NUTRITION

Chapter 31 NUTRITION

• Define the key terms/concepts

• Identify the three major groups of nutrients

• List the six groups of vitamins required for health

• List the eight major elements or electrolytes required for health

• Identify the functions and common food sources of the essential nutrients

• Describe the physical characteristics associated with a usual nutritional status

• Identify factors and disorders that may affect a client’s nutritional status

• Identify commonly used assessment techniques to measure a client’s nutritional status

• State the components of a healthy balanced diet

• Describe the components of the food guide pyramid

• State the principles of good nutrition

• Describe how the healthy balanced diet can be adapted to meet specific dietary beliefs and or requirements

• Apply appropriate principles to meet nutritional needs throughout the lifespan, during episodes of illness or alterations in physiological or psychological status

• Assist in meeting a client’s nutritional needs accurately and safely in relation to assisting at mealtimes and caring for a client requiring enteral and parenteral feeds

KEY TERMS/CONCEPTS

anorexia nervosa

basal metabolic rate (BMR)

body mass index (BMI)

bulimia nervosa

essential amino acids

fat-soluble vitamins

monosaccharides

non-essential amino acids

polysaccharides

recommended daily allowances (RDAs)

total parenteral nutrition (TPN)

This chapter focuses on the nutritional needs of clients over the lifespan and how a client’s wellbeing can be affected by an alteration in the quantity and quality of absorbed nutrients. Nurses are required to assess and educate clients to maintain nutritional health status and provide information on how to undertake care for clients related to nutrition. Nutritional requirements vary according to age, height, sex, religion, culture, socioeconomic factors, and physical and psychological status. Nurses must be able to accommodate for all these different factors when they plan, care and educate clients.

LIVED EXPERIENCE

When I was admitted to a hospital with diverticulitis recently, I was unable to eat or drink anything orally for 5 days. By the sixth day, when I was able to start on clear fluids, I found I had lost my appetite! One of the student nurses who was looking after me suggested I clean my teeth and use a mouth wash to freshen my mouth, as she said this would help to stimulate my appetite. Guess what? This worked! Even though I wasn’t thrilled with the broth and jelly, I found I could taste it and by the time I was able to resume my usual diet, my appetite was fully back!

Chrissie, 56 years

NUTRITION

While eating has psychosocial and cultural significance in life, the major roles of food intake are to provide nutrients necessary for the development and growth of cells and the replacement of substances required by cells to maintain efficient body function. Information about the ingestion and digestion of food and the absorption of nutrients, is provided in Chapter 33. After the digested nutrients have been absorbed into the blood and lymph, they are distributed to the cells for further chemical processing, which releases the energy necessary for body function. The process of metabolism converts the nutrients into chemical forms that produce energy and rebuild body tissue. The two phases of metabolism are anabolism (or constructive phase), when simple substances derived from the nutrients are converted into complex substances that can be used by the cells; and catabolism (or destructive phase), when these complex substances are reconverted into simpler forms to release the energy necessary for cell function.

The term nutrition is used to describe all the processes by which the body uses food for energy, maintenance and growth. Nutritional requirements vary in response to changes throughout the lifespan. Factors that increase the body’s metabolic demand include the periods of rapid growth during infancy and adolescence, pregnancy and lactation, increased physical activity, and periods of stress, disease or trauma. Metabolic requirements diminish with reduced energy demands, decreased physical activity and age.

Adequate nutrition is partially dependent on the ability of the body to ingest and digest food, to absorb nutrients from the intestine and to excrete waste products. In addition, the quality and quantity of food consumed has an important influence on a client’s current and future health status. A diet containing the essential nutrients for each stage of the lifespan is vital to maintain wellbeing.

Many factors influence a client’s pattern of eating, and include:

• Availability of food

• Economic status

• Influences such as family, or advertising

• Food fads and fallacies

• Cultural and ethnic beliefs and values

• Social and emotional aspects of food

• Physical or psychological status of the client, such as an allergy or intolerance to specific foods or nutrients, difficulty in chewing or swallowing, level of independence, disorders that interfere with nutrition and result in maldigestion, malabsorption, or loss of nutrients, leading to emotional states such as depression or anxiety.

NUTRITION ASSESSMENT

A client’s nutritional status is assessed by obtaining information about their appetite, food preferences, height and weight and level of activity, and from observing their general appearance. Observation of a client’s general appearance provides information about their general state of health and their nutritional status. Some characteristics of altered nutritional status are presented in Table 31.1. Assessing the client’s eating pattern and their nutritional status may identify problems or risk factors.

TABLE 31.1 CHARACTERISTICS OF ALTERED NUTRITIONAL STATUS

General	Cachexia, hepatomegaly, splenomegaly, cardiomegaly, weight loss or gain
Hair	Dull, dry or brittle hair; hair thinning or loss
Nails	Brittle, broken, ridged or spoon shaped. Pale nail bed
Skin	Dry or scaly, bruising or petechiae unrelated to trauma, ulceration, abnormal colour changes, dermatitis
Oral mucosa	Pale mucous membrane, ulceration and cracking, ketone-smelling breath
Lips	Angular stomatitis, cheilosis
Tongue	Swollen or smooth tongue, atrophic papilla, cracking or fissuring
Gums	Spongy and/or bleeding gums, gum recession
Teeth	Mottled, dental caries, absent teeth
Conjunctiva	Pale to reddish-pink
Vision	Diminished visual acuity or loss
Cardiac	Tachycardia, cardiomegaly, palpitations, angina
Muscles	Muscle wasting, atrophy, diminished strength or tone, constipation
Skeleton	Curvature of arms or legs, altered gait, shortened stature, fractures
Neurological	Altered mood or affect, reduced concentration span, coordination, sensory or motor activity and reflexes, vision loss
Urine	Ketonuria, urobilinogen, haemoglobinuria, haematuria

In addition to the physical characteristics associated with poor nutritional status, psychological symptoms may be evident. A client with a poor nutritional status may experience irritability, lethargy, apathy or inability to concentrate. It is possible, however, that these symptoms and the physical signs presented in Table 31.1 may be related to an underlying condition and/or the client’s nutritional status.

Certain groups of clients may be more at risk of a poor nutritional status, including those who are:

• Suffering emotional or physical stress

• Alcohol, drug or nicotine dependent

• Pregnant or lactating

• Older or the young

• Unaware of nutritional values

• Strict vegetarians

• Following ‘fad’ diets.

To maintain or promote an appropriate intake of food and therefore a good nutritional status, clients should be encouraged to follow the principles of a balanced healthy diet that provides the body with essential nutrients.

HEALTHY BALANCED DIET

A healthy balanced diet is one that consists of foods taken regularly, in sufficient quantities, from each of the basic food groups. A healthy balanced diet is a diet that is composed of 60% carbohydrate, 20% protein and 20% fat. The recommended number of daily servings from each of the five food groups varies slightly according to the client’s stage of development. The five food groups and the recommended daily allowances (RDAs) are:

1. Milk and dairy products. The major nutrients provided by foods from this group are protein, fat and calcium; 300–600 mL of milk, or equivalent substitutes such as cheese and yoghurt, should be consumed daily. During pregnancy or lactation the amount should be increased to 900 mL of milk or equivalent substitutes daily

2. Meat, fish and eggs. The major nutrients provided by foods from this group are protein, fat and iron. One to two servings from this group is the RDA

3. Fruits and vegetables. The major nutrients provided by foods from this group are carbohydrate, fibre, water-soluble vitamins and water. The RDA is at least four servings of either fruits or vegetables, or a combination of both

4. Breads and cereals. The major nutrients provided by foods from this group are carbohydrates, protein, vitamins, iron and fibre. Depending on energy requirements, at least four servings daily are recommended

5. Fats (butter, margarine, oils). The major function of foods in this group is to provide a vehicle for the fat-soluble vitamins: A, D, E and K. The RDA of fats is 15–30 g.

Nutritional needs of infants and children

Throughout all stages of development, a healthy balanced diet is necessary to provide the nutrients required for the body’s needs. For information on maternal and newborn nutrition, see Chapter 49.

Solids are generally introduced when an infant is about 6 months old, but this varies according to the infant’s needs and development. The term educational diet is sometimes used to describe the gradual introduction of solids. The aim of introducing solids is to wean the infant off milk to prevent such problems as failure to thrive, malnutrition and anaemia, and also to educate the palate to different tastes and textures; eating therefore becomes largely a learning process. Rice cereal, pureed stewed fruit and vegetables are suitable first foods. Because food allergies can be a problem during infancy, it is important that single-ingredient foods are introduced one at a time. If an infant has an adverse reaction to a food, it can then be readily identified and eliminated from the diet. By 6–8 months of age, chewing movements begin and the infant can be introduced to coarser-textured foods.

When the infant begins to grasp objects and put them in their mouth, they may be ready to be introduced to finger foods. When an infant can take fluids from a cup, at about 7–8 months of age, fruit juice may be introduced. Giving fruit juice from a bottle should be discouraged, as this may contribute to the development of jaw and tooth deformity and dental caries, and excessive volumes of fruit juice may result in diarrhoea.

At about 12 months of age the infant should be eating a range of basic foods. The diet should consist of bread and cereals, fruit and vegetables, meat and/or other protein foods, milk and/or milk products and small amounts of butter or margarine. Salt, sugar and fatty foods should be avoided.

The toddler and pre-school child

During this stage of development a child’s rate of growth is slower than in infancy and this is normally reflected by a decrease in appetite, although appetite is generally unpredictable during these years. Children should be encouraged to eat a variety of nutritious foods, which should be served at regular times in a calm and relaxed atmosphere. Because young children are active, snacks between meals are important. The foods offered for snacks should contribute to the nutritional needs of the child, while foods with poor nutritional value should be avoided. Small hard foods, such as nuts, raw carrots, etc, are potentially dangerous for the young child, as they may be inhaled and obstruct airways. The toddler and preschool child should be having, each day:

• 4–5 servings from the bread and cereal group

• 3–4 servings from the fruit and vegetable group

• 1–2 servings from the meat and protein group

• 600 mL of milk, or equivalent in dairy cheese or yoghurt

• 5–10 g of butter or margarine.

The school-age child

During the first 12 months of life a foundation is laid down for good dietary practices. By the time the child is of school age, eating patterns are usually firmly established. As the child grows and develops, their tastes can change — foods that were previously enjoyed may be refused, while the child may acquire a taste for other foods, due in part to social interaction and their changing physiological needs and subsequent sensory changes.

Nutritional requirements are similar to those for children of preschool age, although kilojoule needs are diminished in relation to body size. However, fat and protein reserves are being laid down for the increased growth needs of the adolescent period, and the school-age child should be encouraged to consume a healthy balanced diet consisting of foods from each of the five food groups and should be discouraged from consuming foods that have poor nutritional value. If the child consumes an excessive quantity of food and/or food that is high in kilojoules, and does not exercise, they may be at risk of childhood obesity and subsequent development of conditions such as adult-onset diabetes and cardiovascular disease. Iron-deficiency anaemia is another nutritional problem associated with school-age children due to inadequate amounts of iron in the diet.

Adolescence

From 10 years of age, children’s bodies are developing rapidly to prime the body for reproduction. A pre-puberty growth spurt occurs earlier in girls than in boys, as they store more fat, which initiates adolescence faster (see Chapter 16 for further information). During this time there can be major changes in their selection and volume of food; hormones alter senses such as taste to enable the adolescent to adapt to obtain changing nutrient requirements. Some clients at this age may be vulnerable to self, peer and social influences that may alter their perception of appearance and self-worth and drastically modify their eating habits (see ‘Eating disorders’, later in this chapter).

ENERGY REQUIREMENTS

In addition to the consumption of foods from the five food groups that provide the essential nutrients, dietary requirements need to be considered in terms of energy requirements. Energy is needed for all the chemical and physical activities of the body, such as muscular activity, production of glandular secretions and the synthesis of substances in cells. The amount of energy required by a client is the amount necessary to maintain physiological processes and depends on factors such as age, sex, climate, body build, height and weight, level of physical activity, and usual function or dysfunction.

Energy requirements are increased during periods of rapid growth, for example, during pregnancy, infancy and adolescence and when a person engages in a high level of physical activity. Certain types of body dysfunction, such as hyperthyroidism — a disorder of the thyroid gland — can also increase the amount of energy required. Energy requirements are decreased when a client’s level of physical activity is low, with certain metabolic conditions, such as hypothyroidism, and during stages of development when there is little growth, such as old age.

The two units of measurement that specify the energy value of food are calories and joules. A calorie is defined as the amount of heat required to raise 1 gram of water by 1°C. A joule, which is the standard international (SI) unit of energy and heat, is equivalent to the amount of work performed when a 1 kg mass is moved 1 m by the force of 1 newton. One calorie is equal to 4.184 joules. As joules are very small units, it is more convenient to measure food energy in terms of kilojoules. One kilojoule (kJ) is 1000 joules. (For further units of measurement, see Appendix 2.)

The energy value of the three major types of nutrients are:

1. 1 g protein produces about 17 kJ

2. 1 g carbohydrate produces about 17 kJ

3. 1 g fat produces about 38 kJ.

Energy expenditure varies with the level of physical activity a client engages in and ranges from about 5 kJ/min during sleep to about 120 kJ/min during heavy physical activity. When the intake of kilojoules is increased or energy expenditure is decreased, weight gain occurs. Conversely, loss of weight occurs when the intake of kilojoules is decreased or energy expenditure is increased.

Basal metabolism is the term used to describe the minimal maintenance of all normal body functions at rest and in the absence of disease. The amount of energy required to support basal metabolism is measured when a client is awake but at complete rest and has not eaten for at least 12 hours. The measurement is expressed as basal metabolic rate (BMR), according to the number of kilojoules consumed per hour per square metre of body surface area (or per kilogram of body weight). The BMR is one diagnostic test commonly used to estimate nutritional needs. Variations in the BMR between clients of the same weight and height may be due to alteration in body composition, such as muscle mass as opposed to fatty tissue, and the presence of certain disease states.

Appendix 7 gives reference ranges for acceptable weight for height for Australians. This table is based on body mass index (BMI) which is calculated using the following formula:

BMI = Weight in kilograms divided by height in metres²

For example, the BMI of a male who is 6 feet (1.83 metres) tall and weighs 115 kg is:

The value obtained when this formula is used should be rounded to the nearest whole number. A BMI value below 20 is common in certain ethnic groups, such as people of Asian descent, and in athletes, but otherwise indicates that a person is underweight. A BMI of 20–25 is within the healthy weight range. A BMI of 25–30 may indicate more muscular build or overweight, while a value of 31–40 is defined as moderate to severe obesity and a value above 40 signifies morbid obesity.

GLYCAEMIC INDEX

Glycaemic index (GI) classifies carbohydrate foods according to how rapidly glucose is released from them and absorbed into the blood. It has traditionally been used to treat clients with diabetes mellitus but is now being used for establishing optimal diets for the general populace. The lower the GI the slower the rate of absorption and the slower the rate of insulin release. Complex carbohydrates such as starch provide lower GI nutrients and result in a more stable blood glucose level.

Some simple carbohydrates, such as those found in fruits, have a lower GI value than some complex carbohydrates, such as those found in rice and potatoes. Foods with low-GI values have been used to treat hypercholesterolaemia and obesity. Low-GI foods include multigrain breads, bran, legumes, milk, yoghurt and fruits. High-GI foods, of which there are more than 70, include rice, potatoes, wholemeal and white bread, and some cereals. Further health benefits may be gained by including foods that are high in fibre.

NUTRIENTS

Nutrients are chemical substances in food that provide energy, build and maintain cells or regulate body processes. The essential nutrients are:

• Carbohydrates

• Lipids (fats)

• Mineral salts.

CARBOHYDRATES

Carbohydrates are a group of organic compounds that includes sugar, starch and cellulose. They are composed of one or more monosaccharide (single-sugar) units. Sugars can be classified as either simple or complex and are divided into groups according to the complexity of their molecular structure. Simple sugars, or monosaccharides, include glucose, fructose and galactose. Disaccharides, which are a combination of two sugars, include sucrose, lactose and maltose. For example, glucose and fructose combine to form sucrose. Complex sugars or polysaccharides are a combination of many sugars and include starch, glycogen and cellulose. Before carbohydrates can be utilised by the body cells, disaccharides and polysaccharides must be converted by chemical digestion into glucose.

Carbohydrates provide energy, assist in the metabolism of fat and act as a protein sparer (if there is insufficient carbohydrate in the diet, protein is converted to glucose and used for energy). Carbohydrate foods also supply indigestible cellulose, which adds bulk to the intestinal contents, resulting in stimulation of peristalsis. The major food sources of carbohydrates are:

• Sugars, present in fruits, honey, cane sugar, milk and cereals

• Starch, present in vegetables, cereals and foods made from cereals (e.g. bread and pasta)

• Cellulose, present in vegetables, fruits and cereals (complex carbohydrates).

PROTEINS

Proteins are a group of nitrogenous compounds composed of chains of amino acid subunits. Twenty-two amino acids have been identified in humans. Eight of these — the essential amino acids — the body is unable to make, and they must be obtained from dietary sources. The remaining 14 non-essential amino acids can be synthesised by the body. Before proteins can be utilised by the cells, they must be broken down by physical and chemical digestion into their constituent amino acids. According to the number and type of amino acids present, proteins are classed either as complete (containing all essential amino acids) or incomplete (lacking one or more essential amino acids).

Proteins build and repair tissue and supply energy (protein that is not needed for growth and repair of tissues is converted into glucose and stored in the liver and muscles as a reserve store of energy). The major food sources of protein are meat, fish, eggs, cheese, milk, poultry and soya beans (complete [or first-class] protein); and cereals, lentils, legumes and nuts (incomplete [or second-class] protein).

LIPIDS (FATS)

Lipids are a group of substances that are insoluble in water and are composed of fatty acids and glycerol. Fatty acids are classed as saturated or unsaturated. Saturated, or solid, fats are chiefly of animal origin, such as butter, and contain a full complement of hydrogen. Unsaturated, or soft or liquid, fats are chiefly of vegetable origin, such as margarine, and are capable of adding more hydrogen to their molecular structure.

Before fats can be utilised by the body cells they must be broken down by chemical digestion into their constituent fatty acids and glycerol. Fat supplies energy and may be used in the tissues or stored in adipose tissue, which functions to support and protect nerves and organs from trauma, insulate the body to prevent excessive heat loss or gain, and as a reserve store of fuel. Fats also supply the fat-soluble vitamins A, D, E and K as well as stimulating adolescence, fertility and mood, and suppressing appetite through the action of hormones such as leptin, secreted by adipocytes.

The major food sources of fat are animal fats, present in meat, butter, cream, egg yolk, cheese and fish oils; and vegetable fats, present in margarine, cocoa and oils such as olive, safflower, corn and peanut.

WATER

Water is a chemical compound obtained by the body from food and fluid and as a result of the metabolism of protein, fat and carbohydrate in the tissues. Water constitutes about 60% of the total body weight and is present as intracellular fluid and extracellular fluid. Water is also the basis of all body secretions and excretions.

Water is necessary for the digestion, absorption and metabolism of food, for the production of secretions and for the maintenance of body fluids. Water is also necessary for the regulation of body temperature by evaporation of sweat, and for the elimination of waste products through the kidneys, bowel, skin and lungs.

Water is present in all body fluids and as part of the cellular structure of solid foods. Foods vary in water content; fruit and vegetables contain about 80–90% water, meat contains about 70%, and bread contains about 35%.

FIBRE

Dietary fibre, often referred to as cellulose, is the fibrous parts of food that the digestive system has difficulty in digesting. Fibre creates bulk in the stools, which enhances defecation and is used to prevent or minimise symptoms of certain disorders, such as haemorrhoids, diverticular disease, formation of gallstones, simple constipation and intestinal cancer. Foods with a high fibre content are fruits, vegetables and wholegrain products. Clinical Interest Box 31.1 provides discussion on the effects of constipation on the older client.

CLINICAL INTEREST BOX 31.1 Constipation and the older client

Constipation can occur at any age but is common in the elderly, associated with diminished exercise, fibre and fluid intake, as well as diminished neurogenic gastrointestinal regulation. Measures to avoid constipation are required to reduce the incidence of conditions such as diverticulosis, megacolon, carcinoma, strokes and heart attacks. A nutritional assessment of dietary intake is required, as is examination for any underlying pathologies, such as those causing disorders such as iron-deficiency anaemia from per-rectal bleeding, for example. The clinical features of this anaemia include constipation, lethargy, easy exhaustion, pale conjunctivae and pagophagia (craving for ice). Iron is obtained in large quantities from meat, and many older clients may be unable to obtain and consume or absorb the required amounts. Iron-replacement therapy may be required; however, supplemental iron can result in constipation, false-positive occult blood test and gastrointestinal upset.

VITAMINS

Vitamins are a group of organic compounds that, with few exceptions, must be obtained from dietary sources. Although they have no energy value, they are essential for normal metabolic and physiological bodily function. The term vitamin was first used in 1912, and letters of the alphabet were assigned to them as they were discovered. Now that more is known about their composition, the chemical name for a vitamin is frequently used.

Vitamins are classed as being either water or fat soluble. The water-soluble vitamins are easily destroyed during the preparation and prolonged cooking of food. If they are consumed in excess of the body’s need, they are excreted in the urine. Fat-soluble vitamins are oxidised by exposure to air, light and high temperatures. As fat-soluble vitamins are not soluble in water, any excess is stored in the body, and a condition known as hypervitaminosis may occur, which may result in organ failure.

Excessive intake of vitamin A over long periods can result in hypervitaminosis A, a condition characterised by yellow discolouration of the skin (often mistaken as jaundice), loss of appetite and dry itchy skin. Excessive intake of vitamin B may result in allergic-type reactions. Hypervitaminosis D may occur if excessive amounts of vitamin D are taken and is characterised by nausea, vomiting, diarrhoea, general irritability and severe impairment of kidney function. In normal circumstances a healthy balanced diet will provide the body with sufficient quantities of all vitamins without the need for supplemental vitamin ingestion. Table 31.2 describes the functions and effects of vitamin deficiencies.

TABLE 31.2 VITAMINS AND HEALTH

MINERAL SALTS

Mineral salts are a group of compounds that play an important role in metabolism, maintenance of blood pressure, cardiac function, fluid and electrolyte balance, acid–base balance and the regulation of other body processes. Storage and processing of food does not alter its mineral content, although mineral salts may be lost when food is soaked or cooked in water. The elements that mineral salts contain are classed as either major or trace elements; trace elements are present in only minute quantities in the body. A mineral salt that has the property of being a conductor of electrical current is referred to as an electrolyte. The functions and effects of mineral salt deficiencies are listed in Table 31.3.

TABLE 31.3 MINERAL SALTS AND HEALTH

DIETS TO MEET CLIENT NEEDS

A person’s normal diet depends on their age, pattern of eating and the food they choose. Dietary requirements may change during illness; for example, a client may avoid eating foods that cause adverse reactions such as indigestion, nausea or diarrhoea. The client’s diet may also need to be adapted as part of their treatment during certain conditions and disease states.

While acknowledging the factors that influence a client’s choice of foods and observing any restrictions to their diet in the management of disease processes, nurses should encourage the consumption of healthy balanced meals, following the principles of good nutrition. The principles of good nutrition are that:

• A variety of foods from each of the basic food groups should be eaten each day

• The intake of fat, sodium, sugar and alcohol should be limited

• The intake of complex carbohydrate and dietary fibre should be high

• Adequate amounts of water should be consumed

• Food should be prepared and cooked in such a way that the nutrient value is not lost

• Dietary intake and energy expenditure should be adjusted to achieve and maintain the appropriate weight for age and height

• Breastfeeding for babies is recommended

• People should become aware of the information contained on the labels of prepared and packaged foods. Notice should be taken of the expiry date, the presence of preservatives and other additives. The listing of ingredients on the container denotes the relative quantities of each, with the major ingredient listed first. The remainder are listed in order of decreasing quantities.

CLINICAL INTEREST BOX 31.2 High rates of malnutrition in elderly

A ground-breaking Australian study involving UNSW has revealed alarming levels of malnutrition in the elderly, with close to 80% malnourished or at risk when first admitted to hospital.

However, early intervention with a dietitian proved doctors could dramatically reduce length of hospital stay and health costs.

The findings follow a one-year study by a team of gastroenterologists, geriatricians and dietitians at Sydney’s Prince of Wales Hospital. The results will be presented at Digestive Diseases Week in Washington on May 19.

The study, led by President of the Gut Foundation, Professor Terry Bolin together with the Prince of Wales Department of Geriatric Medicine and Department of Nutrition and Dietetics, showed that when arriving for admission to hospital 80% of elderly patients were malnourished or ‘at risk’ but their hospital stay could be halved by implementing a nutritional care program. Professor Terry Bolin said:

What this study has shown is that the prevalence of malnutrition among the elderly in the community is high but we have simple and effective remedies. Malnutrition has significant impact on mortality, morbidity, length of hospital stay and readmission. The benefit of early action could potentially save our health system hundreds of millions of dollars.

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Feb 12, 2017 | Posted by admin in NURSING | Comments Off

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