Chapter 21

Kidney Disease

Key Concepts

• Kidney disease interferes with the normal capacity of nephrons to filter waste products of body metabolism.

• Short-term kidney disease requires basic nutrition support for healing rather than dietary restriction.

• 3.8 million Americans have some form of kidney disease.

• 42,000 persons die from such diseases each year.

Kidney Disease, cont’d

Dual Role of the Kidneys

• Kidneys make urine, through which they excrete most of the waste products of metabolism.

• Kidneys control the concentrations of most constituents of body fluids, especially blood.

Basic Structure and Function

• Structures– Basic unit is the nephron

• Glomerulus• Tubules

• Function– Excretory and regulatory– Endocrine

Basic Structure

Renal Nephrons

• Basic functional unit of the kidney• Major nephron functions

– Filtration of materials in blood– Reabsorption of needed substances– Secretion of hydrogen ions to maintain acid-base balance– Excretion of waste materials

• Additional functions– Renin secretion (for body water balance)– Erythropoietin secretion (for red cell production)– Vitamin D activation

Nephron Structures

• Glomerulus– Cluster of branching capillaries– Cup-shaped membrane at the head of each nephron forms the

Bowman’s capsule– Filters waste products from blood– Glomerular filtration rate: Preferred method of monitoring kidney

function

• Tubules– Proximal tubule– Loop of Henle– Distal tubule– Collecting tubule

Tubules

Causes of Kidney Disease

• Infection and obstruction

• Damage from other diseases

• Toxins

• Genetic defect

• Risk factors

Causes of Kidney Disease, cont’d

Risk Factors and Causes of Kidney Disease

• Sociodemographic factors– Older age– Racial or ethnic minority status– Exposure to certain chemical and

environmental conditions– Low income or education

Risk Factors and Causes of Kidney Disease, cont’d

• Clinical factors– Poor glycemic control in diabetes– Hypertension– Autoimmune disease– Systemic infections– Urinary tract infections– Urinary stones

Risk Factors and Causes of Kidney Disease, cont’d

• Clinical factors– Lower urinary tract obstruction– Neoplasia– Family history of chronic kidney disease– Recovery from acute kidney failure– Reduction in kidney mass– Exposure to certain nephrotoxic drugs– Low birth weight

– Copyright National Kidney Foundation.

Medical Nutrition Therapy

• Based on the nature of the disease process and individual responses– Length of disease

• Long term: More specific nutrient modifications

– Degree of impaired renal function• Extensive: Extensive nutrition therapy required

– Individual clinical symptoms

Acute Glomerulonephritis or Nephritic Syndrome

• Clinical symptoms: Hematuria, proteinurea, edema, mild hypertension, depressed appetite, possible oliguria or anuria

Medical Nutrition Therapy

• Acute glomerulonephritis– Uncomplicated disease: Antibiotics and bed

rest– Advanced disease:

• Possible restriction of protein, sodium• Liberal intake of carbohydrates• Potassium intake may be monitored• Fluid intake may be restricted

Nephrotic Syndrome

• Clinical symptoms: Massive edema, ascites, proteinurea, distended abdomen, reduced plasma protein level, body tissue wasting

Medical Nutrition Therapy

• Nephrotic syndrome– Protein intake to meet nutrition/growth needs

(without excess)– Carbohydrate– Lipids– Sodium (~3 g/day)– Potassium– Water– Other minerals and vitamins

Key Concepts

• The progressive degeneration of chronic renal failure requires dialysis treatment and modification according to individual disease status.

Key Concepts, cont’d

• Current therapy for renal stones depends more on basic nutrition and health support for medical treatment than on major food and nutrient restrictions.

Acute Kidney Failure

• Prerenal

• Intrinsic

• Postrenal obstruction

Acute Renal Failure

• Clinical symptoms: Oliguria, proteinurea, hematuria, loss of appetite, nausea/vomiting, fatigue, edema, itchy skin

• Short-term dialysis may be needed

• May progress to chronic renal failure

Medical Nutrition Therapy

• Acute kidney failure– Goal is to improve or maintain nutritional status– Parenteral nutrition therapy may be required– Recommendations for protein intake have been

debated– Individualized therapy based on renal function

(indicated by glomerular filtration rate)

Medical Nutrition Therapy

Mosby items and derived items © 2006 by Mosby, Inc. Slide 26

Chronic Kidney Failure

• Caused by progressive breakdown of renal tissue, which impairs all renal functions

• Develops slowly• No cure (other than kidney transplant)• Clinical symptoms: Polyuria/oliguria/anuria,

electrolyte imbalances, nitrogen retention, anemia, hypertension, azotemia, weakness, shortness of breath, fatigue, thirst, appetite loss, bleeding, muscular twitching

Medical Nutrition Therapy Objectives

• Reduce protein breakdown• Avoid dehydration or excess hydration• Correct acidosis• Correct electrolyte imbalances• Control fluid and electrolyte losses• Maintain optimal nutritional status• Maintain appetite and morale• Control complications of hypertension, bone pain,

nervous system involvement• Slow rate of renal failure

Medical Nutrition Therapy Principles

• Provide enough protein therapy to maintain tissue integrity while avoiding excess

• Provide amino acid supplements for protein supplementation

• Reserve protein for tissue synthesis by ensuring adequate carbohydrates and fats

• Maintain adequate urine volume with water• (Possibly) restrict sodium, phosphate, calcium• Supplement diet with multivitamin

Stages of Chronic Kidney Disease

End-Stage Kidney Disease

• Occurs when patient’s glomerular filtration rate decreases to 15 ml/min

• Irreversible damage to most nephrons

• Dialysis or transplant are only options

Hemodialysis

• Uses an artificial kidney machine to remove toxic substances from blood, restore nutrients and metabolites

• Two to three treatments per week typically required

• Patient’s blood makes several “round trips” through machine

• Dialysis solution (dialysate) removes excess waste material

Hemodialysis, cont’d

Hemodialysis, cont’d

Hemodialysis Patient

• Medical nutrition therapy– Maintain protein and energy balance– Prevent dehydration or fluid overload– Maintain normal serum potassium and sodium

levels– Maintain acceptable phosphate and calcium

levels

Hemodialysis Patient, cont’d

• Other dietary concerns– Avoid protein energy malnutrition by careful

calculation of protein allowance– Maintain body mass index of 25 to 28 kg/m2 – Fluid intake: 1000 ml/day, plus amount equal to urine

output– Sodium: 2000 mg/day– Potassium: 2000-3000 mg/day– Supplement of water-soluble vitamins (e.g., B

complex, C)

Peritoneal Dialysis

• Performed at home• Patient introduces dialysate solution directly

into peritoneal cavity four to five times per day• Surgical insertion of permanent catheter is

required• Disposable bag containing dialysate solution is

attached to catheter• Diet is more liberal than with hemodialysis

Peritoneal Dialysis, cont’d

Peritoneal Dialysis, cont’d

Peritoneal Dialysis, cont’d

• Medical nutrition therapy– Increase protein intake to 1.2 to 1.5 g/kg body

weight– Increase potassium with a wide variety of

fruits and vegetables– Encourage liberal fluid intake of 1500 to 2000

ml/day– Avoid sweets and fats– Maintain lean body weight

Comorbid Conditions

• Osteodystrophy– Bone disease resulting from defective bone formation– Found in about 40% of patients with decreased

kidney function and 100% of patients with kidney failure

• Neuropathy– Central and peripheral neurologic disorders– Found in up to 65% of patients at the initiation of

dialysis

Kidney Stones

• Basic cause is unknown• Factors relating to urine or urinary tract

environment contribute to formation• Present in 5% of U.S. women and 12% of U.S.

men• Major stones are formed from one of three

substances:– Calcium– Struvite– Uric acid

Kidney Stones, cont’d

Risk Factors

Calcium Stones

• 70% to 80% of kidney stones are composed of calcium oxalate

• Almost half result from genetic predisposition• Other causes

– Excess calcium in blood (hypercalcemia) or urine (hypercalciuria)

– Excess oxalate in urine (hyperoxaluria)– Low levels of citrate in urine (hypocitraturia)– Infection

Examples of Food Sources of Oxalates

• Fruits: Berries, Concord grapes, currants, figs, fruit cocktail, plums, rhubarb, tangerines

• Vegetables: Baked/green/wax beans, beet/collard greens, beets, celery, Swiss chard, chives, eggplant, endive, kale, okra, green peppers, spinach, sweet potatoes, tomatoes

• Nuts: Almonds, cashews, peanuts/peanut butter • Beverages: Cocoa, draft beer, tea• Other: Grits, tofu, wheat germ

Struvite Stones

• Composed of magnesium ammonium phosphate

• Mainly caused by urinary tract infections rather than specific nutrient

• No diet therapy is involved

• Usually removed surgically

Other Stones

• Cystine stones– Caused by genetic metabolic defect– Occur rarely

• Xanthine stones– Associated with treatment for gout and family

history of gout– Occur rarely

Kidney Stones: Symptoms and Treatment

• Clinical symptoms: Severe pain, other urinary symptoms, general weakness, fever

• Several considerations for treatment– Fluid intake to prevent accumulation of materials– Dietary control of stone constituents– Achievement of desired pH of urine with medication– Use of binding agents to prevent absorption of stone elements– Drug therapy in combination with diet therapy

Nutrition Therapy: Calcium Stones

• Low-calcium diet (~400 mg/day) recommended for those with supersaturation of calcium in the urine and who are not at risk for bone loss

• If stone is calcium phosphate, sources of phosphorus (e.g., meats, legumes, nuts) are controlled

• Fluid intake increased• Sodium intake decreased• Fiber foods high in phytates increased

Nutrition Therapy: Uric Acid Stones

• Low-purine diet sometimes recommended• Avoid:

– Organ meats– Alcohol– Anchovies, sardines– Yeast– Legumes, mushrooms, spinach, asparagus,

cauliflower– Poultry

Medical Nutrition Therapy: Cystine Stones

• Low-methionine diet (essentially a low-protein diet) sometimes recommended

• In children, a regular diet to support growth is recommended

• Medical drug therapy is used to control infection or produce more alkaline urine

General Dietary Principles: Kidney Stones

Summary

• The nephrons are the functional units of the kidneys. Through these unique structures the kidney maintains life-sustaining blood levels of materials required for life and health.

• The nephrons accomplish their tremendous task by constantly “laundering” the blood many times each day, returning necessary elements to the blood and eliminating the remainder in concentrated urine.

Summary, cont’d

• Various diseases that interfere with the vital function of nephrons can cause kidney disease.

• At its end stage, chronic kidney disease is treated by dialysis or kidney transplantation.

• Dialysis patients require close monitoring for protein, water, and electrolyte balance.

Summary, cont’d

• Kidney diseases have predisposing factors (e.g., recurrent urinary tract infections may lead to renal calculi, and progressive glomerulonephritis may lead to chronic nephrotic syndrome and kidney failure).

• Kidney stones may be formed from a variety of substances. For some patient, a change in dietary intake of the identified substance (e.g. fluid, sodium, oxalate, purine) may decrease stone formation.

Chapter 22

Surgery and Nutrition Support

Key Concepts

• Surgical treatment requires nutrition support for tissue healing and rapid recovery.

• To ensure optimal nutrition for surgery patients, diet management may involve enteral and parenteral nutrition support.

Nutrition Needs of General Surgery Patients

• Nutrition needs are greatly increased in patients undergoing surgery

• Deficiencies easily develop

• Pay careful attention to:– Nutritional status before surgery– Individual nutrition needs after surgery

Poor Nutritional Status

• Associated with:– Impaired wound healing, immune system– Increased risk of postoperative infection– Reduced quality of life– Impaired function of gastrointestinal tract,

cardiovascular system, respiratory system– Increased hospital stay, cost, mortality rate

Preoperative Nutrition Care: Nutrient Reserves

• Nutrient reserves can be built up before elective surgery to fortify a patient

• Protein deficiencies are common• Sufficient kilocalories are required

– Extra carbohydrates maintain glycogen stores

• Vitamin and mineral deficiencies should be corrected

• Water balance should be assessed

Immediate Preoperative Period

• Patients are typically directed not to take anything orally for at least 8 hours before surgery.

• Before gastrointestinal surgery, a nonresidue diet may be prescribed.

• Nonresidue elemental formulas provide complete diet in liquid form.

Nonresidue Diet

• Includes only foods free of fiber, seeds, and skins

• Prohibited foods include fruits, vegetables, cheese, milk, potatoes, unrefined rice, fats, pepper

• Vitamin and mineral supplements required for prolonged nonresidue diet

Postsurgical Nonresidue Diet

• Nonresidue diet plus:– Processed cheese, mild cream cheeses– Potatoes– Bread without bran– All desserts except those containing fruit and

nuts– Condiments as desired

Postoperative Nutrition Care: Nutrient Needs for Healing

• Postoperative nutrient losses are great but food intake is diminished.

• Protein losses occur during surgery from tissue breakdown and blood loss.

• Catabolism usually occurs after surgery (tissue breakdown and loss exceed tissue buildup).

• Negative nitrogen balance may occur.

Need for Increased Protein

• Building tissue for wound healing

• Controlling shock

• Controlling edema

• Healing bone

• Resisting infection

• Transporting lipids

Problems Resulting from Protein Deficiency

• Poor healing of wounds and fractures • Rupture of suture lines (dehiscence)• Depressed heart and lung function• Anemia, liver damage• Failure of gastrointestinal stomas to function• Reduced resistance to infection• Extensive weight loss• Increased mortality risk

Other Postoperative Concerns

• Ensure sufficient fluids to prevent dehydration• Provide sufficient nonprotein kilocalories for

energy to spare protein for tissue building• Ensure adequate vitamins• Ensure adequate potassium, phosphorus, iron,

zinc• Avoid electrolyte imbalances

Energy

• Mifflin–St. Jeor equations: – Male:

BMR = 10 × Weight + 6.25 × Height – 5 × Age + 5– Female:

BMR = 10 × Weight + 6.25 × Height – 5 × Age – 161

• Energy needs for burn patients directly depend on percent of body surface area (BSA) burned and are calculated as follows:Energy needs = 20 kcal/kg + (40 % of BSA burned)

Initial Intravenous Fluid and Electrolytes

• Oral feeding is encouraged soon after surgery.

• Routine postoperative intravenous fluids supply hydration and electrolytes, not kilocalories and nutrients.

Methods of Feeding

• Enteral: Nourishment through regular gastrointestinal route, either by regular oral feedings or by tube feedings

• Parenteral: Nourishment through small peripheral veins or large central vein

Oral Feeding

• Allows more needed nutrients to be added

• Stimulates normal action of the gastrointestinal tract

• Can usually resume once regular bowel sounds return

• Progresses from clear to full liquids, then to a soft or regular diet

Enteral Feeding

• Used when oral feeding cannot be tolerated

• Nasogastric tube is most common route

• Nasoduodenal or nasojejunal tube more appropriate for patients at risk for aspiration, reflux, or continuous vomiting

Enteral Feeding, cont’d

Alternate Routes for Enteral Tube Feeding

• Esophagostomy

• Percutaneous endoscopic gastrostomy

• Percutaneous endoscopic jejunostomy

Tube-Feeding Formula

• Generally prescribed by the physician

• Important to regulate amount and rate of administration

• Diarrhea is most common complication

• Wide variety of commercial formulas available

Enteral Nutrition Monitoring

• Monitoring the patient receiving enteral nutrition– Weight (at least three times per week)– Signs and symptoms of edema (daily)– Signs and symptoms of dehydration (daily)– Fluid intake and output (daily)– Adequacy of enteral intake (at least twice per

week)

Enteral Nutrition Monitoring, cont’d

• Abdominal distention and discomfort• Gastric residuals (every 4 hours) if appropriate• Serum electrolytes, blood urea nitrogen,

creatinine (two to three times per week)• Serum glucose, calcium, magnesium,

phosphorus (weekly or as ordered)

• Stool output and consistency (daily)

Sample Calculation*

• How much formula (in milliliters) does the following patient need at each feeding?

– 37-year-old woman, 5 feet, 7 inches tall – Under considerable catabolic stress, with an injury factor of 1.8– Formula: 1.5 kcal/ml– Schedule: 6 bolus feedings per day

1. IBW: 100 lb + (7 in 5 lb) = 135 lb/2.2 = 61.4 kg

2. RMR: (10 61.4 kg) + (6.25 170.2 cm) - (5 37) - 161 = 1332 kcal/day

1332 kcal/day 1.8 = 2398 kcal/day

3. Formula: 2398 kcal/day 1.5 kcal/ml = 1599 ml/day

4. Feeding schedule: 1599 ml/day 6 feedings/day = 266.5 ml/feeding*These equations require the weight in kilograms, the height in centimeters, and the age in years.

Parenteral Feeding Routes

• Peripheral parenteral nutrition uses less-concentrated solutions through small peripheral veins when feeding is necessary for a brief period (10 days)

• Total parenteral nutrition used when energy and nutrient requirement is large or to supply full nutrition support for long periods through large central vein

Catheter Placement for Parenteral Nutrition

Catheter Placement for Parenteral Nutrition, cont’d

Catheter Placement for Parenteral Nutrition, cont’d

Catheter Placement for Parenteral Nutrition, cont’d

Administration of Parenteral Nutrition

• Careful administration of total parenteral nutrition formulas is essential. Specific protocols vary somewhat but usually include the following points:– Start slowly– Schedule carefully– Monitor closely– Increase volume gradually– Make changes cautiously– Maintain a constant rate – Discontinue slowly

Nutrition after GI SurgeryKey Concepts

• Nutrition problems related to gastrointestinal surgery require diet modifications because of the surgery’s effect on normal food passage.

• Gastrointestinal surgery requires special nutrition attention

• Nutrition therapy varies depending on the surgery site

Mouth, Throat, and Neck Surgery

• This surgery requires modification in the mode of eating.

• Patients cannot chew or swallow normally.• Oral liquid feedings ensure adequate nutrition.• Mechanical soft diet may be optimal.• Tube feedings are required for radical neck or

facial surgery.

Gastric Surgery

• Because the stomach is the first major food reservoir in the gastrointestinal tract, stomach surgery poses special problems in maintaining adequate nutrition.

• Problems may develop immediately after surgery or after regular diet resumes.

Immediate Postoperative Period

• Increased gastric fullness and distention may result if gastric resection involved a vagotomy (cutting of the vagus nerve)

• Weight loss is common• Patient may be fed by jejunostomy• Frequent small, simple oral feedings are

resumed according to patient’s tolerance

Dumping Syndrome

• Common complication of extensive gastric resection in which readily soluble carbohydrates rapidly “dump” into small intestine

• Symptoms include:– Cramping, full feeling– Rapid pulse– Wave of weakness, cold sweating, dizziness– Nausea, vomiting, diarrhea

• Occurs 30 to 60 minutes after meal

• Results in patient eating less food

Diet for Postoperative Gastric Dumping Syndrome

• Five or six small meals daily• Relatively high fat content, low simple

carbohydrate content, low-roughage foods, high protein content

• No milk, sugar, alcohol, or sweet sodas; no very hot or very cold foods

• Fluids avoided 1 hour before and after meals; minimal fluids during meals

Gallbladder Surgery

• Cholecystectomy is the removal of the gallbladder.

• Surgery is minimally invasive.• Some moderation in dietary fat is usually

indicated after surgery.• Depending on individual tolerance and

response, a relatively low-fat diet may be needed over a period of time.

Gallbladder with Stone

Intestinal Surgery

• Intestinal resections are required in cases involving tumors, lesions, or obstructions.

• When most of the small intestine is removed, total parenteral nutrition is used with small allowance of oral feeding.

• Stoma may be created for elimination of fecal waste (ileostomy, colostomy).

Intestinal Surgery, cont’d

Intestinal Surgery, cont’d

Rectal Surgery

• Clear fluid or nonresidue diet may be indicated after surgery to reduce painful elimination and allow healing.

• Return to a regular diet is usually rapid.

Nutrition Needs for Burn Patients

• Tremendous nutritional challenge

• Plan of care influenced by:– Age– Health condition– Burn severity

• Plan constantly adjusted

• Critical attention paid to amino acid needs

Type and Extent of Burns

Stages of Nutrition Care of Burn Patients

• Stage 1, part 1: Immediate shock period– Immediate loss of water, electrolytes, protein– Immediate intravenous fluid therapy with salt solution

administered– Albumin solutions or plasma used after 12 hours to

restore blood volume– Little attempt made to meet protein and energy

requirements

Stages of Nutrition Care of Burn Patients, cont’d

• Stage 1, part 2: Recovery period– Tissue fluids and electrolytes are gradually

reabsorbed after 48 to 72 hours.– Diuresis indicates successful initial therapy.– Constant attention to fluid intake and output

remains essential.

Stages of Nutrition Care of Burn Patients, cont’d

• Stage 2, part 1: Secondary feeding period– Adequate bowel function returns after 7days.– Life depends on rigorous nutrition therapy.– Protein and electrolytes lost through tissue

destruction must be replaced.– Lean body mass and nitrogen are lost through tissue

catabolism.– Increased metabolism occurs.– Increased energy is needed.

Stages of Nutrition Care of Burn Patients, cont’d

• Stage 2, part 2: Nutrition therapy– High protein intake– High energy intake

• Caloric needs based on total BSA burned• Liberal portion of kilocalories from carbohydrates• Avoid overfeeding

– High vitamin and mineral intake

Stages of Nutrition Care of Burn Patients, cont’d

• Stage 2, part 3: Dietary management– Enteral feeding

• Solid foods based on individual preferences• Concentrated liquids with added protein or amino

acids• Calculated tube feedings when required

– Parenteral feeding• When enteral feeding is impossible or inadequate

Stages of Nutrition Care of Burn Patients, cont’d

• Stage 3: Follow-up reconstruction– Continued nutrition support to maintain tissue

strength for successful grafting or reconstructive surgery

Summary

• The nutritional demands of surgery begin before a patient reaches the operating table. Before surgery, the task is to correct any existing deficiencies and build nutritional reserves to meet surgical demands.

• After surgery, the task is to replace losses and support recovery.

Summary, cont’d

• Postsurgical feedings are given in a variety of ways.

• The oral route is always preferred. However, inability to eat or damage to the intestinal tract may require feeding through a tube or into veins.

• Special formulas are used for such alternate means of nourishment and are designed to meet specific individual needs.

Summary, cont’d

• For patients undergoing surgery on the gastrointestinal tract, special diets are modified according to the surgical procedure performed.

• For patients with massive burns, increased nutrition support is necessary in successive stages in response to the burn injury and to the continuing tissue rebuilding requirements.

Chapter 23

Nutrition Support in Cancer and AIDS

Key Concepts

• Environmental agents, genetic factors, and weaknesses in the body’s immune system can contribute to the development of cancer.

• The strength of the body’s immune system relates to its overall nutritional status.

Cancer

• Malignant tumor (neoplasm) can express itself in multiple forms

• Tumors identified by primary site of origin and state of growth

• Stages of tumor development depend on growth rate, degree of functional self-control, and amount of spread

Causes of Cancer Cell Development

• Underlying cause is the functional loss of cell control over normal cell reproduction from:– Mutations– Chemical carcinogens– Radiation damage– Viruses – Epidemiologic factors– Stress and dietary factors

Epidemiology

The Body’s Defense System

• Two populations of lymphocytes in immune system– T cells

• Derived from thymus cells• Activate phagocytes that attack antigens

– B cells• Derived from bursal intestinal cells • Produce antibodies that attack antigens

T- and B-Cell Development

Nutrition and Immunity

• Inadequate nutrition weakens the immune system and causes atrophy of tissues in gastrointestinal structures

• Antibodies are proteins

Nutrition and Healing

• Body tissue strength depends on ability to build and rebuild, which requires optimal nutrition intake

• Protein and key vitamins and minerals, as well as nonprotein energy sources, must be constantly supplied by the diet

Key Concepts

• Nutrition problems affect the nature of the disease process and the medical treatment methods in patients with cancer or AIDS.

Surgery

• All surgery requires nutrition support for the healing process.

• General condition of cancer patients often is weakened by the disease process.

Radiation Therapy

• Involves high-energy radiographs targeted on the cancer site

• Often kills surrounding healthy cells as well as cancerous cells

• Nutrition problems driven by site and intensity of radiation treatment

Chemotherapy

• Highly toxic drugs administered by the bloodstream to kill cancer cells

• Use of monoamine oxidase inhibitors (pretreatment antidepressant drugs) requires tyramine-restricted diet

Systemic Effects of Cancer

• Several systemic effects cause continuing weight loss– Anorexia, loss of appetite– Increased metabolism– Negative nitrogen balance

Cachexia

• Extreme weight loss and weakness caused by inability to ingest or use nutrients

• Body feeds off its own tissue protein

• Experienced by half of all cancer patients

• Aggressive nutrition therapy is necessary

Objectives of Nutrition Therapy

• Prevention of catabolism– Meet increased metabolic demands

• Relief of symptoms

Principles of Nutrition Care

• Nutrition assessment– Determine and monitor nutritional status– Body measurements, calculations of body

composition, laboratory tests, physical examination, clinical observation, dietary analysis

• Personal care plan– Daily plan for nutrition therapy incorporated into

nursing care plan

Nutrition Needs

• Energy

• Protein

• Vitamins and minerals

• Adequate fluid intake

Enteral: Oral Diet

• Oral diet with supplementation is optimal when tolerated

• Food plan must include adjustments in food texture and temperature, food choices, and tolerances

Tips for Controlling Nausea and Vomiting

• Try smaller, more frequent meals.• Eat more when feeling better.• Eat drier foods with fluids in between.• Try cold foods, saltier foods.• Avoid fatty or overly sweet foods.• Do not recline immediately after eating.• Replace fluids and electrolytes.• Use foods with pleasant aromas.

Tips for Increasing Energy and Protein Intake

• Add high-calorie condiments, sauces, dressings• Add extra ingredients during food preparation• Drink commercial food supplements• Avoid low-calorie foods and beverages• Have a meal or snack every 1 to 2 hours

Enteral: Tube Feeding

• When gastrointestinal tract can be used but patient is unable to eat

Parenteral Feeding

• When gastrointestinal tract cannot be used

• Peripheral vein feeding (for brief period)

• Central vein feeding (for extended period)

Prevention

• American Cancer Society– Eat a variety of healthful foods– Adopt a physically active lifestyle– Maintain a healthful weight– Limit alcohol consumption

• U.S. Food and Drug Administration– Low-fat diets rich in grain products, fruits, and

vegetables may reduce the risk of some cancers

Key Concepts

• Nutrition problems affect the nature of the disease process and the medical treatment methods in patients with cancer or AIDS.

• The progressive effects of HIV, through its three stages of white T-cell destruction, have many nutrition implications and often require aggressive medical nutrition therapy.

Human Immunodeficiency Virus

• Virus causes immune system suppression

• Created a widespread epidemic

Stages of Disease Progression

• Stage 1: Clinical category A– Flulike symptoms 4 to 8 weeks after initial

exposure

• Stage 2: Clinical category B– Infectious illnesses invade the body

• Stage 3: Clinical category C– Rapidly declining T-helper lymphocyte counts

Goals of Medical Management

• Delay progression of the infection and improve the immune system

• Prevent opportunistic illnesses

• Recognize the infection early

Severe Malnutrition, Weight Loss

• Decreased appetite, insufficient energy intake in addition to elevated resting energy expenditure

• Major weight loss, eventual cachexia

Causes of Body Wasting

• Inadequate food intake

• Malabsorption of nutrients

• Disordered metabolism

Nutrition Assessment

• Anthropometry

• Biochemical tests

• Clinical observations

• Diet observations

• Environmental, behavioral, and psychological assessment

• Financial assessment

Principles of Nutrition Counseling

• Motivation for dietary changes

• Rationale for nutrition support

• Provider-patient agreement on plan

• Development of manageable steps for change

• Development of personal food management skills

Summary

• The general term cancer is given to various abnormal, malignant tumors in different tissue sites.

• The cancer cell is derived from a normal cell that loses control over its growth and reproduction.

• Cancer cell development occurs from mutation of regulatory genes and is influenced by environmental chemical carcinogens, radiation, and viruses.

Summary, cont’d

• Cell integrity is mediated by the body’s immune system, primarily through its two types of white blood cells: T cells that kill invading agents that cause disease and B cells that make specific antibodies to attack these agents.

• Cancer therapy primarily consists of surgery, radiation, and chemotherapy.

Summary, cont’d

• Likewise, nutrition care of patients with AIDS must be built on knowledge and compassion, with a sensitivity and concern for individual patient needs.

• The current worldwide spread of HIV and its fatal consequences have reached epidemic proportions and are still growing.

Summary, cont’d

• Nutrition management centers on providing individual nutrition support to counteract the severe body wasting and malnutrition characteristic of the disease.

• The process of nutrition care involves comprehensive nutrition assessment and evaluation of personal needs, planning care with patient and caregivers, and meeting practical food needs.