Nursing Management

Nutritional Problems

To eat is a necessity, but to eat intelligently is an art.

Reviewed by Katie Clark, RD, MPH CDE, Assistant Clinical Professor, Nutrition, University of California San Francisco, School of Nursing, San Diego, California; Shellie Simons, RN, PhD, Assistant Professor, University of Massachusetts Lowell, Lowell, Massachusetts; and Patricia Worthington, RN, MSN, CNSC, Nutritional Support Clinical Specialist, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

This chapter focuses on problems related to nutrition. A review of normal nutrition provides a basis for evaluating nutritional status. Malnutrition and types of supplemental nutrition, including enteral and parenteral nutrition, are discussed. Obesity is discussed in Chapter 41.

Nutritional Problems

Nutrition is the sum of processes by which one takes in and utilizes nutrients.¹ Nutritional status can be viewed as a continuum from undernutrition to normal nutrition to overnutrition. An alteration in the process of nutrient intake or utilization can potentially cause nutritional problems. Nutritional problems occur in all age-groups, cultures, ethnic groups, and socioeconomic classes and across all educational levels.

The nutritional status of a person or a family is influenced by many factors. Attitudes toward the importance of food and eating habits are established early. Cultural or religious preferences and requirements are frequently reflected in dietary intake. The financial status of a family or an individual may influence the type and amount of nutritionally sound food that can be purchased.²

eNursing Care Plan 40-1 Patient Receiving Enteral Nutrition

Nursing Diagnosis*

Imbalanced nutrition: less than body requirements related to inability to ingest food due to physiologic and/or psychologic factors as evidenced by body weight 20% or more below ideal weight range, pale conjunctivae and mucous membranes, poor muscle tone

Patient Goal

Achieves adequate nutritional status

Outcomes (NOC)	Interventions (NIC) and Rationales
Nutritional Status • Nutrient intake _____ • Food intake _____ • Fluid intake _____ • Weight/height ratio _____ • Hematocrit _____ • Muscle tone _____ • Hydration _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range	Nutrition Therapy • Determine, in collaboration with the dietitian, the number of calories and type of nutrients needed to meet nutrition requirements. • Monitor appropriateness of diet orders to meet daily nutritional needs. • Determine need for enteral tube feedings. • Discontinue use of tube feedings as oral intake is tolerated. Enteral Tube Feeding • Monitor weight three times a week initially, decreasing to once a month, to make adjustments as needed in calorie intake. • Keep open containers of enteral feeding refrigerated to prevent bacterial growth. • Discard enteral feeding containers and administration sets q24 hr because they can become contaminated over time. • Refill feeding bag q4 hr to avoid contamination of formula. • Monitor for presence of bowel sounds q4-8 hr to ensure presence of GI function.

Outcomes (NOC)

Interventions (NIC) and Rationales

Nutritional Status

• Nutrient intake _____

• Food intake _____

• Fluid intake _____

• Weight/height ratio _____

1 = Severe deviation from normal range

2 = Substantial deviation from normal range

3 = Moderate deviation from normal range

4 = Mild deviation from normal range

5 = No deviation from normal range

Nutrition Therapy

• Determine, in collaboration with the dietitian, the number of calories and type of nutrients needed to meet nutrition requirements.

• Monitor appropriateness of diet orders to meet daily nutritional needs.

• Determine need for enteral tube feedings.

• Discontinue use of tube feedings as oral intake is tolerated.

Enteral Tube Feeding

• Monitor weight three times a week initially, decreasing to once a month, to make adjustments as needed in calorie intake.

• Keep open containers of enteral feeding refrigerated to prevent bacterial growth.

• Discard enteral feeding containers and administration sets q24 hr because they can become contaminated over time.

• Refill feeding bag q4 hr to avoid contamination of formula.

• Monitor for presence of bowel sounds q4-8 hr to ensure presence of GI function.

Nursing Diagnosis

Risk for aspiration related to gastrointestinal tubes and tube feedings

Patient Goal

Experiences no aspiration

Outcomes (NOC)	Interventions (NIC) and Rationales
Aspiration Prevention • Identifies risk factors _____ • Avoids risk factors _____ • Positions self upright for eating/drinking _____ • Remains upright for 30 minutes after eating _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Enteral Tube Feeding • Check for residual q4-6 hr for the first 24 hr, then q8 hr during continuous feedings, to validate gastric emptying. • Hold tube feedings if residual is greater than 500 mL and reassess the patient’s tolerance to enteral nutrition. • Elevate head of the bed 30-45 degrees during feedings to prevent aspiration. • Monitor for sensation of fullness, nausea, and vomiting because these are signs of gastric retention. • Discontinue feedings 30-60 min before putting patient in a head-down position to prevent aspiration.

Outcomes (NOC)

Interventions (NIC) and Rationales

Aspiration Prevention

• Identifies risk factors _____

• Avoids risk factors _____

• Positions self upright for eating/drinking _____

• Remains upright for 30 minutes after eating _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Enteral Tube Feeding

• Check for residual q4-6 hr for the first 24 hr, then q8 hr during continuous feedings, to validate gastric emptying.

• Hold tube feedings if residual is greater than 500 mL and reassess the patient’s tolerance to enteral nutrition.

• Elevate head of the bed 30-45 degrees during feedings to prevent aspiration.

• Monitor for sensation of fullness, nausea, and vomiting because these are signs of gastric retention.

• Discontinue feedings 30-60 min before putting patient in a head-down position to prevent aspiration.

Nursing Diagnosis

Risk for deficient fluid volume related to diarrhea and/or inadequate water intake

Patient Goal

Maintains adequate fluid volume

Outcomes (NOC)	Interventions (NIC) and Rationales
Hydration • Skin turgor _____ • Moist mucous membranes _____ • Fluid intake____ • Urine output _____ • Serum sodium _____ • Cognitive function _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Fluid/Electrolyte Management • Assess patient’s buccal membranes, sclerae, and skin for indications of altered fluid and electrolyte balance (e.g., dryness, cyanosis) to identify signs of fluid volume deficit. • Provide free water with tube feedings to compensate for high-concentration enteral feedings. Diarrhea Management • Identify factors (e.g., medications, bacteria, tube feedings) that may cause or contribute to diarrhea. Enteral Tube Feeding • Check gravity drip rate or pump rate every hour to maintain adequate fluid intake. • Slow tube feeding rate and/or decrease strength to control diarrhea. • Irrigate the tube q4-6 hr during continuous feedings and after every intermittent feeding to provide free water.

Outcomes (NOC)

Interventions (NIC) and Rationales

Hydration

• Skin turgor _____

• Moist mucous membranes _____

• Fluid intake____

• Urine output _____

• Serum sodium _____

• Cognitive function _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Fluid/Electrolyte Management

• Assess patient’s buccal membranes, sclerae, and skin for indications of altered fluid and electrolyte balance (e.g., dryness, cyanosis) to identify signs of fluid volume deficit.

• Provide free water with tube feedings to compensate for high-concentration enteral feedings.

Diarrhea Management

• Identify factors (e.g., medications, bacteria, tube feedings) that may cause or contribute to diarrhea.

Enteral Tube Feeding

• Check gravity drip rate or pump rate every hour to maintain adequate fluid intake.

• Slow tube feeding rate and/or decrease strength to control diarrhea.

• Irrigate the tube q4-6 hr during continuous feedings and after every intermittent feeding to provide free water.

^*Nursing diagnoses listed in order of priority.

eNursing Care Plan 40-2 Patient Receiving Parenteral Nutrition

Nursing Diagnosis

Risk for infection related to presence of a central venous catheter, administration of solutions that support rapid bacterial growth, and decreased defense mechanisms

Patient Goal

Experiences no manifestations of infection

Outcomes (NOC)	Interventions (NIC) and Rationales
Infection Severity • Fever _____ • Chilling _____ • Malaise _____ • Blood culture colonization _____ • Wound site culture colonization _____ • WBC count elevation _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Infection Control • Maintain an optimal aseptic environment during bedside insertion of central lines to minimize the possibility of infection. • Maintain an aseptic environment while changing PN tubing and bags to minimize the possibility of infection. • Change peripheral IV and central line sites and dressings according to guidelines to prevent infection. • Wash hands before and after each patient care activity to minimize possibility of infection. • Encourage rest so that nutrition is used for healing purposes. Infection Protection • Monitor for systemic and localized signs and symptoms of infection to ensure early detection of infection. • Monitor WBC count and WBC differential (especially neutrophils) to ensure early detection of infection.

Outcomes (NOC)

Interventions (NIC) and Rationales

• Blood culture colonization _____

• Wound site culture colonization _____

• WBC count elevation _____

• Maintain an optimal aseptic environment during bedside insertion of central lines to minimize the possibility of infection.

• Maintain an aseptic environment while changing PN tubing and bags to minimize the possibility of infection.

• Change peripheral IV and central line sites and dressings according to guidelines to prevent infection.

• Wash hands before and after each patient care activity to minimize possibility of infection.

• Encourage rest so that nutrition is used for healing purposes.

Infection Protection

• Monitor for systemic and localized signs and symptoms of infection to ensure early detection of infection.

• Monitor WBC count and WBC differential (especially neutrophils) to ensure early detection of infection.

Collaborative Problems

Potential Complications

Hyperglycemia, Hypoglycemia, and Electrolyte Imbalances

Nursing Goals	Nursing Interventions and Rationales
• Monitor blood glucose and serum electrolytes • Report deviations from acceptable parameters • Carry out appropriate medical and nursing interventions	• Monitor for manifestations of hyperglycemia such as thirst, polyuria, confusion, elevated blood glucose, blurred vision, dizziness, nausea and vomiting, and dehydration to plan appropriate treatment. • Monitor for signs of hypoglycemia such as sweating, hunger, weakness, and tremors to ensure early intervention. • Check capillary blood glucose every 4-6 hr until blood glucose levels are stable to detect glucose imbalances. • Monitor serum electrolyte levels daily to identify and treat complications early. • Check for manifestations of hyperkalemia (e.g., muscle weakness, flaccid paralysis, cardiac dysrhythmias, abdominal cramps, diarrhea) and hypokalemia (e.g., general weakness, decreased muscle tone, weak or irregular pulse, low BP, shallow respirations, abdominal distention, and ileus).† • Maintain accurate infusion rate to control the amount of glucose administered and prevent fluctuations in blood glucose levels.

Nursing Goals

Nursing Interventions and Rationales

• Monitor blood glucose and serum electrolytes

• Report deviations from acceptable parameters

• Carry out appropriate medical and nursing interventions

• Monitor for manifestations of hyperglycemia such as thirst, polyuria, confusion, elevated blood glucose, blurred vision, dizziness, nausea and vomiting, and dehydration to plan appropriate treatment.

• Monitor for signs of hypoglycemia such as sweating, hunger, weakness, and tremors to ensure early intervention.

• Check capillary blood glucose every 4-6 hr until blood glucose levels are stable to detect glucose imbalances.

• Monitor serum electrolyte levels daily to identify and treat complications early.

• Check for manifestations of hyperkalemia (e.g., muscle weakness, flaccid paralysis, cardiac dysrhythmias, abdominal cramps, diarrhea) and hypokalemia (e.g., general weakness, decreased muscle tone, weak or irregular pulse, low BP, shallow respirations, abdominal distention, and ileus).†

• Maintain accurate infusion rate to control the amount of glucose administered and prevent fluctuations in blood glucose levels.

BP, Blood pressure; IV, intravenous; PN, parenteral nutrition; WBC, white blood cell.

^†Other manifestations of electrolyte imbalances are discussed in Chapter 17.

eTABLE 40-1

USDA FOOD PATTERNS

The Food Patterns suggest amounts of food to consume from the basic food groups, subgroups, and oils to meet recommended nutrient intakes at 12 different calorie levels. Nutrient and energy contributions from each group are calculated according to the nutrient-dense forms of foods in each group (e.g., lean meats and fat-free milk). The table also shows the number of calories from solid fats and added sugars (SoFAS) that can be accommodated within each calorie level, in addition to the suggested amounts of nutrient-dense forms of foods in each group.

Daily Amount of Food From Each Group
Calorie Level¹	1000	1200	1400	1600	1800	2000	2200	2400	2600	2800	3000	3200
Fruits²	1 cup	1 cup	cups	cups	cups	2 cups	2 cups	2 cups	2 cups	cups	cups	cups
Vegetables³	1 cup	cups	cups	2 cups	cups	cups	3 cups	3 cups	cups	cups	4 cups	4 cups
Grains⁴	3 oz eq	4 oz eq	5 oz eq	5 oz eq	6 oz eq	6 oz eq	7 oz eq	8 oz eq	9 oz eq	10 oz eq	10 oz eq	10 oz eq
Protein Foods⁵	2 oz eq	3 oz eq	4 oz eq	5 oz eq	5 oz eq	oz eq	6 oz eq	oz eq	oz eq	7 oz eq	7 oz eq	7 oz eq
Dairy⁶	2 cups	cups	cups	3 cups	3 cups	3 cups	3 cups	3 cups	3 cups	3 cups	3 cups	3 cups
Oils⁷	15 g	17 g	17 g	22 g	24 g	27 g	29 g	31 g	34 g	36 g	44 g	51 g
Limit on calories from SoFAS⁸	137	121	121	121	161	258	266	330	362	395	459	596
Vegetable Subgroup Amounts Per Week
Calorie Level	1000	1200	1400	1600	1800	2000	2200	2400	2600	2800	3000	3200
Dark-green vegetables	cup	1 cup	1 cup	cups	cups	cups	2 cups	2 cups	cups	cups	cups	cups
Red and orange vegetables	cups	3 cups	3 cups	4 cups	cups	cups	6 cups	6 cups	7 cups	7 cups	cups	cups
Beans and peas (e.g. pintos, lentils, split peas)	cup	cup	cup	1 cup	cups	cups	2 cups	2 cups	cups	cups	3 cups	3 cups
Starchy vegetables	2 cups	cups	cups	4 cups	5 cups	5 cups	6 cups	6 cups	7 cups	7 cups	8 cups	8 cups
Other vegetables	cups	cups	cups	cups	4 cups	4 cups	5 cups	5 cups	cups	cups	7 cups	7 cups
Protein Foods Subgroup Amounts Per Week
Calorie Level	1000	1200	1400	1600	1800	2000	2200	2400	2600	2800	3000	3200
Seafood	3 oz	5 oz	6 oz	8 oz	8 oz	8 oz	9 oz	10 oz	10 oz	11 oz	11 oz	11 oz
Meat, poultry, eggs	10 oz	14 oz	19 oz	24 oz	24 oz	26 oz	29 oz	31 oz	31 oz	34 oz	34 oz	34 oz
Nuts, seeds, soy	1 oz	2 oz	3 oz	4 oz	4 oz	4 oz	4 oz	5 oz	5 oz	5 oz	5 oz	5 oz

¹Calorie Levels are set across a wide range to accommodate the needs of different individuals. The attached table “Estimated Daily Calorie Needs” can be used to help assign individuals to the food pattern at a particular calorie level.

²Fruit Group includes all fresh, frozen, canned, and dried fruits and fruit juices. In general, 1 cup of fruit or 100% fruit juice, or cup of dried fruit can be considered as 1 cup from the fruit group.

³Vegetable Group includes all fresh, frozen, canned, and dried vegetables and vegetable juices. In general, 1 cup of raw or cooked vegetables or vegetable juice, or 2 cups of raw leafy greens can be considered as 1 cup from the vegetable group.

⁴Grains Group includes all foods made from wheat, rice, oats, cornmeal, barley, such as bread, pasta, oatmeal, breakfast cereals, tortillas, and grits. In general, 1 slice of bread, 1 cup of ready-to-eat cereal, or cup of cooked rice, pasta, or cooked cereal can be considered as 1-ounce–equivalent from the grains group. At least half of all grains consumed should be whole grains.

⁵Protein Foods Group includes meat, poultry, seafood, eggs, processed soy products, and nuts and seeds. In general, 1 ounce of lean meat, poultry, or seafood, 1 egg, 1 Tbsp peanut butter, or ounce of nuts or seeds can be considered as 1-ounce–equivalent from the protein foods group. Also, cup of beans or peas may be counted as 1-ounce–equivalent in this group.

⁶Dairy Group includes all milks, including lactose-free products and fortified soymilk (soy beverage), and foods made from milk that retain their calcium content, such as yogurt and cheese. Foods made from milk that have little to no calcium, such as cream cheese, cream, and butter, are not part of the group. Most dairy group choices should be fat-free or low-fat. In general, 1 cup of milk or yogurt, ounces of natural cheese, or 2 ounces of processed cheese can be considered as 1 cup from the dairy group.

⁷Oils include fats from many different plants and from fish that are liquid at room temperature, such as canola, corn, olive, soybean, and sunflower oil. Some foods are naturally high in oils, like nuts, olives, some fish, and avocados. Foods that are mainly oil include mayonnaise, certain salad dressings, and soft margarine.

⁸SoFAS are solid fats and added sugars. The limits for calories from SoFAS are the remaining amount of calories in each food pattern after selecting the specified amounts in each food group in nutrient-dense forms (forms that are fat-free or low-fat and with no added sugars).

ESTIMATED DAILY CALORIE NEEDS
To determine which food intake pattern to use for an individual, the following chart gives an estimate of individual calorie needs. The calorie range for each age/sex group is based on physical activity level, from sedentary to active.
Calorie Range
	Sedentary	→	Active
Children
2-3 yr	1000	→	1400
Females
4-8 yr	1200	→	1800
9-13 yr	1600	→	2200
14-18 yr	1800	→	2400
19-30 yr	2000	→	2400
31-50 yr	1800	→	2200
51+ yr	1600	→	2200
Males
4-8 yr	1400	→	2000
9-13 yr	1800	→	2600
14-18 yr	2200	→	3200
19-30 yr	2400	→	3000
31-50 yr	2400	→	3000
51+ yr	2200	→	2800

Sedentary means a lifestyle that includes ony the light physical activity associated with typical day-to-day life.

Active means a lifestyle that includes physical activity equivalent to walking more than 3 miles per day at 3 to 4 miles per hour, in addition to light physical activity associated with typical day-to-day life.

Source: From U.S. Department of Agriculture Center for Nutrition Policy and Promotion, USDA Food Patterns, September 2011. Accessed from www.cnpp.usda.gov/Publications/USDAFoodPatters/USD.

eTABLE 40-2

SAMPLE MEAL PLANS FOR THE USDA FOOD PATTERN AT THE 2000-CALORIE LEVEL

Meal and snack plans A, B, and C are examples that show just a few ways to combine meals and snacks to meet daily food group intake targets. For the 2000-calorie food pattern, these targets are:

Fruits 2 cups

Vegetables cups

Grains 6 ozs (at least 3 oz whole grains)

Protein foods oz

Dairy 3 cups

Meal and Snack Plan A	Mean and Snack Plan B	Meal and Snack Plan C
Breakfast
1 oz grains cup fruit cup dairy	1 oz grains1 cup dairy oz protein foods	1 cup fruit1 cup dairy
Morning Snack
1 oz grains1 cup fruit	1 cup fruit cup dairy	1 oz grains cup dairy oz protein foods
Lunch
2 oz grains1 cup vegetables cup fruit1 cup dairy oz protein foods	2 oz grains1 cup vegetables cup dairy2 oz protein foods	2 oz grains1 cup vegetables1 cup dairy
Afternoon Snack
cup vegetables cup dairy	1 oz grains cup vegetables	1 oz grains cup vegetables cup dairy2 oz protein foods
Dinner
2 oz grains1 cup vegetable1 cup dairy3 oz protein foods	2 oz grains1 cup vegetables1 cup fruit1 cup dairy2 oz protein foods	2 oz grains1 cup vegetables1 cup fruit2 oz protein foods

From: U.S. Department of Agriculture Center for Nutrition Policy and Promotion: Sample Meal Patterns for the USDA Food Pattern at the 2000 calorie level. Retrieved from http://www.cnpp.usda.gov/Publications/USDAFoodPatterns/SampleMealPatterns.pdf

eTABLE 40-3

Vitamin	DRI	Manifestations of Overdose	Manifestations of Deficiencies
Fat Soluble
A	Men: 900 mcg/retinol equivalents*Women: 700 mcg/retinol equivalents	Hair loss, dry skin; headaches; dry mucous membranes; liver damage; bone and joint pain; blurred vision; nausea and vomiting	Dry, scaly skin; increased susceptibility to infection; night blindness; anorexia; eye irritation; xerosis (dry skin); keratinization of respiratory and GI mucosa; bladder stones; anemia; retarded growth
D	Adults: 5-10 mcg of cholecalciferol^†	Deposits of calcium and phosphorus in soft tissue; kidney and heart damage; bone fragility; constipation; anorexia; nausea, vomiting; headache	Muscular weakness; excessive sweating; diarrhea and other GI disturbances; bone pain; active rickets; healed rickets; osteomalacia
E	Adults: 15 mg	Relatively nontoxic	Neurologic deficits
K	Men: 120 mcgWomen: 90 mcg	Anemia	Defective blood coagulation
Water Soluble
B₁	Men: 1.2 mgWomen: 1.1 mg	Not stored in body, therefore overdose does not occur	Loss of appetite; fatigue; nervous irritability; constipation; paresthesias; insomnia
B₆	Men: 1.3-1.7 mgWomen: 1.3-1.5 mg	Not stored in body, therefore overdose does not occur	Seizures; dermatitis; anemia; neuropathy with motor weakness; anorexia
Cobalamin (B₁₂)	Adults: 2-4 mcg	Not stored in body, therefore overdose does not occur	Megaloblastic anemia; inadequate myelin synthesis; anorexia; glossitis; sore mouth and tongue; pallor; neurologic problems such as depression and dizziness; weight loss; nausea; constipation
C	Adults: 75-90 mg	Not stored in body, therefore overdose does not occur	Bleeding gums; loose teeth; easy bruising; poor wound healing; scurvy; dry, itchy skin
Folate (folic acid)	Adults: 400 mcg	Not stored in body, so overdose does not occur	Impaired cell division and protein synthesis; megaloblastic anemia; anorexia; fatigue; sore tongue; diarrhea; forgetfulness

DRI, Dietary Reference Intake; GI, gastrointestinal.

^*1 retinol equivalent = 10 international units vitamin A activity from β-carotene or 3.33 international units vitamin A activity from retinol.

^†1 mcg of cholecalciferol = 40 international units vitamin D.

eTABLE 40-4

COMMON DRUG AND FOOD/NUTRIENT INTERACTIONS

Drug Category/Drug	Food/Nutrient	Drug-Food Effects or Cautions
Anticoagulants	Dietary vitamin K (e.g., green leafy vegetables, green tea, dairy products/meats)	Decrease or loss of anticoagulant effect
Antiseizure agents • phenytoin (Dilantin)	Folate (folic acid)	Long-term drug use may increase folic acid requirement
Antidepressants • trazodone (Desyrel) • tricyclic antidepressants (e.g., amitriptyline [Elavil])	FoodRiboflavin	Food slows drug absorptionRiboflavin requirements may increase with amitriptyline (Elavil) or imipramine (Tofranil)
Antidiabetic agents • glyburide (Micronase, DiaBeta)	High-fat diet	Drug should not be taken with high-fat diet
Barbiturates • phenobarbital • mephobarbital (Mebaral)	Folate (folic acid)	Drugs may increase folic acid requirements; long-term therapy may require vitamin D supplements for osteomalacia
β-Adrenergic blockers • labetalol (Normodyne) • metaproterenol (Alupent) • carteolol (Cartrol) • sotalol (Betapace)	Food	Bioavailability of these drugs may be enhanced when taken with food
Bronchodilators • theophylline • oxtriphylline (Choledyl) • dyphylline (Lufyllin)	High-carbohydrate, low-protein dietsCaffeine-containing foods and fluids	↓ Drug eliminationCaffeine may increase CNS-stimulant effects of xanthine-derivative bronchodilators
Corticosteroids (prolonged therapy)	Salt seasonings	May require decreased sodium and/or potassium supplementation intake
Phenothiazines • procarbazine (Matulane)	RiboflavinFood and fluids containing tyramine (e.g., aged cheese, smoked or pickled meats or poultry, fermented meat, beer, wine, liqueurs)	Drugs may increase riboflavin requirementsWhen used concurrently, may cause sudden and severe hypertensive reactions; dietary restrictions need to continue for at least 2 wk after MAO inhibitors discontinued
Zinc supplements	Foods	Many foods (e.g., fiber, milk casein) impair zinc absorption
Others
etidronate (Didronel)	Foods, fluids, or drugs high in calcium	May prevent drug absorption
isoniazid (INH)	Cheese (e.g., Swiss) or fish (e.g., tuna, skipjack)	Concurrent ingestion may lead to redness or itching, HR changes, sweating, chills or clammy feeling, headache or light-headedness; thought to be related to altered metabolism of tyramine in foods
selegiline (Eldepryl)	Food and fluids containing tyramine (e.g., see above)	Same as above
ticlopidine (Ticlid)	Food	Drug absorption increased when taken after a meal
zafirlukast (Accolate)	High-fat and high-protein meal	When taken concurrently, drug bioavailability reduced by about 40%
cholestyramine (Questran)	Fat-soluble vitamins	Drug may interfere with their absorption

CNS, Central nervous system; HR, heart rate; MAO, monoamine oxidase.

eTABLE 40-5

MANIFESTATIONS OF PROTEIN-CALORIE MALNUTRITION

Body System	Subclinical Manifestations	Clinical Manifestations
Integumentary	Slowed tissue turnover rate, surface temperature 1°-2° F cooler	Brittle nails, ↓ tone and elasticity of skin, xeroderma (dry skin), pigment changes (brown-gray), erythematous seborrheic dermatitis, scrotal dermatitisHair: easy loss of hair, color changes, lack of luster
Visual	Night blindness	Blood vessel growth in cornea, Bitot’s spots (gray keratinized epithelium on conjunctiva), dryness of conjunctiva and cornea, pale to red conjunctiva
Gastrointestinal
Mouth and lips	Reduction in saliva production	Cheilosis (crusting and ulceration at angle of mouth)
Tongue	Mucosa more permeable to bacteria	Raw and beefy red, edematous and smooth, atrophy or hypertrophy of papillae
Teeth	Improper development, delayed eruption	Cavities, loose teeth, discolored enamel
Gingivae		Periodontal disease, tendency to bleed easily, receding, pale, and soft
Stomach	↓ Gastric secretion, delayed gastric emptying	Constant hunger, ↑ incidence of ulcers
Intestines	↓ Motility and absorption, normal flora causing infection from ↑ permeability of mucosa	Diarrhea and flatulence, protruding abdomen, ↑ incidence of parasitic diseases
Liver-biliary	Fatty liver, ↓ absorption of fat-soluble vitamins	Hepatomegaly
Cardiovascular	↓ Cardiac output, ↓ hemoglobin, shift in heart position, ↑ risk of thrombophlebitis	↓ BP and pulse, slight cyanosis, anemia, body edema
Endocrine	↓ Insulin production	Thyroid enlargement, polydipsia, polyuria, ↓ sensitivity to cold
Immunologic	↓ Lymphocyte proliferation, ↓ albumin levels, ↓ acute-phase protein production, ↓ antibody production, diminished febrile response to infection	↑ Number of infections, ↓ response to delayed hypersensitivity skin tests
Musculoskeletal	↓ Growth rate, ↓ body stature with chronic PCM, ↓ muscle mass	Prominence of bony structures such as face, clavicle, scapula, ribs, iliac crests, and spinal vertebrae caused by subcutaneous tissue loss; weak and spindly arms and legs, flat buttocks, weak and flabby muscles; ↓ physical activity and ability to work; severe weight loss
Neurologic	Loss of ambition, feeling of being tired	Depression, confusion, ↓ reflexes in legs and ankles, ↓ position sense, ↓ vibratory sense, paresthesias of hands and feet, syncope, motor weakness
Renal	Negative nitrogen balance, ↓ BUN and creatinine levels	Nocturia, ↓ urinary output
Reproductive	↓ Gonadotropin levels	Amenorrhea, impotence, atrophied breasts
Respiratory	Pulmonary edema, ↓ strength of respiratory muscles	↑ Susceptibility to respiratory infection, ↓ respiratory rate, ↓ vital capacity

BUN, Blood urea nitrogen; PCM, protein-calorie malnutrition.

eTABLE 40-6

NUTRITIONAL THERAPY High-Calorie, High-Protein Diet

General Principles

1. A normal diet is supplemented with larger portions to increase the protein and caloric content. It is used for patients with hypermetabolism, burns, excessive stress, and cancer.

2. It is important to eat regularly and not to skip meals or snacks.

Meal	Protein (g)	SampleMenu Plan 1	SampleMenu Plan 2	SampleMenu Plan 3
Breakfast
Fruit	2	Large orange juice	Large apple juice	grapefruit
Starch, fat		1 toast with butter or jelly	Flour tortilla with butter	Biscuits and gravy
Starch, protein supplement	4	Cream of wheat with 2 Tbsp skim milk powder	Atole with 2 Tbsp skim milk powder	Grits with 2 Tbsp margarine
Meat	14	2 poached eggs	2 fried eggs	Omelet with 2 eggs
Milk, protein supplement	10	High-protein milk shake (2 Tbsp skim milk powder added)	High-protein milk shake	High-protein milk shake
Lunch
MeatStarchesVegetable	2882	Cheeseburger on bun with double meat patty, lettuce, tomato	2 burritos with extra cheese, meatLettuce and tomato salad with dressing	Split pea soup with ham hocksGrilled cheese sandwichWatermelon wedge
Fat		French fried potatoes	Biscochitos	Sugar cookies
Milk, protein supplement	10	High-protein milk shake	High-protein milk shake	High-protein milk shake
Dinner
MeatStarchesVegetable	2862	Spaghetti with 4 oz meat sauce, Parmesan cheeseGreen beans with 2 Tbsp margarine	2 tamales with red chili sauceSpanish ricePeas with 2 Tbsp butter	4 oz fried chickenSweet potatoMustard greens with 2 Tbsp butter
Fats		Bread with butterTapioca pudding	Custard	BiscuitVanilla ice cream
Milk, protein supplement	10	High-protein milk shake	High-protein milk shake	High-protein milk shake
Snack
Milk	8	Fruit yogurt	Cottage cheese with fruit	sandwich with peanut butter
Fruit				Banana
TOTAL	132

eTABLE 40-8

NURSING MANAGEMENT OF PARENTERAL NUTRITION INFUSIONS

Component/Potential Problem	Nursing Management
Preparation of parenteral nutrition (PN) solutions	• All PN solutions are prepared by a pharmacist or a trained technician using strict aseptic techniques under a laminar flow hood. • Add nothing to PN solutions after they are prepared in the pharmacy. Danger of drug incompatibilities and contamination is high. • Limit number of personnel involved in the preparation and administration of PN to reduce risk of infection. • PN solutions are ordered daily to adjust to the patient’s current needs. • PN solution label indicates the nutrient content, all additives, the time mixed, and the date and time of expiration. In general, solutions are good for 24 hr and must be refrigerated until 30 min before use.
IV filters, tubing, and infusion pumps	• Proper aseptic techniques are followed to reduce infection risk. • FDA recommends that a 0.22-micron Millipore filter be placed on parenteral solutions not containing fat emulsion and a 1.2-micron filter be placed on solutions containing fat emulsion. • Change filters and IV tubing q24 hr if PN with lipids is being administered and q72 hr for PN with amino acids and dextrose. • Label tubing and the filter with the date and the time they are put into use. • Control rate of infusion. Peripheral PN solutions should be administered with a volumetric controller, whereas a pump is used for central PN solutions. An infusion pump is used during administration of PN to maintain rate. • Set alarm to alert for tubing obstruction. • Periodically check the volume infused because pump malfunctions can alter the rate.
Catheter site care	• Change dressings covering the catheter site according to institutional protocol, ranging from every other day to once a week. The procedure for changing the dressing is similar to that followed after catheter insertion. • Carefully observe the catheter site for signs of inflammation and infection. Phlebitis can readily occur in the vein as a result of the hypertonic infusion, and the area can become infected. • High-risk patients include those who are immunosuppressed. Note subtle signs of infection in patients receiving chemotherapy, corticosteroids, or antibiotics, which can mask signs of infection. • If an infection is suspected during a dressing change, a culture specimen of the site and drainage should be sent for analysis, and the health care provider notified immediately.
Ensuring patient safety	• Check the label and ingredients in the solution to see that they match what the health care provider ordered before starting PN. • Examine the solution for leaks, color changes, particulate matter, clarity, and fat emulsion cracking. If present, promptly return it to the pharmacy for replacement. • Ensure that the PN solution is discontinued and replaced with a new solution if the bag is not empty at the end of 24 hr. At room temperature, the solution, especially when containing fat emulsion, is a good medium for microorganism growth. • Sometimes fat emulsions are infused separately from the PN solution. The preferred delivery method is a continuous low volume, such as 20% lipids delivered over 12 hr. • Monitor for adverse reactions, including allergic manifestations, dyspnea, cyanosis, fever, flushing, phlebitis, chest and back pain, and pain at the IV site. • IV fat administration provides a large number of calories in a relatively small amount of fluid. This is beneficial when the patient is at risk for fluid overload. Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Introduction Nursing Management: Sexually Transmitted Infections Nursing Management: Integumentary Problems Fluid, Electrolyte, and Acid-Base Imbalances Stay updated, free articles. Join our Telegram channel Tags: Medical-Surgical Nursing Assessment and Management of Clinical P Nov 17, 2016 \| Posted by admin in NURSING \| Comments Off on Nursing Management: Nutritional Problems Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access

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