Nutrition

Nutrition is the study of how food affects the body and how the body utilizes food. A healthy diet is essential to maintaining good health and preventing chronic diseases such as obesity, diabetes, and heart disease. Proper nutrition is especially important for vulnerable populations such as infants, children, pregnant and breastfeeding women, and older adults.

More tested concepts in the NCLEX RN:

1. Nutrient requirements: The NCLEX RN may test your knowledge of the daily nutrient requirements for various age groups and conditions such as pregnancy or lactation. For example, an infant needs more fat in their diet than an adult, and pregnant women require more iron and folate.
2. Nutrient deficiencies: You may be asked about common nutrient deficiencies and the associated symptoms. For instance, iron deficiency anemia can cause fatigue, shortness of breath, and pale skin.
3. Special diets: Understanding various types of special diets is essential. For example, a low-sodium diet is necessary for individuals with hypertension, while a diabetic diet is designed to regulate blood sugar levels.
4. Enteral and parenteral nutrition: You may be asked about enteral and parenteral nutrition, which are methods of providing nutrition to individuals who are unable to eat or digest food normally. Knowledge of the indications, administration, and complications of these methods is crucial.
5. Health promotion and disease prevention: The NCLEX RN may test your knowledge of nutrition education and counseling, as well as strategies to prevent nutrition-related diseases. For example, promoting a diet high in fiber and low in saturated fat can help reduce the risk of heart disease.
6. Cultural and religious influences: Understanding how cultural and religious beliefs impact food choices is important for providing culturally competent care. For instance, certain religions may prohibit the consumption of certain foods, such as pork or beef.
7. Medication-nutrient interactions: Certain medications can interact with nutrients in food, potentially leading to adverse effects. You may be asked about common medication-nutrient interactions and how to manage them. For example, some antibiotics can interfere with the absorption of calcium, so it is important to advise patients to separate the administration of these medications from calcium-rich foods and supplements.
8. Assessment and monitoring: Assessing a patient’s nutritional status and monitoring their response to nutrition interventions is an important aspect of nursing care. You may be asked about how to perform a nutrition assessment, including anthropometric measurements and dietary analysis, and how to monitor for changes in weight and laboratory values.

Assessing the Client’s Ability to Eat

Adequate nutrition is reliant on the client’s ability to consume, chew, and swallow food.

Nurses are responsible for assessing a client’s nutritional status, identifying any risks for nutritional deficits, and collecting both subjective and objective data. Several standardized tools, such as the Patient Generated Subjective Global Assessment and the Nutrition Screening Inventory, are used in addition to the A, B, C, and Ds of nutritional assessment. These include:

• A: Anthropometric Data, which includes measurements of height, weight, body mass index, mid-arm circumference, and triceps skin fold.
• B: Biochemical Data, which includes laboratory tests of serum albumin, hemoglobin, urinary creatinine, and serum transferrin.
• C: Clinical Data, which includes assessments of the client’s skin condition, level of activity, and status of mucous membranes.
• D: Dietary Data, which includes the client’s self-reported food and fluid intake over the past 24 hours and the types of foods typically consumed.

Some of the factors that impact on the client’s nutrition, their nutritional status and their ability to eat include:

• Level of health
• Psychological influences and disorders
• Ethnicity
• Culture
• Personal preferences
• Religious practices and rituals
• Gender
• Level of development
• Lifestyle choices
• Personal beliefs about food and food intake
• Medications
• Therapeutic treatments
• Level of health
• Psychological influences and disorders
• Economic status
• Swallowing disorders
• Chewing disorders
• Dentition

Swallowing disorders, chewing disorders, and poor dentition can hinder a client’s mechanical ability to eat. Such conditions increase the risk for impaired nutrition, and clients with such conditions include:

• Those with a chewing disorder due to damage to the trigeminal nerve that controls chewing muscles.
• Clients with poor dentition and ill-fitting dentures.
• Clients with dysphagia, a swallowing disorder, which can result from a cerebrovascular accident.
• Clients with anatomical strictures, which may be present from birth.
• Those undergoing cancer therapeutic radiation therapy.
• Clients with neurological deficits that affect the vagus nerve and/or hypoglossal cranial nerve, which are critical for swallowing and preventing aspiration.

Clients with swallowing disorders are typically evaluated and treated by a team of healthcare professionals, including speech and language therapists, dietitians, and nurses. Dental professionals, dietitians, and nurses can assist clients with poor dentition and missing teeth by fitting proper dentures and recommending a special diet that may include pureed foods and thickened liquids to the consistency of honey to ensure safe swallowing and prevent aspiration.

Assessing the Client for Actual/Potential Specific Food and Medication Interactions

Medications can significantly impact a client’s nutritional status, as some can interfere with the digestive process or interact with certain foods. This includes thiazide diuretics, which can reduce the body’s absorption of vitamin B12, and acetylsalicylic acid, which can cause excessive excretion of substances such as vitamin C, potassium, amino acids, and glucose.

In addition to food interactions, medications (including over-the-counter drugs) can also interact with herbs and supplements. These interactions can be either synergistic or antagonistic, meaning they can either enhance or inhibit the medication’s effects. For instance, those taking anticoagulants like warfarin should avoid consuming vegetables with high vitamin K content, as vitamin K acts as an antagonist to warfarin.

Considering Client Choices Regarding Meeting Nutritional Requirements and/or Maintaining Dietary Restrictions

Client’s food preferences and choices are influenced by various factors, such as gender, cultural and ethnic practices, spiritual and religious beliefs, and personal preferences. When a client has a dietary restriction, it can be challenging to satisfy their preferences. For instance, a person from the southern region of the United States may prefer fried foods, but if they have high cholesterol levels, dietary changes are necessary. Similarly, a Hindu vegetarian may lack protein, and their diet requires modification. To achieve adherence to their dietary plan, clients must be offered alternatives that align with their preferences. Educating clients and their families about the modified diet and its importance to their health and wellness is crucial for successful dietary management.

The NCLEX-RN exam may include questions that evaluate the interactions between drugs and food. Here are some common drug-food interactions that may be tested:

1. Warfarin and vitamin K: Warfarin is an anticoagulant that can be affected by vitamin K intake. Clients taking warfarin should be advised to avoid or limit foods high in vitamin K, such as green leafy vegetables.
2. Calcium and tetracycline: Tetracycline, an antibiotic, can bind with calcium in dairy products, decreasing its effectiveness. Clients taking tetracycline should avoid taking it with milk or other dairy products.
3. Monoamine oxidase inhibitors (MAOIs) and tyramine: Certain foods high in tyramine, such as aged cheeses, cured meats, and fermented foods, can interact with MAOIs, causing a dangerous increase in blood pressure.
4. Grapefruit and statins: Grapefruit juice can interact with some statin drugs, such as atorvastatin and simvastatin, increasing the risk of side effects such as muscle pain and liver damage.
5. Alcohol and sedatives: Alcohol can increase the sedative effects of certain medications, such as benzodiazepines, leading to dangerous respiratory depression.
6. Iron and caffeine: Caffeine can decrease the absorption of iron from food and supplements. Clients taking iron supplements should avoid consuming caffeine at the same time.

The NCLEX-RN may evaluate various types of allergies, but some of the most commonly tested types include:

1. Food allergies: These are immune responses triggered by specific foods or food components. Common allergens include peanuts, tree nuts, fish, shellfish, eggs, milk, soy, and wheat.
2. Medication allergies: These are immune responses to specific medications or classes of medications. Common drug allergens include antibiotics such as penicillin, sulfa drugs, nonsteroidal anti-inflammatory drugs (NSAIDs), and chemotherapy drugs.
3. Environmental allergies: These are immune responses triggered by environmental allergens such as pollen, dust mites, animal dander, and mold.
4. Latex allergies: These are immune responses to natural rubber latex products such as gloves, condoms, and medical devices.
5. Insect allergies: These are immune responses to insect stings or bites, with the most common allergens being bees, wasps, hornets, and fire ants.

Food Allergies and Restrictions

Gluten-Free
No Gluten

For those with Celiac Disease or allergies to gluten, foods with wheat, barley, rye, and oats should be avoided. Breads, pastas, cereals and alcohols that contain these should not be eaten unless labeled as gluten-free

Lactose-Free
No Lactose

Those with lactose intolerance should avoid dairy products such as milk, milk powders, butter, cheese, cream, and even some margarines.

Plant-Based
No Meat or Poultry

Lacto-ovo vegetarians may eat dairy and eggs, while an ovo vegetarian diet can include eggs. Lacto vegetarians may include dairy in their diet. Pescetarians include fish in their diets, while vegans will only ingest plant-based foods. All of these diets exclude meat and poultry.

Diabetic and Sugar-Free
No Sugar

A diabetic or sugar-free diet will limit foods that are high in sugars and carbohydrates and tend to avoid overly processed products. It is important to strike a balance and stick to more whole foods that are low in trans fats.

Nut Allergy
No Nuts

Those who have allergies to peanuts and tree nuts such as almonds, walnuts, and cashews should avoid products that contain them or are cooked in unrefined peanut oil. Nuts can be unexpectedly included in many recipes and preprepared foods such as baked goods and dressings, so care should be taken to read food labels.

Soy Allergy
No Soy

Tofu, edamame, tempeh, tamari and soy oil should be avoided if one is allergic to soy. Textured vegetable protein is mainly made from soy, and is included as a filler in many foods, so take care to ensure it is not included when reading food labels.

Monitoring the Client’s Hydration Status

Fluid excess, also known as hypervolemia, is a condition where there is an excessive amount of fluid and sodium in the body, resulting from fluid gains exceeding fluid losses. There are several risk factors associated with fluid excess, including poor renal functioning, medications such as corticosteroids, excessive sodium intake, heart failure, hepatic failure, and excessive oral or intravenous fluids. The client’s weight gain, adventitious breath sounds, tachycardia, bulging neck veins, occasional confusion, hypertension, an increase in central venous pressure, and edema are the common signs and symptoms of fluid excess.

Edema is the abnormal accumulation of excessive fluids in the interstitial and/or intravascular spaces, and it is often identified in the dependent extremities, such as the legs and feet, or in the abdomen. Edema occurs as a result of increased capillary permeability, decreased osmotic pressure of the serum, and increased capillary pressure, which together push fluids into the interstitial spaces. Nurses assess edema based on its location and severity.

Pitting edema is assessed and classified as:

• 1+ Pitting Edema: The edematous area is depressed or indented 1 cm or less
• 2+ Pitting Edema: The edematous area is depressed or indented 2 cm or less
• 3+ Pitting Edema: The edematous area is depressed or indented 3 cm or less
• 4+ Pitting Edema: The edematous area is depressed or indented 4 cm or less
• 5+ Pitting Edema: The edematous area is depressed or indented 5 cm or less

Some professional literature classifies pitting edema on a scale of 1+ to 4+ with:

• 1+ Pitting Edema: The edematous area is hardly detectable
• 2+ Pitting Edema: The edematous area is depressed or indented 2 cm to 4 cm
• 3+ Pitting Edema: The edematous area is depressed or indented 5 cm to 7 cm
• 4+ Pitting Edema: The edematous area is depressed or indented > 7 cm

Fluid Deficits, dehydration happens when there is an imbalance between the amount of fluids lost and the amount of fluids taken in. The loss of fluids occurs during normal body processes like urination, defecation, and sweating, as well as during abnormal physiological functions such as vomiting and diarrhea. Some medications like diuretics or corticosteroids can cause abnormal fluid and electrolyte loss or retention. Clients who are at risk for inadequate fluid intake include those who are confused and unable to express their needs. Signs and symptoms of mild to moderate dehydration include orthostatic hypotension, dizziness, constipation, headache, thirst, dry skin, dry mouth and oral membranes, and decreased urinary output. Severe dehydration is indicated by oliguria, anuria, renal failure, hypotension, tachycardia, tachypnea, sunken eyes, poor skin turgor, confusion, fluid and electrolyte imbalances, fever, delirium, confusion, and unconsciousness.

Initiating Calorie Counts for Clients

Calorie counting is a common approach for individuals who are trying to lose or gain weight. The number of calories in a particular food item can be calculated based on the number of calories per gram of protein (4 calories), fat (9 calories), and carbohydrates (4 calories). One way to count calories is by weighing the food and multiplying the weight in grams by the number of calories per gram. For instance, if a client plans to eat 14 grams of tuna fish, the number of calories can be obtained by multiplying 14 by 4, which is equal to 56 calories. However, this method can be tedious. Another easier method is to read the food label. For example, if a package of frozen chicken nuggets contains 2500 calories per package and has 3 servings, then one serving will contain approximately 833 calories (1/3 of the package).

According to the U.S. Department of Health and Human Services, a body mass index of:

• < 18.5 is considered underweight
• 18.5 to 24.9 is considered a normal body weight
• 25 to 29.9 is considered overweight
• 30 to 39.9 is considered obese
• 40 is considered extremely obese

A client’s nutritional status can be determined by using mathematical calculations, such as the body mass index (BMI) and ideal body weight. BMI is calculated by dividing the client’s weight in kilograms by the square of their height in meters. For example, a client weighing 75 kg and measuring 1.72 meters tall has a BMI of 28.8.

The ideal body weight is calculated based on a client’s height, weight, and body frame size, which is classified as small, medium, or large. For females with a medium body build, the ideal body weight is 100 pounds per 5 feet of height plus 5 pounds for every inch over 5 feet tall. For females with a small body build, the ideal body weight is calculated by subtracting 10% of the client’s weight from the weight for a medium body build. For females with a large body build, the ideal body weight is calculated by adding 10% of the client’s weight to the weight for a medium body build. The same calculations apply to males, with the ideal body weight calculated based on their body build size.

Providing and Maintaining Special Diets Based on the Client’s Diagnosis/Nutritional Needs and Cultural Considerations

The client’s diagnosis and nutritional needs determine the special therapeutic diets provided by healthcare professionals. These special diets must also consider the client’s cultural and personal preferences. Here are some of the most common special diets, their indications, and components:

• Clear Fluid Diet
  • Indications: Post-operative, prior to some diagnostic tests, bowel rest, and acute illness
  • Components: Clear fluids like broth, apple juice, water, tea, ginger ale, clear Italian ice, and Jell-O
• Full Fluid Diet
  • Indications: Advancement from clear diet post-operatively, gastrointestinal disorders like gastritis
  • Components: All clear fluids plus vegetable juice, milk, all fruit juices, yogurt, and pudding
• Soft Bland Low Fiber Low Residue Diet
  • Indications: Advancement from full fluids diet, chewing problems, and gastrointestinal disorders
  • Components: Soft foods, except for those with fiber like fruits and vegetables
• Mechanical Soft Diet
  • Indications: Poor dentition, swallowing disorders, intestinal tract strictures, post-operatively after face or neck surgery
  • Components: Ground meats, mashed potatoes, clear and full fluids, soft vegetables, and fruits
• Low Sodium Diet
  • Indications: Renal, cardiac, and liver disease
  • Components: All foods except frozen and canned foods, cold cuts, and smoked meats like bacon and sausage
• Low Cholesterol Diet
  • Indications: Cardiac disease
  • Components: Low cholesterol foods, limited fats and meats
• High Fiber Diet
  • Indications: Constipation, and other gastrointestinal disorders
  • Components: High fiber foods like fruits, vegetables, and whole grains
• Dysphagia Diet
  • Indications: Swallowing disorders
  • Components: Honey consistency thickened fluids, and easy-to-swallow ground and pureed foods
• High Protein Diet
  • Indications: Cachexia, wasting, and during renal dialysis
  • Components: Meats, eggs, fish, dairy products, and protein supplements
• Diabetic Diet
  • Indications: Diabetes
  • Components: Carbohydrate restrictions
• Calorie Restricted Diet
  • Indications: Weight reduction
  • Components: Balanced diet without sugars and low in carbohydrates.

Providing Client Nutrition Through Continuous or Intermittent Tube Feedings

Clients who cannot obtain sufficient calories and nutrients through oral meals may receive enteral nutrition. This method is commonly used for clients with gastrointestinal disorders, chewing or swallowing disorders, inflammatory bowel disorders, severe burns, anorexia caused by acute illness, chemotherapy, or radiation therapy. Enteral nutrition can be given through continuous or intermittent tube feedings, as a bolus, or as a supplement to oral feedings. Commercially prepared formulas vary in terms of calories, fat content, osmolality, carbohydrates, and protein, and can be given with regular pureed foods.

Different types of tubes may be used for enteral tube feedings, including nasointestinal, nasogastric, nasojejunal, nasoduodenal, jejunostomy, gastrostomy, and percutaneous endoscopic gastrostomy (PEG) tubes. Naso tubes are preferred because their placement is noninvasive, but are contraindicated for clients with a poor gag reflex or swallowing disorder due to the risk of aspiration. During continuous tube feedings, clients should be placed in a 30-degree upright position to prevent aspiration, and for at least one hour after an intermittent tube feeding.

Complications associated with tube feedings include aspiration, tube leakage, diarrhea, dehydration, nausea, vomiting, improper placement or dislodgment, nasal irritation (when naso tubes are used), and infection at the insertion site (when an ostomy tube is used). Slowing down the rate of feeding can help prevent abdominal cramping and diarrhea. Doctors should be notified if residual volume is excessive or if the tube is not patent or properly placed.

Continuous tube feedings are usually given throughout the 24-hour day and controlled by a pump. Residual volume is aspirated, measured, and recorded at least every 6 hours, and the tube is flushed every 4 hours to maintain patency. Intermittent tube feedings are given every 4 to 6 hours, and the residual volume is aspirated, measured, and recorded prior to each feeding. The tube is flushed before and after each intermittent feeding with about 30 ml of water and before and after each medication administration to maintain patency. Bolus enteral feedings are given using a large syringe, up to 6 times a day for about 15 minutes. The volume of bolus enteral feedings is usually 200 to 400 ml, not exceeding 500 ml per feeding. Dumping syndrome is a common complication of bolus feedings.

Tube placement is determined by aspirating the residual and checking the pH of the aspirate, as well as radiography and/or auscultation of the epigastric area with a stethoscope to hear air sounds when about 30 ml of air are injected into the feeding tube. If the pH is greater than 6, the tube is improperly placed in the respiratory tract rather than the gastrointestinal tract.

In addition to measuring intake and output, the nurse should monitor the client for complications, check the incisional site for any signs of irritation or infection (for internally placed tubes), secure the tube to prevent dislodgment or malpositioning, clean the nostril and tube using a benzoin swab stick, apply water-soluble jelly just inside the nostril to prevent dryness and soreness, provide frequent mouth care, and replace securing tape as necessary.

In conclusion, this NCLEX review lesson has provided an overview of nutrition and its importance in maintaining optimal health. We have discussed the six essential nutrients, their sources, functions, and daily recommended intake. We have also explored various nutritional assessment tools and the role of nurses in providing nutrition to clients, including those who require special diets or enteral feedings. As nurses, it is crucial to have a solid understanding of nutrition principles and the ability to identify and address nutritional issues in our clients. By integrating this knowledge into our practice, we can help promote optimal health outcomes for our clients.