Chapter 45
Nutrition
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Case Study
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Mrs. Gonzalez is a 65-year-old Hispanic woman
who comes to the emergency department with
slurred speech, right facial droop, and weakness
in her upper and lower right-side extremities.
She is admitted to the hospital with a diagnosis
of acute stroke.
She has a daughter and two teenage
grandchildren who live in another town nearby.
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Nutrients: The Biochemical
Units of Nutrition
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Basal metabolic rate (BMR)
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Resting energy expenditure (REE)
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Energy needed at rest to maintain life-sustaining
activities for a specific amount of time
Amount of energy needed to consume over 24-hour
period for the body to maintain internal working
activities while at rest
Nutrients

Energy necessary for the normal function of
numerous body processes
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Nutrients: The Biochemical
Units of Nutrition (Cont.)
Carbohydrates
Complex and simple saccharides
Main source of energy
Proteins
Amino acids
Necessary for nitrogen balance
Fats
Saturated, polyunsaturated, and
monounsaturated
Calorie-dense
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Scientific Knowledge Base:
Nutrients (Cont.)
Water
All cell function depends on a fluid environment
Vitamins
Essential for metabolism
Water-soluble or fat-soluble
Minerals
Catalysts for enzymatic reactions
Macrominerals; trace elements
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Digestion

Mechanical
breakdown that
results from chewing,
churning, and mixing
with fluid and
chemical reactions in
which food reduces to
its simplest form
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Absorption
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The small intestine, lined with fingerlike
projections called villi, is the primary absorption
site for nutrients.
The body absorbs nutrients by means of passive
diffusion, osmosis, active transport, and
pinocytosis.
Absorption of carbohydrates, protein, minerals,
and water-soluble vitamins occurs in the small
intestine.
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Metabolism and Storage
of Nutrients
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Metabolism
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Anabolism
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All biochemical reactions within the cells of the body
Building of more complex biochemical substances by
synthesis of nutrients
Catabolism
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Breakdown of biochemical substances into simpler
substances; occurs during physiological states of
negative nitrogen balance
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Elimination
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Chyme moves by peristaltic action through the
ileocecal valve into the large intestine, where it
becomes feces.
Water absorbs in the mucosa as feces move
toward the rectum.
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Dietary Guidelines
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Dietary reference intakes
(DRIs)
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Acceptable range of
quantities of vitamins and
minerals for each gender
and age group
Food guidelines
Daily values

Needed protein, vitamins,
fats, cholesterol,
carbohydrates, fiber,
sodium, and potassium
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Case Study (Cont.)
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Mrs. Gonzales is awake and alert in her hospital
room, yet is drooling from the right side of her mouth.
When she tries to drink water, she starts to cough.
The physician has ordered nothing by mouth (NPO).
Evaluation by the speech language pathologist (SLP)
indicates inadequate clearance of food and liquid
from the vocal folds and aspiration of thickened
liquids.
Mrs. Gonzalez has trouble swallowing with
oropharyngeal dysphagia. The SLP recommends
enteral feedings, and speech and swallowing therapy
to help her return to oral feedings.
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Quick Quiz!
1. A 22-year-old new mother is breastfeeding.
You ask her if she is taking the correct
quantities of nutrients. Which statement
reflects that she understands the dietary
guidelines?
A. “I am not concerned with what I am eating.”
B. “I am taking vitamin doses based on TV.”
C. “I am taking a daily MVI.”
D. “I am making eating choices according to the
recommended dietary allowances.”
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Nursing Knowledge Base
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Factors influencing nutrition
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Environmental factors
Developmental needs
• Infants through school age

Breastfeeding, formula, solid foods
• Adolescents
• Young and middle adults
• Older adults
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Case Study (Cont.)
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
Matt is a nursing student assigned to Mrs. Gonzalez. As
he prepares to assess her, he recalls information about
the effects of dysphagia on nutrition and rehabilitation.
He will assess Mrs. Gonzales’ weight, weight history, diet
history, and cultural customs.
Matt knows to consult with a registered dietitian (RD) to
assess Mrs. Gonzales’s nutritional status and
interventions. Matt is responsible for inserting Mrs.
Gonzalez’s small-bore nasogastric feeding tube and
starting her tube feedings. The RD has recommended
continuous tube feeding for 12 hours during the day.
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Alternative Food Patterns
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Based on religion, cultural background, ethics,
health beliefs, and preference
Vegetarian diet consists predominantly of plant
foods:
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Ovolactovegetarian (avoids meat, fish, and poultry,
but eats eggs and milk)
 Lactovegetarian (drinks milk but avoids eggs)
 Vegan (consumes only plant foods)
 Zen macrobiotic
 Fruitarian (consumes fruit, nuts, honey, and olive oil)
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Critical Thinking
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Synthesis of knowledge, experience, information
Apply professional standards
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DRIs
USDA MyPlate dietary guidelines
Healthy People 2020
American Heart Association
American Diabetes Association
American Cancer Society
American Society for Parenteral and Enteral Nutrition
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Assessment

Through the patient’s
eye
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Assess patient’s
nutritional history.
Ask patient about food
preferences, values
regarding nutrition,
and expectations from
nutritional therapy.
Screening
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Assessment (Cont.)
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Anthropometry is a measurement system of the
size and makeup of the body.
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An ideal body weight (IBW) provides an estimate of
what a person should weigh.
Body mass index (BMI) measures weight corrected
for height and serves as an alternative to traditional
height–weight relationships.
Laboratory and biochemical tests.
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Assessment (Cont.)
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Dietary and health history
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Health status; age; cultural background; religious food
patterns; socioeconomic status; personal food
preferences; psychological factors; use of alcohol or
illegal drugs; use of vitamin, mineral, or herbal
supplements; prescription or over-the-counter (OTC)
drugs; and the patient’s general nutrition knowledge
Physical examination
Dysphagia (difficulty swallowing)
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Case Study (Cont.)
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Assessment findings:
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Mrs. Gonzales starts to cough when she tries to drink
water.
Mrs. Gonzales is unable to swallow and aspirates pills
and thickened liquid.
Lung sounds are clear. Respirations are regular at
12/min. She has no dyspnea. Oxygen saturation is
96% on room air.
Enteral nutrition will begin at 60 mL/hr.
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Nursing Diagnosis
Risk for
aspiration
Readiness for
enhanced
nutrition
Diarrhea
Feeding selfcare deficit
Deficient
knowledge
Impaired
swallowing
Imbalanced nutrition: less than body requirements
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Case Study (Cont.)
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Diagnosis: Risk for aspiration related to impaired
swallowing
Goals:

Mrs. Gonzales will receive adequate nutrients through
enteral tube feeding without aspiration by the time of
discharge.
 Mrs. Gonzalez will regain swallowing ability from
speech therapy by the time of discharge.
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Planning
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Goals and outcomes
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Reflect a patient’s physiological, therapeutic, and
individualized needs
Setting priorities
Teamwork and collaboration
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Discharge planning
Enteral tube feedings
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Implementation
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Health promotion
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Education
Early identification of potential or actual problems
Meal planning
Weight loss plans
Food safety
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Implementation
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Acute care
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Risk factors in acutely
ill patient
Advancing diets =
Gradual progression of
dietary intake or
therapeutic diet to
manage illness
Promoting appetite
Assisting with oral
feedings
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Enteral Tube Feeding
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Enteral nutrition (EN) provides nutrients into the
GI tract. It is physiological, safe, and economical
nutritional support.
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Nasogastric, jejunal, or gastric tubes
Surgical or endoscopic placement
•
•
•
•
•
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Nasointestinal
Gastrostomy
Jejunostomy
PEG (percutaneous endoscopic gastrostomy)
PEJ (percutaneous endoscopic jejunostomy)
Risk of aspiration
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Enteral Access Tubes

When patients are unable to ingest food but
are still able to digest and absorb nutrients, the
use of enteral tube feeding is supported
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Case Study (Cont.)
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Nutritional management
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Aspiration precautions
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Insert feeding tube as ordered.
Initiate enteral feeding as prescribed.
Advance tube feeding as tolerated; monitor for
tolerance.
Position Mrs. Gonzalez with head of bed elevated a
minimum of 30 degrees.
Check tube placement every 4 to 6 hours.
Check gastric residual volume every 4 hours.
Continue with speech therapy.
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Quick Quiz!
2. You receive an order to begin enteral tube
feedings. The first step is to:
A. place the patient in a prone position.
B. irrigate the tube with normal saline.
C. check to see that the tube is properly placed.
D. introduce a small amount of fluid into the
tube before feeding.
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Parenteral Nutrition
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Nutrients are provided
intravenously
Patients unable to digest
or absorb enteral nutrition
or are in highly stressed
physiological states
Peripheral or central line
Initiating parenteral
nutrition
Preventing complications
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Restorative and Continuing Care
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Medical nutrition therapy (MNT)
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Specific nutritional therapy usage for treating illness,
injury, or a certain condition
Necessary for
• Metabolizing certain nutrients
• Correcting nutritional deficiencies
• Eliminating foods that worsen disease states

Most effective with collaborative health care team and
dietitian
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Medical Nutrition Therapy
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Gastrointestinal diseases
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Peptic ulcer etiology
• Helicobacter pylori
• Stress
• Acid overproduction
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Peptic ulcer treatments
• Avoid caffeine
• Avoid spicy foods
• Avoid aspirin, nonsteroidal antiinflammatory drugs
(NSAIDs)
• Consume small, frequent meals
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Medical Nutrition Therapy (Cont.)
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Gastrointestinal diseases
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Inflammatory bowel disease
• Crohn’s and idiopathic ulcerative colitis
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Elemental diets
Parenteral nutrition
Vitamins and iron supplements
Fiber increase
Fat reduction
Large meal avoidance
Lactose and sorbitol avoidance
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Case Study (Cont.)
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Matt must keep in mind that Mrs. Gonzalez will
progress to restorative care and return to oral
feedings, and also must consider cultural
preferences. Matt knows that food safety is an
important issue.
Matt consults the dietitian, and together they
develop a teaching plan regarding food safety
for the foods that Mrs. Gonzalez’s family will be
preparing at home.
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Medical Nutrition Therapy (Cont.)
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Diabetes mellitus
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Type 1: insulin and dietary restrictions
Type 2: exercise and diet therapy initially
•
•
•
•
•
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Individualized diet
Carbohydrate consistency and monitoring
Saturated fat less than 7%
Cholesterol intake less than 200 mg/dL
Protein intake 15% to 20% of diet
Goals
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Medical Nutrition Therapy (Cont.)
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Cardiovascular diseases
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American Heart Association (AHA) dietary guidelines
• Balance caloric intake and exercise.
• Maintain a healthy body weight.
• Eat a diet rich in fruits, vegetables, and complex
carbohydrates.
• Eat fish twice per week.
• Limit foods and beverages high in sugar and salt.
• Limit trans-saturated fat to less than 1%.
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Medical Nutrition Therapy (Cont.)
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Cancer and cancer treatment
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Malignant cells compete with normal cells for
nutrients.
Anorexia, nausea, vomiting, and taste distortions are
common.
Malnutrition associated with cancer increases
morbidity and mortality.
Radiation causes anorexia, stomatitis, severe
diarrhea, intestinal strictures, and pain.
Nutrition management.
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Medical Nutrition Therapy (Cont.)
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Human immunodeficiency virus (HIV)/acquired
immunodeficiency syndrome (AIDS)
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Body wasting and severe weight loss
Severe diarrhea, GI malabsorption, altered nutrient
metabolism
Hypermetabolism as a result of cytokine elevation
Maximize kilocalories and nutrients
Encourage small, frequent, nutrient-dense meals
with fluid in between
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Case Study (Cont.)
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What nursing actions are appropriate for
evaluating whether goals have been met?
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Consider the patient’s perspective.
Check measurable outcomes.
Consult with interdisciplinary staff.
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Evaluation
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Through the patient’s eyes
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Patients expect nurses to recognize when the
outcomes are unsuccessful and modify the plan
Patient outcomes
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Compare actual to expected
Use multidisciplinary collaboration
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Case Study (Cont.)
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Matt sees Mrs. Gonzalez before discharge to a
restorative care facility for rehabilitation before returning
home. Mrs. Gonzalez now is able to consume all of her
required nutrients with a ground diet and nectarthickened liquids. Matt removes the feeding tube in
preparation for her transport to the new facility.
Matt advises Mrs. Gonzalez to continue the care plan
and emphasizes that it is important to continue speech
therapy.
Matt also discusses the importance of compliance with
diet modifications until swallowing function returns
completely.
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