Nutrition and Diet Therapy

["226 PART III NUTRITION AND DIET THERAPY FOR ADULTS MODIFYING SEASONINGS 2. Give an example and the rationale for decreasing a nutrient in the diet. Seasonings are usually adjusted to individual tolerances, but a few are not advised in certain diseases. Salt restric- 3. Name three situations where diet supplementa- tion is prescribed for various conditions, including tion would be needed: sodium retention in the body, edema, ascites, and others. a. Whatever the modification, the goal of diet therapy remains the same: to restore and maintain good nutri- b. tional status. Nutrient supplements of vitamins, miner- als, and high-protein formulas are needed for highly c. restricted diets, anorexia, and impaired absorption and metabolism. 4. Explain how a diet can be individualized and still provide the correct modifications. A planned diet is successful only when it is eaten. The diet must be individualized to take into account the psy- ACTIVITY 4: chological and cultural factors that influence food ac- ceptance. In addition, the food must be attractively Alterations in Feeding Methods presented, palatable, and safe. The patient\u2019s environment at mealtime is also an important factor, as is the attitude It is estimated that protein energy malnutrition (PEM) is of the individuals serving the meals. present in 25%\u201350% of all medical surgical patients. The most common reason is exhausted nutrient reserves NURSING IMPLICATIONS when entering a facility. In addition, hospitalized patients who were previously stable can experience malnutrition 1. Recognize the unique position of the nurse in pro- in as little as two weeks. moting dietary compliance to modified diets: a. Assess nutritional status. Of particular significance are those patients at high b. Observe and document nutritional intake. risk for whom oral feedings are inadequate, such as being c. Evaluate response to diet therapy. on five days or more of clear liquids. Other high-risk pa- d. Teach or support the diet teaching and diet ther- tients who may require alternate feeding methods are apy ordered for the client. those with eating disorders, malabsorption syndromes, cancer, or a hypermetabolic condition such as burns. 2. Be aware that diet therapy, alone or in conjunction Whenever a patient cannot or will not eat, for any one of with other treatment, may play an important role in myriad reasons, an alternate method of feeding should be the prevention and treatment of disease by: employed. a. lessening severity of symptoms. b. decreasing need for medication. There are two parenteral or intravenous feeding meth- c. delaying onset of disease or delaying progression. ods. One method injects nutrients into the blood via a pe- d. increasing resistance to diseases or speeding ripheral vein (for example, a vein in the arm, near the recovery. surface). The other method injects nutrients into the blood via a central vein (those deeper into the central 3. provide the client and caregivers with nutrition infor- portion of the system; for example, the subclavian lo- mation, encouragement, education, and referrals as cated under the collarbone). needed. SPECIAL ENTERAL FEEDINGS 4. Recognize the social, cultural, and psychological as- (TUBE FEEDINGS) pects that influence nutritional status of hospitalized clients and intervene when needed. Enteral (tube) feedings are used only for patients who have enough functioning of the GI tract to digest and ab- 5. Continue to update knowledge regarding diet therapy. sorb their food. They are also used when the patient can- not eat enough regular food to promote healing, even PROGRESS CHECK ON ACTIVITY 3 though the GI tract is functional. Frequently, an oral sup- plement has been added to the diet (such as Ensure from FILL-IN Ross Laboratories) before tube feedings are considered, but it has been insufficient. After careful assessment of 1. What are the four basic modifications made in a diet? a. b. c. d.","CHAPTER 14 OVERVIEW OF THERAPEUTIC NUTRITION 227 nutritional status, tube feedings are added as an addi- market. They are used for routine feedings for patients tional supplement. Tube feedings must be provided that who need them as prescribed by physicians. Each prod- meet the individual patient\u2019s needs. Many new commer- uct is made of regular foods and individual nutrients. cial modular formulas are available. Defined enteral formulas contain specific nutrients A tube feeding is a nutritionally adequate diet of liqui- or modified nutrients, including simple and complex car- fied foods administered through a tube into the stom- bohydrates, amino acids, peptides, fatty acids, triglyc- ach or duodenum. These foods are commercially erides, and so on. There are about 15 or so in the market. available. From the standpoint of accuracy in measur- ing, sanitation, and convenience, most hospitals prefer Disease-specific enteral formulas are available for five commercial mixtures. These mixtures can be milk-based or more clinical disorders such as those of the kidney, formulas, lactose-free formulas, meat-based formulas, liver, pancreas (diabetes), lung, and the immune system. and residue-free formulas. Tube feedings usually furnish one calorie per milliliter. A 24-hour intake of three liters There are four companies that manufacture most of would furnish 3000 calories. the products although some smaller companies manufac- ture one or two of these formulas. Table 14-6 describes Enteral feedings have several advantages, including the type of enteral formulas and the companies manufac- the following: turing them. 1. It is more economical to feed enterally than intra- PARENTERAL FEEDINGS VIA venously, considering equipment, time, and foods PERIPHERAL VEIN used. Nutrient fluids entering a peripheral vein can be saline 2. It is safer to feed enterally than intravenously. The with 5%\u201310% dextrose (clinically represented by D5W risk of fluid and electrolyte imbalances and infection or D10W); amino acids; electrolytes; vitamins; and med- is less than for intravenous feedings. ications. Intravenous fluids may be either isotonic, hypo- tonic, or hypertonic. Both hypotonic and hypertonic Some disadvantages of enteral feedings include the solutions create a shift in body fluids. Hypotonic solu- following: tions draw fluid from the blood vessels into the intersti- tial spaces and cells. Hypertonic solutions create the 1. Nutritional inadequacy for certain patients (not opposite effect; they draw fluids out of interstitial spaces enough protein and calories) into the blood. 2. Overnutrition for certain patients (excess calories and When enteral feedings are contraindicated, feeding by formula) a peripheral vein is often used. This type of feeding is safer than feeding by a central vein, but it fails to provide 3. Diarrhea or constipation adequate calories and other nutrients for repair and re- 4. Vomiting placement of losses. The dangers of overloading with 5. Problems of preparation and safety. Bacterial contam- fluid in order to meet caloric needs are inherent in using solutions via the peripheral vein. Some examples of nu- ination can be a factor if preparation is not carefully trient quantities in these solutions will illustrate the clin- controlled. ical problem. For example, 2500 cc of D5W provides 425 6. Home-prepared tube feedings are not recommended. calories and 0 g protein; 200 cc of 3.5% amino acid so- Prepared formulas are preferred over the use of home- lution provides 70 g protein, 280 calories, but 0 g carbo- blenderized diets, which can clog tubes, are not ster- hydrate to spare protein. A 10% fat emulsion (intralipids ile, and in which nutrient composition is not well may be used via the peripheral vein) furnishes 1 calorie defined. per 1 cc emulsion, contains no amino acids, and is not compatible with any other added nutrients. It elevates Depending on the patient and the circumstances, serum cholesterol levels and is questionable in its ability some or all of the above problems can be avoided or to promote nitrogen balance by sparing protein. remedied. PARENTERAL FEEDING VIA CENTRAL VEIN There is an increasing movement back toward use of (TOTAL PARENTERAL NUTRITION [TPN]) more enteral feedings. Recent studies indicate that the intestinal bacteria will translocate to other areas, become When a patient is severely depleted nutritionally or if the pathogenic, and create sepsis when they are not fed. GI tract cannot be used, parenteral feeding via a catheter inserted into a central vein (usually the subclavian to the Enteral feedings depend on enteral formulas. There superior vena cava) can provide adequate nutrition. The are three categories of commercial enteral formulas: solution for TPN is a sterile mixture of glucose, amino acids, and micronutrients. The intralipids are not given 1. Standard, intact, or routine enteral formulas 2. Elemental or defined enteral formulas 3. Disease-specific enteral formulas Standard enteral formulas have existed for many years with a few commercial products coming to the market 30 years ago. Now, there are more than 35 products in the","TABLE 14-6 Manufacturers and Enteral Formulas 228 PART III NUTRITION AND DIET THERAPY FOR ADULTS Manu- Standard Elemental Formulas for Formulas for Formulas for Formulas for Formulas for Immune system facturers formulas formulas kidney disorder liver disorder Diabetes lung disorders: lung disorders: disorder Nutren\u00ae [COPD [ARDS Nestle Probalance\u00ae F.A.A.\u00ae Nutren\u00ae Glytrol\u00ae Formulas] Formulas] Crucial\u00ae Renal Hepatic Renalcal\u00ae Nutren\u00ae Pulmonary NovaSource\u00ae Nutren\u00ae 1.0 Peptamen\u00ae Renal Nutren\u00ae 1.0 Peptamen\u00ae Nepro\u00ae with fiber with FOS Suplena\u00ae Nutren\u00ae 1.5 Peptamen\u00ae 1.5 Hepatic-Aid\u00ae II Nutren\u00ae 1.5 fiber Peptamen\u00ae VHP Replete\u00ae Replete\u00ae with fiber Norvatis Compleat\u00ae Peptinox\u00ae Diabetisource\u00ae NovaSource\u00ae Impact\u00ae AC Pulmonary Fibersource\u00ae Peptinox\u00ae DT Impact\u00ae 1.5 Fibersource\u00ae HN Subdue\u00ae Rosource\u00ae Diabetic Impact\u00ae Gtutamine Isocal\u00ae Subdue\u00ae plus Impact\u00ae with Fiber Isocal\u00ae HN Tolerex\u00ae Isosource\u00ae Vivonex\u00ae plus Isosource\u00ae HN Vivonex\u00ae RTF Isosource\u00ae VHN Vivonex\u00ae TEN Novasource\u00ae 2.0 Traumacal\u00ae Ultracal\u00ae Ross Jevity\u00ae Optimental\u00ae Glucema\u00ae Select Pulmocare\u00ae Oxepa\u00ae Perative\u00ae Products Pivot\u00ae 1.5 Jevity\u00ae 1.2 Vital\u00ae HN Jevity\u00ae 1.5 Osmolite\u00ae Osmolite\u00ae 1 cal Osmolite\u00ae 1.2 cal Osmolite\u00ae 1.5 cal Promote\u00ae Promote\u00ae with fiber Twocal\u00ae HN Hormol Healthlabs","CHAPTER 14 OVERVIEW OF THERAPEUTIC NUTRITION 229 in this solution and may be administered via a peripheral c. fluid overload vein. The amounts of micronutrients added are based on d. all of the above the individual\u2019s blood chemistry. Multivitamin prepara- tions can be added to the TPN solutions, except for B12, 2. The solution used for TPN consists of: K, or folic acid, which are given separately. a. glucose, amino acids, and micronutrients. TPN has many advantages. It can be used for long pe- b. glucose, amino acids, and fatty acids. riods of time to meet the individual body\u2019s total nutri- c. 10% dextrose in saline and vitamins. tional needs. The solutions can be adjusted according to d. commercial hydrolyzed mixtures. individual needs by increasing or decreasing any or all of the nutrients. 3. Which of the following vitamins would need to be given separately instead of added to a formula? TPN also has many disadvantages. The solutions are very expensive, and they support rapid growth of bacte- a. thiamin, niacin, and riboflavin ria and fungi. The rate of infusion must be adhered to b. the fat-soluble vitamins rigidly, around the clock. Dressing changes are done c. B12, K, and folic acid using sterile technique. Careful monitoring of the pa- d. none of the above tient\u2019s response and corrective measures when needed are mandatory for safe administration of these solutions. TRUE\/FALSE NURSING IMPLICATIONS Circle T for True and F for False. The responsibilities or implications for nutritional sup- 4. T F Nutrient fluids via peripheral vein are as ade- port by the nursing staff are varied and many. A brief quate for long-term feedings as those via cen- summary of some of these implications follows: tral vein. 1. Discard all unused, cloudy, or sedimented fluids. 5. T F Tube feedings are always commercial prepara- 2. Do not add drugs and other mixtures to a solution tions. containing protein. 6. T F Parenteral feedings will sustain the fluid and 3. Refrigerate solutions until they are used. electrolyte balance of a postoperative patient. 4. Be aware that dates should be on tube feedings, and 7. T F TPN can be used for long periods of time and that they should not be given past 24 hours of date. still maintain cell integrity. 5. Be alert for signs of gas, regurgitation, cramping, 8. T F Enteral feedings are more likely to become and diarrhea, and be prepared to intervene. contaminated than parenteral ones. 6. Take necessary precautions when using nutrient so- MATCHING lutions because they are excellent sources for bacte- rial growth. Match the statement to the appropriate fluid. 7. Be especially alert for signs of hypo- or hyper- glycemia when TPN is used and intervene if neces- 9. Draws fluid from interstitial a. isotonic fluid sary. spaces into the blood. b. hypotonic fluid 8. Assist the patient in adjusting to an alternate feed- c. hypertonic fluid ing method. Many patients experience stress due to 10. Does not create a fluid shift. fear and concern of unfamiliar feeding methods. 11. Draws fluid from blood into 9. Encourage and practice good oral hygiene measures with the patient, even though he or she is not eating interstitial spaces. by mouth. 10. Encourage early ambulation, which makes use of FILL-IN the muscles and increases the use of calcium and protein. Physical activity also raises morale. 12. Define tube feedings. PROGRESS CHECK ON ACTIVITY 4 13. List two advantages and two disadvantages of en- teral feeding. MULTIPLE CHOICE a. Circle the letter of the correct answer. b. 1. Which of the following is an important concern 14. List two conditions requiring TPN. for the nurse who is providing nutrition by pe- a. ripheral vein? b. a. calorie overload b. contamination of the injection site","230 PART III NUTRITION AND DIET THERAPY FOR ADULTS 15. List three important nursing measures for a pa- Escott-Stump, S. (2002). Nutrition and Diagnosis- tient receiving TPN. Rrelated Care (5th ed.). Philadelphia: Lippincott, a. Williams and Wilkins. b. Food and Agriculture Organization. (2002). Human Vitamin and Mineral Requirements: Report of a Joint c. FAO\/WHO Expert Consultation. Rome, Italy: World Health Organization. 16. List three types of formulas used in tube feedings and describe the major difference of each from Gupta, V. B., Anitha, S., Hegde, M. L., Zecca, L., Garruto, the other. R. M., & Ravid, R., et al. (2005). Aluminium in Alz- a. heimer\u2019s disease: Are we still at a crossroad? Cellular and Molecular Life Sciences, 62(2):143\u201358. b. Higdon, J. (2003). An Evidence-Based Approach to c. Vitamins and Minerals: Health Implications and Intake Recommendations. New York: Thieme. REFERENCES Iannotti, L. L. (2006). Iron supplementation in child- Abrams, S. A. (2005). Calcium supplementation during hood: Health benefits and risks. American Journal of childhood: Long-term effects on bone mineralization. Clinical Nutrition, 84: 1261\u20131276. Nutrition Reviews, 63: 251\u2013255. Kaplan, R. J. (2006). Beverage guidance system is not Block, A., Maillet, J. O., Winkler, M. F., & Howell, W. H. evidence-based. American Journal of Clinical (2006). Issues and Choices in Clinical Nutrition and Nutrition, 84: 1248\u20131249. Practice. Philadelphia: Lippincott, Williams and Wilkins. Lane, H. W. (2002). Water and energy dietary require- ments and endocrinology of human space flight. Bogden, J. D., & Klevay, L. M. (Eds.). (2000). Clinical Nutrition, 18: 820\u2013828. Nutrition of the Essential Trace Elements and Minerals: The Guide for Health Professionals. Totowa, Lopez, M. A., & Martos, F. C. (2004). Iron availability: An NJ: Humana Press. updated review. International Journal of Food Sciences and Nutrition, 55(8): 597\u2013606. Brazin, L. R. (2006). Internet Guide to Medicinal Diets and Nutrition. New York: Haworth Information Mahan, L. K., & Escott-Stump, S. (Eds.). (2008). Krause\u2019s Press. Food and Nutrition Therapy (12th ed.). Philadelphia: Elsevier Saunders. Caballero, B., Allen, L., & Prentice, A. (Eds.). (2005). Encyclopedia of Human Nutrition (2nd ed.). Boston: Mann, J., & Truswell, S. (Eds.). (2007). Essentials of Elsevier\/Academic Press. Human Nutrition (3rd ed.). New York: Oxford Univer- sity Press. CRC. Handbook of Chemistry and Physics (85th ed.). (2004). Boca Raton, FL: CRC Press. Moore, M. C. (2005). Pocket Guide to Nutritional Assess- ment and Care (5th ed.). St. Louis, MO: Elvesier Mosby. Deen, D., & Hark, L. (2007). The Complete Guide to Nutrition in Primary Care. Malden, MA: Blackwell. Mosby\u2019s Medical, Nursing and Allied Health Dictionary. (2002). (6th ed.). St. Louis, MO: Elsevier Health Droke, E. A. (2008). Dietary fatty acids and minerals. In Sciences. Chow, C. K. (Ed.). Fatty Acids in Foods and Their Health Implications. Boca Raton, FL: CRC Press. Navarra, T. (Ed.). (2004). The Encyclopedia of Vitamins, Minerals, and Supplements (2nd ed.). New York: Facts Eckhert, C.D. (2006). Other trace elements. In Shils, M. E. on File. (Ed.). Modern Nutrition in Health and Disease (10th ed., pp. 338\u2013350). Philadelphia: Lippincott, Williams Neilsen, F. H. (2001). Other trace elements. In Bnowman, and Wilkins. B. A. & Russell, R. M. (Eds.). Present Knowledge in Nutrition (8th ed., pp. 384\u2013400). Washington, DC: ILSI Press. Otten, J. J., Pitzi Hellwig, J., & Meyers, L. D. (Eds.). (2006). Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC: National Academy Press. Papanikolaou, G., & Pantopoulos, K. (2005). Iron metab- olism and toxicity. Toxicology and Applied Pharma- cology, 202(2): 199\u2013211. Sardesai, V. M. (2003). Introduction to Clinical Nutrition (2nd ed.). New York: Marcel Dekker. Shils, M. E., & Shike, M. (Eds.). (2006). Modern Nutrition in Health and Disease (10th ed.). Philadelphia: Lippincott, Williams and Wilkins.","CHAPTER 14 OVERVIEW OF THERAPEUTIC NUTRITION 231 Water, Sanitation, and Health Protection and Human Yves, R., Mazue, A., & Durlach, J. (2001). Advances in Environment (WHO). (2005). Nutrients in Drinking Magnesium Research: Nutrition and Health. Eastleigh, Water. Geneva, Switzerland: World Health Organization. England: John Libby. Webster-Gandy, J., Madden, A., & Holdworth, M. (Eds.). (2006). Oxford Handbook of Nutrition and Dietetics. Oxford, England: Oxford University Press.","","OUTLINE 15C H A P T E R Objectives Diet Therapy for Glossary Surgical Conditions Background Information Progress Check on Background Time for completion Information Activities: 1 hour ACTIVITY 1: Pre- and Optional examination: 1\u20442 hour Postoperative Nutrition OBJECTIVES Preoperative Nutrition Postoperative Nutrition Upon completion of this chapter, the student should be able to do the Rationale for Diet Therapy following: Progress Check on Activity 1 1. Identify the physiological and psychological effects of body trauma or ACTIVITY 2: The Postoperative stress. Diet Regime 2. Contrast the outcomes of surgery in a patient with poor nutritional sta- Goals of Dietary Management Feeding the Patient tus and in a patient with good nutritional status. 3. Explain the rationale for the importance of the nutrients most needed Immediately After the Operation during the surgical experience. Dietary Management for 4. List the major nutritional problems encountered in preoperative patients Recovery Gastrointestinal Surgery: An and possible solutions to these problems. Illustration 5. Describe the diet therapy regime for the postoperative patient and ration- Nursing Implications Progress Check on Activity 2 ale for its use. References 6. Identify common foods and fluids suitable for replacing losses and promot- ing healing in the surgical patient. 7. Relate nursing interventions to the nutritional care of the surgery patient. GLOSSARY Acidosis: an accumulation of excess acid or depleted alkaline reserve (bicar- bonate content) in the blood and body tissues. It almost always occurs as part of a disease process. 233","234 PART III NUTRITION AND DIET THERAPY FOR ADULTS Ambulatory: able to walk; not confined to bed. Peripheral veins: veins away from the central portion of Calcification: process in which organic tissue becomes the system; near the surface. hardened by deposition of lime salts in the tissues. Peristalsis: the wormlike movement by which the ali- Capillary walls: the sides of the minute blood vessels (cap- mentary canal propels its contents, consisting of a wave of contractions passing along the tube. illaries). Capillaries connect the smallest arteries with the smallest veins. Plasma protein: the liquid part of the blood and lymph is Coenzymes: enzyme activators, such as vitamins, that the plasma. Plasma contains numerous chemicals and enter into a variety of body processes. protein, glucose, and fats. Protein in plasma prevents Collagen: the protein in connective tissue and bone undue leakage of fluids out of the capillaries. matrix. Colloidal osmotic pressure: the pressure that develops Prothrombin: a chemical substance in the blood that in- on either side of a membrane. The colloid does not teracts with calcium salts to produce thrombin, which pass through the membrane, so therefore keeps the clots blood. concentration of the solution approximately equal to that of circulating blood. The colloidal substance is a Subclavian vein: a large vein located under the collar- protein; therefore, when protein in the diet is depleted, bone that unites with the interior jugular and forms edema develops because the solution can then pass the innominate vein. from inside the membrane into the tissues. Connective tissue: fibrous insoluble protein that holds Superior vena cava: the principal vein draining the upper cells together; collagen represents approximately 30% portion of the body. Formed by the junction of right of body protein. and left innominate veins, it empties into the right Decubitis ulcers: inflammation, sore, or ulcer over a bony atrium of the heart. prominence (exercise, movement, good skin care, and a high-protein, high-vitamin diet are needed for BACKGROUND INFORMATION prevention). Dehiscence: splitting open; separation of all the layers of The nutritional status of the patient before, during, and a surgical wound. after surgery is important to a rapid and successful recov- Dehydration: the loss or deprivation of water from the ery. Factors affecting pre- and postoperative conditions body or tissues. are introduced below. Diuresis: increased excretion of urine. Duodenum: the first portion of the small intestine ex- Effects of Stress tending from the pylorus to the jejunum. It is about 10 inches long and both the common bile duct and All kinds of stress or trauma deplete body stores and in- pancreatic duct empty into it. terfere with ingestion, digestion, and metabolism. Injury, Edema: swelling; the body tissues contain an excess accidents, trauma, burns, cancer, illness, fever, infections, amount of tissue fluid. loss of blood and other fluids, loss of body tissues, and Enteral nutrition: fed by way of the small intestine. other conditions requiring surgery can significantly de- Evisceration: extrusion of the internal organs; disem- plete body substances in a patient. Such injuries or stress bowelment. require an increased amount of nutrients for repair. Exudate: fluid with a high content of protein and debris These problems are usually compounded by psychologi- that has escaped from blood vessels and deposited on cal stress such as anxiety, fear, and pain, which greatly in- tissues. terfere with the desire or ability to eat. Hyperglycemia: glucose in the blood elevated above the normal limit. During periods of stress there may be reduced func- Hypoglycemia: blood sugar below the normal limit. tion of the gastrointestinal (GI) tract. Muscular activity Interstitial: pertaining to or situated between parts or in is lowered in the digestive tract. This may cause abdom- the interspaces of a tissue. inal distention, gas pains, and constipation. In some a. fluid: the extracellular fluid bathing most tissues, cases, the nervous system may be stimulated by these conditions, resulting in nausea, vomiting, and diarrhea. excluding fluid in the lymph and blood vessels. Prolonged stress results in depleted liver glycogen and b. tissue: connective tissue between cells. the wasting of muscle tissue. Intravenous: within the veins. Parenteral nutrition: not fed through the alimentary Effects of Nutrition canal but rather by subcutaneous, intramuscular, in- trasternal, or intravenous injection. Good nutrition prior to surgery leads to effective wound a. via central vein: in the central portion of the healing, increases resistance to infection, shortens con- valescence, and lowers the mortality rate. system. b. via peripheral vein: near the surface. Poor nutrition prior to surgery leads to poor wound healing, dehydration, edema, excessive weight loss, decu- bitis ulcers, increased infections, potential liver damage, and a high mortality rate.","CHAPTER 15 DIET THERAPY FOR SURGICAL CONDITIONS 235 Most patients are not at optimum nutritional status cates the nutrition assessment of surgical patients via when they are admitted to a healthcare facility. If surgery laboratory and physical data in combination with a is to be performed, the patient\u2019s nutritional status must subjective global assessment (SGA). The SGA encom- be improved by an appropriate dietary regimen prior to passes food intake, maldigestion, and malabsorption surgery. This minimizes surgical risk. Unfortunately, this and is useful in determining the effects of malnutrition is not always possible due to the acute need for surgery. on organ function and body composition. Some also believe that such consideration is given low priority because of poor hospital practice, limited staffing, PROGRESS CHECK ON BACKGROUND INFORMATION lack of communication, relatively low urgency, and so on. MULTIPLE CHOICE Nutrients for the Surgical Experience Circle the letter of the correct answer. The following are nutrients considered important for per- sons undergoing surgery: 1. Effects of stress on the body include all except: 1. Protein is needed to build and repair damaged tissue. a. stimulation of the desire to eat. 2. Carbohydrate and fat are needed to spare protein and b. depletion of body tissues. c. depressed GI functioning. furnish energy. d. decreased liver glycogen. 3. Glucose is necessary to prevent acidosis and vomiting. 4. Vitamins: 2. Poor nutrition prior to surgery may result in all of the following except: a. Vitamin C is required to hasten wound healing and collagen formation. a. increased resistance to infection. b. dehydration. b. Vitamin B complex is needed to form the coen- c. edema. zymes for metabolism, especially of carbohydrates. d. liver damage. c. Vitamin K is needed to promote blood clotting. FILL-IN 5. Minerals: List four effects of good nutritional status on the out- a. Zinc is needed to aid wound healing. come of surgery. b. Iron is needed to permit hemoglobin synthesis to 3. replace blood loss. 4. Surgery Outcome 5. There is strong evidence that nutrition plays an impor- tant role in the outcomes of surgical cases. Some recent 6. clinical findings are listed below. MATCHING 1. In a National Veterans Affairs Surgical Risk Study of 87,000 noncardiac surgical cases, nutrition played an Some nutrients have been identified as being very impor- important role in surgical success. The preoperative tant in the surgical experience. Match the nutrient at the serum albumin levels, an indicator of nutritional sta- left with the letter of its major function at the right. tus, were the strongest predictors of patients who would show complications or die within 30 days. 7. Glucose a. builds and repairs tissue 8. Vitamin C b. blood clotting 2. A Veterans Affairs study found that malnourished pa- 9. Protein c. synthesis of hemoglobin tients who received postsurgical total parenteral nu- 10. B complex d. aids in wound healing trition support had fewer noninfectious complications 11. Iron than controls. and collagen formation e. prevents acidosis and 3. One study found that the number of days in the ICU and days on a ventilator were highest among those pa- vomiting tients that did not receive postoperative enteral feed- f. provides coenzymes for ing. Length of hospital stay, infectious complications, hospital costs, and antibiotic usage were highest in metabolism the study\u2019s \u201cunfed\u201d group. Match the word with its definition. 4. In a study of 300 patients undergoing major surgical procedures, malnutrition was associated with in- 12. Dehiscence a. excessive urine creased rates of morbidity and mortality. 13. Evisceration b. connective tissue 14. Collagen c. between the cells 5. A report by the National Institutes of Health, the 15. Interstitial d. splitting open American Society for Parenteral and Enteral Nutrition, 16. Diuresis e. disembowelment and the American Society for Clinical Nutrition advo-","236 PART III NUTRITION AND DIET THERAPY FOR ADULTS TRUE\/FALSE ously not recommended preoperatively. Conversely, a re- duction diet after surgery is not in the patient\u2019s best in- Circle T for True and F for False. terest when the need for all nutrients is high. If weight loss is needed, a low-calorie diet should not be instituted 17. T F Physical stress reduces functioning of all body until healing is complete. organs. Dietary considerations for an adequately nourished 18. T F Psychological stress depletes body stores. patient prior to surgery are also important. The special 19. T F If the patient is not fed orally he or she won\u2019t nutritional needs of surgical interventions should be met. The preoperative diet for these persons should be rich in get edema and ascites. carbohydrate, protein, minerals, vitamins, and fluids. 20. T F Most patients have adequate nutritional sta- This diet will assist in a rapid recovery as it promotes wound healing and decreases the risk of infections and tus prior to surgery. other complications. 21. T F The postoperative serum albumin level is the If a patient has preexisting conditions\u2014for example, strongest predictor of patients who show com- diabetes\u2014the blood sugar should be stabilized before plications or die within 30 days. surgery. Other problems such as anemia, dehydration, 22. T F The number of days in ICU and days on a venti- acidosis, or electrolyte imbalances should be corrected lator probably is the highest among patients that before the surgical procedure. did not receive postoperative enteral feeding. 23. T F Malnutrition is not related to increased rate of POSTOPERATIVE NUTRITION morbidity and mortality. 24. T F Subjective global assessment (SGA) encom- The goal of postoperative diet therapy is to replace body passes food intake, maldigestion, and malab- losses as soon as possible. Energy, protein, and ascor- sorption and is useful in determining the bic acid are major factors in achieving rapid wound effects of malnutrition on organ function and healing. Fluid replacement is another major concern. body composition. Minerals and other vitamins also play a vital role in recovery. ACTIVITY 1: The postoperative diet may be liquid, soft, or of regu- Pre- and Postoperative Nutrition lar consistency, but it must be high in calories, protein, vitamins, minerals, and fluids. PREOPERATIVE NUTRITION RATIONALE FOR DIET THERAPY The major nutritional problems in the preoperative pe- riod are undernutrition and overnutrition. Both the un- Protein dernourished and obese patients present special needs. 100\u2013200 grams of high-quality protein per day are needed: The undernourished patient, because of a lack of the major nutrients necessary for recovery, is at higher risk in 1. Up to 1 pound of tissue protein per day may be lost surgery than a patient of normal weight. Protein deficiency through bleeding, high metabolic rate (using protein is most common among these patients. Low protein stor- for energy), from exudate, and catabolism of muscle age will predispose the patient to shock, less detoxifica- tissue as well as from surgery itself. tion of the anesthetic agent by the liver, increased edema at the incision site, and decreased antibody formation. The 2. Plasma protein loss from hemorrhage or wound last factor increases the risk of infection. Intravenous feed- bleeding may occur. Loss of plasma protein and blood ing of solutions that are more concentrated in nutrients volume increases the risk of shock. Extra protein is prior to surgery is one way to replenish nutrient storage. required to replace these losses. This assumes that surgery can be postponed for a time. Aggressive oral nutrition, although more time consum- 3. Fever and inflammation that may accompany surgery ing, can accomplish the same goals. can be reduced by an increased supply of protein. Obese patients are at higher health risk in surgery 4. When antibody production decreases, infections in- than those of normal weight. Excess fat complicates sur- crease. A high protein intake can reduce the risk of gery, puts a strain on the heart, increases the risk of in- infection. fection and respiratory problems, and delays healing. The risks of dehiscence and evisceration are greater in the 5. Edema may develop due to an imbalance of colloidal obese patient. Preexisting conditions such as hyperten- osmotic pressure. Serum protein levels must be in- sion and diabetes, which are prevalent in obese persons, creased to reduce edema. Edema at the incision site also increase risks. There is no quick way for an obese may also develop, slowing healing. This is another person to safely lose weight prior to surgery. If time per- reason for protein intake. mits, a low-calorie diet, high in the essential nutrients, should be attempted. Starvation or fad diets are obvi- 6. Bone healing is delayed if the protein intake is not high. The bone marrow is considered a special protein that anchors minerals and favors calcification.","CHAPTER 15 DIET THERAPY FOR SURGICAL CONDITIONS 237 7. Hormones and enzymes are protein substances. A sium, and iron will need replacing and an increase in cal- lack of protein can lower production of these vital cium supply is mandatory if bone surgery or loss is in- substances. volved. Table 15-1 lists food sources of some of the most essential nutrients needed by surgical patients. 8. In the liver, protein combines with fat for removal. This prevents fatty infiltration. Thus, increased protein can PROGRESS CHECK ON ACTIVITY 1 protect the body against liver damage. When a protein combines with a fat, the product is a lipoprotein. MULTIPLE CHOICE Fluids Circle the letter of the correct answer. There must be sufficient fluids to replace potential losses 1. The major nutritional problems that the health from vomiting, fever, diuresis, drainage, and exudates. Preventing dehydration is of great importance. Up to team encounters among patients scheduled for seven liters of fluid per day may be needed. Because the body tends to retain sodium and fluid postoperatively, surgery are and . total fluid intake and output must be measured and recorded to assure proper fluid balance. a. anxiety b. undernutrition Calories c. pain d. overnutrition If the caloric intake in the postoperative patient is inad- equate, protein will be used for energy rather than for 2. Low protein reserves can cause all except which of tissue rebuilding and wound healing. More than half of the following conditions? ingested proteins will be used to provide energy in the ab- sence of sufficient carbohydrates and fats. A minimum of a. shock and edema 2800 calories per day from carbohydrates and fat must be b. muscle wasting available to spare protein for its primary purpose. Review c. anxiety the protein-sparing action of carbohydrates in Chapters d. liver damage 4 and 5. An example of protein-sparing action is if a pa- tient has had extensive surgery that requires 250 grams 3. Sufficient fluids are supplied in the diet to replace of protein for tissue building and repair, the total caloric losses from all except: content of the diet should range from 4000 to 6000 calories. a. edema. b. diuresis. Vitamins c. vomiting. d. drainage. Vitamin C availability is imperative. The role of vitamin C, as you will recall, is to supply the cementing material TRUE\/FALSE of connective tissue, capillary walls, and new tissue. Depending on the nature and extent of the surgery, the Circle T for True and F for False. patient may need 6 to 20 times the RDAs\/DRIs. 4. T F A minimum of 1200 calories per day from Vitamin K is also of special concern because of its func- carbohydrate and fat is required for protein- tion in blood clotting. Intestinal bacteria synthesis of this sparing of the postoperative patient. vitamin is decreased because of the use of antibiotics. Any liver damage reduces prothrombin formation, which can 5. T F The major problem in preoperative patients is be corrected by the presence of more vitamin K. under- or overnutrition. The need for B complex vitamins increases with rising 6. T F Decreased protein increases antibody formation. caloric requirements. These vitamins function as coen- 7. T F It is more important to increase total calories zymes in carbohydrate and protein metabolism, the for- mation of hemoglobin, and the prevention of anemia. than carbohydrate in the preoperative diet. Minerals FILL-IN Minerals are of great importance in the replacement of 8. Using the following menu, indicate the major nutrients electrolytes simultaneously lost with fluid from the body. supplied by each food listed by placing an X in the The amount and kinds of minerals to be replaced are de- appropriate column. termined by the type of surgery and extent of loss in the patient. Certainly, sodium, chloride, phosphorus, potas- Pro CHo Thia Nia Ribo Fe Vit C Oyster stew Whole wheat garlic toast Green pepper and cabbage slaw Raisin rice pudding with orange sauce","238 PART III NUTRITION AND DIET THERAPY FOR ADULTS TABLE 15-1 Some Food Sources of the Nutrients Identified as Essential to a Successful Surgery Protein Vitamin C Vitamin B Vitamin K Iron Zinc Complex* Complete: Milk Citrus fruits 1. Thiamin: Green leafy Liver Shellfish Eggs Sweet and hot pork, oysters, vegetables\u2020 Heart (especially Meat organ meats, Eggs oysters) Fish peppers enriched Fruits Raisins Poultry Greens bread and Prunes Dairy products Strawberries cereals Cereals Whole wheat Eggs Meats and enriched cereals and Whole grain breads cereals Apricots, dried Red meats Oysters Pork Almonds Incomplete: Vegetables Broccoli 2. Riboflavin: Grains Tomatoes milk, milk Nuts and seeds Cantaloupe products, Cabbage organ meats muscle meats, oysters, enriched bread and cereals 3. Niacin: liver, tuna, peanuts and peanut butter, peas, pork, en- riched bread and cereals *Others not listed of this group will be supplied if these three B vitamins in the diet are adequate. \u2020Best source ACTIVITY 2: A postoperative dietary regimen also requires aggres- sive nutritional support that is needed to maintain nor- The Postoperative Diet Regime mal body functions and tissues. Tissue maintenance is especially important since additional losses may result GOALS OF DIETARY MANAGEMENT from postoperative bed confinement and ensuing muscle atrophy. Nutritional supports should also attempt to re- The main goal of postoperative nutritional and dietary place tissue (such as muscle, bone, blood, exudate, and care is for the patient to regain a normal body weight. skin) that may have been lost during the trauma of sur- This is brought about by a positive nitrogen balance gery. Any malnourishment should be remedied if it has and subsequent muscle formation and fat deposition. not already been treated. Plasma protein should be sup- This goal can be achieved by first correcting all fluid plied to control or prevent edema and shock. Plasma pro- and electrolyte imbalances and giving appropriate trans- tein also provides vital components for the synthesis of fusions. The second step is to provide carefully planned albumin, antibodies, enzymes, and other necessary sub- dietary and nutritional support for the patient, with stances, which may have been lost through bleeding or special emphasis on those nutrients discussed at the the escape of fluids. Finally, plasma protein also acceler- beginning of this chapter. The third step is to monitor ates the healing of wounds. food intake by maintaining a detailed record of what is consumed. Inadequate nutritional supports increase morbidity and mortality, delay the return of normal body functions,","CHAPTER 15 DIET THERAPY FOR SURGICAL CONDITIONS 239 and retard the process of tissue rebuilding. Inadequate protein-sparing solutions made up mainly of essential nutrition prevents wounds from healing at a normal pace amino acids. The preliminary trials have been very en- and causes edema and muscular weakness. Most impor- couraging. However, if such means are used every day, it tantly, all of these consequences prolong convalescence may not only be expensive, but further deteriorate frag- and discomfort for the patient. ile peripheral veins. Some hospitals use vitamin and min- eral supplements as well as protein-sparing solutions. FEEDING THE PATIENT IMMEDIATELY AFTER THE OPERATION Although solid foods are withheld from patients im- mediately after an operation, most hospitals provide pa- Since a patient usually cannot tolerate solid food imme- tients with oral feedings after their intestinal functions diately after an operation, it is withheld anywhere from return to normal (as early as 24 hours after the opera- a few hours to two or three days. A feeding that is too tion). The feedings consist of routine hospital progressive early may nauseate the patient and cause vomiting and diets (see Chapter 14). This stepwise postoperative feed- possible aspiration. This results in further fluid and ing may cover one to three days, depending on the pa- electrolyte losses, discomfort, and potential pneumo- tient\u2019s tolerance, strength, and type of operation or nia. The following outline lists the various types of di- trauma. etary support that can be used during this short part of the postoperative period. Some patients may be able to start with a soft diet, while others must begin with a clear liquid diet. 1. No food by mouth (NPO) Progressive feedings occasionally may be supplemented 2. Intravenous feeding: blood transfusion, fluids and with commercial formulas. Some patients are given liquid-protein supplements with or without nonprotein electrolytes, 5% dextrose, vitamin and mineral sup- calories if they can tolerate the feedings. Again, depend- plements, protein-sparing solutions (with or without ing on the patient and his or her condition, a combina- Intralipid), combinations of above tion of feeding methods, including total parenteral 3. Oral feeding: routine hospital progressive liquid diets nutrition (see Chapter 14), may be used. For patients re- with or without supplements, liquid-protein supple- quiring tube feeding, consult the detailed procedures de- ments with or without nonprotein calories, combi- scribed in Chapter 14. nations of above 4. A combination of oral and intravenous feedings At this early stage of postoperative recovery, physi- cians, nurses, and dietitians should work closely to de- Many clinicians feel that it is not worthwhile to pro- termine whether dextrose solution or oral liquid diets vide aggressive nutritional support during such a short should be continued. This is important, since both types period of food deprivation. This decision is justified in of feeding may not be nutritionally sound without con- a well-nourished individual who can afford temporary centrated supplements. Nutritional supports, including catabolic losses and would not be able to efficiently use fluids, electrolytes, protein, calories, and other nutri- the supplied protein or calories. As described in Activity ents, should be carefully reviewed. Finally, a long-term 1, the majority of patients do not fit this category. The aggressive postoperative dietary treatment should be attending physician must decide if the patient is well planned and executed to combat the catabolic conse- nourished and if enteral or parenteral feedings can be quences of trauma and to bring about a speedy recovery. tolerated. If the feedings can be tolerated, a subsequent decision must be made on benefits of these exogenous DIETARY MANAGEMENT FOR RECOVERY nutrients. The health professional may, after his or her assessment of the patient\u2019s status, request the physi- When a patient can tolerate regular hospital foods, the cian to evaluate the patient and prescribe additional health team should plan and prescribe an appropriate feedings. diet. Experts in clinical nutrition have tried for a num- ber of years to develop a postoperative diet that will pro- Blood transfusions and fluid and electrolyte compen- vide patients with an optimal amount of nutrients. In sation are administered to those patients needing them. general, the following diet prescription should satisfy Some doctors prescribe 5% dextrose solution in saline or most clinical conditions that involve trauma: water, but the amount given is limited by the patient\u2019s tolerance. Another problem is that a concentrated dex- 1. 40\u201350 kcal\/kg body weight\/d trose solution may cause thrombosis in the peripheral 2. 12%\u201315% of total calories as protein veins. Because of the relatively low nutrient density of 3. Well-balanced intakes of the established RDAs\/DRIs dextrose solution, it should not be used as a long-term 4. Carefully monitored intakes of vitamins A, K, C, B12; means of feeding. It has been claimed generally that the infusion of dextrose spares some body protein from folic acid; and the minerals, iron and zinc breakdown to provide needed calories. Recently various medical centers have experimented with the infusion of To illustrate the protein and calorie composition of such a diet, Table 15-2 includes two examples (40 kcal and 50 kcal\/d) for a man weighing 70 kg.","240 PART III NUTRITION AND DIET THERAPY FOR ADULTS TABLE 15-2 Approximate Protein and Calorie Zinc has a definitive role in wound healing and clinical Content of a Postoperative Diet supplementation with zinc postoperatively is now com- for a Male Patient Weighing 70 kg mon. Zinc sulphate is the preferred form, given in dosage amounts of 18\u201322.5 mg\/day. (See Table 15-1 for food kcal\/kg Total Daily Approximate Total sources of these essential nutrients.) Body Kilocalories Dietary Calories Weight Protein (g) from There are differences with the dietary care of patients Protein (%) undergoing different types of surgery, such as digestive tract, gynecological organs, or pancreas. Space limita- 40 2800 84 12 tion does not permit discussions of details for each sur- 50 3500 131 15 gical condition. However, the next section presents a discussion of important considerations in the nutritional If the patient has a minimal amount of tissue and and dietary care of a patient with part of the intestine blood loss, a sound preoperative nutritional status, a surgically removed. moderate to good appetite, and no sign of surgical com- plications, a diet of 35 to 40 kcal\/kg is probably sufficient. GASTROINTESTINAL SURGERY: However, the diet for a postoperative patient should be in- AN ILLUSTRATION dividualized, especially the serving sizes and the fre- quency of feeding. Patients usually tolerate solids better According to some professionals, early removal of the if the feedings are small and frequent. nasogastric tube, early oral feeding, and a reasonable transition to a regular diet is safe and tolerated in most Both carbohydrates and fats are important sources of patients after gastrointestinal (GI) surgery. The patients calories, and they should be provided in about equal who may not benefit from or tolerate this more progres- quantities to constitute 85%\u201388% of the total calories. (If sive postoperative care are those who have had emer- this reduces the patient\u2019s appetite, less fat should be con- gency GI surgery. In terms of the first postoperative sumed.) The calories from carbohydrates and fats used to meals, the ideal approach may be to allow patients to se- correct hypermetabolism supply energy for all processes lect their foods and beverages. Those patients who are of rebuilding and repairing, and spare protein for ana- nauseated or not hungry are more likely to choose clear bolic purposes. liquids, and those who are hungry and feeling well will choose from a regular diet. If the patient is given solid food, a good quantity of fruits and vegetables should be included in meals in ad- As an illustration, we will study the dietary care of a dition to protein, fat, and carbohydrate. Refer to Chapter patient undergoing partial removal of the GI tract. 14 for planning a high-protein, high-calorie, balanced diet. The need for vitamins A, K, C, B12, and folic acid in The normal small intestine is 300\u2013800 cm (10\u201325 ft) a postoperative regimen requires special attention. in length (1\u20443 jejunum and 2\u20443 ileum). The normal colon Vitamins A and C have been proven experimentally and (large intestine) is about 150 cm (10 ft). Most nutrients clinically to assist in wound healing as well as tissue re- are absorbed in the jejunum. Nine liters of fluid per day pair. Vitamin A is well known for its role in maintaining enters the small bowel. Normally, all but 1 liter is ab- epithelial structures, and vitamin C is important for col- sorbed proximal to the colon. The colon absorbs more lagen synthesis. In addition, vitamin A acid (retinoic acid) than 80% of the remaining fluid, and can absorb up to has recently been shown to assist in wound healing and 3\u20134 liters daily. The colon also has the capability to sal- is currently suspected to be a possible curative agent for vage energy by the fermentation of complex carbohy- certain types of human cancer. drate and soluble fiber to short chain fatty acids. The body\u2019s ability to clot blood postoperatively de- Short-bowel syndrome refers to a surgical loss of sig- pends on an adequate supply of vitamin K. Folic acid nificant distal ileum, ileocecal valve, and\/or colon. The re- and vitamin B12 are necessary for the synthesis and sult is a faster overall transit and the potential for greater turnover of all body cells, especially red blood cells, and loss of fluid and nutrient. Following a resection, the should be amply provided. The postoperative use of an- ileum has a greater ability to adapt than the jejunum. tibiotics may inhibit the formation of these three im- The adaptation depends on the size of section of ileum or portant vitamins by the intestinal flora, thus partially colon removed or nonfunctional. The function of the re- reducing the body\u2019s supply. Therefore, patients must be maining bowel may further be handicapped by: monitored for deficiencies of these nutrients and given adequate supplementation. \u2022 Mucosal disease \u2022 Bacterial overgrowth The importance of iron and zinc cannot be underes- \u2022 Rapid gastric emptying timated. Iron is vital for hemoglobin synthesis and is \u2022 Excessive gastric acid with inactivation of pancreatic used to compensate for blood loss and possible anemia. lipase and deconjugation of bile salts, or pancreatic insufficiency","CHAPTER 15 DIET THERAPY FOR SURGICAL CONDITIONS 241 If 100 cm or more of terminal ileum is removed, there NURSING IMPLICATIONS is impairment of the absorption of vitamin B12 and bile salts, which means the absorption of fat and fat soluble Recognizing that inadequate nutritional support may in- vitamins will also be affected. If there is less than 100 cm crease morbidity and mortality during the early postop- of remaining jejunum or ileum (without a colon or ileo- erational period, the nurse should do the following: cecal valve) or less than 50 cm of small bowel attached to the colon, central parenteral nutrition may be required 1. Recognize that malnutrition even in the short pe- until clinical conditions indicate otherwise. riod of 1\u20133 days postoperatively may retard the heal- ing process. The process of intestinal adaptation is facilitated by complex foods and continues for one or more years in 2. Monitor the patient closely and provide nourishment adults. Stool output with diarrhea may depend on the as soon as bowel sounds are present. type of carbohydrate consumed, simple or complex. Excessive eating is an important adaptive response to 3. Check for other feeding methods that will fur- maldigestion and malabsorption. nish adequate nutrients, if oral feedings are con- traindicated. Thus, approaches to diet therapy for a patient with short-bowel syndrome are as follows: 4. Assess total fluid intake carefully and compare total fluid losses to avoid circulating overload. During the initial postoperative period, recommended management includes no food by mouth, with intra- 5. Be aware that any weight gain during this period venous feeding of electrolytes and central parenteral feed- may be indicative of excess fluids. ing if indicated. Increase oral intake gradually, which will be determined by patient response and clinical status, 6. Recognize the need for extra nutrients and fluids if starting with 6 small feedings per day, avoiding hyperos- the patient has elevated temperature. molar liquids. 7. Request specific written orders for change of diet Advance to regular diet, mostly unrestricted with high and\/or feeding method as the condition indicates. calories and protein intake. In most patients, lactose is well tolerated except those with a significant amount of 8. Provide aggressive nutritional support during the jejunum removed. early postoperative period as well as in subsequent convalescence. Some patients require supplements of vitamins and some trace elements and minerals. Some patients re- 9. Refer to the nutritional support team for assistance quire supplemental calcium, magnesium, and zinc. If the if the facility has one. Otherwise, work within the distal ileum is removed, the patient may need Vitamin B12 health team of which you are part. injection via vein or musculature. 10. Document all changes, requests, and rationales The attending physician will prescribe a constant carefully. monitoring of blood chemistry especially levels of vita- mins and minerals, organ integrity, bone density, and PROGRESS CHECK ON ACTIVITY 2 urinary analysis for components and volumes. FILL-IN If patient has no ileum or colon, dehydration is the greatest concern. Sipping an oral rehydration solution 1. State the main goal of dietary management in the containing a calculated amount of sodium can reduce postoperative period. the need for intravenous fluid. There are several accept- able commercial preparations, though it is important to 2. List three ways this goal can be achieved. consider palatability and patient rejection. a. If a patient\u2019s colon is intact and functioning, encour- age the consumption of soluble fiber which is fermented b. to short-chain fatty acids in the large intestine. Supple- mental medium chain triglycerides can increase total c. calories when absorbed in the small bowel and the colon. Restrict the following: 3. Describe the three major functions of plasma protein. \u2022 Oxalate because it can bind calcium especially in a supplement a. \u2022 Sugars to avoid diarrhea b. \u2022 Fat if steatorrhea is present and more than 100 cm of c. distal ileum is removed 4. Identify five intravenous feedings that may be Consider the use of enteral feeding. Several accept- used in the immediate postoperative period. able commercial preparations are available. a.","242 PART III NUTRITION AND DIET THERAPY FOR ADULTS Lunch Mid-PM b. Dinner c. d. e. 5. Describe the normal progression of routine hospi- tal diets and approximate time periods of use for each (consult Chapter 12 if in doubt about the time periods). Situation H.S. (Hour of Sleep) Johnny B, 5\u04086\u0408\u0408, 150 lb, wrecked his motorcycle. He was wear- REFERENCES ing a helmet, but sustained a mild concussion. In addition, he received a compound fracture of the left femur and multiple lac- American Dietetic Association. (2006). Nutrition Diagno- erations of the arms, face, and upper body. He was in surgery sis: A Critical Step in Nutrition Care Process. Chicago: for three hours. The diet prescription is for a soft diet in six Author. feedings with the following specifications: 45 kcal\/kg body weight\/day, 15% of total calories as protein, 55% as carbohy- Babor, S. (2005). Early feeding compared with parenteral drate, and the remainder as fat. Answer the following questions nutrition after oesophageal or oesophagastric resec- about this situation. tion and reconstruction. British Journal of Nutrition, 93: 509\u2013513. 6. What is the total kcal content of Johnny\u2019s diet? Round to nearest whole number. Beham, E. (2006). Therapeutic Nutrition: A Guide to Patient Education. Philadelphia: Lippincott, Williams 7. How many grams of protein per day will he and Wilkins. receive? Buchman, A. (2004). Practical Nutritional Support 8. How many grams of fat are in his diet order? Technique (2nd ed.). Thorofeue, NJ: SLACK. 9. How many grams of carbohydrate will Johnny Deen, D., & Hark, L. (2007). The Complete Guide to get? Nutrition in Primary Care. Malden, MA: Blackwell. 10. Write a 1-day menu, including the three snacks, Escott-Stump, S. (2002). Nutrition and Diagnosis- that will satisfy the diet requirements. Related Care (5th ed.). Philadelphia: Lippincott, Breakfast Williams and Wilkins. Mid-AM Garrow, J. S. (2000). Human Nutrition and Dietetics (10th ed.). New York: Churchill Livingston. Haas, E. M., & Levin, B. (2006). Staying Healthy with Nutrition: The Complete Guide to Diet and Nutrition Medicine (21st ed.). Berkeley, CA: Celestial Arts. Hark, L., & Morrison, G. (Eds.). (2003). Medical Nutrition and Disease (3rd ed.). Malden, MA: Blackwell. Kang, I. (2007). Mineral deficiency in patients who have undergone gastrectomy. Nutrition, 23: 318\u2013322. Ljungqvist, O. (2005). To fast or not to fast before surgi- cal stress. Nutrition, 21: 885\u2013886. Lopez Hellin, J. (2008). Nutritional modulation of protein metabolism after gastrointestinal surgery. European Journal of Clinical Nutrition, 62: 254\u2013262. Luis, D. A. (2007). Clinical and biochemical outcomes after a randomized trial with a high dose of enteral","CHAPTER 15 DIET THERAPY FOR SURGICAL CONDITIONS 243 arginine formula in postsurgical head and neck can- Moore, M. C. (2005). Pocket Guide to Nutritional Assess- cer patients. European Journal of Clinical Nutrition, ment and Care (5th ed.). St. Louis, MO: Elvesier 61: 200\u2013204. Mosby. Luo, M. H. (2008). Depletion of plasma antioxidants in surgical intensive care unit patients requiring paen- Payne-James, J., & Wicks, C. (2003). Key Facts in Clinical teral feeding: Effects of parental nutrition with or Nutrition (2nd ed.). London: Greenwich Medical Media. without alanyl-glutamine dipeptide supplementation. Nutrition, 24: 37\u201344. Sardesai, V. M. (2003). Introduction to Clinical Nutrition Mahan, L. K., & Escott-Stump, S. (Eds.) (2008). Krause\u2019s (2nd ed.). New York: Marcel Dekker. Food and Nutrition Therapy (12th ed.). Philadelphia: Elsevier Saunders. Shils, M. E., & Shike, M. (Eds.). (2006). Modern Nutrition Mann, J., & Truswell, S. (Eds.). (2007). Essentials of Human in Health and Disease (10th ed.). Philadelphia: Nutrition (3rd ed.). New York: Oxford University Press. Lippincott, Williams and Wilkins. Marian, M. J., Williams-Muller, P., & Bower, J. (2007). Integrating Therapeutic and Complementary Nutri- Sungurtekin, H. (2004). The influence of nutritional sta- tion. Boca Raton, FL: CRC Press. tus on complications after major intraabdomnal sur- Mertes, N. (2006). Safety and efficacy of a new parental gery. Journal of American College of Nutrition, 23: lipid emulsion (SMOFlipid) in surgical patients: A ran- 227\u2013232. domized, double-blind multicenter study. Annals of Nutrition & Metabolism, 50: 253\u2013259. Thomas, B., & Bishop, J. (Eds.). (2007). Manual of Di- etetic Practice (4th ed.). Ames, IA: Blackwell. Webster-Gandy, J., Madden, A., & Holdworth, M. (Eds.) (2006). Oxford Handbook of Nutrition and Dietetics. Oxford, England: Oxford University Press.","","OUTLINE 16C H A P T E R Objectives Diet Therapy for Glossary Cardiovascular Disorders Background Information ACTIVITY 1: The Lipid Time for completion Disorders Activities: 11\u20442 hours Definitions Optional examination: 1\u20442 hour Cholesterol and Lipid Disorders Dietary Management OBJECTIVES NCEP Recommendations Third Edition of NCEP (ATP 3) Upon completion of this chapter, the student should be able to do the Metabolic Syndrome following: Special Considerations for 1. Discuss the recommendations regarding the role of diet in preventing Different Population Groups heart disease. Racial and Ethnic groups 2. Describe and state the rationale of diet therapies used for the different The Role of Fish Oils Drug Management heart disorders. Nursing Implications 3. List the foods allowed, limited, and forbidden on selected therapeutic diets Progress Check on Activity 1 ACTIVITY 2: Heart Disease and for heart disorders. 4. Identify resources available for patient education. Sodium Restriction 5. Identify nursing implications involved in the use of modified diets in car- Diet and Hypertension Diet and Congestive Heart diovascular disease. Failure GLOSSARY The Sodium-Restricted Diet Nursing Implications Atherosclerosis: thickening of the inside walls of arteries by deposits of fat or Progress Check on Activity 2 cholesterol substances (plaques). ACTIVITY 3: Dietary Care After Cardiovascular: of or relating to the heart and blood vessels. Heart Attack and Stroke Cerebrovascular accident (CVA): when the blood vessels in the cerebrum Myocardial Infarction (MI): (brain) are deprived of oxygen by an obstruction (occluded). This may be Heart Attack due to plaque formation, thrombus (blood clot), or aneurism (rupture of Cerebrovascular Accident 245 (CVA): Stroke Nursing Implications Progress Check on Nursing Implications Progress Check on Activity 3 References","246 PART III NUTRITION AND DIET THERAPY FOR ADULTS the blood vessel). Absence of oxygen to brain tissue that the nurse should have accurate information about for more than 5 to 6 minutes leads to irreversible cere- available dietary treatments for heart problems and the bral changes and tissue death. Commonly called a rationale for their use. \u201cstroke.\u201d Cholesterol: a fatlike substance manufactured in the liver There is no known single cause of heart disease. from saturated fats, including body fat. It is widely However, the presence of a combination of certain factors distributed in the body tissues and serves many impor- predisposes a person to high risk of the disease. Some tant functions. personal characteristics, such as a family history of heart Coronary: encircling (like a crown). disease, sex, and age cannot be changed, but dietary fac- Coronary arteries: two large arteries that branch from the tors and stressful lifestyles can be modified. Therefore, ascending aorta and supply the heart muscle with blood. the diets discussed in this chapter serve two goals: to re- Coronary heart disease (CHD): the coronary arteries sup- duce or prevent further damage to the cardiovascular ply all of the blood to the heart muscle. Occlusion, system, and to prevent development of the disorder in most often caused by narrowing of the vessels by yet unaffected individuals. plaque (atherosclerosis), deprives it of its nutrients and causes death to the part of the heart muscle that Current Consensus is occluded. When the occlusion is complete, myocar- dial infarction results (see coronary occlusion). The National Cholesterol Education Program (NCEP) is Coronary occlusion: closing off of a coronary artery-most one of three principal programs administered by the often caused by the plaques of atherosclerosis. When Office of Prevention, Education, and Control of the the occlusion is complete, myocardial infarction (MI) National Heart, Lung, and Blood Institute (NHLBI) of results. the National Institutes of Health (NIH). It came about Hyperlipoproteinemia: the presence of abnormally high after years of trials and scientific evidence that linked levels of lipoproteins in the serum. blood cholesterol levels to coronary heart disease. These Hypertension: blood pressure elevated above the normal trials showed that levels could be lowered safely by both range for age and sex. diet and drugs (see Table 16-1). Lipoproteins: the form in which lipids are transported in the blood. There are four main classes of lipoproteins: The First Report of the Expert Panel on Detection, chylomicrons, very-low-density lipoproteins, low- Evaluation, and Treatment of High Blood Cholesterol in density lipoproteins, and high-density lipoproteins. Adults was produced in 1988. An additional report was a. Low-density lipoproteins (LDLs) transport 60%\u201375% published in 1991 that presented recommendations for high blood cholesterol in children and adolescents. The of the serum cholesterol. They carry from the liver to Second Report by the Expert Panel, in 1993, included the body cells (including blood vessels). High serum evidence that had emerged since 1991 and updated rec- levels of LDLs, therefore, increase the risk of CHD ommendations for the management of high blood cho- (see above). lesterol in adults. This edition includes assessments for b. High-density lipoproteins (HDLs) transport 20%\u2013 cholesterol lowering in women, the elderly, and young 25% of plasma cholesterol. They are believed to adults as well as physical activity and weight loss as com- collect excess cholesterol from body cells and carry ponents of diet therapy. it back to the liver to be excreted or used for making bile. TABLE 16-1 Criteria for Treatment Intervention Myocardial infarction (MI): death of tissue of an area of in Adults the heart muscle as a result of oxygen deprivation, which in turn was caused by an obstruction of the Classification based on total cholesterol blood supply (see coronary heart disease). Commonly referred to as a \u201cheart attack.\u201d \u03fd 200 mg\/dl\u2014desirable level Triglycerides: the principal form of fat in foods and in 200\u2013239 mg\/dl\u2014borderline high blood cholesterol the body, consisting of three fatty acids and glycerol. \u0546 240 mg\/dl\u2014high blood cholesterol BACKGROUND INFORMATION Classification based on LDL cholesterol More than half the people who die in this country each \u03fd 130 mg\/dl\u2014desirable LDL cholesterol year die of heart and blood vessel disease. About 75% of 130\u2013159 mg\/dl\u2014borderline high risk all adult hospitalized patients show symptoms of heart \u0546 160 mg\/dl\u2014high risk problems even though they are admitted for other causes. The high occurrence of these health problems means Source: Second Report of the Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults, September 1993, and Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents, September 1991.","CHAPTER 16 DIET THERAPY FOR CARDIOVASCULAR DISORDERS 247 The third report (ATP 3), May 2001, updates clinical other members of the health team. The patient is, of ne- guidelines for cholesterol testing and management. It cessity, the center of this team and must be educated to reports and expands indications for intensive cholesterol- make the dietary and lifestyle changes necessary to re- lowering therapy in clinical practice. Many persons have duce CHD risk. high risk for CHD and will benefit from more intensive treatment than was recommended in ATP 1 and 2. Implementing dietary guidance with the use of nutri- tion labeling and standards of identity is one example of ATP 3 continues to use LDL cholesterol as the pri- steps being taken to help Americans implement the mary target of cholesterol-lowering therapy; therefore, guidelines. (Refer to Table 16-3.) The major objective for the primary goals are stated in terms of LDL. There have this sweeping revision is to increase the availability of been some modifications in lipid and lipoprotein classi- health-promoting foods. fications. Compare Tables 16-1 and 16-2. This report is available at the Web site, www.nih.gov. ATP 4, the fourth Nutritional Risk Factors in Heart Disease report, is in the planning and preparation stage. The risk factors of heart disease include the following: The reports outline \u201cheart-healthy\u201d eating for the gen- eral population, as well as treatment for persons with 1. Elevated serum cholesterol high cholesterol levels, or those at high risk for develop- 2. Elevated serum triglycerides ing CHD. 3. Obesity 4. Hypertension Guidelines have been established for health profes- 5. Generally poor eating habits and a sedentary lifestyle sionals, patients, and the public. Among these important guidelines are two of particular interest to students of All of these factors can be altered by diet and exercise. nutrition: ACTIVITY 1: 1. To increase the knowledge of health professionals re- garding the major role that diet plays in reducing The Lipid Disorders blood cholesterol. DEFINITIONS 2. To improve the knowledge, skills, and attitudes of stu- dents in the health professions regarding high blood The term used most frequently in describing the lipid cholesterol and its management. disorders is hyperlipoproteinemia (hyper \u03ed excess, lipoprotein \u03ed fat and protein, emia \u03ed in blood, which See Table 16-2. translates as excess level of fat\/protein complex in blood). You are encouraged to add these publications to your It refers to higher than normal levels of certain lipids in database for clinical practice, as the reports present the blood. guidelines that are the responsibility of not only physi- cians but also nurses, dietitians, pharmacists, and all Cholesterol and triglycerides are water-insoluble lipids, carried in the blood by lipoproteins. Diet, genet- TABLE 16-2 ATP III Classification of LDL, Total, ics, and acquired factors affect the circulating levels of and HDL Cholesterol (mg\/dl) one or more lipoproteins. LDL Cholesterol Optimal Lipoproteins are lipids combined with proteins. They Near optimal\/above optimal are called apolipoproteins. Three main classes of lipopro- \u03fd 100 Borderline high teins are very-low-density lipoproteins (VLDL), low- 100\u2013129 High density lipoproteins (LDL), and high-density lipoproteins 130\u2013159 Very high (HDL). LDL and HDL mainly transport cholesterol, and 160\u2013189 VLDL transports triglycerides. \u0546 190 Desirable Borderline high The liver makes cholesterol from saturated fat. The Total Cholesterol High amount of cholesterol synthesized is directly related to the quantity of saturated fat consumed. LDLs carry cho- \u03fd 200 Low lesterol to the artery plaques. Plaque formation is di- 200\u2013239 High rectly related to the amount of LDLs present. The \u0546 240 connection is cholesterol, LDLs, plaques, and coronary heart disease. HDLs carry cholesterol away from the HDL Cholesterol plaques to the liver, to the gallbladder, and into the intes- tines, where it is excreted. HDLs, therefore, lower the \u03fd 40 risk of CHD. It appears that a person with a high HDL \u0546 60 level is less likely to develop the disease than a person with a low HDL level. On the other hand, the reverse Source: Third Report of the Expert Panel on Evaluation and Treatment of High Blood Cholesterol in Adults, May 2001.","248 PART III NUTRITION AND DIET THERAPY FOR ADULTS TABLE 16-3 Descriptive Labeling Terms Approved by the FDA: A Translation to Components Important in a Cholesterol-Lowering Diet* Nutrient Free Low Reduced\/Less\/Fewer Other All Synonyms for \u201cFree\u201d: Synonyms for \u201cLow\u201d: Synonyms for \u201cFree of,\u201d \u201cNo,\u201d \u201cContains a Small \u201cReduced\/Less\/Fewer\u201d: Total calories \u201cZero,\u201d \u201cWithout,\u201d Amount of, \u201cLow \u201cReduced in,\u201d Total fat \u201cTrivial Source of,\u201d Source of,\u201d \u201cLow in\u201d \u201cLower,\u201d \u201cLow\u201d \u201cNegligible Source of,\u201d \u201cDietary Less than 40 calories\/ Reduced by at least 25% Insignificant Source reference serving of\u201d Reduced by at least 25% \u201c__% Fat Free\u201d 3 g or less\/reference Less than 5 calories\/ serving \u201c__% Lean,\u201d must meet reference serving requirements for \u201cLow Meal and main dish Fat\u201d Less than 0.5 g\/reference products: 3 g or less serving per 100 g product and 30% or less calories Saturated fat Less than 0.5 g\/reference from fat Reduced by at least 25% serving, levels of trans-fatty acids must 1 g or less\/reference be 1% or less of total serving and 15% or fat less of calories from saturated fatty acids Cholesterol Less than 2 mg\/ Reduced by at least 25% reference serving; Meal and main dishes saturated fat content products: 1 g or less Contains 2 g or less must be 2 g or less per 100 g, and less saturated fat per than 10% of calories reference serving from saturated fat Sodium Less than 5 mg\/ Reduced by at least 25% \u201cVery Low Sodium,\u201d reference serving 20 mg or less\/reference \u201cVery Low in serving; saturated fat Sodium\u201d: 35 mg or content must be 2 g less\/reference serving or less per serving Meal and main dish products: 20 mg or less per 100 g, with saturated fat content less than 2 g\/100 g 140 mg or less\/ reference serving Meal and main dish products: 140 mg or less\/100 g of food *The new FDA labeling requirements make it possible for patients to determine how many grams of total fat and saturated fat are con- tributed by a serving of a particular food. In addition, the new nutrition label will indicate in a \u201cPercent Daily Value\u201d column the percent the food contributes to the maximum amount of fat allowed in a 2,000-calorie diet that meets recommendations for less than 30% of calo- ries from fat, and less than 10% of calories from saturated fat (see Module 1). Patients will also be able to use the fat and cholesterol de- scriptors that are now defined by the FDA. Source: Second Report of the Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults, September 1993. applies to blood LDL levels; that is, a high LDL level in- lesterol, one may use the following formula (quantities creases the risk of heart disease. are in mg\/dl): CHOLESTEROL AND LIPID DISORDERS triglycerides LDL cholesterol \u03ed total cholesterol \u03ea HDL cholesterol \u03ea When we talk about blood cholesterol, we now refer to three forms: total, LDL, and HDL. Some health-screening 5 procedures measure the LDL cholesterol since it reflects the actual risk of atherosclerosis. To calculate LDL cho- Normally, the plasma levels of different forms of lipid exist within certain limits. However, particular individuals may deviate from such norms and develop","CHAPTER 16 DIET THERAPY FOR CARDIOVASCULAR DISORDERS 249 hyperlipidemia, or an elevated level of serum lipid. are reduction in saturated fat and cholesterol intakes, Three main types of lipid are involved in this condi- weight reduction, and physical activity. If the patient can- tion: cholesterol (an excess of which is called hyper- not achieve LDL of \u03fd 100mg\/dl by diet alone, LDL- cholesterolemia), triglyceride (hypertriglyceridemia), lowering drugs can be started simultaneously. Table 16-4 and certain forms of lipoprotein (hyperlipoproteine- lists the nutrient composition of the TLC diet. Notice the mia). Hyperlipoproteinemia is usually associated with increase in the amount of fiber in this diet. Fiber, espe- hypercholesterolemia or hypertriglyceridemia, or both, cially soluble forms, helps to lower cholesterol by remov- although the reverse is not necessarily true. Any of the ing it via excretion in feces. The TLC diet generally hyperlipidemias is undesirable because it may potenti- follows the Dietary Guidelines for Americans 2000. One ate atherosclerosis or cause its associated clinical exception is that total fat is allowed to range from 25% symptoms. to 35% of total calories, provided saturated fats and trans- fatty acids are kept low. A higher intake of total fat, mostly DIETARY MANAGEMENT in the form of unsaturated fat, can help to reduce triglyc- erides and raise HDL cholesterol in persons with meta- To treat a patient with a lipid disorder, the attending bolic syndrome. Examples of daily food choices that meet physician uses laboratory data and clinical examination the dietary guidelines are found in Table 16-5. Table 16-6 to type the patient. The typing uses many data: sex, age, delineates the types of fat, cholesterol, and omega-3 con- symptoms, blood and laboratory tests, family history, and tent of meat, fish, and poultry, which is a helpful tool in so forth. After the physician has typed the patient, the planning diet therapy. dietitian implements the appropriate dietary treatment according to the diagnosis. This is not the proper forum METABOLIC SYNDROME to discuss details for treating individual patients. A constellation of major risk factors, life-habit risk fac- The second approach involves the public and is appli- tors, and emerging risk factors constitute a condition cable to all individuals. It has one goal: to lower blood called metabolic syndrome. Factors characteristic of cholesterol while maintaining adequate diet. At present, metabolic syndrome are abdominal obesity, elevated the dietary management of a person with high blood triglycerides, small LDL particles, low HDL, hyperten- (total or LDL) cholesterol is being promoted by three sion, insulin resistance, and prothrombotic and proin- major groups: the American Heart Association (AHA), flammatory states (see Table 16-8). the National Cholesterol Education Program (NCEP), and other private health groups. All three groups target Metabolic syndrome is a secondary target of risk- the amount and type of fats we eat. reduction therapy after the primary target LDL cholesterol. NCEP RECOMMENDATIONS TABLE 16-4 Nutrient Composition of the TLC Diet Dietary intervention is the first priority in lowering blood cholesterol. The NCEP has also issued a guide for foods Nutrient Recommended Intake low in saturated fat and cholesterol. (See Tables 16-3 through 16-6.) Saturated fat* Less than 7% of total calories Polyunsaturated fat* Up to 10% of total calories The NCEP has other recommendations that are of im- Monounsaturated fat Up to 20% of total calories portance in patient care and public health programs: Total fat 25%\u201335% of total calories Carbohydrate\u2020 1. The use of blood cholesterol as a means of classifying Fiber 50%\u201360% of total calories the risk of atherosclerosis for the population: The two Protein (approximately) 20%\u201330 g\/day classifications are based on plasma total cholesterol or Cholesterol 15% of total calories LDL cholesterol (Table 16-1). These classifications Total calories (energy)\u2021 Less than 200 mg\/day can be applied if a person\u2019s blood cholesterol is known through screening or other means. Balance energy intake and expenditure to maintain 2. Using the LDL cholesterol recommendations, one can desirable body weight\/ make a careful study of a person\u2019s blood lipid and set prevent weight gain goals. *Trans-fatty acids are another LDL-raising fat that should be THIRD EDITION OF NCEP (ATP 3) kept at a low intake. ATP 3 recommends a multifaceted approach to reduce \u2020Carbohydrate should be derived predominantly from foods the risk for CHD. This approach is designated therapeu- tic lifestyle changes or TLC. The major features of TLC rich in complex carbohydrates including grains, especially whole grains, fruits, and vegetables. \u2021Daily energy expenditure should include at least moderate physi- cal activity (contributing approximately 200 kcal per day).","250 PART III NUTRITION AND DIET THERAPY FOR ADULTS TABLE 16-5 Examples of Daily Food Choices That Meet the Dietary Guidelines Food Group No. of Some Suggested Foods Servings Serving Size Vegetables 3\u20135 1 c leafy\/raw Leafy greens, lettuce Fruits 2\u20134 1\u20442 c other Corn, peas, green beans, broccoli, carrots, cabbage, Breads, cereals, pasta, 6\u201311 3\u20444 c juice celery, tomato, spinach, squash, bok choy, mush- grains, dry beans, peas, 1 piece fruit rooms, eggplant, collard and mustard greens potatoes, and rice 1\u20442 c diced fruit Tomato juice, vegetable juice Orange, apple, applesauce, pear, banana, grapes, Skim\/low-fat dairy 2\u20133 3\u20444 c fruit juice grapefruit, tangerine, plum, peach, strawberries products and other berries, melons, kiwi, papaya, mango, 1 slice lychee Lean meat, poultry, and fish Orange juice, apple juice, grapefruit juice, grape 1\u20442 bun, bagel, muffin juice, prune juice Fats and oils \u05456\u20138* 1 oz dry cereal Wheat, rye or enriched breads\/rolls, corn and flour tortillas Eggs 1\u20442 c cooked cereal English muffin, bagel, muffin, cornbread Sweets and snack foods 1\u20442 c dry beans or peas Wheat, corn, oat, rice, bran cereal, or mixed-grain 1\u20442 c potatoes cereal 1\u20442 c rice, noodles, barley, or Oatmeal, cream of wheat, grits Kidney beans, lentils, split peas, black-eyed peas other grains Potato, sweet potato 1\u20442 c bean curd Pasta, rice, macaroni, barley, tabbouli 1 c skim, 1% milk 1 oz low-fat, fat-free cheese Tofu \u05456 oz\/day\u2014Step I Diet Low\/nonfat yogurt, skim milk, 1% milk, buttermilk \u05455 oz\/day\u2014Step II Diet Low-fat cheeses Lean and extra-lean cuts of meat, fish, and skinless 1 tbsp soft margarine 1 tbsp salad dressing poultry, such as sirloin, round steak, skinless 1 oz nuts chicken, haddock, cod \u05454 yolks\/week\u2014Step I Diet Soft or liquid margarine, vegetable oils \u05452 yolks\/week\u2014Step II Diet In moderation Walnuts, peanuts, almonds, pecans Used in preparation of baked products Cookies, fortune cookies, pudding, bread pudding, rice pudding, angel food cake, frozen yogurt, candy, punch, carbonated beverages Low-fat crackers and popcorn, pretzels, fat-free chips, rice cakes *Includes fats and oil used in food preparation, also salad dressings and nuts. The risk factors can be reduced by weight reduction and inal obesity and the metabolic syndrome. A large frac- physical activity. The risk factors of the metabolic syn- tion of all CHD occurs in men of middle age. For those drome correlate to enhanced risk for CHD at any given who carry relatively high risks, intensive LDL-lowering LDL level. Abdominal obesity is more highly correlated therapy is needed. than is an elevated body mass index (BMI). For women, aged 45 to 75 years, onset of CHD is gen- SPECIAL CONSIDERATIONS FOR DIFFERENT erally delayed by 10\u201315 years compared with that of men; POPULATION GROUPS most CHD in women occurs after age 65. CHD in women younger than 65 occurs in those with multiple risk fac- Men, aged 35 to 65 years have a higher risk of CHD than tors and the metabolic syndrome. Previous belief that do women. Middle-aged men in particular have a high the protective effect of estrogen in women accounted prevalence of risk factors, and are predisposed to abdom- for the gender difference in risk for CHD has been cast in doubt in clinical trials of the use of hormone","CHAPTER 16 DIET THERAPY FOR CARDIOVASCULAR DISORDERS 251 TABLE 16-6 Saturated Fat, Total Fat, Cholesterol, and Omega-3 Content of Meat, Fish, and Poultry in 3-Ounce Portions Cooked Without Added Fat Source Saturated Fat g\/3 oz Total Fat g\/3 oz Cholesterol mg\/3 oz Omega-3 g\/3 oz Lean Red Meats 1.4 4.2 71 \u2014 Beef 7.8 78 \u2014 2.8 8.6 71 \u2014 (rump roast, shank, bottom 4.9 93 \u2014 round, sirloin) 3.0 Lamb 4.2 331 \u2014 (shank roast, sirloin roast, 2.0 shoulder roast, loin chops, 5.9 477 \u2014 sirloin chops, center leg chop) 1.6 Pork 2.2 4.6 537 \u2014 (sirloin cutlet, loin roast, 1.6 sirloin roast, center roast, 7.3 21.3 250 \u2014 butterfly chops, loin chops) 0.9 Veal 2.5 2.9 329 \u2014 (blade roast, sirloin chops, 1.4 shoulder roast, loin chops, 10.7 1,747 \u2014 rump roast, shank) 1.1 Organ Meats 2.3 4.8 164 \u2014 Liver Beef 0.9 3.8 72 \u2014 Calf 2.0 8.3 71 \u2014 Chicken Sweetbread 0.1 2.7 59 \u2014 Kidney 0.3 6.1 72 \u2014 Brains 1.7 Heart 0.2 0.8 63 0.22 Poultry 1.3 58 0.47 Chicken (without skin) 0.1 7.0 54 1.88 Light (roasted) 0.7 25 0.24 Dark (roasted) 0.1 Turkey (without skin) 0.2 0.5 61 0.07 Light (roasted) 0.2 Dark (roasted) 1.3 45 0.38 Fish 0.3 1.5 85 0.45 Haddock 0.2 0.9 166 0.28 Flounder 0.7 Salmon 1.3 1.3 144 0.15 Tuna, light, canned in water 0.1 1.7 57 0.33 Shellfish 0.6 3.8 48 0.70 Crustaceans 4.2 93 1.06 Lobster 1.2 56 0.36 Crab meat 2.4 400 0.84 Alaskan King Crab Blue Crab Shrimp Mollusks Abalone Clams Mussels Oysters Scallops Squid Source: Dietary Guidelines for Americans. 2000. Washington, DC: USDA.","252 PART III NUTRITION AND DIET THERAPY FOR ADULTS replacement therapy (HRT) to reduce risk of CHD in Also, alpha linolenic acid (ALA) found in tofu, soy- postmenopausal women. Cholesterol-lowering drug beans, canola oil, walnuts, flaxseeds, and their oils, can therapy is preferred to HRT. convert into omega-3 fatty acids in the body. With older adults (men \u03fe 65 years and women \u03fe 75 The American Heart Association provides the follow- years), most new CHD events and coronary deaths occur ing guide in the consumption of omega-3 fatty acids for in this age group. A high level of LDL cholesterol and a reducing cardiovascular risk: low level of HDL still are predictive of the development of CHD in older persons, but TLC is the primary therapy 1. For the general population: for older people, followed by drug therapy if they are at \u2022 Eat a variety of fish (fatty fish) at least twice a week. higher risk because of multiple risk factors or advanced \u2022 Include oils and food rich in ALA (flaxseed, canola, atherosclerosis. and soybean oils; flaxseed and walnuts). Young adults (men 20 to 35 years, women 20 to 45 2. For patients with cardiovascular diseases: Consume 1 years): CHD is rare in this group except in those with se- gm\/day of EPA\u03e9DHA, preferably from fatty fish. Use vere risk factors such as family history, diabetes, heavy of capsule supplements must be under a physician\u2019s smoking, and so on. Life-habit changes and early detec- guide. tion and intervention of elevated LDL cholesterol can delay or prevent onset of CHD later in life. 3. For patients with high triglyceride levels: 2 to 4 grains of EPA\u03e9DI IA per day, provided in capsules under a RACIAL AND ETHNIC GROUPS physician\u2019s supervision. African-Americans have the highest overall CHD mor- DRUG MANAGEMENT tality rate of any ethnic group in the United States, par- ticularly at younger ages. It is accounted for by the high As we have discussed, dietary management has two ap- prevalence of coronary risk factors. Hypertension, dia- proaches: patient specific or the population as a whole. betes mellitus, cigarette smoking, obesity, physical inac- tivity, and multiple CHD risk factors occur more Initiation of drug therapy depends upon whether it is frequently in this population than in white populations. used for primary prevention (no evidence of CHD) or sec- ondary prevention (evidence of atherosclerotic disease). Other ethnic groups and minority populations in the The physician makes the decision after careful assess- United States vary somewhat in baseline CHD risk, but the ment of all factors. evidence is not sufficient to modify general recommenda- tions for cholesterol management in these populations. In primary prevention, at least six months of intensive diet therapy and counseling are usually prescribed be- Sample menus based on the TLC diet for men and fore considering drug therapy. Even one year of diet ther- women aged 25 to 49 years, as well as sample menus for apy may be considered if the patient is not at immediate several ethnic and regional groups, are found in risk. If, at this time, the LDL cholesterol still remains Appendix B. above the target level, drug therapy may be added to diet therapy. THE ROLE OF FISH OILS For those individuals with severely elevated LDL cho- In population and clinical studies omega-3 fatty acids, lesterol at the beginning, diet therapy alone will not be eicosapentaennic acid (EPA), and decosahezaenoic acid adequate. Drug therapy is started simultaneously. (DHA) found in fatty fish such as albacore tuna, herring, lake trout, mackerel, salmon, and sardines, have been All nondrug treatments should be tried: diet modifi- shown to reduce sudden cardiac death, reduce serum cation (the TLC diet), weight control, exercise, and smok- triglyceride levels, and retard the accumulation of ing cessation, before drugs are initiated. The drugs have plaques in blood vessels. Omega-3 fatty acids can also re- many side effects, are expensive, and are usually used for duce metabolic processes that increase the risk of heart the rest of the patient\u2019s life. For these reasons diet ther- diseases. The matter of safety must consider: apy and exercise are the safest and best treatment and should certainly be used as long as possible before drugs 1. Intake of more than 3 grams\/day of omega-3 fatty acid are prescribed. from capsules can cause bleeding in some patients, so this should be done only on a physician\u2019s advice. Both prescription and over-the-counter (OTC) drugs are available. The OTC drugs are nicotinic acid or their 2. Mercury contamination of fish is an established risk. derivatives. Federal agencies have issued guides about eating fish with a potential presence of mercury. Chapter 9 dis- Table 16-7 lists drugs used at present. cusses a detailed list of mercury content of commer- cial fish and shellfish and should be consulted for NURSING IMPLICATIONS details. Physicians usually refer patients to registered dietitians or other qualified nutritionists for medical nutrition ther- apy, which is the term for nutritional intervention and guidance provided by a nutritional professional. However,","CHAPTER 16 DIET THERAPY FOR CARDIOVASCULAR DISORDERS 253 TABLE 16-7 Drugs Affecting Lipoprotein Metabolism Drug Class, Agents Lipid\/Lipoprotein Clinical Trial Results and Daily Doses Effects Side Effects Contraindications HMB CoA LDL \u219318\u201355% Myopathy Absolute: Reduced major coro- reductase HDL \u21915\u201315% nary events, CHD inhibitors TG \u21937\u201330% Increased liver \u2022 Active or chronic deaths, need for (statins)* enzymes liver disease coronary proce- dures, stroke, and Relative: total mortality \u2022 Concomitant use of certain drugs Bile acid LDL \u219315\u201330% Gastrointestinal Absolute: Reduced major coro- Sequestrants\u2021 HDL \u21913\u20135% distress \u2022 dysbeta- nary events and Nicotinic acid\u00b6 TG No change or CHD deaths Constipation lipoproteinemia Fibric acids\u00a7 increase Decreased absorption \u2022 TG \u03fe 400 mg\/dL Reduced major coro- Relative: nary events, and pos- LDL \u21935\u201325% of other drugs \u2022 TG \u03fe 200 mg\/dL sibly total mortality HDL \u219115\u201335% Absolute: TG \u219320\u201350% Flushing \u2022 Chronic liver disease Reduced major coro- Hyperglycemia \u2022 Severe gout nary events LDL \u21935\u201320% Hyperuricemia (or Relative: (may be increased \u2022 Diabetes in patients with gout) \u2022 Hyperuricemia high TG) Upper GI distress \u2022 Peptic ulcer disease Hepatotoxicity Absolute: HDL \u219110\u201320% \u2022 Severe renal disease TG \u219320\u201350% Dyspepsia \u2022 Severe hepatic Gallstones Myopathy disease Unexplained non-CHD deaths in WHO study *Lovastatin (20\u201380 mg), pravastatin (20\u201340 mg), simvastatin (20\u201380 mg), fluvastatin (20\u201380 mg), atorvastatin (10\u201380 mg), cerivastatin (0.4\u20130.8 mg). \u2021Cholestyramine (4\u201316 g), colestipol (5\u201320 g), colesevelam (2.6\u20133.8 g). \u00b6Immediate release (crystalline) nicotinic acid (1.5\u20133 g), extended release nicotonic acid (Niaspan[R]) (1\u20132 g), sustained release nicotinic acid (1\u20132 g). \u00a7Gemfibrozil (600 mg BID), fenofibrate (200 mg), clofibrate (1000 mg BID). Source: Third Report of the Expert Panel on Evaluation and Treatment of High Blood Cholesterol in Adults, May 2001. the nurse has the closest contact with the patient and in 7. Provide the patient with a list of possible side effects, many instances may be the primary teacher. if drug therapy is used. If you are the primary teacher: 8. Be able to check the diet tray and recognize any er- rors in the food served. 1. Work with the health team to implement all treat- ment goals: careful assessment, diet counseling, 9. Lend assistance to the patient in selecting an ade- monitoring, and follow-up. quate menu within the limitations of the diet. 2. Provide explicit patient instruction and use good 10. Remind the patient to check labels when shopping counseling techniques to teach the patient how to fol- and describe what to look for. Meet with any others low the prescribed diet. Use an approved, up-to-date who are directly concerned in shopping and food diet manual, or other acceptable sources of material. preparation. 3. Provide the patient with a list of foods to be used, 11. Discuss appropriate cooking methods. limited, or omitted from the diet. 12. Recommend reliable resources, either persons or 4. Provide an explanation of the reasons these foods materials, when necessary. are controlled. 13. Encourage the support of family and friends. 14. Involve patients in their care through self-monitoring. 5. Encourage the use of prompts to help patients re- 15. Utilize case management and collaborative care of member. pharmacists, dietitians, and all other members of the 6. Make arrangements for diet consultation with the health team. dietitian or nutritionist to reinforce teaching.","254 PART III NUTRITION AND DIET THERAPY FOR ADULTS TABLE 16-8 Clinical Identification of the 6. The most characteristic feature in the identifica- Metabolic Syndrome tion of metabolic syndrome is Risk Factor Defining Level . Abdominal Obesity* Waist Circumference\u2020 7. Statins are the most commonly prescribed drugs Men \u03fe 102 cm (\u03fe 40 in) for . Women \u03fe 88 cm (\u03fe 35 in) \u0546 150 mg\/dl 8. Which drug is currently available OTC? Triglycerides HDL cholesterol \u03fd 40 mg\/dl . \u03fd 50 mg\/dl Men \u0546 130 \/\u0546 85 mmHg MULTIPLE CHOICE Women \u0546110 mg\/dl Blood pressure Circle the letter of the correct answer. Fasting glucose 9. Amount of fiber per day recommended in the TLC *Overweight and obesity are associated with insulin resistance diet is: and metabolic syndrome. However, the presence of abdominal obesity is more highly correlated with the metabolic risk fac- a. 10\u201315 g tors than is an elevated body mass index (BMI). Therefore, the b. 15\u201320 g simple measure of waist circumference is recommended c. 20\u201330 g to identify the body weight component of the metabolic d. 30\u201340 g syndrome. \u2020Some male patients can develop multiple metabolic risk fac- 10. Most deaths from coronary heart disease occur in tors when the waist circumference is only marginally in- which of these age groups? creased, e.g., 94\u2013102 cm (37\u201339 in). Such patients may have a strong genetic contribution to insulin resistance. They should a. men age 35\u201345 years, women age 45\u201365 years benefit from changes in life habits, similarly to men with cate- b. men over age 65 years, women over age 75 gorical increases in waist circumference. Source: Third Report of the Expert Panel on Evaluation and years Treatment of High Blood Cholesterol in Adults, May 2001. c. minority groups of all ages d. a and b PROGRESS CHECK ON ACTIVITY 1 e. a, b, and c FILL-IN 11. Which of the following groups of foods would be most suitable for a patient on a TLC diet? 1. List the five nutritional risk factors for heart disease. a. beef rounds, lamb, coconut, pasta b. tofu, chicken, catfish, peanut butter a. c. duck, avocado, shrimp, almonds d. liver, bologna, sherbert, olives b. LIST c. 12. List at least eight techniques a nurse should use d. when teaching a patient about cholesterol-lowering diet therapy. e. 2. Define TLC. 3. Name the three major features of the TLC diet. a. b. c. 4. A combination of major risk factors, life habit fac- tors, and emerging risk factors identify a condi- tion known as . 5. The total fat allowed in a LDL-lowering diet is % of total calories.","CHAPTER 16 DIET THERAPY FOR CARDIOVASCULAR DISORDERS 255 PRACTICE QUESTION trated sweets are not recommended. High-potassium foods should be encouraged if drug therapy causes loss of Write a 1-day menu for a 45-year-old Mexican-American this mineral in the urine. Some physicians prescribe spe- woman on the TLC diet. Write your menu first, then cial potassium supplements. check Appendix B and grade yourself on how well you did. DIET AND CONGESTIVE HEART FAILURE ACTIVITY 2: The treatment for congestive heart failure consists of rest Heart Disease and Sodium Restriction to reduce the demands on the heart; drug therapy to strengthen the heartbeat and slow it down; and diet ther- Dietary sodium restriction is an important part of the apy to reduce edema and decrease the workload on the medical treatment for hypertension and congestive heart heart. The dietary regimen is as follows: failure. Although hypertension is a symptom, not a dis- ease, it is one leading contributor to heart attack and 1. Reduce edema. A low-sodium diet is used, usually in stroke and is also associated with kidney diseases. For the moderate to low range. It is difficult to severely re- these reasons, controlling hypertension is one way to duce the sodium intake of a patient because such a prevent the development of these conditions. Congestive diet is most unpalatable. heart failure occurs when the heart fails to pump out the returning blood fast enough, allowing blood to accumu- 2. Decrease workload. The diet may be of soft consis- late in the right side of the heart. This raises venous pres- tency and divided into five or six small meals per day. sure (pressure in the vein from the accumulation of If the patient is overweight, the diet may also be re- blood), causing fluid retention (edema) in the heart and stricted in calories. Fluids are not usually restricted, its associated parts. but excess fluid intake is not allowed. Although indi- vidual need varies, 2000 to 3000 ml of fluid per day is DIET AND HYPERTENSION acceptable. Secondary hypertension is caused by some known fac- Some patients with hypertension and\/or congestive tor, such as a kidney disorder. The cause of essential or heart failure may also require a modification of fat or primary hypertension is unknown. Dietary factors that cholesterol intake. may cause high blood pressure include obesity and exces- sive use of salt. Some believe that caffeine in coffee and When a patient with this clinical disorder loses 6% or alcoholic beverages can potentiate the condition. New more of body weight (fat and muscle, not water) in half research indicates that calcium deficiency may be a fac- a year, the condition is known as cardiac cachexia (CC). tor in hypertension. CC signals poor prognosis with increased mortality. A low-sodium diet is usually supplemented with drug When this patient undergoes nutritional therapy before therapy (antihypertensives). Most antihypertensives con- an operation, he or she may have a better survival rate tain diuretics. While most diuretics remove water and after an operation. Therefore identifying the susceptible sodium from the body, some also remove potassium. patient is a priority, meaning that an appropriate nutri- Since the patient frequently is overweight, a low-calorie tional intervention can be implemented before the pa- diet is also prescribed. Weight loss by itself will often re- tient develops CC. duce blood pressure, especially in males. The diet should be individually prescribed and tailored to the patient\u2019s A patient with CC suffers wasting of muscle mass, need for sodium and calorie reduction. Since there are bone atrophy, lower bone density, and severe loss of fat different levels of sodium restriction and many levels of storage. Some potential candidates and causes for CC calorie restriction, the diet order must be specific to be may include the following: effective. A diet order that reads \u201csalt poor, low cal\u201d is unacceptable. Sodium is ordered in milligrams or grams, 1. Senior patients suffering from anorexia, difficulty in and calories by a specific number designed to help the pa- chewing and swallowing, nausea from medications, tient lose weight. An adequate diet under 1200 calories depression, and isolation. daily is difficult to plan; it results in low patient compli- ance, especially with long-term usage. A normal level of 2. Patients undergoing diuretic treatment, where mi- protein of high biological value is recommended. Fats in cronutrient and antioxidant deficiencies created by the diet are moderately low and the types of fat flexible. the therapy can also precipitate malnutrition or mus- Unsaturated fats used within the caloric allowance are cle wasting. Micronutrients involved include sele- more acceptable than saturated fats. Carbohydrates pro- nium, copper, zinc, and magnesium. The diuretic vide up to 50% of the total caloric intake, but concen- therapy may also precipitate calcium losses. These nutrient deficiencies increase the rate of oxidative stress, one major cause of muscle wasting. 3. Other potential problems that may lead to CC include abnormal clinical conditions such as higher require- ment for resting energy expenditure, lower capacity to exercise, and edema.","256 PART III NUTRITION AND DIET THERAPY FOR ADULTS CC can lead to serious problems for the patient. When TABLE 16-9 Foods Excluded in a 3- to 5-Gram diagnosed early it can be treated. Therapy includes but is Sodium Diet not limited to nutritional intervention, drug manage- ment, scheduled physical activity, use of medical devices, Meat Group Fruit and Vegetable Group and heart transport. 1. Cured, canned, or 1. Any vegetable prepared THE SODIUM-RESTRICTED DIET smoked meats and fish in brine 2. Canned dried beans, The average intake of sodium in the American diet ranges 2. Sauerkraut from 3 to 8 grams per day. Although some sodium is es- meat stews, soups sential for body functioning, the amount needed is ap- 3. Meat analogs, e.g., 3. Canned tomatoes; proximately 1\u20442 to 1 gram daily. The main source of tomato juice sodium in our diets is table salt (sodium chloride). Salt imitation bacon bits is about 40% sodium by weight. It is used extensively in 4. Cheeses: regular, 4. Tomato sauce or paste food processing for items such as processed meats (lunch meat, ham, bacon, canned meats, and fish), dried foods, processed 5. V-8 juice sauerkraut, olives, and pickles. It is used in baking and 5. Frozen TV dinners cooking, and then used again at the dining table. In ad- 6. Ready-prepared meats Other dition, most foods contain some sodium before any pro- cessing or cooking takes place. Some unprocessed foods in gravy or sauces 1. Salted sauces and are higher in naturally occurring sodium than others. 7. Kosher meats seasonings: barbecue For example, meats, milk, and eggs are high in natural sauce, chili sauce, sodium, whereas most plant foods are low. There are ex- Grain Group meat sauce, ceptions. Beets, spinach, chard, and kale are fairly high 1. Salty crackers Worcestershire sauce, in sodium. Fruits, oils, sugars, and cereal grains contain 2. Rolls with salted tops etc.; any type of salt, only a trace of sodium or none at all, if no sodium chlo- 3. Seasoned mixes (e.g., including tenderizers ride is added in processing. If a diet is based on the basic and flavor enhancers food groups, unsalted bread\/butter and unprocessed stuffing, pasta, rice) grains and meats are used, and no salt is used during 2. Salted snacks: chips, cooking or at the table, then the diet contains approxi- Milk Group pretzels, popcorn, nuts, mately 500 mg sodium. It is not difficult to see how we 1. Cheese spreads pickles, olives, seeds can \u201coverdose\u201d our foods with sodium. 2. Processed cheese 3. Miscellaneous: mus- The Diet Guidelines for Americans recommends the (cheese spreads) tard, relishes, bacon use of salt and sodium in moderation (see Chapter 1.) 3. Cheese: Roquefort, drippings, bouillon Four levels of sodium restriction are recommended by cubes, catsup, etc. the American Heart Association to control a patient\u2019s blue, camembert sodium intake. The levels vary from 250 mg up to 3 to 5 4. Salted buttermilk grams of sodium daily. Moderate Sodium Restriction The DASH diet (Dietary Approach to Stop Hyper- (1000 Milligrams Daily) tension) from the NIH is more commonly recommended to prevent or control hypertension than is the AHA diet. This diet is used both in the hospital and at home. In ad- The eating plan is rich in various nutrients believed to dition to avoiding the foods indicated for the 3- to 5-gram benefit blood pressure and in other factors involved in sodium diet, the diet has the following restrictions: maintaining good health. The sodium content is ~2400 mg\/day. Access DASH from the following Web site: www. 1. No more than 2 c milk per day. nhlbi.nih.gov\/health\/public\/heart\/hbp_low\/recap.htm. 2. No more than 5 oz meat per day. One egg may be sub- Mild Sodium Restriction (3 to 5 Grams Daily) stituted for 1 oz meat. 3. No salt in cooking. This is a regular diet that omits only salty foods and the 4. Bread and butter beyond three servings daily should use of salt at the table. Salt may be used lightly in cook- ing; for example, use half the amount stated in the be unsalted. recipe. This diet is used frequently after discharge from 5. No commercial mixes or regular canned vegetables. the hospital, when edema is under control. A wide va- riety of foods from the basic food groups is recom- Strict Sodium Restriction mended. Table 16-9 illustrates the foods to avoid within (500 Milligrams Daily) each food group. This diet is used primarily for hospitalized patients, though it may be followed at home. The restrictions, how- ever, result in low patient compliance except in a hospi- tal setting. In addition to the restrictions indicated for 3- to 5-gram and 1000-mg sodium diets, two other restric- tions are required to lower the dietary sodium to 500 mg: 1. No bread and butter that has salt added 2. No vegetables that are naturally high in sodium content","CHAPTER 16 DIET THERAPY FOR CARDIOVASCULAR DISORDERS 257 Severe Sodium Restriction put records are necessary. Meal sizes and intervals (250 Milligrams Daily) may need adjusting. 6. Check for inadequate potassium intake when antihy- The substitution of low-sodium milk for regular milk in pertensives are used. the 500-mg sodium diet will lower the dietary sodium 7. Be aware that iodine intake may be low when salt is content to 250 mg. restricted. 8. Do not suggest salt substitutes without asking the The Exchange Lists for Meal Planning, issued by the physician first: there may be impaired renal function American Dietetic Association and the American Diabetic or, if a potassium supplement is being used, a patient Association (see Appendix F), may be modified for the could develop hyperkalemia. Salt substitutes are high various levels of sodium restriction. This booklet is a in potassium. helpful tool for diet planning, particularly when a caloric or fat modification is also necessary. PROGRESS CHECK ON ACTIVITY 2 Some drinking water is high in sodium, especially if FILL-IN water softeners are used. Patients on low-sodium diets should ascertain their drinking water\u2019s sodium content 1. Complete Exercise 16-1. and, if necessary, use distilled water. 2. Write a day\u2019s menu for a person on a 500-mg Many drugs, both prescription and over-the-counter, sodium diet with no calorie restriction (use sepa- contain high levels of sodium. Patients need to be made rate sheet). aware of these. 3. List 10 appropriate seasonings that may be used in place of salt. NURSING IMPLICATIONS a. The nurse should follow the following guidelines. b. 1. Be aware that sodium-restricted diets are unpalat- c. able, especially at very restricted levels. d. 2. Be prepared to offer alternative seasonings to enhance flavor and encourage the patient to consume an ade- e. quate diet. f. 3. Caution patients to read the labels on foods and to avoid self-medication. Check medications received in g. the hospital, and, if they are too high in sodium, ask about alternates. h. 4. Check trays of all patients on sodium-restricted diets i. to make sure salt has not been included accidentally. j. 5. Recognize that patients with congestive heart failure tend to have poor appetites. Accurate intake and out- Exercise 16-1 Complete Each Column with the Appropriate Information Diet Disease or Foods Foods Foods Nursing 5000 mg sodium Condition Allowed Limited Forbidden Implications 1000 mg sodium 500 mg sodium 250 mg sodium","258 PART III NUTRITION AND DIET THERAPY FOR ADULTS ACTIVITY 3: 4. Depending on the patient, the diet may be low in calo- ries, sodium, fat, and\/or cholesterol. Dietary Care After Heart Attack and Stroke After the initial emergency measures, the health team MYOCARDIAL INFARCTION (MI): will implement many care procedures, and those affect- HEART ATTACK ing eating and diet will include the following: Priority is given to life-saving measures immediately fol- 1. An evaluation of the patient is made by a speech ther- lowing a myocardial infarction (MI). An intravenous line apist and an occupational therapist. (IV) is prepared and inserted. If needed, the IV can be used to administer drugs and regulate fluid and elec- 2. The patient\u2019s food and beverage tolerance is observed, trolyte balance. applying aspiration when necessary. The goals of diet therapy are to reduce the workload 3. Initially, the patient is fed thickened liquids with a of the heart, restore and maintain electrolyte balance consistence of a nectar, honey, or pudding when and, after a brief period of undernutrition, to maintain an indicated. adequate nutritional intake. The diet therapy progresses as follows: 4. Commercial preparations such as roll thickeners (Thick It) or other prethickened products may be or- 1. For the first 24 to 48 hours after oral feedings are or- dered from the food service department. dered by the physician, the patient receives only clear liquids. 5. Standard procedures indicate the texture of the food be modified according to the dysphagia diet used rou- 2. The liquid diet is followed by a low-residue diet, and tinely in hospitals. This diet progresses in 4 stages. then a soft diet. Foods are divided into five to six small Stage 1: Diet is pureed. meals. The diet also may be restricted in sodium, if Stage 2: Diet is mechanically changed to a semi- necessary. solid and moist consistence that is cohesive with the following characteristics: 3. Beverages containing caffeine are omitted. a. Presence of some chewing ability 4. The physician may prescribe fluid restriction, if intake b. Meats that are grounded or minced c. Fruits and vegetables fork-mashable and output records warrant. d. No dry food such as bakery products (bread, 5. Constipation may accompany a restriction of fiber crackers) Stage 3: Diet is advanced to soft solids with the fol- and\/or fluids. Nursing measures to solve this compli- lowing characteristics: cation are needed. a. More chewing ability 6. A gradual return to regular foods, with a restriction b. Meats that can be cut easily of sodium, fat, and\/or cholesterol for certain patients. c. Fruits and vegetables that are not hard and crunchy CEREBROVASCULAR ACCIDENT (CVA): d. Sticky food STROKE e. Foods with little moisture Stage 4: Diet is a regular one with solid textures. As with a myocardial infarction, the first measures taken by health professionals after a cerebrovascular accident There are other considerations for a patient suffering are life saving, not dietary. Ongoing therapy focuses on from a stroke: restoring and maintaining adequate nutrition. Diet ther- apy after a CVA progresses as follows: 1. Visual impairment 2. Low appetite 1. An intravenous line is used for the first 24 to 48 3. Use of tube feedings hours. Careful monitoring is necessary. Fluids must 4. Food-drug interactions be restricted if cerebral edema is present. 5. Lifestyle modification if indicated 2. If the patient is comatose, tube feeding will be the The health team is familiar with all the above issues diet of choice after IV therapy. Oral liquid feedings and adjustments. Lifestyle modification is an important may begin when the patient is conscious. If the pa- public concern. The issues cover exercise, lowering blood tient develops paralysis of one side of the throat, he or pressure, salt intake, and the quantity and quality of fat she will choke more easily on liquids than on semi- consumed. Government and private institutions have solids. In the event of such paralysis, very thick liquids made recommendations, most of which have been pre- or very soft solids may be necessary. sented in various chapters in this book. Use the index to find the appropriate chapter for more details. 3. Eventually, with training, the patient may return to a regular diet.","CHAPTER 16 DIET THERAPY FOR CARDIOVASCULAR DISORDERS 259 NURSING IMPLICATIONS PROGRESS CHECK ON ACTIVITY 3 The responsibilities of the nurse include the following: FILL-IN 1. Assess food deficits as soon as oral feedings are re- 1. List five hidden sources of sodium. sumed, and take measures to restore sufficient intake. a. 2. Allow self-feeding for both MI and CVA patients as b. soon as possible. c. d. 3. Position the patient to allow maximum use of his or e. her remaining abilities and to give the patient some control. 2. List 10 seasonings that may be used freely on a low-sodium diet. 4. Schedule nursing care and treatment far enough in advance of meals to let the patient rest before eating. a. b. 5. Relieve pain before meals are served. c. 6. Promote comfort, relieve anxiety, and be very patient. d. 7. Explain all restrictions in the patient\u2019s diet. e. 8. Teach diet restrictions when the patient is able to lis- f. g. ten (when anxiety and fear have diminished). h. 9. Make arrangements for those involved in food pur- i. j. chasing and preparation to be involved in the teach- ing session with the dietitian. 3. State five nursing measures applicable to the feed- ing of a CVA patient with right-sided hemiplegia PROGRESS CHECK ON NURSING IMPLICATIONS who is not comatose. FILL-IN a. b. 1. List four objectives of diet therapy for a patient c. who has had a myocardial infarction. d. e. a. 4. Explain the rationale for a diet therapy that speci- b. fies \u201csoft 2 g sodium in 6 feedings\u201d for a 5-day, post-MI patient. c. d. 2. List as many nursing measures as you can think of to assist a stroke victim to ingest an adequate diet. a. b. c. d. e. f. g. h. i. j.","260 PART III NUTRITION AND DIET THERAPY FOR ADULTS MULTIPLE CHOICE Klein, S. (2007). Waist circumference and cardiometa- bolic risk: A consensus statement from Shaping Circle the letter of the correct answer. America\u2019s Health: Association for Weight Management and Obesity Prevention: NAASO, The Obesity Society: 5. Which of the following menus would be the best The American Society for Nutrition; and The Ameri- choice for a person on a 1-g sodium, low- can Diabetes Association. American Journal for cholesterol diet? Nutrition, 85: 1197\u20131202. a. split pea soup, crackers, tuna salad, ice cream, Lichtenstein, A. H. (2008). Cardiovascular disease. In and tea Thompson, L. U., & Ward, W. E., (Eds.). Optimizing Women\u2019s Health Through Nutrition. Boca Raton, FL: b. scrambled eggs, baked potato, fruit salad, CRC Press. baked apple, and skim milk Lopez-Miranda, J. (2006). Monounsaturated fat and cardio- c. broiled fresh trout with lemon, baked potato, vascular risk. Nutrition Reviews, 64, (10, part 2): s2\u2013s12. sliced tomato salad, skim milk, and peach halves Mahan, L. K., & Escott-Stump, S. (Eds.). (2008). Krause\u2019s d. prime rib roast, broccoli, mashed potatoes, Food and Nutrition Therapy (12th ed.). Philadelphia: sliced pineapple, and tea Elsevier Sauders. 6. From the following list, which foods would be most Mann, J. (2007). Dietary carbohydrate: Relationship to suitable for a person on a 500-mg sodium diet? cardiovascular disease and disorders of carbohydrate metabolism. European Journal of Clinical Nutrition, a. tuna fish salad with lettuce 61: s100\u2013s111. b. sliced turkey with cranberry sauce c. scalloped potatoes and ham Mann, J., & Truswell, S. (Eds.). (2007). Essentials of d. honey and peanut butter sandwich Human Nutrition (3rd ed.). New York: Oxford Uni- versity Press. REFERENCES Mead, A. (2006). Dietary guidelines on food and nutri- American Dietetic Association. (2006). Nutrition tion in the secondary prevention of cardiovascular Diagnosis: A Critical Step in Nutrition Care Process. disease-evidence from systemic reviews of random- Chicago: Author. ized controlled trials (2nd update). Journal of Human Nutrition and Dietetics, 19: 401\u2013419. Beham, E. (2006). Therapeutic Nutrition: A Guide to Patient Education. Philadelphia: Lippincott, Williams Merchant, A. T. (2008). Interrelation of saturated fat, trans and Wilkins. fat, alcohol intake, and subclinical atherosclerosis. American Journal of Clinical Nutrition, 87: 168\u2013174. Bendich, A., & Deckelbaum, R. J. (Eds.). (2005). Preventive Nutrition: The Comprehensive Guide for Health NHLBI. (2001). Third Report of the Expert Panel on Professionals (3rd ed.). Totowa, NJ: Humana Press. Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Burrowes, J. D. (2007). Preventing heart disease in Executive Summary. Washington, DC: National Cho- women: What is new in diet and lifestyle recommen- lesterol Education Program (NCEP), National Heart, dations. Nutrition Today, 42: 242\u2013247. Lung, and Blood Institute. Chow, C. K. (2006). Does potassium-enriched salt or Ordovas, J. M. (2007). Nutrition in the genomics era: sodium reduction reduce cardiovascular mortality and Cardiovascular disease risk and the Mediterranean diet. medical expenses? American Journal of Clinical Molecular Nutrition and Food Research, 51: 1293\u20131299. Nutrition, 84: 1552\u20131553. Rudolph, T. K. (2007). Acute effects of various fast-food Coulston, A. M., Rock, C. L., & Monsen, E. L. (Eds.). meals on vascular functions and cardiovascular dis- (2001). Nutrition in the Prevention and Treatment of ease risk markers: The Hamburg Burger Trial. Amer- Disease. San Diego, CA: Academic Press. ican Journal of Clinical Nutrition, 86: 334\u2013340. Deen, D., & Hark, L. (2007). The Complete Guide to Ryan, D. (2007). Bioactivity of oats as it relates to cardio- Nutrition in Primary Care. Malden, MA: Blackwell. vascular disease. Nutrition Research Reviews, 20: 147\u2013162. Dietary guidelines for Americans (6th ed.). (2005). Washington, DC: United States Department of Agricul- Shils, M. E., & Shike, M. (Eds.). (2006). Modern Nutrition ture (USDA) and United States Department of Health in Health and Disease (10th ed.). Philadelphia: Lippin- and Human Services (U.S.-DHHS). www.healthierus.gov. cott, Williams and Wilkins. Haas, E. M., & Levin, B. (2006). Staying Healthy with Stipanuk, M. H. (Ed.). (2006). Biochemical, Physiological Nutrition: The Complete Guide to Diet and Nutrition and Molecular Aspects of Human Nutrition (2nd ed.). Medicine (21st ed.). Berkeley, CA: Celestial Arts. St. Louis, MO: Elsevier Saunders. Hill, A. M. (2007). Combining fish-oil supplements with Temple, N. J., Wilson, T., & Jacobs, D. R. (2006). Nutrition regular aerobic exercise improves body composition Health: Strategies for Disease Prevention (2nd ed.). and cardiovascular disease risk factors. American Totowa, NJ: Humana Press. Journal of Clinical Nutrition, 85: 1267\u20131274.","OUTLINE 17C H A P T E R Objectives Diet and Disorders of Glossary Ingestion, Digestion, and Background Information ACTIVITY 1: Disorders of the Absorption Mouth, Esophagus, and Time for completion Stomach Mouth Activities: 1\u20131\u20442 hours Esophagus: Hiatal Hernia Optional examination: 1\u20442 hour Stomach: Peptic Ulcer Gastric Surgery for Ulcer OBJECTIVES Diseases Nursing Implications Upon completion of this chapter, the student should be able to do the Progress Check on Activity 1 following: ACTIVITY 2 : Disorders of the 1. List the diet modifications used in certain gastrointestinal disorders. Intestines 2. Explain the rationale for the use of diet modifications. Dietary Fiber Intake 3. Describe the diet modification sequence and progression. Constipation 4. List foods that meet the diet requirements. Diarrhea 5. State nursing implications for dietary care. Diverticular Disease Inflammatory Bowel Disease GLOSSARY Nursing Implications Gastric Surgery for Severe Antiemetics: an agent (drug) that relieves vomiting. Obesity Aspiration: the act of inhaling. Pathological aspiration of vomitus or mucus Colostomy and Ileostomy Nursing Implications into the respiratory tract (lungs) may occur when a patient is unconscious Progress Check on Activity 2 or under the effect of anesthesia. References Cachexia: general wasting of the body, especially during chronic disease. 261","262 PART III NUTRITION AND DIET THERAPY FOR ADULTS Cholinergic: an agent (drug) that stimulates the action very first ever used in the treatment of diseases. of the sympathetic nerves. Unfortunately, many have not changed much since they were first used, even though recent research has shown Colostomy: creation of an opening between the colon that some of the diets used to treat diseases are ineffec- and surface of the body. A surgical procedure. tive and incompatible with the clinical conditions of pa- tients. Two notable examples include the diets for Defecate: to eliminate waste and undigested food from diverticular diseases and peptic ulcer. the rectum. Psychological factors play a role when we consider Esophageal varices: varicose veins in the esophagus. many disorders of the GI tract. The digestive system is Flatulence: excessive formation of gas in intestinal tract. said to \u201cmirror the human condition.\u201d If this is true, then Gallstones: precipitation of cholesterol crystals in the specific foods do not cause the problem in all cases; rather, the psychological state of the body that receives gallbladder to form stones. them can be responsible. Stress factors such as anxiety, Gastrectomy: removal of part of the stomach. fear, work pressure, grief, emotional makeup, and coping Helicobacter pylori (H. pylori): common rod-shaped bac- patterns have a great deal to do with how or if foods are tolerated. If a person has specific food allergies or a phys- teria that live in the gastrointestinal tract around the iological basis for food intolerance (such as an enzyme pyloric valve, lower gastric antrium, and upper duo- deficiency), then the offending foods obviously should denal bulb. They are well known for their role in not be eaten. Otherwise, as in the case of an ulcer pa- chronic gastritis and, more recently, in the gastric tient, there is no sound basis for the traditional diet ther- ulcer process. apy that permits only soft, white, or mildly flavored foods. Hemorrhoidectomy: surgical removal of varicose veins in the mucosa either outside or just inside the rectum. Frequently, patients who have experienced traditional Ileostomy: creating an opening between the ileum and diet therapy will challenge a prescription of modern diet the surface of the body by establishing a stoma (see therapy. Nurses must understand and be prepared to ex- Stoma) on the abdominal wall. plain the newer concepts of dietary management. Ileum: distal portion of the small intestine extending from jejunum to cecum. ACTIVITY 1: Immunotherapy: passive immunization of an individual with preformed antibodies. It activates the entire im- Disorders of the Mouth, Esophagus, mune system to fight off disease. Most recently used and Stomach in terminology relating to treatment of cancer. Intraluminal: within the lumen (wall) of a tubular MOUTH structure. Jejunum: part of the small intestine extending from the Cleft Lip and\/or Palate duodenum to the ileum. Mucosa (mucous membrane): the membrane that lines A congenital defect of newborns, cleft lip and\/or palate is the tubular organs of the body. corrected by a series of surgeries after the infant reaches NSAIDS: nonsteroidal anti-inflammatory drugs. a weight safe enough to withstand a surgical procedure. Osteomate: one who has had an ostomy (colostomy or These infants have a high nutritional requirement to pre- ileostomy). These are surgical procedures for creat- pare for surgery and rapid growth. The care provider ing an opening to the outside of the body for the elim- must practice care in the positioning and feeding of these ination of waste. children to prevent aspiration. Certain types of nipples Pectin: a carbohydrate that forms a gel when mixed with and\/or tubing may be required for infant feeding. a sweetened liquid. Families need counseling in the feeding and care of these Pylorus: a distal part of the stomach opening into the infants. Nurses should receive additional training when duodenum. Contains many glands that secrete hy- caring for and teaching others to care for such patients. drochloric acid. Stoma: a mouthlike opening. A surgical opening kept Dental Caries open for drainage and other purposes. Varices: plural for varix; an enlarged, tortuous vein, ar- Almost all children in the United States are afflicted with tery, or lymph vessel. decayed teeth, and about 30% of Americans past the age of 25 wear full dentures. While poor dental hygiene (im- BACKGROUND INFORMATION proper brushing, not flossing, and failing to get check- ups) may account for part of the problem, much is dietary The gastrointestinal (GI) tract extends from the mouth in nature. Lack of essential nutrients such as calcium, to the anus. All disturbances related to food intake, diges- phosphorus, fluorine, and vitamins D, A, and C affect tion, absorption, and elimination affect the GI tract and usually require special diets. Such diets were among the","CHAPTER 17 DIET AND DISORDERS OF INGESTION, DIGESTION, AND ABSORPTION 263 tooth and gum formation and development. Because both The treatment of choice is to wire the jaws together, deciduous (\u201cbaby\u201d) and permanent teeth are formed in which poses obvious problems with eating. A diet high in utero (before birth), the diet of the mother affects the protein, calories, minerals, and vitamins is necessary for offspring\u2019s teeth. Fetuses are not parasites and cannot proper healing. Liquid food must pass through a straw necessarily derive adequate amounts of each nutrient without moving the jaw. Care must be taken to prevent needed for development from the mother. Some children choking, and a wire cutter must be close at hand to cut are born without all of their permanent teeth buds, and, the wire if choking occurs. As the person is usually home in this case, it is prudent to maintain deciduous teeth as for a considerable length of time before the wires are re- long as possible. moved, the caretaker must be taught how to use the wire cutter. Since the practice of oral hygiene is difficult, the A youngster\u2019s diet affects the strength and function oral tissues must be cleaned by a special and thorough of his or her teeth. Milk, juice, or sweetened drinks left procedure to prevent bacterial growth. Lack of adequate in the bottle against an infant\u2019s gums during sleep can cleaning can cause cavities and produce odors that de- cause decay of newly erupted teeth. This is known as the crease the appetite. Table 17-1 lists examples of foods \u201cbaby bottle syndrome.\u201d Children learn to like sweets if suitable for the person with a fractured jaw. they receive them early in their diet. It is believed that the high use of concentrated sweets, especially the sticky ESOPHAGUS: HIATAL HERNIA type, is the main culprit in the formation of cavities (den- tal caries). The esophagus is separated from the stomach by the di- aphragm. When the stomach partially protrudes above Health promotion measures that will benefit oral tis- the diaphragm because of the weakening of the diaphragm sues throughout life include a well-balanced diet with opening, hiatal hernia results. Hiatal hernia is usually adequate amounts of essential nutrients, limitation or treated with antacids and a low-fat diet. Six small feedings omission of sweets, and proper oral hygiene and dental per day are recommended, and fluids are taken between care. meals. Foods that irritate esophageal mucosa are eliminated\u2014for example, orange, tomato, or grapefruit Dentures juices. Alcoholic beverages should be avoided. Patients should not eat within two hours of bedtime. Extra fluids The wearing of dentures can be a mixed blessing. If prop- and laxative foods help to prevent constipation that can erly fitted, they provide the ability to ingest a variety of put pressure on the esophagus. Patients should not lie foods not possible otherwise. Dentures are cosmetically at- down or bend over after eating. Extra height in the form tractive and improve self-esteem, but there are disadvan- of pillows or an elevated bed-head for sleeping is recom- tages associated with them. As bone recedes after teeth mended. If the patient is obese, weight loss will improve have been extracted, frequent realignments are mandatory the clinical condition. Fats are usually avoided, since they for proper fit. Loose dentures may collect particles un- tend to lower esophageal pressure and add calories. derneath them, causing pain. Rubbing between dentures and the gum tissue creates sore spots that can lead to in- STOMACH: PEPTIC ULCER flammation or even tumors. The health of the gums on which dentures rest determines the success of wearing Dietary Management dentures. An adequate supply of vitamins A and C, along with other nutrients, is essential to gum tissue integrity. Peptic ulcer is the most common of the problems affect- ing the upper GI tract. An ulcer is an erosion of the stom- Many older people have ill-fitting dentures or no den- ach, pylorus, or duodenum. Ulcers occur only in areas tures at all, even though they may have no teeth. This can affected by excess hydrochloric acid and pepsin (an en- cause great difficulty in chewing food, and therefore, in zyme). The most common location is the duodenal bulb, the digestion of food. This leads to a decreased intake of because the gastric contents emptying through the py- fiber and other essential nutrients, since unchewed and loric valve are most concentrated in acid at this point. The undigested foods are not absorbed. The effect of this con- following are the major causative factors of peptic ulcer: dition on health is obvious. 1. Increased acidity and secretion of gastric juices Whenever dental problems exist or dentures are ab- 2. Decreased secretion of mucous lining and buffers sent, the mechanical soft diet is preferred, since it pro- 3. Prolonged use of nonsteroidal anti-inflammatory vides adequate nutrition and ease of chewing. Chapter 12 provides additional information on the mechanical drugs (NSAIDs) such as aspirin, ibuprofen, and others soft diet. 4. Helicobacter pylori (H. pylori) infection\u2014Infection Fractured Jaw by this bacteria, along with hydrochloric (HCl) acid and pepsin secretion, is now believed to be a major The nutritional needs for a person following the trauma cause of ulcers. of a fractured jaw are high, as in other types of fractures.","264 PART III NUTRITION AND DIET THERAPY FOR ADULTS TABLE 17-1 Foods for a Patient with a Fractured Jaw Composition of feedings These are oral feedings composed of approximately 250 g carbohydrate 115 g protein 110 g fat 2400 calories General instructions 1. Follow the family menu as closely as possible, if the meal pattern is adequate. 2. Plan for the increase in protein by using meats of all kinds (beef, pork, poultry, lamb, veal, fish, organ meats) and meat substitutes such as eggs, cottage cheese, other soft cheeses, and yogurt. 3. All meats should be lean and, with the exception of beef, should be well cooked; beef may be used raw or rare if desired. Use sufficient broth when blending. 4. All meats, vegetables, breads should be cubed before being added to blender. Eggs should be added last when blending. 5. If butter or margarine is used, it should be very soft or melted before adding to mixture. 6. It may be necessary to strain the mixture after it has been blended to prevent clogging. 7. Variety can be obtained by using soups, vegetable juices, or broths for blending instead of milk, but be aware that this lowers total caloric intake. 8. The patient should participate in the selection of the various meats, vegetables, and pastas that go into the blender. Meal plan for oral liquid feedings Breakfast Lunch Dinner Strained juice Fruit drink Fruit eggnog Hot blended drink Hot blended drink Hot blended drink Coffee\/cream\/sugar if desired Coffee\/cream\/sugar if desired Beverage of choice or Beverage of choice or Beverage of choice Supplemental Feedings To increase caloric intake over 2400 add any of these: fruit drink, fruit eggnog, a thick milkshake, liquid gelatin, chocolate milk, malted milk, or regular eggnog. Dry milk powder or vitamin supplements may be added to increase nutrients upon recommen- dations of the physician. Recipes: follow for those items marked Recipes for oral feedings: Hot Blended Drink #1 1\u20442 c cooked refined cereal such as farina, grits, cream of wheat, etc. 1 c hot milk* 2 soft-cooked eggs 1 tsp melted butter or margarine 1\u20442 tsp salt (optional) Mix all ingredients except fat. Blend to desired consistency and strain. Add the melted fat and salt. Reheat to desired temperature. Hot Blended Drink #2 1\u20442 c cubed poultry, veal, pork, lamb, or cheese 1\u20442 c cooked rice or pasta 1\u20442 c cooked vegetable of choice 1\u20132 slices whole wheat bread, cubed 11\u20442 c milk* 1 tsp melted butter or margarine 1\u20442 tsp salt (optional) Blend the meat or substitute separately with 1\u20442 c of the milk for approximately 2 min- utes. Add rice or pasta, vegetable, and bread. Add remaining milk and salt. Blend to desired consistency. Strain the mixture. Add the melted fat and reheat to desired temperature before serving. (continues)","CHAPTER 17 DIET AND DISORDERS OF INGESTION, DIGESTION, AND ABSORPTION 265 TABLE 17-1 (continued) Hot Blended Drink #3 1\u20442 c chopped raw or rare beef or ground beef patty 1 c broth* 1\u20442 c cooked or canned vegetable of choice 1\u20442 c cooked potato (without skins) 1 c milk, tomato juice, or cream soup* 1 tsp melted butter or margarine 1\u20442 tsp salt (optional) Blend beef and broth together for approximately 2 minutes. Add other ingredients except fat. Blend together to desired consistency. Strain. Add fat and salt. Heat to desired tem- perature before serving. Fruit Drink 1 banana or 1\u20442 c any canned or cooked fruit 2\u20443 c fruit juice, preferably a vitamin C source (orange, grapefruit)* Blend. Strain. Chill before serving. Fruit Eggnog To the above recipe for fruit drink, add 2 tsp lemon juice, 1 tbsp sugar, and 1 egg. Blend. Strain. Serve cold. *All liquids used may be increased to thin the mixture to the consistency that will not clog a straw. Treatment goals for the peptic ulcer are to relieve pain, dition of the individual, determined after a complete heal erosion, prevent complications, and prevent recur- nutritional assessment, will determine the amount rences. Therapy usually includes rest, antacids, and an- of calories and nutrients needed. ticholinergics. Physicians recommend reduction of 2. Another change that has occurred in the dietary man- ulcer-predisposing factors such as stress, hurried or agement of peptic ulcer is that of the meal pattern: skipped meals, and excess coffee, colas, smoking, and Patients are advised to eat three meals a day without aspirin. snacks, especially at bedtime. This change from former meal plans is to avoid the production of excess acid. Current drug therapy for ulcers now includes the use 3. Meal size should be moderate; large meals cause dis- of histamine receptor blockers (H2 blockers) such as tention and pain. Tagamet, Zantac, Axid, and Pepsid. Some newer, more 4. There is no need to eliminate a particular food unless potent drugs approved for use help ulcers to heal more it causes repeated discomfort. rapidly. Antacids are still used as standard therapy, the 5. Dietary fiber, especially soluble dietary fiber, is not preferred ones being those with a magnesium or alu- restricted. In fact, it is encouraged according to pa- minum base, such as Maalox or Mylanta. Calcium-based tient tolerance. antacids (e.g., Tums) are thought to stimulate acid se- 6. Individualized tolerances include: cretions and are not generally recommended. Antibiotics, a. Seasonings: Hot chilies and black pepper are com- including Flagyl, Achromycin, and Amoxil, are used to counter the H. pylori bacteria. (The drugs mentioned are mon irritants; other than these, the individual may brand names. Consult the Physician\u2019s Desk Reference have any seasonings that do not cause a problem. for more information.) b. Alcohol: High-proof alcohols (80 proof) and beer are potent gastric juice stimulants and should be These drugs are used in tandem with the general avoided. Some patients tolerate small amounts of measures of adequate rest, sleep, and stress-reduction wine when taken with a meal. measures that have always been standards. c. Coffee (regular and decaffeinated), tea, and colas are to be avoided as they are gastric stimulants. If small Principles of Diet Therapy for Peptic amounts of coffee are used, the coffee should be Ulcer Disease drunk with or after a meal to minimize its effects. 7. General recommendations: 1. A highly restrictive diet is no longer ordered for pep- a. Avoid aspirin and other NSAIDS. If pain medica- tic ulcer. The diet is a regular one that follows dietary tion is needed, use the acetaminophen types (e.g., guidelines, with enough increases for tissue healing Tylenol). and promotion of optimal nutritional status. The con-","266 PART III NUTRITION AND DIET THERAPY FOR ADULTS b. Eliminate smoking. potatoes, and tender beef or chicken. Milk and reg- c. Eat slowly in a calm environment. ular carbonated beverages are not included, and liq- d. Antidepressant therapy may be prescribed for some uids are given separately from solid foods. These precautions are to prevent development of the patients as a sedative and for relaxation. \u201cdumping syndrome.\u201d e. If a patient is in acute pain when admitted, the diet 6. Resume a regular diet gradually. will require modification to lessen symptoms. The The \u201cdumping syndrome\u201d is a complication of gastric regular diet will be reordered when the pain is surgery that may occur a short time after recovery from gone. Most diet manuals in facilities contain some the operation, after eating is resumed. It may also be the form of modified diet therapy suitable for these delayed type, occurring from one to five years after a gas- conditions. trectomy. It is more likely to occur in the patient who has had two-thirds or more of the stomach removed. Patients and physicians accustomed to the traditional diets have been slow to accept the liberal diet. Most hos- The process is as follows: Food reaches the jejunum 10 pitals generally offer the minimum fiber diet initially to to 15 minutes after eating. With part of the stomach re- ulcer patients (see Chapter 14). Individual changes are moved, the food is not digested properly and, instead of made toward a regular diet as the patients and their con- being delivered slowly, it is \u201cdumped\u201d quickly into the ditions indicate acceptance and improvement. small intestine. The patient then experiences nausea, cramping, weakness, dizziness, cold sweating, a rapid Nursing responsibilities in treating ulcer patients are pulse, and possibly vomiting. These symptoms of shock as follows: occur as the concentrated foodstuff draws water from the body tissues into the intestine. The symptoms are es- 1. Explain the rationale for use of the newer diet ther- pecially severe when the meal is high in simple carbohy- apy (some patients are very fearful and skeptical of drate, which can exert high osmotic pressure. Two to the less restrictive diet). three hours after the meal, hypoglycemic symptoms may occur, because the absorbed monosaccharides, especially 2. Evaluate the diet for nutritional adequacy after indi- glucose, cause a rapid rise in blood glucose. This, in turn, vidual changes have been made. stimulates the body to produce more insulin that quickly removes the excess glucose from the blood, resulting in 3. Encourage the consumption of laxative foods, espe- hypoglycemia. cially if the patient is prescribed antacids, which cause constipation. The aim of diet therapy is to provide the patient with optimum nutrition that will control these symptoms: 4. Explain the adoption of a less stressful lifestyle to help prevent a recurrence. 1. Small, frequent meals (that will not overload the je- junum) eaten slowly. 5. Intervene on the patient\u2019s behalf if the prescribed diet is not tolerated. 2. No liquid during meals and the following hour; the absence of liquid slows absorption. GASTRIC SURGERY FOR ULCER DISEASES 3. High-protein foods for tissue repair and moderately Perforation and hemorrhage are two major complications high-fat foods to add calories and delay the time food of ulcer disease for which surgery is indicated. The types is emptied from the stomach. of surgical procedures can be found in all nursing and medical texts, but space prohibits discussion here. After 4. Moderate to low amounts of complex carbohydrate the initial period of NPO and fluid and electrolyte replace- foods (which are digested more slowly). ment, and when peristalsis has returned, oral feedings may be resumed. The necessity for optimum nutrition 5. No milk, sugar, sweets, desserts, alcohol, or sweet- following gastric surgery is the same as in any other op- ened beverages. All of these pass rapidly into the je- eration, but postgastrectomy diet therapy (which must junum and pull fluid there. Also, simple sugars be ordered by the physician) differs in some respects. In stimulate insulin release and so should be avoided. general the health practitioner should follow these basic principles: 6. Raw foods as tolerated (low-fiber types are usually given). 1. Implement a progressive diet for a 2-week course. 2. Keep meals small (1 to 2 oz each) and frequent Table 17-2 presents an antidumping diet, and Table 17-3 provides a sample menu. (hourly). Low carbohydrate clear liquids with 1\u20442 slice toast or two crackers are appropriate for first feedings. NURSING IMPLICATIONS 3. Increase the size of feedings by 1 oz daily. 4. Use a six-meal, low-carbohydrate, high-protein, 1. Encourage a supine position after meals to decrease moderate-fat, diet by approximately day 10 to day 16, the force of gravity. if conditions permit. 5. Introduce simple, mild, low-fiber, and easily di- 2. Advise mouth rinsing before meals as cholinergic gested foods, such as cream of wheat or rice, sugar- blocking agents can cause dryness of mouth. free gelatin, soft-cooked (poached) eggs, mashed","CHAPTER 17 DIET AND DISORDERS OF INGESTION, DIGESTION, AND ABSORPTION 267 TABLE 17-2 Permitted and Prohibited Foods in an Antidumping Diet Food Group Foods Permitted Foods Prohibited Breads All breads and crackers except those noted Breads with nuts, jams, or dried fruits or made with bran Fats Margarine, butter, oil, bacon, cream, may- onnaise, French dressing None Cereals and equivalents All grains, rice, spaghetti, noodles, and Presweetened cereals Eggs macaroni except those noted Meats None Beverages All egg dishes Highly seasoned or smoked meats All tender meats, fish, poultry No milk or alcohol; carbonated beverages if Tea, coffee, broth, liquid unsweetened gela- not tolerated; beverages with meal unless tin, artificially sweetened soda (1\u20442\u20131 hour symptoms begin to subside\u2020 before and after meals)* The following foods are to be added as patient tolerance and condition progress. Vegetables Mashed potato, all tender vegetables (peas, Creamed; gas-forming varieties if not toler- Fruits carrots, spinach, etc.) ated (cabbage, broccoli, dried beans and Dairy products peas, etc.) Miscellaneous Fresh or canned (unsweetened or artifici- ally sweetened); one serving citrus fruit Canned with sugar syrup; avoid sweetened or juice dried fruits; e.g., prunes, figs, dates Milk, cheese, cottage cheese, yogurt, etc. Introduce small amounts of dairy to deter- mine tolerance Salt, catsup, mild spices, smooth peanut butter Pickles, peppers, chili powder, nuts, olives, candy, milk gravies *Some practitioners prefer 1 to 2 hours before and after meals. \u2020Some practitioners permit 4 oz of fluid with a meal. TABLE 17-3 Sample Menu Plans for Antidumping Diets Soon after Surgery Later after Surgery Sample 1 Sample 2 Sample 1 Sample 2 Breakfast Egg, poached, 1 Egg, scrambled, 1 Cream of wheat, 1\u20442 c Juice, tomato, 4 oz Toast, 1 slice Toast, 1 slice Butter, 1 tsp Oatmeal, 1\u20442 c Butter, 1 tsp Butter, 1 tsp Egg, soft-cooked, 1 Bacon, crisp, 2 slices Banana, 1\u20442 Peaches, 1\u20442 c Toast, 1 slice Butter, 1 tsp Snack Gelatin, fruit-flavored, Smooth peanut butter, 2 oz Gelatin, fruit-flavored Diet soda Lunch unsweetened, 1 c Crackers, 2 Crackers, 4 Crackers, 4 Snack Chicken breast, Fish, 3 oz Roast beef, 3 oz Beef patty, 3 oz Dinner stewed, 3 oz Rice, 1\u20442 c Rice, 1\u20442 c Potato, 1\u20442 c Spinach, 1\u20442 c Peas, buttered, 1\u20442 c Asparagus, 1\u20442 c Snack Potato, mashed, 1\u20442 c Butter, 2 tsp Butter, 2 tsp Butter, 2 tsp Gelatin, fruit-flavored, Juice, orange, 1\u20442 c Apple juice Soft-cooked egg unsweetened, 1 c Crackers, 2 Crackers, 4 Crackers, 4 Turkey, sliced, 3 oz Beef, 3 oz Chicken, 3 oz Meat, 3 oz Potato, baked, 1 Potatoes, mashed, 1 c Noodles, 3 oz Rice with grated Butter, 2 tsp Carrots, 1\u20442 c Spinach, 1\u20442 c Tomato, 2 slices Tomato, sliced, 1\u20442 Margarine, 1 tsp cheese, 1\u20442 c Butter, 2 tsp Asparagus, tips, 1\u20442 c Peach, halves Margarine, 1 tsp canned, unsweetened Smooth peanut butter Sandwich: Crackers (2) Bread, 2 slices Bread, 1 slice Mayonnaise, 2 tsp Meat, 2 oz Meat, 2 oz Margarine, 1 tsp","268 PART III NUTRITION AND DIET THERAPY FOR ADULTS 3. Emphasize eating slowly in a relaxed, pleasant ACTIVITY 2: environment. Disorders of the Intestines 4. Explain the reasons for diet restrictions to the patient and family or care provider. DIETARY FIBER INTAKE 5. Be aware that vitamin B12 by injection may be neces- The structural parts of brans, husks of whole grain prod- sary following total gastrectomy, because the intrin- ucts, hulls, skins, and seeds are important sources of sic factor necessary for its absorption will be lost. fiber. A low-fiber and a low-residue diet are not the same. Make sure that the patient understands the need for Residue is the portion of the diet that contributes to the this treatment. content of the feces. Dietary fiber is the portion of food that cannot be digested by the human body. 6. Check weight and caloric intake frequently. We can provide the patient with a low-fiber diet or a PROGRESS CHECK ON ACTIVITY 1 diet in which the amount of fiber is regulated. This is used for preoperative and postoperative states of lower FILL-IN gastrointestinal surgery or a condition in which de- 1. Fill out the section in Exercise 17-1 for the low- creased fecal bulk is desired such as diverticulitis, ulcer- residue diet, listing all diseases or conditions for ative colitis, Crohn\u2019s disease, or any time stenosis of the which this diet is applicable. esophageal or intestinal lumen occurs. Simply put, we 2. a. Fill out the section in Exercise 17-1 for foods can provide a nutritionally adequate diet that leaves a suitable for a patient with a gastric ulcer. minimum of residue in the colon by limiting the amount b. Repeat Exercise 17-1, using foods suitable for of fiber. dumping syndrome. 3. Explain the rationale for the important changes in The fiber content of a diet can be reduced with the diet therapy for peptic ulcers. following practices: 4. Make a 1-day meal plan for a patient who is four 1. Use young, very tender, cooked vegetables. days postgastrectomy. 2. Omit foods with seeds, skin, and structural fiber, such as berries, celery, cabbage, corn, and peas. 3. Peel fruits and vegetables and cook to soften fiber. 4. Puree or strain foods. 5. Use only refined white breads and cereals. 6. Omit fruits and vegetables and use only strained juices. Exercise 17-1 A practice on the dietary management of selected disorders and nursing implications Complete the chart by filling in the information for each column. Disease or Foods Foods Foods Nursing Diet Condition Allowed Limited Forbidden Implications Low-Residue Diet Gastric Ulcer Dumping Syndrome","CHAPTER 17 DIET AND DISORDERS OF INGESTION, DIGESTION, AND ABSORPTION 269 Table 17-4 shows the foods permitted in a low- to mod- CONSTIPATION erate-fiber or residue-restricted diet. Table 17-5 shows a sample menu for a low- to moderate-fiber or residue- Because constipation is a symptom, many variables have restricted diet. been implicated in its treatment. One cause is related to the stress and strain of modern life. Poor personal habits The most common of the intestinal disorders that oc- may be responsible, including irregular routine and casionally affect people are constipation and diarrhea. meals, inadequate rest and exercise, tension, and ignor- Both disorders are usually managed with simple changes ing the body\u2019s need to defecate. Some medications that in diet and lifestyle. Other, more severe intestinal condi- contain iron, aluminum, or calcium can cause constipa- tions are diverticular disease, inflammatory bowel dis- tion. Regular use of laxatives also is a contributing ease (IBD), and cancer. TABLE 17-4 Foods Permitted in Low- to Moderate-Fiber or Residue-Restricted Diets Foods and Daily Servings Permitted Meat, equivalents Beef, veal, ham, liver, and poultry (broiled, baked, or stewed to tender); fish, fresh or salt (broiled, baked); canned tuna or salmon; shellfish, tender meat only Milk, milk products Whole, skim, chocolate; buttermilk, yogurt (2 c daily including amount in food preparation) Cheese Cottage, cream, American, Muenster, and Swiss 1 c milk \u03ed 1 oz cheese Eggs All varieties except fried Grain, grain products Bread (Italian, Vienna, or French); toast (French or melba); crackers (saltines or soda); rolls (plain, soft, or hard); others: biscuits, zwieback, rusk All above prepared with refined whole wheat or rye Cereals (ready-to-eat, cooked, all prepared from refined grains); oatmeal Flours from refined grains other than graham or bran White rice Plain spaghetti, noodles, and macaroni Potatoes Potatoes without skin (creamed, mashed, scalloped, boiled, baked); sweet potatoes without skin Fruits Daily allowance: 2 servings All juices and nectars; fruit, ripe and fresh (peeled, without seeds), frozen, or canned; grapes, bananas, apricots, plums, peaches, pears, cherries, avocados, citrus fruits (segments only; e.g., oranges, grapefruit, tangerine, honeydew, cantaloupe, pineapple, and nectarines) Vegetables Daily allowance: 1 serving for vegetables, with no limitation on juices Vegetables, well-cooked or canned: green and waxed beans, carrots, asparagus, beets, eggplant, mushrooms, onions, cauliflower, peas, winter squash, pumpkin, cabbage Vegetables, cooked, chopped: turnip greens, broccoli, spinach, kale, collards Vegetables, raw, chopped: lettuce Beverages Coffee (regular, decaffeinated), tea; others: soft drinks, cereal beverages All drinks may be flavored with permitted fruits. Broth and cream-based soups made from other permitted ingredients Candies, sweets Plain candies, jelly, honey, syrup, sugar, jelly beans, mints Fats Cream: regular, dried substitutes, sour; dressings: mayonnaise and mayonnaise-type, all must be plain; regular smooth salad oil; butter, margarine, oils; others: crisp bacon, shortenings Desserts All must be plain and made from permitted ingredients: pie, cakes, cookies, pudding, gelatin, sherbet, ice cream Miscellaneous Spices and herbs (ground or finely chopped); flavorings: soy sauce, vinegar, salt, monosodium glutamate, chocolate, catsup, and all commercial flavoring extracts; sauces and gravies: mild and made from permitted ingredients","270 PART III NUTRITION AND DIET THERAPY FOR ADULTS TABLE 17-5 Sample Menu for Low- to Moderate-Fiber or Residue-Restricted Diet Breakfast Lunch Dinner Tomato juice, 1\u20442 c Melted cheese sandwich: Roast beef, tender, 3 oz Egg, poached, 1 White bread, 2 slices Potato, mashed, 1 c Toast, white bread, 1 slice Cheese, mild, 2 oz Carrots, cooked, 1\u20442 c Bacon, 2 slices Green beans, 1\u20442 c Orange juice, strained, 1\u20442 c Margarine Apple juice, 1\u20443 c White bread, 1 slice Jelly Gelatin, 1 c Margarine Coffee or tea Vanilla wafers, 2 Ice cream, 1\u20442 c Coffee or tea Coffee or tea Snacks Milk, 1 c Cookies, plain, 2 factor. Ideal treatment requires adopting good health If the need for IV fluids continues beyond 72 hours, habits to restore regularity and break the laxative cycle. amino acids and vitamins may be added. If diarrhea is prolonged, total parenteral nutrition (TPN) is A regular balanced diet high in fiber and fluids is rec- necessary. ommended to avoid constipation. Eight to ten glasses of 2. Resumption of oral feedings: First day include clear fluids daily should be consumed. Foods high in fiber in- liquids with a minimum of sugar. Second day pro- clude whole grains and raw fruits and vegetables. If the gressively introduce a minimum-residue diet (see patient cannot tolerate the latter, cooked ones may be used. Tables 17-4 and 17-5), high in protein. Calcium sup- Prune juice, apple juice, figs, and raisins are especially plements are provided. Applesauce and raw apples helpful. Bran with a high fiber content is an effective agent. may be used for their pectin content, which can thicken the stools. Implement gradual progression Nursing Implications of a low-fiber, low-residue, soft, solid-to-regular diet as the situation improves. 1. Explain the benefits of a high-fiber diet. In addition to increasing bulk, the foods that provide fiber are high Mild diarrhea usually responds to the following: in vitamins and minerals. reducing the total food intake, especially carbohy- drate and fat; limiting residue; and replacing fluids. A 2. Discourage regular and excessive use of laxatives. bland low-residue diet may ease the discomfort. 3. Reassure patients that a daily bowel movement is not Nursing implications for individuals or patients with an absolute necessity. It may not be normal for them. diarrhea: 4. Advise gradual inclusion of high-fiber foods in the 1. Note daily weight changes. diet. Excess dietary fiber at the beginning may cause 2. Keep accurate daily records of intake and output. cramping and gas. This can discourage patients from 3. Do not permit carbonated beverages. Use flat soda or continuing the diet. 5. Encourage a high fluid intake, especially of water. ginger ale if carbonated beverages are desired. 4. Relieve any pain before serving meals. DIARRHEA 5. Employ diversionary tactics during meals. 6. Offer replacements later, if patient does not finish Diarrhea in infants, small children, and the elderly can be serious if prolonged, especially if an infection is present. food when it is first offered. Common mild diarrhea of short duration usually re- sponds well to simple treatment. Diarrhea is functional DIVERTICULAR DISEASE when related to stress, irritation of the bowel, or a change in the regular routine, such as traveling. It is organic if Diverticuli are herniations (pockets or sacs) of intestinal it is caused by a GI lesion. Treatment includes eliminat- mucosa through the muscles of the bowel wall. The ing the underlying cause, using antidiarrheal drugs as process is referred to as diverticulosis. If accompanied needed, and using appropriate diet therapy. by inflammation, the disorder is called diverticulitis. It is important to distinguish between the two, as the diet Diet therapy during severe diarrhea is characterized by therapy used is different for each. the following: One cause of diverticulosis appears to be related to a 1. No oral feeding for first 24 to 48 hours. Intravenous lack of fecal bulk, which increases intraluminal pressure. (IV) fluids are used to replace electrolytes and water.","CHAPTER 17 DIET AND DISORDERS OF INGESTION, DIGESTION, AND ABSORPTION 271 The treatment of diverticulosis is aimed at preventing cause is unknown, one major culprit is related to psy- inflammation. A high-fiber diet is prescribed. Fiber chological factors. The disorder is characterized by wide- sources include bran, whole grains, and fruits and vegeta- spread ulceration and inflammation of the colon, fever, bles. Pepper and chili powder, sometimes nuts and corn, chronic bloody diarrhea, edema, and anemia. The patient may be eliminated. is severely malnourished, suffering from avitaminosis, negative nitrogen balance, dehydration, electrolyte im- Diverticulitis requires special attention. During acute balances, and skin lesions. Patients are nervous, anorexic, periods when the diverticuli are inflamed and there is and in pain. The obvious need for maximum nutrition pain, tenderness, nausea, vomiting, and distention, fecal for a patient who cannot eat is a challenge to the health residue may add to the discomfort. Diet therapy during team. this period may be limited to clear liquids progressing to full liquids, then to low-residue and to regular high-fiber The treatment of UC includes rest, sedation, antibi- diet as the inflammation subsides. Severe diverticulitis is otics, antidiarrheal drugs, and rigorous diet therapy. usually treated by surgical methods (colostomy, bowel Surgical removal of the diseased portion of the bowel is resection). the treatment of choice, if other medical procedures fail. Diet therapy includes the following: Nursing implications are as follows: 1. A regular, high-fiber diet supplemented with formula 1. Patient education is most important here, as all diver- feeding, as tolerated ticular disease was formerly treated with a low-residue diet. 2. High protein: 125 to 150 g 3. High calorie: 3000\u03e9 calories 2. The older patient should be especially reassured, as 4. High vitamins\/minerals, especially vitamins C, B most diverticulosis occurs in the elderly, and they be- come most anxious on a high-fiber diet. complex, and K 5. Moderate fat or as tolerated 3. A symptomatic patient should be encouraged to rest 6. Dairy products usually eliminated to avoid second- and to take medicines as prescribed. ary lactose intolerance, or lactose-free products used 4. Patients who are malnourished on admission should 7. IV fluids used in addition to oral feedings to correct be replenished nutritionally to facilitate healing and recovery. fluid and electrolyte losses due to diarrhea 8. TPN is most effective when the bowel has been short- INFLAMMATORY BOWEL DISEASE ened or the disease is extensive Inflammatory bowel disease is a term used for ulcerative colitis and Crohn\u2019s disease. Both may have the related Crohn\u2019s Disease condition of short bowel syndrome if there have been re- peated surgeries that removed sections of the bowel as Crohn\u2019s disease is another manifestation of inflamma- the disease progressed. tory bowel disease. It is particularly prevalent in indus- trial areas and among the 55 to 60 age group. It has an Both ulcerative colitis (UC) and Crohn\u2019s disease have insidious onset and is characterized by tenderness, pain, increased in incidence in the United States. They have diarrhea, and cramping in the right lower quadrant of similar pathophysiology and clinical symptoms, but are the bowel. There is less blood in the stool than in ulcer- prevalent in different groups. They both have severe nu- ative colitis, but increased secretion of mucus by the tritional consequences, but are separate diseases. Crohn\u2019s bowel. The patient runs a low-grade fever. can occur anywhere in the GI tract, but UC is confined to the colon and rectum. The pattern of disease in Crohn\u2019s Widespread involvement of the small bowel results in is that of a chronic disorder, often involving the entire in- malabsorption of fat, protein, carbohydrates, vitamins, testinal wall. This may cause complications, such as par- and minerals, and subsequent weight loss. Vitamin B12 tial or complete obstruction and the formation of fistulas. deficiency may occur, leading to macrocytic anemia and The inflammatory processes in UC, on the other hand, are neurologic damage. Bile salt losses lead to cholelithia- usually acute and are limited to the mucosa and submu- sis, diarrhea, and steatorrhea. There may also be anemia cosa of the intestine. The patient may have periods of due to loss of blood in the stool. Children with Crohn\u2019s remission. disease show retarded growth patterns. Diet therapy for inflammatory bowel disease is based As with UC, the effects of malabsorption are wide- upon the common clinical symptoms of bloody diarrhea spread. Malabsorption of vitamins C and K leads to cap- and the various associated nutritional problems. illary fragility, hemorrhagic tendencies, and petechiae. Malabsorption of calcium and vitamin D puts the patient Ulcerative Colitis (UC) at risk for osteomalacia and osteoporosis. The bone pain that is a frequent symptom of both UC and Crohn\u2019s is Primarily a disease of young adults, especially women, due to this impairment. Tetany and paresthesia are also ulcerative colitis is a life-threatening disorder. While the related to calcium and magnesium malabsorption. The","272 PART III NUTRITION AND DIET THERAPY FOR ADULTS whole vitamin B complex is destroyed, giving rise to glos- diet with appropriate increases in protein, vita- sitis, cheilosis, skin changes, and peripheral neuritis. mins, minerals, and calories for healing leads to more improvement and fewer hospitalizations The rational for diet therapy for both diseases is to re- than traditional diet therapy. While more re- store nutrient deficits, prevent further losses, promote search will be necessary to confirm this study, healing, and repair and maintain body tissue. the nurse should stay abreast of the changing na- ture of diet therapy. NURSING IMPLICATIONS e. High calorie to spare the protein for tissue heal- ing and rebuilding. Nursing responsibilities for patients with ulcerative co- f. Supplemental defined formula as needed. litis or Crohn\u2019s disease include the following: GASTRIC SURGERY FOR SEVERE OBESITY 1. Be aware that the patient\u2019s need for high levels of food and fluids parallels that of a burn patient. According to the National Institutes of Diabetes, Digestive, and Kidney Diseases, stomach surgery is one 2. Interpret the diet to the patient and family member option for severe obesity. Severe obesity is a chronic con- or care provider. A young person on a bland low- dition that is difficult to treat through diet and exercise residue diet for long periods of time becomes dis- alone. Gastrointestinal surgery is the best option for peo- couraged. ple who are severely obese and cannot lose weight by tra- ditional means or who suffer from serious obesity-related 3. Be aware that, if steroid-type medication is used, health problems. The surgery promotes weight loss by sodium restriction may also become necessary. restricting food intake and, in some operations, inter- rupting the digestive process. As in other treatments for 4. Do not confuse fluid retention with nutritional im- obesity, the best results are achieved with healthy eating provement (body weight gain). behaviors and regular physical activity. 5. Keep careful daily records: fluid intake and output, People who may consider gastrointestinal surgery in- weight changes, nutrient intake, and calorie counts. clude those with a body mass index (BMI) above 40, about 100 pounds of overweight for men and 80 pounds for 6. Seek outside resources for the patient (counselor, women (see Appendix B for a BMI conversion chart). therapist) as needed. Work closely with dietitian and People with a BMI between 35 and 40 who suffer from other health team members. type 2 diabetes or life-threatening cardiopulmonary prob- lems such as severe sleep apnea or obesity-related heart 7. Provide the patient with the rationale for strict med- disease may also be candidates for surgery. ical management and the side effects of same. Gastrointestinal surgery for obesity, also called 8. Provide education for continuing diet therapy for bariatric surgery, alters the digestive process. The oper- UC and Crohn\u2019s. It is based on: ations promote weight loss by closing off parts of the a. Restoring adequate nutrition intake stomach to make it smaller. Operations that only reduce b. Correcting deficits, usually with supplements stomach size are known as restrictive operations, because c. Preventing further losses they restrict the amount of food the stomach can hold. d. Controlling substances that do not absorb well, Some operations combine stomach restriction with a such as fats partial bypass of the small intestine. These procedures e. Promoting the healing and repairing and main- create a direct connection from the stomach to the lower taining of tissue segment of the small intestine, literally bypassing por- tions of the digestive tract that absorb calories and nu- 9. Any number of commercial preparations to add addi- trients. These are known as malabsorptive operations. tional calories in easily digestible form may be ob- tained from the local pharmacy, (MCT, Portagen, etc.). Restrictive Operations 10. The diet for both UC and Crohn\u2019s remains: As a result of this surgery, most people lose the ability to a. High protein: 120%\u2013150% of the RDA. Assuming eat large amounts of food at one time. After an opera- 60 g\/day as recommended for healthy adults, the tion, the person usually can eat only 3\u20444 to 1 cup of food diet would contain from 72\u201390 g\/day of HBV without discomfort or nausea. Also, food has to be well protein. chewed. Although restrictive operations lead to weight b. High vitamin, especially those found to be most loss in almost all patients, they are less successful than deficient. malabsorptive operations in achieving substantial, long- c. High minerals as needed by the individual (espe- term weight loss. About 30% of those who undergo this cially iron, which may be administered by trans- fusion; calcium, zinc, and potassium if diarrhea persists). d. Low residue to regular. Recent research indicates that the low-residue diet as diet of choice for IBD may become obsolete, as the bland low-residue diet did for diverticulosis and ulcers. Five-year trials of patients with IBD showed that a regular","CHAPTER 17 DIET AND DISORDERS OF INGESTION, DIGESTION, AND ABSORPTION 273 surgery achieve normal weight, and about 80% achieve fluids are normally absorbed, patients with colostomies some degree of weight loss. Some patients regain weight. have stools with high water content. Others are unable to adjust their eating habits and fail to lose the desired weight. Successful results depend on the Diet therapy is characterized by the following: patient\u2019s willingness to adopt a long-term plan of healthy eating and regular physical activity. 1. A well-balanced diet that is appropriate for the preop- erative patient is indicated. See Chapter 15 for diet A common risk of restrictive operations is vomiting, planning. which is caused when the small stomach is overly stretched by food particles that have not been chewed 2. The initial postoperative diet is clear liquid, followed well. In a small number of cases, stomach juices may by a high-soluble fiber diet as tolerated. Progress as leak into the abdomen, requiring an emergency opera- rapidly as possible to a regular diet. Nutrient supple- tion. In less than 1% of all cases, infection or death from ments are provided as needed. complications may occur. 3. General goals are to promote healing and prevent Malabsorptive Operations odor, constipation, and diarrhea. In addition to the risks of restrictive surgeries, malab- 4. Each patient must experiment with the diet. The pa- sorptive operations also carry greater risk for nutritional tient can identify those foods to be limited or avoided. deficiencies. This is because the procedure causes food to bypass the duodenum and jejunum, where most iron and The nursing implications in caring for this group of calcium are absorbed. Menstruating women may develop patients include the following: anemia because not enough vitamin B12 and iron are absorbed. Decreased absorption of calcium may also 1. Colostomy patients have real concerns about odors and bring on osteoporosis and metabolic bone disease. flatulence. Help them with corrective measures. For Patients are required to take nutritional supplements example, spinach and parsley have deodorizing action that usually prevent these deficiencies. Depending on the and a commercial deodorant may be used in the bag. particular method of bypass, some patients must also take water-soluble vitamins A, D, E, and K supplements. 2. A diet must be evaluated for adequacy, if certain food items are prohibited. These operations may also cause dumping syndrome. This means that stomach contents move too rapidly 3. Eating slowly and thorough chewing can prevent through the small intestine. Symptoms include nausea, swallowing air. weakness, sweating, faintness, and sometimes diarrhea after eating. 4. Patients with colostomy usually progress rapidly as they gain control over the elimination process and The more extensive the bypass, the greater the risk adapt well to changes in lifestyle. for complications and nutritional deficiencies. Patients with extensive bypasses of the normal digestive process 5. Emotional support for the patient and family is require close monitoring and life-long use of special mandatory. foods, supplements, and medications. 6. Compile information regarding outside resources that Surgery to produce weight loss is a serious undertak- will help patients. ing. Anyone thinking about surgery should understand what the operation involves. Patients and physicians Ileostomy should carefully consider the benefits and risks. This surgery is indicated for intractable ulcerative colitis, COLOSTOMY AND ILEOSTOMY Crohn\u2019s disease, and cancer of the colon. An ileostomy bypasses the colon and rectum, and the distal ileum is Many intestinal diseases not responsive to medical and di- led to the outside of the body through an opening in the etary measures must be treated surgically. Depending on abdomen. Since the surgery is performed higher in the in- the location of the obstruction or disease, a colostomy or testine, the waste material is mainly in fluid form. There an ileostomy may be performed. are great losses of fluid, sodium, vitamin K, and other es- sential nutrients. Fat absorption is poor and vitamin B12 Colostomy absorption is reduced or absent. Body-weight loss is high. In a colostomy, the rectum and anus are removed. The re- Diet therapy after the operation is as follows: maining intestine is led to the outside through a hole in the abdomen. Because this surgical procedure diverts 1. The diet progresses from clear liquids to a high- fecal material from the distal colon and rectum, where soluble fiber diet as tolerated. New foods are given one at a time to test the patient\u2019s tolerance. 2. Nutritional supplements and\/or TPN may be needed in the early stages. 3. Vitamin B12 injections are given at scheduled times to prevent pernicious anemia. 4. Extra fluid is required. Orange juice and bananas are high in potassium, while extra salt with food increases sodium intake.","274 PART III NUTRITION AND DIET THERAPY FOR ADULTS c. inadequate diets d. malabsorption 5. The progression to a regular diet is longer for the patient with an ileostomy than a patient with a 4. An appropriate diet for the patient with IBD colostomy. would allow the basic principles of optimum nutrition and would: NURSING IMPLICATIONS a. be increased in fiber. Nursing implications for caring for this group of patients b. contain extra fats for energy. include the following: c. be decreased in fiber. d. be decreased in sodium. 1. Provide emotional support and encouragement to eating adequately. 5. Patients with colostomies usually gain control of evacuation faster than patients with ileostomies 2. Work closely with the dietary department, and plan because: for the family of the patient to participate. a. they have better preoperative nutritional status. 3. Be aware that the same nursing measures are appli- b. they have better neuromuscular functions. cable to colostomy and ileostomy patients. c. the surgery site is lower in the gut. d. the surgical site heals more quickly. 4. Become familiar with obesity and the role of surgery. The nurse\u2019s role is extremely important before, dur- 6. General goals of diet therapy following a ing, and after the operation. Apart from clinical nurs- colostomy are to promote healing and prevent: ing considerations, the significant role of nutrition in patient care during these three phases should be a. constipation. acknowledged. The implementation of proper enteral b. diarrhea. and parenteral nutrition revolves around the close c. odors. working relationships among the doctor, the nurse, d. all of the above. and the dietitian. 7. The restricted-residue diet: PROGRESS CHECK ON ACTIVITY 2 a. is always very high in calories. MATCHING b. is very similar to the full-liquid diet. c. may be inadequate in vitamins and minerals. 1. Indicate which of the following foods would be al- d. is nutritionally adequate. lowed on a minimum-residue diet by writing Y (yes) or N (no) in the blanks: 8. The minimum-residue diet: a. broccoli with hollandaise sauce a. is always very high in calories. b. bouillon b. is very similar to the full-liquid diet. c. applesauce c. may be inadequate in vitamins and minerals. d. fresh pears d. is nutritionally adequate. e. sherbet f. fruitcake 9. Which of the following foods are allowed on a g. poached egg minimum-residue diet? h. macaroni i. pecan waffles a. milkshake, hamburger, and french fries j. broiled chicken b. tomato wedge, scrambled egg, and broiled MULTIPLE CHOICE bacon c. chicken sandwich on white bread with butter Circle the letter of the correct answer. d. all of the above 2. Residue is that part of food that: 10. Which of these foods would be included in a high- fiber diet? a. remains longest in the GI tract. b. is indigestible. a. whole wheat bread, prunes, celery c. is left uneaten after the meal. b. carrot sticks, bran cereal, apples d. is inedible. c. coconut bars, pecan rolls, oatmeal d. all of the above 3. IBD is the result of which of these factors? 11. If the minimum-residue diet must be used for a a. short bowel syndrome period of time, the physician should: b. infectious processes a. alternate it weekly with the high-iron diet. b. substitute the full-liquid diet.","CHAPTER 17 DIET AND DISORDERS OF INGESTION, DIGESTION, AND ABSORPTION 275 c. add fresh fruit juices before each meal. 19. T F Malabsorptive operations may cause nutri- d. prescribe a vitamin and mineral supplement. tional deficiencies because the diet therapy is too restrictive. FILL-IN 20. T F The nurse\u2019s role in the nutritional care of a pa- 12. Name 10 foods high in fiber content. tient with bypass surgery is extremely impor- tant before, during, and after the operation. a. REFERENCES b. Alanis, A. D. (2005). Antibacterial properties of some c. plants used in Mexican traditional medicine for the treatment of gastrointestinal disorders. Journal of d. Enthnophrarmacology, 22: 153\u2013157. e. American Dietetic Association. (2006). Nutrition Diag- nosis: A Critical Step in Nutrition Care Process. Chi- f. cago: American Dietetic Association. g. Beham, E. (2006). Therapeutic Nutrition: A Guide to Patient Education. Philadelphia: Lippincott, Williams h. and Wilkins. i. Bendich, A., & Deckelbaum, R. J. (Eds.). (2005). Preventive Nutrition: The Comprehensive Guide for Health j. Professionals (3rd ed.). Totowa, NJ: Humana Press. 13. List five goals for feeding a patient with an inflam- Buchman, A. (2004). Practical Nutritional Support matory bowel disease. Technique (2nd ed.). Thorofeue, NJ: SLACK. a. Coulston, A. M., Rock, C. L., & Monsen, E. L. (Eds.). (2001). Nutrition in the Prevention and Treatment of b. Disease. San Diego, CA: Academic Press. c. Deen, D., & Hark, L. (2007). The Complete Guide to Nutrition in Primary Care. Malden, MA: Blackwell. d. Eastwood, M. (2003). Principles of Human Nutrition. e. (2nd ed.). Malden, MA: Blackwell Science. 14. List five nursing implications for nutritional care Escott-Stump, S. (2002). Nutrition and Diagnosis- of the osteomate. Related Care. (5th ed.). Philadelphia: Lippincott, Williams and Wilkins. a. Fauci, A. S., Braunwald, E., Kapser, D. L., Hauser, S. L., b. Longo, D. L., Jameson, J. L. et al. (Eds.). (2008). Harrison\u2019s Principles of Internal Medicine (17th ed.). c. New York: McGraw-Hill. d. Garrow, J. S. (2000). Human Nutrition and Dietetics. (10th ed.). New York: Churchill Livingston. e. Haas, E. M., & Levin, B. (2006). Staying Healthy with TRUE\/FALSE Nutrition: The Complete Guide to Diet and Nutrition Medicine (21st ed.). Berkeley, CA: Celestial Arts. Circle T for True and F for False. Hark, L., & Morrison, G. (Eds.). (2003). Medical Nutrition 15. T F Severe obesity is a chronic condition that does and Disease. (3rd ed.). Malden, MA: Blackwell. not respond to treatment through diet and ex- ercise alone. Hay, D. W. (2001). Blackwell\u2019s Primary Care Essentials: Gastrointestinal Diseases. Ames, IA: Blackwell. 16. T F Bypass surgery should be considered for a fe- male who is 30 pounds overweight. Lagua, R. T., & Qaudio, V. S. (2004). Nutrition and Diet Therapy: Reference Dictionary (5th ed.). Ames, IA: 17. T F Following bypass surgery, a patient should be Blackwell. able to resume original eating habits to control body weight. Mahan, L. K., & Escott-Stump, S. (Eds.). (2008). Krause\u2019s Food and Nutrition Therapy (12th ed.). Philadelphia: 18. T F Restrictive surgeries for chronic obesity pro- Elsevier Saunders. mote weight loss by decreasing the size of the stomach. Mann, J., & Truswell, S. (Eds.). (2007). Essentials of Human Nutrition (3rd ed.). New York: Oxford Uni- versity Press."]