NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021.
Base your decisions on the action of nutrients, signs of excess and deficiency, and specific foods associated with each nutrient
Base your decisions on the interpretation of diagnostic tests and lab values indicative of a disturbance in nutrition
Give examples of appropriate vitamin use across the life span Identify evidence-based practices related to nutritionNurses promote healthy nutrition to prevent disease, assist patients to recover from illness and surgery, and teach patients how to optimally manage chronic illness with healthy food choices. Healthy nutrition helps to prevent obesity and chronic diseases, such as diabetes mellitus and cardiovascular disease. By proactively encouraging healthy eating habits, nurses provide the tools for patients to maintain their health, knowing it is easier to stay healthy than to become healthy after disease sets in. When patients are recovering from illness or surgery, nurses use strategies to promote good nutrition even when a patient has a poor appetite or nausea. If a patient develops chronic disease, the nurse provides education about prescribed diets that can help manage the disease, such as a low carbohydrate diet for patients with diabetes or a low fat, low salt, low cholesterol diet for patients with cardiovascular disease.
Nurses also advocate for patients with conditions that can cause nutritional deficits. For example, a nurse may be the first to notice that a patient is having difficulty swallowing at mealtime and advocates for a swallow study to prevent aspiration. A nurse may also notice other psychosocial risk factors that place a patient at risk for poor nutrition in their home environment and make appropriate referrals to enhance their nutritional status. Nurses also administer alternative forms of nutrition, such as enteral (tube) feedings or parenteral (intravenous) feedings.
This chapter will review basic information about the digestive system, essential nutrients, nutritional guidelines, and then discuss the application of the nursing process to addressing patients’ nutritional status.
Before discussing assessments and interventions related to promoting good nutrition, let’s review the structure and function of the digestive system, essential nutrients, and nutritional guidelines.
The digestive system breaks down food and then absorbs nutrients into the bloodstream via the small intestine and large intestine. Because good health depends on good nutrition, any disorder affecting the functioning of the digestive system can significantly impact overall health and well-being and increase the risk of chronic health conditions.
The gastrointestinal system (also referred to as the digestive system) is responsible for several functions, including digestion, absorption, and immune response. Digestion begins in the upper gastrointestinal tract at the mouth, where chewing of food occurs, called mastication. Mastication results in mechanical digestion when food is broken down into small chunks and swallowed. Masticated food is formed into a bolus as it moves toward the pharynx in the back of the throat and then into the esophagus. Coordinated muscle movements in the esophagus called peristalsis move the food bolus into the stomach where it is mixed with acidic gastric juices and further broken down into chyme through a chemical digestion process. As chyme is moved out of the stomach and into the duodenum of the small intestine, it is mixed with bile from the gallbladder and pancreatic enzymes from the pancreas for further digestion. [ 1 ]
Absorption is a second gastrointestinal function. After chyme enters the small intestine, it comes into contact with tiny fingerlike projections along the inside of the intestine called villi. Villi increase the surface area of the small intestine and allow nutrients, such as protein, carbohydrates, fat, vitamins, and minerals, to absorb through the intestinal wall and into the bloodstream. Absorption of nutrients is essential for metabolism to occur because nutrients fuel bodily functions and create energy. Peristalsis moves leftover liquid from the small intestine into the large intestine, where additional water and minerals are absorbed. Waste products are condensed into feces and excreted from the body through the anus. [ 2 ] See Figure 14.1 [ 3 ] for labeled parts of the gastrointestinal system.
The Gastrointestinal System
In addition to digestion and absorption, the gastrointestinal system is also involved in immune function. Good bacteria in the stomach create a person’s gut biome. Gut biome contributes to a person’s immune response through antibody production in response to foreign materials, chemicals, bacteria, and other substances. [ 4 ] For example, patients may develop Clostridium difficile (C-diff) after taking antibiotics that kill these beneficial bacteria in the gut. Read additional details about our microbiome and immune response in the “Infection” chapter of this book.
Nutrients from food and fluids are used by the body for growth, energy, and bodily processes. Essential nutrients refer to nutrients that are necessary for bodily functions but must come from dietary intake because the body is unable to synthesize them. Essential nutrients include vitamins, minerals, some amino acids, and some fatty acids. [ 5 ] Essential nutrients can be further divided into macronutrients and micronutrients.
Macronutrients make up most of a person’s diet and provide energy, as well as essential nutrient intake. Macronutrients include carbohydrates, proteins, and fats. However, too many macronutrients without associated physical activity cause excess nutrition that can lead to obesity, cardiovascular disease, diabetes mellitus, kidney disease, and other chronic diseases. Too few macronutrients result in undernutrition, which contributes to nutrient deficiencies and malnourishment. [ 6 ]
Carbohydrates are sugars and starches and are an important energy source that provides 4 kcal/g of energy. Simple carbohydrates are small molecules (called monosaccharides or disaccharides) and break down quickly. As a result, simple carbohydrates are easily digested and absorbed into the bloodstream, so they raise blood glucose levels quickly. Examples of simple carbohydrates include table sugar, syrup, soda, and fruit juice. Complex carbohydrates are larger molecules (called polysaccharides) that break down more slowly, which causes slower release into the bloodstream and a slower increase in blood sugar over a longer period of time. Examples of complex carbohydrates include whole grains, beans, and vegetables. [ 7 ]
Foods can also be categorized according to their glycemic index, a measure of how quickly glucose levels increase in the bloodstream after carbohydrates are consumed. The glycemic index was initially introduced as a way for people with diabetes mellitus to control their blood glucose levels. For example, processed foods, white bread, white rice, and white potatoes have a high glycemic index. They quickly raise blood glucose levels after being consumed and also cause the release of insulin, which can result in more hunger and overeating. However, foods such as fruit, green leafy vegetables, raw carrots, kidney beans, chickpeas, lentils, and bran breakfast cereals have a low glycemic index. These foods minimize blood sugar spikes and insulin release after eating, which leads to less hunger and overeating. Eating a diet of low glycemic foods has been linked to a decreased risk of obesity and diabetes mellitus. [ 8 ] See Figure 14.2 [ 9 ] for an image of the glycemic index of various foods.
Proteins are peptides and amino acids that provide 4 kcal/g of energy. Proteins are necessary for tissue repair and function, growth, energy, fluid balance, clotting, and the production of white blood cells. Protein status is also referred to as nitrogen balance. Nitrogen is consumed in dietary intake and excreted in the urine and feces. If the body excretes more nitrogen than it takes in through the diet, this is referred to as a negative nitrogen balance. Negative nitrogen balance is seen in patients with starvation or severe infection. Conversely, if the body takes in more nitrogen through the diet than what is excreted, this is referred to as a positive nitrogen balance. [ 10 ] During positive nitrogen balance, excess protein is converted to fat tissue for storage.
Proteins are classified as complete, incomplete, or partially complete. Complete proteins must be ingested in the diet. They have enough amino acids to perform necessary bodily functions, such as growth and tissue maintenance. Examples of foods containing complete proteins are soy, quinoa, eggs, fish, meat, and dairy products. Incomplete proteins do not contain enough amino acids to sustain life. Examples of incomplete proteins include most plants, such as beans, peanut butter, seeds, grains, and grain products. Incomplete proteins must be combined with other types of proteins to add to amino acids and form complete protein combinations. [ 11 ] For example, vegetarians must be careful to eat complementary proteins, such as grains and legumes, or nuts and seeds and legumes, to create complete protein combinations during their daily food intake. Partially complete proteins have enough amino acids to sustain life, but not enough for tissue growth and maintenance. Because of the similarities, most sources consider partially complete proteins to be in the same category as incomplete proteins. See Figure 14.3 [ 12 ] for an image of protein-rich foods.
Fats consist of fatty acids and glycerol and are essential for tissue growth, insulation, energy, energy storage, and hormone production. Fats provide 9 kcal/g of energy. [ 13 ] While some fat intake is necessary for energy and uptake of fat-soluble vitamins, excess fat intake contributes to heart disease and obesity. Due to its high-energy content, a little fat goes a long way.
Fats are classified as saturated, unsaturated, and trans fatty acids. Saturated fats come from animal products, such as butter and red meat (e.g., steak). Saturated fats are solid at room temperature. Recommended intake of saturated fats is less than 10% of daily calories because saturated fat raises cholesterol and contributes to heart disease. [ 14 ]
Unsaturated fats come from oils and plants, although chicken and fish also contain some unsaturated fats. Unsaturated fats are healthier than saturated fats. Examples of unsaturated fats include olive oil, canola oil, avocados, almonds, and pumpkin seeds. Fats containing omega-3 fatty acids are considered polyunsaturated fats and help lower LDL cholesterol levels. Fish and other seafood are excellent sources of omega-3 fatty acids.
Trans fats are fats that have been altered through a hydrogenation process, so they are not in their natural state. During the hydrogenated process, fat is changed to make it harder at room temperature and have a longer shelf life. Trans fats are found in processed foods, such as chips, crackers, and cookies, as well as in some margarines and salad dressings. Minimal trans fat intake is recommended because it increases cholesterol and contributes to heart disease. [ 15 ]
Micronutrients include vitamins and minerals.
Vitamins are necessary for many bodily functions, including growth, development, healing, vision, and reproduction. Most vitamins are considered essential because they are not manufactured by the body and must be ingested in the diet. Vitamin D is also manufactured through exposure to sunlight. [ 16 ]
Vitamin toxicity can be caused by overconsumption of certain vitamins, such as vitamins A, D, C, B6, and niacin. Conversely, vitamin deficiencies can be caused by various factors including poor food intake due to poverty, malabsorption problems with the gastrointestinal tract, drug and alcohol abuse, proton pump inhibitors, and prolonged parenteral nutrition. Deficiencies can take years to develop, so it is usually a long-term problem for patients. [ 17 ]
Vitamins are classified as water soluble or fat soluble. Water-soluble vitamins are not stored in the body and include vitamin C and B-complex vitamins: B1 (thiamine), B2 (riboflavin), B3 (niacin), B6 (pyridoxine), B12 (cyanocobalamin), and B9 (folic acid). Additional water-soluble vitamins include biotin and pantothenic acid. Excess amounts of these vitamins are excreted through the kidneys in urine, so toxicity is rarely an issue, though excess intake of vitamin B6, C, or niacin can result in toxicity. [ 18 ] See Table 14.2a for a list of selected water-soluble vitamins, their sources, and their function. [ 19 ] , [ 20 ] , [ 21 ] , [ 22 ] , [ 23 ] , [ 24 ] , [ 25 ] , [ 26 ] , [ 27 ]
Selected Water-Soluble Vitamins
Fat-soluble vitamins are absorbed with fats in the diet and include vitamins A, D, E, and K. They are stored in fat tissue and can build up in the liver. They are not excreted easily by the kidneys due to storage in fatty tissue and the liver, so overconsumption can cause toxicity, especially with vitamins A and D. [28] See Table 14.2b for a list of selected fat-soluble vitamins, their sources, their function, and manifestations of deficiencies and toxicities. [ 29 ] , [ 30 ] , [ 31 ] , [ 32 ] , [ 33 ] , [ 34 ] , [ 35 ] , [ 36 ] , [ 37 ]
Selected Fat-Soluble Vitamins
Minerals are inorganic materials essential for hormone and enzyme production, as well as for bone, muscle, neurological, and cardiac function. Minerals are needed in varying amounts and are obtained from a well-rounded diet. In some cases of deficiencies, mineral supplements may be prescribed by a health care provider. Deficiencies can be caused by malnutrition, malabsorption, or certain medications, such as diuretics.
Minerals are classified as either macrominerals or trace minerals. Macrominerals are needed in larger amounts and are typically measured in milligrams, grams, or milliequivalents. Macrominerals include sodium, potassium, calcium, magnesium, chloride, and phosphorus. Macrominerals are discussed in further detail in the “Electrolytes” section of the “Fluids and Electrolytes” chapter of this book.
Trace minerals are needed in tiny amounts. Trace minerals include zinc, iron, chromium, copper, fluorine, iodine, manganese, molybdenum, and selenium. [ 38 ] See Table 14.2c for a list of selected macrominerals and Table 14.2d for a list of trace minerals. [ 39 ] , [ 40 ] , [ 41 ] , [ 42 ]
Nutritional guidelines are developed by governmental agencies to provide guidance to the population on how to best meet nutritional needs. These guidelines may vary by country. The National Academies of Sciences, Engineering, and Medicine set the Dietary Reference Intakes (DRIs) for the United States and Canada. Dietary Reference Intakes (DRIs) are a set of reference values used to plan and assess nutrient intakes of healthy people, including proteins, carbohydrates, fats, vitamins, minerals, and fiber. Nutrients included in the DRIs are obtained through a typical diet, although some foods may be fortified with certain nutrients that are commonly deficient in diets. [ 43 ]
The U.S. Department of Agriculture (USDA) issues dietary guidelines for appropriate serving sizes of each food group and number of servings recommended each day. The “Choose MyPlate” food guide is an easy-to-understand visual representation of how a healthy plate of food should be divided based on food groups. See Figure 14.4 [ 44 ] for a Choose MyPlate image. A little more than half of the plate should be grains and vegetables, with a focus on whole grains and a variety of vegetables. About one quarter of the plate should be fruits, with an emphasis on whole fruits. About one quarter of the plate should be protein, with an emphasis on consuming a variety of low-fat protein sources. All of these groups combined should make up no more than 85% of daily caloric intake based on a 2,000 calorie diet. Fats, oils, and added sugars are not included, but should make up no more than 15% of daily caloric intake. Foods should be selected that are as nutrient-dense as possible. Nutrient-dense means there is a high proportion of nutritional value relative to calories contained in the food, such as fruits and vegetables. Conversely, calorie-dense foods should be minimized because they have a large amount of calories with few nutrients. For example, candy and soda are calorie-dense with few nutrients and should be minimized. [ 45 ] , [ 46 ] See the following hyperlink to the MyPlate web site for further information on USDA dietary guidelines and patient educational materials
Read more about USDA dietary guidelines at https://www.myplate.gov/. [ 47 ]
MyPlate information and images are also available in several other languages so that education can be tailored to the patient’s preferred language. For example, Figure 14.5 [ 48 ] shows MyPlate in Vietnamese. This image would be accompanied with written information about food groups that include the patient’s typical dietary choices.
MyPlate in Vietnamese
For a well-rounded diet, a variety of vegetables should be consumed, including vegetables from all five vegetable groups: dark green leafy vegetables; red and orange vegetables; beans, peas, and lentils (formerly called the legumes group); starchy vegetables; and other vegetables. Vegetables can be fresh, frozen, canned, or dried. Dark green leafy vegetables include kale, Swiss chard, spinach, broccoli, and salad greens. Red and orange vegetables include carrots, bell peppers, sweet potatoes, tomatoes, tomato juice, and squash. The beans, peas, and lentils group includes dried beans, black beans, chickpeas, kidney beans, split peas, and black-eyed peas. (Note that this group does not include green beans or green peas.) This vegetable group also supplies some protein and can be included in the protein group as well. Starchy vegetables include root vegetables, such as potatoes, as well as corn. The “other vegetables” category includes any vegetable that doesn’t fit in the other four categories, such as asparagus, avocados, brussels sprouts, cabbage, cucumbers, snow peas, and mushrooms, and a variety of others.
Daily serving suggestions of vegetables for individuals with a 2,000 calorie diet are 2 ½ cup equivalents of vegetables per day. For example, a “one cup equivalent” equals 1 cup raw or cooked vegetables, one cup 100% vegetable juice, ½ cup of dried vegetables, or 2 cups of leafy green vegetables. Approximately 90% of Americans do not meet the recommended daily intake of vegetables. [ 49 ] See Figure 14.6 [ 50 ] for an image of vegetables.
Grains are classified as whole grains or refined grains. Whole grains include the entire grain kernel and supply more fiber than refined grains. Examples of whole grains include amaranth, whole barley, popcorn, oats, whole grain cornmeal, brown or wild rice, and whole grain cereal or crackers. Refined grains have been processed to remove parts of the grain kernel and supply little fiber. As a result, they quickly increase blood glucose levels. Examples of refined grains include white bread, white rice, Cream of Wheat, pearled barley, white pasta, and refined-grain cereals or crackers. Some grains are fortified to ensure adequate intake of folic acid. See Figure 14.7 [ 51 ] for an image of whole grain whole wheat bread.
Whole Grain, Whole Wheat Bread
The daily serving suggestions of grains for an individual with a 2,000 calorie diet are six ounce equivalents per day, split equally between whole and refined grains. For example, a “one ounce equivalent” of grains equals ½ cup of cooked rice, pasta, or cereal or 1 cup of flaked cereal. Most Americans consume adequate amounts of total grains, although roughly 98% are deficient in recommended whole grain amounts, and 74% consume more than the recommended refined grain amounts. [ 52 ]
Fruits can be frozen, canned, or dried, in addition to 100% fruit juice. A few examples of fruits include apples, oranges, bananas, melons, peaches, apricots, pineapples, and rhubarb. Daily serving suggestions of fruits for an individual with a 2,000 calorie diet are 2 cup equivalents per day. For example, “one cup equivalent” equals 1 cup of raw or cooked fruit, 8 ounces of 100% fruit juice, or ½ cup of dried fruit. Approximately 80% of Americans do not consume the recommended daily intake of fruits. [ 53 ] See Figure 14.8 [ 54 ] for an image of fruits.
Dairy products can be liquid, dried, semi-solid, or solid depending on the type of product. Dairy products include milk, lactose-free milk, fortified soy milk, buttermilk, cheese, yogurt, and kefir. Sour cream and cream cheese are not considered dairy items in terms of nutritional benefits. Daily serving suggestions of dairy products for an individual with a 2,000 calorie diet are 3 cup equivalents per day. For example, “one cup equivalent” equals 1 cup of milk, soy milk, or yogurt; 1 ½ ounces of natural cheese, or 2 ounces of processed cheese. Approximately 90% of Americans consume less than the recommended daily intake of dairy products. [ 55 ] See Figure 14.9 [ 56 ] for an image of dairy products.
Proteins are categorized by the type of protein source. The meats, poultry, and eggs category consists of any type of animal or poultry meat, organ meat, or poultry egg. Lean meats should be selected to minimize fat and calorie intake from high-fat meats.
The seafood category includes any type of fish, clams, crab, lobster, oyster, and scallops. It is important to choose fish with low mercury levels to prevent negative effects of a buildup of mercury in the body. In general, large, fatty ocean fish, such as tuna, have higher levels of mercury due to their diet and storage of mercury in their fatty tissues.
The nuts, seeds, and soy products category includes tree nuts, peanuts, nut butters, seeds, or seed butters. Soy products include tofu and any other products made from soy. Unsalted nuts should be selected to avoid excess salt intake.
Protein is also contained in other food groups, such as dairy or the vegetable category of peas, beans, and lentils. Daily serving suggestions of proteins for individuals with a 2,000 calorie diet are 5 ½ ounce equivalents per day. Servings should total up to 26 ounce equivalents per week of meats, eggs, and poultry; 8 ounce equivalents per week of seafood; and 5 ounce equivalents per week of nuts, seeds, or soy products. A “one ounce equivalent” of protein equals 1 ounce of lean meat, one egg, ¼ cup cooked beans, or 1 tablespoon of peanut butter. Most Americans consume adequate amounts of protein, but many consume proteins high in saturated fat and sodium that contribute to diseases such as coronary artery disease. [ 57 ]
Examples of oils are vegetable oil, canola oil, olive oil, butter, lard, and coconut oil. Daily serving suggestions of fats or oils for individuals with a 2,000 calorie diet are 27 grams per day. While it is important to limit oils and fats due to their calorie-dense nature, some fat and oil intake is essential for nutrient absorption and overall health. It is best to select healthy unsaturated fats, such as avocados, nuts, or olive oil. [ 58 ]
A person’s gender affects their calorie and nutrient requirements. Males typically have higher calorie and protein needs related to increased muscle mass. Females typically require fewer calories to maintain their body weight due to a higher proportion of adipose (fat tissue) than muscle. Menstruating females also have higher iron requirements to offset losses that occur during menstruation.
Now that we have discussed basic nutritional concepts and dietary guidelines, let’s discuss factors that can affect a person’s nutritional status. Many things that can cause altered nutrition, such as physiological factors, cultural and religious beliefs, economic resources, drug and nutrient disorders, surgery, altered metabolic states, alcohol and drug abuse, and psychological states.
Nutritional intake is affected by several physiological factors. Appetite is controlled by the hypothalamus, a tiny gland deep within the brain that triggers feelings of hunger or fullness depending on hormone and neural signals being sent and received. See Figure 14.10 [ 59 ] for an image of the hypothalamus indicated by the red arrow. Hunger causes a feeling of emptiness in the abdomen and is often accompanied by audible noises coming from the abdomen as the stomach contracts due to emptiness. Hunger can cause feelings of discomfort, nausea, and tiredness. Satiety is a feeling of fullness that often comes after eating, although it can also be caused by impairments of the hypothalamus. Electrolyte imbalances and fluid volume imbalances can also trigger hunger and thirst by sending signals to the hypothalamus. [ 60 ]
The five senses play an important role in food intake. For example, food with a pleasing aroma may induce mouth watering and hunger, whereas food or environments with displeasing aromas often suppress the appetite. Texture and taste of foods also play a role in stimulation of appetite.
Poor dentition or poor oral care has a negative effect on appetite, so adequate oral care is crucial for patients prior to eating. [ 61 ] Additionally, the condition of a patient’s teeth and gums, the fit of dentures, and gastrointestinal function also play an important role in nutrition. Loose teeth, swollen gums, or poor-fitting dentures can make eating difficult.
Difficulty swallowing, called dysphagia, can make it dangerous for the patient to swallow food because it can result in pneumonia from aspiration of food into the lungs. Special soft diets or enteral or parenteral nutrition are typically prescribed for patients with dysphagia. Nurses collaborate with speech therapists when assessing and managing dysphagia.
A poorly functioning gastrointestinal tract makes nutrient absorption difficult and can result in malnourishment. Diseases that cause inflammation of the gastrointestinal tract impair absorption of nutrients. Examples of these conditions include esophagitis, gastritis, inflammatory bowel disease, and cholecystitis. Patients with these disorders should select nutrient-dense foods and may require prescribed supplements to increase nutrient intake.
Cultural and religious beliefs often influence food selection and food intake. It is important for nurses to conduct a thorough patient assessment, including food preferences, to ensure adequate nutritional intake during hospitalization. The nurse should not assume a particular diet based on a patient’s culture or religion, but instead should determine their individual preferences through the assessment interview.
Cultural beliefs affect types of food eaten and when they are eaten. Some foods may be restricted due to beliefs or religious rituals, whereas other foods may be viewed as part of the healing process. For example, some cultures do not eat pork because it is considered unclean, and others eat “kosher” food that prescribes how food is prepared. Some religions fast during religious holidays from sunrise to sunset, where others avoid eating meat during the time of Lent. [ 62 ] , [ 63 ]
If a patient has inadequate financial resources, food security and food choices are often greatly impacted. Healthy, nutrient-dense, fresh foods typically cost more than prepackaged, heavily processed foods. Poor economic status is correlated with the consumption of calorie-dense, nutrient-poor food choices, putting these individuals at risk for inadequate nutrition and obesity. [ 64 ] Social programs such as Meals on Wheels, free or reduced-cost school breakfast and lunch programs, and government subsidies based on income help reduce food insecurity and promote the consumption of healthy, nutrient-dense foods. Nurses refer at-risk patients to social workers and case managers for assistance in applying for these social programs.
Some prescription drugs affect nutrient absorption. For example, some medications such as proton pump inhibitors (omeprazole) alter the pH of stomach acid, resulting in poor absorption of nutrients. Other medications, such as opioids, often decrease a person’s appetite or cause nausea, resulting in decreased calorie and nutrient intake.
Surgery can affect a patient’s nutritional status due to several factors. Food and drink are typically withheld for a period of time prior to surgery to prevent aspiration of fluid into the lungs during anesthesia. Anesthesia and pain medication used during surgery slow peristalsis, and it often takes time to return to normal. Slow peristalsis can cause nausea, vomiting, and constipation. Until the patient is able to pass gas and bowel sounds return, the patient is typically ordered to have nothing by mouth (NPO). If a patient experiences prolonged NPO status, such as after significant abdominal surgery, intravenous fluids and nutrition may be required.
Surgery also stimulates the physiological stress response and increases metabolic demands, causing the need for increased calories. The stress response can also cause elevated blood glucose levels due to the release of corticosteroids, even if the patient has not been previously diagnosed with diabetes mellitus. For this reason, nurses often monitor post-op patients’ bedside blood glucose levels carefully.
Bowel resection surgery in particular has a negative impact on nutrient absorption. Because all or parts of the intestine are removed, there is decreased absorption of nutrients, which can result in nutrient deficiencies. Many patients who have experienced bowel resection require nutrient supplementation.
Bariatric surgery is used to treat obesity and reduce obesity-related cardiovascular risk factors. Bariatric procedures alter the anatomy and physiology of the gastrointestinal tract, which makes patients susceptible to nutritional deficiencies. [ 65 ] Read more about bariatric surgery and long-term nutritional issues using the hyperlink in the following box.
Metabolic demands impact nutrient intake. In conditions where metabolic demands are increased, such as during growth spurts in childhood or adolescence, nutritional intake should be increased. Disease states, such as cancer, hyperthyroidism, and AIDS, can increase metabolism and require an increased amount of nutrients. However, cancer treatment, such as radiation and chemotherapy, often causes nausea, vomiting, and decreased appetite, making it difficult for patients to obtain adequate nutrients at a time when they are needed in high amounts due to increased metabolic demand.
Other diseases like diabetes mellitus cause complications with nutrient absorption due to insulin. Insulin is necessary for the metabolism of fats, proteins, and carbohydrates, but in patients with diabetes mellitus, insulin production is insufficient or their body is not able to effectively use circulating insulin. This lack of insulin can result in impaired nutrient metabolism.
Alcohol and drug abuse can affect nutritional status. Alcohol is calorie-dense and nutrient-poor. With alcohol use, the consumption of water, food, and other nutrients often decreases as patients “drink their calories.” This may result in decreased protein intake and body protein deficiency. Nutrient digestion and absorption can also decrease with alcohol consumption if the stomach lining becomes eroded or scarred. This can cause hemoglobin, hematocrit, albumin, folate, thiamine, vitamin B12, and vitamin C deficiencies, as well as decreased calcium, magnesium, and phosphorus levels. [ 67 ]
Drug abuse of stimulants, such as methamphetamine and cocaine abuse, causes an increased metabolic rate and decreased appetite and contributes to weight loss and malnourishment.
Various psychological states have a direct effect on appetite and a patient’s desire to eat. Acute and chronic stress stimulates the hypothalamus and increases production of glucocorticoids and glucose. This can increase the person’s appetite, causing increased calorie intake, fat storage, and subsequent weight gain. When a person feels stressed, their food choices are often nutrient-poor and calorie-dense, which further increases weight gain and nutrient deficiencies. In other individuals, the stress response causes loss of appetite, weight loss, and nutrient deficiencies. [ 68 ]
Depression can cause loss of appetite or overeating. Many people eat calorie-dense “comfort foods” as a coping mechanism. Additionally, many antidepressants can cause weight gain as a side effect.
This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 ↵.
This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 ↵.
“Digestive-41529 _1280.png” by Sarahguess5 is licensed under CC0 ↵.“Eat-Foods-Low-on-the-Glycemic-Index-Step-1-Version-2.jpg” by unknown is licensed under CC BY-NC-SA 3.0. Access for free at https://www .wikihow.com /Eat-Foods-Low-on-the-Glycemic-Index#aiinfo ↵.
Brazier, Y. (2020, December 10). How much protein does a person need? Medical News Today. https://www .medicalnewstoday .com/articles/196279 ↵.
“Protein-rich_Foods .jpg” by Smastronardo is licensed under CC BY-SA 4.0 ↵.Healthwise. (2020, December 17). Types of fats. Michigan Medicine at University of Michigan. https://www .uofmhealth .org/health-library/aa160619 ↵.
Healthwise. (2020, December 17). Types of fats. Michigan Medicine at University of Michigan. https://www .uofmhealth .org/health-library/aa160619 ↵.
Healthwise. (2020, December 17). Vitamins: Their functions and sources. Michigan Medicine at University of Michigan. https://www .uofmhealth .org/health-library/ta3868 ↵.
Healthwise. (2020, December 17). Vitamins: Their functions and sources. Michigan Medicine at University of Michigan. https://www .uofmhealth .org/health-library/ta3868 ↵.
Healthwise. (2020, December 17). Vitamins: Their functions and sources. Michigan Medicine at University of Michigan. https://www .uofmhealth .org/health-library/ta3868 ↵.
Healthwise. (2020, December 17). Vitamins: Their functions and sources. Michigan Medicine at University of Michigan. https://www .uofmhealth .org/health-library/ta3868 ↵.
Healthwise. (2020, December 17). Vitamins: Their functions and sources. Michigan Medicine at University of Michigan. https://www .uofmhealth .org/health-library/ta3868 ↵.
Healthwise. (2020, December 17). Vitamins: Their functions and sources. Michigan Medicine at University of Michigan. https://www .uofmhealth .org/health-library/ta3868 ↵.
MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated 2020, Oct 19]. Minerals; [reviewed 2015, Apr 2; cited 2021, Mar 5]. https://medlineplus .gov/minerals.html ↵.
U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
“ MyPlate_blue.png ” by USDA is licensed under CC0 ↵ .U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
USDA MyPlate. (n.d.). What’s on your plate? U.S. Department of Agriculture. https://www .myplate.gov/ ↵.
“MyPlate_blue .png” by USDA is licensed under CC0 ↵. “MyPlate_Vietnamese .png” by USDA is licensed under CC0 ↵.U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
“front_en .3.400.jpg” by openfoodfacts-contributors is licensed under CC BY-SA 3.0 ↵.U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
“Culinary _fruits_cropped_top_view.jpg” by Bill Ebbesen is licensed under CC BY 3.0 ↵.U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
“Good_Dairy_Sources .png” by Brookepinsent is licensed under CC BY-SA 4.0 ↵.U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
“Hypothalamus .jpg” by Methoxyroxy~commonswiki is in the Public Domain ↵.Human Nutrition by University of Hawai’i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0 ↵.
Human Nutrition by University of Hawai’i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0 ↵.
Dindyal, S., & Dindyal, S. (n.d.). How personal factors, including culture and ethnicity, affect the choices and selection of food we make. Internet Scientific Publications, 1(3). https://ispub .com/IJTWM/1/2/11779 ↵.
Alkerwi A., Vernier C., Sauvageot N., Crichton G., Elias M. Demographic and socioeconomic disparity in nutrition: Application of a novel correlated component regression approach. BMJ Open. 2015; 5 (5) https://www .ncbi.nlm .nih.gov/pmc/articles/PMC4431064/ ↵ [PMC free article : PMC4431064 ] [PubMed : 25967988 ]
Lupoli R., Lembo E., et al. Bariatric surgery and long-term nutritional issues. World Journal of Diabetes. 2017; 8 (11):464–474. ↵ [PMC free article : PMC5700383 ] [PubMed : 29204255 ] [CrossRef]
Lupoli R., Lembo E., et al. Bariatric surgery and long-term nutritional issues. World Journal of Diabetes. 2017; 8 (11):464–474. ↵ [PMC free article : PMC5700383 ] [PubMed : 29204255 ] [CrossRef]
Ulrich-Lai Y. M., Fulton S., Wilson M., Petrovich G., Rinaman L. Stress exposure, food intake and emotional state. Stress (Amsterdam, Netherlands). 2015; 18 (4):381–399. https://www .ncbi.nlm .nih.gov/pmc/articles/PMC4843770 ↵ [PMC free article : PMC4843770 ] [PubMed : 26303312 ]
Now that we have discussed basic nutritional concepts, dietary guidelines, and factors affecting nutritional status, let’s apply the nursing process to this information when caring for patients.
A thorough nutritional assessment provides information about an individual’s nutritional status, as well as risk factors for nutritional imbalances. Assessment starts with reviewing the patient’s medical record and initiating a patient interview, followed by a physical exam and review of lab and diagnostic test results.
Subjective assessments include questions regarding normal eating patterns and risk factor identification. Subjective assessment data is obtained by interviewing the patient as a primary source or a family member or caregiver as a secondary source. While a wealth of subjective information can be obtained through a chart review, it is important to verify this information with either the patient or family member because details may be recorded inaccurately or may have changed over time. Subjective information to obtain when completing a nutritional assessment includes age, sex, history of illness or chronic disease, surgeries, dietary intake including a 24-hour diet recall or food diary, food preferences, cultural practices related to diet, normal snack and meal timings, food allergies, special diets, and food shopping or preparation activities.
A detailed nutritional assessment can also provide important clues for identification of risk factors for nutritional deficits or excesses. For example, a history of anorexia or bulimia will put the patient at risk for vitamin, mineral, and electrolyte disturbances, as well as potential body image disturbances. Swallowing impairments place the patient at risk for decreased intake that may be insufficient to meet metabolic demands. Use of recreational drugs or alcohol places the patient at risk for insufficient nutrient intake and impaired nutrient absorption. Use of nutritional supplements places the patient at risk for excess nutrient absorption and potential toxicity. Recognizing and identifying risks to nutritional status help the nurse anticipate problems that may arise and identify complications as they occur. Ideally, the nurse will recognize subtle cues of impending or actual dysfunction and prevent bigger problems from happening.
Objective assessment data is information derived from direct observation by the nurse and is obtained through inspection, auscultation, and palpation. The nurse should consider nutritional status while performing a physical examination.
The nurse begins the physical examination by making general observations about the patient’s status. A well-nourished patient has normal skin color and hair texture for their ethnicity, healthy nails, a BMI within normal range according to their height, and appears energetic.
Height and weight should be accurately measured and documented. Height and weight in infants and children are plotted on a growth chart to give a percentile ranking across the United States. The infant or child should show a trend of consistent height and weight increase.
Height and weight in adults are often compared to a Body Mass Index (BMI) graph. BMI can also be calculated using the following formulas:
BMI = weight (kilograms)/height(meters) 2 BMI = weight (pounds) x 703)/height(inches) 2To calculate BMI using a BMI table, the patient’s height is plotted on the horizontal axis and their weight is plotted on the perpendicular axis. The BMI is measured where the lines intersect. See Figure 14.11 [ 1 ] for an image of a BMI table. BMI is interpreted using the following ranges:
After completing the subjective and objective assessment, the data should be analyzed for expected and unexpected findings. See Table 14.3a for a comparison of expected versus unexpected assessment findings related to nutritional status on assessment, including those that require notification of the health care provider in bold font.
Expected Versus Unexpected Findings During Nutritional Assessment [ 3 ]
Diagnostic and lab work results can provide important clues about a patient’s overall nutritional status and should be used in conjunction with a thorough subjective and objective assessment to provide an accurate picture of the patient’s overall health status. Common lab tests include hemoglobin (hgb), hematocrit (HCT), white blood cells (WBC), albumin, prealbumin, and transferrin.
Anemia is a medical condition diagnosed by low hemoglobin levels. Hemoglobin is important for oxygen transport throughout the body. Anemia can be caused acutely by hemorrhage, but it is often the result of chronic iron deficiency, vitamin B12 deficiency, or folate deficiency. Iron supplements, B12 injections, folate supplements, and increased iron or folate intake in the diet can help increase hemoglobin levels.
Albumin and prealbumin are proteins in the bloodstream. They maintain oncotic pressure so that fluid does not leak out of blood vessels into the extravascular space. (Read more about oncotic pressure in the “Fluids and Electrolytes” chapter.) Albumin and prealbumin levels are used as markers of malnutrition, but these levels can also be affected by medical conditions such as liver failure, kidney failure, inflammation, and zinc deficiency. Low albumin levels can indicate prolonged protein deficiency intake over several weeks, whereas prealbumin levels reflect protein intake over the previous few weeks. For this reason, prealbumin is often used to monitor the effectiveness of parenteral nutrition therapy. [ 4 ] , [ 5 ]
Transferrin is a protein required for iron transport on red blood cells. Transferrin levels increase during iron deficiency anemia and decrease with renal or liver failure and infection.
A patient’s amount of muscle wasting due to malnutrition is measured by a 24-hour urine creatinine level. [ 6 ] If insufficient calories are consumed, the body begins to break down its own tissues in a process called catabolism. Blood urea nitrogen and creatinine are released as a by-product. A 24-hour urine collection measures these by-product levels to assess the degree of catabolism occurring.
White blood cells will decrease with malnourishment, specifically with protein and vitamins C, D, and E and B-complex deficiencies. Low white blood cell counts place the patient at risk for infection because adequate white blood cells are necessary for a fully functioning immune system.
See Table 14.3b for a description of selected lab values associated with nutritional status. As always, refer to agency lab reference ranges when providing patient care.
Selected Lab Values Associated with Nutritional Status [ 7 ] , [ 8 ] , [ 9 ]
Various diagnostic tests may be ordered by the health care provider based on the patient’s medical conditions and circumstances. For example, a swallow study is a diagnostic test used for patients having difficulty swallowing. An abdominal X-ray is used to determine the correct placement of a feeding tube or to note any excess air or stool in the colon. A barium swallow is used in conjunction with a CT scan to note any blockages in the intestines.
A crucial amount of growth and development happens between birth to age two. For proper growth, development, and brain function, this age group requires nutrient-dense food choices, primarily because they eat so little compared to adults, but also because of their rapid growth rate that is higher than any other time of development. Ideally, newborns through age 6 months should be fed exclusively human breast milk if possible to develop immunity. Vitamin D and iron supplementation may be needed. [ 10 ] For the first two to three days after birth, human milk contains colostrum, a thick yellowish-white fluid rich in proteins and immunoglobulin A (IgA). Colostrum is lower in carbohydrates and fat than mature breast milk. Colostrum helps protect the newborn from infection and builds normal intestinal bacteria. As breast milk matures after two to three days postpartum, it becomes lower in proteins and IgA and higher in carbohydrates and fat. [ 11 ] Human donor milk may be used in some situations when the mother cannot breastfeed. If human donor milk is given, it should be sourced through an accredited human milk bank and pasteurized to minimize risk of spreading infectious diseases.
There are many reasons infants may not be breastfed, including insufficient breast milk production, a personal choice not to breastfeed, or adoption of the newborn. If breastfeeding or donor milk is not an option, an iron-fortified commercial infant formula should be used exclusively through at least 6 months of age. Homemade or non-FDA approved infant formulas or toddler formulas should not be used because they may not meet the high nutritional needs of infants. Infants fed 100% commercial infant formula will not need vitamin D supplementation. [ 12 ]
After about six months of age, infants should begin to be introduced to additional nutrient-dense complementary foods that are developmentally appropriate. Foods should be introduced one at a time to monitor for food sensitivities. Introducing food at this time is to provide a varied diet, additional nutrients, and an introduction to different flavors and textures of food. Research shows that introduction to certain allergy-risk foods, such as peanut butter prior to one year of age, helps decrease the risk of developing a peanut allergy later in life. It is important to strictly avoid honey and other unpasteurized food and drink before one year of age to prevent botulism and other bacteria. Additionally, cow’s milk, fortified soy drinks, and fruit or vegetable juices should not be introduced before 1 year of age . [13]
Growth rate continues to be rapid from ages one through five, requiring adequate nutrition to meet these growth and metabolic demands. Caloric and nutritional intake requirements increase proportionately with age, but unfortunately, the quality of diet tends to decrease proportionately with age. This is in part due to younger children being dependent on adults for nutritional choices and intake while older children and adolescents begin to make their own food choices as they enter school. Poverty can also negatively impact nutritional intake in children and adolescents. School lunch and breakfast programs help mitigate the effects of poverty on nutrition by providing free to low-cost, nutritionally-balanced meals. [ 14 ]
Healthy dietary habits formed in childhood through adolescence help prevent obesity, cardiovascular disease, diabetes mellitus, and other chronic diseases later in life. It is important to provide children with a variety of different foods prepared in different ways to increase the likelihood of children accepting and growing accustomed to different foods. It is common for children to become picky in their food choices or decide to only eat one or a few different food items over a period of time. Allowing children to help select and prepare food can increase their acceptance of different food choices. [ 15 ]
The adult life stage is ages 19 through 59. A major limiting factor to healthy nutrition in adults is development of poor nutritional habits early in life. These unhealthy diet habits can be very difficult to change due to food preferences, as well as lack of knowledge about proper nutrition. Metabolic rate and caloric needs decrease with increasing age. Females tend to require less caloric intake than males, though caloric and nutritional needs increase with pregnancy and breastfeeding. Without appropriate dietary intake or activity, weight gain will occur that can lead to obesity and other chronic diseases. Over 50% of Americans have one or more chronic diseases that are associated with poor diet and physical inactivity.
Education regarding a healthy diet, including appropriate calorie, saturated fat, sugar, and sodium intakes, helps improve health in adults. Roughly 73% of males and 70% of females in America exceed the recommended daily intake of saturated fat, and up to 97% of males and 82% of females exceed the recommended daily intake of sodium. Approximately 97% of males and 90% of women in America do not consume the recommended intake of dietary fiber, including underconsumption of fruits, vegetables, and whole grains, which contributes to diet-related chronic diseases.
Alcohol consumption can be problematic for maintaining a healthy diet. Chronic alcohol abuse can interfere with vitamin and mineral absorption and result in general malnourishment. Alcohol should be limited to one drink per day or less for women and two drinks or less per day for men. Alcohol should be avoided by those who are pregnant, breastfeeding, younger than 21 years old, have a chemical dependency, or have other underlying health conditions such as diabetes mellitus. [ 16 ]
A well-balanced, healthy diet is essential during pregnancy and lactation to prevent maternal, fetal, and newborn problems. Nutritional requirements, such as calories, vitamins, and minerals, increase during pregnancy and lactation. Increased caloric needs should be met with nutrient-dense foods rather than calorie-dense foods that are higher in fats and sugars. Prenatal vitamins and mineral supplements are often prescribed during pregnancy and lactation, in addition to a nutrient-rich diet, to help ensure women meet requirements for folic acid, iron, iodine, choline, and vitamin D. Folic acid is necessary to prevent neural tube defects in the fetus during the first trimester of pregnancy. Iron requirements increase during pregnancy to support fetal development and prevent anemia. Iodine requirements increase during pregnancy and lactation for fetal neurocognitive development. Choline requirements also increase due to the need to replace maternal stores, as well as for fetal brain and spinal cord development. [ 17 ]
People aged 65 years and older are considered older adults. Older adults are more likely to suffer from chronic illness and disease. Older adults have lower calorie needs than younger people, though they still need a diet full of nutrient-dense foods because their nutrient needs increase. Caloric needs decrease due to decreased activity, decreased metabolic rates, and decreased muscle mass. Chronic disease and medication can contribute to decreased nutrient absorption. Protein and vitamin B12 are commonly under consumed in older adults. Protein is necessary to prevent loss of muscle mass. Vitamin B12 deficiency can be a problem for older adults because absorption of vitamin B12 decreases with age and with certain medications. Adequate hydration is also a concern for older adults because feelings of thirst decrease with age, leading to poor fluid intake. Additionally, older adults may be concerned with bladder dysfunction so they may consciously choose to limit fluid intake. Loneliness, ability to chew and swallow, and poverty can also decrease dietary intake in older adults. [ 18 ] Meals on Wheels, local senior centers, and other community programs can provide socialization and well-balanced meals to older adults.
The Mini-Nutritional Assessment Short-Form is a screening tool used to identify older adults who are malnourished or at risk of malnutrition. Use the hyperlink in the following box to download this tool.
After the assessment stage is conducted, data is analyzed, and pertinent information is clustered together, nursing diagnoses are selected based on defining characteristics. When creating a care plan for a patient, review a current nursing care planning source for current NANDA-I approved nursing diagnoses and interventions related to nutritional imbalances. NANDA-I nursing diagnoses related to nutrition include Imbalanced Nutrition: Less than Body Requirements, Overweight, Obesity, Risk for Overweight, Readiness for Enhanced Nutrition, and Impaired Swallowing. [ 20 ] See Table 14.3c for additional information related to the diagnosis Imbalanced Nutrition: Less than Body Requirements. [ 21 ]
Sample NANDA-I Nursing Diagnosis Related to Nutrition [ 22 ]
A sample nursing diagnosis written in PES format is, “Imbalanced Nutrition: Less than Body Requirements related to insufficient dietary intake as evidenced by body weight 20% below ideal weight range and food intake less than recommended daily allowance.”
Goals for patients experiencing altered nutritional status depend on the selected nursing diagnosis and specific patient situation. Typically, goals relate to resolution of the nutritional imbalance and are broad in nature. An overall goal related to nutritional imbalances is, “The patient will weigh within normal range for their height and age.” [ 23 ]
Outcome criteria are specific, measurable, achievable, realistic, and time-oriented. A sample SMART goal is, “The patient will select three dietary modifications to meet their long-term health goals using USDA MyPlate guidelines by discharge.” [ 24 ]
After SMART outcome criteria are customized to the patient’s situation, nursing interventions are selected to help them achieve their identified outcomes. Interventions are specific to the alteration in nutritional status and should accomodate the patient’s cultural and religious beliefs. The box below outlines selected interventions related to nutrition therapy.
Determine in collaboration with the dietician, the number of calories and types of nutrients needed to meet nutritional requirements, as appropriate
Determine food preferences with consideration of the patient’s cultural and religious preferences Encourage nutritional supplements, as appropriateProvide patients with nutritional deficits high-protein, high-calorie, nutritious finger foods and drinks that can be readily consumed, as appropriate
Determine need for enteral tube feedings in collaboration with a dietician Administer enteral feedings, as prescribed Administer parenteral nutrition, as prescribed Structure the environment to create a pleasant and relaxing meal atmosphere Present food in an attractive, pleasing manner, giving consideration to color, texture, and variety Provide oral care before meals Assist the patient to a sitting position before eating or feeding Implement interventions to prevent aspiration in patients receiving enteral nutrition Monitor laboratory values, as appropriate Instruct the patient and family about prescribed diets Refer for diet teaching and planning, as appropriate Give the patient and family written examples of prescribed dietPatients may be prescribed special diets due to medical conditions or altered nutrition states. See Table 14.3d for commonly prescribed special diets.
Commonly Prescribed Special Diets
“Thickened liquids” are typically prescribed for patients with difficulty swallowing (dysphagia). Three consistencies of thickened liquids are:
Nectar-thick liquids: Easily pourable liquid comparable to apricot nectar or thick cream soups. Honey-thick liquids: Slightly thicker liquid that is less pourable and drizzles from a cup or bowl.Pudding-thick liquids: Liquids that hold their own shape. They are not pourable and usually require a spoon to eat.
Nurses often thicken liquids in the patient’s room using a commercial thickener. Most commercial thickeners include directions for achieving the consistency prescribed.
Enteral nutrition is administered directly to a patient’s gastrointestinal tract while bypassing chewing and swallowing. Enteral feedings are prescribed for patients when chewing and/or swallowing are impaired or when there is poor nutritional intake and/or malnutrition.
Examples of enteral tube access are nasogastric tubes (NG), orogastric tubes (OG), percutaneous endoscopic gastrostomy (PEG) tubes, or percutaneous endoscopic jejunostomy (PEJ) tubes. See Figure 14.12 [ 26 ] for an illustration of common enteral tube placement. Nasogastric tubes enter the nare and travel through the esophagus and into the stomach. Liquid tube feedings are infused through this tube and directly into the stomach. Orogastric tubes work in the same manner except they are inserted through the mouth into the esophagus and then into the stomach. Orogastric tubes are typically used with mechanically intubated and sedated patients and should never be used in conscious patients because they can induce a gag reflex and cause vomiting. PEG tubes are inserted through the abdominal wall directly into the stomach, bypassing the esophagus. PEG tubes are used when there is an obstruction to the esophagus, the esophagus has been removed, or if long-term enteral feedings are expected. PEJ tubes are inserted through the abdominal wall directly into the jejunum, bypassing the esophagus and stomach. PEJ tubes are used when all or part of the stomach has been removed or if the provider determines PEJ placement would best suit the patient’s needs.
Enteral Tube Access
There are several safety considerations for nurses to implement when enteral nutrition is being administered to prevent aspiration and dehydration. Tube placement must be verified after insertion, as well as before every medication or feeding is administered, to prevent inadvertent administration into the lungs if the tube has migrated out of position. Follow agency policy regarding checking placement. The American Association of Critical‐Care Nursing recommends that the position of a feeding tube should be checked and documented every four hours and prior to the administration of enteral feedings and medications by measuring the visible tube length and comparing it to the length documented during X-ray verification. Older methods of checking tube placement included observing aspirated GI contents or the administration of air with a syringe while auscultating (commonly referred to as the “whoosh test”). However, research has determined these methods are unreliable and should no longer be used to verify placement. [ 27 ] , [ 28 ]
In addition to verifying tube placement before administering feedings or medications, nurses perform additional interventions to prevent aspiration. The American Association of Critical‐Care Nurses recommends the following guidelines to reduce the risk for aspiration:
Maintain the head of the bed at 30°- 45° unless contraindicated Use sedatives as sparingly as possible Assess feeding tube placement at four‐hour intervals Observe for change in the amount of external length of the tube Assess for gastrointestinal intolerance at four‐hour intervals [ 29 ] , [ 30 ]Measurement of gastric residual volume (GRV) is often performed when a patient is receiving enteral feeding by using a 60-mL syringe to aspirate stomach contents through the tube. GRVs in the range of 200–500 mL have traditionally triggered nursing interventions, such as slowing or stopping the feeding, to reduce the patient’s risk of aspiration. However, according to recent research, it is not appropriate to stop enteral nutrition for GRVs less than 500 mL in the absence of other signs of intolerance because of the impact on the patient’s overall nutritional status. Additionally, the aspiration of gastric residual volumes can contribute to tube clogging. Follow agency policy regarding measuring gastric residual volume and implementing interventions to prevent aspiration. [ 31 ] , [ 32 ]
Patients receiving enteral nutrition should be monitored daily for signs of tube feeding intolerance, such as abdominal bloating, nausea, vomiting, diarrhea, cramping, and constipation. If cramping occurs during bolus feedings, it can be helpful to administer the enteral nutritional formula at room temperature to prevent symptoms. Notify the provider of signs of intolerance with anticipated prescription changes regarding the type of formula or the rate of administration.
Electrolytes and blood glucose levels should also be monitored for signs of imbalances. Carbohydrates in tube feedings are absorbed quickly, so blood glucose levels are monitored, and elevated levels are typically treated with sliding scale insulin according to health care provider orders.
Parenteral nutrition is nutrition delivered through a central intravenous line, generally the subclavian or internal jugular vein, to patients who require nutritional supplementation but are not candidates for enteral nutrition. Parenteral nutrition is an intravenous solution containing glucose, amino acids, minerals, electrolytes, and vitamins. A lipid solution is typically given in a separate infusion in a hospital setting. This combination of solutions is called total parenteral nutrition because it supplies complete nutritional support. Parenteral nutrition is administered via an IV pump.
Because parenteral nutrition consists of concentrated glucose, amino acids, and minerals, it is very irritating to the blood vessels. For this reason, a large central vein must be used for administration. The patient’s lab work must also be closely monitored for signs of nutrient excesses. See Figure 14.13 [ 33 ] for an image of home parenteral nutrition formula. In this image are three compartments: one with glucose, one with amino acids, and one with lipids. The three compartments are kept separate to enable storage at room temperature, but are mixed together before use.
Total Parenteral Nutrition
Parenteral nutrition is typically used when the patient’s intestines or stomach is not working properly and must be bypassed, such as during paralytic ileus where peristalsis has completely stopped, or after postoperative bowel surgeries, such as bowel resection. It may also be prescribed for severe malnutrition, severe burns, metastatic cancer, liver failure, or hyperemesis with pregnancy.
When implementing interventions to promote good nutrition, it is vital to consider the patient’s cultural and religious beliefs. Encourage patients to make healthy food selections based on their food preferences.
If a patient has nutritional deficit, perform nursing interventions prior to mealtime to promote their appetite. For example, if the patient has symptoms of pain or nausea, administer medications prior to mealtime to manage these symptoms. Do not perform procedures that may affect the patient’s appetite, such as wound dressing changes, immediately prior to meal time. Manage the environment prior to the food arriving and remove any unpleasant odors or sights. For example, empty the trash can of used dressings or incontinence products. If the patient is out of the room when the meal tray arrives and the food becomes cold, reheat the food or order a new meal tray.
When assisting patients to eat, help them to wash their hands and use the restroom if needed. Assist them to sit in a chair or sit in high Fowler’s position in bed. Set the meal tray on an overbed table and open containers as needed. Encourage the patient to feed themselves as much as possible to promote independence. If a patient has vision impairments, explain the location of the food using the clock method. For example, “Your vegetables are at 9 o’clock, your potatoes are at 12 o’clock, and your meat is at 3 o’clock.” When feeding a patient, ask them what food they would like to eat first. Allow them to eat at their own pace with time between bites for thorough chewing and swallowing. If any signs of difficulty swallowing occur, such as coughing or gagging, stop the meal and notify the provider of suspected swallowing difficulties.
It is always important to evaluate the effectiveness of interventions implemented. Evaluation helps the nurse and care team determine if the interventions are appropriate for the patient or if they need to be revised. Table 14.3e provides a list of assessment findings indicating that alterations of nutritional status are improving with the planned interventions.
Evaluation of Alterations in Nutritional Status
Hood, W. A. (2020, September 25). Nutritional status assessment in adults technique. Medscape. https://emedicine .medscape .com/article/2141861-technique ↵.
Hood, W. A. (2020, September 25). Nutritional status assessment in adults technique. Medscape. https://emedicine .medscape .com/article/2141861-technique ↵.
MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated 2020, Nov 30]. Prealbumin blood test; [reviewed 2020, Nov 30; cited 2021, Mar 5]. https://medlineplus .gov /lab-tests/prealbumin-blood-test/ ↵.
Simons S. R., Abdallah L. M. Bedside assessment of enteral tube placement: Aligning practice with evidence. American Journal of Nursing. 2012; 112 (2):40–46. ↵ [PubMed : 22261653 ] [CrossRef]
Hood, W. A. (2020, September 25). Nutritional status assessment in adults laboratory medicine. Medscape. https://emedicine .medscape .com/article/2141861-labs ↵.
Hood, W. A. (2020, September 25). Nutritional status assessment in adults laboratory medicine. Medscape. https://emedicine .medscape .com/article/2141861-labs ↵.
Ignativicius, D. D., Workman, M. L., & Rebar, C. (2018). Medical surgical nursing: Concepts for interprofessional collaborative care (9th ed.). Elsevier. ↵.
U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
This work is a derivative of StatPearls by Bryant & Thistle and is licensed under CC BY 4.0 ↵.U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www .dietaryguidelines.gov/ ↵.
The Hartford Institute for Geriatric Nursing, New York University, Rory Meyers School of Nursing. (n.d.). Assessment tools for best practices of care for older adults. https://hign .org/consultgeri-resources /try-this-series ↵.
Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, pp. 157, 158, 169-174. ↵.
Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, pp. 157, 158, 169-174. ↵.
Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, pp. 157, 158, 169-174. ↵.
Ackley, B., Ladwig, G., Makic, M.B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier, pp. 651-657. ↵.
Ackley, B., Ladwig, G., Makic, M.B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier, pp. 651-657. ↵.
Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing Interventions Classification (NIC). Elsevier, p. 272. ↵.
“Types and Placement of Enteral Tubes” by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵.
Simons S. R., Abdallah L. M. Bedside assessment of enteral tube placement: Aligning practice with evidence. American Journal of Nursing. 2012; 112 (2):40–46. ↵ [PubMed : 22261653 ] [CrossRef]
Boullata J. I., Carrera A. L., Harvey L., Escuro A. A., Hudson L., Mays A., McGinnis C., Wessel J. J., Bajpai S., Beebe M. L., Kinn T. J., Klang M. G., Lord L., Martin K., Pompeii‐Wolfe C., Sullivan J., Wood A., Malone A., Guenter P. ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition. 2017; 41 (1):15–103. ↵ [PubMed : 27815525 ] [CrossRef]
Simons S. R., Abdallah L. M. Bedside assessment of enteral tube placement: Aligning practice with evidence. American Journal of Nursing. 2012; 112 (2):40–46. ↵ [PubMed : 22261653 ] [CrossRef]
Boullata J. I., Carrera A. L., Harvey L., Escuro A. A., Hudson L., Mays A., McGinnis C., Wessel J. J., Bajpai S., Beebe M. L., Kinn T. J., Klang M. G., Lord L., Martin K., Pompeii‐Wolfe C., Sullivan J., Wood A., Malone A., Guenter P. ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition. 2017; 41 (1):15–103. ↵ [PubMed : 27815525 ] [CrossRef]
Simons S. R., Abdallah L. M. Bedside assessment of enteral tube placement: Aligning practice with evidence. American Journal of Nursing. 2012; 112 (2):40–46. ↵ [PubMed : 22261653 ] [CrossRef]
Boullata J. I., Carrera A. L., Harvey L., Escuro A. A., Hudson L., Mays A., McGinnis C., Wessel J. J., Bajpai S., Beebe M. L., Kinn T. J., Klang M. G., Lord L., Martin K., Pompeii‐Wolfe C., Sullivan J., Wood A., Malone A., Guenter P. ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition. 2017; 41 (1):15–103. ↵ [PubMed : 27815525 ] [CrossRef]
“Tpn_3bag .jpg” by Tristanb in English Wikipedia is licensed under CC BY-SA 3.0 ↵.Mr. Curtis is a 47-year-old patient admitted to the hospital with increased weakness, fatigue, and dehydration. His skin appears dry, and tenting occurs when skin turgor is evaluated. He is currently undergoing chemotherapy treatment for multiple myeloma and has experienced weight loss of 10 pounds within the last two weeks. He describes that “nothing tastes good,” and he feels as if there is “metal taste in his mouth.” When he does eat small meals, he reports that he is often nauseous. The patient’s serum protein level is 3.1 g/dL.
Assessment: The nurse identifies that the patient is experiencing signs of imbalanced nutrition with the signs of increased weakness, fatigue, and signs of dehydration such as skin tenting and dryness. The patient has demonstrated a significant weight loss over the past two weeks and reports “nothing tastes good” and “a metal taste in the mouth.” The patient also reports nausea after eating. His serum protein level reflects signs of malnutrition.
Based on the assessment information that has been gathered, the following nursing care plan is created for Mr. Curtis:
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements r/t insufficient dietary intake as manifested by weight loss of 10 pounds in the last two weeks, skin tenting and dryness, reports of “nothing tastes good,” and serum protein of 3.1 g/dL.
Overall Goal: The patient will demonstrate improvement in nutrition intake.
SMART Expected Outcome: Mr. Curtis will eat 50% of offered meals and demonstrate dietary tolerance within 24 hours.
Planning and Implementing Nursing Interventions:
The nurse will validate the patient’s feelings regarding his current symptoms and provide emotional support. The nurse will determine the time of day when the patient’s appetite is highest and offer the highest calorie meal at that time. The nurse will offer high-calorie protein shakes to the patient at frequent intervals. The nurse will assess the patient’s food preferences and ensure that small frequent meals are offered that incorporate those preferences. The nurse will also encourage the use of plastic utensils and encourage the patient to eat mints or chew gum to minimize the metallic taste in the mouth.
Mr. Curtis demonstrates signs of imbalanced nutrition: less than body requirements. He reported a significant weight loss of 10 pounds over the past two weeks associated with chemotherapy. He reports feeling nauseous following small meals. He also reports “nothing tastes good” and having “a metal taste in the mouth.” He demonstrates signs of weakness, fatigue, and dehydration. Interventions have been implemented to increase the patient’s nutritional intake.
Twenty-four hours later, the nurse evaluates Mr. Curtis and finds he is able to consume 50% of breakfast with his preferred dietary items. Planned interventions will continue and the nurse plan to reevaluate his progress the following day.
(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
Mr. Jones is a 67-year-old patient on the medical surgical floor who recently underwent a bowel resection. He is post-op Day 2 and has been NPO since surgery. He has been receiving IV fluids but has been asking about when he can resume eating.
What assessments should be performed to determine if the patient’s diet can be progressed?
What are the first steps during dietary transition from NPO status?
Scenario 2 [ 1 ]
Mrs. Casey is a 78 year-old widow who recently had a stroke and continues to experience mild right-sided weakness. See Figure 14.14 for an image of Mrs. Casey. [ 2 ] She is currently receiving physical therapy in a long-term care facility and ambulates with the assistance of a walker. Mrs. Casey confides, “I am looking forward to going home, but I will miss the three meals a day here.”
Her height is 5’2″ and she weighs 84 pounds. Her recent lab work results include the following:
Hgb: 8.8 g/dL, WBC 3500, Magnesium 1.4 mg/dL, Albumin 1.0 g/dL
What is Mrs. Casey’s BMI and what does this number indicate?
Analyze Mrs. Casey’s recent lab work and interpret the findings.
Describe focused assessments the nurse should perform regarding Mrs. Casey’s nutritional status.
Create a PES nursing diagnosis statement for Mrs. Casey based on her nutritional status.
Create a SMART outcome statement for Mrs. Casey.
Outline planned nutritional interventions for Mrs. Casey while she is at the facility, as well as when she returns home.
How will you evaluate if your nursing care plan is successful for Mrs. Casey?
“Nutrition Case Study” by Susan Jensen for Lansing Community College are licensed under CC BY 4.0
A measure of weight categories including underweight, normal weight, overweight, and obese taking height and weight into consideration.
Foods with a substantial amount of calories and few nutrients.
Sugars and starches that provide an important energy source, providing 4 kcal/g of energy.
Breakdown of food with stomach acids, bile, and pancreatic enzymes for nutrient release.
Broken-down food that has undergone chemical digestion in the stomach.
A thick yellowish-white fluid rich in proteins and immunoglobulin A (IgA) and lower in carbohydrates and fat than mature breast milk secreted within the first 2-3 days after giving birth.
Proteins with enough amino acids in enough quantities to perform necessary functions such as growth and tissue maintenance. These must be ingested in the diet.
Larger molecules of polysaccharides that break down more slowly and release sugar into the bloodstream more slowly than simple carbohydrates.
Dietary Reference Intakes (DRIs)
Set requirements or limit amounts of a certain nutrient, including proteins, carbohydrates, fats, vitamins, minerals, and fiber.
Liquid nutrition given through the gastrointestinal tract via a tube while bypassing chewing and swallowing.
Nutrients that must be ingested from dietary intake. Essential nutrients cannot be synthesized by the body.
Vitamins that dissolve in fats and oils and are stored in fat tissue and can build up in the liver, resulting in toxicity. Fat-soluble vitamins include vitamins A, D, E, and K.
Fatty acids and glycerol that are essential for tissue growth, insulation, energy source, energy storage, and hormone production. Fats provide 9 kcal/g of energy.
A measure of how quickly plasma glucose levels are released into the bloodstream after carbohydrates are consumed.
Proteins that do not contain enough amino acids to sustain life. Incomplete proteins can be combined with other types of proteins to add to amino acids consumed to form complete protein combinations.
Breast milk production.
Minerals needed in larger amounts and measured in milligrams, grams, and milliequivalents.
Nutrients needed in larger amounts due to energy needs. Macronutrients include carbohydrates, proteins, and fats.
The chewing of food in the mouth.
Breaking food down into small chunks through chewing prior to swallowing.
The net loss or gain of nitrogen excreted compared to nitrogen taken into the body in the form of protein consumption; an indicator of protein status where a negative nitrogen balance equates to a protein deficit in the diet and a positive nitrogen balance equates to a protein excess in the diet.
Foods with a high proportion of nutritional value relative to calories contained in the food.
An intravenous solution containing glucose, amino acids, minerals, electrolytes, and vitamins, along with supplemental lipids.
Partially complete proteins
Proteins that have enough amino acids to sustain life, but not enough for tissue growth and maintenance. Typically interchanged with incomplete proteins.
Coordinated muscle movements in the esophagus that move food or liquid through the esophagus and into the stomach or coordinated muscle movements in the intestines that move food/waste products through the intestines.
Sources of peptides, amino acids, and some trace elements that provide 4 kcal/g of energy. Proteins are necessary for tissue repair, tissue function, growth, fluid balance, and clotting, as well as energy in the absence of sufficient intake of carbohydrates.
Grains that have been processed to remove parts of the grain kernel and supply little fiber.
Fats derived from animal products, such as butter, tallow, and lard for cooking, or from meat products such as steak. Saturated fats are generally solid at room temperature and can raise cholesterol levels, contributing to heart disease.
Small molecules of monosaccharides or disaccharides that break down quickly and raise blood glucose levels quickly.
Minerals needed in tiny amounts.
Fats that have been altered through hydrogenation and as such are not in their natural state. Fat is changed to make it harder at room temperature and to make it have a longer shelf life and contributes to increased cholesterol and heart disease.
Fats derived from oils and plants, though chicken and fish contain some unsaturated fats as well. Unsaturated fats are healthier than saturated fats, and some containing omega-3 fatty acids are considered polyunsaturated fats and help lower LDL cholesterol levels.
Vitamins that are not stored in the body and include vitamin C and B-complex vitamins: B1 (thiamine), B2 (riboflavin), B3 (niacin), B6 (pyridoxine), B12 (cyanocobalamin), and B9 (folic acid, biotin, and pantothenic acid). Toxicity is rare as excess water-soluble vitamins are excreted in the urine.
Grains with the entire grain kernel that supply more fiber than refined grains.
