Nutrition and Metabolic Stress

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Chapter 15

• Nutrition and Metabolic Stress

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Leading Causes of Illness and Death

• Industrialized countries
• Chronic diseases
• Developing countries
• Infections
• Protein energy malnutrition (PEM)
• Can have PEM as iatrogenic complication in
  hospital

3
Cultural Views on Balance in Eating

• U.S. Eating foods from all food groups,
  especially fruits and vegetables
• Chinese Yin and yang
• Latin America, Middle East, India, Phillipines
  Hot and cold
• (See Appendix L)

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Malnutrition and Stress
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Metabolic Responses to Starvation

• Hypometabolism with starvation
• Same with strict dieting
• Glycogenolysis
• Protein catabolized , nitrogen excreted
• Free fatty acids to ketones, glycerol to
  gluconeogenesis

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Types of Protein Energy Malnutrition (PEM)

• Primary vs. secondary causes
• Kwashiorkor protein deficit
• See page 160 for photo
• See page 450 for problems
• Marasmus chronic Kcalorie deficit
• See page 160 for photo
• Marasmus-kwashiorkor mix

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Refeeding Syndrome

• Feeding too quickly may be fatal.
• Excess protein and kcals can overload.
• Fluids, electrolytes, and glucose levels must be
  monitored carefully.
• Possible results Cardiac failure, hyperglycemia,
  metabolic acidosis, dehydration, respiratory
  distress, convulsions, coma, death
• Start slowly and be careful for 1 week

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Starvation in the World

• What are the problems?
• What are the solutions?
• See pages 161, 162

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Metabolic Responses to Severe Stress

• Stress response General adaptation syndrome
• Cortisol released from adrenal glands delayed
  healing
• See page 444
• Hypermetabolism
• Ebb phase
• Early - focus on cardiac output and tissue
  perfusion
• Flow phase
• In 36-48 hours - hypermetabolism

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Effects of PEM

• Decreased immune response
• Weak intercostal muscles can lead to pneumonia
• Delayed healing

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Increased Needs With Surgery

• Correct deficits presurgery
• NPO preoperatively to prevent aspiration
• IVs supply only about 500 calories per 24 hours
• Oral intake when bowel sounds return (often 24 to
  48 hours after surgery)
• Progressive dietclear liquid at first

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Review

• Hospital Diet Progressions
• Clear liquid
• Full liquid
• Soft
• Regular
• Appendix H

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Nutritional Care After Surgery(from Nutrition
and Diet Therapy by Townsend)

• Estimated daily kcal requirement for adults after
  surgery is 35 to 45 kcal per kilogram of body
  weight.
• A high-protein diet of 80 to 100g a day may be
  recommended.
• Extra minerals and vitamins are needed.

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Problem

• Your client weighs 192 pounds and has just had
  major surgery.
• How many kcal will the client require in a
  24-hour period?

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Solution

• First, calculate the clients weight in
  kilograms.
• 192 lbs ? 2.2 kg/lb 87.27 kg
• Next, multiply the clients weight in kg by the
  number of kg/lb (35, then 45) to get range.
• 87kg x 35kcal/kg 3045
• 87kg x 45kcal/kg 3915
• Client needs between 3,045-3,915 kcal/day

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Review

• How many calories are in 1 cup of whole milk12 g
  carbohydrate and 8 g protein?
• How many calories are in 3 ounces of white
  chicken without skin21 g protein, 3 g fat?
• How many calories are in 1 slice of whole wheat
  bread15 g carbohydrate, 3 g protein, 1 g fat?

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Nutritional Needs Associated With Severe Stress

• Dietitian may use Harris-Benedict formula to
  determine how many kcalories are needed.
• Page 448
• Factors considered
• Basal energy expenditure (BEE)
• Age, current weight, height
• Gender considered in equation
• Activity factor
• Injury factor (severity of injury)
• Increased need for Kcalories, protein, vitamins A
  and C, zinc, and fluids

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Burns

• Tremendous nutrition needs
• Individualized nutrition
• Fluid and electrolyte replacement
• Early enteral feedings
• Need for more kcalories, protein, vitamins A and
  C
• Case study in book
• Page 453 goals
• Page 454 story
• Page 456 care plan

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Nutrition Multiple Organ Dysfunction Syndrome

• Increased need for kcalories and protein
• Enteral feeding to maintain gut integrity

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Sites for Enteral Feeding Tubes
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Site for Total Parenteral Nutrition
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Ethical Question

• Should you use a feeding tube for an unconscious
  patient after a motor vehicle accident?
• Should you use a feeding tube when a patient is
  terminal?

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Increased Protein Needs

• Normal 0.8 g/ kg
• Surgery 1.0-1.5 g/kg
• Multiple trauma 1.3-1.7 g/kg
• Burns (more than 40) 1.8-2.5 g/kg
• Fever energy stress factor increases

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Calculating Protein Intake

• See page 154
• Change weight to kilograms (lbs./2.2)
• Multiply by recommendation
• (0.8g/kg is normal)
• (2.5g/kg may be needed for burned patient)

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Fluid (Water) Needs

• Depends on
• Weight
• Age
• Energy 1 ml fluid/ kcal needed
• Fluid balance urine output plus 500 ml/day

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Increase Protein and Calories (from Nutrition
Essentials for Nursing Practice by Dudek)

• Add skim milk powder to milk to make it
  double-strength (chill before serving)
• Use double-strength milk on cereal and in
  scrambled eggs, soups, gravies, casseroles, milk
  shakes, milk-based desserts (custards, puddings)
• Use yogurt as a topping for fruit, cake
• Use peanut butter on apples, bananas, pears, and
  crackers
• Add cheese to soups, rice, casseroles
• Dip meat in eggs or milk and bread crumbs

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To Increase Calories (from Nutrition Essentials
for Nursing Practice by Dudek)

• Add cream cheese to butter on bread
• Add butter to pancakes, soups, vegetables, rice,
  pasta
• Use mayonnaise for salad dressing
• Add dried fruit, nuts, and granola to desserts
  and cereal
• Use whipped cream on pies, pudding, ice cream
• Use marshmallows in hot chocolate
• Top baked potatoes with butter and sour cream
• Snack on nuts, dried fruit, candy, buttered
  popcorn, cheese, granola, ice cream
• Use honey on cereal and in coffee and tea

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ReviewCalculation of Ideal Body Weight

• Man
• 5 feet tall 106 pounds
• Additional inches 6 pounds
• ( or 10 for bone structure)
• Woman
• 5 feet tall 100 pounds
• Additional inches 5 pounds
• ( or 10 for bone structure)

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Review Ideal Body Weight

• Actual Weight
• X 100
• Ideal Body Weight

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Review Usual Body Weight

• See page 404 This measures change in weight.
• Usual Weight - Actual Weight
• _________________ X 100
• Usual Body Weight