ATI BOOK: NUTRITION FOR NURSING REVIEW MODULE 6TH EDITION ACTUAL BOOK WITH APPLICATION EXERCISES AT THE END OF EVERY CHAPTER COMPLETE CHAPTER 1 TO CHAPTER 16 ALL UNITS COVERED

ATI BOOK: NUTRITION FOR NURSING REVIEW MODULE 6TH EDITION ACTUAL BOOK WITH APPLICATION EXERCISES AT THE END OF EVERY CHAPTER COMPLETE CHAPTER 1 TO CHAPTER 16 ALL UNITS COVERED Contributors Norma Jean E. Henry, MSN/Ed, RN Mendy McMichael, DNP, MSN Janean Johnson, MSN, RN, CNE Agnes DiStasi, DNP, RN, CNE Honey C. Holman, MSN, RN Robin A. Hertel, EdS, MSN, RN, CMSRN Kellie L. Wilford, MSN, RN Peggy Leehy, MSN, RN Terri Lemon, DNP, MSN, RN Consultants Tracey Bousquet, BSN, RN Penny Fauber, RN, BSN, MS, PhD Donna Russo, RN, MSN, CCRN, CNE Betty Daniel, MSN Nursing Education, RN Pam DeMoss, MSN, RN INTELLECTUAL PROPERTY NOTICE ATI Nursing is a division of Assessment Technologies Institute®, LLC. Copyright © 2016 Assessment Technologies Institute, LLC. All rights reserved. The reproduction of this work in any electronic, mechanical or other means, now known or hereafter invented, is forbidden without the written permission of Assessment Technologies Institute, LLC. All of the content in this publication, including, for example, the cover, all of the page headers, images, illustrations, graphics, and text, are subject to trademark, service mark, trade dress, copyright, and/or other intellectual property rights or licenses held by Assessment Technologies Institute, LLC, one of its affiliates, or by third parties who have licensed their materials to Assessment Technologies Institute, LLC. Director of content review: Kristen Lawler Director of development: Derek Prater Project management: Janet Hines, Nicole Burke Coordination of content review: Norma Jean E. Henry, Mendy McMichael Copy editing: Kelly Von Lunen, Derek Prater Layout: Spring Lenox, Randi Hardy Illustrations: Randi Hardy Online media: Morgan Smith, Ron Hanson, Nicole Lobdell, Brant Stacy Cover design: Jason Buck Interior book design: Spring Lenox IMPORTANT NOTICE TO THE READER Assessment Technologies Institute, LLC, is the publisher of this publication. The content of this publication is for informational and educational purposes only and may be modified or updated by the publisher at any time. This publication is not providing medical advice and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The publisher has designed this publication to provide accurate information regarding the subject matter covered; however, the publisher is not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and makes no guarantee and assumes no responsibility or liability for the use of the products and procedures described or the correctness, sufficiency, or completeness of stated information, opinions, or recommendations. The publisher does not recommend or endorse any specific tests, providers, products, procedures, processes, opinions, or other information that may be mentioned in this publication. Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications and determining the appropriate usage for the product. Any references in this book to procedures to be employed when rendering emergency care to the sick and injured are provided solely as a general guide. Other or additional safety measures may be required under particular circumstances. This book is not intended as a statement of the standards of care required in any particular situation, because circumstances and a patient’s physical condition can vary widely from one emergency to another. Nor is it intended that this book shall in any way advise personnel concerning legal authority to perform the activities or procedures discussed. Such specific determination should be made only with the aid of legal counsel. Some images in this book feature models. These models do not necessarily endorse, represent, or participate in the activities represented in the images. THE PUBLISHER MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, WITH RESPECT TO THE CONTENT HEREIN. THIS PUBLICATION IS PROVIDED AS-IS, AND THE PUBLISHER AND ITS AFFILIATES SHALL NOT BE LIABLE FOR ANY ACTUAL, INCIDENTAL, SPECIAL, CONSEQUENTIAL, PUNITIVE, OR EXEMPLARY DAMAGES RESULTING, IN WHOLE OR IN PART, FROM THE READER’S USE OF, OR RELIANCE UPON, SUCH CONTENT. Welcome to the Assessment Technologies Institute® Nutrition for Nursing Review Module Edition 6.0. The mission of ATI’s Content Mastery Series® Review Modules is to provide user-friendly compendiums of nursing knowledge that will: ● Help you locate important information quickly. ● Assist in your learning efforts. ● Provide exercises for applying your nursing knowledge. ● Facilitate your entry into the nursing profession as a newly licensed nurse. This newest edition of the Review Modules has been redesigned to optimize your learning experience. We’ve fit more content into less space and have done so in a way that will make it even easier for you to find and understand the information you need. ORGANIZATION This Review Module is organized into units covering principles of nutrition, clinical nutrition, and alterations in nutrition. Chapters within these units conform to one of two organizing principles for presenting the content. ● Nursing concepts ● Nutritional considerations for specific disorders Nursing concepts chapters begin with an overview describing the central concept and its relevance to nursing. Subordinate themes are covered in outline form to demonstrate relationships and present the information in a clear, succinct manner. Nutritional considerations for specific disorders chapters include an overview describing nutritional needs of clients who have the given disorder. These chapters cover assessments and data collection, nutritional guidelines, nursing interventions, and complications, if applicable. ACTIVE LEARNING SCENARIOS AND APPLICATION EXERCISES Each chapter includes opportunities for you to test your knowledge and to practice applying that knowledge. Active Learning Scenario exercises pose a nursing scenario and then direct you to use an ATI Active Learning Template (included at the back of this book) to record the important knowledge a nurse should apply to the scenario. An example is then provided to which you can compare your completed Active Learning Template. The Application Exercises include NCLEX-style questions, such as multiple-choice and multiple-select items, providing you with opportunities to practice answering the kinds of questions you might expect to see on ATI assessments or the NCLEX. After the Application Exercises, an answer key is provided, along with rationales. NCLEX® CONNECTIONS To prepare for the NCLEX, it is important to understand how the content in this Review Module is connected to the NCLEX test plan. You can find information on the detailed test plan at the National Council of State Boards of Nursing’s website, . When reviewing content in this Review Module, regularly ask yourself, “How does this content fit into the test plan, and what types of questions related to this content should I expect?” To help you in this process, we’ve included NCLEX Connections at the beginning of each unit and with each question in the Application Exercises Answer Keys. The NCLEX Connections at the beginning of each unit point out areas of the detailed test plan that relate to the content within that unit. The NCLEX Connections attached to the Application Exercises Answer Keys demonstrate how each exercise fits within the detailed content outline. These NCLEX Connections will help you understand how the detailed content outline is organized, starting with major client needs categories and subcategories and followed by related content areas and tasks. The major client needs categories are: ● Safe and Effective Care Environment ◯ Management of Care ◯ Safety and Infection Control ● Health Promotion and Maintenance ● Psychosocial Integrity ● Physiological Integrity ◯ Basic Care and Comfort ◯ Pharmacological and Parenteral Therapies ◯ Reduction of Risk Potential ◯ Physiological Adaptation An NCLEX Connection might, for example, alert you that content within a unit is related to: ● Basic Care and Comfort ◯ Nutrition and Oral Hydration ■ Manage the client who has an alteration in nutritional intake. QSEN COMPETENCIES As you use the Review Modules, you will note the integration of the Quality and Safety Education for Nurses (QSEN) competencies throughout the chapters. These competencies are integral components of the curriculum of many nursing programs in the United States and prepare you to provide safe, high-quality care as a newly licensed nurse. Icons appear to draw your attention to the six QSEN competencies. Safety: The minimization of risk factors that could cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. Patient-Centered Care: The provision of caring and compassionate, culturally sensitive care that addresses clients’ physiological, psychological, sociological, spiritual, and cultural needs, preferences, and values. Evidence-Based Practice: The use of current knowledge from research and other credible sources, on which to base clinical judgment and client care. Informatics: The use of information technology as a communication and information-gathering tool that supports clinical decision-making and scientifically based nursing practice. Quality Improvement: Care related and organizational processes that involve the development and implementation of a plan to improve health care services and better meet clients’ needs. Teamwork and Collaboration: The delivery of client care in partnership with multidisciplinary members of the health care team to achieve continuity of care and positive client outcomes. ICONS Icons are used throughout the Review Module to draw your attention to particular areas. Keep an eye out for these icons. This icon is used for NCLEX Connections. This icon indicates gerontological considerations, or knowledge specific to the care of older adult clients. This icon is used for content related to safety and is a QSEN competency. When you see this icon, take note of safety concerns or steps that nurses can take to ensure client safety and a safe environment. This icon is a QSEN competency that indicates the importance of a holistic approach to providing care. This icon, a QSEN competency, points out the integration of research into clinical practice. This icon is a QSEN competency and highlights the use of information technology to support nursing practice. This icon is used to focus on the QSEN competency of integrating planning processes to meet clients’ needs. This icon highlights the QSEN competency of care delivery using an interprofessional approach. This icon appears at the top-right of pages and indicates availability of an online media supplement, such as a graphic, animation, or video. If you have an electronic copy of the Review Module, this icon will appear alongside clickable links to media supplements. If you have a hard copy version of the Review Module, visit for details on how to access these features. FEEDBACK ATI welcomes feedback regarding this Review Module. Please provide comments to . NCLEX® Connections 1 UNIT 1 CHAPTER 1 Principles of Nutrition Sources of Nutrition Carbohydrates and fiber 3 3 Proteins 4 Lipids 4 Vitamins 5 Minerals and electrolytes 7 Water 8 CHAPTER 2 Ingestion, Digestion, Absorption, and Metabolism 11 CHAPTER 3 Nutrition Assessment/Data Collection 15 CHAPTER 4 Guidelines for Healthy Eating 19 CHAPTER 5 Food Safety 25 CHAPTER 6 Cultural, Ethnic, and Religious Influences 29 CHAPTER 7 Nutrition Across the Lifespan Pregnancy and lactation 33 33 Infancy 34 Childhood 38 Adolescence 39 Adulthood and older adulthood 41 NCLEX® Connections 45 UNIT 2 Clinical Nutrition CHAPTER 8 Modified Diets 47 CHAPTER 9 Enteral Nutrition 51 CHAPTER 10 Total Parenteral Nutrition 57 NCLEX® Connections 61 UNIT 3 CHAPTER 11 Alterations in Nutrition Barriers to Adequate Nutrition 63 CHAPTER 12 Cardiovascular and Hematologic Disorders 67 CHAPTER 13 Gastrointestinal Disorders 73 CHAPTER 14 Renal Disorders 81 CHAPTER 15 Diabetes Mellitus 87 CHAPTER 16 Cancer and Immunosuppression Disorders 93 References 99 Active Learning Templates A1 Basic Concept A1 Diagnostic Procedure A3 Growth and Development A5 Medication A7 Nursing Skill A9 System Disorder A11 Therapeutic Procedure A13 When reviewing the following chapters, keep in mind the relevant topics and tasks of the NCLEX outline, in particular: Client Needs: Health Promotion and Maintenance AGING PROCESS: Provide care and education for the newborn less than 1 month old through the infant or toddler client through 2 years. ANTE/INTRA/POSTPARTUM AND NEWBORN CARE: Provide prenatal care and education. HEATH PROMOTION/DISEASE PREVENTION: Educate the client on actions to promote/maintain health and prevent disease. Client Needs: Psychosocial Integrity CULTURAL AWARENESS/CULTURAL INFLUENCES ON HEALTH: Incorporate client cultural practice and beliefs when planning and providing care. RELIGIOUS AND SPIRITUAL INFLUENCES ON HEALTH: Evaluate whether the client's religious/spiritual needs are met. Client Needs: Basic Care and Comfort NUTRITION AND ORAL HYDRATION Consider client choices regarding meeting nutritional requirements and/or maintaining dietary restrictions, including mention of specific food items. Initiate calorie counts for clients. Apply knowledge of mathematics to client nutrition. CHAPTER 1 UNIT 1 PRINCIPLES OF NUTRITION CHAPTER 1 Sources of Nutrition Nutrients absorbed in the diet determine, to a large degree, the health of the body. Deficiencies or excesses can contribute to a poor state of health. Essential nutrients are those that the body cannot manufacture, and the absence of essential nutrients can cause deficiency diseases. Components of nutritive sources are carbohydrates and fiber, protein, lipids (fats), vitamins, minerals and electrolytes, and water. Carbohydrates, fats, and proteins are all energy‑yielding nutrients. DIETARY REFERENCE INTAKES Dietary Reference Intakes (DRIs) are developed by the Institute of Medicine’s Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. ● The Recommended Dietary Allowance (RDA) was replaced with the DRIs in the mid-1990s. ● The DRIs are comprised of four reference values. ◯ RDAs ◯ Estimated Average Requirement (EAR) ◯ Adequate Intake (AI) ◯ Tolerable Upper Intake Level (UL) Carbohydrates and fiber All carbohydrates are organic compounds composed of carbon, hydrogen, and oxygen (CHO). The main function of carbohydrates is to provide energy for the body. ● The average minimum amount of carbohydrates needed to fuel the brain is 130 g/day. Median carbohydrate intake is 296 g/day among men aged 20 years and older, and 256 g/day among women in the same age range. The acceptable macronutrient distribution range for carbohydrates is 45% to 65% of calories. ● Carbohydrates provide energy for cellular work, and help to regulate protein and fat metabolism. They TYPES OF CARBOHYDRATES (1.1) Carbohydrates are classified according to the number of saccharide units making up their structure. Monosaccharides: simple carbohydrates (glucose, fructose, and galactose) Disaccharides: simple carbohydrates (sucrose, lactose, and maltose) Polysaccharides: complex carbohydrates (starch, fiber, and glycogen) CONSIDERATIONS ● The liver converts fructose and galactose into glucose, which is then released in the bloodstream. This elevates blood glucose levels, which causes the release of insulin from the pancreas. With insulin production, glucose is moved out of the bloodstream into cells in order to meet energy needs. ● The body digests 95% of starch within 1 to 4 hr after ingestion. Digestion occurs mainly in the small intestine using pancreatic amylase to reduce complex carbohydrates into disaccharides. ● Glycogen is the stored carbohydrate energy source found in the liver and muscles. It is a vital source of backup energy, but is only available in limited supply. ● To maintain expected glucose levels between meals, glucose is released through the breakdown of liver glycogen. ● Digestible carbohydrates provide 4 cal/g of energy. FIBER Fiber is categorized as a carbohydrate. ● Dietary fiber is the substance in plant foods that is indigestible. Types are pectin, gum, cellulose, and oligosaccharides. ● Fiber is important for proper bowel elimination. It adds bulk to the feces and stimulates peristalsis to ease elimination. ● Studies show fiber helps to lower cholesterol and lessen the incidence of intestinal cancers. ● Total fiber AI is 25 g/day for women and 38 g/day for men. are essential for normal cardiac and central nervous system (CNS) functioning. 1.1 Carbohydrates at a glance EXAMPLE (SOURCES) FUNCTION Glucose (corn syrup), fructose Monosaccharides (fruits), galactose (found in milk) Basic energy for cells Disaccharides Polysaccharides Sucrose (table sugar), lactose (milk sugar), maltose (malt sugar) Starches (grains, legumes, root vegetables), fiber (whole grains, fruits, vegetables) Energy, aids calcium and phosphorus absorption (lactose) Energy storage (starches), digestive aid (fiber) Proteins Proteins are provided by plant and animal sources. They are formed by linking amino acids in various combinations for specific use by the body. TYPES OF PROTEINS There are three types of proteins. Each is obtained from the diet in various ways. Complete proteins, from animal sources and soy, contain sufficient amounts of all nine essential amino acids. Incomplete proteins, generally from plant sources, contain all nine essential amino acids. However, one or more of the amino acids is not adequate for protein synthesis. Complementary proteins are food sources that are incomplete proteins eaten alone, but together are equivalent to a complete protein. It is not necessary to consume complementary proteins at the same time to form a complete protein; instead, consuming a variety of complementary proteins over the course of the day is sufficient. CONSIDERATIONS ● Proteins have many metabolic functions. ◯ Tissue-building and maintenance ◯ Balance of nitrogen and water ◯ Backup energy ◯ Support of metabolic processes ■ Nitrogen balance ■ Transportation of nutrients, other vital substances ◯ Support of the immune system ● Three main factors influence the body’s requirement for protein. ◯ Tissue growth needs. ◯ Quality of the dietary protein. ◯ Added needs due to illness. ● The RDA of protein is 0.8 g/kg for healthy adults. Protein’s acceptable macronutrient distribution range (AMDR) for adults is 10% to 35% of total calories. ● Underconsumption can lead to protein energy malnutrition (PEM). Kwashiorkor and marasmus are two disorders caused by extreme PEM. These serious disorders are caused by a lack of protein ingestion, or lack of protein metabolism. ● Vegan diets can lack vitamin B12 because it does not naturally occur in plants. ● Protein provides 4 cal/g of energy. Lipids ● The chemical group of fats is called lipids, and they are available from many sources. ◯ Dark meat ◯ Poultry skin ◯ Dairy foods ◯ Added oils (margarine, butter, shortening, oils, lard) ● Fat is an essential nutrient for the body. It serves as a concentrated form of stored energy for the body and supplies important tissue needs. ◯ Hormone production ◯ Structural material for cell walls ◯ Protective padding for vital organs ◯ Insulation to maintain body temperature ◯ Covering for nerve fibers ◯ Aid in the absorption of fat-soluble vitamins TYPES OF FATS Fats are divided into three categories: triglycerides, phospholipids, and sterols. Triglycerides are further comprised of fatty acids, which include saturated fatty acids and unsaturated fatty acids. Triglycerides Triglycerides total 98% of fat in food. They combine with glycerol to supply energy to the body, allow fat-soluble vitamin transport, and form adipose tissue that protects internal organs. ● Saturated fatty acids are solid at room temperature, and are found primarily in animal sources. ● Unsaturated fatty acids, including monounsaturated and polyunsaturated fatty acids, are usually from plant sources and help reduce health risks. ◯ Sources of monounsaturated fatty acids include olives, canola oil, avocado, peanuts and other nuts. ◯ Sources of polyunsaturated fatty acids include corn, wheat germ, soybean, safflower, sunflower, and fish. ● Essential fatty acids, made from broken down fats, must be supplied by the diet. Essential fatty acids, including omega-3 and omega-6, are used to support blood clotting, blood pressure, inflammatory responses, and many other metabolic processes. Phospholipids Phospholipids (e.g., lecithin) are important to cell membrane structure, as well as the transport of fat-soluble substances across the cell membrane. Sterols Sterols (e.g., cholesterol) are found in the tissues of animals, and are not an essential nutrient because the liver is able to produce enough to meet needs. CONSIDERATIONS ● The AMDR for fats is approximately 20% to 35% of total calories. 10% or less of total calories should come from saturated fat sources). ● Cholesterol should be limited to 200 to 300 mg/day. ● A diet high in fat is linked to cardiovascular disease, hypertension, and diabetes mellitus. ◯ The exception is for children under 2 years of age, who need a higher amount of fat to form brain tissue. ◯ Conversely, a diet with less than 10% of fat cannot supply adequate amounts of essential fatty acids and results in a cachectic (wasting) state. ● The majority of lipid metabolism occurs after fat reaches the small intestine, where the gallbladder secretes concentrated bile and acts as an emulsifier to break fat into smaller particles. At the same time, the pancreas secretes pancreatic lipase, which breaks down fat. Intestinal cells absorb the majority of the end products of digestion, with some being excreted in the feces. ◯ Very-low-density lipoproteins (VLDL) carry triglycerides to the cells. ◯ Low-density lipoproteins (LDL) carry cholesterol to the tissue cells. ◯ High-density lipoproteins (HDL) remove excess cholesterol from the cells, and transport it to the liver for disposal. ● Lipids provide 9 cal/g of energy and are the densest form of stored energy. Vitamins Vitamins are organic substances required for many enzymatic reactions. The main function of vitamins is to be a catalyst for metabolic functions and chemical reactions. ● There are 13 essential vitamins, each having a specialized function. ● There are two classes of vitamins. ◯ Water-soluble: Vitamins C and B-complex ◯ Fat-soluble: Vitamins A, D, E, and K ● Vitamins yield no usable energy for the body. WATER‑SOLUBLE VITAMINS Vitamin C Vitamin C (ascorbic acid) aids in tissue building and metabolic reactions (healing, collagen formation, iron absorption, immune system function). ● Vitamin C is found in citrus fruits (oranges, lemons), tomatoes, peppers, green leafy vegetables, and strawberries. ● Stress and illness, as well as cigarette smoking, increases the need for vitamin C. Cigarette smokers are advised to increase Vitamin C intake by 35 mg/day due to increased oxidative stress and metabolic turnover. ● Severe deficiency causes scurvy, a hemorrhagic disease with diffuse tissue bleeding, painful limbs/joints, weak bones, and swollen gums/loose teeth. While scurvy can be fatal, it can also be cured with moderate doses of vitamin C for several days. B‑complex vitamins B-complex vitamins have many functions in cell metabolism. Each one has a varied duty. Many partner with other B vitamins for metabolic reactions. Most affect energy, metabolism, and neurological function. Sources for B vitamins almost always include green leafy vegetables and unprocessed or enriched grains. Thiamin (B1) functions as a coenzyme in energy metabolism, promotes appetite, and assists with muscle actions through its role in nerve functioning. ● Deficiency results in beriberi (ataxia, confusion, anorexia, tachycardia), headache, weight loss, and fatigue. ● Food sources are widespread in almost all plant and animal tissues, especially meats, grains, and legumes. Riboflavin (B2) works as a coenzyme to release energy from cells. ● Deficiency results in cheilosis (manifestations include scales and cracks on lips and in corners of the mouth), smooth/swollen red tongue (also called glossitis), and dermatitis of the ears, nose, and mouth. ● Dietary sources include milk, meats, and dark leafy vegetables. Niacin (B3) aids in the metabolism of fats, glucose, and alcohol. ● Deficiency causes pellagra (manifestations include sun-sensitive skin lesions, and gastrointestinal and neurological findings). ● Sources include meats, legumes, milk, whole grain and enriched breads and cereals. Pyridoxine/Vitamin B6 is needed for cellular function and synthesis of hemoglobin, neurotransmitters, and niacin. ● Deficiency causes macrocytic anemia and CNS disturbances. ● High intake of supplements can cause sensory neuropathy. ● Widespread food sources include meats, grains, and legumes. Pantothenic acid is involved in the metabolism of carbohydrates, fats, and proteins as part of coenzyme A. ● Deficiency is extremely rare, but results in generalized body system failure. ● Rich sources include meats, whole grain cereals, dried peas and beans. Biotin serves as a coenzyme used in fatty acid synthesis, amino acid metabolism, and the formation of glucose. ● Deficiency is rare, but results in neurological findings (depression, fatigue), hair loss, and scaly red rash. ● Widespread food sources include eggs, milk, and dark green vegetables. Folate is required for hemoglobin and amino acid synthesis, new cell synthesis, and prevention of neural tube defects in utero. (Folic acid is the synthetic form.) ● Deficiency causes megaloblastic anemia, CNS disturbances, and fetal neural tube defects (spina bifida, anencephaly). It is important that all women of child-bearing age get an adequate amount of folate due to neural tube formation occurring early in gestation, often before a woman knows she is pregnant. ● Folate occurs naturally in a variety of foods including liver, dark-green leafy vegetables, orange juice, and legumes. Cobalamin (B12) is necessary for folate activation and red blood cell maturation. ● Deficiency causes pernicious anemia and is seen mostly in strict vegans (B12 is found solely in foods of animal origin), and those with the absence of intrinsic factor needed for the absorption of B12. ● Sources include meat, shellfish, eggs, and dairy products. FAT‑SOLUBLE VITAMINS ● All fat-soluble vitamins have the possibility for toxicity due to their ability to be stored in the body for long periods of time. ● Absorption of fat-soluble vitamins is dependent on the body’s ability to absorb dietary fat. Fat digestion can be interrupted by any number of conditions, particularly those that affect the secretion of fat-converting enzymes, and conditions of the small intestine. Clients who have cystic fibrosis, celiac disease, Crohn’s disease, or intestinal bypasses are at risk for deficiencies. ● Clients who have liver disease should be careful not to take more than the daily recommendations of fat-soluble vitamins, as excess is stored in the liver and adipose tissue. Vitamin A Vitamin A (retinol, beta-carotene) contributes to vision health, tissue strength and growth, and embryonic development. ● Care should be taken when administered to pregnant clients as some forms have teratogenic effects on the fetus. ● Deficiency results in vision changes, xerophthalmia (dryness and hardening of the cornea), GI disturbances, and hyperkeratosis. ● Food sources include fatty fish, egg yolks, butter, cream, and dark yellow/orange fruits and vegetables (carrots, yams, apricots, squash, cantaloupe). Vitamin D Vitamin D assists in the absorption of calcium and phosphorus, and aids in bone mineralization. ● Sunlight enables the body to synthesize vitamin D in the skin. ● Deficiency results in bone demineralization, and extreme deficiency results in rickets. Excess consumption can cause hypercalcemia. ● Food sources include fortified milk, fatty fish, and eggs. Vitamin E Vitamin E is an antioxidant that helps to preserve lung and red blood cell membranes. ● Deficiency rare, but results in anemia and can cause edema and skin lesions in infants. ● Food sources include vegetable oils and certain nuts. Vitamin K Vitamin K assists in blood clotting and bone maintenance. ● Deficiency results in increased bleeding time. ● Used as an antidote for excess anticoagulants (warfarin). ● Vitamin K is found in carrots, eggs, and dark green vegetables (spinach, broccoli, asparagus). MAJOR ACTIONS MAJOR SOURCES DEFICIENCY MAJOR ACTIONS MAJOR SOURCES DEFICIENCY Minerals and electrolytes Minerals are available in an abundance of food sources and are used at every cellular level for metabolic exchanges. Minerals are divided into major and trace. MAJOR MINERALS Major minerals occur in larger amounts (more than 5 g) in the body, and 100 mg or more is required through dietary sources each day. The seven major minerals are calcium, phosphorus, sodium, potassium, magnesium, chloride, and sulfur. Electrolytes Electrolytes are electrically charged minerals that cause physiological reactions that maintain homeostasis. Major minerals include sodium, potassium, and chloride. Sodium (Na) MAJOR ACTIONS: Maintains fluid volume, allows muscle contractions, contributes to nerve impulses MAJOR SOURCES: Table salt, added salts, processed foods FINDINGS OF DEFICIENCY: Muscle cramping, memory loss, anorexia FINDINGS OF EXCESS: Fluid retention, hypertension, disorientation NURSING CONSIDERATIONS: Monitor level of consciousness, edema, and blood pressure. Potassium (K) MAJOR ACTIONS: Maintains fluid volume inside cells, muscle action MAJOR SOURCES: Oranges, dried fruits, tomatoes, avocados, dried peas, meats, broccoli, bananas, dairy products, meats, whole grains FINDINGS OF DEFICIENCY: Dysrhythmias, muscle cramps, confusion FINDINGS OF EXCESS: Dysrhythmia, muscle weakness, irritability, confusion, numbness in extremities NURSING CONSIDERATIONS: Monitor cardiac status and ECG. PO tabs irritate the GI system. Give with meals. Chloride (Cl) MAJOR ACTIONS: Assists with intracellular and extracellular fluid balance, aids digestion MAJOR SOURCES: Table salt FINDINGS OF DEFICIENCY: Rare; muscle cramps, anorexia FINDINGS OF EXCESS: Vomiting NURSING CONSIDERATIONS: Monitor sodium levels. Calcium (Ca) MAJOR ACTIONS: Bones/teeth formation, blood pressure, blood clotting, nerve transmission MAJOR SOURCES: Dairy, broccoli, kale, grains, egg yolks FINDINGS OF DEFICIENCY: Tetany, positive Chvostek’s and Trousseau’s signs, ECG changes, osteoporosis in adults, poor growth in children FINDINGS OF EXCESS: Constipation, renal stones, lethargy, depressed deep-tendon reflexes NURSING CONSIDERATIONS: Monitor ECG and respiratory status. Give PO tabs with vitamin D. Magnesium (Mg) MAJOR ACTIONS: Bone formation, catalyst for many enzyme reactions, nerve/muscle function, smooth muscle relaxation MAJOR SOURCES: Green leafy vegetables, nuts, whole grains, tuna, halibut, chocolate FINDINGS OF DEFICIENCY: Weakness, dysrhythmias, vertigo, convulsions, increased blood pressure, anorexia FINDINGS OF EXCESS: Diarrhea, nausea, muscle weakness, hypotension, bradycardia, lethargy NURSING CONSIDERATIONS: Seizure precautions, monitor level of consciousness and vital signs Phosphorus (P) MAJOR ACTIONS: Energy transfer of RNA/DNA, acid-base balance, bone and teeth formation MAJOR SOURCES: Dairy, peas, meat, eggs, legumes FINDINGS OF DEFICIENCY: Unknown FINDINGS OF EXCESS: Decreased serum calcium levels NURSING CONSIDERATIONS: Evaluate the use of antacids (note type) and the use of alcohol (alcohol impairs absorption). Sulfur (S) MAJOR ACTIONS: A component of vitamin structure, by-product of protein metabolism MAJOR SOURCES: Proteins FINDINGS OF DEFICIENCY: Only seen in severe protein malnourishment FINDINGS OF EXCESS: Toxicity does not result in any health issues NURSING CONSIDERATIONS: Sulfur levels are not usually monitored. TRACE MINERALS Trace minerals, also called micronutrients, are required by the body in amounts of less than 5 g, and 20 mg or less is required through dietary sources each day. The nine trace elements are iron, iodine, zinc, copper, manganese, chromium, selenium, molybdenum, and fluoride. Iodine Iodine is used for synthesis of thyroxine, the thyroid hormone that helps regulate metabolism. Iodine is taken up by the thyroid. When iodine is lacking, the thyroid gland enlarges, creating a goiter. ● Grown food sources vary widely and are dependent on the iodine content of the soil in which they were grown. ● Seafood provides a good amount of iodine. Table salt in the U.S. is fortified with iodine, so deficiencies are not as prevalent. ● The RDA is 150 mcg for adults. Iron Iron is responsible for oxygen distribution to hemoglobin and myoglobin. ● The body recycles unused iron from dying red blood cells and stores it for later use. ● Iron in food consists of two forms; heme iron found in meat, fish and poultry and nonheme iron found in grains, legumes, and vegetables. ● Iron supplements can cause constipation, nausea, vomiting, diarrhea, and teeth discoloration (liquid form). They can be taken with food to avert gastrointestinal symptoms, and nurses should encourage fresh fruits, vegetables, and a high-fiber diet. ● Supplements that are unneeded can become toxic. ● Intramuscular injections are caustic to tissues and must be administered by Z-track method. ● ● Females during the menstruating years, older infants and toddlers and pregnant women are at risk for iron deficiency anemia. Fluoride Fluoride forms a bond with calcium and thus accumulates in calcified body tissue (bones and teeth). Water with added fluoride protects against dental cavities. Water Water is the most basic of nutrients. The body can maintain itself for several weeks on its food stores of energy, but it cannot survive without water/hydration for more than a few days. Water makes up the largest portion of our total body weight and is crucial for all fluid and cellular functions. ● Fluid balance is essential for optimum health and bodily function. ● The balance of fluid is a dynamic process regulated by the release of hormones. ● To maintain a balance between intake and output, intake should approximate output. Healthy adults lose approximately 1000 mL of water daily through insensible losses (respirations, skin, fecal), and to get rid of metabolic wastes needs to excrete at least 500 mL of urine daily. Therefore, the minimum daily amount of water intake needed is 1,500 mL. ● Under normal conditions, the AI for adult fluid intake is 3 L/day for men and 2.2 L/day for women. ● Additional hydration can be required for athletes, persons with fever/illness (vomiting, diarrhea), and those in hot climate conditions. ● Young children and older adults dehydrate more rapidly. ● Clients who cannot hold down fluid or must withhold fluids in preparation for a procedure may be hydrated with intravenous fluids. ● Water leaves the body via the kidneys, skin, lungs, and feces. The greatest elimination is through the kidneys. Other loss factors to be considered include bleeding, vomiting, and rapid respirations. Persistent vomiting can quickly dehydrate a person. ● A balanced input/output ratio is almost 1:1. Nurses should consider the health status and individual needs of the client. ● Assessment for proper hydration should include skin turgor, mental status, orthostatic blood pressures, urine output and concentration, and moistness of mucous membranes. ● Thirst is a late sign of the need for hydration, especially in older adults. ● Some individuals can have an aversion to drinking water, and should be encouraged to explore other options (fresh fruits, fruit juices, flavored gelatin, frozen treats, soups). ● Caffeinated drinks have a diuretic effect and should not be substituted for other fluids. Application Exercises 1. A nurse is educating a client who is taking iron supplements about foods which aid in iron absorption. Which of the following foods is the best choice for the client to make? A. 1 baked potato C. ½ cup low‑fat milk D. 2 cups boiled green beans 2. A nurse is discussing foods that are high in vitamin D with a client who is unable to be out in the sunlight. Which of the following should be included in the teaching? A. 1 cup steamed long‑grain brown rice B. 6 medium raw strawberries C. ½ cup boiled Brussels sprouts D. 2 large, poached eggs 3. A nurse is caring for a client who is prescribed warfarin. The nurse should teach the client that which of the following vitamins can interfere with this medication? A. Vitamin A B. Vitamin D C. Vitamin E D. Vitamin K 4. A nurse is conducting a nutritional class on minerals and electrolytes. The nurse should include that ½ cup of which of the following foods is the best source of magnesium? A. Whole almonds B. Chopped tomatoes C. Raw spinach D. Low‑fat vanilla yogurt 5. A nurse is discussing health problems associated with nutrient deficiencies with a group of adolescents. The nurse should include that which of the following conditions is associated with a deficiency of vitamin C? A. Dysrhythmias B. Scurvy C. Pernicious anemia D. Megaloblastic anemia Application Exercises Key 1. A. One baked potato has 20 mg of vitamin C, and is not the best food choice for the client to make. B. CORRECT: Vitamin C aids in the absorption of iron, and ½ cup orange juice has 62 mg of vitamin C. This is the best food choice for the client to make. C. ½ cup low‑fat milk has 1.2 mg of vitamin C, and is not the best food choice for the client to make. D. Two cups green beans has 24 mg of vitamin C, and is not the best food choice for the client to make. NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration 2. A. Long‑grain brown rice does not contain vitamin D. B. Strawberries do not contain vitamin D. C. Brussels sprouts do not contain vitamin D. D. CORRECT: The nurse should include eggs as a food that is high in vitamin D. NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration 3. A. Vitamin A does not interfere with warfarin B. Vitamin D does not interfere with warfarin. C. Vitamin E does not interfere with warfarin. D. CORRECT: Vitamin K assists in blood clotting, is used as an antidote for excess anticoagulants, and can interfere with warfarin. The nurse should instruct the client to avoid increasing sources of vitamin K through supplements or in the diet. NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration 4. A. CORRECT: ½ cup whole almonds is the best source because it has 193 mg of magnesium. B. ½ cup chopped red tomatoes is not the best source because it has 10 mg of magnesium. C. ½ cup raw spinach is not the best source because it has 12 mg of magnesium. D. ½ cup low‑fat vanilla yogurt is not the best source because it has 20 mg of magnesium. NCLEX® Connection: Physiological Adaptation, Fluid and Electrolyte Imbalances 5. A. Dysrhythmias are associated with a potassium deficiency. B. CORRECT: Scurvy is associated with a vitamin C deficiency. C. Pernicious anemia is associated a deficiency of vitamin B12. D. Megaloblastic anemia is associated with a deficiency of folate. NCLEX® Connection: Physiological Adaptation, Illness Management CHAPTER 2 UNIT 1 PRINCIPLES OF NUTRITION CHAPTER 2 Ingestion, Digestion, Absorption, and Metabolism Ingestion is the process of consuming food by the mouth, and moving it through the digestive system. Digestion is a systemic process that includes the breakdown and absorption of nutrients. Absorption occurs as components of nutrients pass through the digestive system into the bloodstream and lymphatic system. Medication absorption can be affected by food intake. It is important for nurses to be aware of food and medication absorption. Nurses should assess liver and kidney functioning to determine adequacy prior to medication administration. Metabolism is the sum of all chemical processes that occur on a cellular level to maintain homeostasis. Nutrients from food must enter a cell in order for metabolism to occur. Metabolism is comprised of two processes: catabolism (the breaking down of substances with the resultant release of energy) and anabolism (the use of energy to build or repair substances). Energy nutrients are metabolized to provide carbon dioxide, water, and adenosine triphosphate (ATP). Excess energy nutrients are stored; glucose is converted to glycogen and stored in the liver and muscle tissue; surplus glucose is converted to fat; glycerol and fatty acids are reassembled into triglycerides and stored in adipose tissue; and amino acids make body proteins. The liver removes excess amino acids and uses the residue to form glucose or store it as fat. Body cells first use available ATP for growth and repair, then use glycogen and stored fat. METABOLIC RATE Metabolic rate refers to the speed at which food energy is burned. ● Basal metabolic rate (BMR), also called basal energy expenditure (BEE), refers to the amount of energy used in 24 hr for involuntary activities of the body, such as maintaining body temperature, heartbeat, circulation, and respirations. This rate is determined while at rest, and following a 12-hr fast. ● Resting metabolic rate (RMR), also called resting energy expenditure (REE), refers to the calories needed for involuntary activities of the body at rest. This rate does not consider the 12-hr fast criteria. ● BMR is affected by lean body mass and hormones. Body surface area, age, and gender are also factors that contribute to BMR. ● ● ◯ ◯ Protein deficiency increases the risk of complications from severe trauma or critical illness (skin breakdown, delayed wound healing, infections, organ failure, ulcers, impaired medication tolerance). ◯ Protein requirements may be increased to more than 2 g/kg of body weight, or up to 25% of total calories, depending on the client’s age and prior nutritional status. ● ● Disease and sepsis also increase metabolic demands and can lead to starvation/death. FACTORS AFFECTING METABOLIC RATE INCREASE BMR