Nutrition 3854a9db03c840bda3cac93d49a2910d
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Texas Tech University *
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2307
Subject
Health Science
Date
Feb 20, 2024
Type
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57
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Nutrition
1
Nutrition Which food group should represent the highest percentage found on a MyPlate dish? VEGETABLES ______
SODA
and sports drinks often contain high amounts of sugar and calories (carbohydrates) with little to no nutritional value (empty calories) and should be limited or removed from the clients dietary intake.
Individuals who are attempting to lose weight should consume beverages with nutritional value and little to no caloric value
Example 12 oz can of regular soda contains about 140 calories. If a client consumed 5 cola beverages per day, that is about 250K
____ kcal per year and 73
____ pounds. Education to substitute zero-calorie beverages for regular sodas could result in the client losing 73
lbs in a year by this simple substitute.
i
O
0
0
Nutrition
2
Complete protiens have all 9 amino acids _____COMPLETE_____ proteins come from which source? __ANIMAL________ and soy, contain sufficient amounts of all nine essential amino acids. Ex: Salmon
____INCOMPLETE______ proteins
, generally from plant sources, can contain an insufficient number or quantity of amino acids, which limits the ability for protein synthesis. examples of incomplete protein pairs that provide complete protein include black beans with rice and hummus with crackers
____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.
All
GEneymes
together
make
complete
Proticus
I
I
are
Nutrition
3
all 7 are metabolic functions The body stores excess proteins as fat
RDA for adults is 10% to 35% of total calories
Three main factors influence the body’s requirement for protein.
Tissue growth needs
Quality of the dietary protein
Added needs due to illness
Recommendation for a High-Protein Liquid Nutritional Supplement
Add skim milk powder to milk (double-strength milk). Use whole milk instead of water in recipes. Add cheese, peanut butter, chopped hard-boiled eggs, or yogurt to foods. Dip meats in eggs or milk and coat with bread crumbs before cooking. Nuts and dried beans are significant sources of protein. These are good alternatives for a dairy allergy or lactose intolerance.
metabolic
functions
4
I
Alterant.ws
for
dairy
Allergy
or
lactose
Intolerance
would
be nuts
and dried
beans
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Nutrition
4
The lipids important to cell membrane structure are the:
PHOSPHOLIPIDS
__
The lipid that removes cholesterol from the arterial wall and transports it to the liver for destruction are the: HDL (UNSATURATED FATS )
__
Protein restriction is essential for clients who have stage 1 to 4 CKD
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.
End
stage
kidney
disease
Nutrition
5
Low-Saturated Fat Diet: _______
Transfats promote an increase in HDL
Transfats are a greater risk factor for heart disease than are saturated fats.
DASH diet: low sodium, high potassium, high calcium – lowers blood pressure and cholesterol
The body stores more energy from __________ than protein or carbs
Recommended for adults to consume Fats in diet: 20% to 35% of daily calorie intake
Fats are solid at room temperature, and are found primarily in animal sources
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.
Trim
Visible
Fat
from
meats
limit
red
meat
choose
leanmeats
chicke
and
turkey
remove
skindont
frie
DL
fats
saturated
Nutrition
6
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
Cholesterol, trans fat, and saturated fats can be restricted to assist in controlling high lipid levels
Cholesterol consumption should be limited to between 200 and 300 mg/day.
Raw fruits and vegetables would be avoided on a soft low fiber diet
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Nutrition
7
Vitamin C (ascorbic acid)
Aids in tissue building and metabolic reactions
Found in citrus fruits (oranges, lemons), tomatoes, peppers, green leafy vegetables, and strawberries.
Aids in the absorption of
_____IRON?_____
Higher amounts needed for those with stress and illness, as well as cigarette smoking.
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
Vitamin B deficiency clinical manifestations: paresthesia to the hands and feet
vitamin
C
numbness
tingling
Nutrition
8
Selecting Foods Containing Vitamin A
Food sources include baked potato, fatty fish, egg yolks, butter, cream, and dark yellow/orange fruits and vegetables (carrots, yams, apricots, squash, cantaloupe). Liver, egg yolk, whole milk, butter, green and yellow vegetables
VITAMIN A TOXICITY CAN RESULT FROM RETINOIDS
Manifestations of Vitamin A Toxicity- Headaches
Toxicity can result from retinoids, and is more common in clients who are taking vitamin A supplements.
Hypercalcemia can result from vitamin a & D toxicity
Vitamin D Deficiency in an Older Adult Client
Active vitamin D is formed in the kidney
Vitamin D assists in the absorption of calcium and phosphorus, and aids in bone mineralization.
Osteoporosis prevention: increasing intake of vitamin D and calcium, engaging in weight- bearing exercise, reducing use of tobacco and alcohol products
Biff
m
Nutrition
9
(VIT D) Deficiency= Low blood calcium, fragile bones, rickets, osteomalacia in adults DEMINERILAZATION of the bone
ENCOURAGE VIT D
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 Vitamin A: ___FATTY FISH, EGGS, YOLK, BUTTER, CREAM, DARK YELLOW ORANGE FRUITS, VEGETABLES (CARROTS, YAMS, APRICOTS, SQUASH, CANTALOUPE), OTHER FOODS LIVER, EGG YOLKS, WHOLE MILK, BUTTER, GREEN AND YELLOW VEGETABLES
Food Sources Vitamin D: ___CHEESE, MARGARINE, BUTTER, FORTIFIED MILK, HEALTHY CEREALS, FATTY FISH
Food Sources Vitamin E: ALMONDS, MUSTARD GREENS, DRIED APPRICOTS, BELLPEPPERS, PINE NUTS, GREEN OLVIES, PAPAYA, COLD PRESSED PLANT OILS, SUNFLOWER SEEDS, COOKED SPINACH, AVACADOS, RED CHILLI POWER/PAPRIKA
Food sources Vitamin K: __DARK LEAFY GREENS
Bone
Softening
Baked
Potato
Order
and
gas
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Nutrition
10
Garlic ingestion may help reduce cardiovascular risks in a client with hyperlipidemia
Education for Ileostomies and colostomies
Avoid foods that cause gas (beans, eggs, carbonated beverages), stomal blockage (nuts, raw carrots, popcorn), and foods that produce odor (eggs, fish, garlic).
Selecting High-Potassium Food for a Client Who Has Hypokalemia: cooked tomatoes
Foods Containing Calcium for Osteoporosis Prevention; Dairy, broccoli, kale, grains, egg yolks
A true statement of calcium is?
a.For most people its intake is not required because it is released from the bone in sufficient amounts under the influence of PTH**
b.9.5 mg would be considered to be low.
c.A (+) trousseau’s sign would be noted by tapping Cranial nerve # 7 in a client with a level of 7.5 mg.
d.Bradycardia may be a manifestation in a client with a level of 6.0 mg.
causes
odor
sodihoride
Hypochloremin
Hyponatremia
Hypokalemia
Hypophosere
Hypocalcemia
Hyponasnesia
Hyponatremia
Hypermen
Hyperchlore
p
Hypercalemia
Hyperiagnesia
Hyperphosoemin
sodciyor.de
Ca
9
10.5
I
Nutrition
11
Alendronate is prescribed for a client for which reason?
a.To treat osteoporosis**
b.To treat hypocalcemia
c.To treat a client with a (+) Chvostek sign
d.To treat hypervolemia
A client with a phosphate level of 2.0 mg/dl would most likely display muscle weakness due to a lack of:
a.ATP
b.Glucose
c.K+
d.Ca++**
Milk, beer, beans, soda, chocolate should be restricted in a client in CRF in order to avoid hyperphosphatemia.
Which client should the R.N. be most concerned about developing hypomagnesemia?
a.A client who has chronic renal failure
b.A client who has chronic alcoholism**
c.A client who has chronic constipation
d.A client who has chronic hypotension
big
a
Phosphorous
2.5
4.5mg
dL
Nutrition
12
Calculating Appropriate Intake of Fat Calories Per Day
The AMDR for fats is approximately 20% to 35% of total calories. 10% or less of total calories should come from saturated fat sources.
Recommended daily calories = 2,000
20% of 2,000= 400
35% of 2,000= 700
A diet high in fat is linked to CVD, hypertension, and diabetes mellitus.
20
7
20
2000
20
450
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Nutrition
13
Nursing assessments should include a complete dietary profile of the client, medications, herbal supplements, baseline knowledge about food safety (salmonella, e coli, listeria, norovirus), and food-medication interactions.
Some foods alter the metabolism/actions of medications
Grapefruit juice interferes with the metabolism of many medications, resulting in an increased blood level of the medication.
Foods high in vitamin K (dark green vegetables, eggs, carrots) can decrease the anticoagulant effects of warfarin.
Foods high in protein can increase the metabolism of the anti-Parkinson’s medication levodopa, which decreases the medication’s absorption and amount transported to the brain.
***Tyramine
is a naturally occurring amine found in many foods that has hypertensive effects similar to other amines (norepinephrine). Tyramine is metabolized by MAO, and clients taking MAOIs (phenelzine, selegiline) who consume foods high in tyramine can suffer a hypertensive crisis.
Foods high in tyramine include aged cheese, smoked meats, dried fish, and overripe avocados.
I
Nutrition
14
Herbal supplements can cause potential interactions with prescribed medications. It is important that any herbal medication consumed by a client be discussed with the provider.
Nursing interventions should include basic teaching about food safety, and the interactions between food and client medications.
Teach the client about the difference between food intolerance and food allergy.
Common allergy in children: eggs, someone with egg allergy should not be given flu vaccine
Hoarseness in voice indicates allergic reaction
Education on iron and calcium supplements: take them together
Medications Affecting Urinary Output: Thiazide Diuretic
Clients with lactase deficiency (lactose intolerance) experience varying degrees of GI symptoms after ingesting milk products, including flatulence, diarrhea, bloating, and CRAMPING
__.
DUE TO A DEFICIENCY OF THE ENZYME LACTASE, WHICH IS REQUIRED FOR THE DIGESTION OF LACTOSE
ITIS
see
Nutrition
15
Treatment includes restricting lactose-containing foods in the diet. These clients may also take lactase enzyme replacements (Lactaid) to decrease symptoms. Calcium and vitamin D supplementation is recommended due to insufficient intake of fortified milk.
Milk and ice cream contain the highest amounts of lactose and should be restricted depending on the clients individual tolerance. Some dairy products, including aged cheeses and live culture yogurts, contain little to no lactose and can be tolerated by most clients with lactase deficiency
Lactase deficiency is not an immune reaction (allergy) to milk products. Rather the symptoms are due to a deficiency of the enzyme lactase and the resulting inability to digest lactose
GLUTEN FREE DIET/AUTOIMMUNE DISORDER
EATING SMALL AMOUNTS OF GLUTEN WILL DAMAGE THE INTESTINAL VILLI THROUGH INGESTION
all sources of gluten must be eliminated = REDUCES RISK FOR NUTRITIONAL DEFICIENCY AND INTESTINAL CANCERS SUCH AS LYMPHOMAS
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Nutrition
16
Celiac disease- a good meal option would be grilled chicken, green beans, and mashed potatoes
All gluten containing products should be eliminated from the diet- wheat, barley, rye, and oats
Rice corn and potatoes are gluten free and are allowed on the diet
Processed foods (chocolate, candy, hot dogs) may contain hidden sources of gluten such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten-free
Teaching About Jewish Dietary Practices
Fast on specific holy days- unleavened bread on Passover
24 hour fast on Yom Kippur
Restrict pork
May not eat meat and dairy at the same time
May consume only fish that contain scales and fins
May consume only kosher animals
Nutrition
17
Prohibits preparation of food on the sabbath
Example: Spaghetti and tomato sauce
Example: Grilled veggies, baked chicken breast, no bacon
Seventh-day Adventist law: No Coffee
Hindu' s dietary practices include: no beef
Islam: Restrict Pork, alcohol, coffee, tea, fasting during Ramadan during the daylight hours
Mormon: No caffeine
Deficient Nutrients in a Vegan Diet
Clients who follow a vegan diet eat only plant based foods, omitting animal proteins ( meat, pultry, fish) and products (dairy, eggs).
Lacto vegetarian diet includes dairy products
Clients who are vegan are at risk for deficiency of vitamin B 12 ( cobalamin) which is primarily supplied by animal products.
Nutrition
18
Chronic vitamin b12 deficiency: megaloblastic anemia = Iron Deficiency Anemia
Manifestations of chronic deficiency include:
Peripheral neuropathy (tingling
, numbness, muscle spasms
)
Neuromuscular impairment (gait problems, poor balance)
Memory loss/ dementia (in cases of severe prolonged deficiencies)
Clients who follow a vegan diet are encouraged to take supplemental vitamin b12 to prevent severe neurological complications. In addition clients are taught to incorporate vitamin b12 fortified toods (cereals, grain products, soy and nut milks, meat substitutes)
NUTRITIONAL‐RELATED HEALTH RISKS: Risk for deficiency in vitamin B12, vitamin D, iron, calcium, and zinc, unless the client incorporates these foods regularly.
SET REALISTIC GOALS(1-2 LBS PER WEEK)
SMALL FREQUENT MEALS
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Nutrition
19
Juice contains high amounts of natural sugar and is not an appropriate alternative to soda
Skipping meals for caloric reduction has been shown to increase the tendency to over eat at subsequent meals
Multiple servings of fruit per day will benefit hypertensive patients
Postoperative diet progression:
1. Clear liquids- clear fat free broth, bouillon
Gelatin (jello): Avoid reds or purples
Clear fruit juices (apple, grape) – reds and purples should be restricted after any type of GI surgery
This will help identify hemataemesis vs. reds/ purples from diet.
Carbonated beverages (sprite, gingerale)
Coffee, tea
2. Full liquids
Clear liquids plus:
Nutrition
20
Strained or blended cream soups
Custards, puddings
Refined cooked cereals (oatmeal grits)
All fruit juices
Ice cream frozen yogurt, sherbet, milkshakes
3. Soft diet (bland low fiber)
Clear and full liquids plus
Soups
Ground or finely diced meats flaked fish
Pancakes, biscuits, muffins
Pasta, rice, mashed potatoes
Cooked or canned fruits, and veggies
Peanut butter
Scrambled eggs
Food Recommendations for a Client Who Has Difficulty Chewing
mechanical soft diet
Includes foods that require minimal chewing before swallowing (ground meats, canned fruits, softly cooked vegetables). Steak would not be allowed on this diet.
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).
Regular diet- no limitations
Barriers to Adequate Nutrition:
Caring for a Client Who Has Dysphagia: pudding, scrambled eggs, yogurt
Full liquid diet Use cautiously with clients who have dysphagia (difficulty swallowing) unless liquids are thickened appropriately.
Nutrition
21
Place the client in an upright or high-Fowler’s position to facilitate swallowing
Use semisolid, thickened foods for clients who have dysphagia, and instruct them to sit upright and tilt their head forward when 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
Administering Medications to a Client Who Has Dysphagia
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.
Interventions for a Client Who Reports Difficulty Swallowing
Evaluated by swallow study- Speech therapy consulted to evaluate- will determine dysphagia diet
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.
Actions for Client at Risk for Aspiration
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.
Thickened liquids can decrease the risk for aspiration
Place the client in an upright or high-Fowler’s position to facilitate swallowing
Promoting the Use of Nutritional Supplements
Consult a dietitian or nutritionist to assist with meal and diet planning, as well as for recommendations on nutritional supplement
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Nutrition
22
HELPS MAINTAIN THE INTEGRITY OF THE GUT, PREVENTS PRESSURE ULCERS, PREVENTS TRANSLOCATION OF BACTERIA INTO THE BLOODSTREAM
STRESS ULCERS ARE COMMON (HYPOXIA OR BLOOD IS SHUNTED TO MORE VITAL ORGANS (INCREASES RISK))
HAS A LOWER RISK OF INFECTION COMPARED TO TPN
ILLNESS-RELATED STRESS, HYPERGLYCEMIA, OR GLUCONEOGENESIS OCCURS WITH CLIENTS RECEIVING BOTH ENTERAL AND PARENTAL NUTRITION BILE = YELLOW
The primary (initial) assessment the R.N. should do prior to administering an enteral feeding? Check the residual volume
Burn patients are commonly fed via NG tube due to high caloric and nutritional needs
Pt with Inflammatory bowel disease: recommended they receive hydrolyzed formula
Prevent aspiration of someone receiving NG tube feeds: check gastric residuals, if vomiting and aspirating, stop feeds, turn pt to left side,
terrors
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Nutrition
23
Prevent clogging of tube: Flush tube every 4 hours with 30 mL of water
Following initial radiographic film verification of correct feeding tube position, you must monitor the tube to ensure that the tube tip remains in the intended site.
Based on a patient’s clinical condition and agency policies, assess feeding tube position at regular intervals (often every 4–6 hours) and before administering formula or medications through the tube.
Assessment techniques to use in combination to detect feeding tube dislocation:
Monitor the external length of the tube and observe the appearance, volume, and pH of fluid aspirated through it. The color of the fluid can help differentiate gastric from intestinal placement. Because most intestinal aspirates are stained by bile to a distinct yellow color and most gastric aspirates are not, the difference in color can often be used to distinguish the sites
Testing the pH of an aspirate at the bedside using pH paper offers some information regarding the position of a feeding tube. However, the pH test has no value if a patient is receiving acid-suppression medication. Results are also less reliable during continuous feeding and should be used in combination with other indicators with careful assessment of a patient in the clinical setting
To ensure a high confirmation rate for a correctly placed prepyloric or gastric tube, the pH or gastric aspirate should be less than or equal to 5. If pH levels are greater than 5, additional confirmation techniques are needed.
Gastric fluid in patient who has fasted for at least 4 hours usually has pH of 1.0 to 4.0 (if not receiving gastric acid inhibitor, then pH of less than or equal to 5).
If patient is receiving continuous feedings into stomach or intestine, check pH if feedings are held for at least 1 hour for diagnostic reasons (stomach pH less than or equal to 5, intestinal pH greater than 6)
Presence of intestinal fluid at pH greater than 6, indicates that end of tube is in small intestine. If fluid tests acidic on pH test or looks like gastric fluid, tube may be displaced into stomach.
If pH greater than 5, do not administer feed, assess further, contact provider.
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Nutrition
24
Consult with health care provider to obtain repeat radiographic verification of tube placement if bedside methods create any doubt regarding feeding tube location.
Check gastric residual volume (GRV) per agency policy. Should not be used as a single measure of tolerance. GRV has poor correlation with pneumonia, regurgitation, and aspiration. Frequent checking may delay feeding. However, if other signs (e.g., abdominal distention or pain) of intolerance are present, GRV of 250 to 500 mL may indicate the need to take measures to prevent aspiration or hold feeding completely.
Clinical Judgment
Limit gastric residual checks to recommended standard intervals because acidic gastric contents may cause protein in enteral feeding to precipitate within the lumen of the tube, causing risk for obstruction. Frequent GRV measurements lead to an increased risk of tube occlusion and decreased amount of enteral nutrition delivered to the patient.
GRVs in range of 200 to 500 mL should raise concern and lead to implementation of measures to reduce risk of aspiration. Automatic cessation of feeding should not occur for GRV less than 500 mL in absence of other signs of intolerance
Patient and caregiver education:
Do not to reconnect lines that have separated but to seek clinical assistance.
If tolerated, patient should remain upright for 1 hour after feedings.
Patient may express feelings of fullness, increased gas, belching, or diarrhea.
Correct placement of feeding tube: ph of gastric content less than 5
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Nutrition
25
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).
A client who is NPO will require meticulous oral care.
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 0
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Nutrition
26
feeding tube.
NURSING ACTIONS
Confirm tube placement prior to feedings.
Elevate the head of the bed at least 60 MIN AFTER ADMINSTERING
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.
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Nutrition
27
USE ASEPTIC TECHNIQUE
Rinse bag and tubing with warm water whenever feedings are interrupted. (HELPS TO CLEAR OLD FEEDINGS AND REDUCES BACTERIAL GROWTH )
Use new administration set every 24 hours
4
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Nutrition
28
TPN WOULD REQUIE A CENTRAL LINE OR PICC LINE Nonfunctional gastrointestinal tract
Hemicolectomy: Small bowel resection, surgery, or gastrointestinal (GI) bleeding
Paralytic ileus
Intestinal obstruction
Trauma to abdomen, head, or neck
Severe malabsorption
Intolerant of slow rates of enteral tube feeding
Colon Cancer: Chemotherapy, radiation therapy, bone marrow transplantation
Severely catabolic patients when GI tract is not functioning for more than 7 days
Gastrointestinal tract malfunctional status
Enterocutaneous fistula
Inflammatory bowel disease
Severe diarrhea
q
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Nutrition
29
Moderate-to-severe pancreatitis
Preoperative parenteral nutrition
Preoperative bowel rest
Severe malnutrition before surgery
Evaluation
Monitor and document flow rate according to agency policy and procedure. If infusion is not running on time, do not attempt to catch up.
Too-rapid or too-slow infusion could result in metabolic disturbances such as hyperglycemia and fluid overload.
Monitor fluid intake and urine and gastrointestinal (GI) fluid output every 8 hours.
Prevents fluid imbalance from too-slow or too-rapid infusion.
Measure vital signs every 4 hours.
Obtain initial weight and then weigh at least 3 times weekly.
Evaluate for fluid retention; palpate skin of extremities; auscultate lung sounds.Weight gain in excess of 0.5 kg (1 lb) per day, dependent edema, lung crackles, and intake greater than output per each 24-hour period indicate fluid retention.
Monitor patient"s glucose levels every 6 hours or as ordered and other laboratory parameters daily or as ordered.
Maintenance of normal electrolyte levels, satisfactory fluid balance, acceptable serum glucose levels, and improvement in serum proteins indicate adequate tolerance .
Inspect central venous access site for signs and symptom of swelling, inflammation, drainage, redness, warmth, tenderness or edema.
Assess IV patency and absence of infection, infiltration, or phlebitis.
Monitor for temperature, elevated white blood cell count, and malaise.
Signs of systemic infection.
Teach-back
I
discomft
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Nutrition
30
TPN is administered via a central venous catheter to meet nutritional needs (glucose, amino acids, vitamins, minerals) of clients who cannot digest nutrients via the GI tract.
Infection is a risk from central lines. The signs of infection include leukocytosis and a left shift. However the risk of infection is not high in the first few days of parental nutrition
7
Highland
of
white
bloodell
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Nutrition
31
Assess for allergies to soy beans and eggs
A complication of TPN is hyperglycemia as evidenced by excessive thirst, increased urination, abdominal pain, headache, fatigue, and blurred vision. The development of hyperglycemia is related to the following:
Excessive dextrose infusion
A low tolerance for dextrose in critically ill clients due to the inflammatory response and the resulting production of counterregulatory hormones
High infusion rate
Administration of medications such at steroids
Infection
Interventions to resolve the TPN associated hyperglycemia incude reducing the amount of carbohydrate in the TPN solution, slowing down the infusion rate and administering subcutaneous insulin
Checking VS will not confirm that the client is experiencing hyperglycemia
Check the clients blood glucose: The nurse needs to assess FIRST. The health care provider will need to be contacted if a change in TPN treatment is indicated
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Nutrition
32
Slowing down the infusion rate is an intervention to resolve hyperglycemia, the nurse needs to first confirm the clients symptoms are related to high blood glucose.
TPN is Hypertonic!
Ensure delivery is never stopped abruptly (line pulled out, line compromise, TPN bag empty, pump malfunction) or the rate is abruptly slowed are at risk risk for severe hypoglycemia due to increased pancreatic insulin production
If abrupt stop of TPN occurs:
Assess and stabilize the client before handeling the malfunction.
Notify the provider to obtain orders for interventions and monitoring.
Anticipate and prepare D10 ( hypertonic) to continue for patient until TPN can be safely resumed.
Preventing abrupt stop in TPN:
Follow up with pharmacy in a timely manner
Ensure lines and connections are secured
Ensure adequate space for movement so line does not get pulled out
Hyperglycemia
Possible blood-draw error, confirm with bedside glucose device; patient receiving too little insulin in PN solution; receiving steroids; new-onset infection
Excessive thirst, urination, blood glucose greater than 160 mg/100 dL, confusion
Call health care provider; may need to slow infusion rate (health care provider order).
Review medical history for blood drawn through central line with PN infusing (repeat peripheral blood draw or obtain fingerstick), glucose intolerance or diabetes, new infection, new medication such as steroids; keep rate as ordered; never increase PN to “catch up.” Maintain blood glucose in range ordered by health care provider. Use aseptic technique and routine blood glucose monitoring.
Hypoglycemia
PN abruptly discontinued; too much insulin
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Patient shaky, dizzy, nervous, anxious, hungry, blood glucose level <80 mg/100 dL
Call health care provider; if PN discontinued abruptly, may need to restart D10W at previous PN rate. If patient has oral intake, give ½ cup fruit juice. Perform blood glucose monitoring; retest in 15 to 30 min.
Decrease PN, “tapering” gradually until discontinued; blood glucose monitoring is used to ensure adequate insulin.
Catheter-related sepsis or bacteremia
Catheter hub contamination; contamination of infusate; spread of bacteria through bloodstream from distant site
Systemic: Isolation of same microorganism from blood culture and catheter segment, with patient showing fever, chills, malaise, elevated white blood cell count
Systemic: Do not exceed hang time of 24 hours for PN that contains dextrose and amino acids either alone or with fat emulsion added as a 3-in-1 formulation
Administer antibiotics intravenously; catheter removal by proper professional (CRNP, PA-C, or physician).
Use full sterile-barrier precautions during catheter insertion and dressing change. Consider the use of antibiotic-impregnated catheters. Do not disconnect tubing unnecessarily. Replace IV tubing and filter every 24 hours. In some situations it is necessary to change administration sets with each new PN container
Localized infection (exit site or tunnel)
Poor aseptic technique in removal of skin flora during site preparation and dressing care
Exit site: Erythema, tenderness, induration, or purulence within 2 cm (0.8 inches) of skin at exit site
Tunnel: Same as above but extends beyond 2 cm from exit site
Call health care provider.
Exit: Apply warm compress, daily care of site, oral antibiotics.
Infection: Collaborate with health care provider regarding removal of catheter
Tunnel: Remove catheter.
S
S
of
Hypoglycemia
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Nutrition
34
Provide catheter site care using aseptic technique, visually inspect site (including cleaning site), apply new stabilization device, and apply sterile dressing
Change transparent dressings at least every 5–7 days and gauze dressings every 48 hours
Change dressing if damp, loosened, or soiled or when inspection of site is necessary
Use chlorhexidine wipes to cleanse site. For adults, consider the use of chlorhexidine-impregnated dressings
Air embolism
IV tubing disconnected; part of catheter system open or removed without being clamped
Sudden respiratory distress: decreased oxygen saturation levels, shortness of breath, coughing, chest pain, decreased blood pressure
Clamp catheter; position patient in left Trendelenburg position; call health care provider; administer oxygen as needed
Make sure that all catheter connections are secure; clamp catheter when not in use.
Never use a stopcock with a CVC.
Unless contraindicated, instruct patient in Valsalva maneuver for tubing changes
Pneumothorax
Tip of catheter enters pleural space during insertion, causing lung to collapse
Sudden chest pain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on affected side, tachycardia
Per health care provider’s order, the proper professional (CRNP, PA-C, or physician) may remove the central catheter. Administer oxygen via nasal cannula. Insert chest tube to remove air under water-seal drainage or dry one-way valve system.
Medical personnel should be properly trained to insert central catheters.
Researchers suggest use of ultrasound when placing CVCs
Catheter should be secured properly to prevent migration, movement.
It
a
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Nutrition
35
Many factors can contribute to malnutrition: poor diet, chronic illness, physical or cognitive impairments such as recent hip surgery or Alzheimer’s.
Assessing for malnutrition involves collecting dietary data (24 hour diet recall, laboratory values (albumin or prealbumin) physical measurements (bmi) and history of recent weight loss. Reports of weight loss especially unintentional are critical findings often indicative of malnutrition. (cancer, TB, faulire to thrive)
During illness, weight loss is monitored to prevent or detect malnutrition.
With starvation or chronic disease, weight loss indicating severe malnutrition: greater than 5%/month, greater than 7.5%/3 months, greater than 10%/6 months, greater than 20%/year
With acute disease or injury, weight loss indicating severe malnutrition: greater than 2%/week, greater than 5%/month, greater than 7.5%/3 months
As malnutrition worsens and protein intake is reduces, muscles become fatigued and weak. Clinical manifestations depend on the severity of the malnutrition, ranging from milk to extreme (emaciation).
Egg
Abdormally
thin
or
weak
Especailly
because
of
Illness
or
lack
of
food
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Nutrition
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Reduced appetite and significant unintentional weight loss are included in the diagnostic criteria for unipolar major depression (major depressive disorder). Interventions to promote adequate nutritional intake includes a diet high in calories and protein to promote adequate nutrition and weight gain. In addition, for a client who has depression, they probably have low energy so providing foods that are easier to chew and swallow may be good choices for promoting intake.
Foods that are protein and or calorie dense include:
Whole milk and dairy products (milkshakes) fruit smoothies
Granola, muffins, biscuits
Potatoes with sour cream and butter
Meat fish eggs dried beans almond butter
Pasta rice dishes with cream sauce
Drugs such as MAOI’s commonly taken for depression have nutrient interactions and need to be considered: foods high in tyramine (aged cheese, yogurt, cured meats, fermented foods, beans, beer, red wine, chocholate, avocados) need to be restricted to reduce the risk of a hypertensive crisis. – you will learn more about this in mental health.
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Meal frequency, eating habits, and recent diet changes are contributing factors leading to malnutrition that should be assessed after determining malnutrition risk
You are caring for an 80 year old client hospitalized with pheumonia and malnutrition. Physical assessment findings include weakness and decreased mnuscle mass. What finding indicates that the client is responding to treatment?
Client consuming 90% of each meal- consuming 90% of each meal indicates that the appetite is good or improving but does not provide conclusive evidence of an improved nutritional status
Serum albumin of 3.6 g/dL- although this is WNL, (3.5-5 g/dL) visceral protein stores are poor indicators of nutritional status in acute and chronic disease. During an inflammatory response, (pheumonia) protein synthesis by the liver is decreased.
Weight gain of 2 lb in 2 weeks- Weight gain is the best inidicator that the client is responding to medical nutritional therapy.
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Nutrition
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Refeeding syndrome: rapid declines in phosphorus, potassium, and or magnesium (mneumonic PPM). Other findings may include fluid overload, sodium retention, hyperglycemia, and thiamine deficiency.
Phosphorus is the primary deficient electrolyte as is is required for energy (adenosine triphosphate) hypophosphatemia causes muscle weakness and respiratory failure. Deficiencies in potassium and magnesium potentiate cardiac arrhythmias. Therefore aggressive initiation of nutrition withoout adequate electrolyte repletion can quickly precipitate cardiopulmonary failure.
Actions to prevent refeeding syndrome include:
Obtaining baseline electrylytes
Initiating nutrition support cautiously with hypocaloric feedings
Closely monitoring electrolytes
Increasing caloric intake gradually
Daily weights and periodic serum albumin level are indicated to evaluate the efficacy of nutritional replenishment but are not the most assessment as failure to monitor these does not result in death.
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Supplements That Promote Wound Healing: __PROTIEN?_____
Protein deficiency increases the risk of complications from severe trauma or critical illness (skin breakdown, delayed wound healing, infections, organ failure, ulcers, impaired medication tolerance).
Protein requirements can be increased to more than 2 g/kg of body weight, or up to 25% of total calories, depending on the client’s age and prior
nutritional status
albumin: 3.5 to 5 g/dL
Many non-nutritional factors (injury, kidney disease), interfere with this measure for protein malnutrition.
Prealbumin: Expected reference range is 15 to 36 mg/dL. (Less than 10.7 mg/dL indicates severe nutritional deficiency. )
Prealbumin levels can decrease with an inflammatory process resulting in an inaccurate measurement.
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Clients with kidney disease should eliminate foods high in oxalate
Kidney Stone formed of calcium oxalate: Reduce intake of foods high in oxalate: spinach
Heartburn related to GERD: eat potatoes
Dumping Syndrome: include protein in each meal, consume small frequent meals
Food sources containing heme iron: ground beef
Dietary recommendation for someone with low hemoglobin: beef liver
No dentures and no teeth should eat pureed diet
Elderly patient who no longer enjoys food: introduce new spices and herbs to enhance flavor
Nutritional Education for patient taking levodopa: low protein
Food recommendation for difficulty chewing and ill-fitting dentures: eat tuna fish
Constipation: increase fiber
Promote eating in elderly patient: use finger foods
Patient experiencing diarrhea: BRAT diet, wheat bread
Bananas
rice
Apples
toast
B.R.AT
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Fiber-rich foods :fruits, vegetables, legumes, whole grains, cooked peas, sweet potatoes
Foods With High Water Content: fresh fruits, fruit juices, flavored gelatin, frozen treats, soups
Recommended snak for patient taking phenelzine: strawberry yogurt
Foods Containing Carbohydrates : fruit juice
Caffeine and sodium should be low in the diet of a client who is in heart failure.
Teaching About a Heart-Healthy Diet to a Client Who Has Coronary Artery Disease: baked salmon
A Na+ intake of less than 1500 mg is recommended for a client who has CAD.
NA+ intake less than 2000mg recommended for client with cirrhosis
Alternative to table salt: sea salt
Supplement to promote wound healing: Vitamin C
Avoid yogurt if labs indicate elevated sodium
Nausea following chemotherapy: eat cold foods
Stomatitis: frequent mouth rinses with normal saline. Snack recommendation: frozen banana
Anorexia with radiation: offer toast with honey
Nausea/ diarrhea with chemo or radiation: offer nutrient dense foods
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LEARN ( WEIGHT (LBS) X 703 / HEIGHT (IN^2)
LEARN BMI CLASSIFICATONS If a client’s BMI is 21.5, the client is considered to have a _________ weight status.
BMI of 28 should be referred to weight loss group.
A client who is demented and has a BMI of 42 would be a candidate for bariatric surgery
Weight
- Daily fluctuations indicative of water weight changes
- Over 2% change in 1 week or 7.5 % in a month = significant wt loss
Anthropometric tool:
Bioelectric impedance scale – weight and percentage of fat
Underwater weighting (hydrodensitometry) – displacement of water when submerging body in water (most accurate)
Triceps skin fold thickness
BMI
5
30
35
weightlbs
703
in
lbs
703
Heathy
I
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Obese patients usually suffer from: low self-esteem, impaired body image, depression and diminished quality of life.
Causes of obesity: Poor eating habits, sedentary lifestyle.
Other causes: Genetic, metabolic, cultural and socioeconomic.
Body mass index (BMI) is a screening tool that can be used to measure obesity. 3. BMI is defined as a person’s body weight in kilograms divided by the square of a person’s height in meters.
(BMI) can be calculated by dividing the client’s weight in kilograms by height in meters squared. For example, a client who weighs 75 kg (165 pounds) and is 1.8 m (5 feet, 9 inches) tall has a BMI of 23.15 (75 divided by 1.82 = 23.15).
Underweight: 18 or less
Celiac disease, vegan, renal disease,, peptic ulcer disease, chronic gastroenteritis. ALL LEAD TO ANEMIA
Folate deficiency causes megaloblastic anemia. Folic acid is the synthetic form. Poor nutritional intake of foods containing folic acid (green leafy vegetables, citrus
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fruits, dried bean, nuts), malabsorption syndromes (Crohn’s disease), certain medications (anticonvulsants and oral contraceptives)
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.
B12/ (cobalamin) is necessary for folate activation and red blood cell maturation.
deficiency (macrocytic anemia) causes pernicious anemia- strict vegan diets and intrinsic factor deficiency. Lack of meat or dairy consumption, small bowel resection, chronic diarrhea, diverticula, tapeworm, excess of intestinal bacteria
Fish
Meat
Poultry
Eggs Milk
People who follow a vegan diet need supplemental B12
Findings of folic acid deficiency anemia mimic those for vitamin B12 deficiency anemia except for the neurologic manifestations
B6 is needed for cellular function and synthesis of hemoglobin, neurotransmitters, and niacin
deficiency causes (macrocytic anemia)
Iron deficiency anemia- Iron deficiency anemia Blood loss, deficient iron intake from diet, alcohol use disorder, malabsorption syndromes, gastrectomy
i
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is the most common nutritional deficiency disorder in children . 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. Children who have low iron intake can experience short attention spans and display poor intellectual performance before anemia begins.
VITAMIN C: Facilitates the absorption 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
Dietary Teaching About Heme Iron for a Client Who Has Anemia
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
Dried beans provide non‐heme iron, as do other legumes, vegetables, and grains.
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General guidelines follow.
Carbohydrates
Encourage the client to consume carbohydrates: 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
Limit 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.
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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.
Carbohydrate counting focuses on counting total grams
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
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
1⁄2 cup (4 oz) juice or regular soda
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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.
Risk Factors: overeating and physical inactivity.
Other contributing factors
: genetics, foods high in fat, slow metabolism, age, certain medications, psychological factors, some medical conditions, race, childhood weight, physical inactivity, hormones, the use of alcohol, and poverty
Overeating clearly leads to weight gain, especially if the diet is high in fat
Foods high in fat (e.g., fast foods, fried foods) have high-energy density (i.e., many calories/small volume of food)
emotions significantly influence eating habits
Drinking alcohol adds calories to the diet (150 calories/beer) and the addition of a single beer daily can result in a weight gain in excess of 1 pound per month.
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Case Study:
Rosa Lopez risk factors for obesity?
Identify health consequences that may have developed in this patient from obesity:
What is the risk for this patient to develop disease if she continues at this weight?
Calculate the patient’s BMI:
290 lbs
5’1
290/61² x703= 54.8
Based on BMI
that is considered extreme, and pts waist size, the RISK for obesity-
related disease in this patient is considered extremely high.
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Nutrition
50
Labs to know related to nutrition:
Normal albumin: _____
Normal WBC: _____
3
S
S
S
lok
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Normal HCT: _____
Normal HGB: _____
Normal Calcium: _____
Normal Triglycerides: _____
Normal Cholesterol: _____
Normal Potassium: _____
C-peptide levels are often elevated in a client who has Type 2 diabetes. Hematocrit would be high in someone with CDIFF
CKD with serum creatinine of 3.5: the nurse should assess for further issues.
Indications of water intoxication: low BUN, hypernatremia
Identifying the Effect of Calorie Reduction on Weight Loss
A reduction of energy expenditure of 3,500 calories (kcal) will result in a weight loss of 1 lb (0.45 kg).
9
10.5mg
dL
F 35
135mg
dL
M
40
160mg
dL
Less
than
zoong
dL
3
S
S
0
MEEK
1lb
3500cal
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To lose 20 lbs, the client needs to reduce intake by a total of 70,000 kcal (3500 kcal x 20 lb= 70,000 kcal) over the desired time frame. If time frame was 16 weeks, this will require a weight reduction of 625 kcal (70,000 kcal/ [16 weeks x 7 days]= 625 kcal/day)
Adding an exercise regimen to the clients daily routine would facilitate additional weight loss and or reduce the need for severe caloric restriction.
Healthy weight loss is about 6 lbs in 1 month
Behavioral mgmt. includes:
Creating a reward system with many small attainable goals to incentivize positive health behaviors
Developing health goals unrelated to weight (climbing stairs without shortness of breath) to measure progress regardless of current weight
Adopting anxiety-reducing diversional activities (reading, meditating, listening to music) as coping mechanisms to reduce stress eating
Placing visual cues (motivational quotes) throughout the environment as positive reinforcement
Vagal blocking increases a feeling of satiety.
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Fat-soluble vitamins may be reduced in a client receiving Orlistat.
Orlistat increases a feeling of satiety in a client.
LOOK AT DRUGS 85% of the stomach is removed in a client who has undergone sleeve gastrectomy bariatric surgery.
VIT B12 FOR LIFE WITH GASTRIC BYPASS
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Dumping syndrome: hypotension, diaphoresis, abdominal pain, nausea, vomiting, cramping, weakness, dizziness, tachycardia, and diarrhea within 30 minutes of eating.
Recommendations to delay gastric emptying include: consuming meals high in fat, protein, and fiber
Avoid consuming liquids with meals . Fluid intake should occur up to 30 minutes before or after meals
Small frequent meals
Avoid meals high in simple carbohydrates (sugar, syrup)
Avoid sitting up after a meal because gravity increases gastric emptying; instead, lying down after meals is encouraged.
* If a client has tube feedings, and you have identified them at risk for dumping syndrome, such as patients receiving GJ tube feedings lying completely flat is contraindicated, be sure to place the client in low fowlers to prevent aspiration.
7
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Complications of Bariatric Surgery:
Anastomotic leak: Severe abdominal pain, radiating to the back/ shoulder, sepsis, restlessness, tachycardia, oliguria
Repositioning the ng tube following bariatric surgery could disrupt the suture line
Consumption of simple carbohydrates can lead to dumping syndrome (cramping and diarrhea)
Clients recovering from a bariatric surgery are given small frequent meals to prevent nausea, vomiting, and regurgitation related to over stretching of the stomach.
NPO until bowel sounds return
Small meals of clear liquids at first, advance to full liquids 24-48 hours after surgery and then progress gradually to solid foods as the GI tract heals.
Yogurt, Fruit juices, puddings, ice cream are high in sugar and not acceptable for a bariatric full liquid diet. Mashed potatoes, eggs, cream soups, sugar free drinks, low sugar high protein shakes, dairy foods, peanut butter, vegetable juice are considered appropriate
Postop care: VTE prophylaxis, turning, coughing, coughing, dep breathing while splinting the surgical site, use of the IS, and aspiration precautions, elevating the y
4
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had of the bed. SCD’s, early ambulation
Folate Intake During Pregnancy: Increasing folate and folic acid during pregnancy helps to decrease the chance of deformities
Prevention of Neural Tube Defects: increase folate and folic acid during pregnancy
Folic acid is found in supplements and in fortified foods. Folate is found in natural foods.
Teaching a Client Who Is Pregnant and Has Chronic 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
Breastfeeding education: expect bursts of sucks and swallows
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.
Newborn with GERD. What position should you place if vomiting: side lying
Teaching About Snacks for a 9-Month-Old Infant: Graham Crackers
Recommended Protein Intake for a Toddler: 5-20%, 13 grams/ day
I
I
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Appropriate Food Choices for a Toddler: cheese, allow toddlers to feed themselves
Adolescent females are often deficient in folate, vitamins A and E, iron, zinc, magnesium, calcium, and fiber
Teaching About Complications of Childhood Obesity: hypertension
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