage of calories from carbohydrates, lessening
fats, and within the carbohydrates, an increase in complex
carbohydrates and a decrease in refined and processed sugars.

Carbohydrates are composed of atoms of carbon,
hydrogen and oxygen. The simple carbohydrate glucose
(C6H12O6), the monosaccharide also called dextrose, is the
main body source of energy. The other monosaccharide,
fructose, found in fruits, and galactose, not found free but
obtained by the hydrolyzing of lactose, are both usually
processed by the liver into glucose. The other carbohydrates,
disaccharides and polysaccharides, need to be broken by the
body into monosaccharides.

Disaccharides are two monosaccharides linked together.
Still a simple carbohydrate, the body has to do only a little
work to break it down. The disaccharides are sucrose, lactose
and maltose. Sucrose is the common table sugar that we use.
Lactose is in milk.

Polysaccharides are complex carbohydrates of at least
three saccharide units, usually long chins. Starch is the
principle form obtained from plants. The starch is where the
plant stored energy.

Humans and other animals store glucose in the
polysaccharide glycogen. The liver acts at the main storehouse.
Excess glucose that can not be stored as glycogen is stored as
fat.

Cellulose and pectin are polysaccharides which supply
dietary fibers.

Artificial Sweeteners

The alternative sweeteners are of two types, the sugar
alcohols which are nutritive sweeteners, and the true artificial
sweeteners.

The nutritive sweeteners of mannitol, sorbital, xylitol and
maltitol are sugar alcohols which provide the same amount of
energy as sugars, however are delayed in absorption and
conversion to glucose especially in the mouth. For this reason
they are found in "sugar free" chewing gums and in some
children's medicines to reduce tooth decay.

The artificial sweeteners of cyclamate, saccharin, and
aspartame provide no energy, although they are much sweeter
in taste than sugars weight for weight. The safety of these
product are still questioned, with cyclamate use banned in the
US since 1970. Aspartame is also known by the brand name of
NutraSweet.

Lactose Intolerance

In order to digest lactose, the mucosal cells of the small
intestine secrets the enzyme lactase which breaks the
disaccharide lactose into the monossacharides of glucose and
galactose. These monosaccharides are absorbed by active
transport in the small intestines.

Without or with less than enough lactase, the
disaccharide lactose will remain in the small intestine. Lactose
causes an osmotic pressure gradient resulting in fluid being
pulled into the small intestine causing diarrhea, one of the
principle signs for lactose intolerance. Abdominal bloating and
discomfort also accompany.

Many people loose lactase activity with age. Infants have the
highest levels of lactase, which one would expect as their diet is
milk only. Some infants are born without this enzyme thus
must be given other milk substitutes such as soy formula.

Lactase deficiency commonly develops in 90% of
Orientals, 80% Native Americans, 75% of American Blacks and
50% of Hispanics, with only 20% of Caucasians developing the
deficiency. This may be due to the Northern European milk
dependency heritage, with the rate of lactose deficiency
dropping through interracial marriages, which supports the
genetic basis for the condition.

Alcohol


b. Proteins

Provide amino acids (20 total 9 essential)
Used in the building and repair of cells
Provide 4 calories per gram when used as energy

With over 50,000 different kinds of protein in the body,
protein is the second most common substance in the body,
second to water.

Protein is used primarily for building and repair of cells
within the body. Protein will be used for energy when there is
not enough energy provided by other sources.

Main problem with dietary meat sources for protein is
the fats associated with them. The meat of wild animals usually
has only 2 to 5 percent fat, and that fat being mainly
polyunsaturated. Domestic meat has 15 to 30 percent fat, with
most of that being saturated.

About 12% of the daily calories should come form protein,
which is the amount that currently is in the average diet. The
change needed is in the fat content.

Protein deficiency
Kwashiorkor
Marasmus
Vegetarians

c. Fats

Lipidsn fats and oils
Triglicerides, saturated, monounsaturated and
polyunsaturated
9 calories per gram
Cholesterol
Hydrogenated oil and trans-fatty acids

Lipoproteins
VLDL, LDL and HDL

d. Vitamins

Fat Soluble (A, D, E, and K)
Water Soluble (B and C0

e. Minerals

Main needs include calcium, phosphorus, magnesium
and iron

f. Fiber

g. Fluids



3. Common nutritional disturbances (e.g., altered
ingestion, digestion and absorption, nutritional
deficiencies)

Malnutrition, starvation and obesity
Eating disorders of anorexia nervosa and bulimia
Dyspepsia, anorexia, and nausea and vomiting
Food Poisoning and Botulism
Vitamin K
Celiac disease

4. Factors affecting nutrition

a. Developmental level: infancy through senescence

b. Individual preferences and patterns (e.g., vegetarian diet,
health habits, use of vitamin supplements, knowledge level,
cooking habits)

c. Physical condition (e.g., dental status, metabolic rate,
weight status, level of physical activity, circulation status,
status of peristalsis)

d. Ethnic and cultural considerations (e.g., religious
restrictions, traditional ethnic foods, cultural
preferences/taboos)

e. Socioeconomic factors (e.g., income level, work habits)

f. Environmental factors (e.g., means of procuring food, food
storage, refrigeration, eating facilities)

g. Psychological factors (e.g., peer pressure, mental status,
stress, increased dependency, loneliness, anxiety,
depression)

5. Theoretical basis fore interventions to promote
nutrition

a. Physiological considerations (e.g., oral care, increased
activity, positioning)

b. Enteral nutrition: oral and tube feedings

c. Parenteral nutrition: total parenteral nutrition (TPN), lipid
emulsions, total nutrient admixture (three-in-one)

d. Altered consistency of diets

1) Clear liquid
2) Full liquid
3) Soft

e. Vitamin and mineral supplements

B. Nursing care related to theoretical framework

1. Assessment: gather and synthesize data about the
patient's nutritional status in relation to the
patient's functional health patterns

a. Obtain the patient's dietary history (e.g., daily nutritional
status, intolerance to certain foods, food preferences, food
allergies, pattern of intake [24-hour food diary], loss of
appetite [Anorexia], dysphagia, nausea and vomiting)

b. Assess factors affecting nutrition (see IA4)

c. Obtain objective data (e.g., weight changes; skin turgor;
level of physical activity; condition of hair and nails; amount,
type, and pattern of intake; triceps skin fold thickness)

d. Review laboratory and other diagnostic data (e.g., serum
albumin, complete blood count [CBC])

2. Analysis: identify the nursing diagnosis (patient
problem) and determine the expected outcomes
(goals) of patient care

a. Identify nursing diagnoses (e.g., altered nutrition: less
than body requirements related to hectic schedule; altered
nutrition: more than body requirements related to
dependence on fast foods; altered health maintenance
related to insufficient knowledge of nutritional needs)

b. Set priorities and establish expected outcomes (patient-
centered goals) for care (e.g., patient will identify form the
Food Guide Pyramid preferred foods that are accessible and
easy to prepare, patient will select low-calorie foods from
fast-food menus, patient will select a balanced daily diet
from a basic food list)

3. Planning: formulate specific strategies to achieve
the expected outcomes

a. Incorporate factors affecting nutrition in planning the
patient's care (e.g., plan a clear liquid diet for a patient
following surgery, plan a nutritionally adequate diet based
on patient's religious preferences, plan a nutritionally
adequate diet for an older adult) (see IA4)

b. Plan nursing measures to help the patient achieve the
expected outcomes (e.g., review nutritional requirements
based on the Food Guide Pyramid, monitor the patient's
weight)

4. Implementation: carry out nursing plans designed
to move the patient toward the expected outcomes

a. Assist in food selection (e.g., for a patient with altered
chewing or swallowing ability, for patients of various
developmental levels, for a patient with an imbalanced diet)

b. Use nursing measures appropriate to particular feeding
methods (e.g., provide nasogastric tube feedings, administer
gastrostomy tube feedings, monitor TPN)

c. Structure an environment conducive to nutritional intake
(e.g., remove noxious stimuli form the environment, make
the patient comfortable)

d. Use nursing measures specific to prescribed vitamin and
mineral supplements (e.g., administer iron supplements with
orange juice, administer vitamin supplements as ordered,
check the serum albumin level for a patient who is receiving
a high-protein liquid supplement)

e. Provide information and instruction regarding nutrition
(e.g., instruct the patient regarding food preservation and
preparation, instruct the patient how to read nutritional
content on food labels, instruct the patient with lactose
intolerance about alternate food sources)

5. Evaluation: appraise the effectiveness of the
nursing intervention relative to the nursing
diagnosis and the expected outcomes

a. Record and report patient's response to nursing actions
(e.g., weight changes, improved skin turgor, changes in
nutritional intake, noncompliance)

b. Reassess and revise the patient's plan of care as necessary
(e.g., provide small, frequent feedings for a patient with loss
of appetite [anorexia])