NUTRITION

 Sum of all the interactions between an organism and the food it consumes
 According to Chemical nature:
- Organic
- Inorganic
 According to Essentiality:
- Dietary essential = you need to have/supplied it daily (water-soluble)
- Non-essential = fat-soluble

Assessing nutritional status:

a. Physical/instrumental Method ( Anthoprometry)

 Weight
 Height
 Mid upper arm circumference
 BMI
= weight (kg) / height (meter)2
= 20-25% Normal
 Triceps skin fold

b. Biochemical tests
 Hemoglobin (12-18 g/dL) = anemia (LOW)
 Hematocrit (40-50%) = Anemia (LOW) /dehydration (INC)
 Serum albumin (3.3-5g/dL) = Malnutrition (LOW), Malabsorption
 Transferrin (240-480 mg/dL) = anemia, iron deficiency
 Total lymphocyte count (greater than 1,800) = impaired nutritional intake, severe
debilitating disease
 Blood urea nitrogen (17-18 mg/dL) = starvation, high protein intake (so NPO
needed), severe dehydration; Malnutrition, overhydration
 Creatinine (0.4-1.5 mg) = dehydration, reduction in total mucle mass

c. Clinical examination
d. Dietary survey
 24-hour diet recall

TYPES OF DIET:
A. Regular
- Has all essentials, no restrictions
- No special diet needed
B. Clear liquid
- “See-through” foods like broth, tea, strained juices, gelatin
- Recovery from surgery or very ill
C. Full liquid
- Clear liquids plus milk products, eggs
- Transition from clear to regular diet
D. Soft diet
- Soft consistency and mild spice
- For patients with difficulty swallowing
- Chopped
 E. Mechanically soft diet
- Regular diet but chopped or ground
- Difficulty chewing
F. Bland diet
- Chemically and mechanically non-stimulation
- No spicy foods
- For patients with ulcers and colitis
G. Low residue diet
- No bulky foods, apples (but you can remove skin) or nuts, fiber, foods having skins
and seeds
- For patients with rectal diseases
H. High calorie diet
- High protein, vitamin and fat
- Malnourished
I. Low calorie diet
- Obese
J. Diabetic Diet
- Balance protein, fat
- Insulin-food imbalance
K. High protein Diet
- Meat, fish, milk, cheese, poultry, eggs
- Tissue repair and underweight
L. Low fat Diet
- Gall bladder, liver or heart disease
- Little butter, cream, whole milk, or eggs
M. Low cholesterol Diet
- Little meat or cheese
- Need to decrease fat intake
N. Low sodium Diet
- No salt added during cooking
- Heart or renal disease
O. Tube feeding

PROTEIN-MODIFIED DIET:

A. Gluten-free diet
- Purpose: to eliminate gluten (protein) from the diet
- Malabsoption syndromes and celiac disease
- Avoid barley, rye, oats, wheat, cream sauces, breaded foods, cakes, breads,
muffins
B. PKU diet
- Purpose: control intake of Phenylalanine
- Cannot be metabolised
- Avoid bread, meat, fish, poultry, cheese
C. Low-purine diet
- Indicated for gout, uric acid retention, kidney stones
- Avoid organ meats, fish and lobster, dried peas and beans, nuts and oatmeal
ENTERAL AND PARENTERAL NUTRITION

Enteral Nutrition Parenteral Nutrition

 Cancer
 Neuromuscular disorder
 GI disorder
 Respiratory failure with
prolonged intubation
 Malfunctional GIT
 Extended bowel rest
 Preoperative TPN

GI TUBES

Stomach tubes:
 Tip of the nose, earlobe, xiphoid process

A. Levin tube
- Single lumen stomach tube
B. Salem-Stump tube
- Double lumen stomach tube
- The other lumen serves as airway to prevent adherence of the tube to the gastric
mucosa
C. Sengstaken-Blakemore
- Triple lumen stomach tube used to treat bleeding esophageal varices
- Third lumen will inflate the balloon (Will put pressure on the bleeding varices)
D. Minnesota-Sump
- Four lumen stomach tubes

Intestinal tubes:
 Tip of the nose, earlobe, xiphoid process, PLUS 8-12 inches

A. Cantor tube
- Single lumen intestinal tube
B. Harris tube
- Single lumen intestinal
C. Miller-Abbott
- Double lumen intestinal tube

GASTRIC GAVAGE (Tube Feeding)

Notes:

 Gastric aspirate: pH of 1-4 (acidic)

 Pleural/Intestinal: Higher than pH 6 (alkanine)
 Continuous type of feeding (Gastric aspirate): ph of 5-6

- Patient should be upright

- Check for patency and placement
- If gastric aspirate is less than 50cc, proceed with feeding
- Drugs are best absorbed with an empty stomach, so administer drugs BEFORE feeding
- If drug is a gastric irritant, IN BETWEEN feeding
- Maintain patency
Question 1: Tube found not to be in the stomach or intestine
 Replace the tube
Question 2: Nausea after tube feeding
 Make sure bed remains elevated
 Check med record if there is order of antiemetic drug
Question 3: When checking for placement, the nurse noted that the tube is clogged.
 Warm water to flush the tube and gentle pressure to remove clog
 NEVER use stylet
 Tube may have to be replaced.

GASTRIC LAVAGE
- Position: Upright
- Check for patency and placement (Inflow and outflow of NSS)
- Normal amount of NSS – 1L (adult); 500 mL (for Pedia)
- Cold NSS (Immerse it in a basin of ice; do not put ice on NSS)
- Inflow should equal the outflow
- If there is NO outflow drained, reposition the patient
- Stop the lavage if you have pinkish drainage (if gastric bleeding)
- Discard the aspirate

GASTRIC DECOMPRESSION
- Draining to gravity or with suction
- If using suction: can be intermittent or continuous and pressure can be low (20-40
mmHg) or high (80-120 mmHg)
- Replace what was lost

REMOVING NGT
- Sitting position
- Take a deep breath and hold
- Pinch the tube with the gloved hand

GASTROSTOMY/JEJUNOSTOMY FEEDING
- Place in high fowler’s position
- Check the patency of the tube (Pour 15-30 cc H2O)
- Check for residual feeding
- Hold asepto syringe 3-6 inches above ostomy feeding
- Frequently assess stoma for skin breakdown

Question 1: Gastrostomy tube is leaking large amount of drainage:

 Check tension of tube
 Apply gentle pressure to tube while pressing the external bumper closer to the skin
 If the tube has an internal balloon holding it in place, check to make sure that the
balloon is inflated poperly

Question 2: Skin irritation is noted around insertion site:

 Stop the leakage as described above
 And apply a skin barrier around the stoma

Question 3: Site appears erythematous and pain on the site

- Notify MD; May be developing cellulitis
Complications:
- Pulmonary aspiration
- Diarrhea/constipation
- Tube occlusion/displacement
- Abdominal cramping/ n/v
- Delayed gastric emptying
- Serum electrolyte imbalance
- Fluid overload
- Hyperosmolar dehydration

PARENTERAL NUTRITION
- “hyperalimentation”
- Site of insertion: Infraclavicular (subclavian vein) = freedom of movement or
ambulation, Supraclavicular (jugular vein) = hinders movement

Preparations and Procedures:

- Explain procedure
- Valsalva maneuver as catheter being inserted with head down in the opposite
direction of insertion (so that vein is more visible)
- Cover area with sterile dressing
- Regulate at ordered rate
- Observe for air embolism, subcutaneous bleeding and allergic reaction
- VS q 4 hours
- CBG (hyperglycemia)
- urine specific gravity (hyperosmolar diuresis = LOW specific gravity)
- Change tubing every 24 hours
- Do not catch up if delayed
- Monitor I and O

Complications:
- Air embolism
- Catheter occlusion and sepsis
- Electrolyte imbalance
- Hypo/hyperglycemia

A. Fecalysis – an inch of formed stool, 15-30 ml if diarrhea/liquid stool

B. Fecal occult blood testing/GUIAC test
- False-positive = to prevent, avoid eating dark colored foods for 3 days, avoid iron
- False-negative = to prevent, avoid eating vitamin C more than 500 mg (vitamin C
supplements)

C. Diagnostic tests

BARRIUM SWALLOW

 Fluoroscopic exam of the upper GI

 Pre-test
- NPO from midnight or 6-8 hours pretest
- Barium will taste chalky
 - No need for enema
 Post test
- Laxatives to enhance elimination of barium and prevent obstruction or
impaction

BARRIUM ENEMA

 Lower GI series
 Pre-test
- NPO 8 hours
- Enema the morning of test
- Laxative or suppository
- Cramping may be experienced during procedure
 Post test
- Laxative and fluids to assist in the expulsion of barium

ENDOSCOPY

 Pre-test
- NPO 6-8 hours
- Consent
- Local Anesthetic will be used
- Hoarseness and sorethroat for several days (common side effect)
 Post test
- NPO until return of gag reflex
- Warm saline gargles

COLONOSCOPY

 Pre-test
- NPO 8 hours
- Laxatives and enemas
- Consent
- Instrument will be inserted into the rectum
- Should have a good platelet count
 Post test
- Obsere for signs of rectal bleeding

LIVER BIOPSY

 Pretest
- NPO 6-8 hours
- Consent
- Hold breath during biopsy
 Post test
- VS every 8-12 hours
 - RIGHT side lying with pillow against the abdomen
- Observe site for bleeding

ALTERATION ON STOOL CHARACTERISTICS

- Alcoholic stool (gray)

- Hematochezia (Lower GI bleeding)
- Melena (upper GI bleeding)
- Steatorrhea (Foul smelling; with fat)

FECAL ELIMINATION PROBLEMS

1. Constipation
 Interventions:
- Regular exercise
- High-fiber foods
- Fluid intake of 2-3 L/day
- Do not ignore urge to defecation
- Allow time to defecation
- Avoid over the counter meds
- Laxative

Types of Laxatives

Type Action Example

Bulk forming Increases fluid, gaseous or solid bulk Metamucil, Citrucel
Emollient/Stool softener Softens, delays drying of feces Colace
Stimulant/irritant Irritates, stimulates Dulcolax, Senekot,Castor oil
Lubricant Lubricates Mineral oil
Saline/osmotic Draws water into intestine

ENEMA

Types of enema:
1. Cleansing enema
- Prior to dx test, surgery
- Incases of constipation and impaction
- Either be:
 High enema = 12-18 inches
 Low enema = 12 inches (Only until ascending colon)
2. Carminative enema
- To expel flatus
- 60-80 ml of fluid
3. Retention enema
- Solution retained for 1-3 hours in colon
- Oil enema,antibiotic enema, antihelminthic, nutritive
 4. Return-flow enema
- To expel flatus
- Alternating frow of 100-200 ml of fluid in and out of the rectum

Enema Administration
A. Appropriate size
- Adult: Fr 22-30
- Child: Fr 12-18
B. Correct Volume:
- Adult: 750-1000 mL
- Adolescent: 500-750 mL
- School-aged: 300-500 mL
C. Length of insertion:
- Adult: 3-4 inches
- Child: 2-3 inches
- Infant: 1-1.5 inches
*** Enemas until clear = when no solid fecal material exists, but solution may be colored (accdg
to book)

COMMONLY USED ENEMA

Hypertonic E.g. sodium phosphate soln; Draws water into colon

fleet enema (osmosis)
Hypotonic Tap water Distend the colon
(persistalis) stimulates,
softens
Isotonic Normal saline
Soapsuds 3-5 mL of soap to 1L of Irriates mucosa, distends
water colon
Oil Mineral, olive, cotton weed Lubricates feces

Question 1: Solution does not flow into rectum

 Reposition rectal tube
 If solution will still not flow, remove the tube and check for any fecal contents
Question 2: Cannot retain enema for an adequate amount of time
 Need to be placed on the bed pan in the supine position
Question 3: Cannot tolerate large amounts of enema solution
 Amount and length of administration may have to be modified if patient begins to
complain of pain
Question 4: Severe cramping with intro of enema
 Lower solution container
 Solution may be too cold

2. Fecal impaction
 Intervention
- Increase fluid intake
- Sufficient bulk in diet
- Adequate activity and exercise
- Oil retention enema  cleansing enema 2-4 hours after
 - Stool softeners/suppositories
- Digital removal of stool as ordered (scissor-like manner; maximum of 10-15
minutes, but if you have to repeat, interval/rest period of 30 minutes)
3. Diarrhea
 Interventions:
- At least 8 glasses of water /day
- Increase Na and K in diet
- BRA diet
- Dec intake of insoluble diet
- Dec fatty foods
- Avoid caffeine drinkd and excessively hot.cold fluids
- Good perianal care
- Promote rest
- Antidiarrheal drugs
4. Flatulence
 Interventions:
- Limit carbohydrate bev, use of drinking straw and chewing gums
- Avoid gas forming foods
- Promote activity and mobility
- Rectal tube insertion
3-4 inches
Fr 22-30
5. Fecal incontinence
 Involuntary elimination of bowel contents
 Often associated with neurologic, mental and emotional impairments
6. Hemorrhoids
 Dilated engorged veins in the lining of the rectum
 Post op hemorrhoidectomy:
- Anal pack (anus) + External pack (to protect anal pack)
- Hot sitz bath, remove external pack ONLY. Anal pack is removed by surgeon

COLOSTOMY CARE

- Normal appearance of stoma: Beefy red

- Bluish: There is cyanosis
- Pale: patient is anemic or there is constriction
- Normal to have inflammation after making of stoma (will stabilize after 6-8 weeks)
- Home base: Clean water on clean cloth
- Changing of wafer: Measure stoma then add 1/8 inch from original size of stoma
traced on paper (to avoid constriction)

BLADDER ELIMINATION

A. Assessment:
Urine characteristics
- pH = 4.6 – 8.0 (average 6)
- Spec gravity = 1.010 – 1.025
- Color = Amber/straw
- Odor = Aromatic upon voiding
- Transparency = clear
Notes:
 For patients who are catheterized:
 Kink the connecting tube for at least 30 minutes for the urine to pool in the catheter.
 If patient is allowed to drink, increase fluid intake.
 Disinfect first
 Aspirate urine from the drainage port (slant the needle to allow the self-sealing
effect of the catheter to close the puncture site)
 10 cc of urine
Urine output:
 Pedia = 1 ml/kg body weight
 Adult = 30 mL/hour
 Urge to void = 150-200 mL
 Really needs to void = 600 mL
 Bladder can hold = 1000-1500 mL

TYPES OF URINARY ALTERATIONS

- Urgency
- Dysuria
- Frequency
- Hesitancy = Difficulty in initiation of urination
- Nocturia = Frequency urination at night
- Retention
- Residual urine = Normal amount: 50-100 mL
- Polyuria = Voiding more than
- Oliguria = Voiding less than 30 mL/hour
- Anuria = 0-10 mL/hour
- Incontinence
a. Functional
b. Overflow = Caused by an over distended bladder
c. Reflex = Filled with a pre-determined amount (easier to manage than
functional)
d. Stress = increase in abdominal pressure
e. Urge

URINE TESTS
- Routine urinalysis
- Urine culture and sensitivity
- Timed urine specimens (there is a period of time wherein the specimen was
collected = 24 hour urine collection)
- Renal function tests
 BUN
 Creatinine clearance

INTRAVENOUS PYELOGRAM (IVP)

Fluorscopic visualization of the tract
- Pre-test
 Assess for iodine sensitivity
 Enema the night before
 Consent
 NPO for 8 hours
 - Post test
 Force fluids

CYSTOSCOPY
- Pre-test
 General or local anesthesia
 Consent
 NPO
 Enema as ordered
- Post test
 Force fluids
 Pink tinged urine 24-48 hours
 Warm sits bath and analgesics

IMPLEMANTIATION
A. Prevent UTI
- Frequent voiding (q 2-4 hours)
- Avoid use of harsh soaps, bubble bath, powder or sprays on perineal area
- Proper perineal hygiene
- Increase acidity of urine (cranberry juice, buko juice, corn)
B. Managing urinary incontinence
- Bladder training
 Inhibiting the urge-to-void sensation; can be done among catheterized
and uncatheterized patients
 Clamp catheter for 4 hours; Release the clamp for 30 minutes
- Pelvic muscle exercise
 Contracting for 3-5 seconds, 10 contractions, 5 times daily
- Positive reinforcement
- Meticulous skin care
- Avoid stimulants at night
- External drainage device (males)
 Condom catheter = leaving 2.5 cm/ 1 inch between the end of penis and
rubber
C. Managing urinary retention
- Provide privacy
- Provide fluids to drink
- Assist in proper positioning for voiding
- Serve clean and warm bedpan
- Allow to listen to sound of running water
- Alternate warm and cold water over perineum
- Most effective: Warm shower (the feel)
- Promote relaxation
- Adequate time for voiding
- Cholinergic drugs as ordered (Urecholine)
- Manual pressure on the bladder – Crede’s maneuver
- Urinary catheterization as ordered

CATHETERIZATION

A. Indications:
- Decompression
 - Instillation
- Irrigation
- Specimen collection
- Urine measurement
 Residual urine
 Hourly urine output
- Promotion of healing of GUT
B. Catheter Size (accdg to Potter and Perry)
- Children: Fr 8-10
- Young female: Fr 12
- Female: Fr 14-16
- Male: Fr 16-18
C. Position
- Female: Dorsal Recumbent
- Male: Supine with thighs slightly abducted
D. Length of insertion:
- Female: 2-3 inches (5-7.5 cm)
- Male: 5-7 inches (17-22.5 cm)
E. Anchor:
- Female: Inner thigh
- Male: Top of the thigh or lower abdomen

Question 1: No urine flow and you note that catheter is in the vaginal orifice
 Leave the catheter in place, get a new set and reinsert catheter in the urinary tract

Question 2: Urine flow is initially well established and urine is clear, but after several hours, flow
dwindles
 Check tubing for kinks or loops

Question 3: Extreme pain when inflating the balloon

 Stop inflation
 Withdraw the solution/NSS
 Insert additional 0.5-1 inch and slowly attempt to inflate the balloon again.

BLADDER IRRIGATION
A. Open System (Intermittent)
- For instillation of medications or irrigation of catheter
B. Closed System (Intermittent or Continuous)
- For those who had genitourinary surgery
- For instillation of medications, promoting hemostasis, flushing of clots or debris
- Continuous Irrigation: for the first 24 hours = red outflow
- If pink outflow then after a few hours, turned to red, check VS then inform MD
(may be bleeding)
Question 1: Continuous bladder irrigation begins and hourly drainage less than amt of irrigation
being given
 Palpate for bladder distension
 If patient is lying supine, change position

Question 2: Bladder irrigation is not flowing at ordered rate, even with clamp wide open
 Check for kinks
PAIN
- Sensation of physical or mental suffering or hurt that usually causes distress or agony to
the one experiencing it
- Highly Subjective
- Unpleasant but it is a protective mechanism

Theories of Pain transmission

A. Specificity Theory = When a specific nerve fiber is stimulated, it will lead to pain
sensation
B. Pattern Theory = If the nerve fiber is stimulated intensely, it will produce pain
C. Affect Theory = A person will feel more pain if the concerned body part is more important
to him.
D. Gate control Theory

PHYSIOLOGY OF PAIN

A. Transduction
- Pain receptors can be excited by mechanical, thermal, or chemical stimuli

B. Transmission
- Pain impulse travels from the peripheral nerve fibers to the spinal cord
- We need to close the gate in the spinal cord

C. Modulation
- When the neurons in the thalamus and brain stem send signals back down to the
dorsal horn of the spinal cord
- Serotonin, endorphins

Neuroregulators:
- Substances that affect the transmission of nerve stimuli
- Increases pain impulses:
 Substance P, prostaglandins
 Bradykinin (universal stimulus for pain)
- Decreases pain impulses:
 Serotonin, engigenous opioids (endorphins, enkephalins, dynophins)

D. Perception
- When the client becomes conscious of the pain
- Actual feeling of pain takes place in the cerebral cortex

PAIN ASSESSMENT
- Fifth VS
- Mnemonic of Pain Assessment
 COLDERR
 PQRST
- 11 Point Pain intensity Scale
- Wong-Baker FACES Rating Scale
NON-PHARMACOLOGIC INTERVENTIONS FOR PAIN CONTROL

A. Target Domain of Pain Control

1. Body
2. Mind
3. Spirit
4. Social Interaction

B. Rest
- State of calmness
- Relaxation without emotional stress or freedom from anxiety

C. Sleep
- State of consciousness in which the individual’s perception and reaction to the
environment are decreased

TYPES OF SLEEP

1. NREM (deep, restful sleep/slow – wave sleep)

Stages of NREM:
 Stage I:
- Very light; drowsy
- Relaxed
- Eyes roll from side-to-side
- Lasting a few minutes
 Stage II:
- Light sleep
- Body processes slow further (decrease PR/RR)
- Eyes are still
- Lasts about 10-20 minutes
 Stage III:
- Domination of the PNS
- Difficult to arouse
- Not disturbed by sensory stimuli
- Snoring
- Muscles totally relaxed
- 15-30 minutes
 Stage IV:
- Delta sleep
- Seep slow wave sleep
- Body will release human growth hormones
- PR/RR drop by 20-30%
- Rarely moves
- Very difficult to arouse
- 15-30 minutes
 2. REM (rapid eye movement)
- Where most dreams take place
- Brain is highly active, hence, paradoxical sleep
- Increase in cortisol activity
- Important in memory and learning retention

COMMON SLEEP DISORDERS

A. Insomnia
- 3 Types:
1. Initial
2. Intermittent or maintenance
3. Terminal (common in the elderly; maaga nagigising)
B. Hypersomnia = Oversleeping
C. Narcolepsy = Attack of overwhelming sleepiness
D. Sleep apnea = Temporary cessation of breathing when asleep
E. Parasomnias
a. Somnabulism = Sleep walking
b. Night terrors
 Noctural eneuresis
 Soliloquy = Sleep talking
 Bruxism = Grinding of teeth
 Noctural erections
c. Sleep deprivation – a syndrome brought about by prolonged disturbance in sleep

MOBILITY AND IMMOBILITY

4 Basic Elements of Body Movements

1. Alignment and posture
2. Joint mobility
3. Balance
4. Coordinated movement

Effects of Immobility
1. Disuse atrophy = Muscle will shrink/ decrease in size
2. Contractures = Shortening of muscle fiber (Stronger muscle: FLEXOR muscle)
3. Ankylosis = Stiffening of joints that impairs joint mobility
4. Disuse osteoporosis = calcium goes to kidneys or blood

Effects on Cardiovascular System

1. Orthostatic hypotension (deprivation of blood supply to the central system)
2. Valsalva Maneuver
3. Dependent edema
4. Thrombophlebitis
- Wearing elastic stockings is a preventive measure (not used in patients with actual
thrombophlebitis because it may dislodge clot with flexion of leg/muscle contraction)
Effects on Respi
1. Atelectasis
2. Hypostatic Pneumonia
 Interventions:
 - Deep breathing/CE
- Turn to sides
- Chest percussion/vibration
- Steam inhalation
3. Respiratory Acidosis

Effects on GI
1. Constipation

Effects on the Metabolic System

1. Decrease metabolic rate
2. Anorexia
3. Demineralization
4. Hypercalcemia

Effects on the Urinary System

1. Urinary retention
2. Urinary stasis
3. Renal calculi formation
4. UTI

Effects on the Integumentary System

1. Ischemia
- Decrease blood circulation due to pressure on the skin
- Result in skin breakdown
2. Bedsore
- Factors:
 Pressure = prependicullar force (most common)
 Friction = parallel force
 Shearing = combination
- Risk Factors:
 Immobility
 Moisture
 Excessive body heat
 Advanced age
 Nutrition
 Hygiene

Stages of Bedsore
1. Non-blanchable skin [epidermis]
2. Partial thickness [epidermis + dermis]
3. Full thickness [dermis+ subcutaneous]
4. Full thickness with extensive destruction [muscles + bones]

Effects on Pyschoneurologic
1. Isotonic (Dynamic)
- Muscle tension is constant and the muscle shortens to produce muscle contraction
and movement
2. Isomeric (Static)
- There is change in muscle tension but no change in muscle length hence no
movement
 3. Active
- Exercise done by the patient himself without assistance from the nurse
4. Passive
- Exercise done by the patient with complete assistance from the nurse
5. Active-Assistive
- Independently by the patient which is then continued or assisted by the nurse for the
patient to complete ROM
6. Resistive
- The client moves of tenses his muscles against a resistance.

 Notes:
 Sulcular Technique = 45 degree angulation starting from gum to entire teeth