Nursing

Management in
Promoting Nutrition
 Overview of the
Anatomy and Physiology
of the Digestive System
 The GIT is composed of 2 general
parts:
 Main GIT: Mouth – Esophagus –
Stomach – Small intestines –
Large Intestines – Rectum
 Accessory Glands: Salivary gland,
Liver, Gallbladder, Pancreas
 Food and Fluid Regulatory
Center: HYPOTHALAMUS
Terminologies
 DIGESTION

•process by which food is broken down for the body to use in

growth, development, healing and prevention of diseases

 ABSORPTION

•process by which digested CHO, CHON, fats, minerals and

vitamins are actively and passively transported into organs and
tissues

 METABOLISM

•process by which nutrients are converted to energy to

support cellular growth and repair

 NUTRITION

• -study of nutrients and the processes by which they are used

by the body
MACRONUTRIENTS
1. Carbohydrates
2. Protein-
3. Fats
MICRONUTRIENTS
1. Vitamins
2. Minerals

CALORIE (KILOCALORIE)
-1 g (CHO) - 4 CAL
- 1 G (CHON) - 4 CAL
- 1 G (FAT) - 9 CAL
 2. Gender 3. Climate
1. Age and
(higher BMR (cold=higher
growth
in males) BMR)
Variable
affecting
Caloric Needs 4. Sleep
5. Activity 6. Fever
(lower BMR)

7. Illness
Review of Vitamins
Fat-soluble Vitamins:
• These vitamins are unaffected by
normal temperature and methods
of food preparation.
• Are found in the fats and oils of
foods.
• Are stored in the liver and in the
fatty tissues of the body for long
periods.
Water-soluble Vitamins:
• These vitamins are easily affected
by cooking process and exposure
to air.
• The body cannot store them in
large amounts as the kidneys filter
out any extra coming from the
diet.
Taxonomy Medical Name Sources Deficiency
A Retinol (animal) All yellow orange fruits Xerophthalmia- Night blindness
and vegetables
Carotene (Plants)
 
B1 Thiamine Rice, chicken, fish, nuts Wernicke’s encephalopathy– neuro disorder characterized by clinical
triad (confusion, ataxia and eye problem)
 Decreased level of consciousness due to increased intracranial
pressure
 Severe Body fatigue

B2 Riboflavin Eggs, eggplant, coconut Ariboflavinosis

  Cheilosis—Cracking at the side of the lips
 
B3 Niacin/ Nicotinic Acid/ Legumes, root crops, Pellagra
Nicotinamide cassava, avocado 3 signs of pellagra
1. Dementia
2. Dermatitis
3. Diarrhea
 

B5 Pantothenic Malunggay, all meat  Poor mental performance

 Stunted growth
 No energy or body malaise
 Liver failure (if severe)
 
B6 Pyridoxine Same as B2 Microcytic anemia- the presence of small, often hypochromic, red
blood cells
 
Peripheral neuritis- conditions that result when nerves that carry
messages to and from the brain and spinal cord from and to the
rest of the body are damaged or diseased
 Paresthesia
 Paralysis
 

B7 Biotin Corn, aubergine, pork Burning feet syndrome- also known as Grierson-Gopalan syndrome,
is a set of symptoms in which the feet often become uncomfortably
hot and painful.
 

B9 Folic acid/ Folate Milk Neural tube defect- are birth defects of the brain, spine, or spinal
cord.
 
B12 Cyanocobalamin (Only All vegetable, all meat Pernicious Anemia- condition in which the body can't make enough
absorbed in the intestines) healthy red blood cells because it doesn't have enough vitamin B12.
 
C Ascorbic Citrus Weak immune system
Scurvy, poor wound healing
 

D Calciferol Dried Fish, Milk, Osteomalacia, rickets

Anchovies, sardines
 

E Tocopherol Vegetable oil, nuts, Dry skin, comedones (skin-colored, small bumps (papules)
atis frequently found on the forehead and chin of those with acne),
sagged skin
 

K Phytomenadione/ Liver, passion fruit Bleeding

Aquamenadione
 

H Inactivated Biotin Same as b7 Burning feet syndrome

 
Review of Minerals
 1. ANTHROPOMETRIC MEASUREMENTS
 height
 weight (best indicator of nutritional status)
ASSESSMENT
 Skin folds (Fat folds)
OF
 Arm Muscle circumference
NUTRITIONAL
 Body Mass Index = wt in kg / (ht in meter)2
STATUS  BMI result:
• 20-25%----- Normal
• 27.5-30%--- Mild Obesity
• 30-40%----- Moderate Obesity
• Above 40%- Severe Obesity
2. Biochemical data
 Hgb and Hct indices
 -Serum Albumin
 -Nitrogen Balance
 -Creatinine Excretion

3. Clinical signs
•- hair, skin, tongue, mucous membrane, abdominal
girth
4. Dietary History
•- 24 hr diet recall; 72 hr diet recall
 1. Serve food in pleasant and attractive
manner
MEASURES TO 2. Place patient in a comfortable position
STIMULATE (SF/HF to prevent aspiration)

APPETITE 3. Provide good oral hygiene measures

4. Promote comfort
5. Remember that color affects color
6. Engage in pleasant conversation
7. Assist weak patient in feeding
 Position conscious clients in SF or HF position; unconscious
patients in lateral position to prevent aspiration

Provide good oral hygiene measures

NURSING
INTERVENTIONS Suction the mouth as needed if the client is unable to
FOR NAUSEA AND expel vomitus
VOMITING
Relieve nausea by offering the client:

• - ice chips
• - hot tea with lemon/ lime
• - hot ginger ale
• - dry toast or crackers
• - cold cola beverage
1. Replace loss fluid by hydration and IV therapy •- poor skin turgor

2. Observe for potential complications: •- altered LOC

a. DEHYDRATION •- elevated BUN, Crea

•- Thirst (first sign) •-elevated Hct

•- dry mouth and mucous membrane Acid-base balance

•- warm, flushed, dry skin • Metabolic Alkalosis: excessive vomiting

•- fever, tachycardia, low bp • Metabolic Acidosis: excessive diarrhea

•- weight loss

•- sunken eyeballs

•- oliguria

•- dark, concentrated urine

•- high urine SG
7. Administer antiemetic as ordered by the physician for vomiting
 Metoclopramide (Plasil)
 Trimethobenzamide (Tigan)
 Promethazine (Phenergan)
 Prochlorperazine maleate (Compazine)
Therapeutic Diet
 Normal diet that is modified to treat or cure diseases;
 Therapeutic = treat or cure
 Diet -food or beverages ingested for a special reason
Dietitian
 specialist in dietetics
 performs therapeutic and preventive roles
 works with both ill and healthy people
Nutritionist
 a specialist in the study of nutrition concerned with the study of nutrients, how
nutrients are used in the body and relationship between diet, health, and disease.
TYPES OF BASIC AND THERAPEUTIC DIETS

1. Regular / Standard / House Diet

 for patients who doesn’t have special needs or dietary modification
 Omitted: foods that produce flatus (cabbage), highly seasoned, and fried
foods

2. Diet as Tolerated (DAT)

 when patient’s appetite, ability to eat, and tolerance for food may change
 ex. 1st post op day patient may be given clear liquid. If no nausea occurs,
normal intestinal motility returned (active bowel sounds, passes gas, and feels
like eating) diet may be advanced to full liquid or regular diet
3. Cold Liquid Diet
 Purposes: Blood Clotting
o Post tonsillectomy
o Post thyroidectomy
o Post adenoidectomy
o Post dental extraction
 Cold Foods allowed
o Plain ice cream (vanilla)
o Sherbet
o Cold milk
o Cold Traditional Iced Tea
   CLEAR LIQUID FULL LIQUID
Purpose  Initial diet after complete bowel  Intermediate diet between clear
rest to: liquid & soft diet
o prevent and correct  Foods that melt or liquefy at
dehydration body temp
o relieve thirst  To provide additional calories to
clients who are unable to tolerate
o minimize gastric stimulation
solid foods.
 Provides fluid and
 Indications
carbohydrates (sugar)

Liquid Diets
o unable to tolerate solid or semi-
 Short – term diet for 24 – 36 hrs
solid foods
 Indications:
o GIT disturbances
o post surgery
o burns and illness
o acute inflammatory of GIT
 
(diarrhea, gastroenteritis,
pancreatitis)  
o burns and illness  
 Liquid Diets

Foods allowed  water, coffee (decaf/regular), tea  all in clear liquid diet
 carbonated drinks  milk and milk drinks
 fat free strained bouillon or broth (soup stock)  eggs (in pudding and custards)
 clear or diluted fruit juices (apple, grape,  plain ice cream, sherbet
cranberry)
 yogurt
 popsicles  orange juice
 gelatin  vegetable juices
 hard candy
 cream, butter, margarine, smooth peanut
butter
 strained cream soups

Foods not allowed  Dairy products and milk  

 Fruit juices with pulp
   SOFT DIET PUREED DIET
Purpose  diet after full liquid  Modification of soft diet
 easily chewed and digested  Any food that is added with
water and blended to produce a
 low – residue or low fiber diet semi-solid consistency
  To supply nutrition to clients

Indications with NGT or gastrostomy tubes
(osterized feeding – food is
o chewing and swallowing placed into a sterile bottle and
difficulties discarded after 24hrs)
o stroke patient

Modified
 
o mandibular fractures, broken Indications
jaw

Consistency o mobility or refused food as

obstruction of esophagus

Diets
o Anorexia nervosa
o Severe burns
o Comatose
 
 Modified Consistency Diets

Foods allowed  all foods in liquid diet  pureed and blended foods
lean, tender, cooked, minced ground meat, poultry, and
fish (chopped / shredded)
scrambled egg, omelet, poached eggs, cottage cheese,
and mild cheeses
low fiber fruits without skin and seeds (banana, mango,
sectioned orange, papaya)
low fiber cooked chopped vegetables (mashed potato,
carrots, chayote, squash)
Rice, Pasta, soft bread, soft cake, bread pudding

Foods not allowed long fibers, hard fried foods, highly seasoned, foods with  
skin/nuts/seeds, raw and gas forming fruits and
vegetables (apple, beans, cabbage, celery, onions,
cherries, coconut, egg plant, melons, onions, wheat)
 Content – Modified Diets

  High – Fiber or High Sodium Restricted Diabetic Diet

Residue
Purpose  To prevent and treat  To treat cardiovascular,  To control blood sugar level
constipation and renal, and liver disorder
diverticulitis  Diet varies with
individual, severity of
diseases type and
extent of insulin therapy
received.

Foods allowed  fruits (apples, oranges)
 vegetables (broccoli,
carrots, corn)
 whole grain (cereals,
wheat, grain)
 Fresh fruits and vegetables
 NO CANNED products,
seafoods, and dairy
products
 Balanced diet
 Use dietary list exchange
o 1 cup rice = 1 half burger
o 1 egg = ¼ cottage cheese
o 1 tsp margarine = 2 tsp
mayonaise
 Electrolyte Reinforced Diets

  High Potassium High Calcium High Phosphorous

Purpose  To maintain skeletal and  To provide rigidity and  To treat hypophosphotemia
cardiac muscle activity structure to bones  

Foods  Coffee  Dairy and milk products  Soft drinks

allowed
 Milk  Green leafy vegetables  Chocolate
 Meat  Small fish with bones  Milk
 Fruits (banana,  Tuna
cantaloupe, avocado,
 Sardines
raisins, strawberry)
 
 Vegetables
  Diet to allow stomach lining to heal (doesn’t stimulate gastric
secretion)
 Indications
o diarrhea
o indigestion
o gastritis
o gall bladder disease

Bland Diet o ulcer

 Foods Allowed
o mild flavour
o soft and smooth in texture
 Not Allowed
o Fibrous, hard meats, herbs and spices, coffee, tea,
citrus fruits, very hot and cold beverages
o strong flavoured vegetables (cabbage, onion, leek,
cauliflower, turnip)
Candidiasis Diet

 Free of:

o Fruits

o Fermented Foods

o Sugar

o Yeast
Acid – Ash Diet

 To alkalinize urine

 To soothe irritated bladder or urethra

 Foods: Citrus fruits and vegetables

 Not Allowed: Prune juice and cranberry juice (both produce acidic urine)
Ash – Acid Diet

 For UTI – to acidify urine

 Give protein, meat, poultry

Culture Related Diets (Religion and
Their Dietary Practices)
  HALAL KOSHER VEGAN Mormons Protestant Roman
s Catholic
 
Purpose To maintain To maintain dietary requirements To maintain dietary (The Church of (Greek  
dietary of Jewish Clients (Judaism/Jewish requirements of Jesus Christ of Orthodox)
requirements Faith) Seventh Day Adventist the latter day
of Muslim Clients saint)
Clients
(Islamic)
Foods No pork Kosher foods can’t be prepared Full Vegetarian diet No Coffee, No dairy Fasting
No gelatin using the utensils that was   Alcohol, Tea Products before
prepared in a non – kosher food   and meat communion
No alcohol May lead to VB12 during
  deficiency No pork and during
Fasting
Holy Week
Milk and meat are not eaten
 
together but may be eaten 6 – 12  
hrs apart No coffee, alcohol, tea,
 
 
Enteral Feeding

 Enteral nutrition is administered to prevent or correct

malnutrition and associated complications. It
provides adequate nutrition via the gastrointestinal
tract, through the delivery of complete
supplementary formulas.
 Indications
o Patient unable to swallow
o Patient unable or unwilling to consume adequate
nutrition orally
o The patient must have a functioning GI tract
 o Malfunctioning GI tract (i.e. short gut
syndrome, severe acute pancreatitis)
o Mechanical obstruction
o Prolonged ileus
Contraindications o Severe GI bleed
o Severe diarrhea/intractable vomiting
o GI tract fistula
o TPN should be considered instead for
patients with contraindications.
Route of Administration

1. Nasogastric (nose into stomach)

 This route is used most frequently due to ease of placement of the tube. This is for short-
term enteral feeding (usually less than or equal to 8-12 weeks).

2. Nasoduodenal (nose into duodenum)

 This route bypasses the stomach and administers feeding directly into the small bowel. The
main advantage of this route is less risk of aspiration and is used if gastric emptying is
impaired.

3. Nasojejuenal (nose into jejunum)

 This route bypasses the stomach and administers feeding directly into the small bowel. The
main advantage of this route is less risk of aspiration and is used if gastric emptying is
impaired.
4. Gastrostomy (feeding tube inserted through abdominal wall into stomach)
 This is the preferred method for long-term enteral feeding. Preferred for
patients who have an intact gag reflex, have normal emptying of gastric
and duodenal contents and whose stomach is not involved in the
primary disease.

5. Jejunostomy (feeding tube is inserted through abdominal wall into

jejunum)
 This route is used for long-term enteral feeding for patients with
impaired gastric emptying.
NASOGASTRIC TUBE (NGT)

• commonly used tube: LEVIN

TUBE

Purposes:
 to provide feeding (gastric
gavage)
 to irrigate stomach
(gastric lavage)
 For decompression
 administration of meds
 administer supplemental
fluid
Insertion procedure:

1. Inform patient and explain procedure.

2. Place in HF position to facilitate insertion.
3. Measure length of tube to be inserted starting from the tip
of the nose to the tip of the earlobe, to the xiphoid process).
4. Lubricate tip of catheter with water-soluble lubricant to
reduce friction. Oil based lubricant may cause lipid
pneumonia.
5. Hyperextend the neck and gently advance the catheter
toward the nasopharynx.
6. Tilt the patient’s head forward once the tube reaches the
oropharynx (throat)and ask the patient to swallow or sip
fluid as tube is advanced.
7. Secure the NGT by taping it to the bridge of the nose
after checking the tube’s placement.
 Administering Tube
Feeding (gastric
gavage)
1. Position pt in SF
2. Assess tube placement and patency
- introduce 5-20 ml of air into NGT and auscultate at the
epigastric area. Gurgling sound indicates patency
-aspirate gastric content (yellowish/greenish)
-immerse tip of the tube in water, no bubbles should be
produced
-measure pH of aspirated fluid (acid)
Note: the most effective method of checking the
NGT placement is radiograph verification.
3. Assess residual feeding contents. To assess absorption of
the last feeding, should be less than 50ml.
4. Introduce feeding slowly to
prevent flatulence, cramping and
vomiting.
5. Height of tube should be 12
inches above insertion point.
6. Instill 30-60 ml of water into the
NGT after feeding to cleanse the
lumen of the tube.
7. Clamp the NGT to prevent entry
of air into the stomach.
8. Maintain Fowler’s position for at
least 30 mins to prevent aspiration.
9. Document
Potential Side Effects

SIDE EFFECT REASON ACTIONS

DIARRHEA  Feedings are administered too quickly  Do not stop feedings
The patient has a lactose intolerance (All unless specifically
 ordered by the
formulas at WOHC are lactose free)
physician.
 A contaminated formula is administered (e.g.
formula is hung too long in sun or tubing not  Investigate potential
cleansed properly. ) causes and notify the
physician and
 Use of antibiotics may lead to overgrowth of C. dietician.
difficile toxin leading to frequent loose stools.
 Protein malnutrition (hypoalbuminemia)
 Malabsorption states
 Lack dietary fibre.
NAUSEA/VOMITING/BLOATING  Feedings are administered too quickly.  If vomiting occurs, stop
feeding, turn patient to
 Intolerance to concentration and/or volume exists.
the side, assess need
 Reduced gastric motility associated with gastric for suctioning and
retention. notify physician and
Feedings are too cold dietician.

 Paralytic ileus
 Obstruction

CONSTIPATION  Inadequate bulk in the diet  Reassess fluid status

and activity level
 Associated with medication therapy
 Notify physician and
 Reduced gastrointestinal motility
dietician
 Associated with decreased level of activity
 Inadequate fluid intake
 Advanced age
MECHANICAL  Skin and/or mucosal irritation
 Pressure against nares of nose
 Hypoallergenic tape
 Change dressings
once per day with
Normal Saline
 Secure taping of tube
Parenteral Nutrition

• Parenteral nutrition, or intravenous feeding, is a method of getting nutrition

into your body through your veins. Depending on which vein is used, this
procedure is often referred to as either total parenteral nutrition (TPN) or
peripheral parenteral nutrition (PPN).
• This form of nutrition is used to help people who can’t or shouldn’t get their
core nutrients from food. It is often used for people with: 
 Crohn’s disease
 cancer
 short bowel syndrome
 ischemic bowel disease
 It also can help people with conditions that result from low blood flow to their bowels.
 Parenteral nutrition delivers nutrients such as sugar, carbohydrates, proteins, lipids, electrolytes,
and trace elements to the body. These nutrients are vital in maintaining high energy, hydration, and
strength levels. Some people only need to get certain types of nutrients intravenously.