GUIDE FOR STUDYING FOR TEST 3

Disclaimer: The following information is only a guide for studying. Be sure to read the assigned
chapters, review the chapter slides, and review notes taken during class.
Additional materials that review the content related to Test 3 include:
*Recordings of the lectures
Chapter 13: Nutrition Care and Assessment

Describe how disease and its treatment can impact nutritional status and how malnutrition
can impact disease.
Illnesses and there treatment may lead to malnutrition by:
o Reducing Food Intake
o Impairing digestion or absorption
o Altering Metabolism
o Altering Excretion
o Malnutrition over or under can lead to malnutrition
o Hospital malnutrition occurs in 40-60% of patients hospitalized with acute
illnesses

Identify members of the health care team who have unique roles in nutrition care of
patients.
Physicians/ Nurse Practitioners- Write diet orders, also include referrals for
nutrition assessment and dietary counseling.
Registered Nurses-Screen, assess, develop care plans, provide direct nutrition
care and education. Responsible for admin tube and IV feedings. In facilities that
do not employ registered dietitians, nurses assume much of the nutrition care.
Registered Dietitians- provide medical nutrition therapy(MNT), which includes
assessing nutritional status/assessment, diagnose nutritional problems, develop
nutrition care plans, provide nutrition counseling/education, plan and improve
menus. May also manage food and cafeteria services in healthcare institutions.
Registered Dietitic Technicians- Assists RD in implementing and monitoring of
nutrition services.
Other Professionals-Pharmacists, speech therapists, social workers, occupational
therapist, certified laboratory specialist, PCAs..- can alert dieticians or nurses on
nutritional problems.

Identify risks for malnutrition.

To identify risk of nutrition a nutrition screening is conducted within 24hrs of a
patients admission, and routinely every 7-14 days.

Describe each of the five components of the nutrition care process (i.e. nutrition
screening, assessment, diagnosis, intervention, and monitoring/evaluation).
Nutrition Screening- A tool for quickly identifying patients most likely to be at
risk for malnutrition.
o Allows for prevention strategies and early intervention. Identifies need for
complete nutrition assessments.
Assessment-involves the collection and analysis of health-related data in order to
identify specific nutrition problems and their underlying causes.
o Info may be obtained from medical record, physical examination, lab
analysis, medical procedure, interviews.
Diagnosis- includes specific nutrition problem, etiology or cause, and signs and
symptoms that provide evidence of the problem.
o EX: unintentional weight loss(the problem), related to insufficient kcaloric
intake(the etiology or cause), evidenced by a 10 pound weight loss in the
past few months(sign or symptom)
Intervention-May include counseling or education about appropriate dietary and
lifestyle practices, a change in meds or other treatment, or adjustments in meals.
To be successful intervention should consider an individuals food habits lifestyles,
and personal habits.
Monitoring and Evaluation- patients progress should be monitored closely, and
updated assessment data or diagnoses may require adjustments in goals or
outcome measures. The nutrition care plan must be flexible enough to adapt to
new situations.

Describe each of the four components of nutrition assessment and the limitations of each.
Medical History- Includes family history. May also reveal genetic susceptibilities
for diseases that can potentially be prevented with dietary and lifestyle changes.
Medication and Supplement History- A number of meds can have detrimental
effects on nutrition status, and some dietary components can alter absorption or
metabolism of drugs.
Personal and Social History-This can influence food choices as well as a
persons ability to manage health and nutrient problems. Ex: cultural/religious
beliefs, financial concerns, individuals who live alone, tobacco and illegal drugs.
Food and Nutrition History- A detailed account of persons dietary practices. It
includes info of food intake, lifestyle habits, food allergies. This includes a 24
hour food recall, and a survey about food choices.

Explain the advantages and disadvantages of each tool to determine food intake and
eating habits.
24-hour dietary recall- guided interview of what a patient has consumed in the
last 24 hrs.

o Advantages: results are not dependent on literacy, interview occurs after

food is consumed so does not influence dietary choices, quick method,
does not require reading/writing
o Disadvantage: Relies on memory, underestimation/overestimations of food
is common, food items that cause embarrassment may be omitted, data
from a single day is not accurate, seasonal variations may not be
addressed, skill of interviewer affects outcome.
Food Frequency Questionnaire-Written survey of food consumption during a
specific period of time
o Advantages: Process examines long-term food intake, so day-today/seasonal variability should not affect results, method does not
influence food choices, inexpensive
o Disadvantage: relies on memory, food lists often only includes common
foods, serving sizes are often difficult for respondent to evaluate without
assistance, calculated nutrient intakes are may not be accurate, food list for
general population are of limited value in special populations, method not
effective for short-term changes in food.
Food Record- Written account of food consumed during a specific period.
o Advantages: does not rely on memory, recording foods as consumed
improves accuracy, process is useful for controlling intake of foods
o Disadvantages: recording process influences food intake,
underreporting/portion size errors are common, time-consuming, requires
literacy/ability to see, seasonal changes in diet may not be taken into
account.
Direct Observation- observation of meal trays or shelf inventories before and
after eating, possible only in residential facilities.
o Advantages: does not rely on memory, does not influence food intake, can
be used to evaluate acceptability of a prescribed diet.
o Disadvantages: possible only in residential situations, is labor intensive.
Chart on pg.387

Identify the amount of weight loss over specified periods of time that indicate risk of
malnutrition. (NUMBERS)

> 2% in 1 week
> 5% in 1 month
> 7.5% of weight loss in 3 months
> 10% of weight loss in 6 months
chart bottom of pg.392

Compare and contrast the use of percent ideal body weight and percent usual body weight
in adults. (NUMBERS)
%UBW- 85-95%, %IBW- 80-90% Risk of mild malnutrition

 %UBW- 75-84%, %IBW-70-79% Risk Of Moderate malnutrition

%UBW- <75, %IBW- <70% Risk of severe malnutrition
***UBW is more effective than IBW for interpreting weight changes that occur in
underweight, overweight, or obese individuals.***
Chart bottom pg. 391

Using the quick method, calculate ideal body weight. (NUMBERS)

Females: 100lbs + 5 lbs for every inch over 60
Males: 106lbs + 6 lbs for every inch over 60

Discuss the pros and cons of tests used for the evaluation of serum protein status.
Albumin- most abundant serum protein
o Insensitive index of early malnutrition due to long half-life of 14-20 days
o Slow to react to changes in health status
o May reflect chronic malnutrition(PEM)- albumin levels remain normal for
a long period despite significant protein depletion, and levels fall only
after prolonged malnutrition.
o Albumin is not a sensitive indicator of effective treatment
Transferrin- An iron transport protein and its concentration responds to iron
status, PEM, and various illnesses.
o More sensitive marker with an 8-10 day half-life
o Dependent on iron status
Prealbumin/Retinol Binding Protein- decrease rapidly during PEM and respond
quickly to improved protein intakes. These proteins are very sensitive.
o More expensive than albumin so not routinely included during nutrition
assessment.
o Use is limited b/c they are affected by a number of different factors such
as metabolic stress, zinc deficiency, and various medical conditions.

Identify the physical signs of malnutrition.

Hair: dull, brittle, dry, corkscrew hair

Eyes: pale membranes, spots, dryness, night blindness
Lips: dry, cracked, sore in corners of lips
Mouth and Gums: bleeding gums, smooth or magenta tongue, poor taste sensation
Skin: poor wound healing, dry, rough, lack of fat, bruising/bleeding, pale
Nails: ridged nails, spoon shaped, pale
Other: dementia, peripheral neuropathy. Swollen glands, bowed legs
Chart on bottom pg.395

Discuss fluid imbalance and its effect on weight and blood test results.
Edema- signs include: weight gain, facial puffiness, swelling limbs, and
abdominal distention.
o May indicate malnutrition, cardiovascular disease, renal/liver disease.
Dehydration- signs include: thirst, dry skin mouth, reduced skin tension, dark
colored urine with low volume. Occurs more rapidly in Infants and elderly.
o May be caused by fever, sweating, vomiting, diarrhea, diuresis, or burns

Chapter 14: Nutrition Intervention and Diet-Drug Interactions

Describe methods of nutrition intervention, including counseling for behavior change.

Food and/or nutrient delivery- Providing appropriate nutrients via foods,
supplements, and nutrition support
Nutrition Education- Providing tailored nutrition information to increase
knowledge and skills
Nutrition counseling- providing assistance in developing goals and plans for
behavior change
Chart on bottom pg.404

State the definitions of diet prescription, diet manual, and medical nutrition therapy.
Diet Prescription- MDs and NPs prescribe diets for patients; RDs and RNs can
ask for modification or clarification of diets.
Diet Manuel- Describes the foods included and excluded on modified diets, the
rationale for use of each diet, and sample menus
Medical Nutrition Therapy(MNT)- Nutrition care; includes assessing
nutritional status, diagnosing nutrition problems, devising diet plans, and
providing education/counseling

Differentiate between regular and modified diets.

Regular Diet(standard or house diet)- diet that includes all foods and meets the
nutrient needs of healthy persons
Modified diet(therapeutic diet)- diet adjusted to meet medical needs. Contains
foods altered in texture, consistency, or nutrient content or that includes or omits
specific foods.

Differentiate between foods allowed on clear liquid and full liquid diets.
Clear Liquid diet- contains clear fluids or foods that are liquid at room temp and
leave minimal residue in the colon. Provides fluids and electrolytes. Includes:
o Strained orange juice

Flavored gelatin
Ginger ale
Coffee/tea
Bouillion
Flavored gelatin
Apple/grape juice
Soft drinks
Chart on pg.411
Full Liquid diet- opaque and transparent liquids/semi-liquids. Deficient in energy
and nutrients. Includes:
o Orange juice
o Strained oatmeal
o Milk
o Margarine
o Yogurt pudding
o Creamed soup
o Milkshakes
o Plain ice cream
o
o
o
o
o
o
o

Describe the components and uses of a diet progression.

Diet Progression- Progress diet from clear liquids to regular diet as tolerated.
Ex: pt given clear liquids and then gradually weaned onto beverages or other solid
foods
Ex: diet progresses from smaller meals to larger meals

Explain the different ways in which drugs and diet can interact, and identify specific
examples of each as shown on slides
Drugs can alter Food Intake by:
o reducing appetite
o increasing appetite
o Interfering with taste
o Causing/reducing nausea and vomiting
o Causing mouth dryness, inflammation, lesions
Drugs can alter nutrient absorption by:
o Changing acidity of stomach
o Changing GI transit time
o Damaging intestinal mucosa
o Competing for carriers/absorption sites
o Binding with nutrients
Diet can alter drug absorption by:
o Changing acidity in the stomach
o changing gastric emptying rate

o competing for carriers/absorption sites

o binding with drugs
Drugs can alter Nutrient Metabolism by:
o Inhibiting or enhancing activity needed for nutrient metabolism
o Competing for enzymes due to being a structural analog
o Altering hormones
Diet can alter drug metabolism by:
o Inactivating enzymes needed for drugs metabolism, thus increasing blood
concentrations od drug toxicity
o Acting as structural analogs
Drugs can alter nutrient excretion by:
o Reducing nutrient reabsorption
o Increasing nutrient reabsorption in the kidneys
o Causing diarrhea and vomiting
Diet can alter drug excretion by:
o Decreasing urinary excretion which increases drug toxicity
o Increasing urinary excretion which increases drug excretion
o Changing urinary pH which can increase or decrease drug excretion
Diet-Drug Interactions & Toxicity
o Increasing side-effects
o Increasing drug action to excessive levels
Ex: Tyramine is a food component and if combined with MAO inhibitors
it can be fatal.
Ex: caffeine enhances effect of amphetamines, but limits effects of
barbiturates.

Chapter 15: Enteral and Parenteral Nutrition Support

Describe characteristics of standard formulas, elemental formulas, specialized formulas,

and modular formulas.
Standard Formulas: also called polymeric formulas
o Provided to individuals who can digest and absorb nutrients w/out
difficulty. They contain intact proteins extracted from milk or soybeans
(called protein isolates) or a combo of such proteins
o The carbohydrates sources include hydrolyzed cornstarch, glucose
polymers (such as maltodextrin and corn syrup solids), and sugars. A few
commercial formulas, called blenderized formulas, are produced from a
mixture of whole foods such as chicken, vegetables, fruits, and oil, along
with some added vitamins and minerals
Elemental Formulas: also called hydrolyzed, chemically defined, or monomeric
formulas
o Prescribed for patients who have compromised digestive or absorptive
functions

o Contains proteins and carbohydrates that have been partially or fully

broken down to fragments that require little (if any) digestion
o The formulas are often low in fat and may provide fat from medium-chain
triglycerides (MCT) to ease digestion and absorption
Specialized Formulas: also called disease-specific or specialty formulas
o Designed to meet the specific nutrient needs of patients with particular
illnesses
o Products have been developed for individuals w/ liver, kidney, and lung
diseases; glucose intolerance; severe wounds; and metabolic stress
o Generally expensive and their effectiveness is controversial
Modular Formulas:
o Created from individual macronutrient preparations called modules, are
sometimes prepared for patients who require specific nutrient
combinations to treat illnesses
o Vitamin and mineral preparations are also included in these formulas so
that they can meet all of a persons nutrient needs
o In some cases one or more modules are added to other enteral formulas to
adjust their nutrient composition

Explain factors that should be considered in selecting an appropriate formula.

Formula is selected after careful assessment of the patients medical problems,
fluid & nutrition status, and ability to digest and absorb nutrients. The formula
chosen should meet the patients medical and nutrient needs w/ the lowest risk of
complications and the lowest cost
The vast majority of patients can use standard formula but a person w/ functional,
but impaired GI tract may require an elemental formula. Factors that influence
formula selection include:
o Nutrient and energy needs: as w/ patients consuming regular diets, an
adjustment in macronutrient & energy intakes may be necessary for tubefed patients. For ex. Pts with diabetes may need to control carb intake,
critical care pts may have high protein and energy requirements, and pts
w/ chronic kidney disease may need to limit their intakes of protein and
several minerals
o Fluid Requirements: High nutrient needs must be met using the volume of
formula a patient can tolerate. If fluids are restricted, the formula should
have adequate nutrient content and energy density to provide the required
nutrients in the volume prescribed
o The need for fiber modifications: the choice of formulas is narrower if
fiber intake needs to be high or low. Formulas that provide fiber may be
helpful for managing diarrhea, constipation, or hyperglycemia in some
patients; other patients may need to avoid fiber due to an increased risk of
bowel obstruction
o Individual tolerances (food allergies and sensitivities): most formulas are
lactose free b/c many patients who need enteral formulas have some

degree of lactose intolerance. Many formulas are also gluten free and can
accommodate the needs of individuals w/ celiac disease (gluten
sensitivity)

Describe how enteral formulas are used orally as supplemental nutrition, and ways to
help patients accept oral formulas.
Patients who are weak or debilitated may find it easier to consume oral
supplements than to consume meals
A patient who can improve nutrition status w/ supplements may be able to avoid
the stress, complications, and expense associated w/ tube feedings
Hospitals usually stock a variety of nutrient-dense formulas, milkshakes, fruit
drinks, puddings, gelatin desserts, and snack bars to provide to patients who are at
risk of becoming malnourished
When a pt. uses an oral supplement, taste becomes an important consideration
Allowing patients to sample different products & select the ones they prefer helps
to promote acceptance
Other ways to help pt accept oral formula:
o Serve supplements attractively. For ex, a formula offered in a glass on an
attractive plate may be more appealing than a formula served from a can
w/ an unfamiliar name
o Try keeping the formula in an ice bath so that it is cool and refreshing
when the pt. drinks it
o If the pt. finds the smell unappealing, it may help to cover the top of the
glass w/ plastic wrap or a lid, leaving just enough room fro a straw
o For pts w/ little appetite, offer the formula or snack food in small amounts
that are easy to tolerate, and serve it more frequently during the day
o Provide easy access, so keep the supplement close to the pt. bed where it
can be reached w/ little effort and w/in sight so the pt. is reminded to
consume it
o If the pt. stops enjoying a particular product, suggest an alternative
Oral supplements are sold in pharmacies and grocery stores for home use; ex:
ensure, boost, and carnation instant breakfast
These are used sometimes as convenient meal replacements or supplements by
healthy individuals

Describe characteristics of candidates for tube feedings.

Severe swallowing disorders

Impaired motility in the upper GI tract
GI obstructions and fistulas that can be bypassed w/ a feeding tube
Certain types of intestinal surgeries
Little to no appetite for extended periods, especially if the patient is malnourished
Extremely high nutrient requirements

 Mechanical ventilation
Mental incapacitation due to confusion, neurological disorders, or coma
Contraindications for tube feedings include severe GI bleeding, high-output
fistulas, intractable vomiting or diarrhea, complete intestinal obstruction, and
severe malabsorption
Several clinical studies have suggested that tube feedings are not always effective
in some of the patient populations in which they are routinely used; thus the
decision to use tube feedings should be considered in light of the most recent
research evidence

Describe the appropriate techniques to prepare formulas to prevent contamination.

Hands should be carefully washed before handling formulas and feeding
containers. Some facilities require that nonsterile gloved be worn whenever
formulas are handled. The following steps can reduce the risk of contamination
for open feeding systems:
o Before opening a can of formula, clean the lid w/ a disposable alcohol
wipe and wash the can opener w/ detergent and hot water. If you do not
use the entire can at one feeding, label the can w/ the date and time it was
opened
o Store opened cans or mixed formulas in clean, closed containers.
Refrigerate the unused portion of formula promptly. Discard unlabeled or
improperly labeled containers and all opened containers of formula that
are not used w/in 24 hours
o Hang no more than an 8-hr supply of formula ( or a 4-hr supply for
newborn infants) when using liquid formula from a can. Formulas
prepared from powders or modules should hang no longer than 4 hrs.
Discard any formula that remains, rinse out the feeding bag and tubing,
and add fresh formula to the feeding bag
o Use a new feeding container and tubing (except for the feeding tube itself)
every 24 hrs
o For closed feeding systems, the hang time should be no longer than 24-48
hrs. Contamination is more likely w/ the longer time periods

Describe the different ways formulas can be administered to patients.

When preparing a tube feeding:
o Discuss w/ patient and family
o Check initial placement w/ X-ray
o Monitor its position throughout the day
o Elevate the upper body during and after feeding: elevate to a 30-45 degree
angle during the feeding and for 30-60 minutes after the feeding to prevent
aspiration
Intermittent Feedings: delivering relatively large amounts of formula several
times per day, has more side effects

o Best tolerated when they are delivered into the stomach (not the intestine)
o Generally, a total of about 250-400 milliliters of formula is delivered over
30-45 minutes using a gravity drip method or an infusion pump
o Due to the relatively high volume of formula delivered at one time,
intermittent feedings may be difficult for some patients to tolerate, and the
risk of aspiration may be higher than w/ continuous feedings
o An advantage is that they are similar to the usual pattern of eating and
allow the patient freedom of movement between meals
o May start w/ 60-120 milliliters at the initial feedings and be increased by
60-120 milliliters at each feeding until the goal volume is reached
Continuous Feedings: delivered slowly and at a constant rate over a period of 824 hours
o Are used to deliver intestinal feedings and are generally recommended for
critically ill patients b/c the slower delivery rate may be easier to tolerate
o May also be recommended for patients who cannot tolerate intermittent
feedings
o An infusion pump is required to ensure accurate and steady flow rates;
consequently, the feedings can limit the patients freedom of movement
and are also more costly
o Usually start at rates of about 40-60 milliliters per hour and be raised by
20 milliliters per hour until the goal rate is reached
Bolus Feedings: rapid delivery of a large volume of formula into the stomach
(250 to 500 milliliters over 5-15 minutes)
o May be given every 3-4 hrs using a syringe
o Convenient for patients and staff b/c they are rapidly administered, do not
require an infusion pump, and allow greater independence for patients
o Can cause abdominal discomfort, nausea, and cramping in some patients,
and the risk of aspiration is greater than with the other methods of feeding
o For these reasons, bolus feedings are used only in patients who are not
critically ill
If the patient cannot tolerate an increased rate of delivery, the feeding rate is
slowed until the person adapts. Goal rates can usually be achieved over 24-36
hours. In some patients, formula delivery can be started at the goal rate
immediately
Slower rates of delivery may be better tolerated by critically ill patients, when
concentrated formulas are used, or in patients who have undergone an extended
period of bowel rest due to surgery, intestinal disease, or the use of parenteral
nutrition

Discuss meeting water needs with tube feedings.

May adults require about 2000 mL of water daily
Additional water is required in pts w/ severe vomiting, diarrhea, fever, excessive
sweating, high urine output, fistula drainage, high-output ostomies, blood loss, or
open wounds. Fluids may be restricted in persons w/ kidney, liver, or heart disease

 Enteral formulas contain about 70-85% water or about 700-850 mL of water per
liter of formula
In addition to the water in formulas, water can be provided by flushing water
separately through the feeding tube
Water flushes are also conducted to prevent feeding tubes from clogging; the
tubes are flushed w/ about 30mL of warm water about very 4 hrs during
continuous feedings and before and after each intermittent feeding
The water used for routine flashes should be included when estimating fluid
intakes

Describe guidelines for delivering medications through feeding tubes.

Continuous feedings are ordinarily stopped for 15 minutes before and after
medication administration so that the components of enteral formulas do not
interfere w/ the medications absorption
Some meds may require a longer formula-free interval; for example, feedings
need to stopped for at least one hour before and after administering phenytoin, a
med that controls seizures. In such cases, the formulas delivery rate needs to be
increased so that the correct amount of formula can be delivered
Meds are a major cause of diarrhea that frequently accompanies tube feedings.
Diarrhea is associated w/ the administration of sorbitol-containing meds,
laxatives, and some types of antibiotics
The high osmolality of many liquid meds can also cause diarrhea, so dilution of
hypertonic meds may be helpful
Guidelines:
o Do not mix meds w/ enteral formulas. Do not mix meds together
o Before administering meds, ensure that the feeding tube is placed
correctly, that it is not clogged, and that the gastric residual volume is not
excessive
o Position the patient in a semi-upright position (30 degrees) or higher) to
prevent aspiration
o Flush the feeding tube w/ 30 mL of warm water before and after
administering a med. When more than one med is administered, flush the
feeding tube w/ water btw meds
o Use liquid forms of meds whenever possible. Dilute viscous or hypertonic
fluid meds w/ at least 30 mL of water before administering them through
the feeding tube
o If tablets are used, crush tablets to a fine powder and mix w/ about 30mL
of warm water before administering

Identify major causes of tube feeding complications and ways to prevent or correct them.
For full list of preventions/corrections go to table 15-2 on page 446
Aspiration of formula
o Caused by inappropriate tube placement, delayed gastric emptying and
excessive sedation

o Prevented/corrected by ensuring correct placement of feeding tube;

elevating head of bed during and after feeding, decreasing formula
delivery rate if gastric residual volume is excessive, consider using
intestinal feedings in high-risk patients; minimize use of meds that cause
sedation
Clogged feeding tube
o Caused by excessive formula viscosity and improper administration of
meds
o Prevented/corrected by ensuring tube is appropriate, flushing tube w/
water etc; using oral, liquid, or injectable meds whenever possible, flush
tubing w/ water before and after each med is given etc
Constipation
o Caused by inadequate dietary fiber, dehydration, lack of exercise and
medication side effect
o Prevented/corrected by using a formula w/ appropriate fiber content;
providing additional fluids; encouraging walking and other activities if
appropriate; consult physician about minimizing or replacing meds that
cause constipation
Diarrhea
o Caused by medication intolerance, infection in GI tract, formula
contamination, excessively rapid formula administration and lactose or
gluten intolerance
o Prevention/corrected by diluting hypertonic meds before administering;
consulting a physician about specific diagnosis & appropriate treatment;
review safety guidelines for formula preparation; decreased formula
delivery or use continuous feedings; use lactose-free or gluten-free
formula in pts. w/ intolerances
Fluid & Electrolyte imbalances
o Caused by diarrhea, inappropriate fluid intake or excessive losses,
inappropriate insulin, diuretic, or other therapy, inappropriate nutrient
intake
o Prevented/corrected by monitoring daily weights, intake and output
records; ensuring that med doses are appropriate; use a formula w/
appropriate nutrient content
Nausea and vomiting, cramps
o Caused by Delayed stomach emptying, formula intolerance, medication
intolerance and response to disease or disease treatment
o Prevented/corrected by decreasing formula delivery rate or use continuous
feedings; ensure that formula is at room temp; consult physician about
replacing meds that are poorly tolerated; consider use of meds that control
nausea and vomiting
Describe the appropriate way to transition from tube feedings to table foods. (NUMBER)
After the pts condition improves, the volume of formula can be tapered off as the
patient gradually shifts to an oral diet

 Individuals using continuous feedings are often switched to intermittent feedings

initially
Swallowing function may be evaluated in some patients before oral feedings
begin
Pts receiving elemental formulas may begin the transition by using a standard
formula, either orally or via tube feeding
If the pt. has not consumed lactose for several weeks, a diet w/ minimal lactose
may be better tolerated
Oral intake equal to 2/3 of nutrient needs before discontinuing the tube feeding

Describe the advantages and potential risks of parenteral nutrition.

Advantage is short term support
Peripheral veins can be damaged by overly concentrated solutions and phlebitis
can occur which is characterized by redness, swelling, and tenderness at the
infusion site. To prevent this keep osmolarity of solution to less than 900
milliosmoles per liter

Compare and contrast the composition, purpose, and uses of peripheral parenteral
nutrition versus TPN by central vein.
Peripheral Parenteral Nutrition
o Delivered using only the peripheral veins
o Often used in patients who require short-term nutrition support (about 710 days) and do not have high nutrient needs or fluid restrictions
o The use of PPN is not possible if the peripheral veins are too weak to
tolerate the procedure and in some cases clinicians must rotate venous
access sites to avoid damaging veins
Total Parenteral Vein
o Most patients meet their nutrient needs using the larger, central veins,
where blood volume is greater and nutrient concentrations do not need to
be limited
o B/c the central veins carry a large volume of blood, the parenteral
solutions are rapidly diluted
o Used for long-term support
o For patients w/ high nutrient needs or fluid restrictions

Explain the proper way to administer TPN solutions.

Only qualified physicians can place catheters directly into central veins. Patients
may be awake for the procedure and given local anesthesia
Make sure to explain procedure to patient beforehand
To reduce the risk of complications, nurses should use aseptic techniques when
inserting catheters, changing tubes, or changing a dressing that covers the catheter
site

Describe the appropriate way to transition from parenteral feedings to enteral feedings.
(NUMBER)
The patient must have adequate GI function before they can be tapered off and
enteral feedings begin
Clear liquids are generally the first foods offered and are given in small amounts
to determine tolerance
Later feedings include beverages and solid foods that are unlikely to cause
discomfort
Once about 65-75 percent of nutrient needs can be provided enterally, the
intravenous infusions may be discontinued

Describe the metabolic complications associated with parenteral nutrition.

Hyperglycemia
o Most often occurs in patients who are glucose intolerant, receiving excess
energy or dextrose, or undergoing severe metabolic stress
o Provide insulin w/ feedings or decrease dextrose
o Dextrose infusions are generally limited to less than 5 mg per kilo of body
weight per minute so that the carbohydrate intake does not exceed the
maximum glucose oxidation rate
Hypoglycemia
o Occurs when parenteral nutrition is interrupted or discontinued of if
excessive insulin is given
o In patients at risk such as young infants, infusions may be tapered off over
several hours before discontinuation or infuse dextrose at the same time
that the parenteral solution is discontinued
Hypertriglyceridemia
o May develop in critically ill patients who cannot tolerate the amount of
lipid emulsion supplied
o Patients at risk include those w/ sever infection, liver disease, kidney
failure, or hyperglycemia and those using immunosuppressant or
corticosteroid meds
o If blood triglyceride levels exceed 500 mg per deciliter, lipid infusions
should be reduced or stopped
Refeeding Syndrome
o Severely malnourished patients who are fed aggressively may develop this
o It is characterized by electrolyte and fluid imbalance & hyperglycemia
o These effects occur b/c dextrose infusions raise circulating insulin levels,
which promote anabolic processes that quickly remove phosphate,
potassium, and magnesium from the blood
o Generally develops within two weeks of beginning parenteral infusions
o To prevent this start parenteral infusions slowly and carefully monitor
electrolyte and glucose levels

 May lead to liver failure

Gallbladder disease
o Sludge builds up, leading to gallstones
o Give meds to stimulate gallbladder or remove gallbladder
Metabolic bone disease
o Lowers bone density
o Alterations in calcium, phosphorus, magnesium & sodium metabolism

Identify the benefits of home nutrition support.

Current medical technology allows for the safe administration of nutrition support
in home settings, and insurance coverage often pays a substantial portion of the
costs
Medical equipment providers and home infusion companies can provide the
supplies, enteral formulas or parenteral solutions, and necessary services for home
nutrition care
Patients using these services can continue to receive specialized care while
leading normal lives

Chapter 16: Nutrition in Metabolic and Respiratory Stress

Describe the body's immune system and hormonal responses to stress and related clinical
signs and symptoms.
The stress response is mediated by several hormones, which are released into the
blood soon after injury
The catecholamines (epinephrine & norepinephrine) often called fight or flight
hormones, stimulate heart muscle, raise blood pressure and increase metabolic
rate
Epinephrine also promotes glucagon secretion from the pancreas, prompting the
release of nutrients from storage
Glucagon increases the breakdown of glycogen, triglycerides and amino acids
Cortisol increases breakdown of glycogen, triglycerides, and amino acids. Over
time, depletes protein throughout body (muscle wasting); causes insulin
resistance; reduces immunity
Aldosterone & antidiuretic hormone maintain blood volume by increasing
reabsorption of sodium and water via the kidneys

Explain how hypermetabolic illnesses affect nutrition status and lead to malnutrition.
A disruption in the bodys chemical environment due to the effects of disease or
injury

 Metabolic stress is characterized by changes in metabolic rate, heart rate, blood

pressure, hormonal status, and nutrient metabolism
Can result from uncontrolled infections or extensive tissue damage, such as deep,
penetrating wounds or multiple broken bones

Describe how hypermetabolism and protein depletion associated with stress can lead to
multiple organ failure.
Hypermetabolism: a higher than normal metabolic rate
Hypermetabolism and negative nitrogen balance can lead to wasting, which may
impair organ function and delay recovery

Explain how severe stress worsens nutritional status.

Severe stress worsens nutritional status and can cause diseases:
Chronic Obstructive Pulmonary Disease
o Chronic bronchitis: chronic inflammation & mucus secretion in main
airways
o Emphysema: progressive damage to bronchioles & alveoli
Symptoms: difficulty breathing, dyspnea, coughing, fatigue, muscle wasting,
decreased physical activity, weight loss; may lead to heart/respiratory failure
Causes: smoking and genetics
Treatment: smoking cessation, meds such as bronchodilators, corticosteroids,
oxygen therapy, physical activity to increase endurance and LBM, high-calorie, highprotein diet (unless overweight); small frequent meals; adequate liquids btw meals; liquid
supplements
Goals: prevent progression of disease; manage symptoms, maintain healthy
weight and lean body mass, prevent or correct malnutrition
Respiratory failure
o Impaired gas exchange leads to:
o hypoxemia (low blood O2) and hypoxia (low tissue O2) cell death,
o hypercapnia (high blood CO2) acidosis,
o cyanosis, headache, confusion, arrhythmias, coma
o Treatment varies according to cause:
o Oxygen support,
o Mechanical ventilation if needed,
o Diuretics for fluid in lungs; anti-inflammatory drugs,
o Adequate energy & protein- but not excessive!,
o Enteral or parenteral nutrition

Identify immediate concerns about stress and possible measures that might be taken by
the health care team.
In patients hospitalized w/ acute stress, initial treatments include restoring fluid
and electrolyte balances and treating infections and wounds

 Metabolic stress can result in hypermetabolism, negative nitrogen balance,

hyperglycemia, and wasting. The objectives of nursing care are to preserve
muscle tissue, maintain immune defenses, and promote healing
To determine energy needs for acute stress, RMR values may be modified using
disease-specific stress factors
Micronutrient needs may be increased during acute stress
Enteral and parenteral nutrition support or oral supplements may be used to help
meet the high nutrient needs of acutely stressed patients

Identify the goals of nutrition support following stress.

Initial goal: correct fluid and electrolyte imbalance with IV solution
Additional goals
o Address hypermetabolism, negative nitrogen balance, & hyperglycemia
o Preserve lean tissues and promote immunity & healing
o Deliver adequate calories & protein
Balance overfeeding and underfeeding
Permissive underfeeding? recommended for critically ill obese
patients. So you will underfeed them by reducing calories. Be fed
only 70% of their energy needs
The method of delivering calories and nutrients depends on the GI function and
nutrient needs:
o High-calorie, high-protein diet w/ an oral supplement
o Enteral nutrition: for these feedings started in the first 24-48 hours after
hospitalization are associated w/ fewer complications and shorter hospital
stays compared w/ delayed feedings
o If enteral nutrition is not possible, malnourished patients may receive
parenteral nutrition support soon after admission to the hospital. In previous
healthy patients, potential parenteral nutrition support may be withheld during
the first seven days of hospitalization to avoid the risk of infectious
complications

Using quick methods, estimate the energy, protein, and fluid needs of patients.
(NUMBERS)
Energy
o 30 kcal/kg/day for weight maintenance (typically a range of 25 to 35
kilocalories/kilogram as seen in the book)
For weight loss: 20-25 kcal/kg/day
For weight gain: 35-40 kcal/kg/day
For critically ill patients: 20-30 kcal/kg/day
Protein
o Healthy adult: 0.8 g/kg/day
o Elderly person: 0.8 to 1.0 g/kg/day
o Critically ill person: 1.2 to 2.0 g/kg/day

o Severe burns 2.0 to 3.0 g/kg/day

Fluids
o 30 ml/kg body weight or 1 ml/kcal of RMR

Describe how refeeding syndrome develops.

Occurs when aggressively feeding a malnourished person
Results in electrolyte and fluid imbalances and hyperglycemia
Increased electrolyte requirements due to preexisting deficiencies and rapid
intracellular uptake

Describe how a practitioner would decide on the nutrient and best route of delivery of
nutrients following stress.
A practitioner would decide by looking at the patient. Its subjective and all
depends on the patients condition
Chapter 17: Nutrition and Upper GI Disorders
List conditions that may interfere with chewing and swallowing.
o Dry mouth (Xerostomia): caused by reduced salivary flow
Side effect of many medications
Associated with many diseases and disease treatments
Ex: antidepressants, antihistamines, antihypertensives,
antieoplastics, bronchodilators, and other medications
Sjgrens syndrome: condition that directly affects salivary gland function
Radiation therapy may permanently damage salivary function
o Dysphagia
Oropharyngeal: involves mouth and pharynx; muscles in mouth and
tongue propel bolus through the pharynx into esophagus
Neuromuscular disorder upsets swallowing reflex or impairs the
mobility of the muscles involved with swallowing
Inhibits transfer of food from the mouth and pharynx to the
esophagus
Common in elderly people
Frequently follows strokes
Esophageal: swallowing, peristalsis forces the bolus through the
esophagus, and lower esophageal sphincter relaxes to allow passage of the
bolus into the stomach
Interferes with passage of materials through esophageal lumen and
into the stomach, and usually caused by an obstruction in the
esophagus or a motility disorder
Obstruction can be caused by stricture (abnormal narrowing),
tumor, or compression of esophagus surrounding tissues
Prevents passage of solid foods
Motility disorder hinders passage of solids and liquids
Achalasia: most common motility disorder; degenerative nerve
condition affecting the esophagus; characterized by impaired

peristalsis and incomplete relaxation of the lower esophageal

sphincter when swallowing
May cause malnutrition, weight loss, and risk of dehydration
If aspiration occurs, it may cause choking, airway obstruction, or
respiratory infections, including pneumonia
***Table 17-2
o Gastroesophageal disease
Describe the nutrition therapy required for patients with chewing difficulties.
o Foods should be easy-to-manage textures and consistencies
o Physically modified foods/beverages
Explain how to improve acceptance of pureed foods.
o Help to stimulate appetite by preparing favorite foods and foods with pleasant
smells. Enliven food flavors with aromatic spices and seasonings
o Substitute brightly colored vegetables for white vegetables; for example, replace
mashed potatoes with mashed sweet potatoes. If serving more than one vegetable,
place contrasting colors side by side or swirl the two together
o Shape pureed and ground foods so they resemble traditional dishes; for example,
meats can be flattened to form a patty or rounded to resemble meatballs. Use food
molds to restore slurried breads and pureed meats to their traditional shapes
o Try layering ingredients so that the food looks like a fancy casserole or popular
hors doeuvre. For example, food items can resemble lasagna, moussaka, tamales,
or sushi
o Use attractive plates and silverware to improve the visual appeal of a meal.
Colorful garnishes can add interest and eye appeal
Discuss the dangers, signs, and diet therapy for dysphagia.
o Dangers
Dehydration
Malnutrition and weight loss
Aspiration
Airway obstruction
Choking
Respiratory infections
o Signs
Oropharyngeal Dysphagia
Inability to initiate swallowing, coughing during or after
swallowing (due to aspiration), and nasal regurgitation
Gurgling noise after swallowing, hoarse or wet voice, or speech
disorder
Esophageal Dysphagia
Main symptom: sensation of food sticking to esophagus after it
is swallowed
o Diet Therapy (Table 17-3)
Level 1: Pureed

Foods should be pureed or well mashed, homogeneous and

cohesive
For patients with moderate to severe dysphagia and poor oral or
chewing ability
Ex: cream of wheat, slurried muffins/pancakes, plain or vanilla
yogurt, well-mashed bananas, pureed meat or poultry, chocolate
pudding, pureed carrots or green beans
Avoid dry breads and cereals, oatmeal, fruit yogurt, cheese, peanut
butter, nuts and seeds, beverages with pulp
Level 2: Mechanically Altered
Foods should be moist, cohesive, and soft textured and should
easily form a bolus
For patients with moderate to severe dysphagia
Some chewing ability is required
Ex: moist oatmeal, cornflakes, moist pancakes/muffins, wellcooked pasta with moist meatballs and meat sauce, baked potato
with gravy
Avoid dry or coarse foods; breads and cereals with nuts/seeds/dried
fruits, hard-cooked eggs, pizza, sliced cheese cabbage, celery,
brussel sprouts
Level 3: Dysphagia Advanced
Foods should be moist and in bite-sized pieces when swallowed;
foods with mixed textures included
For patients with mild dysphagia and adequate chewing ability
Ex: cereal with milk, moist eggs/pancakes, chicken noodle soup,
moistened crackers/bread, fruit yogurt, coffee or tea, fresh fruit
(pealed) or berries
Avoid fruit with skin/seeds/stringy textures, popcorn, chewy
candies, breads and cereals with nuts/seeds/dried fruit, corn and
clam chowders
Liquid Consistencies
Thin: watery fluids; may include milk, coffee, tea, juices,
carbonated beverages
Nectarlike: fluids thicker than water that can be sipped through a
straw; may include buttermilk, eggnog, tomato juice, cream soups
Honeylike: fluids that can be eaten with a spoon but do not hold
their shape; may include honey, some yogurt products, tomato
sauce
Spoon-thick: thick fluids that must be eaten with a spoon and can
hold their shape; may include milk pudding, thickened apple sauce
Identify the potential causes, symptoms, & consequences of GERD as well as the
medical treatments & lifestyle changes for managing it.
o Causes (Figure 17-1 & Table 17-4)
Weak lower esophageal sphincter

o
o

High stomach pressures

Inadequate acid clearance from esophagus
Obesity
Pregnancy
Hiatal hernia: portion of the stomach protrudes above the diaphragm
Medications
Nasogastric tubes in tube feedings
Large meals
Symptoms
Heartburn or acid indigestion
Consequences
Reflux esophagitis: occurs when gastric acid remains in the esophagus
long enough to damage the esophageal lining
Severe and chronic inflammation may lead to esophageal ulcers with
bleeding
Esophageal stricture may be caused due to healing and scaring of
ulcerated tissue that may narrow the inner diameter of the esophagus
Slowly progressive dysphagia for solid foods; swallowing occasionally
becomes painful
Pulmonary disease may occur if gastric contents aspirate into the lungs
Chronic reflux associated with Barretts esophagus (condition in which
damaged cells are gradually replaced by cells that resemble those in
gastric or intestinal tissue
Such changes increase the risk of developing esophageal cancer
May damage tissues in the mouth, pharynx, and larynx, resulting in
eroded tooth enamel, sore throat, cough, laryngitis
Medical Treatments
Proton-pump inhibitors (PPI) used for rapid healing and as a maintenance
treatment
Histamine-2 receptor blockers (H2 blockers)
Antacids: used to relieve occasional heartburn for short-term
Not necessarily appropriate because they may cause nutrient
deficiencies when used long-term
Surgery in severe cases that are unresponsive to medication and lifestyle
changes (fundoplication)
Lifestyle Changes
Consume only small meals and drink liquids between meals so that the
stomach does not become overly distended, which can exert pressure on
the lower esophageal sphincter
Limit foods that weaken lower esophageal sphincter pressure or increase
gastric acid secretion; these include chocolate, fried and fatty foods,
spearmint and peppermint, coffee (caffeinated and decaffeinated), and tea
During periods of esophagitis, avoid foods and beverages that may irritate
the esophagus, such as citrus fruits and juices, tomato products, garlic,

onions, pepper, spicy foods, carbonated beverages, and very hot or very
cold foods (depending on indiv. tolerances)
Avoid eating bedtime snacks or lying down after meals; meals should be
consumed at least 3 hours before bedtime
Reduce nighttime reflux by elevating the HOB on 6-inch blocks, inserting
a foam wedge under the mattress, or propping pillows under the head and
upper torso
Avoid bending over and wearing tight-fitting garments; both can cause
pressure in the stomach to increase, heightening the risk of reflux
Avoid cigarettes and alcohol; both relax the lower esophageal sphincter
Avoid using NSAIDS such as aspirin, naproxen, and ibuprofen, which can
damage the esophageal mucosa
Explain the appropriate nutrition therapy for individuals with: vomiting, reflux
esophagitis, hiatal hernia, gastritis, and ulcers.
o Vomiting
Eat and drink slowly
Small meals
Clear cold beverages
Dry starchy foods (crackers, pretzels)
Foods cold or at room temperature
o Reflux esophagitis (inflammation in the esophagus related to the reflux of acidic
stomach contents)
Refer to lifestyle changes of GERD
o Hiatal hernia
Refer to lifestyle changes of GERD
o Gastritis
In asymptomatic cases, no dietary adjustments needed
If pain/discomfort is present, patient should avoid irritating foods and
beverages (alcohol, coffee, cola beverages, spicy foods, and fried/fatty
foods)
If consumption increases pain or causes nausea and vomiting, food intake
should be avoided 24 48 hours
o Ulcers
Correct nutrient deficiencies
Avoid consumption at least 2 hours before bedtime
Avoid dietary items that increase acid secretion or irritate the GI lining
(alcohol, coffee, caffeine-containing beverages, chocolate, and pepper)
Avoid large meals
Dont smoke
List ways to prevent indigestion.
o Eat small meals
o Avoid spicy or fatty foods
o Avoid foods that may trigger symptoms

Discuss common nutritional problems and related therapies associated with gastric
surgery.
o Common nutritional problems
Dumping Syndrome
Rapid gastric emptying
Related therapy
Limit meal size
Limit amount of food reaching the intestine
Eat slowly
Reduce foods that increase hypertonicity
Eat fiber-rich foods
Limit amount of fluid included in meals
Avoid foods and beverages that are high in sugar
Fat malabsorption
Deficiencies of fat-soluble vitamins & some minerals
Related therapy
Supplemental pancreatic enzymes sometimes provided to
improve fat digestion
Bone disease
Malabsorption of calcium and vitamin D
Osteoporosis and osteomalacia
Related therapy
Calcium and vitamin D supplements
Anemia
Impaired iron & vitamin B12 absorption due to decreased
hydrochloric acid
Related therapy
Iron and vitamin B12 supplements
Describe the post-gastrectomy diet. (Table 17-6)
o Progress to 6-8 small meals & snacks/day
o Avoid sweets and sugars
o Soluble fiber to delay stomach emptying
o Avoid irritating foods
o May need to avoid milk products (lactose intolerance)
o Liquids between meals
Describe the major types of bariatric surgeries, potential candidates for surgery,
and post-surgery nutrition therapy to prevent or manage complications.
o Major types of bariatric surgeries (Figure 17-3)
Partial gastrectomy (Vertical Sleeve Gastrectomy)
Gastric bypass
Small gastric pouch constructed that reduces stomach capacity and
restricts meal size

Pouch connected directly to jejunum (causes significant nutrient

malabsorption)
Usually permanent surgery
Clinical studies suggest that it is more effective than gastric
banding
Gastric banding (LAP band)
Gastric pouch created using fluid-filled inflatable band; adjusting
bands fluid level can tighten or loosen the band and alter size of
opening to the rest of the stomach
Smaller opening slows the pouch-emptying rate and prolongs sense
of fullness after a meal
Fully reversible procedure
o Potential candidates for surgery
Severe obese (BMI 35-40 with severe weight-related problems or BMI
>40)
Obese accompanied with weight-related problems (diabetes mellitus,
hypertension, or debilitating osteoarthritis)
Patient should have attempted nonsurgical weight-loss measures (ex:
dietary adjustments, exercise, medications, and behavior modification)
prior to seeking surgery
o Post-surgery nutrition therapy to prevent/manage complications
First two days: only sugar-free, noncarbonated clear liquids and low-fat
broths provided
4 6 weeks: initial liquid diet high in protein, low sugars and fat; followed
by pureed foods and then solid food; 3 6 small meals/day
Protein intake recommended 1 1.5 grams/kg body weight
Advance 3 6 small meals/day
Recommend vitamin-mineral supplement
Vitamin B12, vitamin D, iron and calcium
Avoid foods that may obstruct the gastric outlet [doughy/sticky breads and
pasta products, melted cheese, fibrous vegetables (asparagus, celery),
foods with seeds, peels or skins, nuts, popcorn, and tough chewy meats]
Control food portions; avoid foods high in sugars; and consume liquids
between meals to avoid dumping syndrome

Chapter 18: Nutrition and Lower GI Disorders

Discuss the causes and treatments of constipation and diarrhea.
o Constipation
Causes
Low-fiber diet
Low food intake
Inadequate fluid intake
Low level of physical activity

Medical conditions: diabetes mellitus, hypothyroidism

Neurological conditions: Parkinsons disease, spinal cord injuries,
multiple sclerosis
Pregnancy
Medications and dietary supplements (opiate-containing
analgesics, tricyclic antidepressants, anticonvulsants, calcium
channel blockers, aluminum-containing antacids, iron and calcium
supplements)
Treatments
Gradual increase in fiber intake to at least 25 grams/day
High-fiber diet (wheat bran, fruits, and vegetables)
Fiber supplements
Laxatives (increase stool weight, increase water content of stool, or
stimulate peristaltic contractions)
Consuming adequate fluids (1.5 2 liters/day)
Enemas and suppositories (distend and stimulate the rectum or
lubricate stool)
Medications (prokinetic agents for severe constipation that
stimulate colonic contractions)
o Diarrhea
Causes
May be induced by infections, medications, or dietary substances
Inadequate fluid reabsorption in the intestines
Osmotic diarrhea: unabsorbed nutrients or other substances attract
water to the colon and increase fecal water content; the usual
causes include high intakes of poorly absorbed sugars (such as
sorbitol, mannitol, or fructose), lactase deficiency (which causes
lactose malabsorption), and ingestion of laxatives that contain
magnesium or phosphates
Secretory diarrhea: fluid secreted by the intestines exceeds the
amount that can be reabsorbed by intestinal cells
Foodborne illnesses
Intestinal inflammation
Irritating chemical substances
Motility disorders
Treatments
Correcting underlying problem
Antibiotics for intestinal infections
Different drug prescribed if medication is the problem
Certain foods omitted from diet that may be responsible
Bulk-forming agents; psyllium (Metamucil) and methylcellulose
(Citrucel) can help reduce liquidity of stool
Antidiarretics may be prescribed in chronic diarrhea
Probiotics (infectious diarrhea)

BRAT diet (bananas, rice, applesauce, and toast)

Low fiber, fat, sugar alcohols and fructose foods
Lactose and caffeine free foods
Identify foods likely to produce gas.
o High-fiber diets
o Carbohydrates
Fructose
Sugar alcohols
Beans
Some grains and potatoes
Identify the causes and effects of bacterial overgrowth.
o Causes
Impaired intestinal motility
Reduced gastric secretions
Atrophic gastritis, use of acid-suppressing medications, and some
gastrectomy procedures
o Effects
Disrupts fat digestion and absorption (may lead to fat malabsorption)
May develop fat-soluble vitamin (A, D, E) & vitamin B12 deficiencies
Describe symptoms of lactose intolerance and the appropriate nutrition therapy.
o Symptoms
Diarrhea and gas
o Nutrition Therapy
Lactose-free diet
May not need to avoid lactose completely; may be able to tolerate
some dairy products
Enzymes prior to consuming dairy products
Identify the cause of malabsorption in pancreatitis and the appropriate nutrition
therapies for acute and chronic pancreatitis.
o Acute pancreatitis
Causes
Gallstones, alcohol abuse, high triglycerides, toxins
Nutrition therapies
Pain control and IV hydration
Withhold food and fluids until patient is pain free and no longer
experiences vomiting or nausea
Nutrient supplements needed until food intake can meet nutritional
needs
o Chronic pancreatitis
Causes
70% alcohol induced
Cigarette smoking
Repeated episodes of acute pancreatitis

Nutrition therapies
Remove pancreas
NPO
Small frequent meals
Low fat diet
Avoid alcohol and cigarettes
Discuss the impact of cystic fibrosis on nutrition status, and how it is treated.
o Effect on nutrition status
Lung disease
Hypermetabolism may cause impaired nutrition status due to
greater energy cost of labored breathing and anorexia
Pancreatic disease
Malabsorption of protein, fat and fat-soluble vitamins
Thickened pancreatic secretions obstruct pancreatic ducts
May lead to diabetes or glucose intolerance
Salt losses in sweat (increases risk of dehydration)
o Treatment
Energy needs = 120 150% of DRI
High-calorie, high-fat foods
Frequent meals and snacks
Pancreatic enzyme replacement
Liberal use of table salt
Describe characteristics of a gluten-restricted diet for the treatment of celiac disease.
(Table 18-6)
o Gluten-free diet for life
No wheat, rye, barley (oats)
Avoid lactose-containing foods in lactose deficiency is suspected
Check food labels
Differentiate between the characteristics of Crohn's disease and ulcerative colitis,
and their appropriate nutrition therapy.
o Crohns disease (Table 18-8)
Characteristics
May occur anywhere in intestine
Most cases involve ileum and/or large intestine
May lead to nutrient malabsorption
Tissue damage, bleeding, diarrhea
Lesions may develop along intestine, with normal tissue separating
affected regions
Ulcerations, fissures, and fistulas
Loop of intestines may become matted together
Malnutrition due to poor food intake, malabsorption, nutrient
losses, surgical resections that shorten small intestine

If the ileum is affected, bile acids may become depleted, causing

malabsorption of fat, fat-soluble vitamins, calcium, magnesium,
and zinc (the minerals bind to the unabsorbed fatty acids)
Possible vitamin B12 deficiency
Anemia due to bleeding, inadequate absorption of nutrients (iron,
folate, and vitamin B12) involved in cell formation, or metabolic
effects of chronic illness
Anorexia due to abdominal discomfort
Nutrition therapy
Aggressive dietary management
Specific measures depend on functional status of GI tract
High calorie, high protein diets to prevent malnutrition or promote
healing
Oral supplements to promote weight gain and increase energy
intake
Vitamin and mineral supplements (calcium, iron, magnesium, zinc,
folate, vitamin B12, vitamin D)
Tube feedings
o Ulcerative colitis
Characteristics
Involves large intestine
Tissue damage, rectal bleeding, diarrhea, constipation, abdominal
pain
Erosion or ulceration affects mucosa and submucosa
In early stages, the mucosa appears reddened and swollen;
advanced stages may feature mucosal atrophy, thin colon walls,
and, in some cases, colon dilation
Frequent, urgent bowel movements that are small in volume and
contain blood and mucus
Weight loss, fever, and weakness
Anemia, dehydration, and electrolyte imbalances in severe cases
Nutrition therapy
Restore fluid and electrolyte balances
Adequate protein, energy fluid, and electrolytes need to be
provided)
Describe the nutrition therapy for irritable bowel syndrome.
o Gradually increase fiber intake from food or supplements to relieve constipation
and improve stool bulk
o Psyllium supplementation (patients with constipation)
o Specific to each patient
o Peppermint oil (under investigation)
Differentiate between diverticulosis and diverticulitis and the appropriate nutrition
therapy for each.
o Diverticulosis

Presence of pebble-sized herniations (outpockets) in intestinal mucosa

Prevalence increases with age
High-fiber diet can be preventative
May need to avoid nuts, popcorn, & seeds
Nutrition therapy
Treatment necessary only if symptoms exist
Increase fiber intake to relieve constipation
Avoid nuts, seeds, and popcorn
o Diverticulitis
Inflammation or infection
Most common complication of diverticulosis
Persistent abdominal pain, fever, alternating constipation and diarrhea
Nutrition therapy
Antibiotics, pain medication
Clear liquid diet or bowel rest
Surgery
Describe important components of nutrition support for ostomies.
o Depends on length of colon removed and portion of ileum that remains
o Dietary adjustments are individualized according to surgical procedure and
symptoms
o Colostomy & ileostomy
o Temporary or permanent
o Chew food thoroughly to prevent obstructions
o Foods that cause unpleasant odors
Fish, eggs, dried beans & peas, onions, garlic beer, other
o Foods that reduce odors
Buttermilk, cranberry juice, parsley yogurt