nutrition - الصفحات الشخصية | الجامعة الإسلامية...

Chapter 1

SCIENCE OF

NUTURTIONNUTURTIONIt is the study of the nutrients in the food and the way in which the body handle these nutrients. In other words it is the study of nutrients in the food and their ingestion , digestion , transport , metabolism , interaction , storage and excretion .

AIM OF STUDY CLINECAL NUTRITION1) Understanding the food constitutes their function and the

requirements for nutrients by various age groups.2) Understanding methods of food utilization in the body.3) Understanding the relation between nutrition and human

health.4) Understanding the importance of nutrition to the recovery

of the pt. from various diseases.

NUTRIENTS : ( these chemical substances obtained from food promote growth and maintain life ).

PROCESSES IN THE FOOD UTILIZATION 1-Ingestion : The intake of food .2-Digestion : The breakdown of foods into their constituent nutrients .3-Absorption : Transfer of nutrients from the gastrointestinal tract into the circulation .

4-Transportation : Movement of nutrients through the circulatory system to sites for their use.5-Respiration : Provision of oxygen to the tissues for the oxidation of food and removal of the waste and carbon dioxide with the circulatory system responsible for transport of these gases. 6-Metabolism : Oxidation to create heat and energy as well as formation of new cell. 7-Excretion : Undigested food wastes and certain body wastes from the bowel , CO2 , from lungs , nitrogenous , mineral and other ( Wastes from kidney and skin ) .

RELEVANT DEFINITIONIONS1- Health : Is defined by WHO. AS the stat of complete physical, mental and social wellbeing and not merely the absence of disease.2- Nutrients : Are the constituents in the food that must be supplied to the body in suitable amounts, these include, carbohydrates, mineral ,proteins waters and vitamins.3- Malnutrition : Is an impairment of health resulting from a deficiency, excess or imbalance of nutrients, includes under-nutrition and over nutrition.4- Nutritional care : Is application of the science and art of human nutrition in helping people select and obtain food for the primary purpose of nourishing their bodies in health or in disease through out the life cycle. 5- Calorie : The amount of heat needed to raise 1C centigrade. One gram of water. 6- Basal metabolism : Is the minimal amount of energy or number of calories needed to basic metabolic process of person at rest and at least 12hr after taking food.7- Enzyme : Chemical substances which act upon other substances and speed up the specific chemical reaction but do not itself become apart of final products.

SCIENCE OF NUTURTIONNUTURTION 1

8- Deficiency disease : A disease due to lake of essential substances in the diet or defective metabolism. 9- Obesity : Any abnormal fat in the body or abnormal condition due to excessive deposits of fat in the body.

NUTRITIONAL PROBLEM1. Low socioeconomic levels: ( Those are more prone to

dietary problem ). 2. Lack of knowledge: ( Is a further contributing factor ).3. Increase incidence of dying baby from low wt. : ( Especially

babies who born to young women in teens who also poor ).4. Anemia: ( Occurs frequently in all age and especially in

children 6 years ).5. Increasing incidence of teeth problems: ( Decayed teeth,

missing teeth ).6. Retarded growth and retarded bone development in

some children 1-3yrs of age. 7. Chronic illness: ( About 80% of elderly have some

chronic condition contributing factors include low income, poor nutrition, and social isolation ).

PROBLEM OF NUTRITIONAL EXCESSIVE 1. Excessive caloric intake leads to obesity, which is

associated with chronic disease such as DM, gallbladder disease and cardiovascular disease.

2. Excessive intake of saturated fats, cholesterol is important risk factors in the incidence of cardiovascular disease.

3. Excessive intake of sugars contributes to an increase in dental caries.

4. Excessive intake of salt has been associated with hypertension.

5. Excessive intake of some vitamins A and D are Known to be toxic.

NUTRITIONAL BALANCE To achieve nutritional balance a good diet must fulfill the following : 1. It must nourish the appropriate levels of all nutrients to

meet the physiologic and biochemical needs of the body at all stages of the life cycle.

2. It must avoided excessive of calories, fats, sugar, salt and alcohol.

A DAILY FOOD GUIDE It includes 5 food groups, which are:1. Vegetables – Fruit group

4 basic servings daily : One is 1/2 cup or atypical portion such as one orange,

half a medium grapefruit, a medium potato. One good vit. C source daily. One includes green vegetables. One includes unpeeled fruits and vegetables.

2. Bread – cereal group 4 basic servings daily. 3. Milk- cheese group:-

Children less than 9 year's 2-3 servingsChildren 9-12 years 3 servingsTeen agars 4 servingsAdults 2 servingsPregnant 3 servingsNursing mothers 4 servings

One serving is a cup of milk, whole, skim, low fat, butter, non dry milk.4. Meat, fish, poultry and beans group:-

2 basic servings daily One servings is 2-3 ounces of lean, cooked meat,

poultry or fish. 1 egg.


1/2 to 2/3 cooked dry– beans, dray peas or lentils. 1/4 to1/2 cup nuts.

5. Fat, sweet, alcohol group:-No basic servings suggested. Include butter, margarine, fats, oil, candy, sugars.

FACTORS INFLUANCING FOOD INTAKE1) Physiological factors that determine food intake :

A. Hunger : Is physiologic sense has been defined as that set of internal single that stimulate the consumption of food.

B. Appetite: Commonly refers to the pleasurable sensations provided by food the choices – made specific food item.

C. Hedonic factors in food choice: The palatability of food is a composite of taste, smell and temperature .

2) Environmental and behavioral factors influencing food acceptance :

A. Role of culture : The ethnic group and a heritage account – these patterns reflect the social organization of he people including their economy, religion, belief and attitudes.

B. Economic influences on food intake : The income influences the Varity of foods from which people can choose. (Poor increase bread and cereal)

C. Social values of food : The food served to guests is the best that one can afford and the table appointments are as beautiful as one can make them.

D. Religious and Moral values attributed to foods : Certain food is forbidden by religious regulations.

E. Age and sex influence food choices.F. Illness modifies food acceptance : Disease and drugs.

Good Nutrition Poor nutrition

-Normal weight high, body from. -Overweight, underweight, failure to grow.

-Erect posture, arms and legs straight, abdomen in chest up.

-Poor posture, chest forward, rounded, shoulder, protruding abdomen.

-Firm, strong muscle. -Thin, flabby muscle, excessive fat.

-Firm, clear skin with good color, pink mucus membranes.

-Dry, pale skin, pale mucus membranes.

-Well-formed jaw and teeth. -Poorly formed jaw with teeth poorly aligned.

-Soft, glossy hair. -Dull, dry hair. -Clear bright eyes, not sensitive to light.

-Dull eyes, sensitive to light, puffiness under eye.

-Good appetite and digestion. -Poor appetite, complaints of, indigestion diarrhea.-Short attention span.

-Ability to concentrate. Cooperative,interested, agreeable, cheerful.

-Irritable, apathetic, depressed.

-Resistance to infection. -Many infection, longer convalescence of disease.


Common Therapeutic Diets

Diet Types of food / fluids

Clear liquid Consists of fluid that are liquids at body temperature, it is given as the first meal after surgery.

Full liquid Consists of any food and drinks that are liquid at room temperature , may provide adequate calories cereals it is given as post op. surgery

Soft diet Easy to – digest food, omit rough grains, nuts, spicy or fatty food, dried fruits, raw vegetables, adequate nutrients 2,000 - 2,500kcal, used in transition room full liquid to regular diet

Mechanical soft For Pt with difficulty chewing and swallowingBland diet Removal of food knows stomach irritant as caffeine

dinks, citrus fruits, food with spicesGeneral diet or regular diet

Permit all foods

Six small feeding

Variety of foods from any type of diet divided into six fairly equal portion: used for post op. Pt, anorexia, poor appetite, Pt with reduced stomach capacity

Diet alteringFiber :-High fiber

-Low fiber

-Fiber restricted

Fiber is not digested and form fecal material.

Used in constipation and no inflammatory disease of colon e.g. ( fresh fruit and vegetables )

Used during acute phase of chronic GI disease e.g. Inflammation of bowel.

Used before and after surgery on the large bowel or rectum partial obstructive GI problem.

Foods, which are the sources of nutrients in the body, have the following function :-1. Provide energy for the body2. Build and repair tissues3. Regulate body process

There are six types of nutrients:1. Carbohydrates2. Fats3. Proteins4. Minerals salt5. Water6. Vitamins


Chapter 2

UTILZATION OF

NUTRIENTSNUTRIENTSCarbohydrates , fats , and proteins must be digested and further metabolized before they can be utilized by his body. Water, minerals salt, and vitamins can be utilized without further breakdown .

A.CARBOHYDRATES C H O SOURCES OF CARBOHYDRATES 1- Plants are the principle source of carbohydrates in the diets some plants that contains high amount of carbohydrates are vegetables and fruits.2- Animal starch is stored in the liver of animals, including man, as glycogen.

COMPOSTION OF CARBOHYDRATES Sugars and starches are composed of carbon, hydrogen and oxygen with general formula of ( CnH2nOn ) .

FUNCTION OF CARBOHYDRATES 1-furnish heat and energy ( 4C.\gram of carbohydrates )2-spare protein from being used for energy.3-supply bulk in the form of cellulose.

CLASSIFICATION There are three principles form of carbohydrates:-

1-Monosaccharides , E.g. glucose, fructose and glactose. 2-Disaccharides , E.g. maltose, sucrose and lactose. 3-Polysacharides , E.g. starch, glycogen, cellulose, dextrin and other.

MONOSACCHARIDES ( C6 H12 O6 )There are three monosaccharide:

1. Glucose or dextrose : Is the form which circulates in blood. It is also found in fruits and vegetables.

2. Fructose : Is the sweetest of all sugars. It is found in the honey, fruits and vegetable.

3. Galactose : Is not found free in nature but occurs as a result of the breakdown of lactose.

DISACCHARIDES (C12 H22 O11)There are three disaccharides:

1. Sucrose or table sugar : Is found in molasses, maple sugar, fruit and vegetables. It is also found in beet and cane sugar.

2. Lactose : Is milk sugar. It remains in the intestines fairly long and encourages the growth of favorable bacteria.

3. Maltose : Occurs as a result of the breakdown of starch. It is also found in cereals and beer.

POLYSACCHAIDES ( )There are several polysaccharides:

1. Starch : is encased in cellulose walls and must be ground or cooked to release the starch. It is found in creels, fruit and vegetables.

2. Cellulose : forms the framework of vegetables, the skin of fruits and vegetables and the coverings of whole grains. It is not digested but provides bulk.

3. Glycogen : is the form in which carbohydrates are stored in the animal glycogen can be converted to glucose rapidly .

ROLE OF CARBOHYDRATES IN THE DIET1-Carbohydrates provide the cheapest sources of energy.


2-Carbohydrates provide about 50% of calories in the Arabic diet.

B.FATSSOURCESThere are 2 general sources of fat:- 1- Animal fats, e.g. Butter, cream, fat meat, bacon and lard. 2- Plant oils, e.g. olive oil, peanut oil and soy bean oil.

COMPOSTIONFat are compounds of carbon, hydrogen and oxygen but the oxygen is less in the proportion to carbon and hydrogen than it is in carbohydrates. For this reason, fats yield more energy than do carbohydrates.

FUNCTION OF FAT 1. Provides energy (9C. /gram)2. Aids in digestion, absorption and utilization of other

nutrients. 3. Carries fat soluble vitamins and aids in their absorption and

utilization.

ROLE OF FATS IN THE DIETFats provide from 35-40% of calories in the diet. This is too high and creates a serious health problem by contributing to atherosclerosis. N.B: ATHEROSCLEROSIS ( Fatty deposits of cholesterol on the inner linings of arteries ) is caused by elevated blood cholesterol level.Dietary factors can affect the blood cholesterol level in

three ways :1. Food high in cholesterol raise the blood cholesterol

level slightly but generally the liver compensates for this by producing less cholesterol.

2. Ingestion of fat containing highly unsaturated fatty acids, e.g. those found in most vegetables oils, depress the blood cholesterol level.

3. The most important factor in high blood cholesterol is

the total amount of fat ingested, because increased fat metabolism causes increased amounts of cholesterol to be produced by the liver.

C.PROTEINSOURCESWhen the word protein is mentioned most people immediately think of meat, also they think that diets cannot be adequate in protein if they don't include meat. There are 2 general sources of protein:-1-Animal protein : e.g. milk, eggs, cheese, meat, poultry and fish. 2- Plant protein : e.g. peas, beans, nuts, cereals, soy beans

COMPOSTIONProteins are complex compound which contain carbon, hydrogen, oxygen, nitrogen, and some times other elements such as sulfur and phosphorus. The protein molecules are composed of amino acids which are Known as a building blocks of protein.That can not be manufactured by the body must be present in the protein of the diet and are called essential amino acid.It is a good idea to be able recognizes the name of essential amino acid.When you see them they are:--Histidine -Phenylamine-Leucine -Threonine-Lysine -Tryptophan-Valine-Isoleucine -Methionine

FUNCTION1. Building and repair tissue.2. Form much of body from work and are a major component

of skin, hair, nails and matrix of teeth and bones.3. Used in the manufacture of enzymes, hormone, antibiotics

and hemoglobin.4. Proved energy, if it is not provided by carbohydrates or

fates.


► proteins furnish 4 Kcal per gram. If the diet contains more protein than is needed, the nitrogen will be removed from the excess amino acids by the liver. The nitrogen is excreted in the form of urea by the kidney if the diet does not contain sufficient calories from carbohydrate and fat, the protein will be used for energy rather than for building or replacing tissue.► The protein need of the adult is based on body size . the recommended allowance is 0.8 gram per kilogram.

CLASSIFICATION OF PROTIEN Protein are classified either as a complete or incomplete protein.

1. Complete protein There are over 20 different amino acids : 10 of this cannot synthesized be by a child and 9 cannot be synthesized by an a adult. The amino acid which can not synthesized are known as essential amino acid , because it is essential that these be taken into the body daily .any food which contain all of essential amino acid is called the a complete protein food . Most animal protein such as eggs, milk, meet; poultry and fish are complete protein.

2. Incomplete proteins These lacks at list one of essential amino acid, plant protein such as beans, peas, macaroni, grain, vegetables and nuts are incomplete protein .

CLINICAL PROPLEMS1) Negative protein balance : this means the body is

breaking down protein tissues faster than they are being replaced, so the individual is less able to resist infection.Negative protein balance can exist when individual dose not eat enough protein containing food, many elderly person are unable to chew well or don’t like milk. ►The nurse should be alert to the possibility of protein mal nutrition in pt. With poor appetite.

2) Protein-calorie malnutrition :a) Kwashiorkor: Usually appears after the child is weaned from the mothers breast.S/S: edema of hands and feet, fail to grow, poor appetite and the skin and hair change in texture and color. b) Marasmus: Occurs in infants who are weaned very early and who are fed diets that are low in calories as well as protein. S/S: emaciated appearance, brain cell have had less opportunity to develop ( mental retardation ).

SOME FALLACY AND FACTS :1. Athletes need more protein than nonetheless ….. (Fallacy)►The protein requirement of the adult depends on the body size and not one the amount of exercise ….. (Fact)2. Older people need less protein than young adult …..

(Fallacy) ►The need for replacing the protein of tissues continues throughout life. ►Older people need the same amount of protein as the young adult of the same size ….. (Fact).3. Gelatin is an excellent source of protein ….. (Fallacy) ►Dry gelatin is about 90% protein ….. (Fact) 4- Protein food should not be eaten in the same meal as starches ….. (Fallacy). ►There is no reason to separate protein foods and starches, many conmen foods contain both proteins, carbohydrates the digestive tract digests protein, carbohydrates and fat components of the diet at the same time ….. (Fact)

D. WATERAMOUNT : Water makes up about 60% of body weight.

FUNCTION1- Serves as a solvent for material.2- Transport materials via the blood and lymph.3- Necessary for digestion.


4- Necessary for removal of body waste products through urine and feces. 5- Helps regulation of body temperature by evaporating perspiration which helps cool the body.

SOURCES1- Drinking water.2- Other liquids, such as milk or fruit juices.3- Many foods are mainly water. 4- Water produce by metabolism of food .

FLUID COMPARTMENT OF THE BODY There are two major fluid compartments in the body:-1- Intracellular fluid ----- 45%2- Extra cellular fluid ---- 15% Is found both as interstitial fluid and as plasma:-

► Interstitial fluid about ---- 11%► Plasma about ---- 4%

WATER BALANCEWater balance occurs when intake loss :► Water intake:

1- Fluid 1500ml2- Food 700ml3- Metabolism 200ml

2400ml► Water loss:-

1- Large intestine (Feces) 200ml2- Lung 350ml3- Skin

* Insensible 350ml* Perspiration 100ml

4- Urine 1400ml2400ml

Negative water balance or dehydration :This occurs when intake is insufficient to provide for losses.Fluid depends not only on water but also on salt.

Causes for negative water balance:1- Insufficient intake of fluid. 2- Excessive loss of fluid:- -Vomiting -Diarrhea -Profuse sweating. -High body temperatures. -Some disease e.g. Diabetes mellitus, Diabetes insipid us .Effect on the body of the negative water balance:1-plasma shows the first effect o dehydration with the Possibility of shock. 2-interstitial or tissue fluid is the next to show a decrease.3-Finally, intracellular fluid decrease and this creates an intense thirst and interference with enzyme.

E.VITAMINSCHARACTERISTIC OF VITAMINS 1- Organic compound not structurally related. 2- Essential for life. 3- Needed in small amounts. 4- Not manufactured by the body, must be taken in through food some vitamins are manufactured by bacteria in the intestines an exception to this is one form of vitamins D. Natural vitamins D is found by ultraviolet light ( sun light ) irradiation of cholesterol compound in the skin. General resources:1-NO one food supplies all of the vitamins but with balanced diet there would be no deficiency. 2- Protective food is diary products, eggs and fruits.

GENARAL FUNCTION :1-Regulates body process by acting as coenzymes which make possible the activities of enzymes. 2-Aids in structure, i.e. the eye requires Vit. A.


TYPES OF VITAMINS There are 2 major types of vitamins:-

1. Fat soluble vitamin (A, D, E, K). A) These are not easily lost by ordinary cooking methods and do not easily dissolve in water, since these are absorbed with fat, any condition such as gall bladder disease which interferes with fat absorption, could cause a deficiency of these vitamins.B) These are stored by the body and deficiencies are not prevalent .

2. Water soluble vitamins (vit. B complex and vit. C)These do dissolve out in water. In general these are not stored by the body. Deficiencies are more prevalent for water soluble vitamins.N.B : ► water- soluble (C, B1, B2, B6, B12) . ► Fat- soluble (A, D, K, E) .

FAT SOLUBLE VITAMINS VITAMIN (A) :SOURCESCheese, Butter, Eggs, Milk, Fish liver oils, Yellow vegetables (carrot, sweet potatoes) green leafy vegetables (spinach).

FUNCTION1. For the normal structure of the bone and teeth .2. Maintain of the epithelium or outer layer of skin and

mucous membrane of nose , mouth , GIT, eyes, URS.3. Formation of the visual purple which make eye adapt to

dim light .

DEFICIENCY OF VITAMIN A 1. slow growth poor teeth and gums .2. skin changes and infection (dry and scaly)3. night blindness(nyctalopia)

Recommended daily allowances:For adult : 0.8-1.6mg or 5000iu-8000iuFor child : 0.4-1.0mg or 1500-5000 unit.

VITAMIN (D) :SOURCESFoods are not good sources of vitamin D, except when they are fortified

FUNCTION1-aids in the absorption of calcium and phosphorus from GIT .2- promote the mineralization of bones and teeth .3-regulates the normal level of calcium in the blood

DEFICIENCY OF VITAMIN D 1. Rictets it seen in the children 2. Osteomalacia: it seen in adult women and who had several

pregnancy.3. Osteodystrophy: it occur in sever renal failure because the

kidney is unable to convert vitamin D to its active form.Recommended daily allowances : 400 units for children and adolescents.

VITAMIN (K) :It is known as the antihemorrhagic vitamin .Small amounts of vitamin K are stored in the liver, heart, skin , muscle and kidney.

SOURCESpork liver, green leafy vegetable and bacteria in the intestine.

FUNCTIONNeeded for the formation of prothrombin and substance necessary for blood clotting.

DEFICIENCY OF VITAMIN K 1-hemorrhagic disease especially in newborn and infants 2-slow blood clotting Recommended daily allowances : It is not established.Dicumarol is vitamin K antagonist, it contract the effect of vitamin K in formation of prothrombin and prevents blood


clotting , It is effective in treating circulatory disease .VITAMIN (E) :SOURCESIt s widely distributed in food, with vegetable oils , margarines , nuts, dark green vegetable.

FUNCTIONprevent the oxidation (antioxidant) of vitamin A in the intestinal tract .

DEFICIENCY OF VITAMIN E Deficiency only providing in premature new infant – irritability, edema and hemolytic anemia (hemolysis of red blood cell)Recommended daily allowances : Male: 15 IU Female: 12 IU

WATER SOLUBLE VITAMINS VITAMIN (C) : ( Ascorbic Acid )SOURCES Oranges, grapefruit, limes and lemons. Tossed salad, fresh tomatoes .

PROPERITIES OF VITAMIN C :1. Vitamin C is highly soluble in water. So avoid soaking

vegetable in large amounts of water cooking in smallest amounts of water.

2. The oxidation of ascorbic acids increase rapidly as temperature is increased :So store fruits and vegetable in a cool place, and use the shorting time in cooking.

3. Ascorbic acid is destroyed in presence of alkali : So, do not use baking soda .

FUNCTION1. It is essential for building the connective tissue .2. It improves the absorption of iron in the intestine.3. It is required for formation of hormones such as thyroxin

and adrenaline.

4. Necessary for blood, teeth and bones.DEFICIENCY OF VITAMIN C 1. Sore of mouth and bleeding from gums.2. Weak walled capillaries. 3. Poor wound healing.4. Scurvy: Is characterized by easy bruising and

hemorrhaging of skin, loosing of the teeth, bleeding of the gums and disruption of the cartilages of that support the skeleton.

Recommended daily allowances : Adult : 60mg.

VITAMIN (B) COMPLEX :1. VITAMIN (B1) : ( Thiamin )

SOURCESMeat especially pork and liver, dry beans, peas, peanuts, eggs and milk.

FUNCTION1. Maintain health nerves, a good mental out look, a normal

appetite and good digestion.2. Breakdown of glucose to energy.

DEFICIENCY OF VITAMIN B1 1. Fatigue and poor appetite.2. Neuritis of legs.3. Beriberi, some times called Rice-eater disease the S&S is:

polyneuritis, edema and heart disease. Recommended daily allowances: 0.5mg per 1000kcal.

2. VITAMIN (B2) : ( Riboflavin )SOURCESMeat, poultry, fish, dark green leafy vegetables and grain breads

FUNCTION1. It is necessary of breaking down glucose to release energy.2. It is essential for healthy skin and for good vision in bright


light. DEFICIENCY OF VITAMIN B2 ► Cheilosis : S&S :

A. Cracking of skin at the corners of the lips and scaliness around the ears.

B. Redness and burning as well as it changing of the eyes and extreme sensitivity to the strong light.

Recommended daily allowances:Men : 1.6mg Women : 1.2mg

3. VITAMIN (B6) : Three forms of Vit. B6 ( Pyridoxal, Pyridoxine and pyridoxamine )SOURCESMeat, especially organ meat, whole-green cereal, soybeans, peanuts, milk and green vegetables.

FUNCTION1. Essential for synthesis and break down of amino acids.2. Essential for production of antibodies, formation of heme in

hemoglobin .

DEFICIENCY OF VITAMIN B61. Gastrointestinal upset .2. Irritability, nervousness and convulsions.Recommended daily allowances :Men : 2mg Women : 2.2mg

4. VITAMIN (B12)SOURCESMilk, eggs, cheese, meat, fish and poultry supply► Plant food supply no vitamin B12

FUNCTION1. Required for the maturation of the red blood cells in the

born marrow.2. required for synthesis of protein.3. Required for metabolism of nervous tissue.

Absorption and storage :The absorption of vitamin B12 is much more complex than other B-complex vitamin:The stomach produces a substance called intrinsic factor, vitamin B12 is attached to intrinsic factor and is carried to the ileum from which it is absorbed. In the absence of intrinsic factor vitamin B12 can not be absorbed. The liver stores most of vitamin B12. One adequate diet, the storage in the adult may be sufficient to provide body needs for as much as 3 to 5years.

DEFICIENCY OF VITAMIN B121. Pernicious anemia it is a genetic defect with an absence of

intrinsic factor, so Vitamin B12 in the diet can not be absorbed, ( the red blood cells are large and reduced in numbers ) the pt. is complaining of sore mouth, poor appetite and gastrointestinal disturbances.

2. The nervous system is affected so that the individual shows poor coordination in walking.

Recommended daily allowances :FOR : Adult : 3mcg. Infant : 0.5mcg / 1.5mcg. Children : 2-3mcg. During pregnancy and lactating : 4mcg.

F.MINERAL ELEMANT OVER 20 different minerals can be found in the human body.Thirteen are essential for life, most of minerals are present in a small amounts and the total amount in the body is about 4% of body weight.

GENERAL FUNCTION OF MINERALS1. Regulate body process e.g. potassium is necessary for

proper functioning of nerves and muscles. 2. Aid in forming structure, e.g. calcium is necessary for

formation of bone.


TYPES OF MINERALS a) Macronutrients: these are major elements that occur in the

largest amount:-Calcium------------99% in bone and teeth.Phosphours --------80-90% in bones and teeth.Potassium---------- Fluid inside cells.Sulfur--------------- Associated with protein. Chlorine----------- Fluid outside cells.Sodium------------- Fluid outside cells.Magnesium--------- 60% in bones and teeth. b) Micronutrients: These are found in very small amounts. Manganese, Copper, Iodine, Fluorine, Zinc.

1. CALCIUM :FOOD SOURCES Any kind of milk, fish whole, skim, yogurt, hard cheeses and butter, turnip green and collards, fruits (oranges)► N.B. : Meat and Cereal foods are poor of calcium.

FUNCTION 1. It gives the rigidity to the skeleton. 2. It required for complex process of blood coagulation.3. It regulates the passage of materials into and out of the

cells. 4. It controls the transmission of nerve messages.5. It aids in the absorption of vitamin B12

DEFICIENCY OF CALCIUM1. Rickets2. Bone pain and susceptibility to fracture. 3. Osteoporosis .4. Periodontal,(changes of the structures of the gums) .Recommended daily allowances:The calcium allowance for school children and adult throughout life is 800mg. During period of rapid growth in teenagers, during pregnancy

and lactation is 1200mg . 2. PHOSPHORS

FOOD SOURCES Milk, meat, poultry, fish, eggs, yolk and nuts are rich sources.

FUNCTION1. It is essential for building bones and teeth.2. Regulate the absorption and transport of fats. 3. Acid-base balance. 4. It is essential component of ATP, DNA and RNA

3. MAGNESIUM About 60% of the body magnesium is found in the bones and teeth.

FUNCTION1. It regulates nervous irritability and muscle contraction. 2. It activates many enzymes including those involved in

energy metabolism. Most absorption occurs from the upper gastrointestinal tract. Recommended daily allowances : Adult : 300-350mg / day.

4. SODIUM, POTASSIUM AND CHLOINE These mineral are collectivity termed electrolytes because they are dissolved in water and able to conduct electricity. Sodium and Chlorine are the chief minerals in the blood plasma and extra cellular fluid while potassium is the chief intracellular mineral. ► These are necessary for acid-base and fluid balance

DEFICIENCY OF SODIUM CHLORID Headache, muscle cramps and vomiting.

DEFICIENCY OF POTASSIUMWeakness of muscles including skeleton muscle, heart and respiratory muscles.


5. IRONThe content of iron in the adult body is only 3 to 5 gm, most of iron is present in hemoglobin .

FOOD SOURCES Meat, eggs yolk, beans, spinach, dark green vegetables, legumes and nuts .

FUNCTIONIt is forms hemoglobin.

Iron is use very economically by the body. When the red blood cells are destroyed after their life span of about 120 days, the hemoglobin is break down. The iron that is released is used over and over again. Small amounts of iron are lost daily in perspiration, in the sloughing of the cells from the skin and mucosal membranes, in the hair and nail clippings and through excretion in the urine. These losses account for 0.5 to 1 mg iron / day. Menstrual losses are about 15 to 30 mg / month.

Daily allowances : The allowances for the well-nourished woman is 18 mg iron per day, whereas that healthy man is 10 mg. Infants and children need liberal intakes of iron take care of expanding blood circulation as grow .

DEFICIENCY OF IRONIron deficiency anemia.

PERCENTAGE OF NUTRIENTS IN THE BODY

Nutrient Percentage1- CHOs Less than 1 %2- LIPIDS ~ 20%3- PROTIEN ~ 20%4- VITAMINS ~ very few5- MINERALS ~ 4%6- WATER ~ 65%

Human body contain 300 – 350mg CHO as blood glucose and glycogen However these percentages vary from individual to another e.g. Alean person has lower fat than obese one and e.g. a baby has more water relative to it is weight than adult .

Energy yielding nutrient :- CHO 4 Kcal.- Protein 4 Kcal.- Lipid 9 Kcal.Thus, the energy content of food depends on the amount of CHO, fat and protein that food contains.

Example : Calculate the Kcal in a slice of bread with 1 teaspoon of butter

(15 gm CHO, 2 gm Protein and 5 gm Fat)

15 gm CHO times 4Kcal / gm = 60 kcal 2 gm Protein times 4Kcal / gm = 8 Kcal5 gm Fat times 9 Kcal /gm = 45 Kcal

Total = 113 Kcal


Chapter 3

FOOD

DIGESTIONDIGESTIONIs the sum of all the changes food undergoes in the alimentary canal.The purpose of digestion is to convert food into substance which can be absorbed in the intestinal tract, e.g. monosaccharide from carbohydrate , amino acid from protein and glycerol and fatty acid from fats.This achieved by mechanical and chemical means

MECHANICAL DIGESTION1. chewing which breaks food into smaller pieces and mixes

it with saliva.2. Churning stomach and intestinal contents so that food

becomes well mixed with digestive juices.3. Peristalsis which move food through tract .

CHEMICAL DIGESTIONGeneral

substance EnzymesOrgan making enzyme

Site of action substrate product

carb

ohyd

rate

s

Salivary amylase

Salivary gland mouth Starch(cooked)

Glycogen Maltose

Pancreatic amylase Pancreas Small

intestineStarch(cooked)

Glycogen Maltose

Maltase Small intestine

Small intestine Maltose 2glucose

sucrose Small intestine

Small intestine sucrose 1glucose

2fructose

Lactase Small intestine

Small intestine Lactose

1glucose 1galactos

e

fats lipase Pancreas Small

intestineBile emulsified

fatsFatty acid

and glycerol

Prot

ein

pepsin stomach stomach ProteinsProtease

s and peptones

Trypsin Pancreas Small intestine

Protein Proteases peptones

Amino acid

peptidase Small intestine

Small intestine peptides Amino

acid


FATE OF CARBOHYDRATE IN THE BODY

FATE OF PROTEINS IN THE BODY

FATE OF FATS IN THE BODY


ENERGY Energy of the body is drive principally from oxidation of food .

MEASUREMENT OF ENERGY The large calorie (Cal or C) is the unit used for measuring the heat energy produced by food when oxidized in the body.

NEED FOR ENERGY Energy is necessary for the work performed by the body.There are two types of work performed by the body, involuntary and voluntary .

1. INVOLUNTARY WORK : ( BASAL METABOLISM )This is the work done by the body in a fasting state and at rest.Energy is needed for vital life process, e.g. breathing, heart beat and circulation of blood, kidney function and all chemical reactions which are constantly taking place in the body .

General factors affecting basal metabolism rate :1-Surface area:The greater the surface area the more heat will be given off and the basal metabolism will be higher. A tall thin person has a greater surface area then a short fat person with the same weight and will consequently have a higher basal metabolic rate. 2-Sex:The meal has a higher basal metabolic rate than does the female .3-Age:Basal metabolism is highest in periods of active growth. It is highest during the first and the second years of life and decreases with age.The calories necessary for basal metabolism in 14 hr period in average 25 year old person are listed:-Male 1650 CFemale 1400 C

2. VOLUNTARY WORK :The energy requirements depend on the type of activity and


increase with the intensity of the work.Examples of calories required per hour for each pound of the body weight.-Bicycling 1.7 C -Eating meals 0.7 C-Swimming 4.5 C -Typing 1 C-Dancing 2.4 C -Running 4.0 C-Walking rapidly 2.2 CTotal energy required includes the requirement for energy both the voluntary and involuntary work of the body .

► Voluntary work : Muscular work is the greatest factor influencing total energy requirements. Mental work requires minimal amount energy► Involuntary work : The requirement for involuntary work vary according to the general factors affecting basal metabolic rate i.e., surface area, sex and age. Also affecting energy requirement for involuntary work are other previously mentioned factors which increase anabolism or catabolism.► Other factors can also increase total energy requirement :1-Stimulant drugs, e.g., Caffeine, nicotine.2-Fall in outside temperature.3-Pregnancy., A rise occurs in the last trimester. 4-Lactation.5-Specific dynamic action of foods. All foods increase metabolism but protein foods increase metabolism much more than do carbohydrates and fats. ► Normal daily calorie requirement :The normal daily calorie requirements depend on sex, weigh, activity and age. The following figures represent the approximate the number of calories necessary to maintain present weight in a moderately active male and female aged 25 years .- Male : Weight 154 pound 3080 C- Female : Weight 125 pound 2125 C► A factor can be used to roughly determine this figure:

* Male : 20 C. per pound of body weight.* Female : 17 C. per pound of body weight.► N.B: Calorie needs decrease with age for 2 reasons:

a. Basal metabolism is decreased. b. Activity is also decreased .

EXCESSES AND DEFICIENCIES OF CALORIES 1. OVER WEIGHT ( OBESITY ) :

Obesity is an increase in weight above normal due to a greater intake of calories from food than expenditure of calories in energy.► The most common cause for this condition is eating more food than is necessary.► A second cause could be alack of exercise or utilization of calories.► Endocrine disorders, e.g. hypothyroidism and hypopituitarism can cause a weight gain .

2. UNDERWEIGHT ( UNDERNOURISHMENT )Underweight is a condition caused by an insufficient intake of calories to meet energy requirements.► The most common cause is insufficient intake of calories in food to meet energy requirement .► A second cause could b over activity or utilization of too many calories. ► Endocrine disorders, e.g. hyperthyroidism and hypopituitarism can cause loss of weight.


Chapter 4

DIET AND

NUTRITIONNUTRITIONA. DIET FOR ADOLESCENT

WHAT IS HEALTHY EATING ??Eating health is an important part of a health lifestyle and is some thing that should be incorporated at a young age and continued throughout your life. The following are some general guidelines any dietary changes with your physician or medical provider.Eat three meals a day, with health snacks.Increase fiber in the diet and decrease the use of salt.Drink a lot of water.Eat balanced meals.Try to choose baked or broiled foods over fried foods.Wash and decrease, if necessary, your sugar intake. Eat fruit or vegetables for a snack. For children over 5yr use low – fat diatry products. Decrease the use of butter and heavy gravies.Eat more chicken and fish.

MAKING-HEALTHY FOOD CHOICES The food guide pyramid, designed by the United state department of agriculture ( USDA ) and the US department of health and human services, is a good guideline to help you eat a heart healthy diet.This guide can help you choose to eat a variety of foods while encouraging the right amount of calories and fat.

HEALTHY EATING DURING ADOLESCENCE


Healthy eating during adolescence is important as necessary body changes during this time affect an individual's nutritional and dietary need.Adolescents are becoming more independent and making many food decisions on other own. Many adolescents experience a growth spurt and an increase in appetite and need healthy foods to meet their growth needs. Adolescents tend to eat more meals away from home than younger children. They are also heavily influence by their peers. Meal convenience is important to many adolescents and they may be eating too much of the wrongs kinds of foods ( i.e., soft drinks, fast food, processed foods).Further, a common concern of many adolescents is dieting. Girls may feel an unhealthy pressure from peers to be thin and to limit what they eat. Both boys and girls may diet to ( make weight ) for a particular sporting or social event. The following are some helpful consideration for

variety and meal choice : Encourage exploration about healthy nutrition. Meal planning at home should be actively participated in

by all household members. Experiment with foods outside your own culture. Have several nutritious snack foods readily available. Avoid overabundance of unhealthy or (junk) Foods in the

home.B. DIET FOR ELDERLY PEOPLE

ELDERLY DIET AND FIBER As the body ages, the gastrointestinal tract changes and people tend to develop more problems with constipation. A high-fiber diet can prevent that but many elderly people, especially those with dentures; do not want to eat the seed-filled or crunchy food that is typically high in fiber.They instead go for soft, slippery food that is easily chewed but is often high in fat.

Cooked or baked vegetables, fresh fruit and high-fiber

breakfast cereals are some denture-friendly ways to get fiber in the diet. Beans and black-eyed peas are also nutritious and inexpensive.

ELDERLY DIET AND FLUIDS It is important to drink lost of fluids, despite the risk of a leak. The elderly have decreased thirst and often do not get enough fluid in their diet as a result. Getting plenty of fluid helps prevent constipation. The fiber nutritionists recommend is more effective in decreasing constipation when fluids are taken generously. Milk, tea, coffee, soda, ice cream and soup all count as fluids.

ELDERLY DIET SHOULD BE COMBINED WITH EXERCISE

Get more physical, not less. The amount of exercise needed depends on the person, but in general people need to step up their activity as they get older. Elderly people often do the opposite because of bad knees or arthritis.Instead of becoming guarded, they need to walk, bicycle, swim, garden and find other ways to stay on the move.

ELDERLY PEOPLE AND CALORIE NEEDS As we age our calorie needs decrease due to a drop in muscle strength from taking less physical activity. However, vitamin and mineral needs may stay the same or even increase if the body absorbs them less efficiently.

Age group 1-3

4-6

7-10

11-1

4

15-1

8

19-5

9

60-7

4

75+

Cal

orie

ne

eds Male 1230 1715 1970 2220 2755 2550 2350 2100

Female 1165 1545 1740 1845 2110 1940 1900 1810

► Note: These are average values only. Heavier or more active people may need more.

FOOD TO INCLUDE FOR OPTIMUM


HEALTH FRUIT In particular those high in vitamin C, like blackberries, strawberries, raspberries, blackcurrants, citrus fruit, kiwi fruit, peaches, mango, cantaloupe melon and apples.

VEGETABLESIn particular vegetables high in vitamin A (beta carotene) and vitamin C. Carrots, squash, sweet potato, tomatoes, spinach, kale, collard greens, broccoli, cabbage, Brussels sprouts, onions leeks and avocado.

OILY FISHRich in omega-3 essential fatty acids and high in vitamin E, like salmon, mackerel, sardines, herring, tuna and trout. Also white fish in place of red meat.

NUTS AND SEEDSRich in omega-3 essential fatty acid and high in vitamin E. Unsalted nuts, like walnuts, cashews, Brazil nuts and almonds and seeds like poppy seeds, sunflower, flax seeds and pumpkinseeds.

PROTEINEggs, white fish, milk, cheese, yogurt, lean meat, chicken and beans.

PULSES AND GRAINS FOR FIBERIncluding, brown rice, whole wheat bread, wheat germ, whole wheat cereals, whole wheat crackers.

C. DIET FOR INFANCY ► Infancy : is a period of rapid growth. During the first year of life, the infant grows and develops far more rapidly than at any other time in life.This is evident from the fact that the totally helpless newly born child, who is completely dependent on the mother or the caretaker, develops a fair degree of physical and mental abilities by the first birthday. The child develops the ability of speech and is able to express himself. He attains a fairly good motion development and starts walking and holding objects. By this time he also develops a strong emotional and psychological relationship with his near and dear ones.

DIET AND FEEDING PATTERN To meet the high nutritional requirements of an infants, good nutrition throughout infancy is very important. The first food for the infants is mother milk. It is nature's gift for the child and is the best Suited for the infant's growth and development. Fortunately even a poorly nourished mother is able to nurse her child satisfactorily at least during the first few months of life.

ADVANTAGES OF BREAST FEEDING 1. Natural method of feeding :

Breast feeding is a simple and a natural method of feeding which eliminates the need for preparation of a feed and sterilization of bottles. It is very convenient for both the mother and child as the milk is available at all times and at right temperature with no worries about the quantity.

2. Nutritionally tailor made for the body :Breast milk provides almost all the nutrients to the infants that are adequate enough to meet his requirement. It has adequate amount of fat which is highly emulsified and is therefore better digested. Lactose present in breast milk provides natural sweetness and also helps in calcium and iron absorption. Low amount of protein in mothers milk reduced pressure on infants kidneys to extreme extra nitrogen. Vitamin C content is


retained as it is not destroyed by heating which happens in case of cows milk.

3. Anti-infection properties:-Breast milk is a very hygienic method of feeding as the milk goes straight from the mother's breast to the child's mouth, reducing the chances of contamination and infection which are plenty in case of artificially fed infants. Breast milk contains antistaphylococcal factor which prevents the growth of bacteria in the infants intestines the gastric juice of breast fed infants is more acidic and this destroys any microorganism that may enter the stomach.

4. Source of natural immunity:-The secretion from the mother's breast for the first 2 to 3 days is a thick yellowish liquid known as colostrums. This colostrums contains certain antibodies, which develop natural immunity in the child, thus protecting him from various infectious diseases. Besides providing antibodies, colostrums is also rich in certain nutrients and should nerve be discarded but fed to the newborn.

5. Anti-allergic properties:-Cow's milk contains lactglobulin and serum bovine which may cause allergy in some infants. As these are not present in mother's milk, there is no danger of allergy with breast milk.

6. Psychological advantages:-Breast feeding is most conducive for a health, happy and emotional relationship between the mother and her newly born baby.

DO YOU KNOW ????- As per documented evidence, infants grow well on

exclusive breast feeding for the first 4 to 6 months of life. - During this period, the baby does not even need water

supplements, as breast milk provides enough water even for the hot summer months.

- In fact water supplements may be unhygienic and also the sucking of breast by reduced thereby diminishing the breast milk output.

When introducing new foods the following points to be kept in mind : Only one food be introduced at a time . Consistency of foods as per child's age i.e. for very young

infants, liquid to semi solid and then to solid with advancing age of child.

Food is given in small quantities in the beginning and the amount gradually increased as child develops a likes for the food.

Never force feed a child. If the child dislikes a particular food, remove it from his/her diet and reintroduce it a later age. If the disliking persists then think of a substitute for it.

Don’t give spicy foods and also avoid fried ones. Include variety to make food more appealing. As child grows older, attract his/her attention by giving

consideration to color, flavor, texture and shape of food. To inculcate good eating habits in a child, parents should not

show personal prejudices and dislike towards any foods It is not always necessary to cook separately for the child, as

the family meals can be easily modified in consistency, spicing, etc, for the amount needed for to feed the child.

NUTRITION FOR PRESCHOOLERSRecommendations to health and child care professionals

► Child care is a shared responsibility. Everyone who cares for children has an important role in promoting their nutritional health. ► The nutritional of young children begins with the attention paid by parents and caregivers to providing a healthy diet and food experiences which foster healthy eating patterns. To promote nutritional health during preschool years, health and child care professionals can do the following : 1. Enable parents and child care providers a healthy diet to

preschool children. 2. Help parents and child care providers to foster food

attitudes and eating practices which promote health.


3. Further the development of programs and policies which advance nutritional health for the preschool population.

1) PROVIDING A HEALTHY DIET FOR PRESCHOOLERS

1- Provide a healthful variety of foods recommended food guide and in amounts appropriate to the needs of the individual preschooler.2- Apply the principle of moderation in selecting foods outlined in the nutrition.3- Ensure a gradual transition from the milk-predominant infants diet to family foods.4- help preschoolers determine the quantity of food they can eat. Allow self-selection of amounts when possible or offer child-sized portions with the opportunity for seconds.5- Recognize the need of most preschoolers to eat small amount of food frequently throughout the day. On a daily basis, this requirement most commonly means three meals with a snack between meals. Snacks should contribute to both nutritional and dental health.6- Recognize the need for routine and structure in the daily eating pattern of preschoolers and plan accordingly.7- take measures to encourage healthy body weight and promote a positive self-image in preschoolers.8- Encourage physical activity and set limits on sedentary activities, especially television viewing.9- Consult appropriate health professionals when deviations in normal growth and development are suspected or when unusual food patterns persist. 10- Protect preschoolers against hazards associated with food, such as choking and food-borne illness. 11- Recognize that routine administration of vitamin-minerals supplements is not advised and that the preschoolers physician should be consulted before any vitamin-minerals supplement is used.2) FOSTERING POSITIVE FOOD ATTITUDES AND

EATING PRACTICES

Parents and child care providers should be supported in their efforts to:1- Establish a positive feeding relationship which sets reasonable limits while supporting the development of the preschooler's food preference and food choice skills.2- Make available and offer a variety of nutritious foods within the framework of the family's cultural heritage, lifestyle and resources. 3- Identify and respond to cues from the preschooler that indicate when the child is hunger and satisfied, with and understanding that fluctuations in appetite are normal at this age. 4- Encourage self-feeding and support increasing independence in eating.5- Respect the individual food preference of preschoolers while encouraging them to experience and enjoy eating deferent foods. 6- Appreciate the strong influence parents and caregivers have as role models in instilling healthy food practices. 7- Avoid using food in emotion-laden contexts such as to control or manage the preschooler's behavior.8- Provide opportunities for the preschooler to learn about the nature of food and to value its role in achieving health. 9- Provide the preschooler with opportunities to discuss claims promoting foods and to acquire decision-making skills related to food selection at home and in the marketplace.

3) DEVELOPING PROGRAMS AND POLICIES TO PROMOTE NUTRITIONAL HEALTH

Health and child care professional involved in designing and delivering programs and developing policy related to the health of preschoolers should:1- Recognize that accessible, affordable, personally acceptable and nutritionally adequate food is essential to support the growth, development and health of preschoolers. 2- Award high priority to good nutritional care in the


development and ongoing delivery of quality child care services. In supervised child care settings, standards should be established where they do not exist for evaluating the nutritional quality of the food served and promoting mealtimes and snack times as opportunities to instill positive attitudes toward food and healthy eating practices.3- Direct nutrition programs to preschoolers and their parents. Consider especially those disadvantage families most vulnerable to inadequate nutrition whether due to economic, social or environmental deprivation or physical and mental handicap. Strategies using self-help and mutual aid and comment-based models should be pursued.4- Design and delivery innovative nutrition education programs that enable child care providers, in both supervised and informal child care settings, to promote the nutritional health of children in their care.5- Consider, in health assessment of preschoolers, the many factors in the family, community and society which act as opportunities for or barriers against healthy eating during preschool years. 6- Incorporate nutritional health during preschool years as an integral component of health promotion and disease prevention programs delivered nationally and regionally. 7- Support efforts by health professionals to identify those children aged 2 years and over at risk for the major diet-related chronic disease so that age-appropriate action may be taken to decrease risk in later life.8- Promote more research on nutrition-related issues of preschoolers. Specific topics in need of research and development are:

► Parameters of an optimum diet during childhood to support normal growth and development and prevent development of chronic disease ► estimates of energy and nutrient requirements of children aged one through five years to further substantiate the recommended nutrient intakes for Canadians.

► Identification of risk factors in early childhood related to the development of major chronic disease such as cardiovascular.► Nutritional assessments of preschoolers living in poverty and development of appropriate intervention strategies. ► Development of screening tools for nutritional assessment of preschool populations.► Development of appropriate growth standards and standards for health body weights for preschool children. ► Development of effective nutrition education techniques for promoting nutrition during preschool.

Chapter 5


TOTAL PARENTERALNUTRITION ( TPN )NUTRITION ( TPN )INDICATIONS FOR TOTAL PARENTERAL NUTRITION ( TPN )The decision to start pt. on TPN can be a difficult one to make. It is widely felt that to outweigh the risks of placing a central line, the pt. should require TPN for at least one week .

When the gastrointestinal tract is not functioning properly :1. Inadequate absorption resulting from short bowel

syndrome. 2. Gastrointestinal fistula.3. Bowel obstruction. 4. Prolonged bowel rest need for pancreatitis, ileus, etc. 5. Sever malnutrition, significant weight loss and/or

hypoproteinemia when enteral therapy is not possible. 6. Other disease states or conditions in which oral or enteral

feeding are not an option.

Benefit of therapy is uncertain or questionable1. Terminal Cancer Patient.2. AIDS Patient.► The purpose of this handbook is to provide a brief outline of policies, procedures, prescribing information and care of individuals receiving parenteral nutrition therapy at the University of low Hospital and Clinics (UI Hospital and Clinics). It is intended to help physicians, nurses, students and other related health care professionals understand the administration of parenteral nutrition. The roles of various members of the nutrition support team are described as well

as indications for use of nutrition support. ► Some patients are unable to eat; therefore nutritional support is an important part of their care. The decision for how the nutritional needs of the patients will be met is determined by the physician. Although feeding by the gastrointestinal tract is preferred, certain individuals cannot be supported in this way. ► A centrally placed catheter is essential for TPN to be infused into the patient. These catheters are usually divided into the nontunneled catheters, tunneled catheters and the implanted ports.

NON-TUNNELED CATHETER 1- They are usually placed in the subclavian, jugular or femoral for a short term therapy of < 8 weeks. These catheters are rarely used for home TPN.2- Insertion of these catheters should be done with sterile technique but can be done at the patient's bedside.3- Once the catheter is inserted, a stat portable chest X-ray should be taken. This assures the physician of correct placement of the catheter and the absence of insertion complications. The tip of the catheter must be in the superior or inferior vena cava to infuse TPN through the catheter. 4- Single lumen a catheter is recommended because of the decreased risk of infection although multiple lumen catheters can be used. If multiple lumen catheters are used, the lumen used to administration TPN must be a lumen where no other solutions could have contaminated the lumen.

TUNNELED CATHETER1-These catheters are more commonly known as Hickman's, Groshongs, Broviac, etc., which are brand names for these catheters. 2- They are placed in patients that need more of a long term therapy. They are placed either in the procedure room in the


clinic or in the operation room. 3- These catheters are made of silicone. They are placed most commonly in the chest area. The catheter is tunneled under the skin and enters a large vein and then is threaded into the superior vena cava.

IMPLANTED PORTS1- These catheters are placed in the procedure room of the clinic or in the operating room. It is used for more intermittent therapies but can be used for TPN infusion both in the hospital and in the home setting. 2- The septum of these catheters is sutured under the skin in the subcutaneous tissue. The silicone catheter that attaches to the septum is then threaded into a major vein.

CENTRAL LINE IS INDICATED FOR INFUSION OF ( TPN )INFUSION1. The amino acids and dextrose solution with additives is

mixed in a one bag per day system at the UT Hospital and Clinics. The fat emulsions are a separate solution, which are added to the intravenous tubing at the designated connection.

2. Starting and weaning the TPN should be done gradually. The starting rate should be no more than 50cc / hr for 4-6 hr. The rate can be increased 25% every 4-6 hr. Weaning is accomplished by decreasing the rate by 25% every 4-6 hr.

3. Blood glucose monitoring is recommended every 6hr after TPN initiation.

SUGGESTED DAILY ELECTROLYTE INTAKE

1- Potassium 50-80mEq/ day.2- Sodium 60-120mEq/day. 3- Calcium 8-20mEq/ day (160-400mg)4- Magnesium 10-30mEq/ day (120-360mg)5- Chloride 100-120mEq/ day. 6- Phosphate 12-30mmol/ day (463-927 mg)

DRESSING CHANGE 1- Central venous dressing should be changed at least once a week or more frequently based on pt. condition/ need.2- Initial dressing change should be completed within 48hrs after placement of catheter. 3- Medical aseptic technique is absolutely essential in the management of parenteral nutrition therapy administration and catheter care.

ADMINISTRATION 1. The parenteral nutrition tubing should be treated as a

closed system. Only after consideration for alternative entries into the system are explored, should the parenteral nutrition catheter lumen be accessed for other uses.

2. TPN should always be given via an infusion pump.3. The pharmacist may be consulted regarding drug

compatibility for simultaneous administration of 2 or more drugs through a single lumen of the catheter.

4. Avoid the use of stopcocks and/ or the administration of blood products into the lumen designated for parenteral nutrition.

HEPARIN FLUSH 1. When parenteral nutrition infusion is being cycled, a

heparin flush is needed to maintain potency of central venous catheter when solution is not infusing.

2. Dosage, volume and frequency is determined by type, size and number of lumens of the central venous catheter.

COMPLICATION WITH CENTRAL VENOUS SCIENCE OF NUTURTIONNUTURTION 25

CATHETER AND ( TPN )1. Sepsis should be assessed by taking patients temperature

at least twice/day.2. Local infection needs to be assessed during every dressing

change.3. The patient should be weighed and intake and out-put

monitored to assess for fluid imbalance. 4. Blood sugars should be obtained to assess the patient for

hypo/hyperglycemia.5. Resistance to flushing may be corrected with the use of

Urokinase instilled into the catheter. 6. Thrombosis should be suspected if the patient complains of

pain or swelling in the extremity or surrounding area on side where the catheter is located. Leakage at catheter insertion site may also occur. Venogram is needed to confirm a thrombosis.

STANDARD TPN SOLUTION 1- Recommended for general use since it can fulfill most patients nutritional requirements and be cost effective. 2- Final concentration is 4.25% amino acids and 25% dextrose.3- Calorie: nitrogen ratio is 125:1 this is a 1Kcal/cc solution.

ADDITIVES1- Electrolytes are included when ordering the standard TPN solution. It is possible to order an electrolyte-free solution and then order the more appropriate electrolytes for the patient. Compatibility can be a problem when adding certain electrolytes together. A pharmacist should be contracted if this need arises.

Standard Electrolyte Electrolyte Free

A. Sodium ( mEq/L ) 35 0B. Potassium 30 0C. Calcium 5 0D. Magnesium 5 0E. Chloride 47-50 17-20F. Phosphate 14.3 0G. Acetate 67-74 37-44

2- Vitamins a) Standard multivitamin additive is MVI-12 ands should be added every day .

1. vitamin C ( ascorbic acid ) 100 mg2. Vitamin A ( retinol ) 3300 I.U.3. Vitamin D( ergocalciferol ) 200 I.U.4. Vitamin B1 ( thiamine) 3 mg5. Vitamin B2 ( riboflavin) 3.6 mg6. Vitamin B6 ( pyridozine HCL) 4 mg7. Niacinamide. 40 mg8. Pantothenic acid 15 mg9. Vitamin E 10 I.U.10. Biotin 60 mcg11. folic Acid 400 mcg12. Vitamin B12 5 mcg

b) Vitamin K 10mg needs to be added every week .3- Trace elements

a- Zinc 5mgb- Copper 1 mg c- Manganese 0.5 mg d- Chromium 1-0 mcg e- Selected patients may require zinc and selenium supplementation .

4- Insulin can be added to the TPN bag if needed to minimize hyperglycemia.5- Heparin is not routinely used at the UI hospital and clinic s in the TPN bags as there is no strong evidence to support that it reduces vein thrombosis.


6- Lipidsa) Used as a calorie source and to prevent fatty acid

deficiency. b) Fat emulsions are available vas a 10% product which is

1.1 Kcal/cc and a 20% product which is 2.0Kcal/cc. c) A three-in-one (3-in-1) mixture in which the fat emulsion is

mixed in with the TPN is not available at the UI hospitals and clinics .

7- Medications should not beaded routinely to the TPN unless it is necessary and they are compatible with the TPN .

SOLUTION FOR RENAL FAILURE1- Patients with renal failure need a balance of both essential and nonessential amino acids. 2- Nephramine:-

a. Contains only essential amino acids.b. Recommended only to decrease net urea synthesis for

short periods of time. c. Close monitoring of serum ammonia levels is important.

3- In order to restrict fluid, it is possible to increase the concentration of dextrose and fat emulsion.

SOLUTION FOR LIVER FAILURE1. Patients with chronic liver disease are usually

malnourished. They are prone to complications such as gastrointestinal bleeding and infection that compromise nutritional status.

2. Standard TPN should be used if the patient doses not have hepatic encephalopathy.

3. Hepatamine can be used with patients with hepatic encephalopathy. It is a liver-specific amino acid mixture.

SOLUTION FOR THE CATABOLIC PATIENT 1- Metabolic response to injury, burn or sepsis generates a

neuron endocrine response that induces hyper metabolism, proteolysis, insulin resistance with hyperglycemia and a depletion of lean body mass. 2- Ina catabolic state nutritional support is extremely important. Patients should be fed within 48-72 hrs of insult to optimize the patient's metabolic state.3- Nutritional requirements should be calculated. The optimal portion requirement of a critically ill patient is 1.5 to 2.0 gm/ kg/day. 4- Nitrogen balance.

ROLE OF NUTRITION SUPPORT TEAM MEMBERS PHYSICIAN : The physician on a nutrition support team will :1. Indicate whether the patient needs to have parenteral

nutrition therapy. 2. Assess the patient and order appropriate nutrition and

electrolytes needed for the patient after evaluating lab values.

3. Evaluate the patient for potential line infections .

NURSE : The nurse as a member of the nutritional support team will :1. Be a resource per so for patients, staff and local health

care providers regarding parenteral nutrition therapy and central venous catheters.

2. Monitor quality care for parenterals nutrition therapy and central venous catheters.

3. Participate in the discharge planning and patient education of home parenteral nutrition therapy patients.

4. Follow-up with home parenteral nutrition therapy patients after discharge from the hospital.

ENTERAL NUTRITION Complete or partial enteral feeding should be considered for the patient if the bowel is capable of handling the delivery and


absorption of nutrients. If the patient is willing and able to eat, feeding can be accomplished by mouth; however, if this is not possible a feeding tube could be placed into the GI tract

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