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Fundamentals of Nursing - Ch. 45 Nutrition - RN Nclex
Adult Health II (NUR 2211)
Hillsborough Community College
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Nutrition
OBJECTIVES
- Explain the effects of a well-balanced diet on the body throughout the life span.
- Discuss the process of digestion and absorption.
- Explain the ChooseMyPlate and discuss its value in planning meals for healthy nutrition.
- List the current dietary guidelines for the general population.
- Explain the variance in nutritional requirements throughout the life span.
- Discuss the major methods of nutritional assessment.
- Correctly perform the procedure for initiation and management of enteral feedings.
- Explain the nursing management of enteral feedings.
- Critique the approaches for how to avoid complications of parenteral nutrition.
- Discuss medical nutrition therapy in relation to three medical conditions.
- Discuss how to implement diet counseling and patient teaching in relation to patient expectations.
KEY TERMS
Albumin, p. 1102 Anabolism, p. 1105 Anorexia nervosa, p. 1107 Anthropometry, p. 1111
- Basal metabolic rate (BMR), p.
- Body mass index (BMI), p.
- Bulimia nervosa, p.
- Carbohydrates, p.
- Catabolism, p.
- Chyme, p.
- Daily values, p.
- Dietary reference intakes (DRIs), p.
- Dispensable amino acids, p.
- Dysphagia, p.
- Enteral nutrition (EN), p.
- Fat-soluble vitamins, p.
- Fiber, p.
- Food security, p.
- Hypervitaminosis, p.
- Ideal body weight (IBW), p.
- Indispensable amino acids, p.
- Insulin, p.
- Intravenous fat emulsions, p.
- Ketones, p.
- Kilocalories (kcal), p.
- Lipids, p.
- Macrominerals, p.
- Malabsorption, p.
- Malnutrition, p.
- Medical nutrition therapy (MNT), p.
- Metabolism, p.
- Minerals, p.
- Nitrogen balance, p.
- Nutrient density, p.
- Nutrients, p.
Healthy People 2020 (USDHHS, 2019). Healthy People 2020 is the United States’ contribution to the “Health for All” strategy of the World Health Organization (WHO, 2019). Healthy People 2020 (Box 45) continues the objectives initiated in Healthy People 2000 and Healthy People 2010, with overall goals of promoting health and reducing chronic disease. All nutrition-related objectives include baseline data from which progress is measured. The challenge remains to motivate consumers to put these dietary recommendations into practice.
B ox 4 5 .1 Examples of Nutrition Objectives for
Healthy People 2020
Weight and Growth
- Increase proportion of adults who are at a healthy weight (body mass index [BMI] 18 to 24).
- Reduce the proportion of adults who are obese.
- Reduce the proportion of children (2 to 11 years) who are overweight or obese.
Food and Nutrient Consumption
- Decrease saturated fat intake in population 2 years and older.
- Increase the variety of vegetables and fruit intake in the population 2 years and older.
- Increase grain product intake and consumption of calcium in the population 2 years and older.
- Reduce sodium daily intake in the population 2 years and older.
Iron Deficiency and Anemia
- Reduce prevalence of iron deficiency in children and childbearing women.
- Reduce prevalence of anemia in pregnant women in third trimester to 20%.
Schools, Work Sites, and Nutrition Counseling
- Increase work-site nutrition-education and weight-management program offerings.
- Offer nutrition assessment and individualized planning at primary care sites.
- Increase the percentage of schools that offer nutritious foods and beverages outside of school meals.
- Increase the number of states with nutrition standards for food and beverages provided to preschool-age children in child care.
Food Security
- Increase food security to 94% of households.
Data from US Department of Health and Human Services: Healthy people 2020, 2019, hp:healthypeople/.
Simple carbohydrate is the classification for both monosaccharides and disaccharides; they are found primarily in sugars. Polysaccharides such as glycogen make up carbohydrate units too (i., complex carbohydrates). They are insoluble in water and digested to varying degrees. Starches are polysaccharides. The body is unable to digest some polysaccharides because we do not have enzymes capable of breaking them down. Fiber, a polysaccharide, is the structural part of plants that is not broken down by our digestive enzymes. The inability to break down fiber means that it does not contribute calories to the diet. Therefore, insoluble fibers, including cellulose, hemicellulose, and lignin, are not digestible. Soluble fibers dissolve in water and include barley, cereal grains, cornmeal, and oats.
Proteins
Proteins provide a source of energy (4 kcal/g); they are essential for the growth, maintenance, and repair of body tissue. Collagen, hormones, enzymes, immune cells, deoxyribonucleic acid (DNA), and ribonucleic acid (RNA) are all made of protein. In addition, blood cloing, fluid regulation, and acid-base balance require proteins. Proteins transport nutrients and many drugs in the blood. Ingestion of proteins maintains nitrogen balance. The simplest form of protein is the amino acid, consisting of hydrogen, oxygen, carbon, and nitrogen. Because the body does not synthesize indispensable amino acids, we need these to be provided in our diet. Examples of indispensable amino acids are histidine, lysine, and phenylalanine. The body synthesizes dispensable amino acids. Examples of amino acids synthesized in the body are alanine, asparagine, and glutamic acid. Amino acids can link together. Albumin and insulin are simple proteins because they contain only amino acids or their derivatives. The combination of a simple protein with a nonprotein substance produces a complex protein such as lipoprotein, formed by a combination of a lipid and a simple protein. A complete protein, also called a high-quality protein, contains all essential amino acids in sufficient quantity to support growth and maintain nitrogen balance. Most complete proteins come from animal sources, such as fish, poultry, beef, milk, cheese, and eggs, but they can also come from plant sources, such as soy. Incomplete proteins are missing one or more of the nine indispensable amino acids and include grains, seeds and nuts, legumes, and vegetables. Complementary proteins are
pairs of incomplete proteins that, when combined, supply the total amount of protein provided by complete protein sources. Nitrogen is a byproduct of protein catabolism. Achieving nitrogen balance means that the intake and output of nitrogen are equal. When the intake of nitrogen is greater than the output, the body is in positive nitrogen balance. Positive nitrogen balance is required for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing. The body uses nitrogen to build, repair, and replace body tissues. Negative nitrogen balance occurs when the body loses more nitrogen than it gains (e., with infection, burns, fever, starvation, head injury, and trauma). The increased nitrogen loss is the result of body tissue destruction or loss of nitrogen-containing body fluids. Nutrition during this period needs to provide nutrients to put patients into positive balance for healing. Protein provides energy, but because its essential role is to promote growth, maintenance, and repair, a diet needs to provide adequate kilocalories from nonprotein sources. When there is sufficient carbohydrate in the diet to meet the energy needs of the body, protein is spared as an energy source.
Fats
Fats (lipids) are the most calorie-dense nutrient, providing 9 kcal/g. Fats are composed of triglycerides and fay acids. Triglycerides circulate in the blood and are composed of three fay acids aached to a glycerol. Fay acids are composed of chains of carbon and hydrogen atoms with an acid group on one end of the chain and a methyl group at the other. Fay acids can be saturated, in which each carbon in the chain has two aached hydrogen atoms, or unsaturated, in which an unequal number of hydrogen atoms are aached and the carbon atoms aach to one another with a double bond. Monounsaturated fay acids have one double bond, whereas polyunsaturated fay acids have two or more double carbon bonds. The various types of fay acids referred to in the dietary guidelines have significance for health and the incidence of disease. Fay acids are also classified as essential or nonessential. Linoleic acid, an unsaturated fay acid, is the only essential fay acid in humans. Linolenic acid and arachidonic acid, other types of unsaturated fay acids, are important for metabolic processes. The body manufactures them when linoleic acid is available. Deficiency occurs when fat intake falls below 10% of daily nutrition. Most animal fats have high proportions of saturated
The fat-soluble vitamins (A, D, E, and K) are stored in the fay compartments of the body. People acquire vitamins primarily through dietary intake, although vitamin D also comes from the sun. The body has a high storage capacity for fat-soluble vitamins. As a result, toxicity is possible when a person takes large doses of them. Hypervitaminosis of fat-soluble vitamins results from megadoses (intentional or unintentional) of supplemental vitamins, excessive amounts in fortified food, and large intake of fish oils.
Water-Soluble Vitamins
The water-soluble vitamins are vitamin C and the B complex (which is eight vitamins). The body does not store water-soluble vitamins; thus, we need them provided in our daily food intake. Water-soluble vitamins absorb easily from the GI tract. Although they are not stored, toxicity can still occur.
Minerals
Minerals are inorganic elements essential to the body as catalysts in biochemical reactions. They are classified as macrominerals when the daily requirement is 100 mg or more and microminerals or trace elements when less than 100 mg is needed daily. Macrominerals help to balance the pH of the body, and specific amounts are necessary in the blood and cells to promote acid-base balance. Interactions occur among trace minerals. For example, excess of one trace mineral sometimes causes deficiency of another. Selenium is a trace element that also has antioxidant properties. Silicon, vanadium, nickel, tin, cadmium, arsenic, aluminum, and boron are trace elements. Arsenic, aluminum, and cadmium can have toxic effects.
Anatomy and Physiology of the Digestive
System
Digestion
Digestion of food is the mechanical breakdown that results from chewing, churning, and mixing with fluid and chemical reactions in which food reduces to its simplest form (Grodner, 2020). Each part of the GI system has an important digestive or absorptive function (Fig. 45). Enzymes are the protein-like substances that act as catalysts to speed up chemical reactions. They are an essential part of the chemistry of digestion.
FIG. 45 Summary of digestive system anatomy/organ function. HCl, Hydrochloric acid.
Most enzymes have one specific function. Each enzyme works best at a specific pH. For example, the enzyme amylase in the saliva breaks down starches into sugars. The secretions of the GI tract have very different pH levels. Saliva is relatively neutral, gastric juice is highly acidic, and the secretions of the small intestine are alkaline. The mechanical, chemical, and hormonal activities of digestion are interdependent. Enzyme activity depends on the mechanical breakdown of food to increase its surface area for chemical action. Hormones regulate the flow of digestive secretions needed for enzyme supply. Physical, chemical, and hormonal factors regulate the secretion of digestive juices and the motility of the GI tract. Nerve stimulation from the
down emulsified fats; and trypsin, elastase, chymotrypsin, and carboxypeptidase to break down proteins. Peristalsis continues in the small intestine, mixing the secretions with chyme. The mixture becomes increasingly alkaline, inhibiting the action of the gastric enzymes and promoting the action of the duodenal secretions. Epithelial cells in the small intestinal villi secrete enzymes (e., sucrase, lactase, maltase, lipase, and peptidase) to facilitate digestion. The major part of digestion occurs in the small intestine, producing glucose, fructose, and galactose from carbohydrates; amino acids and dipeptides from proteins; and fay acids, glycerides, and glycerol from lipids. Peristalsis usually takes approximately 5 hours to pass food through the small intestine.
Absorption
The small intestine, lined with fingerlike projections called villi, is the primary absorption site for nutrients. Villi increase the surface area available for absorption. The body absorbs nutrients by means of passive diffusion, osmosis, active transport, and pinocytosis (Table 45).
TABLE 45.
Mechanisms for Intestinal Absorption of Nutrients
Mechanism Definition Active transport
An energy-dependent process whereby particles move from an area of greater concentration to an area of lesser concentration. A special “carrier” moves the particle across the cell membrane. Passive diffusion
The force by which particles move outward from an area of greater concentration to one of lesser concentration. The particles do not need a special “carrier” to move outward in all directions. Osmosis Movement of water through a semipermeable membrane that separates solutions of different concentrations. Water moves to equalize the concentration pressures on both sides of the membrane. Pinocytosis Engulfing of large molecules of nutrients by the absorbing cell when the molecule aaches to the absorbing cell membrane.
Data from Nix S: Williams’ basic nutrition and diet therapy, ed 15, St Louis, 2017, Mosby.
Absorption of carbohydrates, protein, minerals, and water-soluble vitamins occurs in the small intestine. Then the nutrients are processed in the liver and released into the portal vein circulation. Fay acids are
absorbed in the lymphatic circulatory systems through lacteal ducts at the center of each microvilli in the small intestine. Approximately 85% to 90% of water is absorbed in the small intestine (McCance et al., 2019). The GI tract manages approximately 8 L of GI secretions and 1 L of oral intake daily. The small intestine resorbs 9 L, and the colon absorbs approximately 0 L. Elimination of the remaining 0 L occurs via feces. In addition, electrolytes and minerals are absorbed in the colon, and bacteria synthesize vitamin K and some B-complex vitamins. Finally, feces form for elimination.
Metabolism and Storage of Nutrients
Metabolism refers to all the biochemical reactions within the cells of the body. Metabolic processes are anabolic (building) or catabolic (breaking down). Anabolism is the building of more complex biochemical substances by synthesis of nutrients. It occurs when an individual adds lean muscle through diet and exercise. Amino acids are anabolized into tissues, hormones, and enzymes. Normal metabolism and anabolism are physiologically possible when the body is in positive nitrogen balance. Catabolism is the breakdown of biochemical substances into simpler substances and occurs during physiological states of negative nitrogen balance. Starvation is an example of catabolism when wasting of body tissues occurs. Nutrients absorbed in the intestines, including water, transport through the circulatory system to the body tissues. Through the chemical changes of metabolism, the body converts nutrients into a number of required substances. Carbohydrates, protein, and fat metabolism produce chemical energy and maintain a balance between anabolism and catabolism. To carry out the work of the body, the chemical energy produced by metabolism converts to other types of energy by different tissues. Muscle contraction involves mechanical energy, nervous system function involves electrical energy, and the mechanisms of heat production involve thermal energy. Some of the nutrients required by the body are stored in tissues. The major form of body reserve energy is fat, stored as adipose tissue. Protein is stored in muscle mass. When the energy requirements of the body exceed the energy supplied by ingested nutrients, stored energy is used. Monoglycerides from the digested part of fats convert to glucose by gluconeogenesis. Amino acids are also converted to fat and stored or catabolized into energy through gluconeogenesis. All body cells except red blood cells and neurons oxidize fay acids into ketones for energy when
Food Guidelines
The US Department of Health and Human Services (USDHHS) and the US Department of Agriculture (USDA) published the Dietary Guidelines for Americans 2015-2020 and provide average daily consumption guidelines for the five food groups: grains, vegetables, fruits, dairy products, and meats (Box 45). These guidelines are for Americans over the age of 2 years. As a nurse, consider the food preferences of patients from different cultural groups, vegetarians, and others when planning diets. The USDA developed the ChooseMyPlate program to replace the My Food Pyramid program. ChooseMyPlate provides a basic guide for making food choices for a healthy lifestyle (Fig. 45). It includes guidelines for balancing calories; decreasing portion size; increasing healthy foods; increasing water consumption; and decreasing fats, sodium, and sugars (USDA, 2017a).
B ox 4 5 .2 2015-2020 Dietary Guidelines for
Americans: Key Recommendations for the General
Population
Adopt a healthful eating paern at an appropriate calorie level with a variety of nutrient-dense foods and beverages among all the food groups.
Maintain body weight in a healthy range.
Encourage physical activity and decrease sedentary activities.
Encourage fruits, vegetables, whole-grain products, seafood, and fat- free or low-fat milk.
Eat a variety of proteins, including lean meats, seafood, poultry, eggs, legumes, nuts, seeds, and soy products.
Limit saturated fats and trans fats, consuming less than 10% of calories per day from saturated fats.
Limit added sugar or sweeteners so that less than 10% of calories comes from added sugars.
Consume less than 2300 milligrams (mg) of sodium per day.
Choose and prepare foods with lile salt, and eat potassium-rich foods.
Limit intake of alcohol to moderate use (i., one drink daily for women and two drinks daily for men).
Practice food safety to prevent bacterial foodborne illness. Use food- safety principles of Clean, Separate, Cook, and Chill.
Data from US Department of Health and Human Services and US Department of Agriculture: Dietary guidelines for Americans 2015-2020, 8e, hp:health/dietaryguidelines/2015/guidelines. Accessed June 26, 2019.
FIG. 45 ChooseMyPlate. From US Department of Agriculture: ChooseMyPlate, 2011, choosemyplate).
Nursing Knowledge Base
There are many sociological and psychological factors associated with eating and drinking in all societies. We celebrate holidays and events with food, bring it to those who are grieving, and use it for medicinal purposes. We incorporate food into family traditions and rituals and often associate food with eating behaviors. You need to understand patients’ values, beliefs, and aitudes about food and how these values affect food purchase, preparation, and intake to affect eating paerns. Nutritional requirements depend on many factors. Individual caloric and nutrient requirements vary by stage of development,
body composition, activity levels, pregnancy and lactation, and the presence of disease. Registered dietitians (RDs) use predictive equations that take into account some of these factors to estimate patients’ nutritional requirements.
Factors Influencing Nutrition
Environmental Factors
Environmental factors beyond the control of individuals contribute to the development of obesity. Obesity is an epidemic in the United States. Presently 68% of Americans are overweight or obese (CDC, 2019 ). Overweight is defined as having a BMI of 25 to 29, while obesity is defined as a BMI of 30 or greater (CDC, 2019). Obesity is often associated with a number of factors, such as sedentary lifestyle, overeating, and genetics (Giddens, 2017). Environmental factors can limit a person’s likelihood of healthy eating and participation in exercise or other activities of healthy living. Lack of access to full- service grocery stores, high cost of healthy food, widespread availability of less healthy foods in fast-food restaurants, widespread advertising of less healthy food, and lack of access to safe places to play and exercise are environmental factors that contribute to obesity (Haung and Barnidge, 2016).
Developmental Needs
Fundamentals of Nursing - Ch. 45 Nutrition - RN Nclex
Course: Adult Health II (NUR 2211)
University: Hillsborough Community College
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