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Course: Fundamentals of Nursing�Topic: Nutrition

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Module Goals

Learners will be able to:

Describe the digestion and metabolism of nutrients.
Identify nutrition requirements across the lifespan.
Discuss patterns of altered nutrition and eating disorders.
Interpret laboratory studies used to assess nutrition.
Discuss nursing interventions to maintain nutritional status of clients in the primary, secondary, and tertiary care settings.

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Digestive System (Gastrointestinal System)

Ernstmeyer & Christman, 2021

Purpose: to break down food and for the nutrients to be absorbed into the bloodstream by the small and large intestine.
Many components make up the digestion system.
Responsible for digestion, absorption, and immune response.
Digestion begins with the mouth.

Chewing food, mechanical digestion.
Known as mastication.
Masticated food turns into a bolus and moves down the pharynx to the back of the throat, then into the esophagus.

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Digestive System - Digestion

As the food is being swallowed, there are coordinated muscle movements moving the food down the esophagus into the stomach.

Known as peristalsis.

Once the food is into the stomach, it is mixed with gastric juices present in the stomach and broken down into chyme.

Chemical digestion process.

Chyme then moves out of the stomach and into the duodenum of the small intestine, mixing with bile from the gallbladder and enzymes from the pancreas to digest further.

Ernstmeyer & Christman, 2021

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Digestive System - Absorption

After digestion is complete, absorption begins within the digestive system.
Chyme enters the small intestine and comes into contact with the villi within the intestine.

Villi: finger-like projections lining the inside of small intestinal walls.
Villi increase surface area and allows increased absorption from intestine into the bloodstream.

Absorption is necessary for metabolism because the nutrients being absorbed are being used for fuel and energy.
Peristalsis moves the liquid from small intestine to large intestine where the water and minerals are absorbed.

Ernstmeyer & Christman, 2021

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Digestive System - Absorption and Immune

Ernstmeyer & Christman, 2021

Additional waste products are then formed into feces and excreted out the anus.
Digestive system also is involved with immune system.
Bacteria in the stomach makes up a person’s gut biome.

Gut biome: aids in contribution to the immune response by providing an antibody production to any foreign substances, bacteria, chemical, or material.

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Critical Thinking Question

A client has a chronic disease that affects the small intestine. What does the nurse know about how this affect the client’s absorption of nutrients?

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Lifespan Nutrient Needs - Newborn and Infant

Ernstmeyer & Christman, 2021

Large amount of growth occurs between birth and 2 years old.
Nutrient dense food choices are best for this age range.

Consume less amount of food.
Rapid growth.

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Lifespan Nutrient Needs - Newborn and Infant

Ernstmeyer & Christman, 2021

Newborn feedings

Breastmilk or formula exclusively for first

6 months.

If eating breastmilk, vitamin D and iron supplementation may be needed.
Breast Milk contains passive antibodies from mother to child adding extra protection from illnesses.
For the first two to three days after birth, breast milk is colostrum until the breast milk matures.
Formula is fortified with iron and vitamin D so supplementation is not needed.

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Lifespan Nutrient Needs - Newborn and Infant

Ernstmeyer & Christman, 2021

Around 6 months of age, solid or pureed foods should be introduced to the baby to complement their diet.
Serve as developmentally appropriate.

Texture, size, type of food.

Offer a variety of food but introduce high-allergen foods singularly to monitor for intolerances or allergies.

Dairy, peanuts, shellfish.

Avoid honey in food or raw, as well as avoid unpasteurized foods.

Increased risk of botulism and bacteria.

Cows milk, soy drinks, and juices (fruit and vegetable) should wait until after 1 year of age to be introduced.

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Lifespan Nutrient Needs - Child and Adolescent

Continued rapid growth from ages 1 to 5 years.
Good nutrition is needed for sufficient growth and keeping up with metabolic needs.
As age increases, calories and nutrition intake increases.

Quality of the diet is seen to decrease proportionality with age.

Poverty can impact nutrition of children, especially school age.

Programs providing nutritionally balanced food for a low to no cost in schools or outreach programs can aid in this.

Instilling healthy diet habits young can decrease prevalence of obesity, diabetes mellitus, and cardiovascular disease as the child ages.

Ernstmeyer & Christman, 2021

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Lifespan Nutrient Needs - Adults (Age 19-59)

Prior unhealthy habits may be difficult to alter due to lack of education on healthy choices and resistance of new foods.
Both metabolic rate and caloric needs decrease as one ages.
On average, males require more calories than females.

Aside from pregnancy and breastfeeding.

Obesity and chronic diseases are associated with poor dietary intake and lack of activity.
Health education can benefit the adult diet.
Alcohol abuse can impact diet.

Interfere with absorption of minerals and vitamins.
Limited to one drink per day or less for women and two drinks per day or less for men.

Ernstmeyer & Christman, 2021

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Lifespan Nutrient Needs - Pregnancy and Lactation

Ernstmeyer & Christman, 2021

Well-balanced diet is important for both maternal, fetal, and newborn health.
Nutrition requirements increase during pregnancy and lactation.

Increased calories, vitamins, minerals
The increased calories should be nutrient dense.

Prenatal vitamins should be taken during pregnancy and lactation to ensure the needs are being met for certain nutrients.

Folic acid, iron, choline, iodine, vitamin D.

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Lifespan Nutrient Needs - Older Adults (Age 65+)

Lower caloric needs but need nutrient dense foods.

Lower calories but increased nutrient needs.
Lower caloric needs due to decreased activity, decreased muscle mass, and decreased metabolic rates.

Increased prevalence of chronic diseases managed with medications.

Can impact nutrient absorption.

Protein and vitamin B12 are needed yet under consumed.
Adequate hydration is important and a concern.

As one ages, the feelings of thirst decrease resulting in poor intake of fluid.

Poverty, decreased ability to chew and swallow, loneliness.

Factors altering nutrition.

Ernstmeyer & Christman, 2021

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Common Eating Disorders

Anorexia nervosa

Restriction of food intake
Commonly fear of gaining weight and gain distorted body image
Low body weight

Bulimia nervosa

Binge eating and then compensation behavior to prevent gaining weight and/or to lose weight

Abusing laxatives, inducing self to vomit

Normal body weight
Dry skin, increased heart rate, low blood pressure

Barnard, 2020

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Common Eating Disorders

Binge eating disorder

Recurrently binge eating and does not use compensatory behaviors as seen in bulimia nervosa.
Loss of control or loss of sense of overeating.

Eating disorders development may be multifactorial.

Environmental, social, genetics, psychological.

Results of eating disorders.

Osteoporosis, abnormal presence of electrolytes, dysregulated metabolism, electrolyte imbalances, cardiovascular abnormalities (arrhythmia), dental erosions, infertility, decreased gray matter.

Barnard, 2020

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Common Eating Disorders Treatment

Nutritional therapy as first line treatment.
Additional nutritional professionals may need to assist in treatment plan.
Refeeding

Appropriate for those significantly underweight.
Replacements of essential electrolytes.

Electrolytes must be carefully monitored when refeeding.
Hyponatremia and hypokalemia are prevalent and sudden and quick replacement may cause adverse effects.

Emotional support.
Weight loss and health education for binge-eating clients.

Barnard, 2020

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Case Study

In the clinic, the nurse evaluates Alex, a 15 year old female. Upon admission, Alex has a weight of 50 kg. Her skin has poor turgor and states that her menstrual cycle is irregular, at times not occurring for 3 months. Alex tells the nurse that she is a member of the soccer team and although they practice rigorously, Alex is concerned that she is not in good enough shape. She states that she feels pressure to be on the starting lineup. When asked what she eats during the day, Alex states that she is on a strict calorie count diet of 1500 calories and does not exceed it. What nutritional disorder does the nurse suspect Alex exhibits? What symptoms lead to this diagnosis?

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Altered Nutrition

Ernstmeyer & Christman, 2021

Altered nutrition can occur secondary to an illness or disease process.
Dysphagia: difficulty swallowing.

Examples: may occur after surgeries, cancer, stroke.
May cause aspiration pneumonia.
Specialty diets may be prescribed and care with specialists.

Post-surgery

Food and liquids may be held affecting dietary intake.

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Aside from withholding food and liquid from clients after particular surgeries, the stress on the body increases the metabolic need, therefore increasing caloric needs. The surgical stress also may alter blood glucose levels even in clients without diabetes mellitus.

Nutrition may be administered through enteral feedings if nutrition needs to bypass mastication.

Parenteral nutrition may be administered if the client needs nutritional supplementation but cannot get enteral feedings. This is an intravenous line with a mixture of: minerals, electrolytes, glucose, amino acids, and vitamins. The IV solution is irritating to blood vessels due to high concentration of elements so it is administered through a large central vein. Routine labs must be drawn while the client is on parenteral nutrition to assess if the solution needs altered to meet the client’s needs. This method is used when the intestines or stomach isn’t properly working and needs to be bypassed. Examples of this is a paralytic ileus, postoperative abdominal or bowel surgeries. When clients are malnourished, have hyperemesis in pregnancy, or have metastatic cancer, this may be considered for a form of nutrition therapy.

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Altered Nutrition

Ernstmeyer & Christman, 2021

Administration through enteral feedings.

Nasogastric tube, orogastric tube, percutaneous.
endoscopic gastrostomy (PEG), percutaneous.
endoscopic jejunostomy (PEJ) tube.

Administration parenterally

Delivered through central intravenous line.

Contact info: info@nursesinternational.org

Aside from withholding food and liquid from clients after particular surgeries, the stress on the body increases the metabolic need, therefore increasing caloric needs. The surgical stress also may alter blood glucose levels even in clients without diabetes mellitus.

Nutrition may be administered through enteral feedings if nutrition needs to bypass mastication.

Parenteral nutrition may be administered if the client needs nutritional supplementation but cannot get enteral feedings. This is an intravenous line with a mixture of: minerals, electrolytes, glucose, amino acids, and vitamins. The IV solution is irritating to blood vessels due to high concentration of elements so it is administered through a large central vein. Routine labs must be drawn while the client is on parenteral nutrition to assess if the solution needs altered to meet the client’s needs. This method is used when the intestines or stomach isn’t properly working and needs to be bypassed. Examples of this is a paralytic ileus, postoperative abdominal or bowel surgeries. When clients are malnourished, have hyperemesis in pregnancy, or have metastatic cancer, this may be considered for a form of nutrition therapy.

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Lab Values Influencing Nutrition

Image: (Ernstmeyer & Christman, 2021)

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Lab Values Influencing Nutrition

Ernstmeyer & Christman, 2021

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Nursing Care in Primary Care Setting

Dietary counseling if needed
Assess subjective and objective data
Subjective

Nutritional issues
Activity level
Diet, alcohol use

Objective

Weight, height, body mass index measurements.
Potential lab work to assess electrolytes and other components.

Referral to specialist if necessary if identified risk factors for altered nutrition or eating disorder.

Kraef et al., 2020

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Nursing Care in Secondary Care Setting

Within the hospital, nutritional screening should take place within first 24 hours of admission.
Identify presence of malnourishment or risk of malnourishment.
Any at risk identifiers should be communicated to physician.

Nutrition assessment should occur.

Referral to in-house nutritionist or dietician can assist.
Nursing diagnosis for malnutrition.
Create a care plan for goals and interventions.

Oftentimes, nurses implement interventions for food intake, supplements, administering nutrition enterally or parenterally.

Guenter et al., 2015

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Nursing Care in Tertiary Care Setting

Assisting a specialist for nutritional care.
client referred to tertiary care setting if continued care is needed for a chronic illness.

Eating disorder
Altered nutrition due to chronic illness such as cancer, dementia.

Care dependent on diagnosis.

Assistance with eating.
Administering parenteral and enteral nutrition.
Diet education.

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Cultural Considerations

Religious beliefs may influence dietary choices and intake.

This should be considered and documented during any assessment.
Some food may be limited or completely restricted due to religious or cultural beliefs or rituals.
Some food may also be seen as complementary to the healing process.

Some cultures abstain from pork because they consider it unclean.
Some cultures only eat kosher food.

A way that the food is prepared.

Some religions and cultures fast during certain times of the day or abstain from certain foods during religious periods.

Example: fasting and abstaining from meat during Lent.

Ernstmeyer & Christman, 2021

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References:

Barnard, N. D. (Ed.). (2020, December 14). Eating disorders: Nutrition guide for clinicians. Eating Disorders. Nutrition Guide for Clinicians. Physicians Committee for Responsible Medicine. https://nutritionguide.pcrm.org/nutritionguide/view/Nutrition_Guide_for_Clinicians/1342074/all/Eating_Disorders

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals. By Chippewa Valley Technical College, licensed under CC BY 4.0. https://wtcs.pressbooks.pub/nursingfundamentals/open/download?type=pdf

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References:

Guenter, P., Malone, A., & DiMaria-Ghalili, R.A. (2015, November 10). Six steps to optimal nutrition care. American Nurse Association. https://www.myamericannurse.com/essence-nutrition/

Kraef,C., Wood, B., Philipsborn, P.V., Singh, S., Petersone, S.S., Kallestrup, P. (2020, May). Primary health care and nutrition. Publication: Bulletin of the World Health Organization. https://www.who.int/bulletin/online_first/BLT.20.251413.pdf

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