Oral Nutrition. Dysphagia
The
body requires the consumption of nutrients to support physiological activities
of digestion, absorption, and metabolism to maintain homeostasis. The
metabolism of nutrients (carbohydrates, proteins, fats, vitamins, and minerals)
plays an essential role in providing the body with the necessary substances to
maintain internal homeostasis.
PHYSIOLOGY OF NUTRITION
Nutrition
is the process by which the body metabolizes and utilizes nutrients. Nutrients
are classified as energy nutrients, organic nutrients, and inorganic nutrients;
see the accompanying display. Energy nutrients release energy for maintenance
of homeostasis. Organic nutrients build and maintain body tissues and regulate
body processes. Inorganic nutrients provide a medium for chemical reactions,
transport materials, maintain body temperature, promote bone formation, and
conduct nerve impulses. In the body, essentially all carbohydrates are
converted into glucose before they reach the cells, proteins are converted into
amino acids, and fats are converted into fatty acids. These nutrients are
digested, absorbed by the blood or lymphatic system, and transported to the
body’s cells. Inside the cells’ mitochondria, the nutrients react chemically
with oxygen and various enzymes to produce energy.
Digestion
Digestion
refers to the mechanical and chemical processes that convert nutrients into a
physically absorbable state. Figure 38-1 shows the anatomical structures of the
gastrointestinal (GI) tract (digestive tract). Figure 38-2 explains the
physiological mechanisms that support the digestive process in each anatomical
structure.
The
mouth prepares foodstuffs for digestion by mastication (chewing, tearing, or
grinding of food by the teeth into fine particles and the mixing with enzymes
in saliva). The salivary glands release lubricating secretions that bind with
food particles to facilitate swallowing.
Deglutition
(swallowing of food) begins in the mouth and continues in the pharynx and
esophagus. Peristaltic waves and mucous secretions move food down the
esophagus. Relaxation of the lower esophageal sphincter (gastroesophageal
constrictor muscle) allows food to enter the stomach; contraction of this sphincter
muscle prevents regurgitation (reflux) of stomach contents.
Digestion
begins in the stomach and is completed in the small intestines. This is
accomplished by specific substances entering the duodenum: pancreatic enzymes
through the pancreatic duct, bile through the common bile duct, and intestinal
enzymes produced in the jejunum. Peristalsis (coordinated, rhythmic, serial
contraction of the smooth muscle lining of the intestines) forces chyme (an
acidic, semifluid paste) through the small intestines to the large intestines
and promotes the absorption of vitamins, minerals, and water. Only
carbohydrates, proteins, and fats require chemical digestion by enzymatic
activity for absorption.
Absorption
Absorption
is the process by which the end products of digestion—monosaccharides (simple
sugars), amino acids, glycerol, fatty acid chains, vitamins, minerals, and
water—pass through the epithelial membranes in the small and large intestines
into the blood or lymph systems. Most absorption occurs in the small intestines
through the processes of osmosis, diffusion, and active transport; refer to
Figure 38-3. Water absorption occurs throughout the digestive tract.
The
main functions of the large intestines are to absorb water and collect food
residue (dietary fiber). Dietary fiber is the part of food that body enzymes
cannot digest and absorb, such as outer hulls of corn kernels, grains of wheat,
celery strings, and apple skins. Dietary fiber absorbs water in the large
intestine, promoting the formation of a soft, bulky stool that moves quickly
through the large intestine; some fiber is believed to bind cholesterol in the
colon, thus reducing the risk of heart attack (Townsend & Roth, 1999). In
healthy individuals, most of the end products of digestion are absorbed (99% of
carbohydrates, 95% of fat, and 92% of protein) and used by the body (Townsend
& Roth, 1999).
Metabolism
Metabolism is the
aggregate of all chemical reactions and processes in every body cell, such as
growth, generation of energy, elimination of wastes, and other bodily functions
as they relate to the distribution of nutrients in the blood after digestion.
The liver prepares nutrients
for their role in energy production. The liver converts all monosaccharides to
glucose and excess amino acids to urea, carbohydrates, or fats. Excess fats are
converted in the liver to glycerol and fatty acids, then to acetyl coenzyme A
(acetyl-CoA).
Glycolysis refers to the
breakdown of glucose by enzymes located inside the cell’s cytoplasm. This
process produces adenosine triphosphate (ATP) and pyruvate, which provide the
cell with energy. Pyruvate may be used in two different metabolic functions. In
aerobic metabolism, pyruvate enters the cell’s mitochondria and in the presence
of oxygen is converted to acetyl-CoA. In anaerobic metabolism (metabolism
without the presence of oxygen) lactate is produced in the cytoplasm by an
enzyme (lactate dehydrogenase); this type of metabolism takes place when the
oxygen supply is limited, as in the muscles and red blood cells, which lack
mitochondria.
When pyruvic acid is formed by
glycolysis, it is then converted into acetyl-CoA. This conversion begins a
cyclic metabolic pathway called the Krebs cycle (citric acid cycle or
tricarboxylic acid cycle). The Krebs cycle extracts energy through oxidation of
acetyl-CoA within the mitochondria of body cells. The Krebs cycle is a pathway
common to all energy nutrients because acetyl-CoA may be formed from
carbohydrates, proteins, and fats; refer to Figure 38-4.
Built into the inner
mitochondrial membrane is a series of molecules that assist in electron
transport during aerobic metabolism. The electron transport system converts
energy released from the Krebs cycle into ATP for use by cells in anabolism and
catabolism. Anabolism refers to the constructive phase of metabolism, in which
smaller molecules, such as amino acids, are converted to larger molecules, such
as proteins. Catabolism is the
destructive phase in which larger molecules, such as glycogen, are converted to
smaller molecules, such as pyruvic acid.
The rate of metabolism is
governed primarily by the hormones triiodothyronine (T3) and thyroxine (T4)
secreted by the thyroid gland. Hyperthyroidism refers to the increased
secretion of these thyroid hormones, which increases the rate of metabolism.
With hypothyroidism, a decrease in the secretion of thyroid hormones, the
metabolic rate is decreased.
Energy
Metabolic rate refers to the
rate of heat liberation during chemical reactions; it is expressed in units
called calories. A calorie is the quantity of heat required to raise the
temperature of 1 gram of water 1°C; it is used to express the quantity of
energy released from the different foods or expended by the different
functional processes of the body. Because a large quantity of energy is
released during metabolism, the energy is expressed in terms of kilocalories (kcal),
each of which is equivalent to 1000 calories.
The basal metabolic
rate (BMR) refers to the energy needed to maintain essential physiological
functions, such as respiration, circulation, and muscle tone, when a person is
at complete rest both physically and mentally.
Excretion
Digestive and metabolic waste
products are excreted through the intestines and rectum. Other excretory organs
are the kidneys, sweat glands, skin, and lungs. The skin and sweat glands
remove water, toxins, salts, and nitrogen wastes; the lungs remove carbon
dioxide and water.
NUTRIENTS
Understanding
the role of basic nutrients provides the foundation for selecting foods that
promote health. There are six categories of nutrients: water, vitamins,
minerals, carbohydrates, proteins, and lipids (fats). Selecting the healthiest forms of each of
these nutrients and eating them in proper balance enables the body to function
at its optimal level of health. Nutrients work synergistically; for example,
there is a cooperative action between certain vitamins and minerals,
that work as catalysts, promoting the absorption and assimilation of
other vitamins and minerals.
Water
Water
is the most abundant nutrient in the body and accounts for 60% to 70% of an
adult’s total body weight and 77% of an infant’s weight. It is a major
component of body fluids, secretions, and excretions. Body water decreases as
body fat increases and with aging. Water and electrolytes are substances that
must be acquired from the diet. In the
Normally,
the body maintains a balance between the amount of fluid taken in and the
amount excreted. The requirements for body water are met through the
consumption of liquids and foods and the oxidation of food. Solid foods,
especially fruits and vegetables, contain 85% to 95% water. The normal daily
turnover of water is 4% of an adult’s total body weight and 15% of an infant’s
total body weight.
Vitamins
Vitamins
are organic compounds that regulate cellular metabolism, assisting the biochemical
processes that release energy from digested food. Vitamins are called
micronutrients because they are needed in small quantities when compared with
other nutrients (water, carbohydrates, proteins, and fats). Vitamin
requirements are dependent on many factors, such as body size, amount of
exercise, rate of growth, and pregnancy; refer to Appendix B for the
recommended dietary allowances (RDAs) of vitamins.
Of
the major vitamins, some are classified as either fat-soluble or
water-soluble. Fat-soluble vitamins
(vitamins A, D, E, and K) require the presence of fats for their absorption
from the GI tract and for cellular metabolism and can be stored for longer periods of time in
the body’s fatty tissue and the liver. Watersoluble vitamins (vitamin C and B-complex
vitamins) require daily ingestion in normal quantities because these vitamins
are not stored in the body.
Certain
vitamins, mineral, and enzymes are classified as antioxidants, a substance that blocks
or inhibits destructive oxidation reactions, such as vitamins C and E, the
minerals selenium and germanium, and the enzymes catalase and superoxide
dismutase, coenzyme Q10, and some amino acids. Antioxidants help to protect the
body from the formation of free radicals, atoms or groups of atoms that can
cause damage to cells. Free radicals can impair the immune system and lead to
infections and certain degenerative diseases such as heart disease and cancer.
Free radicals are normally controlled by free radical scavengers, substances
that remove or neutralize free radicals. Certain enzymes (superoxide dismutase,
methionine reductase, catalase, and glutathione peroxidase) are free radical
scavengers that are produced by the body. Besides vitamins C, E, A, and
beta-carotene, certain herbs also act as antioxidants, such as bilberry,
ginkgo, grape seed extract, green tea, and flavonoids. Sprouted grains and
fresh fruits and vegetables contain antioxidants; however, in order to provide
the body with a sufficient quantity of antioxidants, supplements are often
needed by the body to control the free radicals (Fontaine, 2000). The
functions, clinical significance, and dietary sources of fat-soluble and
water-soluble vitamins are presented in Table 38-1.
Minerals
Minerals
(inorganic elements) serve as catalysts in biochemical reactions. Minerals are
classified according to their daily requirement: macrominerals (quantities of
100 mg or greater) and microminerals (trace elements, quantities less than 100
mg). The major macrominerals required by the body are calcium, phosphorus, and
magnesium. Microminerals such as copper, fluoride, iodine, iron, selenium, and
zinc play an essential role in metabolism.
For
example:
·
Copper and iron are needed for
hemoglobin formation.
· Copper is
needed for the synthesis of phospholipids and prostaglandin and for the
formation of some enzymes.
·
Iron is needed for the
synthesis of vitamins, purines, and antibodies.
·
Fluoride is required for teeth
formation and the prevention of dental caries.
·
Iodine is the basic component of
thyroid hormones.
·
Selenium enhances vitamin E
absorption and stimulates antibody response to infection.
· Zinc plays a major role in wound healing, maintains connective tissue
integrity, assists with the formation of enzymes and insulin, and boosts the immune
response and maintains normal blood concentrations of vitamin E. Zinc also aids
in the absorption of vitamin A, has antioxidant properties, and is a
constituent of the antioxidant enzyme superoxide dismutase.
Other
microminerals are arsenic, cadmium, nickel, silicon, tin, and vanadium;
however, the specific roles that these microminerals play in metabolism have
not been identified. Refer to Appendix B for the RDAs of minerals.
Carbohydrates
Carbohydrates
are organic compounds composed of carbon, hydrogen, and oxygen. They play a
significant role in providing cells with energy and supporting the normal
functioning of the body. Table 38-2 identifies the functions of carbohydrates
and the problems that result from insufficient intake.
Carbohydrates
are classified according to the number of saccharides (sugar units):
·
Monosaccharides (simple
sugars) include glucosee, galactose, and fructose.
· Disaccharides
(double sugars) include sucrose, lactose, and maltose.
·
Polysaccharides (complex
sugars) include glycogen, cellulose (fiber), and starch.
Glucose
supplies the major source of energy needed for cellular activity, such as
muscle contractions and nerve impulse transmission. When metabolized, every
gram of glucose yields 4 kcal. Glucose is also needed for the synthesis of
fatty acids and amino acids.
Carbohydrates
have a protein-sparing action, based on a minimum daily ingestion of 50 to 100
grams (200–400 kcal) to spare the metabolism of protein. When dietary intake is
below minimum requirement, triglycerides (lipid compounds consisting of three
fatty acids and a glycerol molecule) and proteins are metabolized to produce
energy. The three major sources of dietary carbohydrates are starches
(nonanimal foods, primarily grains), lactose (milk), and sucrose (cane sugar).
The ordinary diet contains far more starches than either lactose or sucrose.
Refer to Figure 38-2A for information on the digestion of these sugars.
Cells
are unable to store large quantities of carbohydrates. The liver converts
excess galactose and fructose into glucose and stores it in the form of
glycogen. Insulin (pancreatic hormone) aids in the diffusion of glucose into
the liver and muscle cells and in the synthesis of glycogen. Glucose metabolism
is dependent on the availability of insulin, as shown in Figure 38-5.
An
increase in blood glucose levels can cause hyperglycemia (a blood glucose level
greater than 110 mg/dl). This occurs in diabetes mellitus (a disease in which
the pancreas fails to secrete adequate levels of insulin to accommodate blood
glucose levels). When hyperglycemia occurs, ketones (the end product of incomplete
fat metabolism) build up in the bloodstream, causing metabolic acidosis.
In hypoglycemia,
the blood glucose level is below normal (less than 80 mg/dl) because the supply
of insulin is so high that most of the glucose moves from the blood into the
cells. Because brain tissue requires a constant source of glucose for energy,
hypoglycemia can alter the normal functions of the brain.
Glucose
(dextrose) is a common substance in intravenous therapy (dextrose-5%-water)
because it is readily absorbed into the body’s cells. This solution provides 170 kcal/L.
Proteins
Proteins
are organic compounds that contain carbon, hydrogen, oxygen, and nitrogen
atoms; some proteins also contain sulfur.
After water, proteins are the most abundant intracellular substance.
Proteins are essential for almost every bodily function, beginning with the
genetic control of protein synthesis, cell function, and cell reproduction; see
Table 38-2. The end products of protein digestion are amino acids.
The
normal blood concentration of amino acids is between 35 and 65 mg/dl. There are
20 identified amino acids, which are categorized as either essential or
nonessential:
Nonessential
amino acids can be synthesized (manufactured) in the cells; see the
accompanying display.
Essential
amino acids must be ingested in the diet because they cannot be synthesized in
the body; see the accompanying display.
Proteins
are also classified as complete or incomplete.
High-biological-value proteins (complete proteins) contain all of the
essential amino acids. Complete proteins are primarily animal proteins, such as
those in meats, poultry, fish, dairy products, and eggs.
Low-biological-value
proteins (incomplete proteins) lack one or more of the essential amino acids,
usually lysine, methionine, and tryptophan. Most vegetables are incomplete
proteins. By properly mixing complementary proteins in the diet, such as corn
and beans, one can produce a complete protein.
All
essential amino acids are needed by cells for anabolism and repair. The surplus
amino acids are sent back to the liver, where they are degraded (nitrogen is
split from the amino acid); the remaining parts are used for energy or
converted to carbohydrate or fat and stored as glycogen or adipose tissue.
Carbon dioxide, water, and nitrogen are the end products of amino acid
metabolism.
The
degradation of amino acids begins the process of deamination, the removal of
the amino groups from the amino acids. During protein deamination, several
other physiological processes of clinical significance occur:
1. Gluconeogenesis, the conversion of amino acids into glucose or glycogen
2.
Ketogenesis, the conversion of amino acids into
keto acids or fatty acids
3.
Nitrogen balance, the net
result of intake and loss of nitrogen that measures protein anabolism and
catabolism
4. Positive nitrogen balance, the condition that exists when nitrogen
intake exceeds output (protein anabolism exceeds catabolism)
5. Negative nitrogen balance, the condition that exists when nitrogen
output exceeds intake (protein catabolism exceeds anabolism)
6. Obligatory loss of proteins, the degrading of the body’s own proteins
into amino acids, which are then deaminated and oxidized (occurs when a person
fails to ingest adequate amounts of proteins)
Nitrogen
balance measures protein equilibrium and is used to evaluate the client’s
nutritional status. Clients on bed rest or with a fever are in a catabolic
state that produces a negative nitrogen balance. The muscle wasting that occurs
with immobility causes negative nitrogen balance. Massive trauma and burns are
other common examples of catabolic states that produce a negative nitrogen
balance initially upon injury. Diet therapy is directed toward providing
adequate amounts of proteins and kilocalories so that the body does not use its
own protein as an energy source.
Lipids
Lipids
(fats) are organic compounds that are insoluble in water but soluble in organic
solvents such as ether and alcohol. Lipids are composed of the same elements as
carbohydrates (carbon, hydrogen, and oxygen) but have a higher hydrogen
concentration. Refer to Table 38-2 for a discussion of the normal functions of
fats and the problems that arise from insufficient intake.
Fatty
acids are basic structural units of most lipids. They contain carbon chains and
hydrogen. Saturated fatty acids form
fats, glycerol esters of organic acids whose carbon atoms are joined by single
bonds (all the carbon atoms are saturated with hydrogen). Diets high in
saturated fats are associated with a high incidence of coronary heart disease.
Foods high in such fats are animal meats (especially beef), whole-milk
products, butter, most cheeses, and some plant fats, such as chocolate,
coconut, and palm oils.
Unsaturated
fatty acids form glycerol esters of organic acids whose carbon atoms are joined
by double or triple bonds (at least two carbon atoms in the fatty acid chains
in the esters are unattached to hydrogen atoms). Monounsaturated fatty acids
are fatty acids that form esters with one double or triple bond; foods in this
category are nuts, fowl, and olive oil. Polyunsaturated fatty acids form esters
that have many carbons unbonded to hydrogen atoms. Foods such as fish, corn,
sunflower seeds, soybeans, cottonseeds, and safflower oil contain such esters.
The
most important lipids follow:
·
Triglycerides are lipid
compounds composed of three fatty acid molecules attached to a glycerol
molecule.
· Phospholipids
are composed of one or more fatty acid molecules
and one phosphoric acid radical, and usually contain a nitrogenous base.
·
Cholesterol (a lipid that is
produced by the body and used in the synthesis of steroid hormones and excreted
in bile), is considered a fat and is found in whole milk and egg yolk.
Phospholipids
and cholesterol lipids constitute 2% of the total cell mass; they are basically
insoluble in water and are used to form membranous barriers that separate the
different intracellular compartments. The cell membrane is composed almost
entirely of proteins and lipids (phospholipids and cholesterol). Besides
phospholipids and cholesterol, some cells contain triglycerides, which account
for 95% of the fat cell mass. Triglycerides are the body’s main storehouse of
energy-giving nutrients; when dissolved, they can be used for energy as needed.
Most
dietary fats are triglycerides, found primarily in animal food. Most plant
foods contain trace elements of triglycerides. Other than butter fat, which is
digested by gastric lipase (tributyrase), essentially all fat digestion occurs
in the small intestines in the presence of pancreatic juices, as shown in Figure
38-2C.
When
free fatty acids, monoglycerides, free cholesterol, and phospholipids are
absorbed by the blood and lymph system, they are resynthesized into minute
molecules called
chylomicrons (lipoproteins, synthesized in the intestines, that
transport triglycerides to the liver).
Low-density
lipoproteins are responsible for the formation of atherosclerosis (a disease of the
arteries in which fatty lesions called atheromatous plaques develop inside the
wall of the arteries). A diet high in saturated fats and cholesterol causes the
formation of atherosclerosis. Almost half the deaths in the
PROMOTING PROPER NUTRITION
Hunger means a craving for
food and is a subjective sensation. For example, when a person has not eaten
for hours, the stomach undergoes intense rhythmic contractions called hunger
contractions. These contractions sometimes cause pain, in the form of hunger
pangs.
Hunger is not only a
physiological response; it also involves psychological sensations. For
instance, with a total gastrectomy (surgical removal of the stomach) clients
still report a craving for food.
Appetite means the desire for
specific types of food instead of food in general. A person’s appetite
determines the type of foods he or she eats. Satiety means a feeling of
fulfillment from food. It is the opposite of hunger and occurs when the
person’s nutritional stores have been replenished and psychological cravings
have been met.
Daily food guides have been
developed by various organizations to establish standards that promote
nutrition and health. These guides assist healthy persons in meal planning;
however, the guides do not take into account the nutritional needs arising from
metabolic and other medical disorders. Besides the American food guides, there
are guidelines developed by other countries—for instance,
Dietary Reference Intakes
and Recommended Daily Allowances
The recommended
dietary allowances (RDAs) are
recommended allowances of essential nutrients (protein, fatsoluble and
water-soluble vitamins, and minerals) by age category, inclusive of weight and
height. RDAs are established by the National Nutrition Board of the National
Academy of Sciences–National Research Council. RDAs represent the normal
nutritional needs of 97% to 98% of the people in each specific category; the
RDAs do not take into consideration an individual’s specific needs or
physiological disorders.
Although
RDAs have been in existence for the past 20 years as a nutritional guide to
support healthy persons, the Food and Nutrition Board, in partnership with
Health
The Food Guide Pyramid
The
food guide pyramid outlines in graphic presentation six groups of food and the
number of servings based on the dietary guidelines and the basic four food
groups, as shown in Figure 38-6. The pyramid suggests a variety of foods with
the right amount of calories and nutrients to maintain a healthy weight.
Societal Concerns
The
Leading Health Indicators for Healthy People 2010 report recognizes that
one-third of the
Modern
society has turned from a diet of whole grains, fruits, and vegetables to a
diet of processed foods, fast foods, additives, preservatives, and hydrogenated
oils that can have a damaging effect on a person’s health. Processed foods
usually contain excessive amounts of sodium that can cause fluid retention and
lead to hypertension, aggravating many medical disorders such as congested
heart failure, certain forms of kidney disorders and premenstrual syndrome
(PMS). Additives are placed in foods for one or more of the following reasons:
to lengthen shelf life; to make a food more appealing by enhancing color,
texture, or flavor; to facilitate food preparation; or to otherwise make the
product more marketable. Some additives are derived from natural sources such
as sugar, while other additives are made synthetically like aspartame
(NutraSweet). Although additives are usually identified on the “ingredient
label” of a product, they are initially used without health warnings. For
example, monosodium glutamate (MSG), and artifical sweeteners cyclamate,
saccharin, and aspartame are used without warning, but have been known to cause
headaches, diarrhea, confusion, memory loss, and seizures.
Genetically altering of the
world’s food has caused many persons to question the essential ingredients of
nutrients and the role of the U.S. Food and Drug Administration (FDA) in
regulating safe, healthy food products. Although the FDA in 1993 approved the
use of rBGH, a genetically engineered bovine growth hormone that makes dairy
cows produce 100% more milk than normal, Canadian health officials rejected a
major U.S. corporation’s request for approval of rBGH because the product label
acknowledges that it can cause udder infections, painful, debilitating foot
disorders, and reduced life span in treated cows. Humans who drink the milk
from cows treated with rBGH can develop breast or prostate cancer, as well as
other reproductive disorders and diseases.
The European Union’s
Scientific Committee on Veterinary Measures reported that 17 beta-oestradiol,
one of the six growth hormones that are used in 90% of all nonorganic beef
raised in the United States, is “a complete carcinogen.” American beef is
banned in
Weight Management
Maintaining homeostasis
requires a balance between intake of nutrients and energy expenditure. Average
weight is relative to energy balance, the situation in which energy intake
equals energy output.
Overweight
Overweight is an energy
imbalance in which more food is consumed than is needed, causing a storage of
fat. Overweight indicates a positive energy balance and is defined as weight
10% to 20% above average; obesity refers to weight 20% above average.
Overweight may result from one or more factors: genetic, psychological, social,
cultural, economic, or physiological. Genetically linked
factors, such as a low BMR, excess fat distribution, and obese parents, place
the person at risk for obesity. Some people overeat in response to
emotional stress or whenever food is available rather than in response to
hunger. Sociocultural norms influence eating habits; some cultures place a high
value on excess weight. Hormonal imbalances, such as decreased thyroxin levels,
can lower the BMR, causing weight gain if food intake remains constant.
Underweight
An underweight person expends
more calories than are consumed. Underweight, a negative energy balance, is
weight at least 10% to 15% below average. Being underweight decreases the
individual’s resistance to infection and increases susceptibility to fatigue
and sensitivity to cold environments.
Family dynamics and a fear of
fatness are psychological conditions that can contribute to eating disorders.
Anorexia nervosa
(self-starvation) disrupts metabolism because of inadequate calorie intake and
results in hair loss, low blood pressure, weakness, amenorrhea, brain damage,
and even death (Townsend & Roth, 1999). Bulimia nervosa refers to
food-gorging binges followed by purging of food, usually through self-induced
vomiting or laxative abuse. Underweight can also be caused by long-term
conditions that deplete the body’s resources, such as fever, infection, and
cancer, or that prevent nutrient absorption, as occurs with diarrhea, metabolic
or GI disorders, and laxative abuse. Other causes of underweight are
hyperthyroidism and poverty.
FACTORS AFFECTING
NUTRITION
Understanding
the factors that may influence nutrition is essential in eliciting client and
family cooperation in providing optimal nutritional care.
Age
Infants
and children vary in weight and energy requirements; refer to RDA, Appendix B.
The infant’s physiological development has implications for fluid, electrolyte,
and food intake that can predispose this age group to various imbalances. These
factors are directly related to the infant’s total body surface area, immature
physiologic development, and the rate of growth and development during the
first year of life.
From
ages 1 to 6 years, nutritional intake varies in relation to growth rate, making
the child’s eating habits erratic. The child will usually select foods based on
developmental nutritional needs in accord with:
·
High kilocalorie intake to
maintain energy requirements
·
Adequate levels of protein, vitamin D, calcium,
and phosphate to complement teeth eruption and an increase in muscle mass and
bone density
School-age
children can eat larger meals less frequently because of the digestive system’s
maturation and the presence of permanent teeth. A diet that supplies the RDAs
will promote optimal development and health and at the same time avoid weight
gains during the preadolescent period.
Adolescence,
a period of rapid growth and sexual maturation, requires guidance in dietary
choices. Hormonal changes associated with menstruation make girls prone to
fluid imbalance. Teenagers eat many of their meals away from home—for example,
in fast-food restaurants. Peer groups
influence a teenager’s choices, such as what, when, and where to eat. At the
same time, body image is of critical importance for teenagers. The social
pressures and other emotional stressors of adolescence may have a negative
effect on eating habits, leading to obesity, use of fad diets, and eating disorders
such as anorexia nervosa and bulimia.
During
adulthood, growth stops and metabolism declines, thereby decreasing the need
for kilocalorie intake. With pregnancy and lactation, the nutritional needs
once again increase. During pregnancy, changes occur that may result in fluid
retention (dependent edema); for example, hormonal changes, pressure of the
fetus on the inferior vena cava, vascular congestion, and increased capillary
filtration pressure.
The
aging process brings about structural and functional changes that may put older
adults at risk. The older population cannot be classified as a homogeneous
group, because people do not age physically at the same rate as they do
chronologically (Hogstel, 2001); refer to the Client Teaching Checklist for dietary
guidelines for the elderly.
Socioeconomic
factors, access to a grocery store, and lifestyle may affect the nutritional
status of older adults. Having to prepare their own food and eat alone are
other challenges the elderly face.
Lifestyle
Eating
is a social activity in most cultures. A person’s lifestyle may have a major
impact on food-related behaviors. Families with both parents working or with
children involved in sports and other activities might find it difficult to sit
down at the dinner table together for a home-cooked meal. When meals are eaten
on the run, they tend to be high in fat and carbohydrate content, and the
family misses the opportunity to be together and share important events of the
day.
Food
preferences are usually developed in childhood and modified throughout the life
span. Lifestyle nutritional behaviors often come from traditional family
practices. These practices affect not only food-related behaviors but also the
individual’s beliefs regarding health and wellness. If a person gets sufficient
rest, has the self-awareness to recognize stress, exercises regularly, and
avoids addictive behaviors, such as smoking and alcohol, he or she will usually
make healthy nutritional decisions.
Ethnicity, Culture, and
Religious Practices
Dietary
customs reflect the socialization and cultural patterns of ethnic groups
(Figure 38-9). Culture is evidenced by patterns of values and behaviors that
are characteristics of a particular group. Religious beliefs often dictate what
types of foods may be eaten and how they should be prepared.
Although
it is not possible to learn the nutritional behaviors for all ethnic groups,
recognize the need to comply with the client’s routine patterns (see the
accompanying display for nutritional behaviors of some ethnic groups).
Other Factors
There
are other factors that influence the types of foods selected and their
nutritional value. Economics exert a major influence on food selection; fresh
fruits and vegetables and lean meats are expensive and are often substituted
with products that tend to be low in protein and high in starch.
Food
preferences are an expression of an individual’s likes and dislikes. They may
be related to the texture of food, how it is prepared, or what was served to
the individual during childhood. However, preferences can also be an expression
of the person’s economic, ecological, ethical, or religious beliefs.
Vegetarians, for example, follow a diet of plant foods and may include eggs or
milk, depending on preference. A vegetarian diet is healthy when it includes a
wide variety of foods that supply adequate amounts of protein, vitamins, and
minerals.
Gender
may play a role in food selection, owing mainly to stereotyping (for example,
the idea that males eat meat and potatoes and females eat salads). Peer
pressures often dictate what teenagers eat. Stress, depression, and alcohol
abuse alter the appetite.
Medications
can alter food absorption and excretion and affect the taste of food. GI
disorders can cause anorexia, nausea, vomiting, diarrhea, constipation,
discomfort, and pain, all of which may alter eating habits and food
preferences.
ASSESSMENT
The
goals of a nursing assessment are to collect subjective and objective data
regarding the client’s nutritional status and to determine what type of
nutritional support is needed. Nurses are in a unique position to recognize
malnutrition, or alterations related to inadequate intake, disorders of
digestion or absorption, and overeating.
Assessment
must be performed in a logical fashion and should include three basic
components: nutritional history, physical examination with anthropometric
measurements, and diagnostic and laboratory data.
Nutritional History
The
nutritional history of clients experiencing alterations in nutrition and
metabolism is of critical importance in the development of the plan of care.
Several methods can be used in collecting these subjective data: 24-hour
recall, food frequency questionnaire, food record, and diet history; refer to Table
38-3 for an example of a nutritional history. Begin the history with a thorough
exploration of the client’s presenting problems as they relate to onset,
duration, nature, pattern, severity, associated symptoms, and efforts taken to
relieve the symptoms.
24-Hour Recall
The
24-hour recall requires client identification of everything consumed in the
previous 24 hours. It is performed easily and quickly by asking pertinent
questions. However, clients may be unable to recall their intake accurately or
anything atypical for their diet. Family members can often assist with these
data, if necessary.
Food-Frequency Questionnaire
The
food-frequency method gathers data relative to the number of times per day,
week, or month the client eats particular foods. The nurse can tailor the
questions to particular nutrients, such as cholesterol and saturated fat. This
method helps to validate the accuracy of the 24-hour recall and provides a more
complete picture of foods consumed.
Food Record
The
food record provides quantitative information regarding all foods consumed,
with portions weighed and measured for three consecutive days. This method
requires full client or family member cooperation.
Diet History
The
diet history elicits detailed information regarding the client’s nutritional
status, general health pattern, socioeconomic status, and cultural factors, as
presented in Table 38-3. This method incorporates information similar to that
collected by the 24-hour recall and food-frequency questionnaire. Inform the
client that the history might require more than one interview because of the
amount of data to be collected. Although the history data may indicate adequate
nutrition, clients must be reassessed periodically to prevent nutritional
problems from occurring. Fear, anxiety, or depression before or during
hospitalization may lead to poor food intake, which is the leading cause of
malnutrition.
Physical Examination
A
physical assessment requires decision making, problem solving, and
organization. This section presents the physical assessment findings that
suggest nutrient imbalance. “The nurse should be aware of rapidly proliferating
tissues such as hair, skin, eyes, lips, and tongue that usually show nutrient
deficiencies sooner than other tissues”(Hammond, 1999, p. 355). Refer to Table
38-4.
Intake and Output (I&O)
Intake
and output measurements and daily weights are critical components of a
nutritional assessment.
Anthropometric Measurements
Anthropometric
measurements (measurement
of the size, weight, and proportions of the body) evaluate the client’s
calorie-energy expenditure balance, muscle mass, body fat, and protein reserves
based on height, weight, skinfolds, and limb and girth circumferences.
Measurement of Height
and Weight
Measuring
height and weight is as important as assessing the client’s vital signs.
Routine measurement provides data related to growth and development in infants
and children and signals the possible onset of alterations that may indicate
illness in all age groups. The client’s height and weight are routinely taken
on admission to acute care facilities and on visits to physicians’ offices,
clinics, and in other health care settings.
Height
Measurement
of height is expressed in inches (in.), feet (ft), centimeters (cm), or meters
(m). See the accompanying display for conversion equivalents from one system to
another.
A
scale for measuring height, calibrated in either inches or centimeters, is
usually attached to a standing weight scale. This type of scale is used for
measuring the height of children and adults. The nurse should ask the client to
stand erect on the scale’s platform. The metal rod attached to the back of the
scale should be extended to gently rest on the top of the client’s head, and
the measurement should be read at eye level.
When
measuring an infant’s length, the nurse should place the child on a firm
surface. Extend the knees, with the feet at right angles to the table. Measure
the distance from the vertex (top) of the head to the soles of the feet with a
measuring tape. The procedure usually requires two nurses: one to hold the
infant still and the other to measure the length. If the nurse needs to perform
the measurement without assistance, an object should be placed at the infant’s
head, the infant’s knees should be extended, and a second object should be
placed at the infant’s feet. Lift the infant and measure the distance between
the two objects.
Height
increases gradually from birth to the prepubertal growth spurt. Girls usually
reach their adult height between the ages of 16 and 17 years, whereas boys
usually continue to grow until the ages of 18 to 20 years. The older adult
usually decreases in height as a result of a gradual loss of muscle mass and
changes in the vertebrae that occur in conditions such as osteoporosis (a
process in which reabsorption exceeds accretion of bone).
Weight
Measurement
of weight is expressed in ounces (oz), pounds (lb), grams (g), or kilograms
(kg); see the accompanying display for conversion equivalents.
Weight
increases gradually from birth until the prepubertal growth spurt. Height and
weight changes occur in the adolescent’s torso. The resulting redistribution of
body fat gives the body an adult appearance (see the accompanying display for
the normal ranges of body height and weight according to age). The loss of
muscle mass and changes in dietary habits usually cause weight loss in the
elderly.
When
a client has an order for “daily weight,” the weight should be obtained at the
same time of the day on the same scale, with the client wearing the same type
of clothing. Standing scales are used for clients who can bear their own weight
(Figure 27–2). The Nursing Checklist describes the procedure for calibrating a
scale and measuring the weight for children and adults (Figure 27–3).
Several
types of scales, such as stretcher, chair, and bed scales, are available for
clients who are unable to bear weight or are confined to a bed. Figure 27–4 shows a scale that
is equipped with a mechanical lift. A sheet should be placed between the
client’s skin and the surfaces of the belts.
Infants
can be weighed on platform or cradle scales. Before weighing the infant, the
nurse should make sure the room is warm. The infant’s clothing and diaper
should then be removed and the nurse should place a light blanket on the
scale’s surface. The nurse should face the infant, keeping one hand over the
top of the infant to prevent accidental injury while adjusting the scale with
the other hand. The reading should be noted as quickly as possible and the
nurse should return the infant to the crib and dress the child.
Nursing Considerations
Accurate
recordings of weight are imperative because they are used in drug dosage
calculations and to evaluate the effectiveness of drug, fluid, and nutritional
therapy. Weights above the normal range may indicate obesity or fluid
retention. Weights below the normal range may indicate malnutrition, delayed
growth and development, or cachexia (weight loss marked by weakness and
emaciation that usually occurs with a chronic illness such as tuberculosis or
cancer). Height is compared with weight to evaluate growth of infants and children.
Documentation
The
height and weight measurements are recorded on the appropriate form, such as
the admit assessment form. Daily weights are usually recorded on the vital
signs record. If the weight is taken at a different time or on a different scale,
the variation should be recorded.
Skinfold Measurements
Skinfold
measurement indicates the amount of body fat. This information is beneficial in
promoting health and determining risks and treatment modalities associated with
chronic illness and surgery. This assessment is usually performed in an
outpatient setting when the nurse develops a client’s profile. A special
caliper is used to measure skinfolds. The caliper should grasp only the
subcutaneous tissue, not the underlying muscle. Measurements can be taken of
the triceps, subscapular, biceps, and suprailiac skinfolds.
1. To measure the triceps fold, locate the midpoint of the upper arm.
Grasping the skin on the back of the upper arm, place the calipers 1 cm below your
fingers (Figure 38-10), and measure the thickness to the nearest millimeter.
2. For a subscapular skinfold measurement, grasp the skin below the scapula
with three fingers, angle the fold about 45°laterally to the scapula (Figure
38-11), place the caliber 1 cm above your fingers, and read the measurement.
It
is essential to document the skinfold sites, the type
of caliper used, and the measurement in millimeters.
Mid-Upper-Arm
Circumference
The
measurement of mid-upper-arm
circumference (MAC) serves as an index for skeletal muscle mass and protein
reserve. Instruct the client to relax and flex the forearm; with a measuring
tape, measure the circumference at the midpoint of the upper arm (Figure
38-12).
Abdominal-Girth
Measurement
When
made repeatedly over a span of time, an abdominal girth measurement serves as
an index as to whether abdominal distention is increasing, decreasing, or
remaining the same. With an indelible pen, place an X on the client’s abdomen
at the point of greatest distention. Using a measuring tape,
measure the abdomen’s circumference. This measurement should be
performed at the same time each day and consistently recorded in either inches
or centimeters.
Diagnostic and Laboratory
Data
Biochemical
data assessment is another essential source of objective data. Trends revealed
in laboratory results can be used to detect alterations in nutrition and
metabolism before clinical symptoms are assessed in the examination. Refer to
Chapter 28 for a detailed discussion of laboratory testing. No single
laboratory test is diagnostic of malnutrition.
Protein Indices
Several
tests that reflect protein synthesis can also reflect nutritional status. Serum
levels of albumin and transferring are used to identify protein-calorie
malnutrition.
Serum Albumin
Albumin
is synthesized in the liver from amino acids. Serum albumin plays an important
role in fluid and electrolyte balance and the transport of nutrients, hormones,
and drugs. However, serum albumin has a half-life of 21 days and fluctuates
according to the level of hydration; therefore, it is not a good indicator of
acute alterations in protein status. Clinically, this blood test is used to
measure prolonged protein depletion that occurs in chronic malnutrition, liver
disease, and nephrosis. Albumin levels below 3.5 g/dl may indicate some degree
of malnutrition.
Pre-Albumin
Research
has provided a newer, more accurate test to evaluate protein status. Pre-albumin (a precursor of albumin) has a
half-life of 2–3 days; it is used to determine protein depletion in acute
conditions, such as trauma and inflammation, and serves as a guide for
nutritional therapy. Pre-albumin levels between 15 mg/dl to 5 mg/dl reflect
mild to moderate protein depletion while levels below 5 mg/dl indicate severe
protein depletion.
Serum Transferrin
Transferrin
(nonheme iron) is a blood protein in combination with iron; it is used to
transport iron throughout the body to all cells. It is responsive to iron
stores, increasing when iron stores are low and decreasing when iron stores are
high. This test is considered a sensitive indicator of protein deficiency
because it responds promptly to changes in protein intake. Levels below 200
mg/dl may indicate mild to moderate protein depletion and below 100 mg/dl may
indicate severe depletion.
Hemoglobin Level
The
hemoglobin test measures the oxygen- and iron-carrying capacity of the blood;
the normal level is 12 to 15 g/100 ml. A decreased
hemoglobin may indicate some form of anemia, such as microcytic iron deficiency
anemia, or blood loss.
Total Lymphocyte Count
Another
test that may be used to measure protein depletion is total lymphocyte count.
Protein deficiency may cause a depression in the immune system, with a
resultant decrease in the total lymphocyte count; this can occur with severe
debilitating diseases, such as cancer or renal disease.
Nitrogen Balance
Nitrogen
balance studies indicate the degree to which protein is being depleted or
replaced in the body. The blood urea nitrogen (BUN) is increased with severe
dehydration, malnutrition, starvation, excessive protein intake, and most
commonly in kidney disease (the kidneys fail to excrete urea). A decreased BUN
results from a diet low in protein-rich foods.
Urine Creatinine Excretion
During
skeletal muscle metabolism, creatinine is released at a rate in proportion to
the total body mass. A 24-hour urine test is done to measure the total amount
of creatinine excreted by the kidneys. In malnutrition, the creatinine level is
decreased as a result of muscle atrophy.
NURSING DIAGNOSIS
In
order to make a nursing diagnosis, the nurse must interpret the subjective and
objective data and draw conclusions from the client’s assessment data obtained
during a comprehensive health history and physical examination. The approved
nursing diagnoses are discussed to assist with appropriate selection of primary
and secondary nursing diagnoses for clients with nutritional alterations.
Imbalanced Nutrition: Less Than
Body Requirements
An estimated 30% to 50% of
hospitalized clients are at risk for malnutrition; increased morbidity and
mortality rates are associated with malnutrition (McCloskey & Bulechek,
1999). The diagnosis Imbalanced Nutrition: Less Than Body Requirements exists when the client
fails to ingest or digest food or absorb nutrients. The Nursing Process
Highlight lists some possible causes of this nursing diagnosis.
Such clients may experience a
weight loss of 20% or more from their ideal weight. The dietary history may
reveal: inadequate food intake based on the RDAs; a lack of interest in or an
aversion to eating; perceived inability to ingest food; and a reduced energy
level.
Clients have poor muscle tone,
with skinfolds less than 60% of standard measurement, and may experience
difficulty in swallowing or masticating food, because of muscular weakness. The
conjunctive and mucous membranes are usually pale, and the buccal cavity is
sore and inflamed.
Imbalanced Nutrition: More Than
Body Requirements or Risk for More Than Body Requirements
Imbalanced Nutrition: More
Than Body Requirements exists when clients experience or are at risk for an
intake of nutrients that exceeds metabolic needs. Clients may be at risk
because of one or more of the following factors: hereditary predisposition or
obesity in one or both parents; dysfunctional psychological conditioning in
relationship to food, such as using food as a reward or comfort measure; and
age-related factors, most notably early infancy, adolescence, and aging.
Clients with more than body
requirements experience a weight gain of 10% to 20% over the ideal for height
and frame and triceps skinfolds greater than 15 mm in men and 23 mm in women.
The client’s dietary history may reveal a sedentary activity level and one or
more dysfunctional eating patterns: pairing food with other activities, such as
watching TV; concentrating the intake of food at night; eating in response to
internal cues (anxiety) or external cues (such as a social event) instead of in
response to hunger.
Other Nursing Diagnoses
The client who is
protein-depleted may also experience deficiencies in vitamins (especially A and
C) and minerals (especially zinc, magnesium, and iron). Refer to the
accompanying display for a listing of common secondary nursing diagnoses
related to nutritional and metabolic problems. Because the secondary diagnosis
is related to the nutritional/metabolic problem, it is written in terms of the
etiology of the primary diagnosis, for example, High Risk for Impaired Skin
Integrity: related to inadequate intake of proteins, vitamins, and minerals.
OUTCOME IDENTIFICATION AND PLANNING
The nurse relies heavily on
the data obtained from the nutritional history and collaborates with the client
and other health team members in formulating goals and expected outcomes to
promote optimal nutritional care. Nursing diagnoses of life-threatening
conditions, such as Impaired Swallowing related to decreased or absent gag
reflex, are given first priority. Other diagnoses that are actual problems take
priority over high-risk problems.
In the planning phase, the
nurse identifies and explains to the client the need for and basis of the
therapy. The nurse takes into consideration the client’s dietary habits, likes,
dislikes, needs, and nutritional assessment data in defining goals and
developing outcomes in collaboration with the client. Refer to the accompanying
display for a sample list of expected outcomes for clients with imbalanced
nutrition and the Research Focus, which concluded that obese bingeeating women
had no weight loss with diet or non-diet therapies.
The nurse selects appropriate
nursing interventions to match the client’s routine patterns, as obtained in
the health history, and to support achievement of the goals and outcomes.
Proceeding in this fashion facilitates the client’s adaptive capabilities
through skillful interventions.
IMPLEMENTATION
The nurse is responsible for
understanding the client’s nutritional needs and for making clinical judgments
relative to outcomes of therapy. This responsibility includes intervening to
prevent the rapid depletion of the body’s protein and energy reserves.
Performance of nursing interventions to accomplish goals and outcomes includes
monitoring the client’s weight and intake, diet therapy, and feeding. Client
teaching occurs with each intervention to maximize the effectiveness of
nutritional therapy.
Monitoring Weight and Intake
Weight and intake measurements
are used to assess the client’s nutritional status and to monitor the
effectiveness of therapy.
Initiating Diet Therapy
Nutritional problems often
require dietary modification. Therapeutic nutrition requires consideration of
the client’s total needs: cultural, socioeconomic, psychological, and
physiological. Modified diets should promote effective nutrition within the
client’s lifestyle; this often requires client teaching regarding the avoidance
of certain foods or adding food items to the diet, given the client’s
sociocultural context, economic restraints, and religious beliefs.
Nothing
by Mouth
Placing the client on NPO
(nothing by mouth) status is a type of diet modification as well as a fluid
restriction. This intervention is prescribed prior to surgery and certain
diagnostic procedures, to rest the GI tract (and prevent diarrhea or vomiting),
or when the client’s nutritional problem has not been identified.
Clear-Liquid
Diet
Dairy products are not allowed
on a clear-liquid diet. The client is allowed to ingest only liquids that keep
the GI tract empty (no residue), such as water, apple juice, and gelatin. A
clear-liquid diet is prescribed primarily for surgical clients.
Liquid
Diet
A liquid (or full liquid diet)
consisting of various types of liquids is prescribed mainly for postoperative
clients because of calorie and nutrient considerations. If the client tolerates
a liquid diet without nausea or vomiting and has normal bowel sounds, the diet
is progressed to as tolerated (client eats whatever foods that cause no
problems).
Soft
Diet
A soft diet promotes the
mechanical digestion of foods. It is prescribed for clients experiencing
difficulty in chewing and swallowing. A soft diet is also therapeutic for
clients with impaired digestion and/or absorption, due to conditions such as
ulcerative colitis and Crohn’s disease. Foods to be avoided on this diet
include nuts, seeds (tomatoes and berries with seeds), raw fruits and
vegetables, fried foods, and whole grains.
Mechanical
Soft Diet
A mechanical soft diet is
similar to a soft diet; however, it allows clients variation, permitting foods
with different tastes, such as chili beans. It is prescribed for clients
experiencing difficulty chewing or who are unable to chew food thoroughly, as
may occur with poorly fitted dentures.
Pureed
Diet
A pureed diet provides food
that has been blenderized to a smooth consistency. It is prescribed for clients
with dysphagia, or difficulty in swallowing. Special consideration needs to be
given to meal preparation; when food has the same consistency,
it is difficult to distinguish the taste of different foods.
Low-Residue
Diet
A low-residue diet has reduced
fiber and cellulose. It is prescribed to decrease GI mucosal irritation in
clients with diverticulitis, ulcerative colitis, and Crohn’s disease. Foods to
be avoided are raw fruits (except bananas), vegetables, seeds, plant fiber, and
whole grains. Dairy products are limited to two servings a day.
High-Fiber
Diet
High-fiber-diet foods are the
opposite of low-residue foods. A high-fiber diet is an integral part of the
treatment regimen for diverticulosis because it increases the forward motion of
the indigestible wastes through the colon. See the accompanying Research Focus
for additional information.
Liberal
Bland Diet
A liberal bland diet
eliminates chemical and mechanical food irritants, such as fried foods,
alcohol, and caffeine. This diet is prescribed for clients with gastritis and
ulcers because it reduces GI irritation.
Fat-Controlled
Diet
Fat-controlled diets reduce
the total fat ingested by replacing saturated fats with monounsaturated and
polyunsaturated fats and restricting cholesterol. They are prescribed for
clients with atherosclerosis, heart disease, and obesity. Saturated foods to be
avoided include animal fats, gravies, sauces, chocolate, and whole-milk
products.
Sodium-Restricted
Diet
Sodium intake may be
restricted as follows: mild, 2 to 3 g; moderate, 1000 mg; strict, 500 mg;
severe, 250 mg. A sodium-restricted diet is prescribed for clients with excess
fluid volume, hypertension, heart failure, myocardial infarction, and renal
failure.
Lactose
Intolerance Diet
A lactose intolerance diet
eliminates milk and all dairy products except yogurt. Lactose is a sugar found
in milk and aids the body absorption of calcium. Lactose intolerance is caused
by a lack or deficiency of lactase, an enzyme normally made in the small
intestines that splits lactose into glucose and galactose. Incomplete digestion
of lactose results in diarrhea, gas, and abdominal cramps between 30 minutes
and 2 hours after consumption of diary foods.
Candidiasis
Diet
The candidiasis diet is free
of fruits, sugar, yeast, and fermented foods.
Candida albicans is a normal parasitic yeast-like fungus that lives in
healthy balance with other bacteria and yeasts in the body. In response to
certain conditions or therapies such as antibiotics or chemotherapy, this
fungus may multiply, weakening the immune system and causing an infection known
as candidiasis. Candidiasis can infect any bodily structure that contains
mucous membranes, the most common being the mouth, ears, nose, gastrointestinal
tract, and vagina. Candidiasis may be characterized by many symptoms ranging
from diarrhea, acne, muscle and joint pain to impotence, PMS, fatigue,
vaginitis, kidney and bladder infections, arthritis, depression, and even
diabetes (Balch & Balch, 1997).
Assistance with Feeding
Assessment data provide
direction regarding how to assist the client with eating. Clients with
difficulty in self-feeding, chewing, or swallowing will require assistance to
promote safety and adequate intake of nutrients; see the Nursing Process
Highlight.
Because eating is a social
activity (Figure 38-13), it is important to encourage a family member or friend
to be present at meals. If this is not possible, assess the availability of
other resources to provide social stimulation during meals, such as watching
TV, listening to music, or having a staff member remain with the client.
SKILLS -
FEEDING THE DEPENDENT PATIENT
DEPENDENT
PATIENT FEEDING
VOL: 99,
ISSUE: 10, PAGE NO: 31
DEPENDENT
PATIENT FEEDING
- The dependent patient who does not require enteral or parenteral feeding may
still need help with eating. Many conditions, including cancer, cerebrovascular
accident (CVA) and multiple sclerosis, can cause feeding difficulties.
- The task
requires nursing knowledge and skill, although it is often given low priority
or not seen as a nursing intervention.
- The Department
of Health
has stressed the importance of assisting patients with nutrition by setting
this as a benchmark in The Essence of Care (DoH, 2001).
PHASES
OF SWALLOWING
Swallowing occurs in three phases:
- The oral
phase - the food is chewed and mixed with saliva to make a bolus.
- The
pharyngeal phase - the swallowing reflex is triggered when the bolus touches
the back of the patient’s oral cavity. The epiglottis is lowered and the larynx
moves under the base of the tongue closing the airway. The
presence of the bolus in the pharynx stimlates a wave of peristalsis.
- The
oesophageal phase - the bolus is moved through the oesophagus to the stomach by
peristalsis.
BEFORE
FEEDING
- The dependent patient’s ability to eat must be fully assessed.
- Aspiration
of food or drink is a particular risk. Aspiration can cause a blockage in the
bronchus and lead to aspiration pneumonia.
- If the
patient has dysphagia, a swallowing assessment should be carried out by a
competent practitioner using an appropriate assessment tool. Referral to a
speech and language therapist and dietitian should be considered. They may
recommend that foods are thickened to help prevent aspiration.
- Information
can also be obtained through a barium swallow test.
- The patient
should be placed in an upright position with his or her head tilted slightly
forward to aid swallowing.
DURING
FEEDING
- Keep the patient upright.- The nurse who is helping the patient to eat should
sit in the patient’s line of vision and provide prompting, encouragement and
direction, both verbally and non-verbally, when appropriate.
- Avoid
hovering with the next spoonful of food as this may cause a patient to hurry
and worsen any swallowing difficulties. Patience, attention and time are
essential.
- Allow at
least 5-10 seconds for each bite or sip.
- Allow the
patient to take a drink between each mouthful of food to ease the process of
eating.
- The patient
should be observed for pouching (the unconscious collecting of food on one side
of the mouth), particularly after a stroke. When the patient has a hemiplegia
the head should be tilted slightly towards the stronger side to avoid pouching.
- The patient
should remain upright for 15 minutes after eating.
- Ensure that
suction apparatus at the bedside has been checked.
- Report and
document any instances of choking.
Providing Nutrition Support
Proper nutrition in
hospitalized clients is necessary for wound healing, recovery, reduction in
morbidity, and consequent reductions in length of stay and mortality. The most
common nutritional deficiency in hospitalized clients is protein-energy
malnutrition. This type of malnutrition depletes body cell mass and impairs
tissue and organ function. When protein-energy malnutrition is left untreated, the
following client negative outcomes may occur:
·
Weakness
· Compromised
immunity
·
Decreased wound healing
·
Increased risk for
complications
Nutrition support is
prescribed for those clients at risk for protein-energy malnutrition. There are
two routes for delivery of nutrition support (NS) in adult clients: enteral nutrition (EN) and parenteral nutrition (PN). Enteral
nutrition includes both the ingestion of food orally and the delivery of
nutrients through a gastrointestinal tube.
Parenteral nutrition refers to nutrients bypassing the small intestine
and entering the blood directly. EN is preferred over PN because of decreased
bacterial translocation and reduced expense, and is usually delivered through a
feeding tube (Figure 38-14).
Critical indicators for
determining the feeding route and nutrition support formula include GI
function, expected duration of therapy, aspiration risk, and the potential for
or the actual development of organ dysfunction. For example, the decision to
initiate PN or EN support is based on evidence that the client is unable to
meet his or her own nutritional needs by oral intake and will therefore
experience malnutrition. Refer to Figure 38-15 for a clinical-decision
algorithm that outlines the selection process for choosing the route of
nutritional support in adult clients. The client’s nutrition support may be
determined by a nutrition support team (NST) in accord with the American
Society for Parenteral and Enteral Nutrition (ASPEN) guidelines.
DYSPHAGIA
Dysphagia
(difficulty swallowing) is the most common symptom of esophageal disease.
This symptom may vary from an uncomfortable feeling that a bolus of food is
caught in the upper esophagus (before it eventually passes into the stomach) to
acute pain on swallowing (odynophagia). Obstruction of food (solid and soft)
and even liquids may occur anywhere along the esophagus. Often the patient can
indicate that the problem is located in the upper, middle, or lower third of
the esophagus.
There
are many pathologic conditions of the esophagus, including motility disorders
(achalasia, diffuse spasm), gastroesophageal reflux, hiatal hernias,
diverticula, perforation, foreign bodies, chemical burns, benign tumors, and
carcinoma.
ACHALASIA
Achalasia
is absent or ineffective peristalsis of the distal esophagus, accompanied by
failure of the esophageal sphincter to relax in response to swallowing. Narrowing of the esophagus just above the stomach results in a
gradually increasing dilation of the esophagus in the upper chest.
Achalasia may progress slowly and occurs most often in people 40 years of age
or older.
Clinical Manifestations
The
primary symptom of achalasia is difficulty in swallowing both liquids and
solids. The patient has a sensation of food sticking in the lower portion of
the esophagus. As the condition progresses, food is commonly regurgitated,
either spontaneously or intentionally by the patient to relieve the discomfort
produced by prolonged distention of the esophagus by food that will not pass
into the stomach. The patient may also complain of chest pain and heartburn
(pyrosis). Pain may or may not be associated with eating. There may be
secondary pulmonary complications from aspiration of gastric contents.
Assessment and Diagnostic
Findings
X-ray
studies show esophageal dilation above the narrowing at the gastroesophageal
junction. Barium swallow, computed tomography (CT) of the esophagus, and
endoscopy may be used for diagnosis; however, the diagnosis is confirmed
by manometry, a process in which the esophageal pressure is measured by a
radiologist or gastroenterologist.
Management
The
patient should be instructed to eat slowly and to drink fluids with meals. As a
temporary measure, calcium channel blockers and nitrates have been used to
decrease esophageal pressure and improve swallowing. Injection of botulinum
toxin (Botox) to quadrants of the esophagus via endoscopy has been helpful
because it inhibits the contraction of smooth muscle. Periodic injections are
required to maintain remission. If these methods are unsuccessful, pneumatic
(forceful) dilation or surgical separation of the muscle fibers may be
recommended (Streeter, 1999; Annese et al., 2000).
Achalasia
may be treated conservatively by pneumatic dilation to stretch the narrowed
area of the esophagus (Fig. 35-6). Pneumatic dilation has a high success rate.
Although perforation is a potential complication, its incidence is low. The
procedure can be painful; therefore, moderate sedation in the form of an
analgesic or tranquilizer, or both, is administered for the treatment. The
patient is monitored for perforation. Complaints of abdominal tenderness and
fever may be indications of perforation.
Achalasia
may be treated surgically by esophagomyotomy (Fig. 35-7). The procedure usually
is performed laparoscopically, either with a complete lower esophageal
sphincter myotomy and an antireflux procedure (see later discussion of
fundoplasty), or without an antireflux procedure. The esophageal muscle fibers
are separated to relieve the lower esophageal stricture. Although patients with
a history of achalasia have a slightly higher incidence of esophageal cancer,
long-term follow-up with esophagoscopy for early detection has not proved beneficial.
DIFFUSE SPASM
Diffuse
spasm is a motor disorder of the esophagus. The cause is unknown, but stressful
situations can produce contractions of the esophagus. It is more common in
women and usually manifests in middle age.
Clinical Manifestations
Diffuse
spasm is characterized by difficulty or pain on swallowing (dysphagia,
odynophagia) and by chest pain similar to that of coronary artery spasm.
Assessment and Diagnostic
Findings
Esophageal
manometry, which measures the motility of the esophagus and the pressure within
the esophagus, indicates that simultaneous contractions of the esophagus occur
irregularly. Diagnostic x-ray studies after ingestion of barium show separate
areas of spasm.
Management
Conservative
therapy includes administration of sedatives and long-acting nitrates to
relieve pain. Calcium channel blockers have also been used to manage diffuse
spasm. Small, frequent feedings and a soft diet are usually recommended to
decrease the esophageal pressure and irritation that lead to spasm. Dilation
performed by bougienage (use of progressively sized flexible dilators),
pneumatic dilation, or esophagomyotomy may be necessary if the pain becomes
intolerable.
HIATAL HERNIA
The
esophagus enters the abdomen through an opening in the diaphragm and empties at
its lower end into the upper part of the stomach. Normally, the opening in the
diaphragm encircles the esophagus tightly, and the stomach lies completely
within the abdomen. In a condition known as hiatus (or hiatal) hernia, the
opening in the diaphragm through which the esophagus passes becomes enlarged,
and part of the upper stomach tends to move up into the lower portion of the
thorax. Hiatal hernia occurs more often in women than men. There are two types
of hiatal hernias: sliding and paraesophageal. Sliding, or type I, hiatal
hernia occurs when the upper stomach and the gastroesophageal junction (GEJ)
are displaced upward and slide in and out of the thorax (Fig. 35-8A). About 90%
of patients with esophageal hiatal hernia have a sliding hernia. A
paraesophageal hernia occurs when all or part of the stomach pushes through the
diaphragm beside the esophagus (see Fig. 35-8B). Paraesophageal hernias may be
further classified as types II, III, or IV, depending on the extent of
herniation, with type IV having the greatest herniation.
Clinical Manifestations
The
patient with a sliding hernia may have heartburn, regurgitation, and dysphagia,
but at least 50% of patients are asymptomatic. Sliding hiatal hernia is often
implicated in reflux. The patient with a paraesophageal hernia usually
feels a sense of fullness after eating or may be asymptomatic. Reflux usually
does not occur, because the gastroesophageal sphincter is intact. The
complications of hemorrhage, obstruction, and strangulation can occur with any
type of hernia.
Assessment and Diagnostic
Findings
Diagnosis
is confirmed by x-ray studies, barium swallow, and fluoroscopy.
Management
Management
for an axial hernia includes frequent, small feedings that can pass easily
through the esophagus. The patient is advised not to recline for 1 hour after
eating, to prevent reflux or movement of the hernia, and to elevate the
head of the bed on 4- to
8-inch (10- to 20-cm) blocks to prevent the hernia from sliding
upward. Surgery is indicated in about 15% of patients. Medical and surgical
management of a paraesophageal hernia is similar to that for gastroesophageal
reflux; however, paraesophageal hernias may require emergency surgery to
correct torsion (twisting) of the stomach or other body organ that leads to
restriction of blood flow to that area.
DIVERTICULUM
A
diverticulum is an outpouching of mucosa and submucosa that protrudes through a
weak portion of the musculature. Diverticula may occur in one of the three
areas of the esophagus—the pharyngoesophageal or upper area of the esophagus,
the midesophageal area, or the epiphrenic or lower area of the esophagus—or
they may occur along the border of the esophagus intramurally. The most common
type of diverticulum, which is found three times more frequently in men than in
women, is Zenker’s diverticulum (also known as pharyngoesophageal pulsion
diverticulum or a pharyngeal pouch). It occurs posteriorly through the
cricopharyngeal muscle in the midline of the neck. It is usually seen in people
older than 60 years of age. Other types of diverticula include midesophageal,
epiphrenic, and intramural diverticula. Midesophageal diverticula are uncommon.
Symptoms are less acute, and usually the condition does not require surgery.
Epiphrenic diverticula are usually larger diverticula in the lower esophagus
just above the diaphragm. They are thought to be related to the improper
functioning of the lower esophageal sphincter or to motor disorders of the
esophagus. Intramural diverticulosis is the occurrence of numerous small
diverticula associated with a stricture in the upper esophagus.
Clinical Manifestations
Symptoms
experienced by the patient with a pharyngoesophageal pulsion diverticulum
include difficulty swallowing, fullness in the neck, belching,
regurgitation of undigested food, and gurgling noises after eating. The
diverticulum, or pouch, becomes filled with food or liquid. When the
patient assumes a recumbent position, undigested food is regurgitated, and
coughing may be caused by irritation of the trachea. Halitosis and a sour taste
in the mouth are also common because of the decomposition of food retained in
the diverticulum. Symptoms produced by midesophageal diverticula are less
acute. One third of patients with epiphrenic diverticula are asymptomatic, and
the remaining two thirds complain of dysphagia and chest pain. Dysphagia is the
most common complaint of patients with intramural diverticulosis.
Assessment and Diagnostic
Findings
A
barium swallow may be performed to determine the exact nature and location of a
diverticulum. Manometric studies are often performed for patients with
epiphrenic diverticula to rule out a motor disorder. Esophagoscopy usually is
contraindicated because of the danger of perforation of the diverticulum, with
resulting mediastinitis (inflammation of the organs and tissues that
separate the lungs). Blind insertion of a nasogastric tube should be avoided.
Management
Because
pharyngoesophageal pulsion diverticulum is progressive, the only means of cure
is surgical removal of the diverticulum. During surgery, care is taken to avoid
trauma to the common carotid artery and internal jugular veins. The sac is
dissected free and amputated flush with the esophageal wall. In addition
to a diverticulectomy, a myotomy of the cricopharyngeal muscle is often
performed to relieve spasticity of the musculature, which otherwise seems to
contribute to a continuation of the previous symptoms. Postoperatively, the
patient may have a nasogastric tube inserted at the time of surgery. The
surgical incision must be observed for evidence of leakage from the esophagus
and a developing fistula. Food and fluids are withheld until x-ray
studies show no leakage at the surgical site. The diet begins with liquids and
progresses as tolerated.
Surgery
is indicated for epiphrenic and midesophageal diverticula only if the symptoms
are troublesome and becoming worse. Treatment consists of a diverticulectomy
and long myotomy. Intramural diverticula usually regress after the esophageal
stricture is dilated.
PERFORATION
The
esophagus is not an uncommon site of injury. Perforation may result from stab
or bullet wounds of the neck or chest, trauma from motor vehicle crash, caustic
injury from a chemical burn (described later), or inadvertent puncture by a
surgical instrument during examination or dilation.
Clinical Manifestations
The
patient has persistent pain followed by dysphagia. Infection, fever,
leukocytosis, and severe hypotension may be noted. In some instances, signs of
pneumothorax are observed.
Assessment and Diagnostic
Findings
Diagnostic
x-ray studies and fluoroscopy are used to identify the site of the
injury.
Management
Because
of the high risk of infection, broad-spectrum antibiotic therapy is initiated.
A nasogastric tube is inserted to provide suction and to reduce the amount of gastric
juice that can reflux into the esophagus and mediastinum. Nothing is
given by mouth; nutritional needs are met by parenteral nutrition. Parenteral
nutrition is preferred to gastrostomy because the latter might cause refluxinto
the esophagus. Surgery may be necessary to close the wound, and postoperative
nutritional support then becomes a primary concern. Depending on the incision
site and the nature of surgery, the postoperative nursing management is similar
to that for patients who have had thoracic or abdominal surgery.
FOREIGN BODIES
Many
swallowed foreign bodies pass through the gastrointestinal tract without the
need for medical intervention. However, some swallowed foreign bodies (eg,
dentures, fish bones, pins, small batteries, items containing mercury or
lead) may injure the esophagus or obstruct its lumen and must be removed. Pain
and dysphagia may be present, and dyspnea may occur as a result of pressure on
the trachea. The foreign body may be identified by x-ray film.
Perforation may have occurred (see earlier discussion). Glucagon, because of
its relaxing effect on the esophageal muscle, may be injected intramuscularly.
An endoscope (with a covered hood or overtube) may be used to remove the
impacting food or object from the esophagus. A mixture consisting of sodium
bicarbonate and tartaric acid may be used to increase intraluminal pressure by
the formation of a gas. Caution must be used with this treatment because there
is risk of perforation.
CHEMICAL BURNS
Chemical
burns of the esophagus may be caused by undissolved medications in the
esophagus. This occurs more frequently in the elderly than it does among the
general adult population. A chemical burn may also occur after swallowing of a
battery, which may release caustic alkaline. Chemical burns of the esophagus
occur most often when a patient, either intentionally or unintentionally,
swallows a strong acid or base (eg, lye). This patient is emotionally
distraught as well as in acute physical pain. An acute chemical burn of the
esophagus may be accompanied by severe burns of the lips, mouth, and pharynx,
with pain on swallowing. There may be difficulty in breathing due to
either edema of the throat or a collection of mucus in the pharynx.
The
patient, who may be profoundly toxic, febrile, and in shock, is treated
immediately for shock, pain, and respiratory distress.
Esophagoscopy and barium swallow are performed as soon as possible to determine
the extent and severity of damage. The patient is given nothing by mouth, and
intravenous fluids are administered. A nasogastric tube may be inserted
by the physician.
Vomiting
and gastric lavage are avoided to prevent further expo- sure of the esophagus
to the caustic agent. The use of corticosteroids to reduce inflammation
and minimize subsequent scarring and stricture formation is of questionable
value. The value of the prophylactic use of antibiotics for these patients has
also been questioned; however, these treatments continue to be prescribed
(Schaffer & Herbert, 2000).
After
the acute phase has subsided, the patient may need nutritional support via
enteral or parenteral feedings. The patient may require further treatment to
prevent or manage strictures of the esophagus. Dilation by bougienage may be
sufficient, but dilation treatment may need to be repeated periodically.
(In bougienage, cylindrical rubber tubes of different sizes, called bougies,
are advanced into the esophagus via the oral cavity. Progressively larger
bougies are used to dilate the esophagus. The procedure usually is performed in
the endoscopy suite or clinic by the gastroenterologist.) For strictures that
do not respond to dilation, surgical management is necessary. Reconstruction
may be accomplished by esophagectomy and colon interposition to replace the
portion of esophagus removed.
GASTROESOPHAGEAL REFLUX
DISEASE
Some
degree of gastroesophageal reflux (back-flow of gastric or duodenal
contents into the esophagus) is normal in both adults and children. Excessive
reflux may occur because of an incompetent lower esophageal sphincter,
pyloric stenosis, or a motility disorder. The incidence of reflux seems
to increase with aging.
Clinical Manifestations
Symptoms
of gastroesophageal reflux disease (GERD) may include pyrosis (burning
sensation in the esophagus), dyspepsia (indigestion), regurgitation, dysphagia
or odynophagia (difficulty swallowing, pain on swallowing),
hypersalivation, and esophagitis. The symptoms may mimic those of a heart
attack. The patient’s history aids in obtaining an accurate diagnosis.
Assessment and Diagnostic
Findings
Diagnostic
testing may include an endoscopy or barium swallow to evaluate damage to the
esophageal mucosa. Ambulatory 12- to 36-hour esophageal pH monitoring is used
to evaluate the degree of acid reflux. Bilirubin monitoring (Bilitec) is
used to measure bile reflux patterns. Exposure to bile can cause mucosal
damage (Aronson, 2000; Stein et al., 1999).
Management
Management
begins with teaching the patient to avoid situations that decrease lower
esophageal sphincter pressure or cause esophageal irritation. The patient is
instructed to eat a low-fat diet; to avoid caffeine, tobacco, beer, milk, foods
containing peppermint or spearmint, and carbonated beverages; to avoid eating
or drinking 2 hours before bedtime; to maintain normal body weight; to avoid
tight-fitting clothes; to elevate the head of the bed on 6- to 8-inch
(15- to 20-cm) blocks; and to elevate the upper body on pillows. If reflux
persists, the patient may be given medications such as antacids or histamine
receptor blockers. Proton pump inhibitors (medications that decrease the
release of gastric acid, such as lansoprazole [Prevacid] or rabeprazole
[Aciphex]) may be used; however, there is concern that these products may
increase intragastric bacterial growth and the risk for infection. In addition,
the patient may receive prokinetic agents, which accelerate gastric emptying.
These agents include bethanechol (Urecholine), domperidone (Motilium), and
metoclopramide (Reglan). Metoclopramide has central nervous system
complications with long-term use. The use of pectin-based products is now being
studied (Aronson, 2000). If medical management is unsuccessful, surgical
intervention may be necessary. Surgical management involves a fundoplication
(wrapping of a portion of the gastric fundus around the sphincter area of the
esophagus). Fundoplication may be performed by laparoscopy.
BARRETT’S ESOPHAGUS
It
is believed that long-standing untreated GERD may result in a condition known
as Barrett’s esophagus. This has been identified as a precancerous
condition that, if left untreated, can result in adenocarcinoma of the
esophagus, which has a poor prognosis. It is more common among middle-aged
white men; however, the incidence is increasing among women and among African
Americans.
Clinical Manifestations
The
patient complains of symptoms of GERD, notably frequent heartburn. The
heartburn is a result of reflux, which eventually causes changes in the
cells lining the lower esophagus. The patient may also complain of symptoms
related to peptic ulcers or esophageal stricture, or both.
Assessment and Diagnostic
Findings
An
esophagogastroduodenoscopy (EGD) is performed. This usually reveals an
esophageal lining that is red rather than pink. Biopsies are taken, and the
cells resemble those of the intestine.
Management
Monitoring
varies depending on the amount of cell changes. Some physicians may recommend a
repeat EGD in 6 to 12 monthsif there are minor cell changes. Medical and
surgical management is similar to that for GERD. Because this is a condition
that is increasing in incidence, research is underway to determine the best
monitoring and surgical interventions (Mueller et al., 2000; Stein et al.,
1999).
BENIGN TUMORS OF THE
ESOPHAGUS
Benign
tumors can arise anywhere along the esophagus. The most common lesion is a
leiomyoma (tumor of the smooth muscle), which can occlude the lumen of the
esophagus. Most benign tumors are asymptomatic and are distinguished from
cancerous lesions by a biopsy. Small lesions are excised during esophagoscopy;
lesions that occur within the wall of the esophagus may require treatment via a
thoracotomy.
CANCER OF THE ESOPHAGUS
In
the
Chronic
irritation is a risk factor for esophageal cancer. In the
Clinical Manifestations
Many
patients have an advanced ulcerated lesion of the esophagus before symptoms are
manifested. Symptoms include dysphagia, initially with solid foods and
eventually with liquids; a sensation of a mass in the throat; painful
swallowing; substernal pain or fullness; and, later, regurgitation of
undigested food with foul breath and hiccups. The patient first becomes
aware of intermittent and increasing difficulty in swallowing. As the
tumor progresses and the obstruction becomes more
complete, even liquids cannot pass into the stomach. Regurgitation of food and
saliva occurs, hemorrhage may take place, and progressive loss of weight and
strength occurs from starvation. Later symptoms include substernal pain,
persistent hiccup, respiratory difficulty, and foul breath. The delay
between the onset of early symptoms and the time when the patient seeks medical
advice is often 12 to 18 months. Anyone with swallowing difficulties
should be encouraged to consult a physician immediately.
Assessment and Diagnostic
Findings
Although
new endoscopic techniques are being studied for screening and diagnosis of
esophageal cancer, currently diagnosis is confirmed most often by EGD
with biopsy and brushings. Bronchoscopyusually is performed, especially in
tumors of the middle and the upper third of the esophagus, to determine whether
the trachea has been affected and to help determine whether the lesion can be
removed. Endoscopic ultrasound or mediastinoscopy is used to determine whether
the cancer has spread to the nodes and other mediastinal structures. Cancer of
the lower end of the esophagus may be caused by adenocarcinoma of the stomach
that extends upward into the esophagus.
NURSING PROCESS: THE
PATIENT WITH A CONDITION
OF THE ESOPHAGUS
Assessment
Emergency
conditions of the esophagus (perforation, chemical burns) usually occur in the
home or away from medical help and require emergency medical care. The patient
is treated for shock and respiratory distress and transported as quickly as
possible to a medical facility. Foreign bodies in the esophagus do not pose an
immediate threat to life unless pressure is exerted on the trachea, resulting
in dyspnea or interfering with respiration, or unless there is leakage of
caustic alkali from a battery. Educating the public to prevent inadvertent
swallowing of foreign bodies or corrosive agents is a major health issue.
For
nonemergency symptoms, a complete health history may reveal the nature of the
esophageal disorder. The nurse asks about the patient’s appetite. Has it
remained the same, increased, or decreased? Is there any discomfort with
swallowing? If so, does it occur only with certain foods? Is it associated with
pain? Does a change in position affect the discomfort? The patient is asked to
describe the pain. Does anything aggravate it? Are there any other symptoms
that occur regularly, such as regurgitation, nocturnal regurgitation,
eructation (belching), heartburn, substernal pressure, a sensation that food is
sticking in the throat, a feeling of becoming full after eating a small amount
of food, nausea, vomiting, or weight loss? Are the symptoms aggravated by
emotional upset? If the patient reports any of these symptoms, the nurse asks
about the time of their occurrence, their relationship to eating, and factors
that relieve or aggravate them (eg, position change, belching, antacids, vomiting).
This
history also includes questions about past or present causative factors, such
as infections and chemical, mechanical, or physical irritants; the degree to
which alcohol and tobacco are used; and the amount of daily food intake. The
nurse determines whether the patient appears emaciated and auscultates the
patient’s chest to determine whether pulmonary complications exist.
Nursing Diagnosis
Based
on the assessment data, the nursing diagnoses may include the following:
·
Imbalanced nutrition, less
than body requirements, related to difficulty swallowing
· Risk for
aspiration related to difficulty swallowing or to tube feeding
·
Acute pain related to difficulty
swallowing, ingestion of an abrasive agent, tumor, or frequent episodes of
gastric reflux
· Deficient knowledge about the esophageal disorder, diagnostic
studies, medical management, surgical intervention, and rehabilitation
Planning and Goals
The
major goals for the patient may include attainment of adequate nutritional
intake, avoidance of respiratory compromise from aspiration, relief of pain,
and increased knowledge level.
Nursing Interventions
Encouraging adequate nutritional intake
The
patient is encouraged to eat slowly and to chew all food thoroughly so that it
can pass easily into the stomach. Small, frequent feedings of nonirritating
foods are recommended to promote digestion and to prevent tissue irritation.
Sometimes liquid swallowed with food helps the food pass through the esophagus.
Food should be prepared in an appealing manner to help stimulate the appetite.
Irritants such as tobacco and alcohol should be avoided. A baseline weight is
obtained, and daily weights are recorded. The patient’s intake of nutrients is
assessed.
Decreasing risk of aspiration
The
patient who has difficulty swallowing or difficulty handling
secretions should be kept in at least a semi-Fowler’s position to decrease the
risk of aspiration. The patient can be instructed in the use of oral suction to
decrease the risk of aspiration further.
Relieving pain
Small,
frequent feedings are recommended, because large quantities of food overload
the stomach and promote gastric reflux. The patient is advised to avoid
any activities that increase pain, and to remain upright for 1 to 4 hours after
each meal to prevent reflux. The head of the bed should be placed on 4-
to 8-inch (10- to 20-cm) blocks. Eating before bedtime is discouraged. The
patient is advised that excessive use of over-the-counter antacids can cause
rebound acidity. Antacid use should be directed by the primary care provider,
who can recommend the daily, safe dose needed to neutralize gastric juices and
prevent esophageal irritation. Histamine2 antagonists are administered as
prescribed to decrease gastric acid irritation.
Providing patient education
The
patient is prepared physically and psychologically for diagnostic tests,
treatments, and possible surgical intervention. The principal nursing
interventions include reassuring the patient and discussing the procedures and
their purposes. Some disorders of the esophagus evolve over time, whereas
others are the result of trauma (eg, chemical burns, perforation). In instances
of trauma, the emotional and physical preparation for treatment is more difficult
because of the short time available and the circumstances of the injury.
Treatment interventions must be evaluated continually; the patient is given sufficient
information to participate in care and diagnostic tests. If endoscopic diagnostic
methods are used, the patient is instructed regarding the moderate sedation
that will be used during the procedure. If procedures are being performed on an
outpatient basis with the use of moderate sedation, the patient is instructed
to have someone available to drive him or her home after the procedure. If
surgery is required, immediate and long-term evaluation is similar to that for
a patient undergoing thoracic surgery.
Promoting home and community-based care
Teaching Patients Self-Care
The
self-care required of the patient depends on the nature of the disorder and on
the surgery or treatment measures used (eg, diet, positioning, medications). If
an ongoing condition exists, the nurse helps the patient plan for needed
physical and psychological adjustments and for follow-up care
Special
equipment, such as suction or enteral or parenteral feeding devices, may be
required. The patient may need assistance in planning meals, using medications
as prescribed, and resuming activities. Education
about nutritional requirements and how to measure the adequacy of nutrition is
important. Elderly and debilitated patients in particular often need assistance
and education in ways to adjust to their limitations and to resume activities
that are important to them.
Continuing Care
Patients
with chronic esophageal conditions require an individ ualized approach to their
management at home. Foods may need to be prepared in a special way (blenderized
foods, soft foods), and the patient may need to eat more frequently (eg, four
to six small servings per day). The medication schedule is adjusted to the
patient’s daily activities as much as possible. Analgesic medications and
antacids can usually be taken as needed every 3 to 4 hours.
Postoperative
home health care focuses on nutritional support, management of pain, and
respiratory function. Some patients are discharged from the hospital with
enteral feeding by means of a gastrostomy or jejunostomy tube or parenteral
nutrition. The patient and care provider need specific instructions
regarding management of the equipment and treatments. Home care visits by a
nurse may be necessary to assess the patient’s care and the care provider’s
ability to provide the necessary care. For some patients, a multidisciplinary
team comprising a dietitian, a social worker, and family members is helpful.
Hospice care is appropriate for some patients.
Evaluation
Expected patient outcomes
Expected
patient outcomes may include:
1.
Achieves an adequate nutritional intake
a.Eats small,
frequent meals
b.Drinks
water with small servings of food
c.Avoids
irritants (alcohol, tobacco, very hot beverages)
d.Maintains
desired weight
2.
Does not aspirate or develop pneumonia
a.Maintains upright position during feeding
b.Uses oral suction
equipment effectively
3.
Is free of pain or able to control pain within a
tolerable level
a.Avoids
large meals and irritating foods
b.Takes
medications as prescribed and with adequate fluids (at least 4 ounces),
and remains upright for at least 10 minutes after taking medications
c.Maintains
an upright position after meals for 1 to 4 hours
d.Reports
that there is less eructation and chest pain
4.
Increases knowledge level of esophageal condition, treatment, and prognosis
a.States
cause of condition
b.Discusses rationale
for medical or surgical management and diet or medication regimen
c.Describes
treatment program
d.Practices
preventive measures so injuries are avoided