-NUTRI NOTES-

■ Nutrition is an integral part of nursing care. Like air, food is a basic human need.

■ Nutrition screening is used to identify patients or clients who may be at risk for
malnutrition. Screening tools are simple, quick, easy to use, and rely on available data.

■ The Joint Commission stipulates that nutrition screens be performed within 24 hours
of admission to a health-care facility, but facilities are free to decide what criteria to
include on a screen, what findings indicate risk, and who is to conduct the screen.
Screens are often the responsibility of staff nurses because they can be completed
during a history and physical examination upon admission.

■ Patients who are identified to be a low or no nutritional risk are rescreened within a
specified period of time to determine whether their nutritional risk status has changed.

■ Patients who are found to be a moderate to high nutritional risk at screening receive
a comprehensive nutritional assessment by the dietitian that includes the steps of
assessment, diagnosis, intervention, and monitoring and evaluation.

■ Dietitians use information from the nursing history and physical examination to begin
the assessment process. They may also obtain a nutritional history from the patient, calculate
estimated protein and calorie needs, assess the adequacy and appropriateness of
the diet order, and identify the patient’s diagnostic code for malnutrition, if appropriate.

■ Nurses can integrate nutrition into the nursing care process to develop care plans that
address the individual’s needs. Nurses are not expected to be dietitians but rather use
nutrition to provide quality nursing care.

■ Albumin and prealbumin are not valid criteria for assessing protein status because they
become depleted from inflammation and physiologic stress.

■ Accurate height and weight are essential for assessing risk and monitoring progress.
They are used to determine BMI and percentage of weight loss. Significant unintentional
Weight loss is defined according to the length of time over which the loss occurred.

■ Dietary data can help determine whether a nutrition problem is caused by intake or
by illness or its treatments. The term diet inspires negative feelings in most people.
Replace it with eating pattern, eating style, or foods you normally eat to avoid negative
connotations.

■ People with gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and

Anorexia that last more than 2 weeks are at risk for malnutrition.
■ Physical signs and symptoms of malnutrition are nonspecific, subjective, and develop
slowly and should be considered suggestive, not diagnostic, of malnutrition.

■ Medical–psychosocial history can reveal factors that influence intake, nutritional

requirements, or nutrition counseling needs.

■ Medications and nutritional supplements should be evaluated for their potential impact
on nutrient intake, absorption, utilization, or excretion.

■ Nursing diagnoses related directly to nutrition when the pattern of nutrition or metabolism is
altered. Many other nursing diagnoses, such as constipation, impaired skin integrity, knowledge
deficits, and infection, may include nutrition in some aspect of the plan.

■ A nutrition priority for all clients is to obtain adequate calories and nutrients based on
individual needs.

■ Short-term nutrition goals are to attain or maintain adequate weight and nutritional
status and (as appropriate) to avoid nutrition-related symptoms and complications of
illness. Client-centered outcomes should be measurable, attainable, and specific.

■ Intake recommendations are not always appropriate for all persons; what is recommended in
theory may not work for an individual. Clients may revert to comfort foods
during periods of illness or stress.

■ Nurses can reinforce nutrition counseling provided by the dietitian and initiate counseling for
clients with low or mild risk.

■ Use preprinted lists of “do’s” and “don’ts” only if absolutely necessary, such as in the
case of food allergies. For most people, actual food choices should be considered in
view of how much and how often they are eaten rather than as foods that “must” or
“must not” be consumed.

* wellness
a way of life that integrates body, mind,
and spirit

* nutrients
chemical substances found in food that
are necessary for good health

*essential nutrients
nutrients found only in food
The Six Essential Nutrients and Their Functions

ORGANIC NUTRIENTS FUNCTION

Carbohydrates Provide energy
Fats Provide energy
Proteins Build and repair body tissues
Provide energy
Vitamins Regulate body processes

INORGANIC NUTRIENTS FUNCTION

Minerals Regulate body processes
Water Regulates body processes

**The body can make small amounts of some nutrients, but most must be obtained from food in
order to meet the body’s needs. Those available only in food are called essential nutrients.
There are about 40 of them, and they are found in all six nutrient classes

**Organic nutrients contain hydrogen, oxygen, and carbon. (Carbon is an element found in all
living things.) Before the body can use organic nutrients, it must break them down into their
smallest components.

Inorganic nutrients are already in their simplest forms when the body ingests them, except for
Water.

Each nutrient participates in at least one of the following functions:

1. Providing the body with energy
2. Building and repairing body tissue
3. Regulating body processes

-Carbohydrates (CHO), proteins, and fats (lipids) furnish energy.

Proteins are also used to build and repair body tissues with the help of vitamins and minerals.

Vitamins, minerals, and water help regulate the various body processes such as circulation,
respiration, digestion, and elimination.
*carbohydrates (CHO)
the nutrient class providing the major
source of energy in the average diet

*proteins
the only one of the six essential nutrient
classes containing nitrogen

fats (lipids)
highest calorie-value nutrient class

vitamins
organic substances necessary for life
although they do not, independently,
provide energy

minerals
one of many inorganic substances essential
to life and classified generally as minerals

water
major constituent of all living cells;
composed of hydrogen and oxygen

digestion
breakdown of food in the body in
preparation for absorption

elimination
evacuation of wastes

nutritious
foods or beverages containing substantial
amounts of essential nutrients

nourishing
foods or beverages that provide
substantial amounts of essential nutrients

nutrition
the result of those processes whereby the
body takes in and uses food for growth,
development, and the maintenance of health
nutritional status one’s physical condition as determined by diet
one’s physical condition as determined
by diet

CARBOHYDRATES

■ Carbohydrates, which are found almost exclusively in plants, provide the major source
of energy in almost all human diets

■ The two major groups are simple sugars (monosaccharides and disaccharides) and
complex carbohydrates (polysaccharides).

■ Monosaccharides and disaccharides are composed of one or two sugar molecules,

respectively. They vary in sweetness.

■ Polysaccharides—namely, starch, glycogen, and fiber—are made up of many glucose

molecules. They do not taste sweet because their molecules are too large to sit on taste
buds in the mouth that perceive sweetness.

■ Fiber, the indigestible part of plant cell walls or intracellular structure, is commonly
classified as either water soluble or water insoluble. All foods that contain fiber have a
mix of different fibers.

■ Carbohydrates are found in every MyPlate group except Oils. Starches are most
abundant in grains, vegetables, and the plant foods found in the Protein Foods group;
natural sugars occur in fruits and in the Dairy group. Added sugars can be found in any
food group.

■ The majority of carbohydrate digestion occurs in the small intestine, where

Disaccharides and starches are digested to monosaccharides. Monosaccharides are
absorbed through intestinal mucosal cells and transported to the liver through the
portal vein. In the liver, fructose and galactose are converted to glucose. The liver
releases glucose into the bloodstream.

■ The glycemic response is based on the glycemic index of a food and the carbohydrate
content of that food. Because there are so many variables that infl uence the rise in
blood glucose after eating, glycemic response is hard to predict in practice.

■ The major function of carbohydrates is to provide energy, which includes sparing

protein and preventing ketosis. Glucose can be converted to glycogen, used to make
nonessential amino acids, used for specific body compounds, or converted to fat and
stored in adipose tissue.
■ The RDA for total carbohydrates is set as the minimum amount needed to fuel the
brain but not as an amount adequate to satisfy typical energy needs. Most experts
recommend that 45% to 65% of total calories come from carbohydrates and that added
sugars are limited. Twenty-five and 38 g of fiber is recommended daily for adult women
and men, respectively

■ Whole grains offer health benefits beyond the benefits of fiber. Whole grains may
decrease the risk of heart disease, certain cancers, and type 2 diabetes. Whole grains
also promote gastrointestinal health and weight management.

■ Added sugar is sugar added to food during processing or preparation. It is

considered a source of empty calories. The higher the intake of empty calories,
the greater is the risk of an inadequate nutrient intake, an excessive calorie intake,
or both.

■ Polyols are considered to be low-calorie sweeteners because they are incompletely

absorbed and, therefore, provide fewer calories per gram than regular sugar does.
Because they do not promote dental decay, they are well suited for use in gum and
breath mints that stay in the mouth a long time. Most have a laxation effect depending
on the dose consumed.

■ Nonnutritive sweeteners provide negligible or no calories. Their use as food additives

is regulated by the FDA, which sets safety limits known as ADI. The ADI, a level per
kilogram of body weight, reflects an amount 100 times less than the maximum level
at which no observed adverse effects have occurred in animal studies. Nonnutritive
sweeteners have intense sweetening power, ranging from 180 to 8000 times sweeter
than that of sucrose.

■ Acids produced from fermentation of sugars and starches in the mouth by bacteria lead
to dental decay
FATS

■ Ninety-eight percent of lipids consumed in the diet are triglycerides, which are composed of
one glyceride molecule and three fatty acids. Phospholipids and sterols are the
other two types of dietary lipids.

■ Saturation refers to each carbon atom in the fatty acid chain having four single bonds
with hydrogen atoms. In saturated fats, each carbon is “saturated” with as much hydrogen as it
can hold. Unsaturated fats have one (monounsaturated) or more than one
(polyunsaturated) double bond between carbon atoms.

■ All fats in foods contain a mixture of saturated, monounsaturated, and polyunsaturated

fats. When used to describe food fats, these terms are relative descriptions of the type of
fatty acid present in the largest amount.

■ Generally, saturated fats are “bad” because they raise total and LDL cholesterol.
Unsaturated fats are “good” because they lower total and LDL cholesterol when consumed in
place of saturated fats.

■ Trans fatty acids are produced through the process of hydrogenation. They are
chemically unsaturated fats; however, like saturated fat, they raise total and LDL
Cholesterol.

■ Linoleic acid (n-6) and alpha-linolenic acid (n-3) are essential fatty acids because they
cannot be made by the body. They are important constituents of cell membranes, are
involved in eicosanoid synthesis, and function to maintain healthy skin and promote
normal growth.

■ The major function of fat is to provide energy; 1 g of fat supplies 9 calories of energy.
Fat also provides insulation, protects internal organs from mechanical damage, and
promotes absorption of the fat-soluble vitamins.

■ Fish oils lower the risk of heart disease by lowering serum lipids and triglycerides and
by helping to regulate blood pressure. Although they may also be beneficial in preventing other
health problems, the evidence is currently inconclusive or lacking.

■ The best sources of n-3 fatty acids are fatty cold-water fish such as salmon, trout, herring,
swordfish, sardines, and mackerel. Walnuts, soybeans, flaxseed, and canola oil are
plant sources of the n-3 fatty acid alpha-linolenic acid, but alpha-linolenic acid may not
have the same cardioprotective benefits as fish oils.

■ Phospholipids are structural components of cell membranes that facilitate the transport
of fat-soluble substances across cell membranes. They are widespread but appear in
small amounts in the diet.
■ Cholesterol, a sterol, is a constituent of all cell membranes and is used to make bile
acids, steroid hormones, and vitamin D. Cholesterol is found in all foods of animal origin except
egg whites. Most Americans eat about half as much cholesterol as the body
makes each day.

■ Fat digestion occurs mostly in the small intestine. Short- and medium-chain fatty
acids and glycerol are absorbed through mucosal cells into capillaries leading to the
portal vein. Larger fat molecules—namely, cholesterol, phospholipids, and reformed
triglycerides made from monoglycerides and long-chain fatty acids—are absorbed in
chylomicrons and transported through the lymph system.

■ Grains, fruits, and vegetables are generally fat free or low in fat, although certain
preparation methods can add fat. Dairy, protein foods, and the oil food groups
provide fat, with the type and quantity of fat varying considerably among items
within each group.

■ Deficiencies of essential fatty acids are nonexistent in healthy people.

■ To achieve a more optimal fat intake, a plant-based diet rich in fruit, vegetables, whole
grains, legumes, and nuts is recommended with adequate amounts of fat-free dairy
products and lean meats. Fats, such as in margarine and salad dressings, should be trans
fat free, and these products should preferably be made with canola or olive oil. A total
of 8 oz or more of seafood per week is suggested.

-PROTEIN-

■ Protein is a component of every living cell. Protein in the body provides structure and
framework. Amino acids are also components of enzymes, hormones, neurotransmitters, and
antibodies. Proteins play a role in fluid balance and acid–base balance and are
used to transport substances through the blood. Protein provides 4 cal/g of energy.

■ Amino acids, which are composed of carbon, hydrogen, oxygen, and nitrogen atoms,
are the building blocks of protein. Of the 20 common amino acids, 9 are considered
essential because the body cannot make them. The remaining 11 amino acids are no
less important but are considered nonessential because they can be made by the body if
nitrogen is available. Some of these are considered conditionally essential under certain
Circumstances

■ Amino acids are joined in different amounts, proportions, and sequences to form the
thousands of different proteins in the body.
■ The small intestine is the principal site of protein digestion; amino acids and some dipeptides
are absorbed through the portal bloodstream.

■ In the body, amino acids are used to make proteins, nonessential amino acids, and
other nitrogen-containing compounds. Some amino acids can be converted to glucose.
Amino acids consumed in excess of need are burned for energy or converted to fat and
Stored.

■ Healthy adults are in nitrogen balance, which means that protein synthesis is occurring
at the same rate as protein breakdown. Nitrogen balance is determined by comparing the
amount of nitrogen consumed with the amount of nitrogen excreted in urine,
feces, hair, nails, and skin.

■ Except for the Fruits and Oils, all MyPlate groups provide protein in varying amounts.

■ The quality of proteins varies. Complete proteins provide adequate amounts and proportions
of all essential amino acids needed for protein synthesis. Animal proteins and
soy protein are complete proteins. Incomplete proteins lack adequate amounts of one
or more essential amino acids. Except for soy protein, all plants are sources of incomplete
proteins. Gelatin is also an incomplete protein.

■ The RDA for protein for adults is 0.8 g/kg of body weight. The AMDR for protein
among adults is 10% to 35% of total calories. Most Americans consume more protein
than they need.

■ Pure vegans eat no animal products. Most American vegetarians are lacto-vegetarians
or lacto-ovo vegetarians, whose diets include milk products or milk products and eggs,
respectively.
■ Most vegetarian diets meet or exceed the RDA for protein and are nutritionally adequate
across the life cycle. Pure vegans who do not have reliable sources of vitamin B12
and vitamin D need supplements.

■ To gain muscle mass, resistance exercise is necessary. The small increase in protein that
is needed can be easily met by an increase in calorie intake. Nutritionally, adequate
calories are the most important factor for increasing muscle mass.

-METABOLISM, ENERGY, BODY COMPOSITION-

■ Calories are a measure of energy. The body obtains calories from carbohydrates, protein,
fat, and alcohol.

■ Basal metabolism refers to the calories used to conduct the involuntary activities of
the body, such as beating the heart and inflating the lungs. For most Americans, basal
metabolism accounts for approximately 60% to 70% of total daily calories used.

■ The sum of calories spent on basal metabolism and physical activity (PA) represent a
person’s total calorie expenditure.

■ The thermic effect of food is the cost of digesting, absorbing, and metabolizing food.
At about 10% of total calories consumed, it is a small part of total energy requirements
and is often not factored into the total energy equation.

■ MyPlate calorie levels are based on gender, age, and activity. Sedentary women need
approximately 1600 to 2000 cal/day, and sedentary men need 2000 to 2600 cal/day.

■ Desirable weight is defined as weight for height that is statistically correlated to good
health. Ideal body weight, BMI, and waist circumference may be used to assess risk
related to overweight and obesity.

■ BMI may be the best method of evaluating weight status, but it does not account for
how weight is distributed. Overweight is defined as a BMI of 25 to 29.9; obesity is
defined as a BMI of 30 or higher.

■ Waist circumference is a tool to assess abdominal fatness. “Apples” (people with

upper body obesity) have more health risks than “pears” (people with lower body
obesity).

■ Healthy food choices involve eating less of items that are high in added sugar and fat
and more of nutrient-dense foods like fruits, vegetables, whole grains, nonfat dairy
products, and lean protein.
■ Portion sizes have grown over the last two decades, and people often overestimate how
much food they really need. Portion control is facilitated by eating less at restaurants,
using smaller dinner plates, and buying prepackaged, portion-controlled foods.

■ Exercise leads to only modest weight loss if calories are not also restricted. In the long
term, exercise promotes weight loss by promoting fat loss and preventing loss of muscle, which
contributes to metabolic rate.