Nutrition and Metabolism

Nursing Care management 101 Finals Lecture

Nutrition and Metabolism

It is the nurses responsibility to maintain and restore optimal BODY function by providing enough nutrients for tissue repair, for healthy immune system and for life processes to proceed

Definition of Terms

NUTRITION- the sum of all the interactions between an organism and the food it consumes.

Definition of Terms

Nutrients- are organic and inorganic substances found in foods and are required for body functioning

Definition of Terms

Metabolism- sum total of all body processes (biochemical and physiological) to maintain life and growth

Definition of Terms

Anabolism- a type of metabolism characterized by synthesis/building of products

Definition of Terms

Catabolism- a type of metabolism characterized by breakdown of products

Definition of Terms

Energy Balance- the relationship between the energy derived from food and the energy used by the body

Nutrients

Macro Nutrients Carbohydrates Fats Proteins

Fig. 16.22

Nutrients

Micro Nutrients Vitamins

Fat soluble Water soluble

Minerals
Macrominerals Microminerals

CARBOHYDRATES

Composed of elementscarbon, hydrogen and oxygen The preferred source of energy

CARBOHYDRATES

Generally categorized into two basic kindsSimple carbohydrates Complex carbohydrates

CARBOHYDRATES

These include sugars (simple), starches (complex), and cellulose (complex)

CARBOHYDRATES

Calorie provided by ONE gram of Carbohydrates is 4 Kcal/gram

CARBOHYDRATES

Function to promote normal fat metabolism, spare protein, and enhance lower GIT function

CARBOHYDRATES

Major food sources include milk, grains, fruits, and vegetables

CARBOHYDRATES

Inadequate intake of carbohydrate affects metabolism The blood glucose is maintained within relatively narrow limits of 80-109 mg/dL.

Carbohydrate Sources

1. SIMPLE SUGARS 2. COMPLEX CHOSTARCHES 3. COMPLEX CHOFIBER

Carbohydrate Sources

1. SIMPLE SUGARSthese are water-soluble carbohydrates produced by animals and plants.

Simple Sugars Monosaccharides

It can be monosaccharide: a. Glucose b. Fructose c. Mannose and d. Galactose GLUCOSE is the most abundant.

Simple Sugars: Disaccharides

Disaccharides a. Sucrose b. Lactose c. Maltose

Complex Carbohydrates
2. COMPLEX CHO- STARCHESthese are PARTIALY insoluble in water, non-sweet form of CHO. Plant starches are AMYLOSE and AMYLOPECTIN. Glycogen is the counterpart animal starch

Complex Carbohydrate

3. COMPLEX CHO- FIBERderived from plants, this cannot be digested by humans but very essential for roughage, and adds bulk to the diet.

Carbohydrate Metabolism
Ingestion Digestion Absorption Transport Assimilation Storage Metabolism

Carbohydrate Metabolism Digestion

Digestion of carbohydrates begins in the mouth Salivary glands secrete enzyme called SALIVARY AMYLASE (Pyalin)

Carbohydrate Metabolism Digestion

Digestion of carbohydrates begins in the mouth Starches are converted to mixed dextrin, and simple sugars (mono and di)

Carbohydrate Metabolism Digestion

The next site of digestion is the SMALL Intestine Enzymes present in the SI Pancreatic Amylase Intestinal Disaccharidase

Carbohydrate Metabolism Digestion

PANCREATIC AMYLASE
Secreted by pancreas Breaks down mixed dextrin to disaccharides

Carbohydrate Metabolism Digestion

Intestinal Disaccharidase
Secreted by enterocytes Breaks down disaccharides to monosaccharides for absorption

Carbohydrate Metabolism Absorption

Intestinal Mucosa
Has numerous finger-like projection called villi Absorption takes place here

Carbohydrate Metabolism Transport

Portal vessels
Will carry the blood (rich in nutrients) from the intestine to the LIVER

Carbohydrate Metabolism Storage

Liver
Will convert the monosaccharides into glucose Stores glucose as GLYCOGEN

Carbohydrate Metabolism Use

Liver
Will break down Glycogen into glucose Releases the Glucose to the blood for utilization

Carbohydrate Metabolism Use

Hormones that influence Glucose utilization and Metabolism: Insulin Glucagon

Carbohydrate Metabolism Use

Insulin Secreted by the pancreas islets of Langerhans (BETA cells) Released in response to increased glucose level in the body

Carbohydrate Metabolism Use

Insulin Promotes GLUCOSE breakdown

GLYCOLYSIS

Carbohydrate Metabolism Use

Insulin Also promotes GLYCOGEN production

GLYCOGENESIS

Carbohydrate Metabolism Use

Glucagon Also secreted by the pancreatic islets of Langerhans (alpha cells)

Carbohydrate Metabolism Use

Glucagon Promotes Glucose Synthesis

GlucoNEOgenesis

Carbohydrate Metabolism Use

Glucagon Promotes Glycogen Breakdown

Glycogenolysis

Sugar Hormones
Insulin Decreases blood glucose glycogenESIS glycolysis Glucagon Increases blood glucose glyconeoLYSIS glucoNEOgenes is

Lipids

These are heterogeneous group of organic substances that are greasy and insoluble in water but soluble in alcohol and ether.

Lipids

Solid lipids are called fats and liquid lipids are called

oils
Similar to carbohydrates, lipids contain carbon, oxygen and hydrogen

Lipids: Functions
Provide a concentrated source and a stored abundant form of energy Protect internal organs and maintain body temperature Enhance absorption of the fatsoluble vitamins (ADEK)

Lipids

Calorie provided by ONE gram of fats is 9 kcal/gram

Lipids

Inadequate fat intake leads to clinical manifestations of sensitivity to cold, skin lesions, increased risk of infection and amenorrhea in women

Lipids

Diets high in fat can lead to obesity and increase the risk of cardiac disease and some cancers

Lipids
SOURCES OF FATS 1. FATTY ACIDS- these are the basic structure of most BODY and DIETARY lipids. These can be saturated (with single bonds) or unsaturated (with double bonds).

Lipids Fatty acids are found in TRIGLYCERIDES, the most common form of simple lipid. Triglyceride has a backbone of GLYCEROL with 3 fatty acids.

Lipids
2. COMPOUND LIPIDS- HDL, LDL and Chylomicrons are some examples. These compounds have lipids, proteins and cholesterol.

Lipids

Cholesterol is a lipid produced by the body and found in foods of animal origin.

Lipids

Cholesterol is needed to produce bile acids, vitamin D, steroid hormones and cell membranes.

Lipid Metabolism DIGESTION OF LIPIDS Some chemical digestive process can occur in the mouth via the action of salivary lipase. This digestion is usually considered insignificant.

Lipid Metabolism DIGESTION OF LIPIDS The GASTRIC Lipase can break down the lipids in the stomach This is the initial digestion of lipids

Lipid Digestion
The main digestion of lipids occurs in the small intestines where the action of the enzymes pancreatic lipase (from the pancreas), bile acids and intestinal lipase break down lipids into simple fatty acids.

Lipid Digestion

The end products of lipid digestion are: 2-glycerol fatty acids and cholesterol

Lipid Absorption
These products are reassembled into triglycerides by the intestinal cells and are carried into the lymphatic vessels as chylomicrons or lipoproteins

Lipid Transport
The Lipoprotein is carried in the lymphatic vessels called LACTEALS They are not carried to the portalliver circulation. Lymphatic vessels drain the chyle to the superior vena cava

Lipid Storage

Lipids are stored in the liver and adipose tissues.

Lipid utilization and production

The breakdown of lipids is called lipolysis The body can also produce fatty acids, cholesterol and lipoproteins (VLDL and HDL) HDL is the good lipoprotein; LDL is the bad lipoprotein.

Essential fatty acids

Our body cannot produce two important fatty acids

LINOLENIC and LINOLEIC acids.

Arachidonic acid can be derived from Linoleic acid.

PROTEINS
Made of Organic substances carbon, hydrogen, oxygen and

nitrogen
Made from amino acids, critical to all aspects of growth and development of body tissues

PROTEINS

Calorie per ONE gram of Protein is 4 kcal/gram

PROTEIN Functions
Essential for building and repair of body tissues, regulation fluid balance, maintenance acid-base balance, production of antibodies, provision of energy and production of enzymes and hormones

PROTEIN building blocks: Amino acids

AMINO ACIDS can be categorized as essential and non-essential based on dietary requirements

PROTEIN building blocks: Amino acids

Essential amino acids are required in the diet because the

body cannot manufacture them. There are 9 essential and

1 semi-essential

PROTEIN: Amino Acids

Essential amino acids (PVT TIM HALL) Phenylalanie, Valine, Tryptophan. Threonine, Isoleucine, Methionine, Histidine, Arginine (the semi-essential), Leucine and Lysine

PROTEINS: Amino Acids

Nonessential amino acids are those that the body can manufacture and are not needed in the diet.

Protein : Sources
SOURCES OF PROTEINS 1. COMPLETE PROTEIN- these foods contain all the essential amino acids aside from the nonessential ones. Meat, eggs, poultry, fish and dairy products are complete proteins. These are usually animal in origin.

Protein Digestion
The small intestine is the final site of digestion of proteins where the enzymes trypsin (from pancreas), chymotrypsin (from pancreas) and carboxypeptidases (from pancreas also) further break down the proteins.

Protein Sources 2. INCOMPLETE PROTEINfoods that lack ONE or more essential amino acids. Vegetables are usually the foods that lack one or more essential amino acids.

Protein Sources

In order to become complete, a combination of vegetables and fruits called complementary protein foods can augment the intake of essential amino acids

Protein Digestion
The most important initial digestion begins in the stomach The enzyme PEPSIN (secreted by the CHIEF CELLS) in the stomach breaks down complex proteins into simple proteins

Protein Digestion

The HCL, secreted by the PARIETAL CELLS, activates Pepsinogen to PEPSIN

Protein Digestion
Parietal cells also secrete INTRINSIC factor needed to absorb Vitamin B12 Lack of intrinsic factor will impair Vitamin B12 absorption leading to Pernicious anemia

Protein Digestion

The final enzymes come from the intestinal cells Peptidase and dipeptidase completely digest the foods into amino acids.

Protein Absorption and transport

Amino acids are absorbed from the intestine enter the portal circulation The liver takes the amino acids for synthesis of plasma proteins and specific enzymes.

Protein Absorption and transport

The other amino acids are transported to the tissues and cells where they are used to manufacture cellular proteins.

Protein balance

Nitrogen balance- is a measure of the degree of protein anabolism and catabolism. This balance occurs when the nitrogen input equals the nitrogen output

Protein balance

Positive nitrogen balanceexists when the intake of nitrogen is greater than the amount excreted. Example situationspregnancy, recovery from illness, and growth

Protein Balance

Negative nitrogen balance exists when the excretion of nitrogen exceeds the intake of nitrogenous proteins.

Protein Balance
Negative nitrogen balance Example situations- inadequate intake of proteins, tissue breakdown, surgery and acute or early stage of illness.

Micronutrients

These are nutrients needed by the body in small quantities

Vitamins and minerals are examples of micronutrients

Vitamins
1. VITAMINS- are organic compounds that cannot be synthesized by the body (except Vit. D). These are needed for cellular metabolism, but they do not supply energy.

Vitamins

Vitamins can be classified according to their solubility water soluble vitamins are (Vitamins B and C) and Lipid soluble vitamins (Vitamins ADEK)

Vitamin A

Retinoic acid Retinol Retinal Functions: Vision, epithelial maturation and antioxidant

Vitamin D

Cholecalciferol Function: Calcium metabolism

Vitamin E

The tocoperols Function: Antioxidant, reproductive function

Vitamin K

Menadione Function: synthesis of clotting factors 2, 7, 9 and 10

Vitamin C

Ascorbic Acid Functions: Collagen formation Antioxidant Immune system

Vitamin B complex
B1= Thiamine B2= Riboflavin B6= Pyridoxine B12= Cobalamin Niacin Biotin Panthotenic acid Folic Acid

Micronutrients: Minerals

2. MINERALS- are substances that can be found in organic compounds, or they can be found as inorganic compounds and they also can be found as free ions.

Micronutrients: Minerals
Macrominerals are those that are needed daily in amount of more

than 100 milligrams

Examples include calcium, potassium, sodium, magnesium, chloride and sulfur

Micronutrients: Minerals
Microminerals are those that are required by the body less than 100 milligrams. Examples include zinc, iron, manganese, iodine, fluorine, copper, cobalt, chromium and selenium

NUTRITION in Nursing

CHARACTERISTICS OF NORMAL NUTRITON For energy balance to occur energy input must equal energy output

NUTRITION in Nursing
1. ENERGY INPUT The amount of energy that nutrients or foods supply to the body is the caloric value Calorie is the unit of heat energy required to raise the temperature of 1 gram of water 1 degree Celsius

NUTRITION in Nursing

A kilocalorie is the amount of heat required to raise the temperature of 1 gram of water 15-16 degrees Celsius. This is the unit used in NUTRITION

NUTRITION in Nursing

1 kcal= 4.18 kilojoules Carbohydrates= 4 Kcal/gram Proteins= 4 Kcal/gram Fats= 9 Kcal/grams Alcohol= 7 Kcal/grams

Nutrition in Nursing

2. ENERGY OUTPUT Metabolic rate is expressed in terms of the rate of heat liberated during chemical reactions

Nutrition in Nursing
The RESTING ENERGY EXPENDITURE (REE) is the amount of energy required to maintain basic functions to maintain life. This is usually 1 Kcal/kg/hr of body weight. Example: 70 kg male X 1 kcal/kg/hr= 70 kcal REE

Nutrition in Nursing
The BASAL METABOLIC RATE (BMR) is the rate at which the body metabolizes food to maintain the energy requirements of a person who is awake and at rest. REE X 24 hours= BMR 70 kg male X 1 kcal/kg/hr X 24 hr= 1680 kcal/day

Body Weight

IDEAL BODY WEIGHT is the optimal weight recommended for optimal health.

Body Weight

This is conveniently computed by using various formulas like the Tanhaussers method

The rule of 5 (5-foot woman should weigh 100 pounds, with additional 5 lbs per additional inch) and 6 (6-foot man should weigh 105 pounds with additional of 6 pounds per inch).

Body Weight

This can also be computed by using standardized tables.

Body Mass

BODY MASS INDEX- is used as an indicator of changes in body fat stores and whether a persons weight is appropriate for height. This may be used to estimate malnutrition.

Body Mass
the formula for BMI is Weight in KILOGRAMS divided by HEIGHT in meters squared.

Weight in Kilograms __________________

Meters squared

Body Mass
BMI of less than 16 is malnourished, BMI of 16-19 is undernutrition

BMI of 20-25 is normal

BMI of 26-30 is overweight BMI of 31-40 is mod-severely obese BMI of > 40 is morbid obesity

Factors affecting Nutrition

1. Stage of Development 2. Gender 3. Ethnicity and Culture 4. Personal Beliefs about food 5. Personal Preferences

Factors affecting Nutrition

6. Religious practices 7. Lifestyles and Habits 8. Medications and Therapy 9. State of Health 10. Psychological factors 11. Economic factors

What is a healthy diet?

STANDARDS OF A HEALTHY DIET 1. The dietary guideline for Filipinos Developed by the Food and Nutrition Research Institute

What is a healthy diet?

2. The Food Guide Pyramid Developed by the USDA This pyramid suggests that people eat a variety of foods to obtain the nutrients they need

What is a healthy diet?

It divides food into five food groups. The foods needed in largest amount are the group of bread, cereals, rice and pasta.

What is a healthy diet?

This guide is easy to follow and people who eat a variety of foods from each group are likely to come close to recommended nutrient levels.

What is a healthy diet?

This pyramid does not address the fluid intake or provide the guidelines on combination foods.

What is a healthy diet?

3. Vegetarian Diets

Malnutrition
MANIFESTATIONS OF ALTERED NUTRITION OVERWEIGHT OBESE UNDERWEIGHT

Malnutrition

OVERWEIGHT- 10-20% more than the ideal body weight. This usually happens when the person eats more calories than expended.

Malnutrition

OBESITY- weight of more than 20%. Morbid obesity can interfere with normal functioning such as mobility or breathing

Malnutrition

UNDERWEIGHTweight less than 1020% of the ideal body weight

Malnutrition
MANIFESTATIONS OF ALTERED NUTRTION RECENT SIGNIFICANT WEIGHT LOSS DECREASED ENERGY ALTERED BOWEL PATTERNS ALTERED SKIN, TEETH, NAILS AND MUCUS MEMBRANE

Nursing Process and Nutrition

ASSESSMENT The purpose of nutritional assessment is

to identify clients at risk for malnutrition and those with poor nutritional status.
Nurses generally perform nutritional screening for rapid assessment.

Nursing Assessment
NUTRITIONAL SCREENINGassessment performed to identify clients at risk for malnutrition. This can be done by using a screening form, by nursing history and dietary history and physical examination

Nursing Assessment
NURSING HISTORY- data obtained in the routine nursing history usually contain nutritionrelated information. Questions related to this include- changes in appetite, changes in weight, presence of physical disabilities, etcetera

Nursing Assessment PHYSICAL EXAMINATIONthis reveals nutritional deficiencies and excesses in addition to obvious weight changes.

Nursing Assessment
Assessment of the general appearance, skin, hair, nails, eyes, mucosa and other systems can be done to ascertain nutritional status. Height and weight measurements are also taken

Nursing assessment

CALCULATION OF IDEAL BODY WEIGHT AND BODY MASS INDEX

Nursing assessment

Dietary History
24 hour food recall Food frequency record Food diary

Nursing assessment
DIETARY HISTORY- this includes data about the clients usual eating patterns and habits; food preferences, allergies and intolerance: frequency and types of foods consumed; and social, economic, ethnic, and religious factors.

Nursing assessment
24-hour food recall This is the most practical method where the nurse asks the person to recall the type, quality and food preparation of food eaten within 24 hours.

Nursing assessment

Food frequency record

Provides information about the types of food eaten and not the quantity.

Nursing assessment

Food Diary A detailed record of measured amounts of all foods usually 3 days to 1 week period.

Nursing assessment
ANTHROPOMETRIC MEASUREMENTS- these are non-invasive techniques that aim to quantify changes in body composition.

Nursing assessment
MIDARM circumference (MAC) is a measure of fat, muscle and skeleton. MID-ARM MUSCLE circumference (MAMC) is calculated by using reference tables that incorporates the triceps skinfold and the mid-arm circumference.

Nursing assessment
LABORATORY DATA- lab tests results can provide objective data to the nutritional assessment. There is no single test that can specifically predict nutritional risks. The tests most commonly used are SERUM PROTEINS, URINARY UREA and CREATININE.

Nursing Diagnoses
Imbalanced Nutrition: More than Body Requirements Imbalanced Nutrition: Less than Body Requirements Risk for Imbalanced Nutrition Constipation Risk for infection Diarrhea

Nursing Planning
Major goals for clients with or at risk for nutritional problems are: 1. To maintain or restore optimal nutritional status 2. To promote healthy nutritional practices 3. To prevent complications associated with malnutrition 4. To decrease weight or to regain additional weight to reach ideal levels

Nursing implementation

The Nurse reinforces nutritional instructions, creates an atmosphere that encourages eating, and provides assistance with eating

Nursing implementation

The Nurse monitors clients appetite and food intake; administers special diet through enteral (through GIT) and parenteral (Through the blood vessels) feedings

Nursing implementation

The Nurse consults with the physician and nutritionist about the nutritional problems of the client.

Nursing implementation
ASSIST WITH SPECIAL DIETShospitalized patients may need special diets ranging from regular diet to clear liquid, full liquid and soft diets. a. Clear liquid diet b. Full liquid diet c. Soft diet d. Bland diet e. Diet as tolerated

Liquid Diet vs Soft diet

Clear liquid

Coffee Tea

Full liquid Clear liquid PLUS:

Carbonated drink Milk/Milk prod Vegetable juices Bouillon Cream, butter Clear fruit juice Yogurt Popsicle Puddings Gelatin Custard Hard candy

Soft diet All CL and FL plus: Meat Vegetables

Fruits
Breads and cereals

Pureed foods

Ice cream and sherbet

STIMULATE CLIENTS APPETITEa. Provide familiar food b. Select small proportions c. Provide clean environment, oral hygiene, give pain medications first and reduce stress

Nursing Implementation

Nursing Implementation
ASSIST CLIENT with MEALSHospital provides trays and eating utensils for the patients. Older adults and handicapped patients need special assistance from the nurse

Nursing Implementation

PROVIDE ENTERAL NUTRITION Enteral route of nutrition refers to feeding through the gastrointestinal system

Nursing Implementation
Typical examples are the Nasogastric feeding Gastrostomy feeding (opening into the stomach) Jejunostomy feeding (opening into the jejunum)

Nursing Implementation
PROVIDE PARENTERAL FEEDING Parenteral nutrition is provided when the gastrointestinal tract is non-functional. It can be otherwise called TPN or IVH (intravenous hyperalimentation).

Nursing Evaluation

The goals established during the planning phase are evaluated to determine the success.

In Summary
Adequate nutritional intake is important to maintain body functions, promote healing, maintain healthy tissues, maintain body temperature and build resistance to infection

In Summary

Essential nutrients are carbohydrates, protein, fat, vitamins, minerals and water

In Summary

Complex physiologic processes permit the body to break down food so that it can be used by the body as energy

In Summary

Great variations exists in dietary intake among different people, but guidelines such as food groups, RDA and caloric intake can be evaluated

In Summary
Many factors affect normal eating patterns Manifestations of altered nutrition include over/underweight, weight loss, decreased energy, altered skin and mucus membrane

In Summary

Nutritional needs vary across the lifespan

In summary

Nutritional Assessment includes collecting subjective data on normal eating patterns, risks factors for nutritional deficits and identification of altered nutrition

In summary

Anthropometric measurements can provide objective data to help assess a patients nutritional state

In summary

Nursing diagnoses applicable are: Imbalanced nutrition, Risk for infection, etc

In summary

Nursing intervention to promote optimal nutrition include patient teaching, measures to encourage eating, nutrition program and provision of special feedings like NGT, TPN, etc.

In summary
Therapeutic diets are used to promote health Evaluation of nutritional goals are done to determine the success of the interventions