Tonyas gluten free kitchen soft pretzel pieces original 10.8 oz

Susan G. Dudek, RD, CDN, BS Nutrition Instructor, Dietetic Technology Program Erie Community College Williamsville, New York

Consultant Dietitian for Employee Assistance Program of Child and Family Services Williamsville, New York

S E V E N T H E D I T I O N

Nutrition Essentials for Nursing Practice

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Dudek, Susan G. Nutrition essentials for nursing practice / Susan G. Dudek. — 7th ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4511-8612-3 (alk. paper) I. Title. [DNLM: 1. Diet Therapy—Handbooks. 2. Diet Therapy—Nurses’ Instruction. 3. Nutritional Physiological Phenomena — Handbooks. 4. Nutritional Physiological Phenomena—Nurses’ Instruction. WB 39] RM216 615.8'54—dc23

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Care has been taken to confi rm the accuracy of the information presented and to describe generally accepted practices. How- ever, the author, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations.

The author, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant fl ow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.

Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice.

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iv

Reviewers

Zita Allen, RN, MSN Professor of Nursing Alverno College Milwaukee, Wisconsin

Carmen Bruni, MSN, RN, CAN Assistant Professor Texas A&M International University Laredo, Texas

Ann Cleary, DNS, RN, NP-C Associate Professor of Nursing Long Island University, Brooklyn Campus Brooklyn, New York

Tammie Cohen, RN, BS Nursing Instructor, Faculty Advisory Committee

Chairperson Western Suffolk BOCES Northport, New York

Janet Goeldner, MSN Professor University of Cincinnati—Raymond Walters College Cincinnati, Ohio

Coleen Kumar, RN, MSN Associate Professor Nursing Department Deputy Chairperson Kingsborough Community College Brooklyn, New York

Karen Lincoln, RNC, MSN Nursing Faculty Montcalm Community College Sidney, Michigan

Carol Isaac MacKusick, PhDc, MSN, RN, CNN Adjunct Faculty Clayton State University Morrow, Georgia

Marina Martinez-Kratz, RN, BSN, MS Professor of Nursing Jackson Community College Jackson, Michigan

Janet Tompkins McMahon, RN, MSN Clinical Associate Professor of Nursing Towson University Towson, Maryland

Patricia J. Neafsey, RD, PhD Professor University of Connecticut School of Nursing Storrs, Connecticut

Cheryl L. Neudauer, PhD, MEd Biology Faculty Center for Teaching and Learning Campus Leader Minneapolis Community and Technical College Minneapolis, Minnesota

Christine M. Prince, RN, BSN, CCM Nursing Faculty Brown Mackie College Indianapolis Indianapolis, Indiana

Rhonda Savain, RN, MSN Nursing Instructor Ready to Pass Inc. West Hempstead, New York

Nancy West, RN, MN Professor of Nursing Johnson County Community College Overland Park, Kansas

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v

L ike air and sleep, nutrition is a basic human need essential for survival. Nutrition provides energy and vitality, helps reduce the risk of chronic disease, and can aid in recovery. It is a dynamic blend of science and art, evolving over time and in response to technological advances and cultural shifts. Nutrition at its most basic level is food—for the mind, body, and soul.

Although considered the realm of the dietitian, nutrition is a vital and integral compo- nent of nursing care. Today’s nurses need to know, understand, apply, analyze, synthesize, and evaluate nutrition throughout the life cycle and along the wellness/illness continuum. They incorporate nutrition into all aspects of nursing care plans, from assessment and nursing diagnoses to implementation and evaluation. By virtue of their close contact with patients and families, nurses are often on the front line in facilitating nutrition. This text seeks to give student nurses a practical and valuable nutrition foundation to better serve themselves and their clients.

NEW TO THIS EDITION

This seventh edition continues the approach of providing the essential information nurses need to know for practice. Building upon this framework, content has been thoroughly updated to refl ect the latest evidence-based practice. Examples of content updates that are new to this edition are as follows:

■ MyPlate, which replaces MyPyramid as the graphic to illustrate the Dietary Guidelines for Americans

■ Recommended Dietary Allowances (RDAs) for calcium and vitamin D ■ Inclusion of a validated stand-alone nutrition screening tool for older adults that is ap-

propriate for community settings and in clinical practice ■ Expanded coverage of bariatric surgery and obesity in general, particularly with regard

to the importance of behavioral strategies for navigating our increasingly obesogenic environment

■ The low-FODMAP (fermental oligo-, di-, and monosaccharides and polyols) diet for irritable bowel syndrome and possibly other gastrointestinal disorders

■ A shift in focus from single nutrients (e.g., saturated fat) to a food pattern approach (e.g., the DASH diet) for communicating and implementing a heart healthy diet

■ Updated 2011 nutrition therapy guidelines for patients with chronic kidney disease who are not on dialysis

ORGANIZATION OF THE TEXT

Unit One is devoted to Principles of Nutrition. It begins with Chapter 1, Nutrition in Nursing, which focuses on why and how nutrition is important to nurses in all settings. Chapters devoted to carbohydrates, protein, lipids, vitamins, water and minerals, and energy balance provide a foundation for wellness. The second part of each chapter highlights health promotion topics and demonstrates practical application of essential information, such as how to increase fi ber intake, criteria to consider when buying a vitamin supplement, and the risks and benefi ts of a vegetarian diet.

Preface

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vi P R E F A C E

Unit Two, Nutrition in Health Promotion, begins with Chapter 8, Guidelines for Healthy Eating. This chapter features the Dietary Reference Intakes, the Dietary Guide- lines for Americans, and MyPlate. Other chapters in this unit examine consumer issues and cultural and religious infl uences on food and nutrition. The nutritional needs associated with the life cycle are presented in chapters devoted to pregnant and lactating women, chil- dren and adolescents, and older adults.

Unit Three, Nutrition in Clinical Practice, includes nutrition therapy for obesity and eating disorders, enteral and parenteral nutrition, metabolic and respiratory stress, gastro- intestinal disorders, diabetes, cardiovascular disorders, renal disorders, cancer, and HIV/ AIDS. Pathophysiology is tightly focused as it pertains to nutrition.

RECURRING FEATURES

This edition retains popular features of the previous edition to facilitate learning and engage students.

■ Check Your Knowledge presents true/false questions at the beginning of each chapter to assess the students’ baseline knowledge. Questions relate to chapter Learning Objectives.

■ Key Terms are defined in the margin for convenient reference. ■ Quick Bites—fewer and more condensed to improve layout and readability in the new

edition—provide quick nutrition facts, valuable information, and current research. ■ Nursing Process tables clearly present sample application of nutrition concepts in con-

text of the nursing process. ■ How Do You Respond? helps students identify potential questions they may encounter

in the clinical setting and prepares them to think on their feet. ■ A Case Study and Study Questions at the end of each chapter challenge students to

apply what they have learned. ■ Key Concepts summarize important information from each chapter.

TEACHING AND LEARNING RESOURCES

Instructors and students will fi nd valuable resources to accompany the book on at http://thePoint.lww.com/Dudek7e.

Resources for Instructors Comprehensive teaching resources are available to instructors upon adoption of this text and include the following materials.

■ A free E-book on thePoint provides access to the book’s full text and images online. ■ A Test Generator lets instructors put together exclusive new tests from a bank contain-

ing NCLEX-style questions. ■ PowerPoint Presentations provide an easy way to integrate the textbook with the class-

room. Multiple-choice and true/false questions are included to promote class participation. ■ An Image Bank provides the photographs and illustrations from this text for use in

course materials. ■ Access to all student resources is also provided.

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P R E F A C E vii

Resources for Students Students can activate the code in the front of this book at http://thePoint.lww.com/ activate to access the following free resources.

■ A free E-book on thePoint provides access to the book’s full text and images online. ■ NEW! Practice & Learn Interactive Case Studies provide realistic case examples and

offer students the opportunity to apply nutrition essentials to nursing care. ■ Journal Articles provided for each chapter offer access to current research available in

Lippincott Williams & Wilkins journals.

I hope this text and teaching/learning resource package provide the impetus to embrace nutrition on both a personal and professional level.

Susan G. Dudek, RD, CDN, BS

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viii

I am humbled and grateful to be still writing this book after six editions. It is a project that has been professionally rewarding, personally challenging, and rich with opportunities to grow. In large part, the success of this book rests with the dedicated and creative profes- sionals at Lippincott Williams & Wilkins. Because of their support and talents, I am able to do what I love—write, create, teach, and learn. I especially thank

■ David Troy, Senior Acquisitions Editor, who provided the spark to ignite the project. ■ Maria McAvey, Editorial Product Manager, for her meticulous attention to detail and

gentle guidance. ■ Marian Bellus, Production Project Manager; Holly Reid McLaughlin, Design Coordinator;

John Johnson, Education Marketing Manager, Nursing; and Latisha Ogelsby, Editorial Assistant, the behind-the-scene professionals whose efforts help transform an ugly duck- ling into a beautiful swan.

■ The reviewers of the sixth edition, whose insightful comments and suggestions helped shape a new and improved edition.

■ My friends and family—my sideline cheerleaders—who so patiently gave me the time and space to work on “my story.”

■ I am especially thankful to my husband Joe . . . always there through thick and thin.

Acknowledgments

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ix

U N I T O N E Principles of Nutrition 1

CHAPTER 1 Nutrition in Nursing 2 CHAPTER 2 Carbohydrates 18 CHAPTER 3 Protein 46 CHAPTER 4 Lipids 66 CHAPTER 5 Vitamins 92 CHAPTER 6 Water and Minerals 124 CHAPTER 7 Energy Balance 156

U N I T T W O Nutrition in Health Promotion 177

CHAPTER 8 Guidelines for Healthy Eating 178 CHAPTER 9 Consumer Issues 200 CHAPTER 10 Cultural and Religious Infl uences on Food and Nutrition 230 CHAPTER 11 Healthy Eating for Healthy Babies 257 CHAPTER 12 Nutrition for Infants, Children, and Adolescents 286 CHAPTER 13 Nutrition for Older Adults 320

U N I T T H R E E Nutrition in Clinical Practice 353

CHAPTER 14 Obesity and Eating Disorders 354 CHAPTER 15 Feeding Patients: Oral Diets and Enteral and Parenteral Nutrition 393 CHAPTER 16 Nutrition for Patients with Metabolic or Respiratory Stress 423 CHAPTER 17 Nutrition for Patients with Upper Gastrointestinal Disorders 443 CHAPTER 18 Nutrition for Patients with Disorders of the Lower GI Tract and

Accessory Organs 461 CHAPTER 19 Nutrition for Patients with Diabetes Mellitus 497 CHAPTER 20 Nutrition for Patients with Cardiovascular Disorders 535 CHAPTER 21 Nutrition for Patients with Kidney Disorders 567 CHAPTER 22 Nutrition for Patients with Cancer or HIV/AIDS 593

A P P E N D I C E S

APPENDIX 1 Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Total Water and Macronutrients 624

APPENDIX 2 Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Vitamins 625

APPENDIX 3 Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Elements 628

APPENDIX 4 Answers to Study Questions 630

INDEX 633

Contents

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U N I T O N E

Principles of Nutrition

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2

C H E C K Y O U R K N O W L E D G E

Nutrition in Nursing1 TRUE FALSE

1 The nurse’s role in nutrition is to call the dietitian.

2 Nutrition screening is used to identify clients at risk for malnutrition.

3 The Joint Commission stipulates the criteria to be included on a nutritional screen for hospitalized patients.

4 Changes in weight refl ect acute changes in nutritional status.

5 A person can be malnourished without being underweight.

6 The only cause of a low serum albumin concentration is protein malnutrition.

7 “Signifi cant” weight loss is 5% of body weight in 1 month.

8 People who take fi ve or more prescription or over-the-counter medications or dietary supplements are at risk for nutritional problems.

9 Obtaining reliable and accurate information on what the client usually eats can help identify intake as a source of nutrition problems.

10 Physical signs and symptoms of malnutrition develop only after other signs of malnutri- tion are apparent (e.g., abnormal lab values, weight change).

U p o n c o m p l e t i o n o f t h i s c h a p t e r, y o u w i l l b e a b l e t o

1 Compare nutrition screening to nutrition assessment. 2 Evaluate weight loss for its signifi cance over a 1-month or 6-month interval. 3 Discuss the validity and reliability of using physical signs to support a nutritional diagnosis

of malnutrition. 4 Give examples of nursing diagnoses that may use nutrition therapy as an intervention. 5 Demonstrate how nurses can facilitate client and family teaching of nutrition therapy. 6 Explain why an alternative term to “diet” is useful.

L E A R N I N G O B J E C T I V E S

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C H A P T E R 1 Nutrition in Nursing 3

Based on Maslow’s hierarchy of needs, food and nutrition rank on the same level as air in the basic necessities of life. Obviously, death eventually occurs without food. But unlike air, food does so much more than simply sustain life. Food is loaded with personal, social, and cultural meanings that defi ne our food values, beliefs, and customs. That food nour- ishes the mind as well as the body broadens nutrition to an art as well as a science. Nutrition is not simply a matter of food or no food but rather a question of what kind, how much, how often, and why. Merging want with need and pleasure with health are keys to feeding the body, mind, and soul.

Although the dietitian is the nutrition and food expert, nurses play a vital role in nutri- tion care. Nurses may be responsible for screening hospitalized patients to identify patients at nutritional risk. They often serve as the liaison between the dietitian and physician as well as with other members of the health-care team. Nurses have far more contact with the patient and family and are often available as a nutrition resource when dietitians are not, such as during the evening, on weekends, and during discharge instructions. In home care and wellness settings, dietitians may be available only on a consultative basis. Nurses may reinforce nutrition counseling provided by the dietitian and may be responsible for basic nutrition education in hospitalized clients with low to mild nutritional risk. Nurses are inti- mately involved in all aspects of nutritional care.

This chapter discusses nutrition within the context of nursing, including nutrition screening and how nutrition can be integrated into the nursing care process.

NUTRITION SCREENING

Nutrition screening is a quick look at a few variables to identify individuals who are mal- nourished or who are at risk for malnutrition so that an in-depth nutrition assessment can follow. Screening tools should be simple, reliable, valid, applicable to most patients or clients in the group, and use data that is readily available (Academy of Nutrition and Dietetics, 2012). For instance, a community-based senior center may use a nutrition screen that focuses mostly on intake risks common to that population, such as whether the client eats alone most of the time and/or has physical limitations that impair the abil- ity to buy or cook food (Fig. 1.1). In contrast, common screening parameters in acute care settings include unintentional weight loss, appetite, body mass index (BMI), and disease severity. Advanced age, dementia, and other factors may be considered. There is no universally agreed upon tool that is valid and reliable at identifying risk of malnutrition in all populations at all times.

The Joint Commission, a nonprofi t organization that sets health-care standards and accredits health-care facilities that meet those standards, specifi es that nutrition screening be conducted within 24 hours after admission to a hospital or other health-care facility—even on weekends and holidays. The Joint Commission allows facilities to determine screening criteria and how risk is defi ned. For instance, a hospital may use serum creatinine level as a screening criterion, with a level greater than 2.5 mg/dL defi ned as “high risk” because the majority of their patients are elderly and the prevalence of chronic renal problems is high. The Joint Commission also leaves the decision of who performs the screening up to indi- vidual facilities. Because the standard applies 24 hours a day, 7 days a week, staff nurses are often responsible for completing the screen as part of the admission process. Clients who “pass” the initial screen are rescreened after a specifi ed amount of time to determine if their status has changed.

Nutritional Screen: a quick look at a few variables to judge a client’s relative risk for nutritional problems. Can be custom de- signed for a particular population (e.g., preg- nant women) or for a specific disorder (e.g., cardiac disease). Malnutrition: literally “bad nutrition” or any nutritional imbalance including overnutrition. In practice, malnutrition usually means undernu- trition or an inadequate intake of protein and/or calories that causes loss of fat stores and/or muscle wasting.

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4 U N I T 1 Principles of Nutrition

NUTRITION CARE PROCESS

Clients considered to be at moderate or high risk for malnutrition through screening are usually referred to a dietitian for a comprehensive nutritional assessment to identify spe- cifi c risks or confi rm the existence of malnutrition. Nutritional assessment is more accu- rately called the nutrition care process, which includes four steps (Fig. 1.2). While nurses use the same problem-solving model to develop nursing or multidisciplinary care plans that

I have an illness or condition that made me change the kind and/or amount of food I eat.

I eat fewer than two meals per day.

I eat few fruits or vegetables, or milk products.

I have three or more drinks of beer, liquor or wine almost every day.

I have tooth or mouth problems that make it hard for me to eat.

I don't always have enough money to buy the food I need.

I eat alone most of the time.

I take three or more different prescribed or over-the-counter drugs a day.

Without wanting to, I have lost or gained 10 pounds in the last six months.

I am not always physically able to shop, cook and/or feed myself.

TOTAL

YES

2

3

2

2

2

4

1

1

2

2

Total your nutritional score. If it’s –

Remember that warning signs suggest risk, but do not represent diagnosis of any condition.

Good! Recheck your nutritional score in six months.

You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition program, senior citizens center or health department can help. Recheck your nutritional score in three months.

You are at high nutritional risk. Bring this checklist the next time you see your doctor, dietitian or other qualified health or social service professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health.

0-2

3-5

6 or more

DETERMINE YOUR NUTRITIONAL HEALTH

The warning signs of poor nutritional health are often overlooked. Use this checklist to find out if you or someone you know is at nutritional risk.

Read the statements below. Circle the number in the “yes” column for those that apply to you or someone you know. For each “yes” answer, score the number in the box. Total your nutritional score.

■ F I G U R E 1 . 1 Determine your nutritional health. American Academy of Family Physicians, the American Dietetic Association, the National Council on the Aging, Inc. The Nutrition Screening Initiative.

Nutritional Assessment: an in-depth analysis of a person’s nutritional status. In the clinical setting, nutritional assessments focus on moderate- to high-risk patients with suspected or confirmed protein– energy malnutrition.

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C H A P T E R 1 Nutrition in Nursing 5

may also integrate nutrition, the nutritional plan of care devised by dietitians is specifi c for nutrition problems. Some obvious differences in focus are described below:

■ Dietitians may obtain much of their preliminary information about the patient from the nursing history and physical examination, such as height and weight; skin integrity; usual diet prior to admission; difficulty chewing, swallowing, or self-feeding; chief com- plaint; medications, supplements, and over-the-counter drugs used prior to admission; and living situation. Dietitians may request laboratory tests to assess vitamin levels when micronutrient deficiencies are suspected.

■ Dietitians interview patients and/or families to obtain a nutrition history, which may include information on current dietary habits; recent changes in intake or appetite; intake of snacks; alcohol consumption; food allergies and intolerances; ethnic, cultural, or religious diet influ- ences; nutrition knowledge and beliefs; and use of supplements. A nutrition history can help differentiate nutrition problems caused by inadequate intake from those caused by disease.

■ Dietitians usually calculate estimated calorie and protein requirements based on the assessment data and determine whether the diet ordered is adequate and appropriate for the individual.

■ Dietitians determine nutrition diagnoses that define the nutritional problem, etiology, and signs and symptoms. While a nursing diagnosis statement may begin with “Altered nutrition: eating less than the body needs,” a nutrition diagnosis would be more specific, such as “Inadequate protein–energy intake.”

■ Dietitians may also determine the appropriate malnutrition diagnosis code for the patient for hospital reimbursement purposes.

■ Nutrition interventions may include requesting a diet order change, requesting additional laboratory tests to monitor nutritional repletion, and performing nutrition counseling or education.

Screening

Nutrition assessment

Nutrition diagnosis

Nutrition intervention

Nutrition monitoring and evaluation

■ F I G U R E 1 . 2 The nutrition care process. Like the nursing process, the nutrition care process is a problem-solving method used to evaluate and treat nutrition-related problems.

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6 U N I T 1 Principles of Nutrition

NUTRITION IN THE NURSING PROCESS

In nursing care plans, nutrition may be part of the assessment data, diagnosis, plan, implementation, or evaluation. The remainder of this chapter is intended to help nurses provide quality nursing care that includes basic nutrition, not to help nurses become dietitians.

Assessment It is well recognized that malnutrition is a major contributor to morbidity, mortality, im- paired quality of life, and prolonged hospital stays (White et al., 2012). However, there is currently no single, universally agreed upon method to assess or diagnose malnutrition. Approaches vary widely and may lack sensitivity (the ability to diagnose all people who are malnourished) and specifi city (misdiagnosing a well-nourished person). For instance, albumin and prealbumin have been used as diagnostic markers of malnutrition. These pro- teins are now known to be negative acute phase proteins, which means their levels de- crease in response to infl ammation and physiologic stress. Because they are not specifi c for nutritional status, failure of these levels to increase with nutrition repletion does not mean that nutrition therapy is inadequate (Fessler, 2008). Although their usefulness in diagnosing malnutrition is limited, these proteins may help identify patients at high risk for morbidity, mortality, and malnutrition (Banh, 2006). BMI and some or all of the compo- nents of a subjective global assessment (Box 1.1) are commonly used to assess nutrition (Fessler, 2008).

Medical History and Diagnosis

The chief complaint and medical history may reveal disease-related risks for malnutrition and whether infl ammation is present (Fig. 1.3). Patients with gastrointestinal symptoms or disorders are among those who are most prone to malnutrition, particularly when symptoms such as nausea, vomiting, diarrhea, and anorexia last for more than 2 weeks. Box 1.2 lists psychosocial factors that may impact intake or requirements and help identify nutrition counseling needs.

Subjective Global Assessment (SGA): a clinical method of assessing nutritional status based on findings in a health history and physical examination.

Weight Change ■ Unintentional weight loss and the time

period of loss

Dietary Intake ■ Change from normal, duration, type of

diet consumed

Gastrointestinal Symptoms Lasting Longer than 2 Weeks ■ Nausea, vomiting, diarrhea, anorexia

Functional Capacity ■ Normal or suboptimal; ambulatory or

bedridden

Disease and Its Relation to Nutritional Requirements ■ Primary diagnosis; severity of metabolic

stress

Physical Signs and Severity of Findings ■ Loss of subcutaneous fat (triceps, chest),

muscle wasting (quadriceps, deltoids), ankle edema, sacral edema, ascites

CRITERIA INCLUDED IN SUBJECTIVE GLOBAL ASSESSMENTBox 1.1

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C H A P T E R 1 Nutrition in Nursing 7

Psychological Factors ■ Depression ■ Eating disorders ■ Psychosis

Social Factors ■ Illiteracy ■ Language barriers ■ Limited knowledge of nutrition and food

safety ■ Altered or impaired intake related to

culture ■ Altered or impaired intake related to

religion

■ Lack of caregiver or social support system

■ Social isolation ■ Lack of or inadequate cooking

arrangements ■ Limited or low income ■ Limited access to transportation to

obtain food ■ Advanced age (older than 80 years) ■ Lack of or extreme physical activity ■ Use of tobacco or recreational drugs ■ Limited use or knowledge of community

resources

PSYCHOSOCIAL FACTORS THAT MAY INFLUENCE INTAKE, NUTRITIONAL REQUIREMENTS, OR NUTRITION COUNSELINGBox 1.2

Acute illness (e.g., infection,

trauma, pancreatitis)

Inflammation/ catabolism

Frequent infection, altered GI function

Malnutrition

Inadequate intake/ nutrient availability

(anorexia, malabsorption)

Chronic illness (e.g., cancer, AIDS, COPD)

■ F I G U R E 1 . 3 Factors that may be involved in the etiology of illness-related malnutrition.

Body Mass Index

Body mass index (BMI) is an index of a person’s weight in relation to height used to estimate relative risk of health problems related to weight. Because it is relatively quick and easy to measure height and weight and requires little skill, actual measures, not estimates, should be used whenever possible to ensure accuracy and reliability. A patient’s stated height and weight should be used only when there are no other options.

Body Mass Index: an index of weight in relation to height that is calculated mathemat- ically by dividing weight in kilograms by the square of height in meters.

Q U I C K B I T E

Interpreting BMI

�18.5 underweight 18.5–24.9 healthy weight 25–29.9 overweight 30–34.9 obesity class 1 35–39.9 obesity class 2 �40 obesity class 3

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8 U N I T 1 Principles of Nutrition

“Healthy” or “normal” BMI is defi ned numerically as 18.5 to 24.9. Values above and below this range are associated with increased health risks. Although BMI can be calcu- lated with a mathematical formula, tables and nomograms are available for convenience (see Chapter 14). One drawback of using BMI is that a person can have a high BMI and still be undernourished in one or more nutrients if intake is unbalanced or if nutritional needs are high and intake is inadequate.

Weight Change

Unintentional weight loss is a well-validated indicator of malnutrition (White et al., 2012). The signifi cance of weight change is evaluated after the percentage of usual body weight lost in a given period of time is calculated (Box 1.3). Usually, weight changes are more refl ective of chronic, not acute, changes in nutritional status. The patient’s weight can be unreliable or invalid due to hydration status. Edema, anasarca, fl uid resuscitation, heart failure, and chronic liver or renal disease can falsely infl ate weight.

Dietary Intake

A decrease in intake compared to the patient’s normal intake may indicate nutritional risk. However, like other data, validity and reliability may be an issue. Although the nurse may only be required to fi ll in a blank space next to the word “appetite,” simply ask- ing the client “How is your appetite?” will probably not provide suffi cient information. A better question may be “Has the type or amount of food you eat recently changed? If so, please explain.” Consuming only liquids and severely limiting the type or amount of food are risks.

Another question to avoid while obtaining a nursing history is “Are you on a diet?” To many people, diet is synonymous with weight loss diet; they may fail to mention they use nutrition therapy to avoid sodium, modify fat, or count carbohydrates. A better question would be, “Do you avoid any particular foods?” or “Do you watch what you eat in any way?” Even the term “meal” may elicit a stereotypical mental picture. Questions to consider when asking a client about his or her usual intake appear in Box 1.4.

Calculating Percent Weight Change

% weight change � (usual body weight � current body weight)

_____ usual body weight

� 100

Signifi cant Unintentional Weight Loss

Time Period (% of Weight Lost)

1 week �2 1 month �5 3 months �7.5 6 months �10

Source: Academy of Nutrition and Dietetics. (2012). Nutrition Care Manual. Available at http://nutritioncaremanual .org/content.cfm?ncm_content_id=79554. Accessed on 8/16/2012.

CALCULATING AND EVALUATING PERCENT WEIGHT CHANGEBox 1.3

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http://nutritioncaremanual
C H A P T E R 1 Nutrition in Nursing 9

How many meals and snacks do you eat in a 24-hour period? This question helps to establish the pattern of eating and identifi es unusual food habits such as pica, food faddism, eating disorders, and meal skipping.

Do you have any food allergies or intolerances, and, if so, what are they? The greater the number of foods restricted or eliminated in the diet, the greater the likelihood of nutri- tional defi ciencies. This question may also shed light on the client’s need for nutrition counseling. For instance, clients with hiatal hernia who are intolerant of citrus fruits and juices may benefi t from counseling on how to ensure an adequate intake of vitamin C.

What types of vitamin, mineral, herbal, or other supplements do you use and why? A multivitamin, multimineral supplement that provides 100% or less of the daily value offers some protection against less than optimal food choices. Folic acid in supplements or fortifi ed food is recommended for women of childbearing age; people older than 50 years are encouraged to obtain vitamin B12 from fortifi ed foods or supplements. However, potential problems may arise from other types or amounts of supplements. For instance, large doses of vitamins A, B6, and D have the potential to cause toxicity symptoms. Iron supplements may decrease zinc absorption and negatively impact zinc status over time.

What concerns do you have about what or how you eat? This question places the responsibility of healthy eating with the client, where it should be. A client who may benefi t from nutrition intervention and counseling in theory may not be a candidate for such in practice depending on his or her level of interest and motivation. This question may also shed light on whether or not the client understands what he or she should be eating and whether the client is willing to make changes in eating habits.

For clients who are acutely ill: How has illness affected your choice or tolerance of food? Sometimes, food aversions or intolerances can shed light on what is going on with the client. For instance, someone who experiences abdominal pain that is relieved by eating may have a duodenal ulcer. Clients with little or no intake of food or liquids are at risk for dehydration and nutrient defi ciencies.

Who prepares the meals? This person may need nutritional counseling. Do you have enough food to eat? Be aware that pride and an unwillingness to admit inabil-

ity to afford an adequate diet may prevent some clients and families from answering this question. For hospitalized clients, it may be more useful to ask the client to compare the size of the meals they are served in the hospital with the size of meals they normally eat.

How much alcohol do you consume daily? Risk begins at more than one drink daily for women and more than two drinks daily for men.

QUESTIONS TO CONSIDER ABOUT INTAKEBox 1.4

Physical Findings

Loss of subcutaneous fat, such as in the triceps and chest, muscle wasting in the quadriceps and deltoids, ankle edema, sacral edema, and ascites may be indicative of malnutrition. These abnormal fi ndings are subjectively assessed as mild, moderate, or severe.

Box 1.5 lists other physical fi ndings that may suggest malnutrition. Most physical symp- toms cannot be considered diagnostic because evaluation of “normal” versus “abnormal” fi ndings is subjective, and the signs of malnutrition may be nonspecifi c. For instance, dull, dry hair may be related to severe protein defi ciency or to overexposure to the sun or use of hair products such as colorants. In addition, physical signs and symptoms of malnutri- tion can vary in intensity among population groups because of genetic and environmental differences. Lastly, physical fi ndings occur only with overt malnutrition, not subclinical malnutrition.

Subclinical: asymptomatic.

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Nursing Diagnosis A diagnosis is made after assessment data are interpreted. Nursing diagnoses in hospitals and long-term care facilities provide written documentation of the client’s status and serve as a framework for the plan of care that follows. The diagnoses relate directly to nutrition when the pattern of nutrition and metabolism is the problem. Other nursing diagnoses, while not specifi c for nutrition, may involve nutrition as part of the plan, such as teaching the patient how to increase fi ber intake to relieve the nursing diagnosis of constipation. Box 1.6 lists nursing diagnoses with nutritional signifi cance.

Planning: Client Outcomes Outcomes, or goals, should be measurable, attainable, specifi c, and client centered. How do you measure success against a vague goal of “gain weight by eating better”? Is “eating better” achieved by adding butter to foods to increase calories or by substituting 1% milk for whole milk because it is heart healthy? Is a 1-pound weight gain in 1 month acceptable or is 1 pound/week preferable? Is 1 pound/week attainable if the client has accelerated metabolism and catabolism caused by third-degree burns?

Client-centered outcomes place the focus on the client, not the health-care provider; they specify where the client is heading. Whenever possible, give the client the opportunity to actively participate in goal setting, even if the client’s perception of need differs from yours. In matters that do not involve life or death, it is best to fi rst address the client’s con- cerns. Your primary consideration may be the patient’s signifi cant weight loss during the last 6 months of chemotherapy, whereas the patient’s major concern may be fatigue. The two issues are undoubtedly related, but your effectiveness as a change agent is greater if you approach the problem from the client’s perspective. Commitment to achieving the goal is greatly increased when the client “owns” the goal.

Keep in mind that the goal for all clients is to consume adequate calories, protein, and nutrients using foods they like and tolerate as appropriate. If possible, additional short-term goals may be set to alleviate symptoms or side effects of disease or treatments and to prevent complications or recurrences if appropriate. After short-term goals are met, attention can expand to promoting healthy eating to reduce the risk of chronic diet-related diseases such as obesity, diabetes, hypertension, and atherosclerosis.

■ Hair that is dull, brittle, or dry, or falls out easily ■ Swollen glands of the neck and cheeks ■ Dry, rough, or spotty skin that may have a sandpaper feel ■ Poor or delayed wound healing or sores ■ Thin appearance with lack of subcutaneous fat ■ Muscle wasting (decreased size and strength) ■ Edema of the lower extremities ■ Weakened hand grasp ■ Depressed mood ■ Abnormal heart rate, heart rhythm, or blood pressure ■ Enlarged liver or spleen ■ Loss of balance and coordination

PHYSICAL SYMPTOMS SUGGESTIVE OF MALNUTRITIONBox 1.5

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Pattern Nutrition and Metabolic High risk for altered nutrition: intake

exceeds the body’s needs Altered nutrition: intake exceeds the

body’s needs Altered nutrition: eating less than the

body needs Effective breastfeeding Ineffective breastfeeding Interrupted breastfeeding Ineffective infant feeding pattern High risk of aspiration Swallowing disorder Altered oral mucosa High risk for fl uid volume defi cits Fluid volume defi cits Excess fl uid volume High risk for impaired skin integrity Impaired skin integrity Impaired tissue integrity High risk for altered body temperature Ineffective thermoregulation Hyperthermia Hypothermia

Examples of Other Diagnoses in Which Nutrition Interventions May Be Part of the Care Plan Altered health maintenance Ineffective management of therapeutic

regimen Infection Constipation Diarrhea Bowel incontinence Altered urinary excretion Impaired physical mobility Fatigue Self-care defi cit: feeding Household altered Altered tissue perfusion Pain Chronic pain Alterations sensory/perceptual Unilateral oblivion Knowledge defi cits Anxiety Body image disorder Social isolation Ineffective individual coping Ineffective family coping Defensive coping

SELECTED NURSING DIAGNOSES WITH NUTRITIONAL SIGNIFICANCEBox 1.6

Nursing Interventions What can you or others do to effectively and effi ciently help the client achieve his or her goals? Interventions may include nutrition therapy and client teaching.

Nutrition Therapy

Throughout this book, the heading “Nutrition Therapy” is used in place of “Diet” because, among clients, diet is a four-letter word with negative connotations, such as counting cal- ories, deprivation, sacrifi ce, and misery. A diet is viewed as a short-term punishment to endure until a normal pattern of eating can resume. Clients respond better to terminology that is less emotionally charged. Terms such as eating pattern, food intake, eating style, or the food you eat may be used to keep the lines of communication open.

Nutrition therapy recommendations are usually general suggestions to increase/ decrease, limit/avoid, reduce/encourage, or modify/maintain aspects of the diet because exact nutrient requirements are determined on an individual basis. Where more precise amounts of nutrients are specifi ed, consider them as a starting point and monitor the client’s response. Box 1.7 highlights formulas for calculating calorie and protein requirements.

Nutrition theory does not always apply to practice. Factors such as the client’s prog- nosis, outside support systems, level of intelligence and motivation, willingness to com- ply, emotional health, fi nancial status, religious or ethnic background, and other medical

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conditions may cause the optimal diet to be impractical in either the clinical or the home setting. Generalizations do not apply to all individuals at all times. Also, comfort foods (e.g., chicken soup, mashed potatoes, ice cream) are valuable for their emotional benefi ts if not nutritional ones. Honor clients’ requests for individual comfort foods whenever pos- sible. Box 1.8 suggests ways the nurse can promote an adequate intake.

Client Teaching

Compared with “well” clients, patients in a clinical setting may be more receptive to nutritional advice, especially if they feel better by doing so or are fearful of a relapse or complications. But hospitalized patients are also prone to confusion about nutrition messages. The patient’s abil- ity to assimilate new information may be compromised by pain, medication, anxiety, or a dis- tracting setting. Time spent with a dietitian or diet technician learning about a “diet” may be

A “rule-of-thumb” method of estimating calorie requirements:

Multiply weight in kg by

30 cal/kg for most healthy adults 25 cal/kg for elderly adults 20–25 cal/kg for obese adults

Example: For an adult weighing 154 pounds:

154 pounds � 2.2 kg/pound � 70 kg

70 kg � 30 cal/kg � 2100 cal/day

Estimating protein requirements

Healthy adults need 0.8 g protein/kg

Example: For an adult weighing 154 pounds:

154 pounds � 2.2 kg/pound � 70 kg

70 kg � 0.8 g/kg � 56 g protein/day

Box 1.7 CALCULATING ESTIMATED NEEDS

■ Reassure clients who are apprehensive about eating. ■ Encourage a big breakfast if appetite deteriorates throughout the day. ■ Advocate discontinuation of intravenous therapy as soon as feasible. ■ Replace meals withheld for diagnostic tests. ■ Promote congregate dining if appropriate. ■ Question diet orders that appear inappropriate. ■ Display a positive attitude when serving food or discussing nutrition. ■ Order snacks and nutritional supplements. ■ Request assistance with feeding or meal setup. ■ Get the patient out of bed to eat if possible. ■ Encourage good oral hygiene. ■ Solicit information on food preferences.

WAYS TO PROMOTE AN ADEQUATE INTAKEBox 1.8

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C H A P T E R 1 Nutrition in Nursing 13

brief or interrupted, and the patient may not even know what questions to ask until long after the dietitian is gone. Box 1.9 suggests ways nurses can facilitate client and family teaching.

Monitoring and Evaluation In the “Nursing Process” sections of this textbook, monitoring and evaluation are grouped together, even though they are different in practice. In reality, monitoring precedes evalu- ation as a way to stay on top of progress or diffi culties the client is experiencing. Box 1.10 offers general monitoring suggestions. Evaluation assesses whether client outcomes were achieved after the nursing care plan was given time to work. Given the limitations inherent in an abstract nursing care plan, monitoring and evaluation are combined in this textbook.

Ideally, the client’s outcomes are achieved on a timely basis, and evaluation statements are client outcomes rewritten from “the client will” to “the client is.” In reality, outcomes may be only partially met or not achieved at all; in those instances, it is important to deter- mine why the result was less than ideal. Were the outcomes realistic for this particular client? Were the interventions appropriate and consistently implemented? Evaluation includes deciding whether to continue, change, or abolish the plan.

Consider a male client admitted to the hospital for chronic diarrhea. During the 3 weeks before admission, the client experienced signifi cant weight loss due to malabsorption sec- ondary to diarrhea. Your goal is for the client to maintain his admission weight. Your inter- ventions are to provide small meals of low-residue foods as ordered, to eliminate lactose because of the likelihood of intolerance, to increase protein and calories with appropriate

■ Listen to the client’s concerns and ideas. ■ Encourage family involvement if appropriate. ■ Reinforce the importance of obtaining adequate nutrition. ■ Help the client to select appropriate foods. ■ Counsel the client about drug–nutrient interactions. ■ Avoid using the term “diet.” ■ Emphasize things “to do” instead of things “not to do.” ■ Keep the message simple. ■ Review written handouts with the client. ■ Advise the client to avoid foods that are not tolerated.

WAYS TO FACILITATE CLIENT AND FAMILY TEACHINGBox 1.9

■ Observe intake whenever possible to judge the adequacy. ■ Document appetite and take action when the client does not eat. ■ Order supplements if intake is low or needs are high. ■ Request a nutritional consult. ■ Assess tolerance (i.e., absence of side effects). ■ Monitor weight. ■ Monitor progression of restrictive diets. Clients who are receiving nothing by mouth

(NPO), who are restricted to a clear liquid diet, or who are receiving enteral or paren- teral nutrition are at risk for nutritional problems.

■ Monitor the client’s grasp of the information and motivation to change.

MONITORING SUGGESTIONSBox 1.10

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nutrient-dense supplements, and to explain the nutrition therapy recommendations to the client to ease his concerns about eating. You fi nd that the client’s intake is poor because of lack of appetite and a fear that eating and drinking will promote diarrhea. You notify the dietitian who counsels the client about low-residue foods, obtains likes and dislikes, and urges the client to think of the supplements as part of the medical treatment, not as a food eaten for taste or pleasure. You document intake and diligently encourage the client to eat and drink everything served. However, the client’s weight continues to drop. You attribute this to his reluctance to eat and to the slow resolution of diarrhea related to infl ammation. You determine that the goal is still realistic and appropriate but that the client is not willing or able to consume foods orally. You consult with the physician and dietitian about the client’s refusal to eat and the plan changes from an oral diet to tube feeding.

HOW DO YOU RESPOND? Should I save my menus from the hospital to help me plan meals at home? This is not a bad idea if the in-house and discharge food plans are the same, but the menus should serve as a guide, not a gospel. Just because shrimp was never on the menu doesn’t mean it is taboo. Likewise, if the client hated the orange juice served every morning, he or she shouldn’t feel compelled to continue drinking it. By necessity, hospi- tal menus are more rigid than at-home eating plans.

Can you just tell me what to eat and I’ll do it? A black-and-white approach should be used only when absolutely necessary, such as for food allergies or for clients who insist on a rigid plan rather than the freedom to make choices. In most cases, flexible and individ- ualized guidelines and recommendations will promote the greatest chance of compliance. Urge the client not to think of foods as “good” or “bad” but rather “more healthy” and “less healthy,” except in situations of food allergy or intolerance. In most other cases, foods are negotiable.

CASE STUDY Steven is a 44-year-old male who is 5 ft 11 in tall and weighs 182 pounds. Over the last month, he has lost approximately 10 pounds, which he blames on loss of appetite and fatigue. When he went to his family doctor with flu-like symptoms, a blood test revealed a very high white blood cell count, low platelet count, and low hemoglobin. The doctor told him to proceed to the hospital for admission to rule out acute leukemia. Further laboratory tests are pending. Admitting orders include a regular diet. Steven does not have a signifi- cant medical history. He is married, has three children, and enjoys a successful career.

Calculate and evaluate Steven’s weight according to the following standards:

■ BMI ■ Percent weight change ■ Based on Steven’s weight and weight change, is he at nutritional risk? ■ Does Steven’s possible diagnosis place him at nutritional risk? ■ What other criteria would help determine his level of risk? ■ Calculate his estimated calorie requirements. Calculate his Recommended Dietary

Allowance (RDA) for protein. ■ If he is treated for leukemia, his protein need may increase to approximately 1.2 g protein/kg.

How much would he then require? ■ The hospital’s diet manual says that, on average, a regular diet provides 2400 calories

and 90 g of protein. Is this diet adequate to meet his needs?

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C H A P T E R 1 Nutrition in Nursing 15

S T U D Y Q U E S T I O N S 1. Nurses are in an ideal position to

a. Screen patients for risk of malnutrition b. Order therapeutic diets c. Conduct comprehensive nutrition assessments d. Calculate a patient’s calorie and protein needs

2. How much weight would a 200-pound adult need to lose in a month to be considered significant? a. It depends on the patient’s BMI. b. More than 5 pounds c. More than 7.5 pounds d. More than 10 pounds

3. Which of the following criteria would most likely be on a nutrition screen in the hospital? a. Prealbumin value b. Weight change c. Serum potassium value d. Cultural food preferences

4. Which of the following statements is accurate regarding physical signs and symptoms of malnutrition? a. “Physical signs of malnutrition appear before changes in weight or laboratory

values occur.” b. “Physical signs of malnutrition are suggestive, not definitive, for malnutrition.” c. “Physical signs are easily identified as ‘abnormal.’” d. “All races and genders exhibit the same intensity of physical changes in response

to malnutrition.”

5. Your patient has a question about the cardiac diet the dietitian reviewed with him yesterday. What is the nurse’s best response? a. “Ask your doctor when you go for your follow-up appointment.” b. “What is the question? If I can’t answer it, I will get the dietitian to come back to

answer it.” c. “Just do your best. The handout she gave you is simply a list of guidelines, not

rigid instructions.” d. “If I see the dietitian around, I will tell her you need to see her.”

6. Which of the following statements is true regarding albumin? a. Albumin is a reliable and sensitive indicator of protein status. b. An increase in serum albumin accurately reflects the adequacy of nutrition therapy. c. An increase in albumin levels means nutrition therapy is adequate. d. Low albumin is associated with morbidity, mortality, and risk of malnutrition

because it reflects severity of illness.

■ Nutrition is an integral part of nursing care. Like air, food is a basic human need. ■ Nutrition screening is used to identify patients or clients who may be at risk for

malnutrition. Screening tools are simple, quick, easy to use, and rely on available data. ■ The Joint Commission stipulates that nutrition screens be performed within 24 hours

of admission to a health-care facility, but facilities are free to decide what criteria to include on a screen, what fi ndings indicate risk, and who is to conduct the screen.

K E Y C O N C E P T S

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Screens are often the responsibility of staff nurses because they can be completed during a history and physical examination upon admission.

■ Patients who are identifi ed to be a low or no nutritional risk are rescreened within a specifi ed period of time to determine whether their nutritional risk status has changed.

■ Patients who are found to be a moderate to high nutritional risk at screening receive a comprehensive nutritional assessment by the dietitian that includes the steps of assessment, diagnosis, intervention, and monitoring and evaluation.

■ Dietitians use information from the nursing history and physical examination to begin the assessment process. They may also obtain a nutritional history from the patient, cal- culate estimated protein and calorie needs, assess the adequacy and appropriateness of the diet order, and identify the patient’s diagnostic code for malnutrition, if appropriate.

■ Nurses can integrate nutrition into the nursing care process to develop care plans that address the individual’s needs. Nurses are not expected to be dietitians but rather use nutrition to provide quality nursing care.

■ Albumin and prealbumin are not valid criteria for assessing protein status because they become depleted from infl ammation and physiologic stress.

■ Accurate height and weight are essential for assessing risk and monitoring progress. They are used to determine BMI and percentage of weight loss. Signifi cant unintentional weight loss is defi ned according to the length of time over which the loss occurred.

■ Dietary data can help determine whether a nutrition problem is caused by intake or by illness or its treatments. The term diet inspires negative feelings in most people. Replace it with eating pattern, eating style, or foods you normally eat to avoid negative connotations.

■ People with gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and anorexia, that last more than 2 weeks are at risk for malnutrition.

■ Physical signs and symptoms of malnutrition are nonspecifi c, subjective, and develop slowly and should be considered suggestive, not diagnostic, of malnutrition.

■ Medical–psychosocial history can reveal factors that infl uence intake, nutritional requirements, or nutrition counseling needs.

■ Medications and nutritional supplements should be evaluated for their potential impact on nutrient intake, absorption, utilization, or excretion.

■ Nursing diagnoses relate directly to nutrition when the pattern of nutrition or metabo- lism is altered. Many other nursing diagnoses, such as constipation, impaired skin integ- rity, knowledge defi cits, and infection, may include nutrition in some aspect of the plan.

■ A nutrition priority for all clients is to obtain adequate calories and nutrients based on individual needs.

■ Short-term nutrition goals are to attain or maintain adequate weight and nutritional status and (as appropriate) to avoid nutrition-related symptoms and complications of illness. Client-centered outcomes should be measurable, attainable, and specifi c.

■ Intake recommendations are not always appropriate for all persons; what is recom- mended in theory may not work for an individual. Clients may revert to comfort foods during periods of illness or stress.

■ Nurses can reinforce nutrition counseling provided by the dietitian and initiate counsel- ing for clients with low or mild risk.

■ Use preprinted lists of “do’s” and “don’ts” only if absolutely necessary, such as in the case of food allergies. For most people, actual food choices should be considered in view of how much and how often they are eaten rather than as foods that “must” or “must not” be consumed.

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