Nutrition — Study Notes

📋

Nutrition Across the Lifespan

2020–2025 Dietary Guidelines for Americans

Guideline 1

Healthy Pattern

Follow a healthy dietary pattern at every stage of life

Guideline 2

Customize

Enjoy nutrient-dense choices that reflect personal, cultural & budget needs

Guideline 3

Nutrient-Dense

Meet food group needs; stay within calorie limits

Guideline 4

Limit

Limit added sugars, saturated fat, sodium, and alcohol

✅ Focus ON

Fiber-rich fruits & vegetables
Whole grains
Low-fat/fat-free milk & dairy
Lean meats, poultry, fish, legumes, eggs, nuts

⚠️ LIMIT

Added sugars: <10% cal/day (age 2+)
Saturated fat: <10% cal/day
Sodium: <2,300 mg/day (~1 tsp)
Alcohol: ≤2 drinks/day men, ≤1 drink/day women

🤰

Pregnancy & Lactation

⚡ Key Pre-Pregnancy Facts

        Pre-pregnancy matters! Early fetal development occurs before a client knows they're pregnant. Normal weight + adequate folate BEFORE conception is critical.
      

⚠️ Low folate before conception increases risk of neural tube defects

🍽️ Macronutrient Breakdown (Pregnancy)

Protein

20%

DRI: 71 g/day. Essential for fetal tissue, amniotic fluid, blood volume. Watch animal fat content.

Fat

30%

Limit to 30% of total daily calories

Carbohydrates

50%

Spares protein for fetal tissue synthesis

📈 Caloric Increases

2nd Trimester

+340 cal/day

3rd Trimester

+452 cal/day

Lactation (0–6 mo)

+330 cal/day

Lactation (6–12 mo)

+400 cal/day

⚖️ Recommended Weight Gain (by BMI)

1st Trimester: 1.1 – 4.4 lb total | 2nd & 3rd Trimester: 2–4 lb/month

Normal BMI (18.5–24.9)

25–35 lb total

~1 lb/week

Underweight (<18.5)

28–40 lb total

>1 lb/week

Overweight (25–29.9)

15–25 lb total

0.66 lb/week

Obese (>30)

11–20 lb total

0.5 lb/week

💊 Key Micronutrients

🍃 Folic Acid

600 mcg/day during pregnancy
500 mcg/day during lactation
Prior neural tube defect: 4 mg/day
Sources: green leafy vegetables, enriched grains, OJ
Folic acid (synthetic) = better absorbed than folate

🩸 Iron

DRI increases 50% during pregnancy
Supplement: 27–30 mg/day
Supports ↑ maternal blood volume & fetal liver storage
Sources: meats, eggs, leafy greens, enriched breads, dried fruits
Vitamin C aids iron absorption

💧 Fluid & Other Recommendations

Fluid: 2,000–3,000 mL/day. Prefer water, fruit juice, milk. Carbonated drinks = little/no nutrients.

🚫 Alcohol: NO safe amount during pregnancy. Abstain completely.

☕ Caffeine: Crosses placenta, affects fetal HR & movement. Moderate use <200 mg/day appears safe.

🐟 Fish: Limit albacore tuna to 6 oz/week. Total seafood ≤12 oz/week. AVOID: tilefish, shark, swordfish, marlin, orange roughy, king mackerel (mercury risk).

🚨 Dietary Complications

🤢 Nausea

Eat dry crackers, toast, salty/tart foods
Avoid alcohol, caffeine, fats, spices
Avoid fluids WITH meals
No medications without provider approval

😣 Constipation

↑ fluids (at least 8 cups/day)
↑ fiber: fruits, vegetables, whole grains
Regular physical activity

🧬 Maternal PKU (Phenylketonuria)

Genetic disease — high phenylalanine dangerous to fetus. Start PKU diet 3 months BEFORE pregnancy and continue throughout.

🚫 AVOID high-protein foods (fish, poultry, meat, eggs, nuts, dairy) — high phenylalanine content. Monitor blood phenylalanine levels throughout pregnancy.

📊 DRI Table: Major Vitamins (Age 19–30)

Nutrient	Nonpregnant	Pregnant	Lactating
Protein	46 g	71 g	71 g
Vitamin A	700 mcg	770 mcg	1,300 mcg
Vitamin C	75 mg	85 mg	120 mg
Vitamin D*	15 mcg	15 mcg	15 mcg
Vitamin E	15 mcg	15 mcg	19 mcg
Vitamin K*	90 mcg	90 mcg	90 mcg
Thiamin	1.1 mg	1.4 mg	1.4 mg
Vitamin B6	1.3 mg	1.9 mg	2.0 mg
Folic Acid	400 mcg	600 mcg	500 mcg
Vitamin B12	2.4 mcg	2.6 mcg	2.8 mcg
Calcium*	1,000 mg	1,000 mg	1,000 mg
Iron	18 mg	27 mg	9 mg

*Values represent adequate intakes. Source: NIH Office of Dietary Supplements

📝 NCLEX Practice

A nurse is teaching a group of clients who are pregnant about iron-rich foods. Which of the following should be included? (Select all that apply)

A Beans ✓
B Fish ✓
C Dairy products
D Lean red meats ✓
E Apples

👶

Infancy

📈 Growth Milestones

Weight

×2 by 4–6 mo

Triples by 1 year. Avg gain: 4–7 oz/week first 4–6 months

Height

1 in/month

First 6 months. Then 0.5 in/month for months 6–12

Head Circumference

+33%

By 1 year. 1.5 cm/month (0–6 mo); 0.5 cm/month (6–12 mo)

🤱 Breastfeeding

✅ AAP, CDC, and WHO recommend exclusive breastfeeding for first 6 months, continuing while introducing solids up to 2 years or longer.

✨ Advantages of Breast Milk

Carbs, protein, fats predigested for absorption
High in omega-3 fatty acids
Low in sodium
Iron, zinc, magnesium highly absorbable
Calcium:phosphorous ratio 2:1 → enhanced absorption

🍼 Feeding Schedule

8–12 feedings in 24 hours
Nurse up to 15 min per breast
Awaken every 3 hr day / 4 hr night
Assess hunger cues: rooting, suckling hands — crying is late indicator

🥛 Breast Milk Storage

Refrigerator

4 days

Frozen

6 months

In sterile containers

After Thawing

24 hours

Thaw in refrigerator. Never refreeze. No microwave.

🍼 Formula Feeding

Use iron-fortified formula for at least first 12 months
Max 32 oz/24 hr unless directed by provider
Refrigerate opened formula; discard if at room temp >2 hours
Do NOT reuse partially emptied bottles
Do NOT prop bottle or put infant to bed with bottle (→ tooth decay)

🥣 Introducing Solid Foods

⚠️ Do NOT introduce semisolid foods before 6 months (GI system, head control, tongue must be ready)

Introduce one new single-ingredient food every 3–5 days; monitor for allergy
Solid food in any order — no strict sequence required
By 8 months: 3 meals/day + 3 snacks
By 9 months: cooked, chopped, unseasoned table foods
Good finger foods: ripe bananas, toast strips, graham crackers, cheese cubes, noodles, peeled apple/pear/peach chunks

🚫 NEVER give honey (<12 mo) — risk of botulism. AVOID choking hazards (<12 mo): grapes, nuts, raw carrots. No cow's milk until after 1 year.

🩺 Nutrition-Related Problems

😭 Colic

Crying ≥3 hr/day, >3 days/week, >3 weeks
Tense abdomen, legs drawn up
If breastfeeding: eliminate cruciferous vegs, cow's milk, onion, chocolate; limit caffeine & nicotine
Burp in upright position

🥛 Lactose Intolerance

↑ prevalence: Asian, Native American, African, Latino, Mediterranean descent
Signs: abdominal distention, flatus, occasional diarrhea
Tx: soy-based or casein hydrolysate formula

📉 Failure to Thrive

Weight-for-length <5th percentile OR weight-for-age <3rd percentile
Assess: congenital defects, CNS disorders, swallowing/sucking, formula prep, bonding/neglect
Tx: high-calorie, high-protein diet + parenting support

💧 Diarrhea

>3 loose/watery stools/24 hr
Common cause: rotavirus
Mild: no intervention. Moderate: oral rehydration solutions (8 oz after each stool)
Sports drinks CONTRAINDICATED
Dehydration signs: sunken eyes/fontanels, dry mucous membranes, ↓ urine

ℹ️ Constipation: Not common in breastfed infants. May be caused by too-concentrated formula. Stress accurate dilution.

🌟 Special Notes

Supplement Vitamin D soon after birth if consuming <28 oz breast milk/formula
Gestational iron stores deplete ~4 months → iron-fortified cereal when solids introduced
Cow's milk: NOT before 1 year (stresses immature kidney, protein/fat not fully digestible)

📝 NCLEX Practice

A nurse is assessing a 6-month-old infant with lactose intolerance. Which findings should the nurse expect? (Select all that apply)

A Abdominal distention ✓
B Flatus ✓
C Hypoactive bowel sounds
D Occasional diarrhea ✓
E Visible peristalsis

🧒

Childhood

🍼 Toddlers (1–3 years)

Growth: 2–3 inches height and 5–6 lb/year. Food serving size = 1 tbsp per year of age.

✅ Guidelines

Limit 100% juice to 4–6 oz/day
Ages 1–2: whole cow's milk (needed for brain fat)
A new food may need 15–20 exposures before acceptance
Prefer finger foods, plain foods, macaroni & cheese, spaghetti, pizza
Regular meal times + nutritious snacks

⚠️ Risks

Choking risk until age 4
Avoid: hot dogs, popcorn, peanuts, grapes, raw carrots, celery, peanut butter, tough meat, candy
Always adult supervision during meals
Cut small bite-sized pieces
No eating during play or lying down

🩸 Iron deficiency anemia = most common nutritional deficiency in children. Limit milk to 24 oz/day (poor iron source, displaces iron-rich foods). Vitamin C with plant iron sources maximizes absorption.

☀️ Preschoolers (3–6 years)

Growth: 2–3 inches/year, 5–6 lb/year. Protein needs: 13–19 g/day

Can switch to skim or 1% low-fat milk after age 2
Food jags (fixation on one food) are common and short-lived
Dislike strong-tasting veggies (cabbage, onions); like raw finger-food vegetables
Food preferences first learned from family; peers start influencing at ~age 5
Avoid high-fat/high-sugar snacks; encourage daily physical activity
Lead poisoning risk <6 years: feed at frequent intervals (more lead absorbed on empty stomach); ensure adequate Ca, Fe, Zn, phosphorous

🏫 School-Age Children (6–12 years)

Growth: 2–3 inches/year, 5–6 lb/year. Follow MyPlate guidelines.

📊 Key Facts

~10% of children skip breakfast — impairs school performance
Overweight/obesity affects ~41% of children
Overweight children tend to become obese adults
Young athletes: meet energy, protein, and fluid needs

🎯 Interventions

Encourage healthy eating and breakfast
Decrease fats, sugars (empty calories)
Increase physical activity
Weight-loss program only if provider-directed (comorbidity)
Never use food as reward or punishment
Praise abilities and skills

☀️ Vitamin D (All Children)

Essential for bone development
DRI: 5 mcg/day from birth through age 50
Sources: cow's milk, soy milk, fatty fish, sunlight
Children indoors (TV/video games) have ↑ risk of deficiency
Assists calcium absorption into bones

📝 NCLEX Practice

A nurse is educating parents of a toddler about appropriate snack foods. Which should the nurse include? (Select all that apply)

A Graham crackers ✓
B Apple slices ✓
C Raisins (choking hazard)
D Jellybeans (choking hazard)
E Cheese cubes ✓

🧑

Adolescence

📈 Growth rate during adolescence is second only to infancy. Needs for energy, protein, calcium, iron, and zinc all increase at puberty.

📅 Growth Spurts

👩 Female

Begins: 10–11 years
Peaks: 12 years
Completes: 17 years
Less muscle/bone growth; more fat deposition → lower energy needs than males

👨 Male

Begins: 12–13 years
Peaks: 14 years
Completes: 21 years
More muscle/bone growth → higher energy needs

⚡ Energy Requirements

Females (12–18 yr)

~2,000 cal/day

Males (12–18 yr)

2,200–2,800 cal/day

🩸 Iron Requirements

👩 Females (14–18 yr)

15 mg/day

Support ↑ blood volume + menstrual losses

👨 Males (14–18 yr)

11 mg/day

Support muscle mass + blood volume expansion

🦴 Calcium

Adolescents add 45% of bone mass during this period. Inadequate calcium → risk of osteoporosis later in life.

Requirement: 1,300 mg/day
Achieved by 3–4 servings dairy/day
Normal blood calcium maintained by drawing from bones if intake is low

⚠️ Nutritional Risks

⚠️ Average U.S. adolescent diet is deficient in: folate, vitamins A & E, iron, zinc, magnesium, calcium, and fiber (more pronounced in females). Diet EXCEEDS: total fat, saturated fat, cholesterol, sodium, sugar.

Skip meals, especially breakfast; eat more away from home
Vending machines, fast food = high fat, sugar, sodium
Carbonated beverages replacing milk/juice → deficiencies in Vit C, riboflavin, phosphorous, calcium
Males: ↑ risk of supplement/protein drink use; may restrict calories for sports weight

🍽️ Eating Disorders

Anorexia nervosa, bulimia nervosa, binge eating disorder commonly begin in adolescence
Social pressure + obesity stigma → poor body image especially in females
Crash diets can lead to eating disorders

🤰 Adolescent Pregnancy

⚠️ Fetal demands compete with teen's own growth. Risks: anemia, pregnancy-induced hypertension, gestational diabetes, premature labor, miscarriage, low birth weight.

📋 Refer pregnant adolescents to WIC (Women, Infant, and Children nutrition subsidy program)

🏥 Nursing Assessment for Adolescents

24-hr food intake Weight/BMI patterns Attitude about weight Supplements use Medical history OTC/Rx meds Substance use Physical activity Eating disorder screening

✅ Healthy snack teaching: carrot sticks with low-fat dip, unbuttered/unsalted popcorn, pretzels, fresh fruit, string cheese, smoothies with low-fat yogurt/skim milk, raw vegetables with low-fat dip

📝 NCLEX Practice

A school nurse is teaching a group of adolescents about healthy snack food choices. Which foods should the nurse include? (Select all that apply)

A Carrot sticks with low-fat dip ✓
B Cheese and crackers ✓
C Unbuttered popcorn ✓
D French fries
E Hot dog

👴

Adulthood & Older Adulthood

🍽️ Balanced Diet for All Adults

Carbohydrates

45–65%

At least half should be whole grain

Fat

20–35%

≤10% from saturated fats. Prefer mono & polyunsaturated

Protein

Unchanged

Many experts believe needs ↑ in older adults

Healthy BMI

18.5–24.9

Overweight ↑ risk: HTN, DM, stroke

🥗 MyPlate for Adults (Daily)

Food Groups

Grains: Select whole grains
Vegetables: Orange and dark green leafy
Fruits: Fresh, dried, canned, or juice — NO added sugar
Make half your plate vegetables and fruits
Dairy: 1 cup milk/yogurt = 1½ oz natural cheese = 2 oz processed cheese
Protein: Lean meats, fish, poultry, dry beans, eggs, nuts — 1 oz eq = 1 oz meat OR ¼ cup beans OR 1 egg OR 1 tbsp peanut butter
Oils: Use vegetable oils (NOT palm or coconut)
Discretionary calories: 132–362 cal/day

Core Elements

Vegetables: all types (dark green, red/orange, legumes, starchy)
Fruits: especially whole fruits
Grains: ≥half whole grain
Dairy: fat-free or low-fat
Protein: lean meats, eggs, seafood, beans, nuts, soy
Oils: vegetable oils, seafood, nuts

👴 Older Adult Specific Concerns

💧 Dehydration is the most common fluid/electrolyte imbalance in older adults. Fluid needs ↑ with medication-induced losses.

↓ Basal metabolic rate → reduce total caloric intake
↓ Reduced caloric intake → risk of nutrient deficiencies
↓ Lean muscle mass → encourage regular exercise
↓ Calcium efficiency → ↑ calcium requirements
Vitamins A, D, C, E, B6, B12 often decreased → supplemental vitamins recommended
↓ Cellular function, ↓ body reserves → ↓ absorption of vitamins and minerals
↓ Insulin production and sensitivity

🏃 Exercise for Adults & Older Adults

🏃 At least 150 min/week at moderate or vigorous pace. Those unable to do 150 min should be as physically active as tolerated.

Moderate activities: gardening, golf, dancing, brisk walking
Regular exercise improves bone density, relieves depression, enhances CV & respiratory function
Helps counteract loss of lean muscle mass (normal aging)

⚠️ Physical, Mental & Social Challenges (Older Adults)

Physical

Osteoporosis risk → adequate Ca + Vit D + weight-bearing exercise
Arthritis pain → interferes with food prep
Dental problems, ill-fitting dentures, ↓ salivation
Difficulty chewing: mince/chop food
Difficulty swallowing: thickened liquids (↓ aspiration risk)
↓ Smell & vision → ↓ interest in eating

Social & Mental

Dementia → shopping, storing, cooking difficult
Social isolation, partner loss → poor nutrition
Refer to senior centers, community programs
Fixed income → difficulty purchasing food
Refer to: food programs, food banks, Meals on Wheels (housebound)
Medications can cause electrolyte losses

💧 Fluid Intake (Adults)

Classic "8×8" (64 oz/day) is a guideline — solid foods also provide water
For healthy adults: normal eating/drinking habits generally provide sufficient fluids
Encourage water and natural juices
Discourage soda pop and other caffeinated drinks as primary fluids

📝 NCLEX Practice

A nurse providing nutrition counseling for older adults should include which information? (Select all that apply)

A Increase protein to 50% of daily calories ✗
B The need for vitamins and minerals can increase ✓
C Up to 35% of daily calories should come from fat ✓
D At least 45% of daily calories should come from carbohydrates ✓
E Fruits and vegetables should make up one-third of each meal ✗ (should be HALF)

🍽️

Therapeutic Nutrition & Modified Diets

        Therapeutic nutrition = the role of food and nutrition in the treatment of diseases and disorders. The basic diet becomes therapeutic when modifications are made to meet client needs.
      

Modifications include

↑ or ↓ caloric intake, fiber, or specific nutrients

Also includes

Omitting specific foods or modifying food consistency

Key reminder

Food meets physiological AND psychological needs — should be a pleasant experience

Collaboration

Nurses collaborate with the dietitian for nutritional/dietary concerns

🥗

Regular Diet (Normal / House Diet)

✅ Indicated for

Clients who do not need dietary restrictions
Adjusted to meet age-specific needs throughout the life cycle
Many facilities offer self-select menus

🔧 Modifications

Accommodate individual preferences
Respect food habits and ethnic values

💧

Clear Liquid Diet

⚠️ Nutritionally inadequate — should NOT be used long-term

What it is

Foods/fluids that are liquid at room temp with no residue

Purpose

Prevent dehydration, relieve thirst; minimal digestion, minimal residue, non-gas-forming

✅ Acceptable foods

Water, tea, coffee
Fat-free broth
Carbonated beverages
Clear juices, ginger ale
Gelatin

📋 Indications

Acute illness
Pre-colonoscopy / diagnostic tests
Acute GI disorders
Some postoperative recovery

📝 NCLEX Practice

A nurse is caring for a client following an appendectomy with a prescription to "advance diet to clear liquids as tolerated." Which should the nurse offer? (Select all that apply)

A Applesauce ✗ (not clear liquid)
B Chicken broth ✓
C Sherbet ✗ (full liquid)
D Wheat toast ✗ (solid)
E Cranberry juice ✓

🥤

Full Liquid Diet

What it includes

Foods liquid at room temp
Plain ice cream, strained cereals
Some facilities include pureed vegetables

📋 Indications

Transition from liquid → soft diet
Postoperative recovery
Acute gastritis, febrile conditions
Intolerance of solid foods

        ⚠️ If used more than 3 days → may need protein & calorie supplementation

        ⚠️ Use cautiously with dysphagia unless liquids are thickened appropriately

        ℹ️ Many dietary manuals have removed the full liquid diet — may be used infrequently

🫙

Blenderized Liquid (Pureed) Diet

What it is

Liquids and foods pureed to liquid form; each food pureed separately to preserve flavor

Boost calories

Add broth, milk, gravy, cream, soup, tomato sauce, or fruit juice instead of water

Customize

Modify calories, protein, fat based on client's needs

        Indications: Chewing or swallowing difficulties · Oral or facial surgery · Wired jaws
      

📝 NCLEX Practice

A nurse is assessing dietary needs. For which clients should the nurse plan a blenderized liquid diet? (Select all that apply)

A Client with a wired jaw from MVA ✓
B Client 24 hr post-op temporomandibular joint repair ✓
C Client with difficulty chewing due to oral surgery ✓
D Client with hypercholesterolemia / CAD ✗ (needs cardiac diet)
E Client scheduled for colonoscopy ✗ (needs clear liquid)

🍞

Soft (Bland / Low-Fiber) Diet

✅ Includes

Whole foods, low fiber, lightly seasoned, easily digested
Smooth, creamy, or crisp textures
Snacks between meals to add calories

🚫 Excludes

Raw fruits and vegetables
Coarse breads and cereals
Beans and gas-forming foods

        Indications: Transition between full liquid → regular · Acute infections · Chewing difficulties · GI disorders

        ⚠️ Predisposes clients to constipation

🥩

Mechanical Soft Diet

✅ Includes

Minimal chewing required before swallowing
Ground meats, canned fruits, softly cooked vegetables
Butter, gravies, sugar, or honey to ↑ calories

🚫 Excludes

Dried fruits
Most raw fruits and vegetables
Foods with seeds and nuts

        Indications: Limited chewing ability · Dysphagia · Poorly fitting dentures · Edentulous (no teeth) · Head/neck/mouth surgery · Intestinal strictures
      

📝 NCLEX Practice

A nurse is assisting a client on a mechanical soft diet with food selections. Which are correct? (Select all that apply)

A Dried prunes ✗ (hard/chewy)
B Ground turkey ✓
C Mashed carrots ✓
D Fresh strawberries ✗ (seeds)
E Cottage cheese ✓

🫁

Dysphagia Diet (IDDSI Framework)

        Prescribed when swallowing is impaired (e.g., post-stroke). Signs: drooling, pocketing food, choking, gagging.

        Reference: www.iddsi.org

💧 Liquid Consistencies

Level 0 — Thin

Flows like water; consumed by cup or straw (age appropriate)

Level 1 — Slightly Thick

Thin enough to sip through straw, thicker than water

Level 2 — Mildly Thick

Does not hold shape when poured; spoon ok, straw requires effort

Level 3 — Moderately Thick

Smooth, no lumps; cup or spoon ok, not a fork

Level 4 — Extremely Thick

Holds shape; spoon only, not sticky, no chewing needed

🍴 Solid Textures

Level 3 — Liquidized

Same as Level 3 moderately thick liquid

Level 4 — Pureed

Same as Level 4 extremely thick; smooth, no lumps

Level 5 — Minced & Moist

Soft, visible lumps; fork or spoon ok; lumps easy to mash with tongue

Level 6 — Soft & Bite-Sized

Soft, moist, semi-solid; easily chewed and swallowed

Level 7 — Easy to Chew

Near-normal texture, moist, may have mixed consistency; hard/sticky foods eliminated

Level 7 — Regular

Normal everyday foods; vary in texture; developmentally age appropriate

📝 NCLEX Practice

A nurse is caring for a client on a Level 5 dysphagia diet following a stroke. Which dietary selection should the nurse offer?

A Turkey sandwich ✗ (bread too firm/mixed texture)
B Scrambled eggs ✓ (soft, moist, easy to mash)
C Peanut butter crackers ✗ (sticky, hard)
D Granola ✗ (hard, crunchy)

🩺

Nursing Assessment & Interventions

📊 Ongoing Assessment

Daily weights
Prescribed laboratory tests
Evaluate nutritional & energy needs
Evaluate response to diet therapy
Observe & document nutritional intake
Perform calorie count if needed

🔧 Nursing Actions

Provide education & support for diet therapy
Consult with dietitian
For "diet as tolerated" Rx: assess for hunger, appetite, and nausea

        Post-major surgery diet progression: NPO → Clear Liquids → Full Liquids → Soft → Regular

        ⚠️ Assess for return of bowel function (bowel sounds + passage of flatus) before advancing diet

⚡

Quick Reference — Diet Comparison

Diet	Key Feature	Main Indication	Watch out
Regular	No restrictions	No dietary needs	Adapt for culture/preference
Clear Liquid	Liquid, no residue	Pre-procedure, acute illness	⚠️ Nutritionally inadequate
Full Liquid	Liquid at room temp	Transition liquid → soft	Supplement if >3 days
Pureed	Blended to liquid	Chewing/swallowing difficulty	Each food pureed separately
Soft/Bland	Low fiber, easy to digest	GI disorders, acute infection	⚠️ Causes constipation
Mechanical Soft	Minimal chewing	Dysphagia, dentures, edentulous	No seeds, nuts, dried fruit
Dysphagia (IDDSI)	Levels 0–7	Post-stroke, impaired swallowing	Match level to assessment

Chapter 9 · Nutrition

Enteral Nutrition

EN = delivery of nutrients via tube directly into the GI tract when a client cannot consume adequate nutrients orally but has a GI system that functions at least partially. EN most closely utilizes the body's own digestive and metabolic routes, and can augment an oral diet or serve as the sole source of nutrition.

Indications

Burns / Trauma Prolonged intubation Eating disorders Radiation / Chemo Liver or renal dysfunction Infection IBD Neuromuscular impairment Infants: too weak to suck Unable to coord. swallowing No gag reflex Fatigued / weak / cyanotic during feeds

Contraindicated when

Nonfunctional GI tract Paralytic ileus Intestinal obstruction

Key fact

Commercial formulas preferred over home-blended — nutrient composition, consistency, and safety are better ensured.

gavage feeding = EN feeding for infants · Conserves energy when infant becomes fatigued, weak, or cyanotic during breast/bottle feeding

🗺️ Feeding Routes Route Selection 🧪 Feeding Formulas Formula Types ⏱️ Delivery Methods Administration 🩺 Nursing Actions Nursing Care ⚠️ Complications Risk & Response ⚡ Quick Reference Key Numbers

🗺️

Enteral Feeding Routes

Determined by medical status & anticipated duration of tube feeding

Short-Term

< 3–4 weeks

Nasogastric (NG)

Nose → Stomach

Most common. Standard short-term access.

Aspiration risk / Gastroparesis

Nasoduodenal

Nose → Stomach → Duodenum

Bypasses stomach; used when aspiration risk is high or gastric emptying is delayed.

Aspiration risk / Gastroparesis

Nasojejunal

Nose → Stomach → Jejunum

Deepest nasoenteric placement; same indications as nasoduodenal.

Infant Feeding Tube

Nares or mouth → Stomach

Flexible; can remain taped in place up to 30 days.

Long-Term: Ostomies

Surgically created stoma

Used when: long-term feeding is required · high aspiration risk · nasal obstruction prevents nasal insertion

Gastrostomy (PEG)

Percutaneous Endoscopic Gastrostomy

Stomach

Placed via endoscope. Well-tolerated — stomach holds and releases feedings physiologically, promoting effective digestion. Avoids dumping syndrome.

Low-Profile Gastrostomy (Skin-Level Device)

Stomach

More comfortable, longer lasting, fully immersible in water. Checking residual is harder — button sits flush to skin. Usually comfortable for children.

Jejunostomy

Jejunum

Surgically inserted into the jejunal portion of the small intestine.

📝 NCLEX Practice

A nurse is discussing a low-profile (skin-level) gastrostomy device with the guardian of a child receiving EN. Which statement should the nurse make?

A "The device is usually comfortable for children." ✓
B "Checking residual is much easier with this device." ✗ — it is harder due to the button's proximity to the skin
C "This access requires less maintenance than a traditional nasal tube." ✗
D "Mobility of the child is limited with this device." ✗

🧪

Enteral Feeding Formulas

Categorized by protein complexity · Commercial products preferred over home-blended

Standard / Polymeric / Intact

Whole Protein Formula

✓ Requires functioning GI tract

Caloric density 1–2 cal/mL

Osmolality Lower

Residue Low

Proteins: milk, meat, eggs or isolates · Good for bowel rest, post-bowel surgery, GI disease · Fiber-enriched variants available for constipation/diarrhea

Hydrolyzed / Elemental

Pre-Digested Formula

⚠ Partially functioning GI tract

Caloric density 1.0–1.5 cal/mL

Osmolality Higher

Residue None (residue-free)

For: IBD, liver failure, cystic fibrosis, pancreatic disorders, short-gut syndrome · Lactose-free · High-calorie variants: 1.5–2.0 cal/mL

Disease-Specific

Condition-Tailored

Modified for disease process

Formulated for specific conditions:
· COPD
· Kidney disease
· Immunocompromise

Fats & carbs modified for: respiratory disease, malabsorption, diabetes mellitus, kidney disease

Modular

Single-Nutrient Formula

One macronutrient focus

Typically contains a single nutrient:
· Protein
· Carbohydrates
· Fat

Determining the Appropriate Formula

Caloric density: standard = 1.0–1.2 cal/mL
Water content: 1.0 cal/mL formula → 850 mL water/L; higher-calorie = less water → client may need additional free water
Osmolality: more digested protein = higher osmolality; hydrolyzed > standard

Low-residue standard → optimal for bowel rest, post-op bowel surgery, GI disease
Fiber-enriched standard → for constipation or diarrhea (normalizes bowel movements)
Hydrolyzed → residue-free; lactose-free

Packaging

Cans or prefilled bags · Prefilled bags + tubing: discard every 24 hr (even if not empty) · Generic bags: fill with only 4 hr worth of formula · Cans may be used to add formula to a generic bag or for syringe feedings

📝 NCLEX Practice

A nurse is teaching a client starting continuous EN feedings about formula types. Which should the nurse include?

A Formula rich in fiber is recommended when starting EN ✗ — fiber-enriched is for constipation/diarrhea, not routinely at initiation
B Standard formula contains whole protein ✓
C Hydrolyzed formula is recommended for a full-functioning GI tract ✗ — hydrolyzed is for impaired/partially functioning GI tracts
D High-calorie formula has increased water content ✗ — higher-calorie formulas have decreased water content

⏱

Delivery Methods

Dependent on tube type, formula, medical status, and GI function

01

Continuous Infusion

24 hr / day

Constant rate via infusion pump. Recommended for critically ill — associated with smaller residual volumes, lower aspiration and diarrhea risk.

Pump required GRV q4–6h

02

Cyclic Feeding

8–20 hr/day

Continuous rate, often overnight. Used to transition from EN → oral intake. Gives client freedom during the day.

Overnight Weaning tool

03

Intermittent

q4–6h, over 30–60 min

Equal portions every 4–6 hr. Time frame: 20–90 min by gravity drip or pump. Resembles normal eating pattern.

Home feedings Rehab

04

Bolus

250–400 mL over ≥15 min

Large syringe, 4–6×/day. Stomach only — contraindicated for jejunum/duodenum. Can cause dumping syndrome. Infants: ≤5 mL/10 min (premature); 10 mL/min (older).

Stomach only Dumping risk

⚠️

GRV Thresholds: Adults → >250 mL on two consecutive measurements (single measurement range: 100–500 mL) · Children → >¼ of prescribed volume · Policy may specify returning residual to stomach (prevents electrolyte imbalance) or holding/reducing feedings

Flush protocol: Continuous → ≥30 mL warm water every 4 hr · Before & after bolus feedings · Before & after each medication · Between medications if multiple given

📝 NCLEX Practice — Cyclic (SATA)

A nurse is instructing a client about administering cyclic enteral feedings at home. Which should be included?

A "Give a feeding every 6 hours." ✗ — cyclic = continuous overnight, not q6h bolus
B "Set the feeding up before you go to bed." ✓
C "Weigh yourself daily." ✓
D "Flush the tube with a carbonated beverage to dislodge clogs." ✗ — not approved; use warm water
E "Ensure your head is elevated to 15 degrees during administration." ✗ — must be ≥30°

📝 NCLEX Practice — Intermittent (SATA)

A nurse is preparing to administer intermittent enteral feedings. Which actions should the nurse take?

A Fill the feeding bag with 24 hr worth of formula ✗ — generic bags: fill with only 4 hr worth
B Discard feeding equipment after 24 hr ✓
C Ensure the formula is at room temperature ✓
D Flush the feeding tube immediately following the feeding ✓
E Elevate head of bed for 15 min after administration ✗ — must remain elevated 30–60 min

📝 NCLEX Practice — Bolus (SATA)

A nurse is administering bolus EN feedings to a client with malnutrition. Which are appropriate nursing interventions?

A Verify the presence of bowel sounds ✓
B Flush the feeding tube with warm water ✓
C Elevate the head of the bed 20° ✗ — must be ≥30°
D Administer the feeding at room temperature ✓
E Instill the formula over 60 min ✗ — bolus is administered over ≥15 min (not 60 min)

🩺

Nursing Actions

🔧 Preparation

Verify tube placement by radiography before first use
Mark tube with indelible ink or adhesive tape at nose exit; document
Measure tube each shift and before each feeding to check for migration
Aspirating contents + pH check NOT reliable for initial placement verification
Verify bowel sounds present
Flush with warm water to maintain patency
HOB elevated ≥30° during feedings and 30–60 min after
Begin with small volume of full-strength formula; increase in intervals as tolerated
Administer at room temperature — reduces GI discomfort
Do NOT heat in microwave — uneven temperatures within solution
Burp infant after feeding if condition allows

📊 Baseline Parameters

Height · weight · BMI
BUN · albumin · hemoglobin · hematocrit · glucose · electrolytes
Registered dietitian evaluates nutritional & energy needs
Verify GI function — dysfunction may require alternate nutrition forms

📅 Ongoing Monitoring

Daily weights and I&O
Gastric residuals every 4–6 hr
Electrolytes, BUN, creatinine, minerals, CBC
Tube site: pain, redness, swelling, drainage
Bowel movement character and frequency

💊 Medications Through Feeding Tube

Stop feeding before administering medications
Flush 15–30 mL water before and after each medication
Flush between each medication if more than one given

Dissolve medications in water only (not formula)
Use liquid medications when possible
Infants/children: flush = 1.5× the tube prime volume; more water may be needed after suspensions

🔄 Weaning & Transitioning to Oral Intake

DISCONTINUE EN WHEN

Client consumes ⅔ of protein & calorie needs orally for 3–5 consecutive days

TRANSITION STEPS

Stop EN 1 hr before meals →
Increase meal frequency →
Up to 6 small meals/day →
When oral = 500–750 cal/day: tube feeding overnight only

NPO clients require meticulous oral care
Long-term EN may need home nutritional support services — interprofessional team: nurse, dietitian, pharmacist, provider monitor weight, electrolytes, and physical condition

⚠️

Complications & Nursing Actions

🫀 Gastrointestinal

Constipation, diarrhea, cramping, pain

Abdominal distention, nausea, vomiting

Dumping syndrome — rapid emptying of formula into small intestine → fluid shift → dizziness, rapid pulse, diaphoresis, pallor, lightheadedness

🔧 Mechanical

Tube misplacement or dislodgement

Aspiration

Irritation/leakage at insertion site

Irritation of nose, esophagus, and mucosa

Clogging of the feeding tube

🧪 Metabolic

Dehydration, hyperglycemia

Electrolyte imbalances, fluid overload

Rapid weight gain

Refeeding syndrome — potentially fatal; occurs when starved client is restarted on EN (greater risk with parenteral nutrition)

🦠 Foodborne Illness

Result of bacterial contamination of formula

Nursing Actions by Complication Type

GI

Consider a change in formula
↓ Flow rate or total volume of infusion
↑ Free water if constipated
Administer EN at room temperature
Take measures to prevent bacterial contamination

Mechanical

Confirm tube placement before each feeding
HOB ≥30° during feedings; maintain ~60 min after
Administer bolus feedings over ≥15 min
Flush ≥30 mL water every 4 hr (continuous); before/after bolus; before/after each med
Unclog: gentle pressure with 30–50 mL warm water in 60 mL piston syringe
Carbonated beverages NOT approved for unclogging — commercial products available
Do NOT mix medications with formula

Metabolic

Provide adequate amounts of free water
Consider changing to an isotonic formula
Restrict fluids if fluid overload occurs
Monitor electrolytes, blood glucose, and weights
Monitor respiratory, cardiovascular, and neurologic status
Administer insulin per protocol for hyperglycemia

Foodborne (Bacterial Contamination)

Wash hands before handling formula or enteral products
Clean equipment and tops of formula cans
Use closed feeding systems
Cover and label open cans: client name, room number, date, time of opening
Replace bag, tubing, and mixing equipment every 24 hr
Fill generic bags with only 4 hr worth of formula

⚡

Quick Reference — Key Numbers

The numbers most commonly tested on NCLEX

HOB elevation

≥ 30°

During feedings AND 30–60 min after completion

Flush — continuous

≥ 30 mL

Warm water every 4 hr to maintain tube patency

GRV threshold — adult

> 250 mL

On two consecutive checks · Single check range: 100–500 mL

GRV threshold — child

> ¼ vol

Greater than ¼ of the prescribed volume

Bolus volume

250–400 mL

Over ≥15 min · 4–6×/day · Stomach only

Wean EN when

⅔ oral

Client meets ⅔ protein & calorie needs orally for 3–5 days

Generic bag max fill

4 hr

Discard all equipment (bag + tubing) every 24 hr

Nasoenteric duration

< 3–4 wk

Short-term only · Infant tube: up to 30 days

Unclog tube

30–50 mL

Warm water in 60 mL piston syringe · NOT carbonated beverages

Transition: EN → oral

500–750 cal

When oral intake reaches this level, tube feed overnight only

Med flush volume

15–30 mL

Water before and after each medication via tube

Bolus — premature infant

≤ 5 mL / 10 min

Older infants & children: 10 mL/min

🌱

Sources of Nutrition — Overview

        Nutrients absorbed in the diet determine, to a large degree, the health of the body. Deficiencies or excesses contribute to poor health. Essential nutrients = those the body cannot manufacture; their absence causes deficiency diseases.
      

Energy-yielding nutrients

Carbohydrates, fats, and proteins

Other components

Vitamins, minerals, electrolytes, water, fiber

Healthy eating pattern

Provides ALL essential nutrients from a broad assortment of food sources

📐

Dietary Reference Intakes (DRIs)

        Developed by the Institute of Medicine. Used to understand food intake patterns, plan nutrition programs (e.g., SNAP), and help individuals.
      

RDA — Recommended Dietary Allowance

Amount most healthy people of similar life-stage and sex need to decrease risk of chronic disease

EAR — Estimated Average Requirement

Meets basic requirements for half the population; used by researchers/policy makers to determine RDAs

AI — Adequate Intake

Amount most people in a group consume; used when insufficient data exists to establish an RDA

UL — Tolerable Upper Intake Level

Maximum an individual should consume; used when a nutrient has known adverse effects

AMDR — Acceptable Macronutrient Distribution Ranges

Recommended percentages of intake for energy-yielding nutrients (carbs, fat, protein)

        ⚠️ Clients can use DRIs as a guide but should also consider individual factors that increase needs (disease, injury).
      

🌾

Carbohydrates & Fiber

Composition

Organic compounds of carbon, hydrogen, oxygen (CHO)

Main function

Provide energy for the body and brain

Energy yield

4 cal/g

AMDR

45–65%

of total calories

Brain minimum (DRI)

130 g/day

Adults and children

Types of Carbohydrates

Type	Examples / Sources	Function
Monosaccharides (simple)	Glucose (corn syrup), fructose (fruits), galactose (milk)	Basic energy for cells
Disaccharides (simple)	Sucrose (table sugar), lactose (milk), maltose (malt)	Energy; lactose aids calcium & phosphorus absorption
Polysaccharides (complex)	Starches (grains, legumes, root veggies), fiber (whole grains, fruits, veggies), glycogen	Energy storage (starches), digestive aid (fiber)

        Key facts: Liver converts fructose & galactose → glucose → triggers insulin release → moves glucose into cells · Body digests 95% of starch in 1–4 hr (pancreatic amylase in small intestine) · Glycogen = stored energy in liver & muscles (limited supply) · Protein-sparing effect = adequate carbs spare protein for its own functions
      

Fiber

Indigestible substance in plant foods
Types: pectin, gum, cellulose, oligosaccharides
Adds bulk, stimulates peristalsis → aids elimination
Lowers cholesterol, reduces intestinal cancer risk
Slows glucose absorption → stabilizes blood glucose
Provides 1.5–2.5 cal/g via fermentation in colon

AI for Fiber

Females

25 g/day

Males

38 g/day

🥩

Proteins

Types

Complete proteins — animal sources & soy; contain all 9 essential amino acids
Incomplete proteins — mostly plant sources; lack sufficient amino acids for full protein synthesis
Complementary proteins — two incomplete proteins combined to form complete protein (don't need to eat at same time — just throughout the day)
- Black beans + rice
- Hummus + crackers

Key Numbers

RDA

0.8 g/kg

Healthy adults

AMDR

10–35%

Of total calories

Energy yield

4 cal/g

Metabolic Functions

Tissue-building and maintenance
Nitrogen and water balance
Backup energy source
Transport of nutrients
Immune system support
Acid-base, fluid, electrolyte balance
Formation of neurotransmitters, enzymes, antibodies, hormones, breast milk, mucus, histamine, sperm

3 Factors Influencing Protein Requirements

Tissue growth needs
Quality of dietary protein
Added needs due to illness

⚠️ Deficiency

Protein energy malnutrition (PEM)
Kwashiorkor and marasmus — extreme PEM disorders

🫒

Lipids (Fats)

Energy yield

9 cal/g

Most dense form of stored energy

AMDR

20–35%

Of total calories; ≤10% from saturated fat

Functions

Hormone production, cell wall structure, organ padding, insulation, nerve fiber covering, fat-soluble vitamin absorption

Sources

Dark meat, poultry skin, dairy, added oils (margarine, butter, shortening, lard)

Types of Fats

Triglycerides (95% of food fat)

Saturated fatty acids — solid at room temp; primarily animal sources
Monounsaturated — olives, canola oil, avocado, peanuts, nuts
Polyunsaturated — corn, wheat germ, soybean, safflower, sunflower, fish
Essential fatty acids (omega-3 & omega-6) — blood clotting, BP, inflammation, metabolic processes; must come from diet

Phospholipids & Sterols

Phospholipids (e.g., lecithin) — cell membrane structure; transport fat-soluble substances
Sterols (e.g., cholesterol) — found in animal tissue; liver produces enough; excess builds up → ↑ CVD risk

Lipoproteins

VLDL — carries triglycerides to cells
LDL — carries cholesterol to tissue ("bad")
HDL — removes excess cholesterol → liver ("good")

        ⚠️ High fat diet → CVD, hypertension, diabetes · Children under 2 need higher fat for brain development · Diet <10% fat → insufficient essential fatty acids → cachectic (wasting) state · Lipid metabolism occurs mainly in small intestine (bile from gallbladder + pancreatic lipase)
      

💊

Vitamins

        13 essential vitamins · Catalyst for metabolic functions & chemical reactions · Yield no usable energy but needed for energy to be metabolized · Fat-soluble (A, D, E, K) can cause toxicity — stored long-term · Water-soluble (C, B-complex) generally not stored
      

💧 Water-Soluble Vitamins

Vitamin	Major Action	Major Sources	Deficiency
Vitamin C	Antioxidant, tissue building, iron absorption, immune function, collagen formation	Citrus fruits, tomatoes, peppers, green leafy veggies, strawberries	Scurvy — bleeding, painful joints, swollen gums, loose teeth; ↑ need with smoking (+35 mg/day)
Thiamin (B1)	Coenzyme in energy metabolism, appetite, nerve/muscle function	Meats, grains, legumes	Beriberi — ataxia, confusion, anorexia, tachycardia, headache, weight loss, fatigue
Riboflavin (B2)	Releases energy from cells	Milk, meats, dark leafy veggies	Cheilosis (cracked lips/corners), glossitis (swollen red tongue), dermatitis
Niacin (B3)	Fat/glucose/alcohol metabolism; steroid hormone, cholesterol, fatty acid synthesis	Liver, nuts, legumes, meats, whole grain	Pellagra — sun-sensitive skin lesions, GI issues, anxiety, insomnia, confusion, paranoia
Pyridoxine (B6)	Cellular function, hemoglobin, neurotransmitters, niacin synthesis	Meats, grains, legumes	Macrocytic anemia, CNS disturbances; excess supplements → sensory neuropathy
Pantothenic acid	Carb, fat & protein metabolism (coenzyme A)	Meats, whole grain cereals, dried peas & beans	Extremely rare — generalized body system failure
Biotin	Fatty acid synthesis, amino acid metabolism, glucose formation	Eggs, milk, dark green veggies	Rare — neurologic findings (depression, fatigue), hair loss, scaly red rash
Folate	Hemoglobin & amino acid synthesis, new cell synthesis, prevents neural tube defects	Liver, dark green leafy veggies, OJ, legumes	Megaloblastic anemia, CNS disturbances, fetal neural tube defects (spina bifida, anencephaly) — all childbearing-age clients must get adequate folate
Cobalamin (B12)	Folate activation, RBC maturation	Meat, shellfish, eggs, dairy (animal origin only)	Pernicious anemia — at risk: strict vegans, those without intrinsic factor

☀️ Fat-Soluble Vitamins (A, D, E, K)

        ⚠️ All have potential for toxicity (stored long-term) · Absorption depends on ability to absorb dietary fat · At-risk for deficiency: cystic fibrosis, celiac disease, Crohn's disease, intestinal bypass · Liver disease patients: don't exceed daily recommendations
      

Vitamin	Major Actions	Major Sources	Deficiency / Notes
Vitamin A	Vision, tissue strength & growth, immune function, embryonic development	Orange/yellow fruits & veggies, fatty fish, egg yolks, butter, cream, carrots, yams	Vision changes, xerophthalmia (dry/hard cornea), GI disturbances, hyperkeratosis · ⚠️ Teratogenic in pregnancy (retinoids)
Vitamin D	Calcium & phosphorus absorption, bone mineralization	Fatty fish, eggs, fortified milk/OJ/cereals, sunlight	Bone demineralization, rickets, osteomalacia · Excess → hypercalcemia
Vitamin E	Antioxidant; preserves lung & RBC membranes; protects Vitamin A from oxidation	Vegetable oils, grains, nuts, dark green veggies	Rare — anemia; edema & skin lesions in infants
Vitamin K	Blood clotting (prothrombin synthesis), bone maintenance	Carrots, eggs, dark green veggies (spinach, broccoli, asparagus)	Increased bleeding time · Antidote for excess anticoagulants (warfarin)

📝 NCLEX Practice

A nurse is discussing nutrient deficiencies. Which conditions are associated with a deficiency of Vitamin C? (Select all that apply)

A Dysrhythmias ✗
B Scurvy ✓
C Pernicious anemia ✗ (B12 deficiency)
D Megaloblastic anemia ✗ (folate/B12 deficiency)
E Bleeding gums ✓

⚗️

Minerals & Electrolytes

        Minerals = inorganic elements used at every cellular level · Major minerals (>5 g in body; need ≥100 mg/day): Ca, P, Na, K, Mg, Cl, S · Trace minerals (<5 g; need ≤20 mg/day): Fe, I, Zn, Cu, Mn, Cr, Se, Mo, F · Electrolytes = electrically charged minerals that maintain homeostasis (Na, K, Cl)
      

Major Minerals

Mineral	Major Actions	Sources	Deficiency	Excess / Nursing
Sodium (Na)	Fluid volume, muscle contractions, nerve impulses	Table salt, processed foods	Muscle cramping, memory loss, anorexia	Fluid retention, hypertension, disorientation · Monitor LOC, edema, BP
Potassium (K)	Intracellular fluid volume, muscle action	Oranges, bananas, tomatoes, avocados, potatoes, dried fruits, meats, dairy, whole grains	Dysrhythmias, muscle cramps, confusion	Dysrhythmia, muscle weakness, numbness in extremities · Monitor cardiac/ECG · Give oral K with meals
Chloride (Cl)	Intracellular/extracellular fluid balance, acid-base balance, digestion	Table salt, processed foods	Rare — muscle cramps, anorexia	Vomiting · Monitor sodium levels
Calcium (Ca)	Bone/teeth formation, BP, blood clotting, nerve transmission	Dairy, broccoli, kale, fortified grains	Tetany, positive Chvostek's & Trousseau's signs, ECG changes, osteoporosis (adults), poor growth (children)	Constipation, renal stones, lethargy, ↓ DTRs · Monitor ECG & respiratory status · Give PO with Vitamin D
Magnesium (Mg)	Bone formation, enzyme catalyst, nerve/muscle function, smooth muscle relaxation	Green leafy veggies, nuts, whole grains, tuna, halibut, chocolate	Weakness, dysrhythmias, convulsions, ↑ BP, anorexia	Diarrhea, N, muscle weakness, hypotension, bradycardia, lethargy · Seizure precautions, monitor LOC & vitals
Phosphorus (P)	Energy transfer (RNA/DNA), acid-base balance, bone/teeth formation	Dairy, peas, meat, eggs, legumes	Unknown	↓ Blood calcium · Evaluate antacid & alcohol use (impairs absorption)
Sulfur (S)	Vitamin structure component, protein metabolism byproduct	Proteins	Only in severe protein malnourishment	No toxicity issues · Levels not usually monitored

Key Trace Minerals

Iodine

Synthesizes thyroxine (thyroid hormone) · Deficiency → goiter · Excess → thyrotoxicosis · RDA: 150 mcg/day · Sources: seafood, iodized salt

Iron

Oxygen distribution via hemoglobin & myoglobin · Heme iron (meat, fish, poultry) vs. non-heme (grains, legumes, veggies) · Vitamin C ↑ absorption · At risk: menstruating, pregnant, infants/toddlers · Supplements: constipation, nausea, teeth staining (liquid)

Fluoride

Bonds with calcium in bones/teeth · Protects against dental cavities · Deficiency → dental caries, ↑ osteoporosis risk · Toxicity → fluorosis, itching, chest pain

📝 NCLEX Practice

A nurse is conducting a class on minerals. Which food should the nurse include as a major source of magnesium?

A Tuna ✓
B Tomatoes ✗ (potassium source)
C Eggs ✗
D Oranges ✗ (potassium source)

📝 NCLEX Practice

A nurse is reviewing iron intake with a client who has anemia. Which is a non-heme source of iron?

A Ground beef ✗ (heme)
B Dried beans ✓ (non-heme)
C Salmon ✗ (heme)
D Turkey ✗ (heme)

💧

Water & Phytonutrients

💧 Water

Most basic nutrient; body survives weeks without food, only days without water
Largest portion of total body weight
Leaves body via kidneys (greatest), skin, lungs, feces
Minimum daily intake: 1,500 mL (to cover 1,000 mL insensible loss + ≥500 mL urine)
AI: Females 2.7 L/day (2.2 L from fluids) · Males 3.7 L/day (3 L from fluids)
⚠️ Thirst is a late indicator of dehydration (especially older adults)
Young children and older adults dehydrate more rapidly
Caffeinated drinks: mild diuretic — but tolerance develops with regular use
Assess hydration: skin turgor, mental status, orthostatic BP, urine output/concentration, mucous membranes

🌿 Phytonutrients (Phytochemicals)

Occur naturally in plants
Positive health effects: detoxify body, stimulate immune system, promote hormone balance, antioxidants
Sources: fruits, vegetables, green tea, legumes, whole grains, broccoli
⚠️ No recommendations for intake exist at this time

Nutrients of Public Health Concern

Vitamin D · Calcium · Sodium · Potassium · Vitamin A · Vitamin E

📝 NCLEX Practice

A nurse is reviewing dietary recommendations at a health fair. Which information should the nurse include?

A "Fats should be 5%–15% of daily calorie intake." ✗ (AMDR is 20–35%)
B "Make protein 10%–35% of total calories each day." ✓
C "Consume 1,500 mL of water from liquids and solids daily." ✗ (1,500 mL is the minimum total intake; females need 2.7 L, males 3.7 L)
D "The body needs 40 mg of iron each day." ✗

🔄

Ingestion, Digestion, Absorption & Metabolism

Ingestion

Consuming food by mouth and moving it through the digestive system

Digestion

Systemic process of breakdown and absorption of nutrients

Absorption

Nutrients pass through the digestive system into the bloodstream and lymphatic system

Metabolism

All chemical processes at cellular level to maintain homeostasis; comprised of catabolism + anabolism

Catabolism

Breaking down substances with resultant release of energy

Anabolism

Using energy to build or repair substances

        Energy nutrient storage & processing:

        Glucose → glycogen → stored in liver & muscle · Surplus glucose → fat · Glycerol + fatty acids → triglycerides → stored in adipose tissue · Amino acids → body proteins · Liver removes nitrogen from amino acids → remainder converted to glucose or fat · Body cells use ATP first, then glycogen, then stored fat

⚡

Metabolic Rate

BMR / BEE

Basal Metabolic Rate — energy for involuntary activities over 24 hr, measured at rest after a 12-hr fast; affected by lean body mass, hormones, body surface area, age, sex

RMR / REE

Resting Metabolic Rate — same as BMR but does not require 12-hr fast

Sex differences

Males assigned at birth generally have higher metabolic rate due to more muscle mass and less fat

Measure BMR indirectly

Thyroid function tests can be used as an indirect measure of BMR

⬆️ Increase BMR

Lean, muscular body build
Exposure to extreme temperatures
Prolonged stress
Rapid growth (infancy, puberty)
Pregnancy and lactation
Physical conditioning

⬆️ Conditions that Increase Metabolism

Fever, shivering (involuntary muscle tremors)
Hyperthyroidism, Parkinson's disease
Cancer, cardiac failure, burns
Surgery/wound healing, HIV/AIDS

💊 Meds that Increase BMR

Epinephrine · Levothyroxine · Ephedrine sulfate

⬇️ Decrease BMR

Short, overweight body build
Starvation/malnutrition
Age-related loss of lean body mass

⬇️ Conditions that Decrease Metabolism

Hypothyroidism

💊 Meds that Decrease BMR

Opioids · Muscle relaxants · Barbiturates

        ⚠️ Acute stress → ↑ metabolism, ↑ blood glucose, ↑ protein catabolism · Protein deficiency from stress → skin breakdown, delayed wound healing, infections, organ failure, ulcers, impaired medication tolerance · Protein requirements may increase to >2 g/kg or up to 25% of total calories during acute stress · Any catabolic illness (surgery, burns) ↑ caloric requirements · Disease + sepsis → can lead to starvation/death
      

📝 NCLEX Practice

A nurse is reviewing prescribed medications for newly admitted clients. Which medications decrease the BMR? (Select all that apply)

A Epinephrine ✗ (increases BMR)
B Levothyroxine ✗ (increases BMR)
C Opioid ✓
D Barbiturate ✓
E Ephedrine sulfate ✗ (increases BMR)

⚖️

Nitrogen Balance

        Nitrogen balance = difference between daily intake vs. excretion of nitrogen. Also an indicator of tissue integrity.
      

Neutral (Equilibrium)

Intake = excretion · Healthy stable adult

Positive Balance ⬆️

Intake > excretion → body builds more tissue than it breaks down · Normal in: infancy, childhood, adolescence, pregnancy, lactation

Negative Balance ⬇️

Excretion > intake → insufficient protein; body breaking down more than building · Seen in: illness, trauma, aging, malnutrition, critical illness, starvation

📝 NCLEX Practice

A nurse is caring for a client with negative nitrogen balance. Which are possible causes? (Select all that apply)

A Critical illness ✓
B Starvation ✓
C Adolescence ✗ (positive nitrogen balance)
D Trauma ✓
E Pregnancy ✗ (positive nitrogen balance)

🩺

Assessment, Data Collection & Nursing Interventions

📊 Assessment / Data Collection

Weight and history of recent weight patterns
Medical history (diseases affecting metabolism/nitrogen balance)
Extent of traumatic injuries
Fluid and electrolyte status
Lab values: albumin, transferrin, glucose, creatinine
Clinical findings of malnutrition: pitting edema, hair loss, wasted appearance
Medication adverse effects that affect nutrition
Usual 24-hr dietary intake
Use of nutritional, herbal supplements, vitamins, minerals
Use of alcohol, caffeine, nicotine

🔧 Nursing Interventions

Monitor food intake
Monitor fluid intake and output
Use client-centered approach for disease-specific ingestion/digestion/medication problems
Collaborate with dietitian
Provide adequate calories and high-quality protein

🍽️ Strategies to Increase Protein & Calories

Add skim milk powder to milk (double-strength milk)
Use whole milk instead of water in recipes
Add cheese, peanut butter, hard-boiled eggs, or yogurt to foods
Dip meats in eggs or milk; coat with breadcrumbs before cooking
Nuts and dried beans — great alternatives for dairy allergy/lactose intolerance

📋

Nutrition Assessment — Overview

        Nurses play a key role in assessing nutritional needs — monitoring, intervening, and teaching. A collaborative, interprofessional approach provides the best outcomes. TJC requires nutrition screening within 24 hours of inpatient admission, with dietitian referral for clients at risk for malnutrition.
      

Provider/Nurse role

Collect physical assessment data; serve as liaison between health care team and dietitian

Registered Dietitian role

Complete comprehensive nutritional assessments

Nurse ongoing role

Monitor and evaluate interventions; incorporate family nutritional habits into plan of care

Important reminder

A healthy-appearing client can still be malnourished — consider cultural, social, and physical norms

📝

Diet History

        Assessment of usual foods, fluids, and supplements. Part of the nutrition screening to determine malnutrition issues.
      

Components of Diet History

Time, type, and amount of food for each meal and snacks
Time, type, and amount of all fluids (water, coffee/tea, carbonated, caffeinated)
Type, amount, and frequency of "special foods" (celebration foods, movie foods)
Typical food/fluid preparation (e.g., coffee with sugar, fried foods)
Number of meals eaten away from home

Type of preferred or prescribed diet (vegetarian, 2 g sodium/low-fat)
Foods avoided due to allergy or preference
Frequency and dose of medications or nutritional supplements
Satisfaction with diet over a specified time frame (last 3 months, 1 year)

🩺

Physical Assessment — Manifestations of Malnutrition

Hair that is dry or brittle

Skin with dry patches or poor wound healing / sores

Lack of subcutaneous fat or muscle wasting

Irregular cardiovascular measurements (HR, rhythm, BP)

Enlarged spleen or liver

General weakness or impaired coordination

📏

Anthropometric Tools

⚖️ Weight

Weigh at same time of day, similar clothing
Daily fluctuations = water weight changes
% Weight change = (Usual wt − Present wt) ÷ Usual wt × 100

Ideal Body Weight — Hamwi Method

Males: 48 kg (106 lb) for first 152 cm (5 ft) + 2.7 kg (6 lb) per extra 2.5 cm (1 in)
Females: 45 kg (100 lb) for first 152 cm (5 ft) + 2.3 kg (5 lb) per extra 2.5 cm (1 in)

⚠️ Weight Loss → Severe Malnutrition Thresholds

Starvation / Chronic Disease:

>5% / month
>7.5% / 3 months
>10% / 6 months
>20% / year

Acute Disease / Injury:

>2% / week
>5% / month
>7.5% / 3 months

📐 Height

Measure on vertical flat surface; remove shoes and head coverings; stand straight, heels together, looking forward; read to nearest 0.1 cm or 1/8 inch
Infants and young children: recumbent measurement (lying on firm flat surface)

📊 Body Mass Index (BMI)

        Formula: BMI = weight (kg) ÷ height (m²) · Note: large muscle mass can elevate BMI; normal BMI can still have excess body fat
      

Underweight

< 18.5

Healthy Weight

18.5 – 24.9

Overweight

25 – 29.9

~20% above desirable levels

Obese

≥ 30

📝 NCLEX Practice

A nurse is calculating BMI for several clients. Which BMI should the nurse identify as overweight?

A 24 ✗ (healthy weight)
B 30 ✗ (obese)
C 27 ✓ (overweight: 25–29.9)
D 32 ✗ (obese)

🔬

Clinical Values & Lab Markers

Fluid I&O (Adults)

Intake: 2,000–3,000 mL/day · Output: 1,750–3,000 mL/day

Albumin

3.5–5 g/dL

Measures protein levels; affected by non-nutritional factors (injury, kidney disease)

Prealbumin (thyroxine-binding protein)

15–36 mg/dL

Sensitive; reflects acute changes; used for critically ill; <10.7 mg/dL = severe deficiency; monitors TPN effectiveness; more expensive, not routine; ↓ with inflammation

🧪 Nitrogen Balance Calculation

        Step 1: 24-hr protein intake (g) ÷ 6.25 = nitrogen intake (g)

        Step 2: 24-hr urinary urea nitrogen + 4 g = total nitrogen output

        Step 3: Nitrogen intake − nitrogen output = nitrogen balance

        ✅ Neutral = adequate intake · ⬆️ Positive = synthesis > breakdown (growth, pregnancy, recovery) · ⬇️ Negative = breakdown > synthesis (starvation, injury, catabolic state)

📝 NCLEX Practice

A nurse is reviewing data for a trauma client. Which value indicates a catabolic state (using protein faster than synthesizing)?

A Blood albumin 3.5 g/dL ✗ (normal range)
B Negative nitrogen balance ✓
C BMI of 18.5 ✗ (low end of healthy)
D Blood prealbumin 15 mg/dL ✗ (normal range)

⚠️

Risk Factors for Inadequate Nutrition

🧬 Biophysical Factors

Medical diseases/conditions (hypertension, HIV/AIDS)
Surgery, medications, supplements
Genetic predisposition (lactose intolerance, osteoporosis)
Age

🧠 Psychological Factors

Mental illness (clinical depression)
Excessive stress
Negative self-concept (under- or overeating)
Use of comfort foods

🏘️ Social Determinants of Health (SDOH)

Neighborhood/Environment: Pollutants, limited food options, limited transportation
Social/Community: Food prep safety issues, unstable living → inconsistent food supply, health materials lack cultural food preferences
Economic: Choosing between food vs. housing/education; no insurance for dietitian; lack of affordable nutritious food
Food & Nutrition: Availability, access, and reliable sources of healthy food
Health Care: Limited primary care, school nursing, telehealth for nutrition consults
Education: Literacy affects food label reading; education affects wages, problem-solving, healthy choices

Clinical Examples & Nursing Actions

Client with edema → diuretics → Na/K imbalances; low-Na diet may reduce appetite
Osteoporosis prevention → ↑ Vitamin D & calcium, weight-bearing exercise, ↓ tobacco & alcohol
Poor self-concept → may avoid eating or overeat

Nursing Actions

Assess factors that might alter nutrient intake beyond just food choices
Consult provider about altering treatment plan (e.g., different med to prevent anorexia; add antiemetic)
Schedule activities to prevent interruptions at mealtime; avoid fatigue, nausea, or pain before meals

📝 NCLEX Practice

A nurse is teaching about osteoporosis risk factors. Which should the nurse include? (Select all that apply)

A Inactivity ✓
B Family history ✓
C BMI 30 or greater ✗ (obesity may actually increase bone density)
D Hyperlipidemia ✗
E Cigarette smoking ✓

🥦

Dietary Guidelines for Americans (2020–2025)

        Published jointly by USDA and HHS every 5 years. The 2020–2025 edition is the first to provide recommendations by life stage (birth through older adulthood). Evidence-based advice on food intake and physical activity.
      

4 Overarching Guidelines

Guideline 1 — Healthy Pattern

Follow a healthy dietary pattern at every stage of life · First ~6 months: human milk or iron-fortified formula + supplemental Vitamin D soon after birth · ~6 months: introduce nutrient-dense complementary foods from all food groups · 12 months → older adulthood: healthy pattern that meets needs, achieves healthy weight, reduces chronic disease risk

Guideline 2 — Customize

Enjoy nutrient-dense food and beverage choices reflecting personal preferences, cultural traditions, and budget

Guideline 3 — Nutrient-Dense

Meet food group needs with nutrient-dense foods and stay within calorie limits · Core elements: all vegetable types, whole fruits, grains (≥½ whole grain), dairy (fat-free/low-fat), protein foods, oils

Guideline 4 — Limit

Limit added sugars (<10% cal/day, age ≥2; avoid for <2 yr) · Saturated fat (<10% cal/day, age ≥2) · Sodium (<2,300 mg/day ≈ 1 tsp) · Alcohol (≤2 drinks/day men; ≤1 drink/day women)

📊 Daily Recommendations (Based on 2,000-Calorie Diet)

Food Group	Daily Amount	Key Details
Vegetables	2½ cups	Variety: green, orange/red, starchy, peas/lentils
Fruits	2 cups	Especially whole fruits
Grains	6 oz	More than 3 oz must be whole grains
Dairy	3 cups	Fat-free or low-fat milk, yogurt, cheese
Protein	5½ oz	Lean meats, poultry, eggs, seafood, soy, nuts, seeds
Oils	27 g	Vegetable oils; oils in seafood and nuts

        ⚠️ Food safety: Avoid raw eggs and unpasteurized milk/juices · When cooking at home: add frozen veggies/legumes to convenience foods; reduce salt; buy nutrient-adding sides (salad kits, pre-cut fruit, whole-grain bread) · When eating out: eat high-fiber snack 1 hr before; eat lighter other meals that day; ask for high-fat items on the side; choose restaurants with healthy options
      

📝 NCLEX Practice

A nurse is conducting a nutrition class at a community center. Which information should the nurse include?

A Limit saturated fat to less than 10% of total daily intake ✓
B Good bowel function requires 35 g/day of fiber for females ✗ (females need 25 g/day)
C Limit cholesterol to 400 mg/day ✗ (no specific mg limit in current guidelines)
D Normal cardiac function depends on B-complex vitamins ✗ (neurologic, not cardiac)

🍽️

MyPlate & Physical Activity

🏃 Physical Activity

One of the most important things to improve overall health
Promotes cardiovascular health, muscle strength & endurance, psychological well-being
Benefits start immediately with small amounts of activity

🍽️ MyPlate (www.myPlate.gov)

USDA-sponsored; based on current dietary guidelines
Food groups: grains, vegetables, fruit, dairy, protein
Identifies daily amounts based on age, sex, activity level
Reminder to balance calorie intake with activity
Offers MyPlate Kitchen (recipes, budget tips)
Available in multiple languages
Resources for pregnant/lactating women and older adults

🥗

Vegetarian Diets

Vegan

Excludes all meat and animal products

Raw Vegan

Strictly uncooked foods (fruits, veggies, nuts, seeds, legumes, sprouted grains); 75–100% uncooked

Lacto Vegetarian

Includes dairy products

Lacto-Ovo Vegetarian

Includes dairy products and eggs

        Vegetarian diets can meet all nutrient recommendations with variety and correct portions · Can reduce risk of ischemic heart disease, type 2 diabetes, certain cancers · Vegans especially at risk for deficits in: Vitamin D, Vitamin B12, Calcium, Omega-3 fatty acids
      

📝 NCLEX Practice

A nurse is teaching a client who follows vegan dietary practices. The nurse should instruct the client about risk of deficit in which nutrients? (Select all that apply)

A Vitamin D ✓
B Fiber ✗ (plant-based diets are typically high in fiber)
C Calcium ✓
D Vitamin B12 ✓
E Whole grains ✗ (not a nutrient; available in vegan diet)

🏷️

Understanding Food Labels

        FDA requires food labels on packaged foods. Labels must include: product name/form, net amount, manufacturer/distributor name and address. % Daily Values based on 2,000 cal/day diet. Ingredients listed in descending order by weight.
      

Required Nutrients on Label

Calories (larger bold type)
Total fat · Saturated fat · Trans fat
Cholesterol · Sodium
Total carbohydrates · Dietary fiber
Sugars (grams + % DV)
Protein
Vitamin D · Potassium · Calcium · Iron

Additional Label Rules

Must clearly state if food contains any of the 8 major allergens (milk, eggs, fish, shellfish, tree nuts, peanuts, wheat, soybeans) — responsible for 90% of food allergies
Functional foods — whole or additive-enhanced foods marketed for health benefits; currently no regulations
Organic foods — regulated by USDA; no pesticides/synthetic fertilizers; livestock graze, fed 100% organic feed, no hormones/antibiotics
Organic foods: may reduce antibiotic resistance risk; no evidence of health superiority
GMO foods — not proven harmful

💚

Strategies for Specific Areas of Health

❤️ Heart Health

Limit saturated fat to <7% of calories
Limit red/processed meats, refined grains, added sugars, butter, high-sodium foods, trans fat
Consume higher fiber, vitamins, antioxidants, minerals, phytonutrients, unsaturated fat
Lower glycemic index diet
DASH diet — proven to significantly lower systolic & diastolic BP and LDL cholesterol

🧠 Neurologic System

Depends on B-complex vitamins — especially thiamin (B1), biotin, B6, B12
Calcium and sodium are important nerve response regulators
Grain and dairy food groups provide these nutrients

🦴 Bones

MyPlate dairy group → calcium, magnesium, phosphorus for bone formation
Weight-bearing physical activity essential to decrease osteoporosis risk

🚽 Bowel Function

Adequate fluid intake + fiber: 25 g/day females, 38 g/day males
Meet minimum MyPlate servings for fruit, vegetable, and whole grain groups

🎗️ Cancer Prevention

Well-balanced diet (MyPlate) + healthy weight
↑ High-fiber plant-based foods
Limit saturated and trans fat; emphasize omega-3 polyunsaturated fats
Limit sodium intake
Avoid excess alcohol
Regular physical activity

📝 NCLEX Practice

A nurse is discussing essential nutrients for normal neurologic functioning. Which should the nurse include? (Select all that apply)

A Calcium ✓
B Thiamin ✓
C Vitamin B6 ✓
D Sodium ✓
E Phosphorus ✗ (bone health, not neurologic)

🛡️

Food Safety — Overview

        Nurses must educate clients on food safety and food-medication interactions. Key concerns: aspiration prevention, foodborne illness, food allergies, food-medication interactions.
      

Aspiration Risk

Food only for conscious clients with intact gag/swallow reflex · Monitor swallowing post-stroke or post-esophageal anesthesia · Young children at increased risk

3 Food Safety Requirements

Proper storage · Proper handling · Proper preparation

🌡️

Food Storage Guidelines

        Refrigerator temp: ≤40°F (4°C) · Perishables: do not leave at room temp for more than 2 hr (1 hr if ≥90°F/32°C)
      

Food	Storage Time
Bacon	7 days (refrigerator)
Sausage (pork/chicken/beef/turkey)	1–2 days
Summer sausage	3 months (unopened) · 3 weeks (opened)
Steaks, chops, roasts (beef/veal/lamb/pork)	3–5 days
Chicken or turkey (whole/parts)	1–2 days
Fish — lean or fatty	1–2 days
Fish — smoked	14 days
Fresh shellfish	1–2 days
Canned fish (opened)	3–4 days (refrigerator) · 5 years (pantry, unopened)
Eggs (in shell)	3–5 weeks (refrigerator)
Eggs (hard-boiled)	1 week (refrigerator)
Fruits & vegetables (perishable/pre-cut/pre-peeled)	Refrigerate at ≤40°F

        ⚠️ Canned goods: Check for rusting, crushing, denting, or stickiness (indicates leakage) — do NOT use damaged cans
      

🍳

Handling, Preparation & Packaging Labels

🤲 Handling Guidelines

Wash hands and food preparation surfaces frequently and before handling food
Separate foods to avoid cross-contamination

🌡️ Preparation — Cook to Proper Temperature + 3-min rest

Roasts & Steaks

145°F (63°C)

Chicken

165°F (74°C)

Ground Beef

160°F (71°C)

Egg-containing products

160°F (71°C)

🏷️ Packaging Labels

Sell-by date — final recommended day of sale
Use-by date — how long product maintains top quality
Expiration date — final day product should be used or consumed

🦠

Foodborne Illness

        ⚠️ Greatest risk to: children, older adults, immunocompromised clients, pregnant clients

        🦠 Viruses cause most foodborne illnesses · Bacteria responsible for most deaths

High-Risk Foods

Raw or undercooked foods of animal origin
Raw fruits and vegetables contaminated with animal feces
Raw sprouts · Unpasteurized fruit juice and milk products
Uncooked food handled by someone who is ill

Illness	Type	Sources	Manifestations / Notes
Salmonella	Bacterial	Undercooked/raw meat, poultry, eggs, fish, fruit, dairy	Headache, fever, abdominal cramping, diarrhea, N&V · Can be fatal
E. coli O157:H7	Bacterial	Raw/undercooked meat, especially ground beef	Severe abdominal pain, diarrhea · Can cause hemolytic uremic syndrome (severe anemia + kidney failure)
Listeria monocytogenes	Bacterial	Soft cheese, raw milk, undercooked poultry, processed meats, raw vegetables	Sudden fever, diarrhea, headache, back pain, abdominal discomfort · High risk for newborns, pregnant, immunocompromised · Can cause stillbirth or miscarriage
Norovirus	Viral	Contaminated fruits/vegetables, salads prepared by infected person, oysters, contaminated water	Onset: 24–48 hr · Very contagious · Projectile vomiting, fever, myalgia, watery diarrhea, headache

📝 NCLEX Practice

A nurse is teaching about norovirus at a community center. Which information should the nurse include?

A Hand sanitizer will protect against norovirus ✗ (handwashing with soap and water is required)
B Pregnant clients are more susceptible ✗ (Listeria is more dangerous in pregnancy)
C Norovirus usually lasts 4–5 days ✗
D Onset is 24–48 hours after exposure ✓

⚠️

Food Allergies vs. Food Intolerance

🚨 Food Allergy

Reaction occurs every time the client is exposed to the food
Initiates release of serotonin and histamine
Common manifestations: N&V, diarrhea, abdominal distention and pain; some reactions severe

⚡ Food Intolerance

Does not occur consistently
Dependent on the amount of food eaten

        8 Most Reported Food Allergies: Milk · Peanuts · Fish · Eggs · Soy · Shellfish · Tree nuts · Wheat

        ⚠️ Some infants react to cow's milk and/or soy — typically outgrow by age 4

💊

Food-Medication Interactions

📈 Food Affects Drug Absorption

Increased absorption — improves peak effects of some drugs when taken with food
Decreased absorption — food can delay onset (rate ↓) or reduce intended effect (extent ↓)
Some meds must be taken with food to avoid gastric irritation: ibuprofen, amoxicillin, bupropion (some antidepressants)

⚗️ Foods That Alter Metabolism/Drug Action

Grapefruit juice — interferes with metabolism of many meds → ↑ blood levels of medication
Vitamin K foods (dark green veggies, eggs, carrots) — ↓ anticoagulant effects of warfarin
High-protein foods — ↑ metabolism of levodopa (anti-Parkinson's) → ↓ absorption and transport to brain
Tyramine (aged cheese, smoked meats, dried fish, overripe avocados) — metabolized by MAO; clients on MAOIs (phenelzine, selegiline) who eat tyramine-rich foods → hypertensive crisis
Herbal supplements — can interact with prescribed meds; must be discussed with provider

📝 NCLEX Practice

A nurse is teaching a client starting the MAOI selegiline. Which food could cause a hypertensive crisis?

A Grapefruit juice ✗ (affects drug levels, not MAOI/tyramine crisis)
B Dark green vegetables ✗ (affects warfarin)
C Greek yogurt ✗
D Smoked fish ✓ (high tyramine → hypertensive crisis with MAOIs)

        Nursing Assessment & Interventions: Complete dietary profile including medications, herbal supplements, baseline food safety knowledge · Teach about food safety and food-medication interactions · Teach the difference between food intolerance vs. food allergy
      

🌍

Cultural, Ethnic & Religious Influences — Overview

        Cultural, ethnic, and religious considerations greatly affect nutritional health. Identifying and incorporating individual preferences promotes client-centered care and helps prevent ethnocentrism.
      

Acculturation

Process of a cultural/ethnic/religious group adopting the dominant culture's behaviors, beliefs, and values

Foodway

Role of foods, food preparation, what is considered edible, timing of meals, use of food for health or other benefits

Food as symbol

Can represent: masculinity/femininity, love/punishment, connectedness, celebration/mourning, comfort

Food roles

Core = eaten most often · Secondary = eaten frequently but less than core · Peripheral = eaten occasionally (cost, availability, or special days)

        Acculturation effects can be:

        ✅ Positive — if client includes more healthy foods

        ⚠️ Negative — if ↑ high-fat, high-calorie, or high-sodium foods · First-generation members more likely to follow traditional foodway; subsequent generations incorporate dominant culture's practices

👥

Selected Populations — Nutrition Profiles

Group	Key Facts	Nutrition-Related Concerns
Hispanic/Latinx	Largest minority group in U.S.; largest % Mexican heritage · Hot/cold balance beliefs; cinnamon, mint tea, chamomile tea for healing	↑ Fruit, dark green & orange veggies, legumes · ↑ Saturated fat & sodium · ↓ Whole grains & milk · High obesity prevalence · >2× risk of Type 2 DM
Black/African American	2nd largest minority group · Food habits tied more to personal factors (schedule, location, SES) than heritage · More likely to accept larger body size as normal	Just below national USDA healthy eating average · ↓ Whole grains, milk, vegetables · Highest obesity prevalence · ↑ DM with ↑ complications · ↑ Hypertension risk (often uncontrolled)
Asian American/Pacific Islander	3rd largest minority; 37 different ethnic groups; Chinese = largest subgroup · Considerable time/skill in food prep · Yin/yang balance beliefs · Yang foods: fried, coffee, spice, meat, broths · Yin foods: seaweed, fruits, veggies, cold beverages	Lowest obesity prevalence · Highest life expectancy (Asian American females) · ↑ Risk of Type 2 DM when body fat increases (vs. other groups)

🍜

Selected Cultural Diets

Diet	Traditional Foods	Acculturation Changes	Health Risks
American	Foods from many cultures; often prepared quickly; premade ingredients/kits	—	Convenience foods: high Na & cal, low fiber · Portion sizes on kits often small → overeating · Away-from-home meals: low in fruit, veggies, dairy, whole grains; high in fat, sugar, Na
Soul Food	Rice, grits, cornbread, hominy, okra, greens, sweet potatoes, apples, peaches, buttermilk, pork rinds, cheddar, ham, pork, chicken, catfish, black-eyed peas, pinto beans, peanuts, fatback	Buying convenience foods; ↑ milk; possibly ↓ fruits/veggies if unavailable	High fat, protein, sodium · Low potassium, calcium, fiber · Many foods fried
Mexican	Rice, corn, tortillas, tropical fruits, vegetables, nuts, legumes, eggs, cheese, seafood, poultry; infrequent sweets and red meat	↓ Vegetables · Corn → flour products · ↑ Milk/low-fat · ↑ Red meat, ↓ legumes · ↑ Fats (butter, margarine, dressings) · ↑ High-sugar low-nutrient beverages (sodas replacing juice)	↑ Saturated fat, ↑ sodium, ↓ fiber with acculturation
Chinese	Wheat (north), rice (south), noodles, fruits, land & sea veggies, nuts/seeds, soy/tofu, fish, shellfish, poultry, eggs, tea, beer; rarely red meat; tofu/bone soups/fish bones = calcium sources	↑ Wheat-based foods · ↑ Raw vegetables · ↑ Fruit · ↑ Dairy, meat, ethnic dishes, fast food	Most foods cooked · ↑ Sodium risk (salting/drying, salt-based condiments)

🥦 Vegetarian & Special Diets

Semi-vegetarian / Flexitarian

Mainly plant-based with occasional meat, poultry, dairy, or fish

Vegetarian

Typically omits meat, seafood, poultry; some include eggs, dairy, or occasional fish

Vegan (Pure)

No animal products of any type · Requires specific food combinations for all essential amino acids · Adequate protein with sufficient nuts & legumes · ⚠️ Risk: B12, Vitamin D, iron, calcium, zinc, omega-3

Raw Vegan

Uncooked plant-based foods only

Macrobiotic

Whole-foods diet based on locally grown plants; occasional fish or seafood

📝 NCLEX Practice

A nurse is caring for a client with hypertension. Which dietary pattern followed by Asian clients places them at risk for this condition?

A Incorporation of plant-based foods ✗ (protective)
B (not listed)
C Preparation of foods using sodium ✓ (salting/drying/condiments)
D Focus on shellfish ✗

✝️

Religion & Nutrition

        Religion often has more influence on dietary practices than culture and crosses geographic boundaries. Always ask clients to describe their dietary preferences — individual variation within each religion is significant.
      

Practice	Orthodox Judaism	Islam	Hinduism/Buddhism	7th-Day Adventism	Mormon (LDS)	Roman Catholicism
Meat/dairy separate	✓ (pareve foods = neither)	—	—	—	—	—
No pork	✓	✓	✓	✓	—	—
No alcohol	—	✓	✓	✓	✓	—
No beef	—	—	✓ (Hinduism)	—	—	—
Ritual slaughter	✓ Kosher	✓ Halal	—	—	—	—
Vegetarian	—	—	✓ (ahimsa)	✓	—	—
No coffee/tea	—	—	—	✓	✓	—
Fasting	Yom Kippur (24 hr)	Ramadan (monthly)	✓ (partial/total)	5–6 hr between meals	—	No meat Ash Wed & Fridays in Lent; no food/drink 1 hr before communion
Fish rules	Fish must have scales & fins · Passover: unleavened bread only	Halal (permitted) vs. Haram (prohibited)	—	—	—	—

📝 NCLEX Practice

A nurse educator taught a class on culture and food. Which statement shows understanding?

A "Most Roman Catholics do not drink caffeinated beverages." ✗ (Mormons & Seventh-Day Adventists)
B "Most Orthodox Jews do not eat meat with dairy products." ✓
C "Most Mormons eat only animals slaughtered under strict guidelines." ✗ (that is Kosher/Halal — Judaism & Islam)
D "Most Hindus do not eat dairy products." ✗ (Hindus avoid beef, not dairy)

🩺

Nursing Interventions

❓ Questions to Ask Clients

What portions of diet are influenced by personal values?
What does the client consider healthy vs. unhealthy?
What does food and eating mean to the client?
When does the client eat, and is there a sequence to foods?
Who shops for and prepares the client's food?
Does the client abstain from any foods?
Are there restrictions related to food and preparation?
Are foods linked to religious or spiritual beliefs?
Do beliefs dictate fasting, feasting, or types of food on specific days?

🔧 Nursing Actions

Seek further information from reputable sources to guide nutritional counseling
If a cultural food is medically negative — ask client to reduce (not eliminate): smaller portions, less often
Suggest fruits and vegetables similar in taste/texture to preferred foods to increase adequate consumption
Consult dietitian to ensure essential nutrients are met while honoring cultural preferences

Chapter 10 · Nutrition

Parenteral Nutrition

PN = delivery of nutrients directly into the bloodstream via IV when the GI tract is not functioning or when the client cannot consume sufficient nutrients orally or enterally. Bypasses the GI tract entirely — used when EN and oral routes are unavailable.

TPN — Total Parenteral Nutrition ⚡

Nutritionally complete Central vein only Hypertonic (>10% dextrose) Dextrose up to 70% Long-term use

PPN — Peripheral Parenteral Nutrition ⚡

Nutritionally incomplete Peripheral vein ≤10% dextrose · isotonic ≤5% amino acids 7–10 days max

TPN = central vein + hypertonic + complete · PPN = peripheral vein + isotonic + incomplete + ≤10 days

🧪 PN Components Solution Contents 🩺 Indications When to Use 👩‍⚕️ Administration Nursing Care 📈 Outcomes Effectiveness ⚠️ Complications Risk & Response

🧪

Components of PN Solutions

Carbohydrate

Dextrose

PPN: 2.5–10%
TPN: up to 70%
↑ conc = fluid-restricted
↓ conc = hyperglycemia control

Protein

Amino Acids

Conc: 3–20%
Essential + nonessential mix
Dose based on liver & kidney function

Fat ⚡

Lipid Emulsion

Conc: 10%, 20%, 30%
Milky/opaque = normal
Source: soybean oil, safflower oil, egg phospholipids

Micronutrients

Electrolytes · Vitamins · Trace Elements

Amounts based on blood chemistry & physical findings
Vitamin K can be added

Additives

Insulin · Heparin

Insulin — reduces hyperglycemia risk
Heparin — prevents fibrin buildup on catheter tip

Optional / Per Need

Glutamine · Antioxidants

Prebiotics · Probiotics
Prescribed based on individual client needs

🔬

Three-in-One (Total Nutrient Admixture)

Lipids + dextrose + amino acids combined in one bag. Reduces body CO₂ production & fat accumulation in the liver. Not all facilities use this approach.

Lipid Emulsion — Key Points ⚡

What lipids do

Provides calories when dextrose must be reduced (fluid restriction or persistent hyperglycemia)
Corrects or prevents essential fatty acid deficiency
Provides calories without increasing osmolality of PN solution
Milky/opaque appearance = normal

⛔ Contraindications

Severe hyperlipidemia
Severe hepatic disease
Allergy to soybean oil, eggs, or safflower oil — always check before administering

⛔ IV Medication Rule

Never administer any IV medication through a PN line or port. Regular insulin & heparin can only be added to the solution by pharmacy — not pushed via Y-port.

📝 NCLEX Practice

A charge nurse is providing information about fat emulsion added to TPN to a group of nurses. Which of the following should the charge nurse include? (Select all that apply)

A Concentration of lipid emulsion can be up to 30% ✓
B Adding lipid emulsion gives the solution a milky appearance ✓
C Check for allergies to soybean oil ✓
D Lipid emulsion prevents essential fatty acid deficiency ✓
E Lipids provide calories by increasing the osmolality of the PN solution ✗ (lipids do NOT increase osmolality)

📝 NCLEX Practice

A charge nurse is teaching about medication compatibility with TPN. Which statement should the nurse make?

A "Use the Y-port on the TPN IV tubing to administer antibiotics."
B "Regular insulin can be added to the TPN solution." ✓
C "Administer heparin through a port on the TPN tubing."
D "Administer vitamin K IV bolus via a Y-port on the TPN tubing."

🩺

Indications

TPN Indications

Cancer (undergoing treatment)
Bowel disorders
Critically ill clients
Trauma or extensive burns — high caloric requirements
Any condition requiring intense nutritional support for an extended period

PPN Indications

Client unable to consume enough calories to meet metabolic needs
Nutritional support needed for a short time

Home PN

Used as nutrition replacement or to supplement nutrition at home
Client typically has a tunneled catheter
Feedings often occur while the client sleeps

👩‍⚕️

Administration & Ongoing Nursing Care

01

Before Starting PN ⚡

Labs to Review

CBC · BMP · PT/aPTT · Iron · TIBC · Lipid profile · LFTs · Electrolyte panel · BUN (10–20 mg/dL) · Prealbumin & Albumin (15–36 mg/dL) · Blood glucose · Creatinine · Platelets

Equipment

Electronic infusion pump — prevents accidental overload.
Micron filter required for PN tubing — NOT for lipid emulsion.

Safety Checks

Verify with a second nurse before administering. Check allergy to soy, eggs, safflower if lipids ordered. Refrigerated PN → room temp 1 hr before hanging.

02

Active Monitoring ⚡

Monitor I&O, daily weights, vital signs, electrolytes
Monitor blood & urine glucose per prescription/policy
Monitor flow rate carefully:
↓ too slow = unmet nutritional needs
↑ too fast = hyperosmolar diuresis → dehydration, shock, seizures, coma, death
Notify provider if weight gain > 1 kg/day
Stop lipid infusion 12 hr before triglyceride blood specimen

Aseptic technique — high dextrose = bacterial growth risk
Change PN bag & IV tubing every 24 hr
Lipid infusions: hang no more than 12 hr (microbial growth risk)
Change central line dressing with sterile technique
Check for "cracking" — oily layer on top = return to pharmacy. Caused by high Ca/phosphorus or poor-salt albumin.
PN unavailable → hang D10W–D20W — do NOT slow rate to "catch up"

            ⚡ "Cracked" TPN = oily appearance or fat layer floating on top → Return to pharmacy. Do NOT shake, flip, or infuse it.
          

03

Discontinuing PN ⚡

Discontinue only when enteral/oral intake can provide 50–75% of estimated caloric needs
Taper gradually — abrupt stop → rebound hypoglycemia
Transition to oral: start with clear liquids, low-fat foods that won't irritate GI tract
Client may have no appetite for 1–2 weeks — continue PN until adequate calories are taken orally
Ask provider about giving some enteral substance during long-term PN (e.g., diluted juice) to prevent GI tract atrophy
Home PN education: aseptic prep, administration technique, blood glucose monitoring, complication recognition

📝 NCLEX Practice

A nurse is planning care for a client who has a new prescription for PPN. Which of the following actions should the nurse include? (Select all that apply)

A Examine trends in weight loss ✓
B Review prealbumin findings ✓
C Administer an IV solution of 20% dextrose ✗ (PPN max is 10% dextrose)
D Use IV tubing with a micron filter ✓
E Use an IV infusion pump ✓

📈

Therapeutic Outcomes & Effectiveness

Daily Weight

≤ 1 kg/day

Gain >1 kg/day = fluid overload → notify provider immediately

Goal: maintenance or gradual gain

Prealbumin ⚡

15–36 mg/dL

Sensitive acute marker · ↓ with inflammation · monitors TPN effectiveness

Best acute nutritional marker

BUN

10–20 mg/dL

Monitors nitrogen balance & kidney function

Within range = adequate protein utilization

Desired Goals

Therapeutic Outcomes

Improved nutritional status
Weight maintenance or gain
Positive nitrogen balance

⚠️

Complications of TPN

🦠 Infectious

Infection / Sepsis ⚡

Signs: Fever · ↑ WBC · Redness at catheter site
Causes: Contamination during insertion, contaminated solution, long-term indwelling catheter
Actions: Strict aseptic technique · Change bag & tubing q24hr · Monitor for signs of infection

📊 Metabolic

Hyperglycemia ⚡

Signs: Elevated blood glucose
Actions: Monitor glucose · Sliding scale insulin · Add regular insulin to TPN solution

Hypoglycemia ⚡

Signs: Low blood glucose — risk when PN stopped abruptly
Actions: Taper gradually · If unavailable: hang D10W–D20W · Administer additional dextrose

Hyperosmolar Diuresis

Signs: Dehydration, hypovolemic shock, seizures, coma, death
Cause: Too-rapid infusion rate
Actions: Monitor flow rate carefully · Never "catch up" · Use electronic infusion pump

Fluid Overload

Signs: Weight gain >1 kg/day · Edema
Actions: Monitor daily weight & I&O · Notify provider · ↓ concentration, rate, or lipid volume

Electrolyte Imbalances

Hyperkalemia · Hypophosphatemia · Hypocalcemia
Monitor electrolyte panel per policy; adjust solution formulation as needed

⚙️ Mechanical

Pneumothorax / Hemothorax ⚡

Signs: SOB · Diminished or absent breath sounds
Cause: Catheter misplacement during insertion
Actions: Verify placement before infusing · Monitor respiratory status

Other Mechanical Complications

Arterial puncture · Catheter embolus · Air embolus · Thrombosis · Obstruction · Bolus infusion from incorrectly set or malfunctioning electronic pump

🔄 Refeeding

Refeeding Syndrome ⚡

What it is: Body rapidly shifts from catabolic (starvation) → anabolic (nutrition restart). Fluid & electrolyte imbalances result.
Signs: Shallow respirations · Confusion · Seizures · Weakness · Cardiac rhythm changes · Fluid retention · Acidosis
Electrolytes affected: ↓ Potassium · ↓ Magnesium · ↓ Phosphate
Actions: Monitor electrolytes closely · Start PN slowly after prolonged starvation

        ⚡ Refeeding Syndrome: Caused by rapid catabolic → anabolic shift. Electrolytes affected: potassium, magnesium, phosphate. Greater risk with PN. Monitor closely when restarting nutrition after prolonged starvation.
      

📝 NCLEX Practice

A nurse is teaching a client about complications of TPN. Which complication occurs when a previously starved client's metabolism rapidly shifts from catabolic to anabolic?

A Hyperglycemia
B Hyperosmolar diuresis
C Refeeding syndrome ✓
D Catheter sepsis

📝 NCLEX Practice

A nurse is caring for a client receiving TPN through a central venous access device, but the next bag is unavailable. Which action should the nurse take?

A Administer dextrose 10–20% in water IV until the next bag is available ✓
B Slow the infusion rate of the current bag
C Monitor for hyperglycemia and wait
D Increase the rate once the new bag arrives to catch up

📝 NCLEX Practice

A nurse notes a layer of fat floating on top of a TPN bag. Which action should the nurse take?

A Shake the bag to mix the fat
B Turn the bag upside down once
C Return the bag to the pharmacy ✓
D Administer the bag of solution as it is

⚡

Exam High-Yield Summary

TPN vs PPN — route

TPN = central vein only. PPN = peripheral vein, ≤10 days.

PPN dextrose limit

No more than 10% dextrose and 5% amino acids — must be isotonic

Lipid appearance

Milky/opaque = normal. Oily layer floating on top = "cracked" → return to pharmacy

Lipid contraindications

Severe hyperlipidemia · Severe hepatic disease · Allergy to soybean, eggs, safflower

Lipid: does NOT increase

Osmolality — provides calories without raising osmolality

IV meds through PN line

Contraindicated — never push any IV medication through a PN port

Insulin in TPN

Regular insulin added to the solution by pharmacy — not pushed via Y-port

Heparin in TPN

Added to prevent fibrin buildup on catheter tip — added to solution, not Y-port

Micron filter

Required for PN tubing — not used when infusing lipid emulsion

PN unavailable → hang

Dextrose 10–20% in water — prevents rebound hypoglycemia

Never do when PN behind schedule

Do NOT increase rate to "catch up" → hyperglycemia, hyperosmolar diuresis, fluid overload

Bag & tubing change

Every 24 hours. Lipid infusion: do not hang >12 hours.

Refrigerated PN

Allow 1 hour at room temperature before administering

Lipids: stop before triglyceride draw

Stop infusion 12 hours before blood specimen for accurate results

Prealbumin (TPN effectiveness)

Expected: 15–36 mg/dL. Best acute marker for nutritional status.

BUN

Expected: 10–20 mg/dL. Monitors nitrogen balance.

Fluid overload indicator

Weight gain >1 kg/day + edema → notify provider

Discontinue PN when

Client can take 50–75% of caloric needs enterally/orally. Taper gradually.

Refeeding syndrome electrolytes

Monitor K⁺, Mg²⁺, phosphate — drops rapidly when nutrition restarts after starvation

GI atrophy prevention (long-term PN)

Ask provider about giving some enteral substance (e.g., diluted juice) to keep GI tract active

Chapter 11 · Nutrition

Barriers to Adequate Nutrition

30–50% of clients in acute care facilities are malnourished upon admission or during their hospital stay. Medical, psychological, and social factors all create nutritional barriers. Nutritional education is ineffective if the client lacks the resources to follow through.

Medical

Poor dentition Dysphagia Jaw fixation Cancer / COPD / Burns / HIV

Psychological

Dementia / Alzheimer's Altered sensory perception Nutrition misinformation

Social / SDOH

Food insecurity Food deserts Low income No transportation

Assess ALL barriers before designing a nutrition plan — education is only effective when resources match recommendations

🦷 Poor Dentition Medical 💰 Low SES / SDOH Social 🧠 Cognitive Disorders Psychological 👁️ Altered Sensation Psychological 🫁 Dysphagia Medical 🦴 Jaw Fixation Medical 📚 Misinformation Psychological 🏥 Medical Conditions Medical

🦷

Poor Dentition

Children

No Dental Access

Caries from lack of dental care or tools (toothbrush, toothpaste) → impaired ability to chew

Adults

Missing / Damaged Teeth

Lost teeth or teeth needing removal or repair → impaired ability to chew

Post-Extraction

Denture Adjustment

After tooth removal, adjustment to dentures can be difficult

Nursing Interventions

🔍School screenings to identify children needing dental referrals

🍎Provide children with info on healthy, low-sugar snacks

⚠️Advise limiting processed carbohydrates — stick to teeth, increase caries risk

🪥Encourage fluoridated toothpaste and fluoride application

🏥Perform basic dental screening on admission to acute or long-term care

👩‍⚕️Consult dietitian for meal planning and supplement recommendations

💰

Low Socioeconomic Status & Food Insecurity (SDOH)

>1 mi

Urban food desert

>10 mi

Rural food desert

Why It Matters

→Nutritious foods (fresh fruit, vegetables) cost more than canned/boxed foods
→Processed foods are high in calories, sodium, fat — poor for restricted diets
→Lack of transportation to grocery stores is a real access barrier

High-Risk Groups ⚡

Households near or below the poverty line

Single-parent households

Families led by Black or Hispanic head of household

Households in large metropolitan areas

Nursing Interventions

→Refer to dietitian for food substitutions and affordable options

→Frozen fruits & vegetables — affordable and nutritionally preserved longer in freezer

→Educate on how to read food labels (nutritional, caloric, sodium values)

→Contact social services — investigate community nutrition programs and meal delivery

📝 NCLEX Practice — Case Study: SDOH

A nurse is assessing a client's social determinants of health (SDOH). Which of the following factors should the nurse recognize as potential barriers to adequate nutrition? (Select all that apply)

A Economic stability ✓
B Neighborhood and built environment
C Health care access and quality ✓
D Social and community context ✓
E Education access and quality ✓

🧠

Cognitive Disorders (Dementia / Alzheimer's)

Early / Moderate Disease

Impaired memory and judgment
Difficulty shopping, food selection, and food preparation

Advanced Disease

May refuse to eat or choose a very limited food selection
Risk for vitamin and mineral deficits

Nursing Interventions ⚡

🏠 Independent / Community

Encourage shopping with a friend or family member and following a shopping list
Monitor for vitamin/mineral deficits — evaluate need for nutritional supplements
Contact social services for food or meal delivery to the home

🏥 Care Facility

Provide minimal but nutritious menu options
Serve meals at same time · same location · same people
Keep environmental distractions to a minimum
Provide snacks between meals if mealtime intake is inadequate
Cut food into small pieces; remind client to chew then swallow
Lightly stroke the chin and throat to help promote swallowing

👁️

Altered Sensory Perception

👁️ Vision

Problem

Difficulty feeding self, shopping, or food preparation. May need help with tray setup and locating food in a facility.

Interventions

Encourage grocery delivery or shopping with companion
Assist with tray setup and food location in facility
Contact social services for meal delivery to home

👃 Smell & Taste

Problem

Altered smell → altered taste (linked senses). Smokers have diminished smell. Food becomes unpalatable.

Interventions

Food aversion / nausea: recommend cool foods — less aromatic, less likely to precipitate nausea
Decreased taste: suggest spicy or tangy foods to compensate
Avoid empty calories; if more calories needed → milkshakes, juice, supplements

💊 Medication-Induced

Causes

Chemotherapy → metallic taste, masking real flavor. Radiation to head/neck → altered or complete loss of taste (mouth blindness).

Interventions

Recommend hard candies, mints, or chewing gum to counteract unusual taste
Encourage calorie-dense supplements to maintain intake

🫁

Impairment in Swallowing (Dysphagia)

⚡ Partial Laryngectomy

CAN aspirate

Airway not fully separated. Teach chin tuck when swallowing. Arching tongue at back of throat helps close off trachea.

⚡ Total Laryngectomy

CANNOT aspirate

Airway and esophagus are completely separated — no aspiration risk.

Causes — Clients at Risk

Parkinson's disease Cerebral palsy Stroke Oral cancer surgery (lip, tongue, soft palate) Partial laryngectomy Epiglottis / larynx surgery

National Dysphagia Diet — 3 Levels ⚡

1

Pureed

Smooth, uniform — no lumps or chunks

2

Mechanically Altered

Soft, moist — minimal chewing required

3

Advanced

Near-normal with some texture restrictions

Fluid Thickening Consistencies ⚡ — Use a commercial thickener for thin fluids

Thin

water-like

Nectar-like

slightly thick

Honey-like

pours slowly

Spoon-thick

pudding-like

Nursing Interventions ⚡

⚡Continuously monitor during meals — have suction equipment immediately available

👩‍⚕️Consult dietitian for appropriate dysphagia diet level

⏱️Allow adequate time for meals — have client rest beforehand

🔽Teach chin tuck when swallowing (surgical alteration of throat or upper tracheal structures)

👅Teach arching tongue at back of throat to help close off trachea when swallowing

🥤Use commercial thickener for thin fluids to prescribed consistency

📝 NCLEX Practice

A nurse is caring for several clients in an extended care facility. Which client is the highest priority to observe during meals?

A A client who has decreased vision
B A client who has Parkinson's disease ✓
C A client who has poor dentition
D A client who has anorexia

🦴

Mechanical Fixation of the Jaw

Facial trauma or reconstruction → upper and lower jaw wired together for several weeks. Client placed on a liquid diet during immobilization.

✓ DO

Encourage fluid intake
Help client use a straw through the space between jaws
Work with dietitian to develop a complete liquid meal plan including all necessary nutrients

✗ DO NOT

Thicken liquids to honey consistency (straw cannot accommodate thick liquids)
Provide ground meats (jaw is wired — client cannot chew)
Use nasogastric tube (not indicated for jaw fixation)

📝 NCLEX Practice

A nurse is planning care for a client who has mechanical fixation of the jaw following a motorcycle crash. Which actions should the nurse include? (Select all that apply)

A Thicken liquids to honey consistency ✗ (cannot use straw with thick liquids)
B Educate the client about the use of a nasogastric tube ✗ (not indicated)
C Assist the client to use a straw to drink liquids ✓
D Ensure that the client receives ground meats ✗ (jaw is wired; cannot chew)
E Encourage intake of fluids between meals ✓

📚

Lack of Knowledge & Misinformation

Common Sources of Misinformation

📉

Fad Diets

Promise quick results but are generally unhealthy and often eliminate essential nutrients

📺

False Advertising

Fraudulent packaging and media claims can mislead clients into poor food choices

❓

No Basic Knowledge

Clients may lack fundamental understanding of nutrition labels or portion sizes

Reliable Resources ⚡ — Direct Clients Here

🍽️

MyPlate

choosemyplate.gov

❤️

American Heart Association

heart.org

📋

Dietary Guidelines

health.gov/dietaryguidelines

Nursing Interventions

Direct clients to government and health association dietary guidelines
Assist in locating community resources for nutrition education
Assess dietary intake
Instruct on how to read nutrition fact labels

Encourage keeping a food journal / dietary intake log
Provide information on healthy foods and appropriate portion sizes
Warn that advertisements can be fraudulent

🏥

Medical Conditions as Nutritional Barriers

Cancer

Anorexia, nausea, stomatitis from treatment; ↑ metabolic demands

COPD

↑ work of breathing → ↑ calories burned; poor appetite, nausea, bloating

Burns / Trauma

Severely ↑ metabolic demands; inability to consume adequate diet

HIV / AIDS

Wasting syndrome, diarrhea, malabsorption, anorexia, nausea

NPO Status ⚡

Diagnostic testing → at risk for malnutrition, especially if >24 hours

Polypharmacy ⚡

Multiple medications → risk for medication-nutrient interactions

Nursing Interventions ⚡

Monitor diet prescriptions and labs — NPO or clear/full liquids >24 hr → refer to dietitian
Refer to pharmacist for medication-nutrition interaction evaluation in clients with polypharmacy
Offer several small meals / snacks throughout the day instead of 3 large meals

Provide oral care before and after meals
Avoid alcohol-based mouthwashes for clients with stomatitis
Provide liquid supplements between meals to increase nutrient intake

⚡

Exam High-Yield Summary

Malnourishment in acute care

30–50% of hospitalized clients are malnourished on admission or during stay

Food desert (urban)

More than 1 mile from food source. Rural: more than 10 miles.

Affordable veggie option

Frozen fruits and vegetables — nutritionally preserved, last longer

Chemo → taste alteration

Metallic taste — suggest hard candies, mints, or gum to counteract

Radiation head/neck → taste

Mouth blindness — altered or complete loss of taste

Food aversion / nausea

Recommend cool foods — less aromatic, less likely to cause nausea

Decreased taste → suggest

Spicy or tangy foods to compensate for reduced taste sensation

Dysphagia diet levels

Level 1: Pureed · Level 2: Mechanically altered · Level 3: Advanced

Fluid thickening order

Thin → Nectar-like → Honey-like → Spoon-thick

Total laryngectomy

Cannot aspirate — airway and esophagus are fully separated

Partial laryngectomy

Can aspirate — teach chin tuck when swallowing

Aspiration risk → always have

Suction equipment immediately available during meals

Dementia meal environment

Same time · Same location · Same people · Minimize distractions

Dementia: promote swallowing

Lightly stroke chin and throat

Jaw fixation: diet type

Liquid diet via straw — no ground meats, no honey-thick fluids

Highest priority during meals

Client with Parkinson's disease — greatest aspiration risk

NPO / clear liquids >24 hr

Refer to dietitian for complete nutritional evaluation

Stomatitis: avoid

Alcohol-based mouthwashes — irritating to mucosa

Polypharmacy nutrition risk

Refer to pharmacist for medication-nutrient interaction evaluation

Reliable nutrition resources

MyPlate · American Heart Association · health.gov Dietary Guidelines

Chapter 12 · Nutrition

Malnutrition

Malnutrition = lack of adequate nutrients or imbalanced intake. Affects clients who are underweight, overweight, or obese. Major cause of morbidity, mortality, and decreased quality of life. All clients must be screened within 24 hours of hospital admission.

Diagnostic Criteria ⚡ (≥ 2 required)

Inadequate calorie intake Loss of muscle mass Loss of subcutaneous fat Unintentional weight loss ↓ Handgrip strength Weight loss masked by edema

PEM Types ⚡

Marasmus — ↓ calories + protein Kwashiorkor — ↓ protein only Starvation — no inflammation

Healthy People 2030 Goals

↑ BMI measurement ↑ Obesity counseling ↓ Food insecurity

TJC: All clients screened within 24 hours of admission · Prealbumin: best acute marker (15–36 mg/dL)

📉 PEM Types Undernutrition 🫁 Chronic Disease Mild–Moderate Inflammation 🔥 Critical Illness Severe Inflammation ⚠️ Complications By System 🔬 Labs & Assessment Monitoring ⚡ Refeeding Syndrome Critical Watch 👩‍⚕️ Nursing Interventions Promote Intake 📊 Obesity & Bariatric Overnutrition

📉

Protein-Energy Malnutrition (PEM)

M

Marasmus ⚡

↓ Calories + ↓ Protein

Body fat + tissue protein wasted
Serum proteins may be within normal range
Common in children + older adults
Starvation-related

K

Kwashiorkor ⚡

↓ Protein only

Calorie intake may be adequate
Body weight may appear normal
Serum protein levels are LOW
Common with poor-quality protein diets

S

Starvation

Complete lack of nutrients

Does NOT involve inflammation
Key distinction from disease-related malnutrition

📝 NCLEX — Select All That Apply

A nurse is caring for multiple clients who are malnourished. Which of the following client conditions are associated with severe inflammation that can lead to malnutrition?

A Sepsis ✓
B Cystic fibrosis ✗ mild-moderate inflammation
C Starvation ✗ no inflammation
D Chronic kidney disease ✗ mild-moderate
E Third-degree burns ✓
F Chronic alcohol use disorder ✗ chronic, mild-moderate
G AIDS ✗ chronic, mild-moderate

🫁

Chronic Disease-Related Malnutrition

Mild to moderate inflammation → decreased appetite + nutrient underutilization

🍶 Chronic Alcohol Use Disorder

Thiamin absorption impaired → risk of alcoholic encephalopathy
Cirrhosis → deficiency of vitamins A, D, E, K
Ascites + abdominal pain → ↓ appetite + eating discomfort
Use caution with OTC supplements not prescribed

🌬️ COPD

↑ work of breathing → ↑ calories burned → ↑ risk of muscle wasting
Poor appetite, nausea, abdominal bloating → feeling of fullness
Dyspnea while eating further limits intake

🔴 HIV / AIDS

Wasting syndrome → loss of muscle mass
Diarrhea + malabsorption · Anorexia · Nausea
Candida infection of throat / esophageal lesions → difficulty swallowing
Medications may cause intolerance to fat

🧬 Cystic Fibrosis

Decreased fat absorption — lack of pancreatic enzyme
Deficiency of fat-soluble vitamins: A, D, E, K
↑ work of breathing → ↑ calorie expenditure
Abdominal distention + GERD may affect intake

🫘 Chronic Kidney Disease

Risk for uremia + electrolyte imbalances
Early protein restriction preserves kidney function
Protein + calorie needs based on ht/wt, muscle tone, albumin, Hgb, Hct
Protein needs differ for hemodialysis vs peritoneal dialysis clients

🔥

Acute Disease / Critical Illness

Severe inflammation → impaired digestion + absorption. Higher mortality, longer ICU stays, higher costs.

1st Choice

Oral Diet

Preferred if possible

→

2nd Choice

Enteral (EN)

GI tract functioning

→

Last Resort

Parenteral (PN)

GI tract compromised

Calorie Needs by BMI — when Indirect Calorimetry unavailable ⚡

BMI < 30

25–30

cal/kg/day — actual weight

BMI 30–50

11–14

cal/kg/day — admission weight

BMI > 50

22–25

cal/kg/day — ideal body weight

Protein Needs by BMI — adequate protein may be MORE crucial than total calories ⚡

BMI < 30

1.2–2

g/kg/day — actual weight

Higher for burns

BMI 30–40

2

g/kg/day — ideal body weight

BMI > 40

2.5

g/kg/day — ideal body weight

🔥 Burns

Burns <20% TBSA → calorie-dense + protein-dense oral diet is sufficient
Supplement EN if intake <75% of needs for >3 days
If oral not possible → initiate EN (or PN) within 4–6 hours of injury
High metabolic rate may persist for years after injury
High-dose vitamins C & E, selenium, zinc, copper recommended

🦠 Sepsis

Use indirect calorimetry OR weight-based equations for kcal requirements
Initiate EN (or PN if GI not functioning) as soon as possible
Individualize fluid requirements based on blood loss, diarrhea, vomiting, fever, exudates

🏥 Multi-Trauma / Head Injury

Acute tissue injury → ↓ prealbumin + albumin levels
Head injury: assume catabolic state
Skull fracture suspected/confirmed → use oral feeding tube, NOT NG tube
Post-extubation: monitor intake — NPO for tests, anorexia, fatigue → risk of inadequate oral intake

Best calorie assessment: Indirect Calorimetry (IC) — most accurate predictive tool. Use weight-based formula only when IC is unavailable.

⚠️

Complications of Undernutrition

❤️ Cardiovascular / Resp

Dysrhythmias, heart failure
Respiratory muscle weakness
Bradycardia, hypotension

🔬 Endocrine / Immunologic

Impaired immune response → ↑ infection risk
Hormonal dysregulation

🫄 Gastrointestinal

Impaired digestion + absorption
Mucosal atrophy
Constipation, diarrhea

🦴 Musculoskeletal / Neuro

Muscle wasting, weakness
Peripheral neuropathy
Impaired cognition, slow healing

🧠 Psychiatric

Depression, anxiety
Apathy, irritability

🩹 Integumentary

Poor wound healing
Dry, brittle hair and nails
Skin breakdown

SDOH Factors Contributing to Malnutrition

Low income No transportation Language barriers Lack of social support Low literacy Contaminated soil/water

Cultural Considerations

Malnutrition may result during hospitalization or in community-living environments if food provided does not meet cultural food preferences. Always assess and incorporate cultural considerations in meal planning.

🔬

Assessment, Labs & Older Adults

Lab Monitoring ⚡

Prealbumin ⚡ BEST

15–36

mg/dL — best acute indicator; shorter half-life reflects recent intake

Albumin

3.5–5

g/dL — indicates disease severity, not best for acute nutritional status

BUN

10–20

mg/dL — negative nitrogen balance → ↓ urea → ↓ BUN

Creatinine

↓ level

Indicates ↓ muscle mass

CBC

↓ RBC, Hct, Hgb

Anemias from nutrient deficiency

Electrolytes

Monitor all

↓ = nutrient depletion; hypernatremia → dehydration from malnutrition

Note: Both albumin and prealbumin are synthesized in the liver — liver dysfunction causes decreased levels of both. Also monitor liver function tests for clients with substance use disorders or other liver conditions.

Older Adult Risk Factors ⚡

Dental problems + difficulty swallowing
Decreased senses of smell and taste
GI manifestations — constipation, dry mouth
Musculoskeletal + neurological conditions
Multiple medications → drug-nutrient interactions
Challenges purchasing + preparing food
Social isolation · Loss of spouse or partner

TJC Standard + Treatment Ladder ⚡

All clients must be screened within 24 hours of hospital admission

Balanced oral diet + liquid supplements + multivitamins
Correct fluid + electrolyte imbalances
EN if unable to meet needs orally
PN if GI tract impairment prevents absorption

📝 NCLEX Practice

Which is the reason the nurse would monitor albumin levels for a client with malnutrition?

A Albumin levels may indicate severity of disease ✓
B Albumin is the most reliable indicator of protein malnutrition ✗ (prealbumin is more reliable for acute status)
C Increased albumin indicates increased inflammation ✗
D Increased albumin indicates fluid overload ✗

⚡

Refeeding Syndrome

Monitor when reintroducing carbohydrates after undernutrition or starvation

TRIGGER

Carbohydrates
Reintroduced

RESPONSE

↑ Insulin secretion → ↑ carb metabolism

RESULT

Thiamin deficiency + electrolytes shift into cells

↓ SERUM LEVELS

K⁺ · Mg²⁺ · PO₄

Complications ⚡

⚠ Seizures

⚠ Edema

⚠ Heart failure

⚠ Decreased serum electrolytes

⚠ Hemolysis

Nursing Actions ⚡

Supplement thiamin + electrolytes (K⁺, Mg²⁺, phosphate)
If on EN or PN → slow the rate if symptoms develop
Monitor serum electrolyte levels continuously
Increased carb breakdown → thiamin deficiency — supplement proactively

👩‍⚕️

Nursing Interventions

Interdisciplinary collaboration: dietitian · pharmacist · social worker · PT/OT

🌡️ Environment

Pain management before meals
Remove strong odors — lift food lids away from client
Eliminate environmental distractions
Clear area of urinals, bedpans, emesis basins

🛁 Comfort

Toileting, oral care, hand hygiene before meals
Sit upright — chair if possible
Ensure use of hearing aids, glasses, assistive devices

🍴 Function

Minimize non-urgent care during mealtimes
Ensure appropriate food + fluid temperature
Encourage self-feeding as much as possible
Assist with opening packages + cutting food
Allow adequate time to chew + swallow
Observe + document intake

↑ Calorie Density

Butter / mayo / olive oil Cream cheese Honey on cereal Gravy on meats + potatoes Whipped cream on desserts

↑ Protein Density

Cheese on vegetables + salads Peanut butter on cereal Nuts in cereals + salads Fruit mixed with yogurt Milk instead of water in recipes

Ongoing Assessment

Document appetite, daily weights, I&O — may delegate to AP with supervision
Daily calorie count for burns clients
Monitor lab studies: electrolytes, BUN, creatinine, CBC, albumin/prealbumin, liver function tests

Interdisciplinary Referrals

Dietitian — diet ordering, supplement recommendations, calorie goals
Pharmacist — drug-nutrient interaction evaluation
Social worker / case manager — resource-related malnutrition causes
PT/OT — functional issues affecting eating

📊

Obesity

Chronic condition: calorie intake exceeds energy expenditure · Affects culture, metabolism, environment, socioeconomics

BMI — Overweight

25–29.9

BMI — Obese ⚡

≥ 30

Waist Circumference

Females >88.9 cm (35 in)

Males >101.6 cm (40 in)

Waist-to-Hip Ratio (WHR) ⚡

Predictor of coronary artery disease. Indicates excess fat at waist + abdomen.

Males

≥ 0.95

Females

≥ 0.80

Screening Labs

Total cholesterol· Triglycerides· Fasting BG· HbA1c· AST / ALT

Treatment ⚡

Diet: ↓ 500–750 kcal/day. DASH, Mediterranean, or vegetarian plans recommended. Very low-calorie (<800 kcal/day) only under medical supervision.
Physical activity: ↓ sedentary time · ↑ aerobic + resistance exercise
Behavior modification: Goal setting · Avoidance of triggers · Support groups · Motivational interviewing · Stress management
Medications (FDA): BMI ≥30 no complications · OR BMI ≥27 + ≥1 complication
Nursing position: Low-Fowler's to maximize chest expansion

Bariatric Surgery — Candidates ⚡ (most effective treatment for obesity)

≥ 40

BMI ≥ 40

No obesity-related complications required

≥ 35

BMI ≥ 35

+ 1 or more obesity-related complication

30–35

BMI 30–34.9

+ T2DM uncontrolled despite diet, activity & meds

Bariatric Procedures

Adjustable Gastric Band

Restricts stomach to 15–30 mL via inflatable band around upper stomach

Diet: liquids → pureed → soft foods (gradually)
Chew foods thoroughly, slowly, in small amounts

Roux-en-Y Gastric Bypass

Bypasses majority of stomach, duodenum, and part of proximal jejunum → restriction + malabsorption

Complications: anastomotic leaks, GI bleeding, stomal stenosis, dumping syndrome
Micronutrient deficiencies common long-term

Sleeve Gastrectomy

Longitudinal portion of stomach removed → "sleeve" effect. 80% reduction in stomach capacity

↑ satiety hormones
Reduces DM, hypertension, dyslipidemia, mortality

Post-Bariatric Nutritional Deficiencies ⚡ — Protein intake ≥ 60 g/day required

Iron — oral or parenteral supplementation Calcium Thiamin Vitamin B12 — oral or monthly injections Vitamin D

📝 NCLEX Practice

A nurse in a bariatric clinic is caring for clients being evaluated for bariatric surgery. Which client does the nurse recognize as the most appropriate candidate?

A BMI 27 + type 2 diabetes ✗ (BMI 27 doesn't meet criteria even with T2DM — needs 30–34.9 + uncontrolled T2DM)
B BMI 34 + asthma ✗ (asthma is not an obesity-related complication qualifying at BMI 34)
C BMI 35 + osteoarthritis ✓ (BMI ≥35 + obesity-related complication)
D BMI 38 + no complications ✗ (BMI 38 without complications does not meet criteria — needs ≥40)

⚡

Exam High-Yield Summary

Malnutrition diagnosis

≥ 2 criteria: ↓ calorie intake · ↓ muscle mass · ↓ subcut fat · unintentional wt loss · ↓ handgrip strength · edema masking wt loss

Marasmus vs Kwashiorkor

Marasmus = ↓ calories + protein, normal serum proteins · Kwashiorkor = ↓ protein only, LOW serum proteins

Starvation

Complete lack of nutrients — NO inflammation. Key distinction from disease-related malnutrition.

Severe inflammation → malnutrition

Sepsis + third-degree burns. Chronic conditions = only mild-moderate inflammation.

Alcohol + cirrhosis

↓ Thiamin → alcoholic encephalopathy · Cirrhosis → deficiency of vitamins A, D, E, K

Cystic fibrosis

↓ fat absorption (no pancreatic enzyme) · Deficient in fat-soluble vitamins A, D, E, K

CKD: early nutrition action

Protein restriction early in disease → preserves kidney function

Burns: EN timing

Within 4–6 hours of injury if oral intake not possible

Head injury: tube choice

Skull fracture → oral feeding tube, NOT NG tube

Best calorie assessment

Indirect calorimetry (IC) — most accurate for critical illness

Refeeding: key electrolytes

K⁺, Mg²⁺, phosphate shift into cells → ↓ serum levels + thiamin deficiency

Prealbumin vs albumin

Prealbumin = best acute/recent nutritional marker · Albumin = disease severity

TJC screening standard

Nutritional screening within 24 hours of hospital admission

Refeeding complications

Seizures · Edema · Heart failure · ↓ electrolytes · Hemolysis

Promote intake: environment

Pain control before meals · Remove odors · Eliminate distractions · Clear area of bedpans/urinals

Obesity BMI cutoffs

Overweight: 25–29.9 · Obese: ≥ 30

Bariatric: BMI criteria

≥40 (no complications) · ≥35 + complication · 30–34.9 + uncontrolled T2DM

Post-bariatric deficiencies

Iron · Calcium · Thiamin · Vitamin B12 (monthly injections) · Vitamin D

Post-bariatric: protein min

≥ 60 g/day to prevent protein-calorie malnutrition

Obesity: nursing position

Low-Fowler's to maximize chest expansion

Obesity meds: FDA criteria

BMI ≥30 no complications · OR BMI ≥27 + ≥1 complication

Roux-en-Y: watch for

Anastomotic leaks · GI bleeding · Stomal stenosis · Dumping syndrome

Sleeve gastrectomy

80% reduction in stomach capacity · ↑ satiety hormones

Chapter 13 · Nutrition

Cardiovascular & Hematologic Disorders

Heart disease = #1 cause of death in the United States. Hypercholesterolemia → atherosclerosis (cholesterol deposits on vessel walls) → MI, kidney failure, ischemic stroke. Diet is a primary modifiable risk factor in prevention and management.

HDL — "Good" ⚡

≥ 60

mg/dL (males) · ≥ 70 (females)

LDL — "Bad" ⚡

< 130

mg/dL optimal

Total Cholesterol ⚡

< 200

mg/dL optimal

Modifiable Risk Factors

High LDL Low HDL Saturated fat diet Hypertension Diabetes Obesity Sedentary lifestyle Nicotine use

Metabolic syndrome = ≥3 of 5: Abdominal obesity · TG ≥ 150 · Low HDL · BP ≥ 130/80 · Fasting BG ≥ 100 mg/dL

🫀 CHD & Metabolic Syndrome Cardiovascular 🩸 Anemias Hematologic 🥗 Diet Therapy CHD & HTN 💊 Heart Failure & MI Cardiac Events 🥩 Food Sources Anemia Nutrition

🫀

Coronary Heart Disease & Metabolic Syndrome

        Heart disease = #1 cause of death in the United States. Hypercholesterolemia → atherosclerosis (cholesterol deposits on vessel walls) → MI, kidney failure, ischemic stroke.
      

HDL — "Good" ⚡

≥ 60

mg/dL males · ≥ 70 females

Removes cholesterol from tissue → liver

LDL — "Bad" ⚡

< 130

mg/dL optimal

Deposits cholesterol into artery walls → plaques

Total Cholesterol ⚡

< 200

mg/dL optimal

Goal for cardiovascular protection

CHD Risk Factors

Non-Modifiable

Increasing age · Male sex · Family history of early CHD

Modifiable

High LDL · Low HDL · Diet high in saturated fat
Hypertension · Diabetes · Metabolic syndrome
Obesity · Sedentary lifestyle · Nicotine use disorder

Metabolic Syndrome ⚡ — Need ≥ 3 of 5

① Abdominal obesity — males ≥ 40 in · females ≥ 35 in
Asian/non-European clients: use population- or country-specific definitions

② Triglycerides ≥ 150 mg/dL or on meds

③ Low HDL or on meds — males ≤ 40 · females ≤ 50 mg/dL

④ ↑ BP or antihypertensive — systolic ≥ 130 · diastolic ≥ 80 mm Hg

⑤ Fasting BG ≥ 100 mg/dL or on glucose meds

📝 NCLEX Practice

A nurse is reviewing a client health record that includes a report of abdominal obesity and laboratory findings of elevated blood glucose and elevated triglycerides. The nurse should identify that these findings meet the criteria of which of the following conditions?

A Anemia
B Metabolic syndrome ✓ — meets 3 of 5 criteria (abdominal obesity, ↑BG, ↑TG)
C Heart failure
D Hypertension

🩸

Anemias — Types & Manifestations

        Anemia = ↓ RBCs or ↓ hemoglobin. Caused by ↓ RBC production, ↑ RBC destruction, or blood loss. Body requires iron, B12, and folic acid to produce RBCs. Iron deficiency anemia = most common nutritional disorder worldwide (~10% U.S. population), especially in older infants, toddlers, adolescent females, and pregnant clients. Iron intake tends to be marginal from childhood through adolescence.
      

Most common worldwide ⚡

Iron Deficiency

Risk Factors

Blood loss · Poor intake · Alcohol use disorder
Malabsorption · Gastrectomy
Pregnancy, adolescence, infection (↑ metabolic demand)

Signs & Symptoms

Fatigue · Lethargy · Headache
Pallor of nail beds · Intolerance to cold
Tachycardia
⚡ Children: ↓ attention span & poor intellectual performance before anemia develops

Macrocytic — Neurologic ⚡

Vitamin B12 Deficiency

Risk Factors

No meat/dairy (vegans) · Small bowel resection
Chronic diarrhea · Diverticula · Excess intestinal bacteria · Tapeworm
Pernicious anemia = lack of intrinsic factor ⚡

Signs & Symptoms

Pallor · Jaundice · Weakness · Fatigue
Glossitis · Anorexia · Weight loss · Indigestion
Neurologic ⚡: Paresthesia (numbness) hands/feet · ↓ proprioception · poor muscle coordination · ↓ concentration · increasing irritability · delirium

Macrocytic — No neuro symptoms ⚡

Folic Acid Deficiency

Risk Factors

Poor intake of green leafy vegetables, citrus, beans, nuts
Malabsorption (Crohn's disease)
Anticonvulsants · Oral contraceptives

Signs & Symptoms

Fatigue · Pallor · Irritability · Diarrhea · Glossitis
Key distinction ⚡: Mimics B12 deficiency except — NO neurologic symptoms

📝 NCLEX Practice

A community health nurse is assessing a client who reports numbness of the hands and feet for the past 2 weeks. The nurse should identify this finding as a manifestation of which of the following nutritional deficiencies?

A Folic acid ✗ — no neurologic symptoms
B Potassium
C Vitamin B12 ✓ — paresthesia is a neurologic manifestation unique to B12 deficiency
D Iron

🥗

Diet Therapy: CHD & Hypertension

TLC Diet ⚡ — Lower LDL

Therapeutic Lifestyle Change

Cholesterol < 200 mg/day ⚡
Saturated fat < 7% of daily calories ⚡
Trim fat from meats · Choose lean (turkey, chicken) · Remove skin
Broil, bake, grill, steam — no frying
Use liquid oils (olive, canola) — avoid lard, butter, trans-fat
Use spices in place of butter or salt to season foods
Low-fat/nonfat dairy · Avoid partially hydrogenated products
↑ Soluble fiber ↓ LDL ⚡ — oats, beans, fruits, vegetables, whole grains, barley, flaxseed
↑ Omega-3 fatty acids ↓ CAD risk ⚡ — oily fish (tuna, salmon, herring), flaxseed, soybeans, walnuts, canola

⚡ Elevated homocysteine ↑ CHD risk. Deficiencies in folate, B6, and B12 raise homocysteine.

🍷 Conservative use of red wine may ↓ CHD risk.

DASH Diet ⚡ — Lower BP

Dietary Approaches to Stop Hypertension

< 2,300

mg Na/day to start

1,500

mg Na/day goal ⚡

Hypertension = sustained BP ≥ 130/80 mm Hg. African-Americans have highest prevalence. Risk ↑ after menopause.

Avoid: canned soups/sauces, chips, pretzels, smoked meats, processed foods
↑ Potassium ⚡ — apricots, bananas, tomatoes, potatoes
↑ Calcium — low-fat dairy products ⚡
Limit alcohol · Exercise · Weight loss · Smoking cessation
Read labels · Educate on appropriate food choices

✅ DASH lowers both systolic & diastolic BP and cholesterol.

👩‍⚕️ Patient support ⚡: Explain why the diet matters · Involve family · Encourage a food diary · Allow occasional deviations · Use culturally appropriate food choices · Connect clients facing food insecurity to community resources (SDOH).

📝 NCLEX Practice

A nurse is teaching a client about high-fiber foods that can assist in lowering LDL. Which of the following foods should the nurse include? (Select all that apply)

A Beans ✓
B Cheese ✗ — high in fat, not fiber
C Whole grains ✓
D Broccoli ✓
E Yogurt ✗

📝 NCLEX Practice

A nurse is teaching a client about dietary recommendations to lower high blood pressure. Which of the following statements by the client indicates understanding?

A "My daily sodium consumption should be 3,000 milligrams." ✗
B "I should consume foods low in potassium." ✗
C "My limit is three cigarettes a day." ✗
D "I should consume low-fat dairy products." ✓

💊

Heart Failure & Myocardial Infarction

Heart Failure ⚡

Heart unable to maintain adequate circulation → excess Na⁺ & fluid retention → edema.

< 3,000

mg Na/day
mild-moderate HF ⚡

< 2,000

mg Na/day
severe HF ⚡

Fluid restriction (monitor; possibly < 2 L/day)
↑ Protein: 1.12 g/kg daily
Small, frequent meals — soft, easy-to-chew foods

Risk Factors

CHD · arrhythmias · prior MI · valve disorders · HTN · obesity · DM · metabolic syndrome

Myocardial Infarction ⚡

Inadequate O₂ to myocardium → tissue death. Goal: ↓ O₂ demand during recovery.

Liquid diet × first 24 hours ⚡
Avoid caffeine — stimulates heart, ↑ HR ⚡
Small, frequent meals thereafter
Progress to heart-healthy diet (TLC principles)

⚡ Risk factors for MI = same as CHD. Secondary prevention: lower LDL through diet, exercise, weight management, nicotine cessation.

🥩

Anemia Nutrition — Food Sources & Treatment

Iron Sources ⚡

Red meat · Fish · Poultry · Tofu
Dried peas & beans · Whole grains · Dried fruit
Iron-fortified formula · Infant cereal · Ready-to-eat cereals

✅ Vitamin C facilitates iron absorption ⚡ — take together

⚠️ Medicinal iron = #1 cause of accidental poisoning in small children ⚡

Vitamin B12 Sources ⚡

Fish · Meat · Poultry · Eggs · Milk
Fortified foods & supplements

ℹ️ Age > 50 — most B12 from supplements or fortified food ⚡

ℹ️ Vegans need supplemental B12 ⚡ — B12 only in animal products

Folic Acid Sources

Green leafy vegetables
Dried peas & beans · Seeds
Orange juice
Fortified cereals & breads

ℹ️ Supplement when dietary intake is inadequate.

📝 NCLEX Practice

A nurse is providing teaching to a client who has vitamin B12 deficiency. Which of the following foods should the nurse instruct the client to consume? (Select all that apply)

A Meat ✓
B Flaxseed ✗ — plant source, no B12
C Beans ✗ — plant source, no B12
D Eggs ✓
E Milk ✓

⚡

Exam High-Yield Summary

Heart disease

#1 cause of death in the U.S.

HDL goal

≥ 60 mg/dL males · ≥ 70 mg/dL females — "good" cholesterol; ↑ = protective

LDL goal

< 130 mg/dL — "bad" cholesterol → deposits into artery walls → plaques

Total cholesterol goal

< 200 mg/dL

Metabolic syndrome

≥ 3 of 5: abdominal obesity · ↑ TG (≥150) · ↓ HDL · ↑ BP (≥130/80) · ↑ fasting BG (≥100)

TLC diet: limits

Cholesterol < 200 mg/day · Saturated fat < 7% of calories · ↑ soluble fiber · ↑ omega-3

DASH diet: sodium targets

Start < 2,300 mg/day → goal 1,500 mg/day

DASH: key nutrients

↑ potassium (bananas, tomatoes, potatoes) · ↑ calcium (low-fat dairy) · ↓ sodium

Soluble fiber → LDL

Oats · beans · fruits · vegetables · whole grains · barley · flaxseed → ↓ LDL

Omega-3 foods

Tuna · salmon · herring · flaxseed · soybeans · walnuts · canola → ↓ CAD risk

Homocysteine & CHD

↑ homocysteine ↑ CHD risk — caused by ↓ folate, ↓ B6, ↓ B12

Heart failure Na limits

Mild-moderate: < 3,000 mg/day · Severe: < 2,000 mg/day

Post-MI diet

Liquid diet × 24 hrs · No caffeine · Small frequent meals

Iron deficiency anemia

Most common nutritional disorder worldwide. Children: ↓ attention before anemia even appears.

B12 vs folic acid deficiency

Both = macrocytic anemia. B12 ONLY = neurologic symptoms (paresthesia, ↓ proprioception, delirium)

Pernicious anemia

Most common B12 deficiency — lack of intrinsic factor

Vitamin C + iron

Vitamin C ↑ iron absorption — recommend together

Medicinal iron toxicity

#1 cause of accidental poisoning in small children

B12: age > 50 & vegans

Both need B12 from supplements or fortified food — animal products are the only natural source

B12 food sources

Fish · meat · poultry · eggs · milk — animal products only

Chapter 14 · Nutrition

Gastrointestinal Disorders

Nutrition therapy for GI disorders = minimize or prevent manifestations. For celiac disease ⚡, nutrition IS the only treatment. GI symptoms directly affect food tolerance, absorption, and nutritional status.

Upper GI / Structural

GERD — avoid LES relaxers Dumping Syndrome — small meals PUD — no NSAIDs / caffeine Hiatal Hernia

Lower GI / Absorption

IBD — low-residue, high-protein Celiac — gluten-free for life ⚡ Pancreatitis — NPO (acute) Liver Disease — ↑ protein Lactose Intolerance

Celiac disease = gluten-free diet for life (only treatment) · Pancreatitis (acute) = NPO; advance diet as tolerated

🫃 Overview & Assessment GI Fundamentals 💊 Symptom Management N/V, Anorexia, Diarrhea 🔥 Upper GI Disorders GERD, Dumping, Gastritis 🦠 PUD & Lactose Peptic Ulcer 💢 IBD & Diverticular Lower GI 🫀 Organ Disorders Liver, Pancreas, Gallbladder 🌾 Celiac Disease Gluten-Free for Life ⚡

🫃

Gastrointestinal Disorders — Overview & Assessment

🤢

GERD

avoid LES relaxers

🌊

Dumping Syn.

small meals, no sugar

🦠

PUD

no NSAIDs, caffeine

💢

IBD

low-residue, high-protein

🌾

Celiac

gluten-free for life

🫀

Pancreatitis

NPO (acute); low-fat (chronic)

🍶

Liver Disease

↑ protein, no alcohol

🥛

Lactose Intol.

limit lactose; watch Ca/D

Nutrition therapy for GI disorders = minimize or prevent manifestations. For celiac disease ⚡, nutrition IS the only treatment. For some GI disorders it is the foundation of treatment.

Client Assessment: Symptoms ⚡

Difficulty chewing or swallowing
Nausea, vomiting, diarrhea
Bloating, excessive flatus, occult blood, steatorrhea
Abdominal pain/cramping, distention
Pale, sticky bowel movements
Changes in weight, eating patterns, bowel habits

Substance Use Assessment

Tobacco · alcohol · caffeine
OTC medications — many have GI complications or contraindications
Nutritional supplements
Herbal supplements ⚡ — clients often don't report these as medications

Monitor (GI Parameters)

Weight changes · Lab values · Elimination patterns · I&O

Fiber — Know the Difference ⚡

📉 LOW-Fiber Diet

Avoid whole-grain breads/cereals, raw fruits & vegetables
↓ frequency and volume of stool · slows transit time
Used short-term for diarrhea or malabsorption

📈 HIGH-Fiber Diet

>5 g fiber per serving
Females: 25 g/day · Males: 38 g/day ⚡
↑ stool bulk · stimulates peristalsis · prevents constipation
Protects against colon cancer

💊

Symptom Management — N/V, Anorexia, Dysphagia, Constipation & Diarrhea

🤢

Nausea & Vomiting

Clear → Full liquid → Diet as tolerated

⚡ Coffee-ground = blood · Pale green = bile

Assess emesis appearance always
Low-fat carbs best-tolerated (crackers, toast, oatmeal)
Serve food room temp or chilled
Elevate head of bed · good oral hygiene · ice chips

Avoid: hot/spicy foods · liquids with meals · high-fat foods

🍽

Anorexia

Lack of appetite — not anorexia nervosa

Small, frequent meals · serve larger meals early in the day
Hold liquids ≥30 min before/after meals (prevents early fullness)
Liquid supplements between meals
Tart seasonings if taste diminished (OJ, lemon, basil, oregano)
Remove suppressants: odors, soiled linens, bedpans, clutter
Mouth care before and after meals

🗣

Dysphagia ⚡

Refer to speech therapist · position high-Fowler's

Modify food texture and liquid consistency
Position high-Fowler's or upright — ↑ aspiration risk
Dry mouth can contribute — evaluate medications
Allow adequate time · use adaptive eating devices
Nutritional supplements if intake inadequate

Avoid: thin liquids · sticky foods | Pills with ≥8 oz fluid

🔄

Constipation & Diarrhea

↑ fiber for constipation · low-fiber for diarrhea

Constipation Tx

↑ Fiber 25–38 g/day ⚡
≥64 oz fluid/day
Avoid chronic laxatives

Diarrhea Tx

Low-fiber short-term
Replace K⁺, Na⁺, fluid
Liberal fluid intake

📝 NCLEX Practice

A nurse is reviewing information with a client who has constipation about a high-fiber diet. Which of the following food choices should the nurse include as containing the highest amount of fiber?

A Peanut butter
B Peeled apples
C Hardboiled egg
D Baked potato ✓ — provides the most fiber of the options listed; eggs contain zero fiber

🔥

Upper GI Disorders — Dumping Syndrome, GERD & Gastritis

Dumping Syndrome ⚡

Stomach surgically reduced → contents rapidly empty into small intestine. Hallmark: rapid glucose rise → ↑ insulin → rebound hypoglycemia.

⚡ Phase 1 — Early

10–20 min

after eating

Fullness, cramping, nausea, diarrhea
Vasomotor: faintness, syncope, diaphoresis
Tachycardia, hypotension, flushing

→

Phase 2 — Late

1–3 hr

after eating

Diaphoresis, weakness, tremors, anxiety, hunger
Rapid glucose → ↑ insulin → hypoglycemia

Diet Management ⚡

❌ Avoid

Concentrated sugars
Lactose
Liquids with meals (wait ≥30 min)

✓ Eat at meals

Small, frequent meals
Protein at each meal
Fat at each meal

🛏 Positioning

Lie down after meals (delays gastric emptying)
Reclining if reflux present

🔬

Monitor for iron and vitamin B12 deficits in clients with dumping syndrome.

📝 NCLEX Practice

A nurse is monitoring a client who is postoperative from a gastric bypass and who just finished eating a meal. Which of the following findings are manifestations of dumping syndrome? (Select all that apply)

A Bradycardia ✗ — dumping causes tachycardia
B Dizziness ✓
C Dry skin ✗ — it's diaphoresis (sweating)
D Hypotension ✓
E Diarrhea ✓

GERD ⚡

🩺

Abnormal reflux of gastric secretions up the esophagus. Risk: hiatal hernia, obesity, pregnancy, smoking. Long-term → Barrett's esophagus, adenocarcinoma. Manifestations: heartburn, retrosternal burning, regurgitation, hoarseness. Pain can mimic MI ⚡

🚫 AVOID ⚡

LES Relaxers

fatty foods caffeine chocolate alcohol nicotine peppermint

Triggers & Habits

Citrus, spicy foods, carbonated beverages
Eating within 3 hr of lying down
Large meals & bedtime snacks
Tight-fitting clothing (↑ abdominal pressure)

✓ RECOMMENDED

Elevate body on pillows — do not lie flat
Weight loss if overweight/obese
Avoid eating before bedtime

Gastritis (Acute & Chronic)

🩺

Manifestations: abdominal pain, headache, lethargy, nausea, hiccupping, heartburn, belching, sour taste, vomiting, hematemesis

⚡ Acute Causes

Chronic Causes

NSAIDs, bile reflux
Strong acid/alkali ingestion
Radiation, burns, food poisoning
Severe infection, major surgery, organ failure

H. pylori, pernicious anemia (autoimmune)
Excessive caffeine/alcohol
Alendronate, perindopril
Reflux of pancreatic secretions and bile

⚠️

Strong acid/alkali ingestion: Do NOT lavage or induce emesis — risk of perforation & esophageal damage. Dilute and neutralize.

⏱

Acute recovery: typically 1 day (up to 2–3). Eat a bland diet when tolerated. IV fluids if persists.

🚫

Avoid: frequent meals/snacks (↑ acid) · alcohol · smoking · NSAIDs · coffee · black pepper · spicy foods. Monitor: vitamin B12 deficiency. Chronic: H2 antagonist (famotidine).

🦠

Peptic Ulcer Disease & Lactose Intolerance

🦠

Peptic Ulcer Disease ⚡

Erosion of mucosal layer · stomach or duodenum

Causes: H. pylori infection · chronic NSAID use

Dull/gnawing epigastric pain · heartburn · sour taste in mouth
Tarry stools · anemia from blood loss · urea in breath
Eating temporarily relieves pain

H. pylori Tx — Triple therapy ⚡
2 antibiotics + acid-reducing med × 10–14 days

Avoid ⚡: coffee · alcohol · caffeine · NSAIDs · aspirin · cigarettes · black pepper · spicy foods

🥛

Lactose Intolerance ⚡

Inadequate lactase enzyme

Lactose ÷ lactase ✗ → osmotic diarrhea

Distention, cramps, flatus, osmotic diarrhea
Small amounts (4–6 oz milk) with meals may be tolerated
Yogurt & aged cheeses — lower lactose, better tolerated

High-lactose to limit: milk · soft cheese · ice cream · cream soups · sour cream · puddings · creamer

⚡

Monitor: vitamin D & calcium deficiency ⚡

💡

Ask about lactase enzyme supplement.

📝 NCLEX Practice

A nurse is collecting data from a client who has peptic ulcer disease (PUD). Which of the following findings should the nurse expect? (Select all that apply)

A Steatorrhea ✗ — indicates fat malabsorption, not PUD
B Anemia ✓ — from blood loss
C Tarry stools ✓ — melena from GI bleeding
D Epigastric pain ✓
E Swollen lymph nodes ✗ — not a PUD finding

💢

IBD, Diverticular Disease & Ostomies

Inflammatory Bowel Disease (IBD) ⚡

Crohn's disease (regional enteritis) + ulcerative colitis — both chronic, inflammatory, with exacerbation and remission. Manifestations: N/V, abdominal cramps, fever, fatigue, anorexia, weight loss, steatorrhea, low-grade fever.

⚡ Exacerbation / Flare

Low-residue, high-protein, high-calorie
Vitamin/mineral supplementation
Correct fluid/electrolyte imbalances
Enteral nutrition preferred over PN
PN only if EN ineffective or contraindicated

Remission

Diet broadened based on client's specific triggers
Avoid substances that cause/worsen diarrhea
Avoid nicotine

Adjunct Therapies

Vitamin C, flaxseed · yoga, hypnosis, breathing exercises
Aminosalicylates, corticosteroids, immunomodulators · Surgery if needed

Diverticular Disease

Diverticulosis

Diverticulitis ⚡

State

Pouches present, no infection

Fecal matter trapped → inflammation

Symptoms

Often asymptomatic

Abdominal pain, N/V, fever, chills, tachycardia, altered bowel habits

Diet

↑ High-fiber — ↓ intraluminal pressure

Clear liquid until inflammation resolves → high-fiber, low-fat

Treatment

Diet management

Antibiotics, anticholinergics, analgesics. Severe: IV, opioids. Surgery: peritonitis/abscess/obstruction

📍

Diverticula most often in the sigmoid colon.

Ileostomies & Colostomies ⚡

Ostomy = surgically created opening on abdomen from end of small intestine (ileostomy) or colon (colostomy). Begin with liquids only → advance as tolerated.

Primary Concern: Fluid & Electrolytes ⚡

Colon absorbs large amounts of fluid, Na⁺, and K⁺
Fluid intake: 1.9–2.4 L (64–80 oz)/day
↑ calories & protein → promote stoma healing

💛

Provide emotional support — risk of altered body image.

Foods to Avoid

💨 Gas: beans, eggs, carbonated beverages

🚧 Blockage: nuts, raw carrots, popcorn

👃 Odor: eggs, fish, garlic

🫀

Organ Disorders — Cholecystitis, Pancreatitis & Liver Disease

🫐

Cholecystitis

Gallbladder inflammation

Pain: upper right abdomen → right shoulder or midsternal

N/V, anorexia; if pus/gangrenous → perforation
Limit fat intake — ↓ gallbladder stimulation
Diet individualized to client needs & tolerance
Surgery if large stones or diet-uncontrolled
Can lead to pancreatitis and liver involvement

🔴

Pancreatitis — Acute ⚡

Causes: alcohol + gallstones (70%)

NPO + NG tube suction

Reduce pancreatic stimulation

TPN until oral intake resumes
Pancreas secretes enzymes for fat, carb, protein digestion
Chronic pancreatitis can result if acute does not resolve

🟣

Pancreatitis — Chronic ⚡

Ongoing pancreatic inflammation

↓ Fat

↑ Protein

↑ Carbs

💊

Vitamin C + B-complex supplementation

🫁

Liver Disease ⚡

Malnutrition is common · metabolizes most nutrients

↑ Protein → positive nitrogen balance, prevents body protein breakdown
Carbs generally unrestricted (important calorie source)
Caloric needs may need to be increased based on disease stage
Multivitamins: B, C, K
Eliminate alcohol, nicotine, caffeine

📝 NCLEX Practice

A nurse is reviewing information about following a low-fat diet with a client who is recovering from pancreatitis. Which of the following foods should the nurse recommend? (Select all that apply)

A Ribeye steak ✗ — high fat
B Oatmeal ✓ — low fat
C Ice cream ✗ — high fat
D Canned peaches ✓ — low fat
E Pretzels ✓ — low fat

🌾

Celiac Disease — Gluten-Free for Life ⚡

Autoimmune · Inherited · Chronic

Gluten-Free Diet for Life

Gluten (wheat, barley, rye) → immune response → damages intestinal villi → malabsorption. Nutrition IS the only treatment.

⚡ Strict adherence heals intestinal damage over time

✓ Safe Foods

rice corn potatoes milk & cheese eggs fresh meats & fish dried beans fruits & vegetables

Collaborate with dietitian. "Gluten-free" labeled products often cost more.

❌ Avoid — Gluten Sources

wheat barley rye

Hidden Sources ⚡

Gravy mixes, sauces, cold cuts, soups
Non-food: lipstick, communion wafers, vitamin supplements
Read ALL labels on processed products

Manifestations ⚡

Diarrhea, bloating, fatigue
Anemia, malnutrition, osteoporosis (↓ intestinal absorption)
Dermatitis herpetiformis (skin rash) — systemic manifestation
Headache, infertility

Monitor For ⚡

Bleeding/bruising → inadequate vitamin K
Anemias → iron, folate, vitamin B12
Osteoporosis complications

📝 NCLEX Practice

A nurse is instructing a client who has celiac disease about foods to avoid. Which of the following foods should the nurse include?

A Potatoes ✗ — naturally gluten-free
B Graham crackers ✓ — made with wheat flour, contains gluten
C Wild rice ✗ — naturally gluten-free
D Canned pears ✗ — gluten-free

⚡

Exam High-Yield Summary

Fiber & Symptoms

High fiber requirements

Females: 25 g/day · Males: 38 g/day ⚡

Low-fiber = short-term only

Used for diarrhea or malabsorption. Slows transit time. Not for long-term use.

Constipation: preferred Tx

↑ fiber + ≥64 oz fluid/day. Avoid chronic laxative use.

Diarrhea: key electrolyte losses

K⁺, Na⁺, and fluid. Liberal fluid intake. Short-term low-fiber diet.

Coffee-ground emesis

= blood. Pale green = bile. Assess emesis appearance always.

Dysphagia: priority actions

High-Fowler's (aspiration risk). Refer to speech therapist. Pills with ≥8 oz fluid. Avoid thin liquids + sticky foods.

Dysphagia: dry mouth

Dry mouth contributes to dysphagia — evaluate medications for this adverse effect.

Dysphagia: adaptive devices

Allow adequate time · adaptive eating devices · small bites. Nutritional supplements if intake inadequate.

Dumping Syndrome

Dumping: early vs late

Early (10–20 min): vasomotor — tachycardia, hypotension, diaphoresis, diarrhea. Late (1–3 hr): hypoglycemia symptoms.

Dumping: key diet rules

Small frequent meals · protein & fat at each meal · no concentrated sugars · no lactose · liquids ≥30 min after meals · lie down after eating.

GERD & Gastritis

GERD manifestations

Heartburn, retrosternal burning, regurgitation, hoarseness. Can mimic MI ⚡

GERD: LES relaxers = avoid

Fatty foods, caffeine, chocolate, alcohol, nicotine, peppermint/spearmint.

Gastritis manifestations

Abdominal pain, nausea, hiccupping, heartburn, belching, sour taste, hematemesis.

Gastritis: strong acid/alkali

Do NOT lavage or induce emesis → risk of perforation & esophageal damage. Dilute and neutralize.

Gastritis: acute recovery + diet

Typically 1 day (up to 2–3). Eat a bland diet when tolerated. IV fluids if persists.

Gastritis: vitamin to monitor

Vitamin B12 deficiency.

PUD & Lactose Intolerance

PUD: H. pylori treatment

Triple therapy (2 antibiotics + acid-reducing med) × 10–14 days.

PUD expected findings

Anemia · tarry stools (melena) · epigastric pain · sour taste · urea in breath. NOT steatorrhea.

Lactose intolerance: monitor

Vitamin D + calcium deficiency. Yogurt/aged cheeses better tolerated. Ask about lactase enzyme supplement.

IBD · Diverticular · Ostomy

IBD exacerbation diet

Low-residue, high-protein, high-calorie. Enteral nutrition preferred over PN.

Diverticulosis location

Pouches anywhere in colon, most often in the sigmoid colon.

Diverticulitis: treatment

Antibiotics, anticholinergics, analgesics. Severe: IV therapy, opioid analgesics. Surgery for complications (peritonitis, abscess, obstruction).

Diverticulitis: acute diet

Clear liquids until inflammation resolves → then high-fiber, low-fat.

Ostomy: definition

Ileostomy = opening from small intestine. Colostomy = opening from colon.

Ostomy: primary concern

Fluid & electrolyte maintenance. Goal: 64–80 oz/day. Colon absorbs K⁺, Na⁺, water.

Ostomy: foods to avoid

Gas: beans, eggs, soda. Blockage: nuts, raw carrots, popcorn. Odor: eggs, fish, garlic.

Pancreatitis & Liver Disease

Pancreatitis acute: NPO rule

NPO + NG tube suction → reduce pancreatic stimulation. TPN until oral intake resumes.

Pancreatitis chronic: origin

Can result from acute pancreatitis that does not resolve.

Pancreatitis chronic: diet

Low-fat, high-protein, high-carbohydrate + vitamins C & B-complex.

Liver disease: caloric needs

May need to be increased based on stage of disease, weight, and health status.

Liver disease: key vitamins

Multivitamins especially B, C, K. ↑ protein. Eliminate alcohol, nicotine, caffeine.

Celiac Disease

Celiac = only treatment

Strict gluten-free diet for life. Gluten = wheat, barley, rye.

Celiac: hidden gluten sources

Gravy mixes, sauces, cold cuts, soups. Non-food: lipstick, communion wafers, vitamins. Read ALL labels.

Celiac: complications to monitor

Bleeding (↓ vit K) · Anemia (iron, folate, B12) · Osteoporosis.

Chapter 15 · Nutrition

Renal Disorders

Urea = waste by-product of protein metabolism. Levels rise with kidney disease → protein monitoring is critical. Kidneys regulate blood volume, acid-base balance, blood pressure, Ca/PO₄ metabolism, and RBC production. Short-term kidney disease requires nutritional support, not restriction.

Nutrients to Monitor / Restrict (CKD)

Protein ↓ Sodium ↓ Potassium ↓ Phosphorus ↓ Fluid restriction

Kidney Functions

Blood volume regulation Waste (urea) excretion Acid-base balance BP via RAAS Ca/PO₄ metabolism RBC production (EPO)

Always refer to a registered dietitian for renal diet planning · Short-term kidney disease = nutritional support, not restriction

🫘 Overview & Assessment Renal Fundamentals 📉 CKD Stages 1–4 Predialysis 🏥 ESKD Stage 5 / Dialysis ⚠️ Acute Kidney Injury AKI 🪨 Nephrotic & Stones Nephrolithiasis

🫘

Renal Disorders — Overview & Assessment

💧

Blood Volume

primary function

🗑️

Waste Excretion

urea (protein byproduct)

⚖️

Acid-Base Balance

pH regulation

🩸

Blood Pressure

RAAS activation

🦴

Ca/PO₄ Metabolism

activates Vitamin D

🔴

RBC Production

erythropoietin

⚡

Urea = waste by-product of protein metabolism. Levels rise with kidney disease → protein monitoring is critical. Short-term kidney disease requires nutritional support, not restriction. Always refer to a registered dietitian.

CKD Stages Progression ⚡

STAGE 1

At risk

STAGE 2

Mild

STAGE 3

Moderate

STAGE 4

Severe

STAGE 5

ESKD

↑ creatinine · ↓ GFR

←── Stages 1–4: predialysis ────────────────── dialysis/transplant →

Conditions & Key Manifestations

CKD (all stages)

↑ blood creatinine · ↓ GFR
Fatigue, back pain, appetite changes

ESKD (Stage 5)

GFR < 15 mL/min · creatinine steadily rising
Fatigue, ↓ alertness, anemia, ↓ urination, headache, weight loss

Acute Kidney Injury (AKI)

Abrupt decline — trauma, sepsis, poor perfusion, medications
↓ urination, ↓ extremity sensation, lower extremity swelling, flank pain
↑ urea & nitrogenous wastes · Usually reversible

Nephrotic Syndrome

Most pronounced: edema + high proteinuria
Hypoalbuminemia, hyperlipidemia, hypercoagulation

        Kidney Stones: Sudden, intense flank pain unrelieved by position changes. Diaphoresis, N/V, hematuria. Majority are calcium oxalate. ⚡
      

General Nursing Considerations ⚡

Monitor

Daily weight = primary fluid status indicator ⚡
Urine output (catheter may be needed for accuracy)
Fluid intake — compliance with restrictions
Constipation — fluid restrictions predispose to it

Dietary Alterations Needed

Protein · calories · Na⁺ · K⁺ · PO₄ · vitamins
Restrictions depend on stage of disease
Short-term disease → support healing, not restrict
Refer to registered dietitian for individualized plan
Explain why dietary changes are necessary
Provide support for the client and family

📉

CKD Stages 1–4 (Predialysis) — Nutritional Management

💡

Goals: slow CKD progression · control blood glucose & hypertension · preserve remaining kidney function by limiting protein → ↓ phosphorus levels

Protein ⚡

0.8–1.0

g/kg/day ideal body weight

Meat — Male

5–6 oz

per day max

Meat — Female

4 oz

per day max

Dairy

½ cup

per day max

Restrict All of These ⚡

↓ Sodium ↓ Potassium ↓ Phosphorus ↓ Protein

Na⁺ restriction → control blood pressure
K⁺ restriction → prevent hyperkalemia
PO₄ restriction → slows CKD progression (↓ calcium-phosphorus deposits)
Protein restriction → ↓ kidney workload; prevents catabolism

High-Phosphorus Foods to Limit ⚡

Peanut butter · dried peas & beans · bran
Cola · chocolate · beer · some whole grains
Limit to ≤ 1 serving/day

High Biologic Value Proteins ⚡

Eggs · meats · poultry · game · fish · soy · dairy
Preferred — prevent muscle catabolism

⚠️

Avoid: high-protein sports drinks, energy drinks, meal supplements, herbal supplements (affect bleeding time and blood pressure). Vitamin/mineral supplements only when provider-recommended.

📝 NCLEX Practice

A nurse is teaching a client who has stage 2 chronic kidney disease about dietary management. Which of the following information should the nurse include?

A Restrict protein intake. ✓ — slows CKD progression and decreases kidney workload
B Maintain a high-phosphorus diet.
C Increase intake of foods high in potassium.
D Limit dairy products to 1 cup/day. — limit is ½ cup/day, not 1 cup

🏥

End-Stage Kidney Disease (ESKD / Stage 5)

⚡

ESKD = GFR < 15 mL/min with steadily rising creatinine = complete kidney failure. Requires dialysis or transplant for survival.

ESKD Diet: Low protein · Low PO₄ · Low K⁺ · Low Na⁺ · Fluid Restricted

Na⁺ 2–3 g/day

Calories 35 kcal/kg

PO₄ 700–1,200 mg/day

K⁺ & Fluids determined by labs/BP/output

Monitor K⁺ level and replace as needed. Na⁺ and fluid allowances are determined by BP, weight, electrolyte findings, and urine output. The National Renal Diet provides clients with a guided list of food choices.

Protein Needs: Pre-dialysis vs. On Dialysis ⚡

Pre-dialysis (ESKD)

0.6–1.0 g/kg/day

Restrict to ↓ kidney workload

On Dialysis ⚡

1.0–1.2 g/kg/day+

Protein & amino acids lost in dialysate → needs increase. 50% from biologic sources.

Phosphorus & Vitamin D ⚡

Phosphorus Management

High protein need → ↑ phosphorus intake (problematic)
High-PO₄ foods: milk products, beef liver, chocolate, nuts, legumes
Phosphate binders (calcium carbonate or calcium acetate) with ALL meals & snacks ⚡

Vitamin D Deficiency ⚡

Failed kidneys cannot activate Vitamin D
→ altered Ca, PO₄, Mg metabolism
Results in: hyperphosphatemia · hypocalcemia · hypermagnesemia
High-PO₄ foods also high in calcium → calcium supplements likely needed

📝 NCLEX Practice — Select All That Apply

A nurse is planning care for a client who has ESKD. Which of the following should the nurse include in the plan of care?

A Monitor the client's weight daily. ✓
B Encourage the client to comply with fluid restrictions. ✓
C Evaluate intake and output. ✓
D Instruct the client on restricting calories from carbohydrates. — carbohydrates provide needed calories; 35 kcal/kg goal
E Monitor for constipation. ✓ — fluid restrictions predispose to constipation

📝 NCLEX Practice — Select All That Apply

A nurse is teaching a client about protein needs when on dialysis. Which of the following instructions should the nurse include?

A Consume 1.0 to 1.2 g/kg/day to maintain body protein stores. ✓ — protein lost in dialysate must be replaced
B Take phosphate binders when eating protein-rich foods. ✓ — with ALL meals & snacks
C Calcium intake should be less than 800 mg/day. — calcium supplements are likely needed, not restricted
D Drink fluids that are at room temperature. — fluid intake is restricted, not simply temperature-guided
E Consume the majority of daily protein intake in the morning. — no such timing recommendation exists

⚠️

Acute Kidney Injury (AKI)

⚡

AKI = abrupt, rapid ↓ in kidney function (trauma, sepsis, poor perfusion, medications). Usually reversible. Complications: hyponatremia, hyperkalemia, hypocalcemia, hyperphosphatemia, and pulmonary edema from fluid overload.

Three Phases of AKI ⚡

1. Oliguric

↓ urine output
Fluid = daily output + 500 mL

2. Diuretic

↑ urine output
Fluid needs increase

3. Recovery

Function gradually returning

AKI Dietary Recommendations ⚡

Nutrient	Non-dialysis	On Dialysis
Calories ⚡	20–30 cal/kg/day — ALL phases of AKI
Protein	0.6 g/kg (~40 g/day)	1.0–1.2 g/kg/day or higher
Sodium	1–2 g/day	2–4 g/day
Potassium ⚡	Based on urine output & labs	60–70 mEq/day
Calcium	< 2,000 mg/day (hemodialysis or peritoneal dialysis)
Diet composition	Simple carbs, fats, oils, low-protein starches; adequate nonprotein calories to maintain weight

📝 NCLEX Practice

A nurse is teaching about diet restrictions to a client who has acute kidney injury and is on hemodialysis. Which of the following recommendations should the nurse include?

A Calorie intake of 20 to 30 cal/kg. ✓ — standard for all AKI phases to meet energy demands
B Decrease total fat intake to 45% of daily calories. — fat restriction is not the recommendation; simple carbs and fats are included
C Decrease potassium intake to 100 to 130 mEq/kg. — restriction is 60–70 mEq/day, not mEq/kg
D Limit sodium intake to 4.5 g/day. — Na⁺ on dialysis is 2–4 g/day, not 4.5 g

🪨

Nephrotic Syndrome & Nephrolithiasis (Kidney Stones)

Nephrotic Syndrome

💡

↑ protein excretion into urine → hypoalbuminemia · edema · hyperlipidemia · hypercoagulation. Prolonged loss → protein malnutrition, anemia, Vitamin D deficiency. Causes: DM, medications/chemicals, autoimmune disorders, infections.

Therapy Goals

Minimize edema · replace lost nutrients
Control hypertension · prevent muscle catabolism

Dietary Recommendations ⚡

Protein: 0.7–1.0 g/kg/day
Sodium: 2,000 mg/day (controls edema & BP)
Soy-based proteins → ↓ protein losses + ↓ blood lipids
Majority of calories from carbohydrates
Restrict cholesterol, trans fat, saturated fats
Multiple vitamin supplement (vitamins lost with protein excretion)
Vitamin D supplement as needed

Nephrolithiasis ⚡

Most Common Type

Calcium Oxalate ⚡

More influenced by oxalate level than calcium

Contributing factors: ↓ fluid · elevated urine pH · excess oxalate/Ca/uric acid
Ileostomy → ↑ risk for kidney stones ⚡
Preventive risks: excess protein, Na⁺, calcium, oxalates

Primary Intervention ⚡

↑ fluid intake to produce ≥ 2 L urine/day
Drink some fluid before bedtime (urine concentrates at night)
Cystine stones require even greater fluid intake

Stone Type: Dietary Management ⚡

💧 Calcium Oxalate Stones

Limit: animal protein · excess Na⁺ · alcohol · caffeine
Limit high-oxalate foods: spinach · rhubarb · beets · nuts · chocolate · tea · wheat bran · strawberries
Avoid megadoses of Vitamin C — ↑ oxalate excretion ⚡
Low K⁺ can contribute to calcium stone formation

🟡 Uric Acid Stones

Limit purines: lean meats · organ meats · whole grains · legumes

📝 NCLEX Practice

A nurse is completing discharge teaching about diet and fluid restrictions to a client who has a calcium oxalate-based kidney stone. Which of the following instructions should the nurse include?

A Drink at least 2 L/day. ✓ — primary intervention; produces ≥ 2 L urine/day to flush stones
B Decrease calcium intake to less than 400 mg/day. — stone formation is more influenced by oxalate than calcium; excessive calcium restriction is not recommended
C Increase intake of vitamin C supplements. — Vitamin C megadoses increase oxalate excretion, worsening stone risk
D Limit consumption of purine substances. — purines are restricted for uric acid stones, not calcium oxalate stones

⚡

Exam High-Yield Summary

Kidney primary functions

Blood volume + waste excretion. Also: acid-base balance, BP, Ca/PO₄ metabolism, RBC production (erythropoietin).

Urea = protein waste ⚡

Byproduct of protein metabolism. Rises with kidney disease → protein monitoring is critical.

CKD stages 1–4: protein ⚡

0.8–1.0 g/kg/day ideal body weight. Use high biologic value proteins.

Dairy limit (CKD stages 1–4)

½ cup/day max. Meat: 5–6 oz/day males, 4 oz/day females.

ESKD Stage 5 ⚡

GFR < 15 mL/min. Low protein, low PO₄, low K⁺, Na⁺ 2–3 g/day, fluid restricted. 35 kcal/kg to preserve body protein.

Dialysis: protein ⚡

1.0–1.2 g/kg/day+ — protein lost in dialysate. 50% from biologic sources (eggs, meat, fish, soy, dairy).

Phosphate binders ⚡

Calcium carbonate or calcium acetate — taken with ALL meals and snacks.

Vitamin D in ESKD ⚡

Cannot be activated → hyperphosphatemia, hypocalcemia, hypermagnesemia. Calcium supplements likely needed.

AKI calories ⚡

20–30 cal/kg/day in ALL phases of AKI to meet energy demands of stress.

AKI: oliguric fluid rule ⚡

Restrict to daily urine output + 500 mL. Increases in diuretic phase.

AKI K⁺ on dialysis

Restrict to 60–70 mEq/day.

Daily weight monitoring ⚡

Weight = primary fluid status indicator in all renal disorders.

Constipation risk

Fluid restrictions predispose renal clients to constipation — always monitor.

Nephrotic: protein & Na⁺

0.7–1.0 g/kg/day protein. Na⁺ 2,000 mg/day. Soy → ↓ protein loss + ↓ lipids.

Most common kidney stone ⚡

Calcium oxalate. Stone formation more influenced by oxalate level than calcium.

#1 intervention for stones ⚡

↑ fluid intake to produce ≥ 2 L urine/day. Drink before bed (urine concentrates at night).

Ileostomy → stones ⚡

Ileostomy clients have ↑ risk for kidney stones — extra fluid emphasis required.

Calcium oxalate: avoid ⚡

Spinach, rhubarb, beets, nuts, chocolate, tea, wheat bran, strawberries. Avoid Vitamin C megadoses (↑ oxalate excretion).

Uric acid stones: limit

Purines: lean meats, organ meats, whole grains, legumes.

Avoid in all renal disorders

High-protein sports drinks, energy drinks, herbal supplements (affect BP + bleeding time).

Chapter 16 · Nutrition

Diabetes Mellitus

Diabetes = impaired insulin production or function → chronic hyperglycemia. Nutrition is a cornerstone of diabetes management. Goals: blood glucose control, prevention of macro/microvascular complications, and maintaining a healthy weight.

Type 1

Autoimmune — beta cell destruction Insulin-dependent Any age (often < 30) Absolute insulin deficiency

Type 2

Insulin resistance Most common type Lifestyle-related Managed with diet / meds Often overweight / obese

BG targets: 80–130 mg/dL fasting · <180 mg/dL postprandial · HbA1c <7%

🩸 Overview & Types Type 1 vs Type 2 📊 Assessment Hypo vs Hyperglycemia 💉 Treatment 15-15 Rule & More 🥗 Nutritional Guidelines Dietary Management 👩‍⚕️ Nursing Interventions Client Education

🩸

Diabetes Mellitus — Overview & Types

⚡

Glucose

primary energy source

🔑

Insulin

unlocks glucose uptake

📈

Hyperglycemia

result of impaired insulin

🫀

Macro complications

CV + cerebrovascular

🔬

Micro complications

kidney · nerve · vision

🤰

Pregnancy

control prevents complications

Types of Diabetes ⚡

Type	Cause / Mechanism	Key Facts
Prediabetes	Glucose elevated but below DM diagnostic criteria	Lifestyle modifications can prevent progression to DM
Type 1 ⚡	Autoimmune destruction of beta cells → no insulin production. Triggered by genetics or viral infection.	Most common < 18 yrs (but can occur at any age). Requires exogenous insulin lifelong.
Type 2 ⚡	Genetic + environmental. Insulin resistance + altered insulin secretion → cells can't take up glucose.	Most common form. Managed with lifestyle, oral agents, and/or insulin.
GDM ⚡	Glucose intolerance during pregnancy (typically resolves postpartum)	↑ risk of developing Type 2 DM later in life. Monitor up to 8×/day during pregnancy.

📊

Assessment — Hypoglycemia vs Hyperglycemia

Blood Glucose Spectrum ⚡

HYPOGLYCEMIA

< 70 mg/dL

shakiness · confusion
sweating · seizure

NORMAL

70–140 mg/dL

fasting: 70–99
post-meal: < 140

ELEVATED

140–199 mg/dL

prediabetes range
post-meal

HYPERGLYCEMIA

≥ 200 mg/dL

3 P's · DKA risk
fruity breath

← dangerous low dangerous high →

Hypoglycemia ⚡ — < 70 mg/dL

Causes

Too much insulin
Inadequate food intake / skipped or delayed meals
Extra physical activity
Alcohol without food

Manifestations ⚡

Shakiness, palpitations, sweating (diaphoresis)
Mental confusion, headache, blurred vision
Lack of coordination
Seizures → coma (severe)

Hyperglycemia ⚡ — above expected range

Causes

Imbalance of food, medication, and activity
Inadequate insulin (production or resistance)
Infection, illness, stress ⚡ → ↑ blood glucose

Primary Signs ⚡

Polydipsia — excessive thirst
Polyuria — excessive urination
Polyphagia — excess hunger/eating

As it Progresses

Ketones in urine · fruity breath · Kussmaul respirations
Dehydration · headache · inability to concentrate
↓ levels of consciousness · seizure → coma

The Three P's of Hyperglycemia ⚡

💧

Polydipsia

Excessive thirst — body tries to dilute high glucose

🚽

Polyuria

Excessive urination — kidneys excrete excess glucose

🍽️

Polyphagia

Excess hunger — cells starved despite high blood glucose

Somogyi vs Dawn Phenomenon ⚡

Somogyi Phenomenon

Morning hyperglycemia in response to overnight hypoglycemia.
Prevented by: appropriate insulin dose + bedtime snack.

Dawn Phenomenon

Elevation of blood glucose around 0500–0600 due to overnight growth hormone release.
Treated by: ↑ insulin during overnight hours.

Metabolic Syndrome ⚡

⚡

Presence of ≥ 3 of the following: elevated glucose · central obesity · hyperlipidemia · hypertension · low HDL cholesterol. Increases risk for DM and cardiovascular complications.

📝 NCLEX Practice

A nurse is assessing a client who has hypoglycemia. Which of the following findings should the nurse expect?

A Fruity breath odor — sign of hyperglycemia/DKA, not hypoglycemia
B Diaphoresis ✓ — sweating is a classic catecholamine response to low blood glucose
C Ketones in urine — sign of hyperglycemia/DKA
D Polyuria — sign of hyperglycemia (one of the 3 P's)

💉

Treatment — Hypoglycemia 15-15 Rule & Hyperglycemia

Hypoglycemia: The 15-15 Rule ⚡

1

Take 15 g of a fast-acting (readily absorbable) carbohydrate immediately

2

Wait 15 minutes, then recheck blood glucose

3

If still < 70 mg/dL — repeat step 1 and recheck again

4

Once glucose stabilizes → eat carbohydrate + protein snack or small meal, depending on severity of episode and whether the next meal is > 1 hr away

15 g Fast-Acting Carbohydrate Options ⚡

Glucose tablets4 tablets (5g each)

Hard candies5–6 pieces

Fruit juice / regular soda½ cup (4 oz) ⚡

Honey or sugar1 tbsp

Hyperglycemia Actions

When to Notify Provider / Go to ED ⚡

Difficulty concentrating or altered consciousness
Seizure activity

General Action

Take medication if a dose was forgotten
Monitor blood glucose closely
Identify and address the trigger (illness, stress, dietary indiscretion)

📝 NCLEX Practice

A nurse is caring for a client who has diabetes mellitus and reports feeling shaky and weak. The client's blood glucose is 53 mg/dL. Which of the following actions should the nurse take?

A Provide subcutaneous insulin — would further lower blood glucose; contraindicated in hypoglycemia
B Offer the client 120 mL (4 oz) fruit juice ✓ — provides 15 g fast-acting carbohydrate per the 15-15 rule
C Give the client IV potassium — not indicated; no evidence of hypokalemia
D Administer IV sodium bicarbonate — treats metabolic acidosis, not hypoglycemia

🥗

Nutritional Guidelines & Dietary Management

⚡

Diet is individualized based on weight management goals, lipid patterns, glucose trends, and cultural/personal preferences. A registered dietitian works with the client on meal planning. Goal: keep blood glucose as close to normal as possible.

Macronutrient & Dietary Guidelines ⚡

Carbohydrates

Count grams ⚡

Protein

15–20% of kcal

Fiber

≥14g/1,000 cal ⚡

Sodium

≤ 2,300 mg/day

Carbs: Grains, fruits, legumes, milk preferred · limit refined/simple sugars | Fat: ↓ saturated & trans fats · PUFA from fish (2+ servings/week) · plant sterols → ↓ LDL | Protein: Meat, eggs, fish, nuts, beans, soy · reduce if kidney failure

Fiber Sources ⚡

Beans, vegetables, oats, whole grains
Improves carbohydrate metabolism, lowers cholesterol
≥ 14 g per 1,000 calories consumed

Cardiovascular Focus ⚡

CHD = frequent cause of death in DM clients
High-fiber + low saturated/trans fat + low cholesterol diet
Eliminate tobacco use

Alcohol Guidelines ⚡

Moderate intake → may ↓ CV risk
Females: ≤ 1 drink/day · Males: ≤ 2 drinks/day
Consume with a meal or immediately after a meal to prevent hypoglycemia ⚡
Alcohol does not replace food intake

Vitamins & Minerals

Requirements unchanged for DM clients
Supplements only for identified deficiencies

Sweeteners — Know the Difference ⚡

✅ Artificial (Acceptable)

Sucralose
Aspartame
Saccharin
Acesulfame potassium

⚠ Sugar Alcohols (some sugar)

Xylitol
Mannitol
Sorbitol
Less impact than natural sugars

⚡ Sucrose (Table Sugar)

Can be included in diabetic diet
Must be counted in total daily calories
Ensure antidiabetic meds cover intake

Carbohydrate Counting ⚡

        1 serving = 15 g carbohydrates. Simpler than exchange lists — does not require learning exact portion sizes. Clients choose their own carbs but are encouraged to choose a variety of types and include consistent amounts of protein and fats in the diet.
      

Common Foods = 15 g Carbs ⚡

Sandwich bread1 slice

Cooked pasta½ cup

Canned fruit in juice (not syrup)½ cup

Dried fruit¼ cup

Raw vegetables3 cups

Cooked vegetables1½ cups

Snack crackers4–6 pieces

Regular ice cream½ cup

Basic vs Advanced Counting

Basic: eat a specific # of carb servings per meal/snack
Advanced ⚡: calculate mealtime insulin dose based on grams of carbs eaten. Requires basic math skills + pre-meal glucose check for corrective dose.
Can substitute carb selections — grams must stay equal per serving
Selections vary in fat/protein content but carb grams drive the math

Food Lists (formerly Exchange Lists)

3 food groups: protein · carbohydrates · fats
Dietitian specifies # of daily exchanges per group
Goal: maintain blood glucose close to expected range ⚡

📝 NCLEX Practice — Select All That Apply

The nurse is evaluating a discussion about nonnutritive sweeteners. The nurse identifies the client understands the teaching when they select which of the following sweeteners? (Select all that apply.)

A Sucrose — this is table sugar, a nutritive sweetener; must be counted in total calories
B Aspartame ✓ — artificial nonnutritive sweetener; acceptable
C Mannitol ✓ — sugar alcohol; contains less sugar than natural sweeteners; acceptable
D Xylitol ✓ — sugar alcohol; contains less sugar than natural sweeteners; acceptable
E Sucralose ✓ — artificial nonnutritive sweetener; acceptable

📝 NCLEX Practice — Select All That Apply

The nurse is reinforcing dietary teaching with a client who has diabetes mellitus. Which of the following information should the nurse include? (Select all that apply.)

A Carbohydrate counting is vital to the meal planning approach ✓ — cornerstone of DM dietary management
B Use hydrogenated oils for cooking — hydrogenated oils contain trans fats; should be avoided to protect cardiovascular health
C Choose whole grains for fiber ✓ — whole grains improve carbohydrate metabolism and lower cholesterol
D Eat something if choosing to drink alcohol ✓ — alcohol with a meal prevents hypoglycemia ⚡
E Never estimate portion sizes, always use an exact measuring tool — carb counting focuses on grams, not rigid exact measuring; flexibility is a feature

📝 NCLEX Practice — Multiple Choice

The nurse is reviewing dietary teaching with a client who has diabetes mellitus. Which client statement indicates understanding?

A "I will avoid having snacks." — Incorrect; spacing food throughout the day with snacks is recommended
B "I can't eat anything containing sugar." — Incorrect; sucrose can be included if counted in total daily calories
C "I will eat a variety of different foods to get my daily carbohydrates." ✓ — reflects correct understanding of carb variety and counting
D "I will not eat more than 2,800 mg of sodium a day." — Incorrect; limit is 2,300 mg/day, not 2,800

👩‍⚕️

Nursing Interventions & Client Education

Nurse Teaches Client On ⚡

Self-monitoring of blood glucose — calibration, record-keeping, reporting to provider
Dietary and activity recommendations
Manifestations and treatment of hypoglycemia and hyperglycemia
Medication timing ⚡ — some are taken before meals, some with meals, others regardless of food intake; timing affects maximum therapeutic effect
Long-term complications of DM
Psychological implications · community support groups

Exercise Guidelines ⚡

At least 3 days/week for a total of 150 min
Do not sit for more than 90 min at a time ⚡
Exercise only when blood glucose is within acceptable range
Monitor glucose closely — may need to ↓ insulin dose with strenuous exercise

Weight Management (Type 2) ⚡

Priority if BMI > 25 — ↓ insulin resistance, ↑ glucose and lipid control, ↓ BP
Manage calories + exercise + lifestyle modifications

Special Populations ⚡

👧 Children

Require guardian/caregiver support, guidance, and participation
Diet must support normal growth and development
Fluctuating eating patterns and activity make management complex

👴 Older Adults

Assess for: cognitive impairment, vision/hearing changes
Altered dentition, anorexia, financial barriers
Deficits that affect nutrition or safe medication administration

🤰 Pregnant Clients

Balance blood glucose goals with pregnancy nutritional needs
Monitor glucose up to 8×/day ⚡
GDM usually resolves postpartum; ↑ lifetime Type 2 risk

✅

Strict glucose control reduces or postpones long-term complications: retinopathy, nephropathy, and neuropathy. Regular provider evaluations are essential.

⚡

Exam High-Yield Summary

Glucose & Insulin ⚡

Glucose = primary energy source. Insulin is required for glucose cellular uptake. DM impairs production/use of insulin → hyperglycemia.

Type 1 vs Type 2 ⚡

Type 1: autoimmune, beta cell destruction, no insulin. Type 2: insulin resistance + altered secretion. Both: genetic component.

GDM ⚡

Resolves postpartum but carries ↑ lifetime risk for Type 2 DM. Blood glucose monitored up to 8×/day during pregnancy.

Hypoglycemia threshold ⚡

< 70 mg/dL. Classic signs: shakiness, diaphoresis, confusion, palpitations. Can progress to seizure/coma.

3 P's of Hyperglycemia ⚡

Polydipsia · Polyuria · Polyphagia. Primary manifestations. Later: Kussmaul respirations, fruity breath, ketones in urine.

Somogyi vs Dawn ⚡

Somogyi: morning hyperglycemia ← overnight hypoglycemia → bedtime snack. Dawn: BG ↑ at 0500–0600 ← growth hormone → ↑ overnight insulin.

Metabolic Syndrome ⚡

≥ 3 of 5: elevated glucose · central obesity · hyperlipidemia · hypertension · low HDL.

15-15 Rule ⚡

15 g fast-acting carb → wait 15 min → recheck BG. If still <70, repeat. Then add carb + protein snack if next meal >1 hr away.

15 g carb = 4 oz juice ⚡

½ cup (4 oz) regular juice or soda = 15 g. Also: 4 glucose tablets · 5–6 hard candies · 1 tbsp honey or sugar.

Carb counting: 1 serving ⚡

1 serving = 15 g carbohydrates. Count grams, not exchanges. Advanced: calculate insulin dose from grams consumed.

Sodium limit ⚡

≤ 2,300 mg/day for DM clients.

Fiber requirement ⚡

≥ 14 g per 1,000 calories. Sources: beans, vegetables, oats, whole grains. Improves CHO metabolism + lowers cholesterol.

Protein recommendation

15–20% of total caloric intake. Reduce protein if kidney failure is present.

Alcohol rule ⚡

Must be consumed with a meal to prevent hypoglycemia. Females ≤1/day · Males ≤2/day. Never replaces food.

Acceptable sweeteners ⚡

Sucralose, aspartame, saccharin, acesulfame K — all acceptable. Sugar alcohols (xylitol, mannitol, sorbitol) contain less sugar. Sucrose: must be counted in total calories.

Fat guidelines ⚡

↓ saturated & trans fats. Polyunsaturated fatty acids from fish (≥2 servings/week). Plant sterols/stanols → ↓ LDL.

Exercise guidelines ⚡

≥ 150 min/week spread over ≥ 3 days. Do not sit > 90 min at a time. Exercise within acceptable BG range.

Type 2 weight management ⚡

BMI > 25 → weight loss priority. ↓ insulin resistance · ↑ glucose + lipid control · ↓ BP.

Self-monitoring glucose ⚡

Strict control reduces/postpones retinopathy, nephropathy, neuropathy. Teach calibration + record-keeping + reporting.

DM complications ⚡

Macrovascular: CV + cerebrovascular disease. Microvascular: kidney · nerve · vision problems.

Chapter 17 · Nutrition

Cancer & Immunosuppression

Malnutrition is a major cause of morbidity and mortality in both cancer and HIV/AIDS. Both conditions increase metabolic demands while simultaneously decreasing intake through physical symptoms, treatment side effects, and psychological factors.

Cancer Disrupts

Chewing & swallowing Taste & appetite Digestion & absorption Glucose metabolism Anorexia + ↑ metabolism

HIV / Immunosuppression Disrupts

↑ Metabolic demands Fat storage (lipodystrophy) Anorexia / nausea / diarrhea Depression / dementia

Goals: prevent muscle loss · maintain weight · minimize complications · ↑ QOL · enhance treatment effectiveness

🧬 Overview Cancer & Immunosuppression ⚠️ Risk Factors Cancer & HIV 🥦 Preventative Nutrition Reduce Risk 🎗️ Therapeutic Nutrition During Treatment 🔴 HIV/AIDS Immunosuppression 🩹 Complication Management Client Education

🧬

Cancer & Immunosuppression Disorders

⚡

Malnutrition

major cause of morbidity & mortality in both

⚡

Wasting

protein-calorie malnutrition common in both

🎯

Goals

prevent muscle loss · maintain weight · ↑ QOL

🧪

Labs ⚡

prealbumin · albumin · ferritin · transferrin

💊

Lipodystrophy

HIV meds → fat redistribution

How Disease Disrupts Nutrition ⚡

Cancer Disrupts...

Chewing, swallowing, taste, appetite
Digestion, nutrient absorption, satiety
Glucose use and stool formation (type-dependent)
Treatment side effects compound all of the above
Anorexia + ↑ metabolism + negative nitrogen balance

HIV/Immunosuppression Disrupts...

↑ metabolic demands from inflammation & immune response
Fat storage & metabolism (medication effects)
Anorexia, nausea, vomiting, diarrhea (physical)
Depression, dementia (psychological)
Lipodystrophy — face/extremity fat loss; deposits in liver & muscles

Goals of Nutritional Therapy

Minimize nutritional complications Improve nutritional status Prevent muscle wasting Maintain weight Promote healing Reduce adverse effects ↓ Morbidity & Mortality Enhance QOL & treatment effectiveness

Assessment / Data Collection

Current illness & presence of other diagnoses
Nutritional habits, food preferences, restrictions
Food allergies
Height, weight, BMI, weight trends

Lab Tests ⚡

Prealbumin — most sensitive short-term marker
Albumin — overall nutritional status
Ferritin — iron stores
Transferrin — iron transport protein

⚠️

Risk Factors

Cancer Risk Factors

Obesity — ↑ estrogen/progesterone → stimulates cell growth ⚡
Excessive fat intake · sedentary lifestyle
Processed meats, red meats, refined grains
Excessive alcohol intake
Family history · cigarette smoking

⚡ Excess body fat → ↑ estrogen & progesterone → growth of breast, gallbladder, colon, prostate, uterine, kidney cancers

Immunosuppression Risk Factors

Unprotected sex (HIV transmission)
Contaminated needle use (HIV)
Immunosuppressive medications — cytotoxic agents, corticosteroids, DMARDs
History of radiation treatment
Congenital immune deficiencies

🥦

Cancer — Preventative Nutrition

25–38g

dietary fiber / day ⚡

≥2.5 cups

fruits & veg / day ⚡

Eat More of These ⚡

🟠 Dark green, red & orange veg — Vitamin A 🍊 Citrus fruits — Vitamin C 🥦 Cruciferous veg — broccoli, cauliflower, cabbage 🌾 Whole grains (not refined or processed) 🐟 Fish & olive oil — poly/monounsaturated fats 🫘 High-fiber foods — ↓ colon cancer risk

Avoid / Limit These ⚡

🥩 Smoked, pickled, charcoal-grilled meats 🌭 Nitrate-containing processed meats — possibly carcinogenic 🍺 Alcohol — linked to many types of cancer 🧈 Saturated & trans fats 🍞 Refined grains & added sugars 🥓 Red meats & processed meats

ℹ️ Low-fiber + high-fat diets are linked to lung, esophageal, pancreatic, oral, cervical, kidney, bladder, liver, and stomach cancers. Poly/monounsaturated fats (fish, olive oil) may lower risk.

📝 NCLEX · SATA

A nurse is planning a community presentation on nutritional guidelines for cancer prevention. Which of the following instructions should the nurse include? (Select all that apply)

A Increase intake of foods high in vitamin A
B Consume cruciferous vegetables
C Increase intake of red meats
D Consume oils high in saturated fat
E Consume whole grains

Correct: A, B, E. Vitamin A foods (dark vegetables), cruciferous vegetables, and whole grains all reduce cancer risk. Red meats (C) and saturated fats (D) are associated with increased cancer risk and should be limited.

🎗️

Cancer — Therapeutic Nutrition

⚡ Cancer causes anorexia + ↑ metabolism + negative nitrogen balance — systemic effects lead to poor intake, increased nutrient/energy needs, and catabolism of body tissues.

Caloric & Protein Targets ⚡

🎗️ Cancer

Calories 25–35 kcal/kg/day

Protein 1.0–2.5 g/kg/day

Vitamins/Minerals individualized per client needs

🔴 HIV/AIDS

Calories 37–55 kcal/kg/day

Protein 1.2–2.0 g/kg/day

Multivitamin 100% DV (unless specific deficiency)

How to Boost Protein & Calories in Meals ⚡

Dairy Enhancements

Substitute whole milk for water in recipes
Add milk, cheese, yogurt, or ice cream to dishes
Use yogurt as a topping for fruit

Protein Fortification

Peanut butter as spread for fruits
Dip meats in eggs, milk, and breadcrumbs before cooking
High-protein/calorie supplements as between-meal snacks or meal replacements when necessary

✅ Eat more on "good days" when feeling better. Use nutritional supplements high in protein/calories as snacks. Use as a meal replacement when necessary.

        ⚡ Dysphagia (Swallowing Difficulty): Use semisolid, thickened foods. Instruct client to sit upright and tilt head forward when swallowing.
      

🔴

HIV/AIDS — Nutritional Management

HIV-Associated Wasting ⚡

⚡ Wasting Criteria

Unintentional weight loss of ≥10% + at least ONE of: chronic diarrhea · chronic weakness · fever — for ≥30 days

📝 NCLEX · MC

A nurse is collecting data from a client who has HIV. Which of the following findings is a manifestation of HIV-associated muscle wasting?

A Weight gain of 10%
B Report of constipation
C Fever for 30 days
D Stomatitis

C is correct. HIV wasting requires ≥10% unintentional weight LOSS (not gain) PLUS at least one of: diarrhea, chronic weakness, or fever — lasting ≥30 days. Constipation and stomatitis are not criteria for HIV wasting.

Key Nutrition Issues in HIV/AIDS

Clinical Findings

Rapid weight loss · food aversions · fad diets
GI problems (diarrhea, nausea, vomiting)
Inadequate intake + increased nutrient needs
Wasting & fever → ↑ susceptibility to secondary infections
Diarrhea & malabsorption — prominent concerns ⚡

Lipodystrophy ⚡ (HIV Meds)

Fat LOST from

face & extremities (subcutaneous)

↓ leads to

Fat DEPOSITED in

liver & skeletal muscles

↓ causes

Downstream Effects

Insulin resistance · altered glucose tolerance · hyperlipidemia

Therapeutic Plan ⚡

Calories (HIV) ⚡

37–55 kcal/kg

Higher than cancer due to wasting + immune demands

Protein (HIV) ⚡

1.2–2.0 g/kg/day

High-protein diet. Amount varies with disease severity.

Vitamins

100% DV

Multivitamin meeting 100% DV is sufficient unless a specific deficiency is identified

Fluids ⚡

Liberal

Critical — liberal fluid intake to prevent dehydration, especially with diarrhea

✅ Use enteral feedings if client cannot consume sufficient nutrients. Client education: consume small, frequent meals — high-protein, high-calorie, nutrient-dense.

Food Safety for Immunosuppressed Clients ⚡

⚠️ Bacterial risk from: raw fruits & vegetables and undercooked meat, poultry, or eggs. Wash all produce. Cook foods thoroughly. Refrigerate perishables as soon as possible.

Nursing Interventions — Immunosuppression

Nursing Actions

Monitor effectiveness of nutrition — weight, BMI, laboratory findings (prealbumin, albumin, ferritin, transferrin)
Assist client to set realistic goals for nutrition and food consumption
Instruct client on strategies to manage adverse effects of treatment

Make food choices based on:

Nutrition recommendations (individualized plan)
Client preferences and tolerances
Treatment schedule and symptom patterns

🩹

Complication Management — Client Education

😔

Early Satiety & Anorexia

Small, high-protein/calorie foods
Eat in the morning when appetite is best ⚡
Avoid food odors
Don't fill up on low-calorie fillers (broth, high-roughage foods)
Eat cool or room-temperature foods

👄

Mouth Ulcers & Stomatitis ⚡

Soft toothbrush after eating & at bedtime
No alcohol-based mouthwash ⚡
Avoid acidic, spicy, dry, or coarse foods ⚡
Cold or room-temperature foods
Cut food into small bites · try straws
Replace meals with high-calorie/protein drinks
Well-fitting dentures; soft, tender, moistened foods with gravies/mild sauces

😴

Fatigue

Large, calorie-dense breakfast when energy is highest ⚡
Eat easy-to-prepare foods — conserve energy
Use a meal delivery service

👅

Taste Alterations & Thick Saliva

Try tart foods (citrus juices)
Small, frequent meals
Sauces & seasonings for added flavor
Use plastic utensils — reduces metallic taste ⚡
Suck on mints/candy or chew gum to clear bad taste
Sweeten meats with apple or cranberry sauce

🤢

Nausea & Vomiting ⚡

Cold or room-temperature foods
High-carbohydrate, low-fat foods
Avoid fried foods
Do NOT eat prior to chemo/radiation ⚡
Take prescribed antiemetics
Sit upright for 1 hr after meals ⚡
Sip fluids throughout day; try ginger ale or ginger tea

💧

Diarrhea ⚡

Adequate liquids throughout day to replace losses ⚡
Avoid high-roughage foods
Foods high in pectin ⚡ — increases stool bulk, lengthens colon transit time
Limit caffeine, hot/cold drinks, and fatty foods

🚫

Food Aversions

Eat foods that are well-tolerated and liked prior to treatments (chemo/radiation) ⚡
Avoid serving favorite foods on treatment days — prevents conditioned aversion

📝 NCLEX · MC

A nurse is teaching a client undergoing cancer treatment about managing stomatitis. Which statement by the client indicates understanding of the teaching?

A "I will try chewing larger pieces of food."
B "I will avoid toasting my bread."
C "I will consume more food in the morning."
D "I will add more citrus foods to my diet."

B is correct. Toasted bread is dry and coarse — stomatitis clients must avoid acidic, spicy, dry, or coarse foods. A (large bites) worsens mouth pain. C (eating more in the morning) applies to anorexia/fatigue, not stomatitis. D (citrus) is acidic and contraindicated in stomatitis.

⚡

Exam High-Yield Summary

Shared concern ⚡

Both cancer & HIV/AIDS → protein-calorie malnutrition + wasting. A major cause of morbidity & mortality. Plans must be individualized.

Lab markers ⚡

Prealbumin, albumin, ferritin, transferrin. Prealbumin = most sensitive short-term nutritional marker.

Cancer calories ⚡

25–35 kcal/kg/day. Protein: 1.0–2.5 g/kg/day. Based on metabolism, activity, disease state, and absorption ability.

HIV/AIDS calories ⚡

37–55 kcal/kg/day (higher than cancer). Protein: 1.2–2.0 g/kg/day. Multivitamin: 100% DV unless specific deficiency identified.

HIV wasting criteria ⚡

≥10% unintentional weight LOSS + ≥1 of: diarrhea · chronic weakness · fever — for ≥30 days.

Lipodystrophy ⚡

HIV meds → fat lost from face & extremities; deposited in liver & skeletal muscle → insulin resistance · altered glucose tolerance · hyperlipidemia.

Cancer & obesity ⚡

Excess fat → ↑ estrogen & progesterone → growth of breast, gallbladder, colon, prostate, uterine, and kidney cancers.

Cancer prevention ⚡

≥2.5 cups fruits/veg/day · 25–38g fiber/day · whole grains · Vit A (dark veg) · Vit C (citrus) · cruciferous veg · poly/monounsaturated fats (fish, olive oil).

Cancer prevention: avoid ⚡

Smoked/pickled/grilled meats · nitrates · alcohol · saturated & trans fats · refined grains & sugars · red & processed meats.

Dysphagia care ⚡

Semisolid, thickened foods. Client sits upright, tilts head forward when swallowing.

Stomatitis: key avoids ⚡

Acidic · spicy · dry · coarse foods. No alcohol-based mouthwash. No large bites. Use straws, soft toothbrush, room-temp foods.

Nausea: key rules ⚡

Do NOT eat before chemo/radiation. Sit upright ≥1 hr after meals. Cold/room-temp foods. Ginger ale/tea. Take antiemetics as prescribed.

Diarrhea: pectin ⚡

High-pectin foods bulk the stool and lengthen colon transit time. Avoid roughage, caffeine, hot/cold drinks, and fatty foods.

Anorexia tip ⚡

Eat in the morning when appetite is best. Avoid low-calorie fillers (broth, roughage). Small, high-protein/calorie snacks throughout the day.

Taste alterations ⚡

Plastic utensils reduce metallic taste. Tart/citrus foods, sauces/seasonings, mints/gum, apple or cranberry sauce to sweeten meats.

Food safety — immunosuppressed ⚡

Wash all produce. Cook meats/poultry/eggs thoroughly. Refrigerate perishables promptly. Avoid raw/undercooked foods — bacterial risk.

Protein/calorie boosting ⚡

Whole milk for water in recipes · add cheese/yogurt/ice cream · peanut butter on fruits · dip meats in egg + milk + breadcrumbs · supplements as between-meal snacks.