ATI Nutrition For Nursing

Nutrition for Nursing
REVIEW MODULE EDITION 7.0
Contributors
Honey C. Holman, MSN, RN
Debborah Williams, MSN, RN
Sheryl Sommer, PhD, RN, CNE

Consultants
Janean Johnson, MSN, RN, CNE
Penny Fauber, PhD, MS, BSN, RN
Brenda S. Ball, MEd, BSN, RN
Maria Sheilla Membrebe, MSN/Ed.,
Peggy Leehy, MSN, RN RN, ONC, CMSRN, CBN
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REPRINTED MARCH 2021
NUTRITION FOR NURSING I

Director of content review: Kristen Lawler
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II CONTENT MASTERY SERIES

User’s Guide
Welcome to the Assessment Technologies Institute® NCLEX® CONNECTIONS
Nutrition for Nursing Review Module Edition 7.0. The
To prepare for the NCLEX, it is important to understand
mission of ATI’s Content Mastery Series® Review Modules
how the content in this Review Module is connected to
is to provide user-friendly compendiums of nursing
the NCLEX test plan. You can find information on the
knowledge that will:
detailed test plan at the National Council of State Boards
● Help you locate important information quickly.
of Nursing’s website, www.ncsbn.org. When reviewing
● Assist in your learning efforts.
content in this Review Module, regularly ask yourself,

● Provide exercises for applying your nursing knowledge.
“How does this content fit into the test plan, and what
● Facilitate your entry into the nursing profession as a
types of questions related to this content should I expect?”
newly licensed nurse.
To help you in this process, we’ve included NCLEX
This newest edition of the Review Modules has been
Connections at the beginning of each unit and with each
redesigned to optimize your learning experience. We’ve
question in the Application Exercises Answer Keys. The
fit more content into less space and have done so in a
NCLEX Connections at the beginning of each unit point
way that will make it even easier for you to find and
out areas of the detailed test plan that relate to the content
understand the information you need.
within that unit. The NCLEX Connections attached to the
Application Exercises Answer Keys demonstrate how each
exercise fits within the detailed content outline.
ORGANIZATION These NCLEX Connections will help you understand how
This Review Module is organized into units covering the detailed content outline is organized, starting with
principles of nutrition, clinical nutrition, and alterations major client needs categories and subcategories and
in nutrition. Chapters within these units conform to one followed by related content areas and tasks. The major
of two organizing principles for presenting the content. client needs categories are:
● Nursing concepts ● Safe and Effective Care Environment
● Nutritional considerations for specific disorders ◯ Management of Care
◯ Safety and Infection Control
Nursing concepts chapters begin with an overview ● Health Promotion and Maintenance
describing the central concept and its relevance to nursing. ● Psychosocial Integrity
Subordinate themes are covered in outline form to ● Physiological Integrity
demonstrate relationships and present the information in ◯ Basic Care and Comfort
a clear, succinct manner. ◯ Pharmacological and Parenteral Therapies
Nutritional considerations for specific disorders chapters ◯ Reduction of Risk Potential
include an overview describing nutritional needs of ◯ Physiological Adaptation
clients who have the given disorder. These chapters cover

An NCLEX Connection might, for example, alert you that
assessments and data collection, nutritional guidelines,
content within a unit is related to:
nursing interventions, and complications, if applicable. ● Basic Care and Comfort
◯ Nutrition and Oral Hydration
Manage the client who has an alteration in

ACTIVE LEARNING SCENARIOS
■
nutritional intake.
AND APPLICATION EXERCISES
Each chapter includes opportunities for you to test your
knowledge and to practice applying that knowledge. Active
Learning Scenario exercises pose a nursing scenario
and then direct you to use an ATI Active Learning
Template (included at the back of this book) to record
the important knowledge a nurse should apply to the
scenario. An example is then provided to which you can
compare your completed Active Learning Template. The
Application Exercises include NCLEX-style questions, such
as multiple-choice and multiple-select items, providing
you with opportunities to practice answering the kinds of
questions you might expect to see on ATI assessments or
the NCLEX. After the Application Exercises, an answer key
is provided, along with rationales.
NUTRITION FOR NURSING User’s Guide III

QSEN COMPETENCIES ICONS
As you use the Review Modules, you will note the Icons are used throughout the Review Module to draw
integration of the Quality and Safety Education for your attention to particular areas. Keep an eye out for
Nurses (QSEN) competencies throughout the chapters. these icons.
These competencies are integral components of the
curriculum of many nursing programs in the United States This icon is used for NCLEX Connections.
and prepare you to provide safe, high-quality care as a
newly licensed nurse. Icons appear to draw your attention This icon indicates gerontological considerations,
to the six QSEN competencies. or knowledge specific to the care of older
adult clients.
Safety: The minimization of risk factors that could
cause injury or harm while promoting quality care This icon is used for content related to safety
and maintaining a secure environment for clients, self, and is a QSEN competency. When you see this
and others. icon, take note of safety concerns or steps that
nurses can take to ensure client safety and a
Patient-Centered Care: The provision of caring and
safe environment.
compassionate, culturally sensitive care that addresses
clients’ physiological, psychological, sociological, spiritual, This icon is a QSEN competency that indicates
and cultural needs, preferences, and values. the importance of a holistic approach to
providing care.
Evidence-Based Practice: The use of current knowledge
from research and other credible sources, on which to base This icon, a QSEN competency, points out the
clinical judgment and client care. integration of research into clinical practice.
Informatics: The use of information technology as a This icon is a QSEN competency and highlights
communication and information-gathering tool that the use of information technology to support
supports clinical decision-making and scientifically based nursing practice.
nursing practice.
This icon is used to focus on the QSEN
Quality Improvement: Care related and organizational competency of integrating planning processes to
processes that involve the development and meet clients’ needs.
implementation of a plan to improve health care services
This icon highlights the QSEN competency of care
and better meet clients’ needs.
delivery using an interprofessional approach.
Teamwork and Collaboration: The delivery of client care
This icon appears at the top-right of pages
in partnership with multidisciplinary members of the
and indicates availability of an online media
health care team to achieve continuity of care and positive
supplement, such as a graphic, animation, or
client outcomes.
video. If you have an electronic copy of the
Review Module, this icon will appear alongside
clickable links to media supplements. If you have
a hard copy version of the Review Module, visit
www.atitesting.com for details on how to access
these features.
FEEDBACK
ATI welcomes feedback regarding this Review Module.
Please provide comments to [email protected].
As needed updates to the Review Modules are identified,

changes to the text are made for subsequent printings
of the book and for subsequent releases of the electronic
version. For the printed books, print runs are based
on when existing stock is depleted. For the electronic
versions, a number of factors influence the update
schedule. As such, ATI encourages faculty and students to
refer to the Review Module addendums for information on
what updates have been made. These addendums—which
are available in the Help/FAQs on the student site and the
Resources/eBooks & Active Learning on the faculty site—
are updated regularly and always include the most current
information on updates to the Review Modules.
IV USER’S GUIDE CONTENT MASTERY SERIES

Table of Contents
NCLEX® Connections 1
UNIT 1 Principles of Nutrition

CHAPTER 1 Sources of Nutrition 3
Carbohydrates and fiber 3
Proteins 4
Lipids 4
Vitamins 5
Minerals and electrolytes 7
Water 9
Phytonutrients 9
CHAPTER 2 Ingestion, Digestion, Absorption, and Metabolism 11
CHAPTER 3 Nutrition Assessment/Data Collection 15
Obesity 16
CHAPTER 4 Guidelines for Healthy Eating 21
CHAPTER 5 Food Safety 27
CHAPTER 6 Cultural, Ethnic, and Religious Influences 31
CHAPTER 7 Nutrition Across the Lifespan 37
Pregnancy and lactation 37
Infancy 39
Childhood 41
Adolescence 43
Adulthood and older adulthood 44
NUTRITION FOR NURSING TABLE OF CONTENTS V

UNIT 2 Clinical Nutrition

CHAPTER 8 Modified Diets 51
CHAPTER 9 Enteral Nutrition 55
CHAPTER 10 Total Parenteral Nutrition 61
UNIT 3 Alterations in Nutrition

CHAPTER 11 Barriers to Adequate Nutrition 67
CHAPTER 12 Cardiovascular and Hematologic Disorders 71
CHAPTER 13 Gastrointestinal Disorders 77
CHAPTER 14 Renal Disorders 85
CHAPTER 15 Diabetes Mellitus 89
CHAPTER 16 Cancer and Immunosuppression Disorders 93
Active Learning Templates A1

Basic Concept A1
Diagnostic Procedure A3
Growth and Development A5
Medication A7
Nursing Skill A9
System Disorder A11
Therapeutic Procedure A13
Concept Analysis A15
VI TABLE OF CONTENTS CONTENT MASTERY SERIES

NCLEX® Connections
When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:
Health Promotion and Maintenance

AGING PROCESS
Provide care and education for the newborn, infant, and
toddler client from birth through 2 years.
Provide care and education for the adult client ages 65 years and over.
ANTE/INTRA/POSTPARTUM AND NEWBORN

CARE: Provide prenatal care and education.
HEALTH PROMOTION/DISEASE PREVENTION: Educate the

client on actions to promote/maintain health and prevent disease.
HEALTH SCREENING: Perform targeted screening assessments.
Basic Care and Comfort

NUTRITION AND ORAL HYDRATION
Consider client choices regarding meeting nutritional requirements and/or
maintaining dietary restrictions, including mention of specific food items.
Initiate calorie counts for clients.
Apply knowledge of mathematics to client nutrition.
Physiological Adaptation
FLUID AND ELECTROLYTE IMBALANCES: Manage the
care of the client with a fluid and electrolyte imbalance.
NUTRITION FOR NURSING NCLEX® CONNECTIONS 1

2 NCLEX® CONNECTIONS CONTENT MASTERY SERIES
CHAPTER 1
UNIT 1 PRINCIPLES OF NUTRITION
Carbohydrates and fiber
CHAPTER 1 Sources of Nutrition All carbohydrates are organic compounds composed of
carbon, hydrogen, and oxygen (CHO). The main function of
carbohydrates is to provide energy for the body.
Nutrients absorbed in the diet determine, to a ● The average minimum amount (DRI) of carbohydrates
needed to fuel the brain is 130 g/day for adults and
large degree, the health of the body. Deficiencies children. Median carbohydrate intake is 305 g/day for
or excesses can contribute to a poor state of males aged 20 years and older, and 228 g/day for adults,
children, and females in the same age range. The AMDR
health. Essential nutrients are those that the body for carbohydrates is 45% to 65% of calories.
cannot manufacture, and the absence of essential ● Carbohydrates provide energy for cellular work, and
help to regulate protein and fat metabolism. Adequate
nutrients can cause deficiency diseases. amounts of protein in the diet creates a protein-sparing
effect, which results in protein being spared from
Components of nutritive sources are energy use to perform its other essential functions.
carbohydrates and fiber, protein, lipids (fats), Brain and nervous system tissue require carbohydrates
for maximum effective functioning.
vitamins, minerals and electrolytes, and water.
Carbohydrates, fats, and proteins are all TYPES OF CARBOHYDRATES (1.1)
energy‑yielding nutrients. A healthy eating pattern Carbohydrates are classified according to the number of
saccharide units making up their structure.
includes foods that provide all essential nutrients,
Monosaccharides:simple carbohydrates (glucose, fructose,
and allows a broad assortment of food sources.
and galactose)
Disaccharides: simple carbohydrates (sucrose, lactose,
DIETARY REFERENCE INTAKES and maltose)
Polysaccharides: complex carbohydrates (starch, fiber,
Dietary Reference Intakes (DRIs) are developed by the
and glycogen)
Institute of Medicine’s Standing Committee on the
Scientific Evaluation of Dietary Reference Intakes.
● DRIs are useful in understanding the food intake
CONSIDERATIONS
patterns of large groups, planning nutrition program ● The liver converts fructose and galactose into glucose,
standards (Supplemental Nutrition Assistance program which is then released in the bloodstream. This elevates
[SNAP]), and helping individuals. blood glucose levels, which causes the release of insulin
● DRIs are comprised of the following reference values. from the pancreas. With insulin production, glucose is
◯ Recommended Dietary Allowances (RDAs): The moved out of the bloodstream into cells in order to meet
amount of a particular nutrient that most healthy energy needs.
people in a similar life-stage and sex will need to ● The body digests 95% of starch within 1 to 4 hr after
decrease the risk of chronic disease. ingestion. Digestion occurs mainly in the small
◯ Estimated Average Requirement (EAR): The amount intestine using pancreatic amylase to reduce complex
of a nutrient required to meet basic requirements for carbohydrates into disaccharides.
half of the people in a particular population. This ● Glycogen is the stored carbohydrate energy source found
reference is often used by researchers and policy in the liver and muscles. It is a vital source of backup
makers, and is used to help determine RDAs. energy, but is only available in limited supply.
◯ Adequate Intake (AI): The amount of a nutrient that ● To maintain glucose levels between meals, glucose is
most people in a group or population consume. This is released through the breakdown of liver glycogen.
helpful when there is not enough data to establish an ● Digestible carbohydrates provide 4 cal/g of energy and
RDA for a nutrient. make blood glucose levels more stable.
◯ Tolerable Upper Intake Level (UL): The
upper limit on the amount of a particular

nutrient, or the maximum an individual 1.1 Carbohydrates at a glance
should consume. ULs are used when a
nutrient is known to have adverse effects.
EXAMPLE (SOURCES) FUNCTION
◯ Acceptable Macronutrient Distribution
Glucose (corn syrup), fructose
Ranges (AMDRs): The recommended Monosaccharides (fruits), galactose (found in milk) Basic energy for cells
percentages of intake for energy-yielding Energy, aids calcium
nutrients (carbohydrates, fat, protein). Sucrose (table sugar), lactose
and phosphorus
(milk sugar), maltose (malt sugar)
● Clients can use DRIs as a guide for Disaccharides absorption (lactose)
nutrition intake, but should also consider Starches (grains, legumes, Energy storage
individual factors that increase nutrient root vegetables), fiber (whole (starches), digestive
Polysaccharides grains, fruits, vegetables) aid (fiber)
needs (disease, injury).
NUTRITION FOR NURSING CHAPTER 1 Sources of Nutrition 3

FIBER ● The RDA of protein is 0.8 g/kg for healthy adults.
Protein’s acceptable macronutrient distribution range
Fiber i s categorized as a carbohydrate.
(AMDR) for adults is 10% to 35% of total calories.
● Dietary fiber is the substance in plant foods that ● Underconsumption can lead to protein energy
is indigestible. Types are pectin, gum, cellulose,
malnutrition (PEM). Kwashiorkor and marasmus are
and oligosaccharides.
two disorders caused by extreme PEM. These serious
● Fiber is important for proper bowel elimination. It
disorders are caused by a lack of protein ingestion.
adds bulk to the feces and stimulates peristalsis to ● Protein provides 4 cal/g of energy.
ease elimination.
● Fiber helps to lower cholesterol and lessen the incidence
Lipids
of intestinal cancers. It has also been shown to help
keep blood glucose levels stable by slowing the rate of
glucose absorption. ● The chemical group of fats is called lipids, and they are
● Total fiber AI is 25 g/day for females and 38 g/day
available from many sources.
for males. ◯ Dark meat
● The fermentation and metabolization of fiber in the colon ◯ Poultry skin
provides 1.5 to 2.5 cal/g of energy, depending on the type. ◯ Dairy foods
◯ Added oils (margarine, butter, shortening, oils, lard)
Proteins ● Fat is an essential nutrient for the body. It serves as a

concentrated form of stored energy for the body and
Proteins are provided by plant and animal sources. supplies important tissue needs.
They are formed by linking amino acids in various ◯ Hormone production
combinations for specific use by the body. ◯ Structural material for cell walls
◯ Protective padding for vital organs
TYPES OF PROTEINS ◯ Insulation to maintain body temperature
◯ Covering for nerve fibers

There are two types of proteins. Each is obtained from the ◯ Aid in the absorption of fat‑soluble vitamins
diet in various ways.
Complete proteins, from animal sources and soy, contain

sufficient amounts of all nine essential amino acids.
TYPES OF FATS
Fats are divided into three categories: triglycerides,
Incomplete proteins, generally from plant sources, can
phospholipids, and sterols. Triglycerides are further
contain an insufficient number or quantity of amino acids,
comprised of fatty acids, which include saturated fatty
which limits the ability for protein synthesis.
acids and unsaturated fatty acids.
● Complementary proteinsare incomplete proteins
that, when combined, provide a complete protein. It
Triglycerides
is not necessary to consume complementary proteins
at the same time to form a complete protein; instead, Triglycerides total 95% of fat in food. They combine with
consuming a variety of complementary proteins over glycerol to supply energy to the body, allow fat‑soluble
the course of the day is sufficient. vitamin transport, and form adipose tissue that protects
● Examples of incomplete protein pairs that provide internal organs.
complete protein include black beans with rice and ● Saturated fatty acids are solid at room temperature, and
hummus with crackers. are found primarily in animal sources.
● Unsaturated fatty acids, including monounsaturated
and polyunsaturated fatty acids, are usually from plant
CONSIDERATIONS sources and help reduce health risks.
● Proteins have many metabolic functions. ◯ Sources of monounsaturated fatty acids include
◯ Tissue‑building and maintenance olives, canola oil, avocado, peanuts, and other nuts.
◯ Balance of nitrogen and water ◯ Sources of polyunsaturated fatty acids include corn,
◯ Backup energy wheat germ, soybean, safflower, sunflower, and fish.

◯ Support of metabolic processes ● Essential fatty acids, made from broken down fats,
■ Nitrogen balance must be supplied by the diet. Essential fatty acids,
■ Transportation of nutrients, other vital substances including omega‑3 and omega‑6, are used to support
◯ Support of the immune system blood clotting, blood pressure, inflammatory responses,
◯ Facilitating acid-base, fluid, and electrolyte balance and many other metabolic processes.
◯ Formation of neurotransmitters, enzymes
antibodies, peptide hormones, breast milk, mucus, Phospholipids

histamine, and sperm
Phospholipids (e.g., lecithin) are important to cell
● Three main factors influence the body’s requirement
membrane structure, as well as the transport of
for protein.
fat‑soluble substances across the cell membrane.
◯ Tissue growth needs
◯ Quality of the dietary protein

◯ Added needs due to illness
4 CHAPTER 1 Sources of Nutrition CONTENT MASTERY SERIES

Sterols WATER‑SOLUBLE VITAMINS
Sterols (e.g., cholesterol) are found in the tissues of
Vitamin C
animals, and are not an essential nutrient because the
liver is able to produce enough to meet needs. Vitamin C (ascorbic acid) a ids in tissue building and
metabolic reactions (healing, collagen formation, iron
If cholesterol is consumed in excess, it can
absorption, immune system function).
build up in the tissues, causing congestion and ● Vitamin C is found in citrus fruits (oranges,
increasing the risk for cardiovascular disease.
lemons), tomatoes, peppers, green leafy vegetables,
and strawberries.
CONSIDERATIONS ● Stress and illness, as well as cigarette smoking,
increases the need for vitamin C. Cigarette smokers are
● The AMDR for fats is approximately 20% to 35% of total
advised to increase Vitamin C intake by 35 mg/day due
calories. 10% or less of total calories should come from
to increased oxidative stress and metabolic turnover.
saturated fat sources. ● Severe deficiency causes scurvy, a hemorrhagic disease
● A low intake of dietary cholesterol is associated with
with diffuse tissue bleeding, painful limbs/joints, weak
reduced risks of cardiovascular disease (CVD) and obesity.
bones, and swollen gums/loose teeth. While scurvy can
● A diet high in fat is linked to CVD, hypertension, and
be fatal, it can also be cured with moderate doses of
diabetes mellitus.
vitamin C for several days.
◯ The exception is for children under 2 years of age,
who need a higher amount of fat to form brain tissue.

B‑complex vitamins
◯ Conversely, a diet with less than 10% of fat cannot
supply adequate amounts of essential fatty acids and B‑complex vitamins have many functions in cell
results in a cachectic (wasting) state. metabolism. Each one has a varied duty. Many partner
● The majority of lipid metabolism occurs after fat with other B vitamins for metabolic reactions. Most affect
reaches the small intestine, where the gallbladder energy, metabolism, and neurologic function. Sources for
secretes concentrated bile, which acts as an emulsifier B vitamins almost always include green leafy vegetables
and enables the breakdown of fat down into smaller and unprocessed or enriched grains.
particles for digestion. At the same time, the pancreas
Thiamin (B1) functions as a coenzyme in energy
secretes pancreatic lipase, which breaks down fat.
metabolism, promotes appetite, and assists with muscle
Intestinal cells absorb the majority of the end products
actions through its role in nerve functioning.
of digestion, with some being excreted in the feces. ● Deficiency results in beriberi (ataxia, confusion, anorexia,
◯ Very‑low‑density lipoproteins (VLDL) carry
tachycardia), headache, weight loss, and fatigue.

triglycerides to the cells. ● Food sources are widespread in almost all plant and
◯ Low‑density lipoproteins (LDL) carry cholesterol to
animal tissues, especially meats, grains, and legumes.
the tissue cells.
◯ High‑density lipoproteins (HDL) remove excess Riboflavin (B2) works as a coenzyme to release energy
cholesterol from the cells, and transport it to the liver from cells.
for disposal. ● Deficiency results in cheilosis (manifestations include
● Lipids provide 9 cal/g of energy and are the densest scales and cracks on lips and in corners of the mouth),
form of stored energy. smooth/swollen red tongue (also called glossitis), and
dermatitis of the ears, nose, and mouth.
● Dietary sources include milk, meats, and dark
Vitamins leafy vegetables.
Niacin (B3) aids in the metabolism of fats, glucose,

Vitamins are organic substances required for many
and alcohol, and synthesis of steroid hormones,
enzymatic reactions. The main function of vitamins
cholesterol, and fatty acids.
is to be a catalyst for metabolic functions and ● Deficiency causes pellagra (manifestations include
chemical reactions.
sun‑sensitive skin lesions, and gastrointestinal issues
● There are 13 essential vitamins, each having a
with impaired food digestion and excretion, as well as
specialized function.
nutrient absorption and neurologic findings [anxiety,
● There are two classes of vitamins.
insomnia, confusion, paranoia]).
◯ Water‑soluble: Vitamins C and B‑complex
● Sources include meats, legumes, milk, whole grain and
◯ Fat‑soluble: Vitamins A, D, E, and K
enriched breads and cereals.

● Vitamins yield no usable energy for the body, but they
are needed for energy to be metabolized. Pyridoxine/Vitamin B6 is needed for cellular function and
synthesis of hemoglobin, neurotransmitters, and niacin.
● Deficiency causes macrocytic anemia and
CNS disturbances.
● High intake of supplements can cause sensory neuropathy.
● Widespread food sources include meats, grains,
and legumes.

Pantothenic acid is involved in the metabolism of FAT‑SOLUBLE VITAMINS
carbohydrates, fats, and proteins as part of coenzyme A. ● All fat‑soluble vitamins have the possibility for toxicity
● Deficiency is extremely rare, but results in generalized
due to their ability to be stored in the body for long
body system failure.
periods of time.
● Rich sources include meats, whole grain cereals, dried ● Absorption of fat‑soluble vitamins is dependent on the
peas and beans.
body’s ability to absorb dietary fat. Fat digestion can be
Biotin serves as a coenzyme used in fatty acid synthesis, interrupted by any number of conditions, particularly
amino acid metabolism, and the formation of glucose. those that affect the secretion of fat‑converting
● Deficiency is rare, but results in neurologic findings enzymes, and conditions of the small intestine. Clients
(depression, fatigue), hair loss, and scaly red rash. who have cystic fibrosis, celiac disease, Crohn’s disease,
● Widespread food sources include eggs, milk, and dark or intestinal bypasses are at risk for deficiencies.
green vegetables. ● Clients who have liver disease should be careful not to
take more than the daily recommendations of fat‑soluble
Folate is required for hemoglobin and amino acid
vitamins, as excess is stored in the liver and adipose tissue.
synthesis, new cell synthesis, and prevention of neural
tube defects in utero. (Folic acid is the synthetic form.)
Vitamin A
● Deficiency causes megaloblastic anemia, CNS
disturbances, and fetal neural tube defects (spina bifida, Vitamin A (retinol, beta‑carotene) contributes to
anencephaly). It is important that all clients of vision health, tissue strength and growth, and
child‑bearing age get an adequate amount of folate due embryonic development. Retinoids are found in animal
to neural tube formation occurring early in gestation, foods and are the active form of vitamin A. Carotenoids
often before a client knows they are pregnant. are found in plants and are a precursor form of vitamin A,
● Folate occurs naturally in a variety of foods including liver, which the body converts to the usable form as needed.
dark‑green leafy vegetables, orange juice, and legumes. ● Care should be taken when administered to pregnant
clients as some forms have teratogenic effects on the fetus.
Cobalamin (B12) is necessary for folate activation and red ● Deficiency results in vision changes, xerophthalmia
blood cell maturation.
(dryness and hardening of the cornea), GI disturbances,
● Deficiency causes pernicious anemia and is seen mostly
and hyperkeratosis.
in clients who follow a strict vegan diet (B12 is found ● Food sources include fatty fish, egg yolks, butter, cream,
solely in foods of animal origin), and those who have an
and dark yellow/orange fruits and vegetables (carrots,
absence of intrinsic factor needed for absorption of B12.
yams, apricots, squash, cantaloupe).
● Sources include meat, shellfish, eggs, and dairy products. ● Toxicity can result from retinoids, and is more common
in clients who are taking vitamin A supplements.
1.2 Water‑soluble vitamins at a glance

MAJOR ACTIONS MAJOR SOURCES DEFICIENCY
Vitamin C Antioxidant, tissue building, Citrus fruits and Scurvy, decreased iron
(ascorbic acid) iron absorption juices, vegetables absorption, bleeding gums
Muscle energy, energy Beriberi, headache,
Meats, grains, legumes
Thiamin (B1) metabolism weight loss, fatigue
Assists with releasing Milk, meats, dark Skin eruptions, cracked lips,
Riboflavin (B2) energy from cells leafy vegetables red swollen tongue
Metabolism of fat, glucose,
and alcohol; synthesis of Pellagra, skin lesions, GI and
Liver, nuts, legumes
fatty acids, cholesterol, CNS findings, dementia
Niacin (B3) and steroid hormones
Carbohydrate, fat, and Meats, whole grain cereals, Rare
Pantothenic acid protein metabolism dried peas and beans. Generalized body system failure
Cellular function, heme and Meats, grains, Macrocytic anemia, CNS
Pyridoxine (B6) neurotransmitter synthesis and legumes disturbances, poor growth
Synthesis of amino acids
Liver, green leafy Megaloblastic anemia,
and hemoglobin, formation
vegetables, legumes CNS disturbance
Folate of fetal neural tube
Pernicious anemia, GI findings,
Folate activation, red Meats, clams, oysters,
poor muscle coordination,
blood cell maturation eggs, dairy products
Cobalamin (B12) paresthesia of the hands and feet
Fatty acid synthesis, amino acid Eggs, milk, dark Rare; scaly rash, hair loss,
Biotin metabolism, glucose formation green vegetables depression, fatigue

1.3 Fat‑soluble vitamins at a glance
MAJOR ACTIONS MAJOR SOURCES DEFICIENCY

Normal vision, tissue strength, growth Orange/yellow fruits and Reduced night vision, dry/thick
Vitamin A and immune system function vegetables, fatty fish, dairy corneas, mucosa changes
Maintain blood calcium and phosphorus, Fish, fortified dairy products, Low blood calcium, fragile bones,
Vitamin D aid in bone development egg yolks, sunlight rickets, osteomalacia in adults
Vegetable oils, grains, nuts, Anemia, edema and skin
Protects vitamin A from oxidation
Vitamin E dark green vegetables lesions in infants
Essential for prothrombin synthesis,
Green leafy vegetables, eggs Increased bleeding times
Vitamin K aids in bone metabolism
Vitamin D Sodium (Na)

Vitamin D assists in the absorption of calcium and MAJOR ACTIONS: Maintains fluid volume, allows muscle
phosphorus, and aids in bone mineralization. contractions, contributes to nerve impulses
● Sunlight enables the body to synthesize vitamin D
MAJOR SOURCES: Table salt, added salts, processed foods
in the skin.
● Deficiency results in bone demineralization, and FINDINGS OF DEFICIENCY: Muscle cramping, memory
extreme deficiency can cause rickets and osteomalacia. loss, anorexia
Excess consumption can cause hypercalcemia.
FINDINGS OF EXCESS: Fluid retention, hypertension,
● Food sources include fatty fish, eggs, and fortified
disorientation
products (ready-to-eat cereals, milk, orange juice).
NURSING ACTIONS: Monitor level of consciousness,
Vitamin E edema, and blood pressure.
Vitamin E is an antioxidant that helps to preserve lung

Potassium (K)
and red blood cell membranes.
● Deficiency rare, but results in anemia and can cause MAJOR ACTIONS: Maintains fluid volume inside cells,
edema and skin lesions in infants. muscle action
● Food sources include vegetable oils and certain nuts.
MAJOR SOURCES: Oranges, dried fruits, tomatoes,
avocados, dried peas, meats, broccoli, bananas, dairy
Vitamin K
products, meats, whole grains, potato
Vitamin K assists in blood clotting and bone maintenance.
FINDINGS OF DEFICIENCY: Dysrhythmias, muscle
● Deficiency results in increased bleeding time.
cramps, confusion
● Used as an antidote for excess anticoagulants (warfarin).
● Vitamin K is found in carrots, eggs, and dark green FINDINGS OF EXCESS: Dysrhythmia, muscle weakness,
vegetables (spinach, broccoli, asparagus). irritability, confusion, numbness in extremities
NURSING ACTIONS: Monitor cardiac status and ECG. Give
Minerals and electrolytes

oral preparations (tabs, elixirs) with meals to minimize GI
irritation.
Minerals are inorganic elements, are available in an

Chloride (Cl)
abundance of food sources, and are used at every cellular
level for metabolic exchanges. Minerals are divided into MAJOR ACTIONS: Assists with intracellular and
major and trace. extracellular fluid balance, and aids acid-based balance
and digestion
Electrolytes are electrically-charged minerals that cause
physiological reactions that maintain homeostasis. Major MAJOR SOURCES: Table salt, added salts, processed foods
electrolytes include sodium, potassium, and chloride.
FINDINGS OF DEFICIENCY: Rare; muscle cramps, anorexia
FINDINGS OF EXCESS: Vomiting
MAJOR MINERALS
NURSING ACTIONS: Monitor sodium levels.
Major minerals occur in larger amounts (more than 5 g) in
the body, and 100 mg or more is required through dietary
sources each day. The seven major minerals are calcium,
phosphorus, sodium, potassium, magnesium, chloride,
and sulfur.

Calcium (Ca) TRACE MINERALS
MAJOR ACTIONS: Bones/teeth formation, blood pressure, Trace minerals, also called micronutrients, are required
blood clotting, nerve transmission by the body in amounts of less than 5 g, and 20 mg or less
is required through dietary sources each day. The nine
MAJOR SOURCES: Dairy, broccoli, kale, fortified grains
trace elements are iron, iodine, zinc, copper, manganese,
FINDINGS OF DEFICIENCY: Tetany, positive Chvostek’s and chromium, selenium, molybdenum, and fluoride.
Trousseau’s signs, ECG changes, osteoporosis in adults,
poor growth in children Iodine
FINDINGS OF EXCESS: Constipation, renal stones, lethargy, Iodine is used for synthesis of thyroxine, the thyroid
depressed deep‑tendon reflexes hormone that helps regulate metabolism. Iodine is taken
up by the thyroid. When iodine is lacking, the thyroid
NURSING ACTIONS: Monitor ECG and respiratory status.
gland enlarges, creating a goiter. Too much iodine can
Give PO tabs with vitamin D.
result in thyrotoxicosis.
Grown food sources vary widely and are dependent on
Magnesium (Mg)
●
the iodine content of the soil in which they were grown.

MAJOR ACTIONS: Bone formation, catalyst for many ● Seafood provides a good amount of iodine. Table salt in
enzyme reactions, nerve/muscle function, smooth the U.S. is fortified with iodine, so deficiencies are not
muscle relaxation as prevalent.
● The RDA is 150 mcg for adults.
MAJOR SOURCES: Green leafy vegetables, nuts, whole
grains, tuna, halibut, chocolate
Iron
FINDINGS OF DEFICIENCY: Weakness, dysrhythmias,
Iron is responsible for oxygen distribution to hemoglobin
convulsions, increased blood pressure, anorexia
and myoglobin.
FINDINGS OF EXCESS: Diarrhea, nausea, muscle weakness, ● The body recycles unused iron from dying red blood
hypotension, bradycardia, lethargy cells and stores it for later use.
● Iron in food consists of two forms: heme iron found in
NURSING ACTIONS: Follow seizure precautions, and
meat, fish, and poultry and non-heme iron found in
monitor level of consciousness and vital signs.
grains, legumes, and vegetables.
Iron supplements can cause constipation, nausea,
Phosphorus (P)
●
vomiting, diarrhea, and teeth discoloration (liquid form).

MAJOR ACTIONS: Energy transfer of RNA/DNA, acid‑base They can be taken with food to avert gastrointestinal
balance, bone and teeth formation manifestations, and nurses should encourage fresh
fruits, vegetables, and a high‑fiber diet.
MAJOR SOURCES: Dairy, peas, meat, eggs, legumes ● Supplements that are unneeded can become toxic.
FINDINGS OF DEFICIENCY: Unknown ● Vitamin C increases the absorption of iron.
● Clients during the menstruating years, older infants

FINDINGS OF EXCESS: Decreased blood calcium levels
and toddlers, and pregnant clients are at risk for iron
NURSING ACTIONS: Evaluate the use of antacids (note deficiency anemia.
type) and the use of alcohol (alcohol impairs absorption). ● Toxicity can occur when there is too much iron stored
in the body.
Sulfur (S)
Fluoride
MAJOR ACTIONS: A component of vitamin structure,
by‑product of protein metabolism Fluoride forms a bond with calcium and thus accumulates
in calcified body tissue (bones and teeth). Water with
MAJOR SOURCES: Proteins
added fluoride protects against dental cavities.
FINDINGS OF DEFICIENCY: Only seen in severe ● Deficiency can result in dental caries, and increase the
protein malnourishment risk for osteoporosis.
● Toxicity can result in fluorosis, itching, and chest pain.
FINDINGS OF EXCESS: Toxicity does not result in any
health issues
NURSING ACTIONS: Sulfur levels are not

usually monitored.

Water Application Exercises
Water is the most basic of nutrients. The body can maintain
1. A nurse is educating a client who has anemia
itself for several weeks on its food stores of energy, but it about dietary intake of iron. Which of the
cannot survive without water/hydration for more than a few following is a non-heme source of iron?
days. Water makes up the largest portion of our total body A. Ground beef
weight and is crucial for all fluid and cellular functions.
B. Dried beans
● Fluid balance is essential for optimum health and
C. Salmon
bodily function.
D. Turkey
● The balance of fluid is a dynamic process regulated by
the release of hormones.
● Water leaves the body via the kidneys, skin, lungs, and 2. A nurse is discussing foods that are high in
feces. The greatest elimination is through the kidneys. vitamin D with a client who is unable to be
out in the sunlight. Which of the following
Other loss factors include bleeding, vomiting, and
should be included in the teaching?
rapid respirations.
A. 1 cup steamed long‑grain brown rice
● To maintain a balance between intake and output,
intake should approximate output. Healthy adults B. 6 medium raw strawberries
lose approximately 1000 mL of water daily through C. ½ cup boiled Brussels sprouts
insensible losses (respirations, skin, fecal), and to get D. 2 large, poached eggs
rid of metabolic wastes needs to excrete at least 500 mL
of urine daily. Therefore, the minimum daily amount of 3. A nurse is reviewing dietary recommendations
water intake needed is 1,500 mL. with a group of clients at a health fair. Which of the
● Most water intake is from drinking fluids; water is also following information should the nurse include?
present in solid sources (lettuce, gelatin, soup, melons). A. “Fats should be 5% to 15% of daily calorie intake.”
Under normal conditions, the AI for adult water intake B. “Make protein 10% to 35% of
for females is 2.7 L/day, of which 2.2 L should be from total calories each day.”
fluids; and for males 3.7 L/day, of which 3 L should be C. “Consume 1,500 mL of water from
from fluids. liquids and solids daily.”
● Additional hydration can be required for athletes,
D. “The body needs 40 mg of iron each day.”
persons with fever/illness (vomiting, diarrhea), and
those in hot climate conditions. Fluid replacement can 4. A nurse is conducting a nutritional class on minerals
occur orally, enterally, or IV. and electrolytes. The nurse should include which of
● Young children and older adults dehydrate more rapidly.
the following foods is a major source of magnesium?
● Assessment for proper hydration should include skin turgor,
A. Tuna
mental status, orthostatic blood pressures, urine output B. Tomatoes
and concentration, and moistness of mucous membranes. C. Eggs
● Thirst is a late indicator of the need for hydration,
D. Oranges
especially in older adults.
Some individuals can have an aversion to drinking water,
5.
●
A nurse is discussing health problems associated

and should be encouraged to explore other options (fresh
with nutrient deficiencies with a group of clients.
fruits, fruit juices, flavored gelatin, frozen treats, soups).
Which of the following conditions is associated with
● Caffeinated drinks have a mild diuretic effect. However, a deficiency of vitamin C? (Select all that apply.)
tolerance develops in clients who regularly consume
A. Dysrhythmias
caffeinated beverages, which results in little to no effect
B. Scurvy
on fluid volume.
C. Pernicious anemia
D. Megaloblastic anemia
Phytonutrients E. Bleeding gums
Also called phytochemicals, phytonutrients occur

naturally in plants. They can have positive health effects Active Learning Scenario
(detoxifying the body, stimulating the immune system,
promoting hormone balance, serving as antioxidants). A school nurse is conducting a nutritional class for
● They are found in fruits, vegetables, green tea, legumes, a group of athletes. Use the ATI Active Learning
whole grains, and broccoli. Template: Basic Concept to complete this item.
● No recommendations for intake of phytonutrients exists RELATED CONTENT
at this time. ●
Describe two types of protein.
●
Describe complimentary proteins.
●
Describe three main factors influencing
the body’s requirement for protein.

Application Exercises Key Active Learning Scenario Key
1. A. Ground beef is an animal product, which Using the ATI Active Learning Template: Basic Concept
provides heme iron.
RELATED CONTENT
B. CORRECT: Dried beans provide non-heme iron, as
do other legumes, vegetables, and grains.
●
Types of protein
C. Salmon is an animal product, which provides heme iron. Complete proteins, from animal sources and soy, contain
◯
D. Turkey is an animal product, which provides heme iron. sufficient amounts of all nine essential amino acids.
Incomplete proteins, generally from plant sources, can
◯
NCLEX® Connection: Basic Care and Comfort,

contain an insufficient number or quantify of amino
Nutrition and Oral Hydration
acids, which limits the ability for protein synthesis.
●
Complementary proteins
2. A. Long‑grain brown rice does not contain vitamin D. Complementary proteins are those food sources that are
◯
B. Strawberries do not contain vitamin D. incomplete proteins eaten alone, but together are equivalent
C. Brussels sprouts do not contain vitamin D. to a complete protein. It is not necessary to consume
D. CORRECT: Include eggs as a food that is high in vitamin D. complementary proteins at the same time to form a complete
protein; instead, consuming a variety of complementary
proteins over the course of the day is sufficient.
Nutrition and Oral Hydration ●
Main factors influencing the body’s requirement for protein
Tissue growth needs
◯
3. A. Fats should be 20% to 35% of daily calorie intake. Quality of the dietary protein
◯
B. CORRECT: The recommendation for protein Added needs due to illness

◯
intake is 10% to 35% of total daily calories.

C. Recommended water intake from liquids or solids is NCLEX® Connection: Health Promotion and Maintenance,
2.7 L/day for females and 3.7 L/day for males. Health Promotion/Disease Prevention
D. Iron is a trace mineral, which means the
body needs 20 mg or less daily.
4. A. CORRECT: Tuna and halibut are major

sources of magnesium.
B. Green, leafy vegetables are a good source of magnesium.
C. Nuts are a major source of magnesium.
D. Chocolate is a major source of magnesium.
NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances
5. A. Dysrhythmias are associated with a potassium deficiency.

B. CORRECT: Scurvy is associated with a vitamin C deficiency.
C. Pernicious anemia is associated a deficiency of vitamin B12.
D. Megaloblastic anemia is associated
with a deficiency of folate.
E. CORRECT: Bleeding gums is a condition that
results from vitamin C deficiency.
Illness Management

CHAPTER 2
UNIT 1 PRINCIPLES OF NUTRITION METABOLIC RATE
CHAPTER 2 Ingestion, Digestion, Metabolic rate refers to the speed at which food energy
Absorption, and
is burned.
● Basal metabolic rate (BMR), also called basal energy
Metabolism expenditure (BEE), refers to the amount of energy

used in 24 hr for involuntary activities of the body
(maintaining body temperature, heartbeat, circulation,
and respirations). This rate is determined while at rest,
Ingestion is the process of consuming food by the and following a 12‑hr fast.
Resting metabolic rate (RMR), also called resting
mouth, and moving it through the digestive system.
●
energy expenditure (REE), refers to the calories needed

Digestion is a systemic process that includes the for involuntary activities of the body at rest. This rate
does not consider the 12‑hr fast criteria.
breakdown and absorption of nutrients. ● BMR is affected by lean body mass and hormones.
Body surface area, age, and sex are also factors that
Absorption occurs as components of nutrients contribute to BMR.
pass through the digestive system into the ● In general, males have a higher metabolic rate than
females due to their higher amount of body muscle and
bloodstream and lymphatic system. decreased amount of fat.
Thyroid function tests can be used as an indirect
Metabolism is the sum of all chemical processes
●
measure of BMR.
that occur on a cellular level to maintain ● Acute stress causes an increase in metabolism, blood
glucose levels, and protein catabolism.

homeostasis. Metabolism is comprised of ◯ A major nutritional concern during acute stress is
catabolism (the breaking down of substances protein deficiency as stress hormones break down
protein at a very rapid rate.
with the resultant release of energy) and ◯ Protein deficiency increases the risk of complications
anabolism (the use of energy to build or from severe trauma or critical illness (skin
breakdown, delayed wound healing, infections, organ
repair substances). failure, ulcers, impaired medication tolerance).
◯ Protein requirements can be increased to more than
Energy nutrients are metabolized to provide 2 g/kg of body weight, or up to 25% of total calories,
carbon dioxide, water, and adenosine depending on the client’s age and prior
nutritional status.
triphosphate (ATP). Excess energy nutrients are ● Any catabolic illness (surgery, extensive burns)
stored; glucose is converted to glycogen and increases the body’s requirement for calories to meet
the demands of an increased BMR.
stored in the liver and muscle tissue; surplus ● Disease and sepsis also increase metabolic demands and
glucose is converted to fat; glycerol and fatty can lead to starvation/death.
acids are reassembled into triglycerides and

stored in adipose tissue; and amino acids make FACTORS AFFECTING METABOLIC RATE
INCREASE BMR
body proteins. The liver removes nitrogen ● Lean, muscular body build
from amino acids, and the remaining product ● Exposure to extreme temperatures
Prolonged stress
is converted to glucose or fat for energy. Body
●
● Rapid growth periods (infancy, puberty)

cells first use available ATP for growth and repair, ● Pregnancy
then use glycogen and stored fat. Lactation

● Physical conditioning
DECREASE BMR
● Short, overweight body build
● Starvation/malnutrition
● Age-related loss of lean body masses
NUTRITION FOR NURSING CHAPTER 2 Ingestion, Digestion, Absorption, and Metabolism 11

Conditions ASSESSMENT/DATA COLLECTION
INCREASE METABOLISM ● Weight and history of recent weight patterns
● Fever ● Medical history for diseases that affect metabolism and
● Involuntary muscle tremors (shivering, Parkinson’s) nitrogen balance
● Hyperthyroidism ● Extent of traumatic injuries, as appropriate
● Cancer ● Fluid and electrolyte status
● Cardiac failure ● Laboratory values: albumin, transferrin, glucose,
● Burns creatinine
● Surgery/wound healing ● Clinical findings of malnutrition: pitting edema, hair
● HIV/AIDS loss, wasted appearance
● Medication adverse effects that can affect nutrition
DECREASE METABOLISM: Hypothyroidism ● Usual 24‑hr dietary intake
Use of nutritional supplements, herbal supplements,
Medications
●
vitamins, and minerals

INCREASE BMR ● Use of alcohol, caffeine, and nicotine
● Epinephrine
● Levothyroxine
● Ephedrine sulfate NURSING INTERVENTIONS
DECREASE BMR ● Monitor food intake.
● Opioids ● Monitor fluid intake and output.
● Muscle relaxants ● Use client‑centered approach to address disease‑specific
● Barbiturates problems with ingestion, digestion, or
medication regime.
● Collaborate with dietitian.
NITROGEN BALANCE ● Provide adequate calories and high‑quality protein.
Nitrogen balance refers to the difference between the daily STRATEGIES TO INCREASE PROTEIN, CALORIC CONTENT
intake and excretion of nitrogen. It is also an indicator ● Add skim milk powder to milk (double‑strength milk).
of tissue integrity. A healthy adult experiencing a stable ● Use whole milk instead of water in recipes.
weight is in nitrogen equilibrium, also known as neutral ● Add cheese, peanut butter, chopped hard‑boiled eggs, or
nitrogen balance. yogurt to foods.
● Dip meats in eggs or milk and coat with bread crumbs
Positive nitrogen balance indicates that the intake of
before cooking.
nitrogen exceeds excretion. Specifically, the body builds ● Nuts and dried beans are significant sources of protein.
more tissue than it breaks down. This normally occurs
These are good alternatives for a dairy allergy or lactose
during periods of growth: infancy, childhood, adolescence,
intolerance.
pregnancy, and lactation.
Negative nitrogen balance indicates that the excretion

of nitrogen exceeds intake. The individual is receiving
insufficient protein, and the body is breaking down more
tissue than it is building, as seen during periods of illness,
trauma, aging, and malnutrition.
12 CHAPTER 2 Ingestion, Digestion, Absorption, and Metabolism CONTENT MASTERY SERIES

Application Exercises Active Learning Scenario
1. A nurse is discussing how the body processes food A nurse is conducting a nutritional program for a group
with a client during a routine provider’s visit. Which of of newly licensed nurses regarding how the body
the following statements should the nurse include? uses food for energy. Use the ATI Active Learning
Template: Basic Concept to complete this item.
A. Glycerol can be broken down into
glucose for use by the body. RELATED CONTENT: Describe the steps of
B. The liver converts unused glucose into glycogen. ingestion, digestion, and absorption.
C. Excess fatty acids are stored in the muscle tissue. UNDERLYING PRINCIPLES: Explain the two
D. The body uses glycogen for fat processes that occur during metabolism.
before using available ATP.
2. A nurse is reviewing prescribed medications for

a newly admitted client. Which of the following
medications increases the body’s rate of metabolism?
A. Morphine
B. Levothyroxine
C. Phenobarbital
D. Dilaudid
3. A charge nurse is conducting a nutritional class

for a group of newly licensed nurses regarding
basal metabolic rate (BMR). The charge nurse
should inform the class that which of the following
factors increases BMR? (Select all that apply.)
A. Lactation
B. Prolonged stress
C. Malnutrition
D. Puberty
E. Age older than 60 years
4. A school nurse is teaching a high school health class

about the possible causes of a negative nitrogen
balance. Which of the following causes should the
nurse include in the teaching? (Select all that apply.)
A. Illness
B. Malnutrition
C. Adolescence
D. Trauma
E. Pregnancy
NUTRITION FOR NURSING CHAPTER 2 Ingestion, Digestion, Absorption, and Metabolism 13

1. A. Excess glycerol is reassembled with fatty Using the ATI Active Learning Template: Basic Concept
acids into triglycerides.
RELATED CONTENT
B. CORRECT: The liver converts unused glucose into glycogen,
which is stored in the muscle tissue and liver for later use.
●
Ingestion is the process of taking in food by
C. Excess fatty acids are converted back to triglycerides mouth into the digestive system.
and stored in the adipose tissue.
●
Digestion involves the breakdown of food into
D. The body uses available ATP for growth and repair, and nutrients so they can be absorbed.
uses stored fat and glycogen if no ATP is available. ●
Absorption is the process by which nutrients pass through the
walls of the digestive system so they can be used by the body.
NCLEX Connection: Health Promotion and Maintenance,
®
Aging Process UNDERLYING PRINCIPLES

●
Catabolism is the process by which food is broken down into
small molecules to release heat and chemical energy.
2. A. Morphine is an opioid narcotic, which would ●
Anabolism is the formation of new body substances (tissue, bone).
decrease body metabolism.
B. CORRECT: Levothyroxine is used for the NCLEX® Connection: Physiologic Adaptation, Illness Management
treatment of hypothyroidism and increases
the body’s rate of metabolism.
C. Phenobarbital is a barbiturate medication, which
would decrease body metabolism.
D. Dilaudid is an opioid narcotic, which would
decrease body metabolism.
Illness Management
3. A. CORRECT: Include in the teaching that

lactation increases BMR.
B. CORRECT: Include in the teaching that
prolonged stress increases BMR.
C. Include in the teaching that malnutrition decreases BMR.
D. CORRECT: Include in the teaching that
puberty increases BMR.
E. Include in the teaching that being over 60
years of age decreases BMR.
NCLEX® Connection: Health Promotion and Maintenance,
Aging Process
4. A. CORRECT: Illness is a possible cause of

negative nitrogen balance.
B. CORRECT: Malnutrition is a possible cause
of negative nitrogen balance.
C. Adolescence is a possible cause of
positive nitrogen balance.
D. CORRECT: Trauma is a possible cause
of negative nitrogen balance.
E. Pregnancy is a possible cause of positive nitrogen balance.
Illness Management
14 CHAPTER 2 Ingestion, Digestion, Absorption, and Metabolism CONTENT MASTERY SERIES

CHAPTER 3
UNIT 1 PRINCIPLES OF NUTRITION DIET HISTORY
CHAPTER 3 Nutrition Assessment/ A diet history is an assessment of usual foods, fluids, and
Data Collection
supplements. The diet history is part of the nutrition
screening performed using various settings to determine
malnutrition issues. Components of the diet history
include the following.
Time, type, and amount of food eaten for breakfast,
Nurses play a key role in assessing the
●
lunch, dinner, and snacks

nutritional needs of clients. Nurses monitor ● Time, type, and amount of fluids consumed throughout
the day, including water, health drinks, coffee/tea,
and intervene with clients requiring acute and carbonated beverages, and beverages with caffeine
chronic nutritional care. Nurses should consider ● Type, amount, and frequency of “special foods”
(celebration foods, movie foods)
and incorporate the family’s nutritional habits ● Typical preparation of foods and fluids (coffee with
into a client’s individual plan of care. Nurses sugar, fried foods)
Number of meals eaten away from home (at work
should take an active role in assessing and
●
or school)
teaching community groups regarding nutrition. ● Type of preferred or prescribed diet (ovo‑lacto
vegetarian, 2 g sodium/low‑fat diet)
A collaborative, interprofessional approach ● Foods avoided due to allergy or preference
Frequency and dose/amount of medications or
provides the best outcomes for the client.
●
nutritional supplements taken daily

Providers and nurses collect physical assessment ● Satisfaction with diet over a specified time frame
(last 3 months, 1 year)
data, as well as serving as liaison between the
health care team and the dietitian. Registered
dietitians complete comprehensive nutritional TOOLS TO DETERMINE
NUTRITIONAL STATUS
assessments. Nurses monitor and evaluate A physical assessment is performed by the provider or
interventions provided to clients. nurse to identify indicators of inadequate nutrition.
However, other diseases or conditions can cause these
A client’s physical appearance can be clinical findings.
deceiving. A client who has a healthy weight MANIFESTATIONS

Hair that is dry or brittle, or skin that has dry patches
and appearance can be malnourished. Cultural,
●
● Poor wound healing or sores

social, and physical norms must be part of ● Lack of subcutaneous fat or muscle wasting
Irregular cardiovascular measurements (heart rate and
a client’s assessment. Even with adequate
●
rhythm, blood pressure)

client education, personal preferences ● Enlarged spleen or liver
General weakness or impaired coordination
can be an overriding factor to successful
●
nutritional balance.
NUTRITION FOR NURSING CHAPTER 3 Nutrition Assessment/Data Collection 15

ANTHROPOMETRIC TOOLS CLINICAL VALUES
Weight Fluid I&O
● Weigh at the same time of day wearing similar clothing ● Adults: 2,000 to 3,000 mL (2 to 3 L) per day
to ensure accurate weight readings. ● Total average output: 1,750 to 3,000 mL/day
● Daily fluctuations generally are indicative of water
Protein levels are usually measured by albumin levels,
weight changes.
although total protein is sometimes used.
● Percentage weight change calculation (weight change ● Many non-nutritional factors (injury, kidney disease),
over a specified time):
interfere with this measure for protein malnutrition.
(usual weight ‑ present weight) Expected reference range for albumin: 3.5 to 5 g/dL
% weight change = × 100 ●
usual weight
Prealbumin(thyroxine‑binding protein) is a sensitive
● Ideal body weight based on the Hamwi method using measure used to assess critically ill clients who are at risk
height/weight calculation. for malnutrition. This test reflects acute changes rather
◯ MALES: 48 kg (106 lb) for the first 152 cm (5 ft) than gradual changes. However, it is more expensive and
of height, and 2.7 kg (6 lb) for each additional often unavailable. This is not part of routine assessment.
2.5 cm (1 in). ● Prealbumin levels can decrease with an inflammatory
◯ FEMALES: 45 kg (100 lb) for the first 152 cm (5 ft) process resulting in an inaccurate measurement.
of height, and 2.3 kg (5 lb) for each additional ● Prealbumin levels are used to measure effectiveness of
2.5 cm (1 in). total parenteral nutrition.
● During illness, weight loss is monitored to prevent or ● Expected reference range is 15 to 36 mg/dL. (Less than
detect malnutrition. 10.7 mg/dL indicates severe nutritional deficiency.)
◯ With starvation or chronic disease, weight loss
Nitrogen balancerefers to the relationship between

indicating severe malnutrition: greater than
protein breakdown (catabolism) and protein
5%/month, greater than 7.5%/3 months, greater than
synthesis (anabolism).
10%/6 months, greater than 20%/year ● To measure nitrogen balance
◯ With acute disease or injury, weight loss indicating
◯ Record protein intake (g) over 24 hr and divide by 6.25.
severe malnutrition: greater than 2%/week, greater ◯ Record nitrogen excretion in urine over 24 hr
than 5%/month, greater than 7.5%/3 months

and add 4 g.
Height ◯ Subtract nitrogen output from nitrogen intake.
● Measure on a vertical, flat surface. Ask the client to ◯ 24 hr protein intake ÷ 6.25 = nitrogen intake (g)
remove shoes and head coverings and stand straight ◯ 24 hr urinary urea nitrogen + 4 g = total nitrogen output
with heels together looking straight ahead. Read the

Nitrogen intake ‑ total nitrogen
measurement to the nearest 0.1 cm or 1/8 inch.
output = nitrogen balance
● Obtain a recumbent measurement (lying on a firm, flat
surface) for infants and young children. ● A neutral nitrogen balance indicates adequate
nutritional intake.
Body mass index (BMI) ● A positive nitrogen balance indicates protein synthesis
BMI measurements compare the weight to height to
is greater than protein breakdown as during growth,
estimate the effect of the individual’s body weight. Client
pregnancy, or during recovery.
factors should be considered when determining the ● A negative nitrogen balance indicates protein is used at
value of BMI measurement. For example, a client who
a greater rate than it is synthesized as in starvation or a
has large muscle mass compared to height can have an
catabolic state following injury or disease.
increased BMI, since weight can be influenced by both
fat and muscle, or a client with a normal BMI might have
Obesity
excess body fat.
● Healthy weight is indicated by a BMI of 18.5 to 24.9.
● Underweight is indicated by a BMI less than 18.5.
Approximately 36.5% of American adults have obesity, and
● Overweight is defined as an increased body weight in
an estimated 68.5% have obesity or are overweight.
relation to height. It is indicated by a BMI of 25 to 29.9, ● Obesity is a chronic condition caused by calorie intake
and are about 20% above desirable levels.
in excess of energy expenditure. It can be affected by
● Obesity is indicated by a BMI greater than or equal to 30.
numerous factors (culture, metabolism, environment,
BMI = weight (kg) ÷ height (m2) socioeconomics, individual behaviors).
● Obesity might be linked to protective measures
within the body to prevent weight loss during calorie
restriction, which cause it to secrete hormones that
stimulate the appetite to maintain a specific weight. As
weight increases, the body accepts a higher weight as
the expected weight and seeks to maintain it.
16 CHAPTER 3 Nutrition Assessment/Data Collection CONTENT MASTERY SERIES

ASSESSMENT Phentermine-topiramate
Suppresses the appetite and induces a feeling of satiety.
RISK FACTORS ADVERSE EFFECTS: Dry mouth, constipation, nausea,
● Genetic predisposition change in taste, dizziness, insomnia, numbness and
● Hormones (leptin, ghrelin) tingling of extremities
● Behavioral factors (sedentary lifestyle, diet choices)
CONTRAINDICATIONS: Hyperthyroidism, glaucoma,
taking an MAO inhibitor
EXPECTED FINDINGS
Clients report of depression, low self-esteem, avoidance of INTERPROFESSIONAL CARE
health-related appointments, and no desire to exercise as
The care team can include a health care provider, nursing
a result of feeling stigmatized by their excessive weight
team, dietitian, social worker, surgeon, and mental health
Body mass index therapist or counselor.
● Overweight: 25 to 29.9
Obesity: 30 or greater
NURSING CARE
●
Waist circumference ● Maintain low-Fowler’s position to maximize

● Females: greater than 88.9 cm (35 in)
chest expansion.
● Males: greater than 101.6 cm (40 in) ● Monitor respiratory status frequently and include pulse
Waist-to-hip ratio (WHR) oximetry continuously.
● Measurement of difference between peripheral lower ● Supplement oxygen as needed.
body obesity and central obesity ● Monitor blood pressure, using an appropriately-sized
● Can be used as a predictor of coronary artery disease cuff for accurate readings.
● Indicates excess fat at the waist and abdomen ● Monitor frequently for medication adverse effects.
◯ Males: 0.95 or greater ● Use bariatric equipment (lifts, transport equipment,
◯ Females: 0.8 or greater beds) to assist in mobility as needed.
CLIENT EDUCATION: Follow the prescribed diet from the

LABORATORY TESTS provider or dietitian to prevent complications of obesity.
● Screening to evaluate for cardiovascular disease, diabetes
mellitus, fatty liver disease, or thyroid disorders SURGICAL INTERVENTIONS
● Total cholesterol
● Triglycerides Bariatric surgery
● Fasting blood glucose
SEE AMS CHAPTER 47: GASTROINTESTINAL THERAPEUTIC
● Glycosylated hemoglobin
PROCEDURES.
● Aspartate aminotransferase (AST)
● Alanine aminotransferase (ALT)
COMPLICATIONS
PATIENT-CENTERED CARE ● Obesity increases the risk for dyslipidemia, diabetes
mellitus type 2, vascular disease, gallbladder disease,
hypertension, osteoarthritis, respiratory problems,
MEDICATIONS some cancers, and sleep apnea.
● Clients who do not lose weight during weight loss ● Obesity also increases the risk for perioperative
programs can benefit from pharmacological therapy. complications and complications during pregnancy,
● Anorectic medications suppress appetite and reduce food labor, and delivery.
intake. When combined with an exercise program, they
can result in weight loss. Reduced life expectancy
For class I obesity, life expectancy is reduced by 2
Orlistat
●
to 4 years.
Prevents digestion of fats ● For BMI 40 to 50, life expectancy is reduced by 8
to 10 years.
ADVERSE EFFECTS: Oily discharge; reduced food and
vitamin absorption; decreased bile flow; loose, oily stools;
Other complications
abdominal cramps; fecal incontinence
Nonalcoholic fatty liver disease, polycystic ovary
Lorcaserin syndrome, gastroesophageal reflux disease
Stimulates serotonin receptors in the hypothalamus in the

brain to curb appetite
ADVERSE EFFECTS: Headache, dry mouth, fatigue, nausea

RISK FACTORS FOR EFFECT OF RISK FACTORS ON
INADEQUATE NUTRITION NUTRITIONAL STATUS
BIOPHYSICAL FACTORS The following are examples of how risk factors can affect
● Medical disease/conditions (hypertension, HIV/AIDS) nutritional status.
● Preventive measures or disease treatments, including ● A client who has edema can require treatment with
surgery or use of medications and supplements. a diuretic and low‑sodium diet. Diuretics can cause
● Genetic predisposition (lactose intolerance, osteoporosis) sodium and potassium imbalances. A low‑sodium diet
● Age can be unappetizing and cause the client to eat less.
● Osteoporosis has many modifiable risk factors. A client
PSYCHOLOGICAL FACTORS
who takes action to prevent osteoporosis (increasing
● Mental illness (clinical depression)
intake of vitamin D and calcium, engaging in weight-
● Excessive stress
bearing exercise, reducing use of tobacco and alcohol
● Negative self‑concept
products) will positively affect their nutritional status.
● Use of comfort foods ● Poor self‑concept can cause a client to avoid eating or
SOCIOECONOMIC FACTORS to overeat.
● Poverty
NURSING ACTIONS
● Alcohol and other substance use disorders ● In addition to determining the client’s nutrient and
● Fad or “special” diets
calorie intake, assess other factors that might alter
● Food preferences: cultural, ethnic, or religious
nutrient intake.
● Consult with the provider to see if the client’s medical
Active Learning Scenario treatment plan needs to be altered to improve nutrition,
such as administering a different medication to prevent
A community health nurse is conducting a dietary the adverse effect of anorexia, or adding a medication to
assessment for a client. Use the ATI Active Learning treat nausea or improve appetite.
Template: Basic Concept to complete this item. ● Plan the client’s schedule of activities to prevent
interruptions during mealtime, and to avoid fatigue,
UNDERLYING PRINCIPLES: Describe four
nausea, or pain before meals.
components of a diet history.
Application Exercises
1. A nurse in a nutrition clinic is calculating body mass 3. A nurse is performing a nutrition assessment on a
index (BMI) for several clients. The nurse should identify client. Which of the following clinical findings are
which of the following client BMIs as overweight? suggestive of malnutrition? (Select all that apply.)
A. 24 A. Poor wound healing
B. 30 B. Dry hair
C. 27 C. Blood pressure 130/80 mm Hg
D. 32 D. Weak hand grips
E. Impaired coordination
2. A nurse on an orthopedic unit is reviewing data for
a client who sustained trauma in a motor‑vehicle 4. A nurse is teaching a group of female clients
crash. Which of the following values indicates about risk factors for developing osteoporosis.
the client is in a catabolic state (using protein Which of the following risk factors should the
faster than protein is being synthesized)? nurse include? (Select all that apply.)
A. Blood albumin 3.5 g/dL A. Inactivity
B. Negative nitrogen balance B. Family history
C. BMI of 18.5 C. Obesity
D. Blood prealbumin 15 mg/dL D. Hyperlipidemia
E. Cigarette smoking

1. A. A healthy weight is indicated by a BMI of 18.5 to 24.9. Using the ATI Active Learning Template: Basic Concept
B. Obesity is an excess amount of body fat indicated UNDERLYING PRINCIPLES: A diet history is an
by a BMI greater than or equal to 30. assessment of usual foods, fluids, and supplements.
C. CORRECT: Overweight is defined as an increased body ●
Time, type, and amount of food eaten for
weight in relation to height, indicated by a BMI of 25 to 29.9. breakfast, lunch, dinner, and snacks.
D. Obesity is an excess amount of body fat indicated ●
Time, type, and amount of fluids consumed throughout
by a BMI greater than or equal to 30.
the day including water, health drinks, coffee/tea,
NCLEX Connection: Basic Care and Comfort,
®
carbonated beverages, and beverages with caffeine.
Type, amount, and frequency of “special foods”
(celebration foods, movie foods).
●
Typical preparation of foods and fluids
2. A. Blood albumin levels reflect slow changes in protein
(coffee with sugar, fried foods).
levels, not acute. An albumin level of 3.5 g/dL or 4.5 g/
dL is within the expected reference range.
●
Number of meals eaten away from home (at work or school).
B. CORRECT: A negative nitrogen balance indicates protein is ●
Type of diet (ovo‑lacto vegetarian, 2 g sodium/low‑fat diet).
used at a greater rate than it is synthesized as in starvation ●
Foods avoided due to allergy or preference.
or a catabolic state following injury or disease. ●
Frequency and dose/amount of medications or
C. A BMI of 18.5 indicates an ideal body weight. nutritional supplements taken daily.
D. A blood prealbumin of 15 mg/dL is within ●
Satisfaction with diet over a specified time
the expected reference range. frame (last 3 months, year).
NCLEX® Connection: Reduction of Risk Potential, NCLEX® Connection: Health Promotion and Maintenance,
Laboratory Values Health Screening
3. A. CORRECT: Poor wound healing describes

changes reflective of malnutrition.
B. CORRECT: Dry hair describes changes
reflective of malnutrition.
C. A blood pressure value of 130/80 mm Hg is
an expected cardiovascular finding and is
not associated with malnutrition.
D. CORRECT: Weak hand grips describe
E. CORRECT: Impaired coordination describes
4. A. CORRECT: There is an increased risk for osteoporosis

due to inactivity. Weight‑bearing exercises are
a primary prevention measure.
B. CORRECT: A family history of osteoporosis is a risk factor.
C. Weight loss can cause a decreased intake of dietary calcium
and vitamin D, leading to the development of osteoporosis.
D. Hyperlipidemia is not a risk factor for the
development of osteoporosis in females.
E. CORRECT: Cigarette smoking can increase
the incidence of osteoporosis.
Health Promotion/Disease Prevention

CHAPTER 4
UNIT 1 PRINCIPLES OF NUTRITION ◯ Consume a minimum of five servings per day of
Guidelines for fiber‑rich fruits and vegetables to in order to decrease

CHAPTER 4 risk factors for some cancers. The vitamin and
Healthy Eating mineral content of these foods can also decrease the
risk of DNA damage.
◯ Choose monounsaturated and polyunsaturated fats
from fish, lean meats, nuts, and vegetable oils. Fat
Nutrition is vital to maintaining optimal health. intake can average 30% of total caloric intake with
a goal of less than 7% from saturated fats. While
Healthy food choices and controlling weight progressing toward the 7% goal, individuals should
are important steps in promoting health and try to consume less than 10% of intake from saturated
fats, and progress to 7% or less over time.
reducing risk factors for disease. ◯ Limit sugar and starchy foods to decrease the risk of
dental caries.
Nurses should encourage favorable nutritional ◯ Consume less than 2,300 mg/day (about 1 tsp) of
choices and can serve as informational resources salt by limiting most canned and processed foods.
Prepare foods without adding salt. Middle‑aged
for clients regarding guidelines for healthy eating. and older adults benefit even more from a diet with
1,500 mg/day or less of sodium.
Established guidelines for healthy eating that ◯ Drink alcohol in moderation: up to one drink per day
clients and nurses can refer to include the Dietary for females and two per day for males. Some medical
conditions, medication therapies, and physical
Guidelines for Americans and MyPlate, along with a activities preclude the use of alcohol.
number of condition‑ or system‑specific guidelines. ◯ Eating at least 12 oz seafood from a variety of sources
is beneficial for individuals older than age 12 years

Vegetarian diets can meet all nutrient who are not pregnant or nursing. Observe local
seafood advisories closely, and limit consumption of
recommendations. It is essential to consume large, predatory fish.
a variety and correct amount of foods to meet ◯ Follow food safety guidelines when preparing,
cooking, and storing food. Avoid consumption of raw

individual caloric needs. eggs and unpasteurized milk and juices.
● These strategies are beneficial for cooking foods at home.
◯ When using convenience foods or boxed meals, add
DIETARY GUIDELINES FOR AMERICANS healthy ingredients (frozen vegetables, canned legumes)
● The U.S. Department of Agriculture (USDA) and the to increase the volume of food and add nutrition.
U.S. Department of Health and Human Services (HHS) ◯ Decrease the amount of salt or seasonings containing
publish the Dietary Guidelines for Americans sodium when cooking.

jointly every 5 years. These guidelines are based on ◯ Buy side items that increase the nutritional value
evidence‑based advice concerning food intake and of meals (packaged salad kits, pre-cut fruit,
physical activity for Americans older than 2 years of age, whole‑grain bread).
including those at risk for chronic disease. The updates ● When eating out, these strategies can help meet
can be found on the USDA and health‌.‌gov websites. nutritional guidelines.
● The Dietary Guidelines for Americans advocates healthy ◯ Eat a high-fiber snack 1 hour before leaving to eat.
food selections: a variety of fiber‑rich fruits and It is easier to make healthier food choices when not
vegetables, whole grains, low‑fat or fat‑free milk and really hungry.
milk products, lean meats, poultry, fish, legumes, eggs, ◯ If one meal out is going to be high-calorie, make the
and nuts. Recommendations include nutrient‑dense other meals of the day lower in calories and high in
foods and beverages. nutrients and fiber to provide balance.
◯ Balance energy intake with energy expenditure by ◯ Watch for components that add fat content to the meal
selecting a wide variety of foods, and limiting saturated (fatty meats, nuts, creams, gravies and sauces with
and trans saturated fat, sugars, sodium, and alcohol. whole milk, fatty salad dressings). Asking for these
◯ Establish exercise routines to promote cardiovascular items on the side can reduce the amount consumed.
health, muscle strength and endurance, and ◯ Pick restaurants that offer healthy options.
psychological well‑being.
NUTRITION FOR NURSING CHAPTER 4 Guidelines for Healthy Eating 21

Online Video: Understanding Food Labels
MYPLATE
The USDA sponsors a website that promotes healthy 4.1 MyPlate
food choices balanced with physical activity
(www‌.‌c hoosemyplate‌.‌gov). MyPlate is based on the current
USDA dietary guidelines, and is a tool to help individuals
identify daily amounts of foods based on criteria (age, sex,
activity level). The food groups represented are grains,
vegetables, fruit, dairy, oils, and protein foods.
MyPlate can serve as a reminder to balance calorie intake

with suitable activity.
● Adults should engage in at least 2.5 hr/week of
moderate‑level aerobic physical activity or 1.25 hr/week

of vigorous aerobic physical activity.
● Children and adolescents should be physically active for
60 min/day, the majority of which should be moderate or
vigorous aerobic physical activity, but developmentally
appropriate and fun. Children should engage in muscle
strengthening activities at least 3 days/week. Activity
levels can be met in short periods of activity throughout
the day instead of a sustained 60 min.
● The MyPlate image and information sheet are available
in multiple languages to assist with client education. NUTRIENTS INCLUDED ON THE FOOD LABEL
● Calories
● Calories from fat
VEGETARIAN DIETS ● Total fat
● Saturated fat
● A vegetarian diet focuses on plants for food, including ● Trans fat
fruits, vegetables, dried beans and peas, grains, ● Cholesterol
seeds, and nuts. There is no single type of vegetarian ● Sodium
diet. Vegetarian eating patterns usually fall into the ● Total carbohydrates
following groups. ● Dietary fiber
◯ Vegan diet excludes all meat and animal products.
● Sugars
◯ Lacto vegetarian diet includes dairy products. ● Protein
◯ Lacto‑ovo vegetarian diet includes dairy ● Vitamin D
products and eggs. ● Potassium
● People who follow vegetarian diets can get all the ● Calcium
nutrients they need, but they must be careful to eat a ● Iron
wide variety of foods to meet their nutritional needs. It ● Foods marketed as functional foods might be whole
is important to discuss ensuring enough vitamin D and
foods or foods with additives (herbs, minerals). These
B12, calcium, and omega‑3 fatty acids are consumed by
foods are often advertised as having the ability to
clients who follow a vegan diet.
prevent or promote disease. There is no regulation
regarding functional foods at this time.
Organic food products are regulated under the USDA.
FOOD LABELS
●
◯ Organic foods are produced without the use of

● The Food and Drug Administration (FDA) requires pesticide or synthetic fertilizer.
certain information be included with packaged foods ◯ Organic livestock must be fed organic feed during
and beverages. The information is included on the pregnancy for a specific time period and cannot receive
nutrition facts label or food label, which is a boxed label growth hormones, antibiotics, or other medications.
found on foods and beverages. Food labels must include ● Organic foods might help prevent pathogen resistance
single serving size, number of servings in the package, to antibiotics. While they reduce exposure to pesticides,
percent of daily values, and the amount of each nutrient there is no evidence that it has a healthy effect. Clarify
in one serving. misinformation about these foods with clients.
● The Percent Daily Values information is typically based
CLIENT EDUCATION
on a 2,000 calorie/day diet, but for certain nutrients and ● Read food labels properly (comparing nutrient, calorie,
food components can be based on 2,500 calorie/day.
fat, and sodium levels) to ensure individual nutritional
needs are met, and healthy choices are made.
● Goods that are genetically engineered or contain
genetically modified organisms (GMO) have not been
proven harmful.
22 CHAPTER 4 Guidelines for Healthy Eating CONTENT MASTERY SERIES

4.2 MyPlate recommended servings
RECOMMENDED DAILY SERVINGS FOOD SOURCES
Grains
Whole grains should equal half of the grains eaten.
Children Females Males One slice bread = 1 oz
2 to 3 years: 3 oz 9 to 13 years: 5 oz 9 to 13 years: 3 oz 1 cup flake cereal = 1 oz
4 to 8 years: 5 oz 14 to 50 years: 6 oz 14 to 18 years: 4 oz ½ cup cooked pasta = 1 oz
51 years and older: 5 oz 19 to 30 years: 8 oz 1 6‑inch flour tortilla = 1 oz
31 to 50 years: 7 oz
51 years and older: 6 oz
Vegetables
Vegetables include raw, cooked, frozen, canned, dried, or 100% juice. Broccoli, carrots, pumpkin,
tomato juice, peas, corn,
potatoes, onions, mushrooms
Children Females Males
2 to 3 years: 1 cup 9 to 13 years: 2 cups 9 to 13 years: 2.5 cups
4 to 8 years: 1.5 cups 14 to 50 years: 2.5 cups 14 to 50 years: 3 cups
51 years and older: 2 cups 51 years and older: 2.5 cups
Fruits
Fruits include fresh, frozen, canned, dried, or 100% juice.
Children Females Males One small banana = ½ cup serving
2 to 3 years: 1 cup 9 to 18 years: 1.5 cups 9 to 13 years: 1.5 cups One small orange = ½ cup serving
4 to 8 years: 1 to 1.5 cups 19 to 30 years: 2 cups 14 years and older: 2 cups ¼ cup dried apricots = ½ cup serving
31 years and older: 1.5 cups
Dairy
Dairy selections should include reduced‑fat or fat‑free options. Higher‑fat options are Milk, yogurt, cheese, pudding,
counted as part of daily calories from solid fats and added sugars (i.e., empty calories). ice cream, soy milk
Children Females and Males ¼ cup evaporated milk = 1 cup serving
2 to 3 years: 2 cups 9 years and older: 3 cups ½ cup shredded cheese = 1 cup serving
4 to 8 years: 2.5 cups 1.5 oz hard cheese = 1 cup serving
½ cup ricotta cheese = 1 cup serving
2 cups cottage cheese = 1 cup serving
1.5 cups ice cream = 1 cup serving
Proteins
Protein requirements can increase with physical activity. Selection should Meats (beef, pork), poultry, eggs,
include lean or low‑fat proteins. Higher fat options are counted as part of kidney beans, soy beans, seafood,
daily calories from solid fats and added sugars (i.e., empty calories). nuts and seeds, peanut butter
Children Females Males One small chicken breast = 3 oz
2 to 3 years: 2 oz 9 to 18 years: 5 oz 9 to 13 years: 5 oz 1 can drained tuna = 3 to 4 oz
4 to 8 years: 4 oz 19 to 30 years: 5.5 oz 14 to 30 years: 6.5 oz One egg = 1 oz
31 years and older: 5 oz 31 to 50 years: 6 oz ¼ cup cooked beans = 1 oz
51 years and older: 5.5 oz ½ oz seeds or nuts = 1 oz
Oils
Children Females Males Vegetable oils (canola, corn,
2 to 3 years: 3 tsp 9 to 18 years: 5 tsp 9 to 13 years: 5 tsp olive, peanut, safflower, soybean,
sunflower), mayonnaise, some salad
4 to 8 years: 4 tsp 19 to 30 years: 6 tsp 14 to 18 year: 6 tsp dressings, avocado, nuts and seeds
31 years and older: 5 tsp 19 to 30 years: 7 tsp Avocados and olives are also part
31 years and older: 6 tsp of the vegetable food group.
Nuts and seeds are also part
of the protein food group.

STRATEGIES FOR PROMOTION OF Bowel function
SPECIFIC AREAS OF HEALTH ● Normal bowel functioning depends on adequate fluid
intake and 25 g/day of fiber for females, and 38 g/day
Heart
for males.
● Limit saturated fat to 10% of calories. Consume as little ● The minimum number of servings from MyPlate’s fruit,
cholesterol in the diet as possible, as long as it does not vegetable, and grain food groups (specifically whole
hinder a healthy eating pattern. grains) provides the essential nutrients.
● For individuals with elevated low density lipoprotein
(LDL), the American Heart Association (AHA) Cancer prevention
recommends increasing monounsaturated fats and ● A well‑balanced diet using MyPlate and a healthy weight
soluble fiber.
are guidelines to prevent cancer.
● The Dietary Approaches to Stop Hypertension (DASH) ● Increase high‑fiber plant‑based foods.
diet is proven by research to significantly lower systolic ● Limit saturated and trans fat, while emphasizing foods
and diastolic blood pressure.
with polyunsaturated fats (omega‑3 fatty acids).
Limit sodium intake.
Nervous system
●
● Avoid excess alcohol intake.

● Normal functioning of the nervous system depends on ● Include regular physical activity.
adequate levels of the B‑complex vitamins, especially
thiamin, niacin, and vitamins B6 and B12.
● Calcium and sodium are important regulators of nerve
responses. Consuming the recommended servings
from the grain and dairy food groups provides
these nutrients. Active Learning Scenario
Bones A community health nurse is conducting a nutritional class
● Consuming the recommended servings from the regarding cancer prevention strategies. Use the ATI Active
MyPlate’s dairy group supplies the calcium, magnesium, Learning Template: Basic Concept to complete this item.
and phosphorus necessary for bone formation.
RELATED CONTENT: Describe four components
● Weight‑bearing physical activity is essential to decrease recommended to prevent cancer.
the risk of osteoporosis.
1. A nurse is providing teaching to a client who follows 3. A nurse is discussing essential nutrients for
vegan dietary practices. The nurse should instruct the normal functioning of the nervous system with a
client that there is a risk of having a deficit in which client. Which of the following should the nurse
of the following nutrients? (Select all that apply.) include in the teaching? (Select all that apply.)
A. Vitamin D A. Calcium
B. Fiber B. Thiamin
C. Calcium C. Vitamin B6
D. Vitamin B12 D. Sodium
E. Whole grains E. Phosphorus
2. A nurse is conducting a nutrition class at a local 4. A school nurse is teaching a group of students how to
community center. Which of the following information read food labels. Which of the following is a required
should the nurse include in the teaching? component of food labels that the nurse should
A. Progress toward limiting saturated include in the teaching? (Select all that apply.)
fat to 7% of total daily intake. A. Total carbohydrates
B. Good bowel function requires B. Total fat
35 g/day of fiber for females. C. Calories
C. Limit cholesterol consumption to 400 mg/day. D. Magnesium
D. Normal functioning cardiac systems E. Dietary fiber
depends on B‑complex vitamins.

1. A. CORRECT: Instruct the client to ensure an adequate Using the ATI Active Learning Template: Basic Concept
consumption of vitamin D because most dietary vitamin D is RELATED CONTENT
consumed via fortified milk products. The vegan diet includes
plant foods, and excludes all animal‑derived products. A well‑balanced diet using the MyPlate and a healthy
B. Because the vegan diet consists of plant foods, weight are guidelines to prevent cancer.
adequate fiber consumption is not a concern. ●
Increase high‑fiber plant‑based foods.
Fiber is found primarily in plants. ●
Limit saturated and polyunsaturated fat while emphasizing foods
C. CORRECT: Instruct the client to monitor and ensure an with monounsaturated fat or omega‑3 fatty acids (nuts and fish).
adequate consumption of calcium because there are ●
Limit sodium intake.
few good sources of calcium from plant sources. The ●
Avoid excess alcohol intake.
vegan diet excludes all animal‑derived products. ●
Include regular physical activity.
D. CORRECT: Instruct the client to ensure they are
consuming adequate vitamin B12 because all reliable NCLEX® Connection: Health Promotion and Maintenance,
sources of vitamin B12 are in animal products. The Health Promotion/Disease Prevention
vegan diet excludes all animal‑derived products.
E. Because the vegan diet consists of plant foods,
adequate consumption of whole grains is not a concern.
Grains are included as part of the vegan diet.
2. A. CORRECT: Include for the clients to progress toward

limiting saturated fat to 7% of total daily intake.
B. Good bowel function requires 25 g/day of fiber
for females, and 38 g/day for males.
C. Cholesterol consumption should be limited
to between 200 and 300 mg/day.
D. Normal functioning nervous system, instead of
cardiac, depends on B‑complex vitamins.
3. A. CORRECT: Calcium is an important

regulator of nerve responses.
B. CORRECT: Normal functioning of the nervous system
depends on adequate levels of the B‑complex vitamins,
especially thiamin, niacin, and vitamins B 6 and B12.
C. CORRECT: Normal functioning of the nervous system
depends on adequate levels of the B‑complex vitamins,
especially thiamin, niacin, and vitamins B 6 and B12.
D. CORRECT: Sodium is an important
regulator of nerve responses.
E. Phosphorus helps maintain acid‑base balance, as
well as formation of bone and teeth, and does not
directly affect functioning of the nervous system.
4. A. CORRECT: The Food and Drug Administration

(FDA) requires certain information be included
with packaged foods and beverages. Total
carbohydrates are included on food labels.
B. CORRECT: Food labels must include single serving
size, number of servings in the package, percent of
daily values, and the amount of each nutrient in one
serving. Total fat is included on food labels.
C. CORRECT: Calories are included on food labels.
D. Magnesium is not included on food labels.
E. CORRECT: Dietary fiber is included on food labels.
Aging Process

CHAPTER 5
UNIT 1 PRINCIPLES OF NUTRITION Fruits and vegetables: Refrigerate perishable fruits and
Food Safety vegetables at 40° F (4° C). All pre‑cut and pre‑peeled fruits
CHAPTER 5 and vegetables should also be refrigerated.
Perishables: Do not leave at room temperature for more

than 2 hr (1 hr if the temperature is 90° F [32° C] or above).
Food safety is an important concept in nursing.
Canned goods: Check for rusting, crushing, and denting.
It is essential to provide clients with the
Observe for stickiness on the outside of can, which
necessary education regarding food safety and can indicate leakage. Do not use any canned foods that
are damaged.
food‑medication interactions.
Food safety concerns include preventing HANDLING GUIDELINES

aspiration of food, reducing the risk of ● Wash hands and food preparation surfaces frequently,
and before handling food.
foodborne illness, assessing for food allergies, ● Separate foods to avoid cross‑contamination.
and understanding food‑medication interactions.
PREPARATION GUIDELINES
FOOD SAFETY GUIDELINES Cook food to the proper temperature followed by a 3‑min
rest time.
Ingestion of food poses a risk of aspiration in ● Roasts and steaks: 145° F (63° C)
some circumstances. ● Chicken: 165° F (74° C)
● To minimize the risk of aspiration, food should be ● Ground beef: 160° F (71° C)
consumed only by individuals who are conscious and ● Products that contain eggs: 160° F (71° C)
have an intact gag or swallow reflex.
● For clients who have a known risk of aspiration PACKAGING LABELS
(following a stroke or a procedure involving anesthesia ● Sell‑by date: The final recommended day of sale.
of the esophagus), it is important for nurses to monitor ● Use‑by date: How long the product will maintain
the client’s ability to swallow prior to eating. top quality.
● Young children are at an increased risk for aspiration of ● Expiration date: The final day the product should be
some foods. used or consumed.
FOOD SAFETY REQUIREMENTS

Proper food storage
FOODBORNE ILLNESS
●
● Proper handling
● Proper preparation Foodborne illnesses occur due to improper storage of food
products, as well as unsafe handling and preparation. In
order to decrease the incidence of foodborne illnesses,
FOOD STORAGE GUIDELINES primary education should be conducted by nurses. Proper
Fresh meat: Maintain refrigerator temperature at 40° F handing and preparation is simple and includes
(4° C) or colder. performing frequent hand hygiene. It is important to
● Bacon: 7 days refrigerate food products when necessary, and to avoid
● Sausage (pork/chicken/beef/turkey): 1 to 2 days cross‑contamination when preparing food. Food should be
● Summer sausage: 3 months (unopened); 3 weeks (opened) heated to recommended temperatures to kill unwanted
● Steaks, chops, roasts (beef, veal, lamb, or pork): 3 to 5 days bacteria. Following these basic principles can prevent the
● Chicken or turkey (whole/parts): 1 to 2 days occurrence of foodborne illnesses.
● Fish: Maintain refrigerator temperature at 40° F (4° C) ● Foodborne illnesses pose the greatest risk to children,
or colder. older adults, immunocompromised clients, and
◯ Lean or fatty: 1 to 2 days pregnant clients.
◯ Smoked: 14 days ● Viruses cause the majority of foodborne illnesses, but
◯ Fresh shellfish: 1 to 2 days bacteria are responsible for the majority of deaths
◯ Canned: 3 to 4 days (after opening); 5 years (pantry) caused by foodborne illness.
● Foods most commonly associated with foodborne illness
Eggs: Store in the refrigerator for 4 to 5 weeks in shell,
are the following.
and 1 week if hard‑boiled. ◯ Raw or undercooked foods of animal origin
◯ Raw fruits and vegetables contaminated with
animal feces
◯ Raw sprouts
◯ Unpasteurized fruit juice and milk products
◯ Uncooked food handled by someone who is ill
NUTRITION FOR NURSING CHAPTER 5 Food Safety 27

COMMON FOODBORNE ILLNESSES Foods can alter the absorption of medications.
● Increased absorption: Improves the peak effects of
Bacterial some drugs when taken with food.
● Decreased absorption: Food can decrease the rate and
Salmonella: Occurs due to eating undercooked or raw
extent of absorption.
meat, poultry, eggs, fish, fruit, and dairy products. ◯ Reducing the rate of absorption delays the onset of
Common manifestations include headache, fever,

peak effects.
abdominal cramping, diarrhea, nausea, and vomiting. This ◯ Reducing the extent of absorption reduces the
condition can be fatal.

intended effect of the medication.
Escherichia coli 0157:H7: Raw or undercooked meat,
Some medications cause gastric irritation. It is important
especially ground beef, can cause this foodborne pathogen.
to take those medications (ibuprofen, amoxicillin, some
Findings include severe abdominal pain and diarrhea.
antidepressants [bupropion]) with food to avoid gastric upset.
The pathogen can also cause hemolytic uremic syndrome,
which manifests as severe anemia and kidney failure. Some foods alter the metabolism/actions of medications.
● Grapefruit juice interferes with the metabolism of many
Listeria monocytogenes: Soft cheese, raw milk products,
medications, resulting in an increased blood level of
undercooked poultry, processed meats, and raw vegetables
the medication.
can cause the illness. Listeria monocytogenes causes ● Foods high in vitamin K (dark green vegetables, eggs,
significant problems for newborns, pregnant clients, and
carrots) can decrease the anticoagulant effects of warfarin.
immunocompromised clients. Onset occurs with the ● Foods high in protein can increase the metabolism
development of a sudden fever, diarrhea, headache, back
of the anti‑Parkinson’s medication levodopa, which
pain, and abdominal discomfort. It can lead to stillbirth
decreases the medication’s absorption and amount
or miscarriage.
transported to the brain.
Tyramine is a naturally occurring amine found in many
Viral
●
foods that has hypertensive effects similar to other

Norovirus: A viral infection caused by consuming amines (norepinephrine). Tyramine is metabolized
contaminated fruits and vegetables, salads prepared by by MAO, and clients taking MAOIs (phenelzine,
someone who is infected, oysters, and contaminated water. selegiline) who consume foods high in tyramine can
Norovirus is very contagious, and has an onset of 24 to suffer a hypertensive crisis. Foods high in tyramine
48 hr. Manifestations include projectile vomiting, fever, include aged cheese, smoked meats, dried fish, and
myalgia, watery diarrhea, and headache. overripe avocados.
● Herbal supplements can cause potential interactions
with prescribed medications. It is important that any
FOOD ALLERGIES herbal medication consumed by a client be discussed
with the provider.
Nutritional assessment/data collection includes
identification of food allergies. A food allergy is a reaction
that will occur each time the client is exposed to the food
and initiate release of serotonin and histamine. Food
NURSING ASSESSMENT/DATA
intolerances do not occur consistently and are dependent
COLLECTION AND INTERVENTIONS
on the amount of food eaten. ● Nursing assessments should include a complete
● Milk, peanuts, fish, eggs, soy, shellfish, tree nuts, and dietary profile of the client, medications, herbal
wheat are the most commonly reported food allergies supplements, baseline knowledge about food safety, and
in adults. Some infants exhibit an allergic reaction to food‑medication interactions.
cow’s milk and/or soy, but typically outgrow this by ● Nursing interventions should include basic teaching
4 years of age. about food safety, and the interactions between food
● Common manifestations of food allergy include nausea, and client medications.
vomiting, diarrhea, abdominal distention, and pain. ● Teach the client about the difference between food
Some reactions are severe and can cause anaphylaxis. intolerance and food allergy.
FOOD‑MEDICATION INTERACTIONS
Foods and medications can interact in the body in
ways that alter the intended action of medications.
The composition and timing of food intake should be
considered in relation to medication use.
28 CHAPTER 5 Food Safety CONTENT MASTERY SERIES

1. A nurse is teaching about food safety and A nurse is providing teaching to a client about
foodborne illness to a group of adults at a food safety. What should the nurse include in the
local community center. Which of the following teaching? Use the ATI Active Learning Template:
information should the nurse include? Basic Concept to complete this item.
A. ”Unpasteurized fruit juice is a common UNDERLYING PRINCIPLES
cause of foodborne illness.”
●
Describe four food storage guidelines.
B. ”Store hard‑boiled eggs in the
refrigerator for up to 2 weeks.”
●
Describe three foodborne illnesses
and how they are acquired.
C. ”The recommended cooking temperature
for ground beef is 145° F.”
D. ”The onset of norovirus is 5 to 7 days
after exposure to the bacteria.”
2. A nurse is providing teaching about food

allergies to a group of new parents. Infants who
react to which of the following foods typically
outgrow the sensitivity? (Select all that apply.)
A. Soy
B. Wheat
C. Cow’s milk
D. Eggs
E. Fish
3. A nurse is providing teaching to a client who

is to begin taking phenelzine. Consuming
which of the following foods while taking this
medication could cause a hypertensive crisis?
A. Grapefruit juice
B. Dark green vegetables
C. Greek yogurt
D. Smoked fish
NUTRITION FOR NURSING CHAPTER 5 Food Safety 29

1. A. CORRECT: Include in the teaching that unpasteurized Using the ATI Active Learning Template: Basic Concept
fruit juice is a common cause of foodborne illness.
UNDERLYING PRINCIPLES
Other common causes of foodborne illness include
raw or undercooked foods of animal origin, raw fruits
●
Proper food storage guidelines
and vegetables contaminated with animal feces, and Fresh meat: Maintain refrigerator temperature
◯
uncooked food handled by someone who is ill. at 40° F (4° C) or colder.

B. Include in the teaching to store hard‑boiled Bacon: 7 days
■
eggs no longer than 1 week. Sausage (pork/chicken/beef/turkey): 1 to 2 days

■
C. Include in the teaching that the recommended cooking Summer sausage: 3 months (unopened); 3 weeks (opened)
■
temperature for ground beef is 160° F (71° C). Steaks, chops, roasts (beef, veal, lamb, or pork): 3 to 5 days
■
D. Include in the teaching that the onset of norovirus Chicken or turkey (whole/parts): 1 to 2 days
■
is 24 to 48 hr after exposure to the virus.

Fish: Maintain refrigerator temperature at 40° F (4° C) or colder.
◯
NCLEX® Connection: Health Promotion and Maintenance, Lean or fatty: 1 to 2 days

■
Aging Process Smoked: 14 days

■
Fresh shellfish: 1 to 2 days

■
2. A. CORRECT: Infants who react to soy typically outgrow Canned: 3 to 4 days (after opening); 5 years (pantry)
■
the sensitivity by the age of 4 years. Eggs: Store in the refrigerator for 5 weeks
◯
B. Include in the teaching that wheat is a common food in shell, and 1 week if hard‑boiled.
allergy, but do not include that sensitivities during Fruits and vegetables: Refrigerate perishable fruits and
◯
infancy are typically outgrown later in life. vegetables at 40° F (4° C). All pre‑cut and pre‑peeled
C. CORRECT: Infants who react to cow’s milk typically fruits and vegetables should also be refrigerated.
outgrow the sensitivity by the age of 4 years. Do not leave perishables at room temperature for more than
◯
D. Include in the teaching that eggs are a common food 2 hr (1 hr if the temperature is 90° F [32° C] or above).
allergy, but do not include that sensitivities during Canned goods: Check for rusting, crushing, and denting.
◯
infancy are typically outgrown later in life. Observe for stickiness on the outside of can, which may indicate
E. Include in the teaching that fish is a common food leakage. Do not use any canned foods that are damaged.
allergy, but do not include that sensitivities during ●
Foodborne illnesses
infancy are typically outgrown later in life.
Salmonella: Occurs due to eating undercooked or raw meat,
◯
NCLEX® Connection: Health Promotion and Maintenance, poultry, eggs, fish, fruit, and dairy products. Common
Aging Process manifestations include headache, fever, abdominal cramping,
diarrhea, nausea, and vomiting. This condition can be fatal.
Escherichia coli 0157:H7: Raw or undercooked meat,
◯
3. A. Grapefruit juice interferes with the metabolism of especially ground beef, can cause this foodborne pathogen.
many medications, but will not cause a hypertensive Findings include severe abdominal pain and diarrhea.
crisis in the client who is taking phenelzine.
Listeria monocytogenes: Soft cheese, raw milk products,
◯
B. Dark green vegetables can decrease the anticoagulant

undercooked poultry, processed meats, and raw vegetables
effects of warfarin, but will not cause a hypertensive
can cause the illness. Listeria monocytogenes causes
significant problems for newborns, pregnant clients, and
C. Greek yogurt is a source of protein that can increase the
immunocompromised clients. Onset occurs with the development
metabolism of levodopa, but will not cause a hypertensive
of a sudden fever, diarrhea, headache, back pain, and
abdominal discomfort. It can lead to stillbirth or miscarriage.
D. CORRECT: Smoked fish is high in tyramine, which
has hypertensive effects similar to other amines. Norovirus: A viral infection caused by consuming contaminated
◯
Because tyramine is metabolized by MAO, clients fruits and vegetables, salads prepared by someone who is infected,
who are taking MAOIs (phenelzine) and consume oysters, and contaminated water. Norovirus is very contagious,
tyramine can experience a hypertensive crisis. and has an onset of 24 to 48 hr. Manifestations include projectile
vomiting, fever, myalgia, watery diarrhea, and headache.
Nutrition and Oral Hydration NCLEX® Connection: Health Promotion and Maintenance, Health
Promotion/Disease Prevention
30 CHAPTER 5 Food Safety CONTENT MASTERY SERIES

CHAPTER 6
UNIT 1 PRINCIPLES OF NUTRITION ● The types of foods within a culture fall into three
Cultural, Ethnic, and categories regarding the role they have in the diet.
CHAPTER 6 Core foods make up the majority of dietary intake (the
Religious Influences
◯
foods eaten most often and consistently).

◯ Secondary foods are not consumed as often as core
foods, but are included often.
◯ Peripheral foods are consumed occasionally due to cost
Cultural, ethnic, and religious considerations or availability. Peripheral foods might be reserved for
special days, or consumed less often because they are
greatly affect nutritional health. Understanding not well-tolerated.
that ideas regarding food choices and nutrition ● Food preparation guidelines can include how the food
is obtained or prepared prior to being obtained by the
vary among cultures prevents ethnocentrism. client, methods of cooking, and the use of seasonings.
Identifying and incorporating individual ● The timing and frequency of meals can vary
across cultures.
preferences promotes client-centered care. ● Foods are often linked to health beliefs, with cultures
defining what foods are helpful or not, whether or not
Cultural traditions affect food choices foods are curative, and under what conditions the foods
and routines. Nurses should take this should be consumed.
American culture values eating foods from food groups
into consideration when planning and
◯
(fruits and vegetables, grains, proteins).

communicating nutritional goals with clients. ◯ Many cultures (Chinese, Middle Eastern, Latin
American, Indian, Filipino) have health beliefs
Acculturation is the process of a cultural, ethnic, regarding hot and cold balance.
Through acculturation, individuals and groups
or religious group’s adopting of the dominant
●
change their practices to reflect the dominant culture.

culture’s behaviors, beliefs, and values. First‑generation members of a family are more likely
to follow their traditional foodway, with subsequent
Considering the client’s foodway can be a helpful generations incorporating the dominant culture’s food
practices through socialization. Acculturation of the diet
way to determine dietary preferences, which can include removing or replacing traditional foods with
includes the role of foods, food preparation, what new ones, and adding new foods to the diet.
Dietary changes resulting from acculturation can be:
foods are considered edible, timing of meals, and
●
◯ Positive, if the client includes more healthy foods.

use of food for health or other benefits. ◯ Negative, if intake of high-fat, high-calorie, or high-
sodium foods increases.
CULTURE AND NUTRITION SELECTED POPULATIONS

Culture influences every aspect of life, including
Hispanic/Latinx
●
nutritional intake. While common preferences

exist within some cultures, individual preferences This is the predominant minority group in the U.S., with
and the degree to which the client follows cultural the largest percentage clients being of Mexican heritage.
recommendations can vary greatly. For further Certain foods are considered hot or cold and can be used
information on culture, refer to FUNDAMENTALS to provide balance for healing. Cinnamon and teas (mint,
CHAPTER 35: CULTURAL AND SPIRITUAL NURSING CARE . chamomile) can be used as part of healing.
● Food might be symbolic for a client.
NUTRITION-RELATED CONCERNS
◯ Representing masculinity or femininity ● High intake of fruit, dark green and orange
◯ Viewed as expressions of love or punishment
vegetables, legumes
◯ Representing connectedness or separateness ● Increased intake of saturated fat and sodium
◯ Part of celebration or mourning ● Decreased intake of whole grains and milk
◯ “Comfort foods” that relate to a client’s past ● High prevalence of obesity
● Culture defines what foods are edible, or allowable, in ● Diabetes mellitus type 2 as a leading cause of death
the diet. This idea is not always based on the nutritional
value, or the visual appeal. Considerations include:
◯ Whether the food is perceived as harmful
◯ What foods are for animal consumption (not human)
◯ Whether others within the culture consume it
NUTRITION FOR NURSING CHAPTER 6 Cultural, Ethnic, and Religious Influences 31

African American NUTRITIONAL HEALTH RISKS
● Convenience foods for home cooking are high in sodium
This is the second largest minority group in the U.S.
and calories, while low in fiber.
Most individuals can identify a West African heritage ● Portion sizes on packaged meal kits are often small,
or ancestors who immigrated through the Caribbean,
leading to consuming more than one serving.
Central America, or Eastern Africa. Food habits of African ● Meals and snacks eaten away from home are low in
American clients are related more to personal factors
fruit, vegetables, dairy, and whole grains, but high in
(work schedule, location, socioeconomic status) than
fat, sugar, and sodium.
heritage. African Americans are more likely than white
Americans accept a larger body size as normal.
Soul food
NUTRITION-RELATED CONCERNS
The soul food diet had its origins in Southern and Western
● Score just under the national average on USDA
Africa. Many Americans have adopted soul food practices,
healthy eating scores (total and saturated fat, sodium,
particularly in the Southern U.S. It is more common in low
cholesterol intake)
socioeconomic or rural areas.
● Lower intake of whole grains, milk, and vegetables
than clients who are white, who have a higher intake of TRADITIONAL FOODS: Rice, grits, cornbread, hominy,
sodium and saturated fat. okra, greens, sweet potatoes, apples, peaches, buttermilk,
● Highest prevalence rates of obesity. pudding, cheddar or American cheese, ham, pork, chicken,
● Increased rates of diabetes mellitus with increased risk catfish, black‑eyed peas, red and pinto beans, peanuts,
of complications soft drinks, fatback
● Increased risk for hypertension, usually uncontrolled
ACCULTURATION
Buying convenience foods rather than preparing home
Asian American
●
made (breads, luncheon meat, cured meats)

This is the third largest minority group in the U.S., ● Increased milk consumption
and includes 37 different ethnic groups. The Chinese ● Possible reduced intake of fruits and vegetables if not
population is the largest subgroup of Asian American readily available
people. Common food patterns among this diverse group
NUTRITIONAL HEALTH RISKS
include devoting considerable skill and time to food ● High in fat, protein, and sodium
preparation and consumption of rice and vegetables more ● Low in potassium, calcium, and fiber
than meats.
(protective nutrients)
Many Asian cultures believe in the balance of yin and yang ● Many foods are fried
forces, and that, when food is digested, it turns into one of
these components. Diseases associated with yin forces are Mexican
treated by consuming yang foods, and yang illness with
Spanish and Native American cultures have influenced the
yin foods.
traditional Mexican diet.
Yang foods: Fried foods, coffee, spice, meat, meat broths
TRADITIONAL FOODS: Rice, corn, tortillas, tropical fruits,
Yin foods: Seaweed, many fruits and vegetables, cold vegetables, nuts, legumes, eggs, cheese, seafood, poultry,
beverages infrequent sweets and red meat
● Tortillas eaten at most meals
NUTRITION-RELATED CONCERNS ● Animal protein from ground poultry, pork, goat
● Lowest prevalence of obesity ● Vegetables often incorporated into the main dish
● Highest life expectancy (Asian American females)
● Higher risk of diabetes mellitus type 2 when body fat ACCULTURATION
increases (compared to other groups) ● Decreased intake of vegetables
● Intake of corn-based products replaced with flour-based
● Increased milk intake or replaced with low-fat options
SELECTED CULTURAL DIETS ● Red meat intake increased while legume
intake decreased
These diets common to the major subcultural groups ● Increased use of fats (butter, margarine, salad dressing)
in the United States can vary from client to client. ● Increased use of high-sugar, low-nutrient beverages
Acculturation causes a moving away from the traditional
(e.g., replacing fruit juice with carbonated sodas)
foods in place of others.
Chinese
American
Largest Asian American subgroup
● Many foods from various cultures are components of
American cuisine. TRADITIONAL FOODS: Wheat (northern), rice (southern),
● Foods are often prepared quickly or are expected to noodles, fruits, land and sea vegetables, nuts/seeds, soy
be made fast. Foods prepared at home often include foods (tofu), nut/seed oils, fish, shellfish, poultry, eggs,
premade ingredients or packaged kits to reduce sweets, rarely red meats, seafoods, tea, beer
mealtime preparation. ● Tofu, soups made from bone, and fish containing small
bones provide most of calcium intake.
32 CHAPTER 6 Cultural, Ethnic, and Religious Influences CONTENT MASTERY SERIES

ACCULTURATION RELIGION AND NUTRITION
● Increased intake of wheat-based foods ● Religion has a profound influence on foodways,
● Increased intake of raw vegetables and replacement of
especially because religion crosses geographic
traditional vegetables
boundaries. Although culture and religion are linked,
● Increased fruit intake
religion often has more of an influence on dietary
● Increased intake of dairy, meat, ethnic dishes,
practices than culture. Variations among individual
and fast food
denominations of a religion can vary greatly.
NUTRITIONAL-RELATED HEALTH RISKS ◯ The dietary laws for Orthodox Judaism are outlined in
● Most foods are cooked, with exception of occasional the Torah.
fresh fruit. ◯ Two Protestant Christian faiths prescribe dietary laws
● Risk of increased sodium is possible due to salting/ (Church of Jesus Christ of Latter-Day Saints [Mormon],
drying to preserve foods and use of salt-based Seventh-Day Adventists).
condiments. ◯ The Qur’an contains food laws for the Islamic
faith. Foods are either permitted (halal) or
Vegetarian diets prohibited (haram).
◯ Hindu and Buddhist religions have values related to
Semi-vegetarian/flexitarian diets are mainly plant-based
not harming living creatures (ahimsa), which lends to
diet with occasional intake of meat, poultry, dairy, or fish.
followers practicing vegetarianism.
Vegetarian ● Some followers of a particular religion follow the moral
● A vegetarian diet typically omits meat, seafood, laws but not dietary prescriptions. Always ask clients to
poultry, or fish. describe their dietary preferences.
● Some clients include eggs, dairy products, fish, and/or
occasional other animal products. Variations based on religion
Vegan Eating on Holy Days: Some religions observe feasts on
● Pure vegan diets do not include animal products of any specific days (Eastern Orthodox Christian, Judaism).
type, including eggs and milk products. During Passover, Judaism calls for consumption of
● A pure vegan diet requires a variety of plant materials to unleavened bread only.
be consumed in specific combinations in order to ensure
Fasting for religious holidays: Islam calls for fasting
essential amino acid intake.
during Ramadan. Roman Catholicism calls for refraining
◯ The vegan diet is adequate in protein with sufficient
from meat consumption on Ash Wednesday and Fridays
intake of nuts and legumes (dried peas, cooked beans).
during Lent, and to avoid food or beverage intake for 1 hr
◯ Clients following a vegan diet should ensure adequate
before communion. Seventh-Day Adventism recommends
intake of iron, zinc, calcium, vitamin D, omega-3
a 5- to 6-hr interval between meals. Judaism calls for a
fatty acids and vitamin B12, because there is a risk of
24-hr fast during Yom Kippur.
deficiency of these nutrients depending on the types
of foods selected. Restricting specific substances
● A raw vegan diet is based on consuming uncooked ● Alcohol (Islam, Hindu, Mormon,
plant-based foods. Seventh-Day Adventism)
● A macrobiotic diet is a whole-foods diet based on locally ● Pork (Seventh-Day Adventism, Orthodox Judaism, Islam,
grown plants with occasional fish or seafood. Hindu, Buddhism)
● Coffee or tea (Seventh-Day Adventism, Mormonism)
NUTRITIONAL-RELATED HEALTH RISKS: Risk for deficiency ● Other: Clients who follow Orthodox Judaism might not
in vitamin B12, vitamin D, iron, calcium, and zinc, unless
eat meat and dairy products at the same time; pareve
the client incorporates these foods regularly.
foods contain neither and can be consumed at any time.
Clients who follow Judaism might consume only fish
that have scales and fins.
6.1 Food Label Examples Consuming animal products
● Vegetarian diet: Seventh-Day Adventism,
Hinduism, Buddhism
● Orthodox Judaism and Islam call for consumption
of Kosher animals. Both have regulations for how
animals are slaughtered, particularly so that no blood
is consumed.
Preparing foods: Orthodox Judaism prohibits food

preparation on the Sabbath.

NURSING INTERVENTIONS ● If specific foods associated with the client’s culture are
deemed negative medically, ask the client to reduce
● Obtaining the client’s preferences related to nutrition
consumption of the foods rather than eliminating them
is vital. The information on cultural and religious
(reducing portion size, eating less often).
influences on nutrition is so vast that the nurse should ● Suggest fruits and vegetables that are similar in taste or
focus more on the needs of the individual clients
texture to what the client prefers, to increase or ensure
for whom the nurse is assigned care. Ask questions
adequate consumption.
regarding the following. ● Seek the assistance of a dietitian to ensure the client
◯ What portions of the client’s diet are influenced by
will receive essential nutrients and to help combine
personal values
medical recommendations with personal preferences.
◯ What the client considers healthy versus unhealthy
◯ What food and eating means to the client
◯ When the client eats meals, and if there is a sequence Active Learning Scenario
to the foods eaten
◯ Who shops for and prepares the foods the A nurse is providing teaching to a group of clients
client consumes who consume a primarily Mexican diet. What cultural
◯ Whether the client abstains from any foods considerations should guide the nurse with the teaching?
◯ Whether there are restrictions related to foods and Use the ATI Active Learning Template: Basic Concept
food preparation to complete this item to include the following.
◯ Whether foods are linked to religious practice or
RELATED CONTENT
spiritual beliefs
◯ Whether the client’s beliefs dictate fasting, feasting,
●
Traditional foods: Include at least six
foods common to this diet.
or types of foods consumed on specific days or dates
● Seek further information about the client’s preferred ●
Acculturation: Describe three examples of how
dietary practices from reputable sources, as needed, to food practices change as clients who follow this diet
acculturate to the dominant American culture.
guide nutritional counseling.
1. A nurse is assisting a client with selecting food 3. A nurse educator is teaching a class on culture
choices on a menu. Which of the following actions and food to a group of newly hired nurses.
by the nurse demonstrates ethnocentrism? Which of the following statements by a nurse
A. Asking the client about some favorite food choices indicates an understanding of the teaching?
B. Notifying the dietitian to complete the menu A. “Most clients who practice Roman Catholicism
do not drink caffeinated beverages.”
C. Recommending one’s own favorite foods
B. “Most clients who practice orthodox Judaism
D. Asking the client’s family to fill out the menu do not eat meat with dairy products.”
C. “Most clients who are Mormon eat
2. A nurse is caring for a client who has hypertension. only the protein of animals that are
Which of the dietary patterns is sometimes followed by slaughtered under strict guidelines.”
Asian clients and places clients at risk for this condition? D. “Most clients who practice Hinduism
A. Incorporation of plant-based foods in the diet do not eat dairy products.”
B. Consumption of raw fruits
C. Preparation of foods using sodium 4. A nurse is reviewing the effect of culture on nutrition
D. Focus on shellfish in the diet during a staff in-service. Which of the following groups
prescribes eating specific foods to balance forces
in the body during illness? (Select all that apply.)
A. Asian culture
B. African culture
C. Roman Catholicism
D. Hispanic/Latinx culture
E. Buddhism

1. A. Asking the client about some favorite foods choices Using the ATI Active Learning Template: Basic Concept
demonstrates sensitivity to the client’s food preferences. RELATED CONTENT
B. Calling the dietitian to fill out the menu does not demonstrate ●
Traditional foods
sensitivity to the client’s food preferences. However, it
is not an example of an ethnocentric approach. Grains: rice, corn
◯
C. CORRECT: Recommending one’s own favorite foods is an Tropical fruits and vegetables
◯
example of ethnocentrism, which is the belief that one’s own Protein: nuts, legumes, eggs, cheese, seafood, poultry
◯
cultural practices are the only correct behaviors/beliefs. ●

Acculturation
D. Having the family fill out the menu does not demonstrate Increased milk use
◯
sensitivity to the client’s food preferences. However, it Decreased vegetable consumption

◯
is not an example of an ethnocentric approach. Replacement of corn by wheat in tortillas and breads
◯
NCLEX® Connection: Psychosocial Integrity, Decreased bean use and change in rice
◯
Cultural Awareness/Cultural Influences on Health preparation to plain boiled rice

Added fats in the form of butter or salad dressings
◯
on cooked vegetables and side salads

2. A. Encourage plant‑based foods to increase
Replacement of fruit‑based drinks by sugar‑laden drinks
◯
nutrients in the diet.

B. Encourage raw fruits in the client’s diet NCLEX® Connection: Psychosocial Integrity, Cultural Awareness/
to increase vitamin intake. Cultural Influences on Health
C. CORRECT: The preparation of foods using sodium places
the client at risk for hypertension. Many spices in the
Asian diet contain sodium, or it is used as a preservative.
The client should reduce sodium consumption.
D. Encourage the consumption of shellfish because
it is a good source of protein and vitamins.
High Risk Behaviors
3. A. This is generally not a practice of Roman Catholics.

Caffeinated beverages are often not consumed by Mormons
and Muslims because caffeine is a stimulant.
B. CORRECT: Most clients who practice Orthodox
Judaism do not eat meat with dairy products.
C. Most clients who follow the teachings of
Islam eat only the protein of animals that are
slaughtered under strict guidelines.
D. Most clients who practice Hinduism believe
dairy products enhance spiritual purity.
High Risk Behaviors
4. A. CORRECT: Asian traditions can include balancing

yin and yang forces within the body, and foods
are grouped into those categories.
B. African culture has influenced development of the soul
food diet, but individual preferences differ widely.
C. Roman Catholicism includes few laws related to
fasting on holidays or from certain foods.
D. CORRECT: Hispanic/Latinx cultural traditions can
include balancing hot and cold forces within the body,
and foods are grouped into those categories.
E. Buddhism has recommendations for eating foods
in a manner that do not cause harm.
NCLEX® Connection: Psychosocial Integrity,
Cultural Awareness/Cultural Influences on Health

CHAPTER 7
UNIT 1 PRINCIPLES OF NUTRITION DIETARY GUIDELINES
CHAPTER 7 Nutrition Across ● Achieving an appropriate amount of weight gain during
the Lifespan
pregnancy prepares a client for the energy demands of
labor and lactation, and contributes to the delivery of a
newborn of normal birth weight.
● The recommended weight gain during pregnancy varies
for each client depending on their body mass index
Nutritional needs change as clients pass (BMI) and weight prior to pregnancy. (7.1)
through the stages of the lifespan, reflecting ● Lactating clients require an increase in daily caloric
intake. If the client is breastfeeding during the
physiological changes. postpartum period, an additional daily intake of
330 calories is recommended during the first 6 months,
Nurses must address nutritional needs across the and an additional daily intake of 400 calories is
lifespan and have a thorough understanding of recommended during the second 6 months.
how needs change. This includes planning and

implementing dietary plans that meet clients’ MAJOR AND MICRONUTRIENT
specific needs and assist in health promotion. REQUIREMENTS
● Dietary requirements for major nutrients
Major stages of the lifespan that have specific ◯ Protein should comprise 20% of the daily total calorie
intake. The Dietary Reference Intake (DRI) for protein

nutritional needs include pregnancy and during pregnancy is 71 g/day. Protein is essential for
lactation, infancy, childhood, adolescence, and rapid tissue growth of maternal and fetal structures,
amniotic fluid, and extra blood volume. Clients who
adulthood and older adulthood. are pregnant should be aware that animal sources of
protein might contain large amounts of fats.
◯ Fat should be limited to 30% of total daily calorie intake.
Pregnancy and lactation ◯ Carbohydrates should comprise 50% of the total daily
calorie intake. Ensuring adequate carbohydrate intake
● Prepregnancy nutrition is highly significant and plays an allows for protein to be spared and available for the
important role, because early fetal development occurs synthesis of fetal tissue.
before a client might realize they are pregnant. A client ● The need for most vitamins and minerals increases
should be well-nourished and within the normal weight during pregnancy and lactation. Vitamins are
range prior to conception. Low levels of folate prior to essential for blood formation, absorption of iron,
conception increases the likelihood of neural tube defects. and development of fetal tissue. TABLE 7.2 lists the
● Good nutrition during pregnancy is essential for the comparative DRIs of major vitamins for clients age 19 to
health of the unborn child. 30 during nonpregnancy, pregnancy, and lactation.
● Maternal nutritional demands are increased for the
development of the placenta, enlargement of the uterus,
formation of amniotic fluid, increase in blood volume, 7.1 Recommended weight
and preparation of the breasts for lactation.
gain during pregnancy
● A daily increase of 340 calories is recommended during
the second trimester of pregnancy, and an increase of FIRST TRIMESTER: Recommended weight gain is 1.1 to 4.4 lb.
452 calories is recommended during the third trimester
SECOND AND THIRD TRIMESTERS:
of pregnancy. Recommended weight gain is 2 to 4 lb/month.
● The nutritional requirements of clients who are ●
Normal weight client (BMI 18.5‑24.9):
pregnant or lactating involves more than increased 1 lb/week for a total of 25 to 35 lb.
caloric intake. Specific dietary requirements for major ●
Underweight client (BMI < 18.5): just more
than 1 lb/week for a total of 28 to 40 lb.
nutrients and micronutrients should be met. ●
Overweight client (BMI 25‑29.9):
0.66 lb/week for a total of 15 to 25 lb.
●
Obese client (BMI > 30): 0.5 lb/week
for a total of 11 to 20 lb.
NUTRITION FOR NURSING CHAPTER 7 Nutrition Across the Lifespan 37

ADDITIONAL DIETARY DIETARY COMPLICATIONS
RECOMMENDATIONS Nausea and constipationare common during pregnancy.
Fluid: 2,000 to 3,000 mL fluids daily from food and ● For nausea, eat dry crackers, toast, and salty or tart
drinks. Preferred fluids include water, fruit juice, and milk. foods. Avoid alcohol, caffeine, fats, and spices. Avoid
Carbonated beverages and fruit drinks provide little or drinking fluids with meals, and do not take medications
no nutrients. to control nausea without checking with the provider.
● For constipation, increase fluid consumption (at least
Alcohol: It is recommended that clients abstain from
8 cups per day) and include extra fiber in the diet.
alcohol consumption during pregnancy. There is no safe
Fruits, vegetables, and whole grains contain fiber.
recommendation for alcohol use during pregnancy. ● Regular physical activity can minimize or
Caffeine: Caffeine crosses the placenta and can affect the prevent constipation.
movement and heart rate of the fetus. However, moderate
Maternal phenylketonuria (PKU)is a maternal genetic
use (less than 200 mg/day) does not appear to be harmful.
disease in which high levels of phenylalanine pose danger
Vegetarian diets: Well‑balanced vegetarian diets that to the fetus.
include dairy products can provide all the nutritional ● It is important for a client to start the PKU diet at least
requirements of pregnancy. 3 months prior to pregnancy, and continue the diet
throughout pregnancy.
Folic acid intake: It is recommended that 600 mcg/‌day ● The diet should include foods low in phenylalanine.
of folic acid be taken during pregnancy. Current
Foods high in protein (fish, poultry, meat, eggs, nuts,
recommendations for lactating clients include
dairy products) must be avoided due to high
500 mcg/‌day folic acid. It is necessary for the neurologic
phenylalanine levels.
development of the fetus and to prevent birth defects. It ● The client’s blood phenylalanine levels should be
is essential for maternal red blood cell formation. Clients
monitored during pregnancy.
who have had a child born with a neural tube defect ● These interventions will prevent fetal complications
should consume 4 mg daily of folic acid during pregnancy.
(intellectual disability, behavioral problems).
Food sources include green leafy vegetables, enriched
grains, and orange juice.
Folic acid is the synthetic form of folate and is absorbed
ASSESSMENT/DATA COLLECTION
●
better by the body. Folic acid is found in supplements

and in fortified foods.
AND INTERVENTIONS
● Folate is found in natural foods. ● Nursing assessments should include a complete profile
of the client’s knowledge base regarding nutritional
Iron: The DRI for iron increases by 50% during pregnancy
requirements during pregnancy.
to support the increase in maternal blood volume and to ● Nurses should review with the client the recommended
provide iron for fetal liver storage. Iron can be obtained
dietary practices for pregnant and lactating clients,
from meats, eggs, leafy greens, enriched breads, and
while providing materials containing this information.
dried fruits. Consuming foods high in vitamin C aids in
the absorption of iron. It is recommended that pregnant
clients take a supplement of 27 to 30 mg iron daily to
assure adequate intake. 7.2 DRIs of major vitamins
Nonnutritive sweeteners: Several nonnutritive sweeteners
have been approved for use during pregnancy. Occasional NUTRIENT NONPREGNANT PREGNANT LACTATING
use is not considered harmful, but it is not known if they Protein 46 g 71 g 71 g
are beneficial. Vitamin A 700 mcg 770 mcg 1,300 mcg
Vitamin C 75 mg 85 mg 120 mg
Fish: The FDA has issued advisories regarding fish and
Vitamin D* 15 mcg 15 mcg 15 mcg
shellfish consumption during pregnancy due to the risk of
mercury levels. Mercury can be toxic to developing fetal Vitamin E 15 mcg 15 mcg 19 mcg
brain tissue. Fish are a good source of omega 3 fatty acids, Vitamin K* 90 mcg 90 mcg 90 mcg
which are important for fetal brain and eye development. Thiamin 1.1 mg 1.4 mg 1.4 mg
● Limit albacore tuna to 6 oz/week. Vitamin B6 1.3 mg 1.9 mg 2.0 mg
● Avoid tilefish, shark, swordfish, marlin, orange roughy,
Folic acid 400 mcg 600 mcg 500 mcg
and king mackerel due to mercury content. Vitamin B12 2.4 mcg 2.6 mcg 2.8 mcg
● Limit weekly consumption of seafood to 12 oz. Calcium* 1,000 mg 1,000 mg 1,000 mg
Iron 18 mg 27 mg 9 mg
*Values represent adequate intakes.
Source: Office of Dietary Supplements. National Institutes of Health, ods.od.nih.gov
38 CHAPTER 7 Nutrition Across the Lifespan CONTENT MASTERY SERIES

Infancy ● Donor milk can be considered in certain circumstances.
◯ The choice to feed an infant human milk from a
● Growth rate during infancy is more rapid than any other source other than the infant’s parent should be
period of the life cycle. It is important to understand made in consultation with the provider, because the
normal growth patterns to determine the adequacy of nutritional needs of each infant depend on many
an infant’s nutritional intake. factors, including the infant’s age and health.
● Birth weight doubles by 4 to 6 months and triples by ◯ The FDA recommends that if an infant is to be fed
1 year of age. The need for calories and nutrients is high human milk from a source other than the infant’s
to support the rapid rate of growth. parent, use only milk from a source that has screened
● Appropriate weight gain averages 0.15 to 0.21 kg (5 to its donors and take other precautions to ensure the
7 oz) per week during the first 5 to 6 months. safety of the milk.
● An infant grows approximately 2.5 cm (1 in) per month ● The AAP recommends that for the first 6 months,
in height during the first 6 months, and approximately infants should receive no water or formula except in
1.25 cm (0.5 in) per month during the second 6 months. cases of medical indication or informed parental choice.
● Head circumference increases rapidly during the first In the hospital, no water or formula should be given to a
6 months at a rate of 1.5 cm (0.6 in) per month. The breastfed infant unless prescribed by a provider.
rate slows to 0.5 cm/month for months 6 to 12. By
1 year, head size should have increased by 33%. This is Nutritional advantages of breast milk
reflective of the growth of the nervous system. ● Carbohydrates, proteins, and fats in breast milk are
● Breast milk, infant formula, or a combination of
predigested for ready absorption.
the two is the sole source of nutrition for the first ● Breast milk is high in omega‑3 fatty acids.
6 months of life. ● Breast milk is low in sodium.
● Semisolid foods should not be introduced before ● Iron, zinc, and magnesium found in breast milk are
6 months of age to coincide with the development of the
highly absorbable.
gastrointestinal system, head control, ability to sit, and ● Calcium absorption is enhanced, as the
the back‑and‑forth motion of the tongue.
calcium‑to‑phosphorous ratio is 2:1.
● Gestational iron stores begin to deplete around
4 months of age, so iron supplementation is
Breastfeeding teaching points
recommended after this time for infants who are
exclusively fed breast milk. Once solid foods are ● The newborn is offered the breast immediately after
introduced, iron-fortified cereal is a good source of iron. birth and frequently thereafter. There should be eight to
● Cow’s milk should not be introduced into the diet until 12 feedings in a 24‑hr period.
after 1 year of age because protein and mineral content ● Instruct the client to demand‑feed the infant and to
stress the immature kidney. A young infant cannot fully assess for hunger cues. These include rooting, suckling
digest the protein and fat contained in cow’s milk. on hands and fingers, and rapid eye movement. Crying
is a late indicator of hunger.
● The newborn should nurse up to 15 min per breast.
MEETING NUTRITIONAL NEEDS Findings that indicate the newborn has completed the
feeding include the slowing of newborn suckling, a
Additional information about feeding is available in
softened breast, or sleeping. Eventually, the infant will
MATERNAL NEWBORN CHAPTER 25: NEWBORN NUTRITION and
empty a breast within 5 to 10 min, but might need to
NURSING CARE OF CHILDREN CHAPTER 3 : HEALTH PROMOTION
continue to suck to meet comfort needs.
OF INFANTS (2 DAYS TO 1 YEAR).
● Do not offer the newborn any supplements unless
indicated by the provider.
BREASTFEEDING ● Frequent feedings (every 2 hr can be indicated) and
manual expression of milk to initiate flow can be needed.
● The American Academy of Pediatrics (AAP), World ● Awaken the infant to feed every 3 hr during the day and
Health Organization (WHO), Department of Health
every 4 hr at night.
and Human Services (HHS), and American College ● Encourage clients to express breast milk for
of Obstetricians and Gynecologists recommend that
supplementation if extra fluids or calories are required.
infants receive breast milk for the first 6 to 12 months ● Expressed milk can be refrigerated in sterile bottles or
of age (exclusive breast feeding) followed by
storage bags and labeled with the date and time the milk
breastfeeding with the introduction of complementary
was expressed. It can be maintained in the refrigerator
foods until at least 12 months of age, then continuation
for 24 hr or frozen in sterile containers for 3 months.
of breastfeeding for as long as the parent and infant ● Thaw milk in the refrigerator. It can be stored for 24 hr
desire. Even a short period of breastfeeding has
after thawing. Defrosting or heating in a microwave oven
physiological benefits.
is not recommended because high heat destroys some of
milk’s antibodies, and can burn the infant’s oral mucosa.

● Do not refreeze thawed milk. ● Open jars of infant food can be stored in the refrigerator
● Unused breast milk must be discarded. for up to 24 hr.
● Limit alcohol and caffeine while breastfeeding. ● By 9 months of age, the infant should be able to eat
● Begin manual expression of the breast or use an electric table foods that are cooked, chopped, and unseasoned.
breast pump if the infant is unable to breastfeed due to ● Do not feed the infant honey due to the risk of botulism.
prematurity or respiratory distress. ● Appropriate finger foods include ripe bananas, toast
strips, graham crackers, cheese cubes, noodles, and
peeled chunks of apples, pears, or peaches.
FORMULA FEEDING
Can be used in place of breastfeeding, as an occasional
supplement to breastfeeding, or when exclusively NUTRITION‑RELATED PROBLEMS
breastfed infants are weaned before 12 months of age.
● Commercial infant formulas provide an alternative to Colic
breast milk. They are modified from cow’s milk to provide
Colic is characterized by persistent crying lasting 3 hr or
comparable nutrients. However, breast milk is superior to
longer per day.
any formula and even more crucial for a premature infant. ● The cause of colic is unknown, but usually occurs in the
● If formula-fed, an iron‑fortified formula is recommended
late afternoon, more than 3 days per week for more than
for at least the first 12 months of life or until the infant
3 weeks. The crying is accompanied by a tense abdomen
consumes adequate solid food.
and legs drawn up to the belly.
● Fluoride supplements can be required if an adequate level ● If breastfeeding, eliminate cruciferous vegetables
is not supplied by the water supply.
(cauliflower, broccoli, and Brussels sprouts), cow’s milk,
● Precisely follow the manufacturer’s mixing directions.
onion, and chocolate, and limit caffeine and nicotine.
● Bottles of mixed formula or open cans of liquid formula ● Burp the infant in an upright position.
require refrigeration. Do not use if the formula has been
left at room temperature for 2 hr or longer. Do not reuse
Lactose intolerance
partially emptied bottles of formula.
● Formula can be fed chilled, warmed, or at room Lactose intolerance is the inability to digest significant
temperature. Always give formula at approximately the amounts of lactose (the predominant sugar of milk) and is
same temperature. due to inadequate lactase (the enzyme that digests lactose
● The infant should not drink more than 32 oz formula into glucose and galactose).
per 24 hr period unless directed by a provider. ● Lactose intolerance has an increased prevalence in
individuals of Asian, Native American, African, Latino,
and Mediterranean descent.
BOTTLE FEEDING ● Findings include abdominal distention, flatus, and
● Hold the infant during feedings with the head slightly occasional diarrhea.
elevated to facilitate passage of formula or breast milk ● Soy‑based or casein hydrolysate formulas can be
into the stomach. Tilt the bottle to maintain liquid in prescribed as alternative formulas for infants who are
the nipple and prevent the swallowing of air. lactose intolerant.
● Do not prop the bottle or put an infant to bed with a
bottle. This practice promotes tooth decay. Failure to thrive
Failure to thrive is defined as inadequate gains in
INTRODUCING SOLID FOOD weight and height in comparison to established growth
and development norms (weight-for-length less than
● Indicators for readiness include voluntary control of the
5th percentile or weight for age below the 3rd percentile).
head and trunk, hunger less than 4 hr after vigorous ● Assess for findings of congenital defects,
nursing or intake of 8 oz of formula, and interest of

central nervous system disorders, or partial
the infant.
intestinal obstruction.
● New foods should be introduced one at a time over a ● Monitor for swallowing or sucking problems.
5‑ to 7‑day period to observe for indications of allergy ● Identify feeding patterns, especially concerning
or intolerance, which can include fussiness, rash, upper
preparation of formulas.
respiratory distress, vomiting, diarrhea, or constipation. ● Observe for psychosocial problems, especially impaired
The order of introduction of new foods is no longer
caregiver‑infant bonding, abuse/neglect.
considered important, and meat can be introduced first ● Provide supportive nutritional guidance. Usually a
due to its iron and zinc content.
high‑calorie, high‑protein diet is indicated.
● The infant can be ready for three meals per day with ● Provide supportive parenting guidance.
three snacks by 8 months of age.
● Homemade baby food is an acceptable feeding option.
Do not use canned or packaged foods that are high in
sodium. Select fresh or frozen foods, and do not add
sugars or other seasonings.

Diarrhea
Childhood
Diarrhea is characterized by the passage of more than ● Growth rate slows following infancy.
three loose, watery stools over a 24‑hr period. ● ChooseMyPlate.gov is a food guidance system that offers
● Overfeeding and food intolerances are common causes
an Internet‑based tool to provide clients with
of osmotic diarrhea.
individualized recommendations for adequate nutrition.
● Infectious diarrhea in the infant is commonly caused
Children require the same food groups as adults, but in
by rotavirus.
smaller serving sizes.
● Mild diarrhea can require no specific interventions. ● Energy needs and appetite vary with the child’s activity
Check with the provider for any diet modifications.
level and growth rate.
● Treatment for moderate diarrhea should begin at ● Generally, nutrient needs increase with age.
home with oral rehydration solutions. After each loose ● Attitudes toward food and general food habits are
stool, an 8 oz solution should be given. Sports drinks
established by 5 years of age.
are contraindicated. ● Increasing the variety and texture of foods helps the
● Educate parents about the findings of dehydration:
child develop good eating habits.
listlessness, sunken eyes, sunken fontanels, decreased ● Foods like hot dogs, popcorn, peanuts, grapes, raw
tears, dry mucous membranes, and decreased
carrots, celery, peanut butter, tough meat, and candy
urine output.
can cause choking or aspiration.
● Breastfed infants should continue nursing. ● Inclusion in family mealtime is important for
● Formula‑fed infants usually do not require diluted
social development.
formulas or special formulas. ● Group eating becomes a significant means of
● Contact the provider if findings of dehydration are
socialization for school‑age children.
present, or if vomiting, bloody stools, high fever, change
in mental status, or refusal to take liquids occurs.
Constipation
TODDLERS: 1 TO 3 YEARS OLD
Constipation is the inability or difficulty to evacuate
the bowels.
NUTRITION GUIDELINES
● Constipation is not a common problem for ● Toddlers generally grow 2 to 3 inches in height and gain
breastfed infants. approximately 5 to 6 lb/year.
● Constipation can be caused by formula that is ● Limit 100% juice to 4 to 6 oz a day.
too concentrated. ● The 1‑ to 2‑year‑old child requires whole cow’s milk to
● Stress the importance of accurate dilution of formula. provide adequate fat for the still‑growing brain.
● Advise adherence to the recommended amount of ● Food serving size is 1 tbsp for each year of age.
formula intake for age. ● Exposure to a new food might be needed 15 to 20 times
before the child develops an acceptance of it.
● If there is a negative family history for allergies, cow’s
NURSING ASSESSMENT/DATA milk, chocolate, citrus fruits, egg white, seafood,
COLLECTION AND INTERVENTIONS and nut butters can be gradually introduced while
monitoring the child for reactions.
● Nursing assessments should include an assessment ● Toddlers prefer finger foods because of their increasing
of knowledge base of the client regarding nutritional
autonomy. They prefer plain foods to mixtures, but
guidelines for infants, normal infant growth patterns,
usually like macaroni and cheese, spaghetti, and pizza.
breastfeeding, formula feeding, and the progression for ● Regular meal times and nutritious snacks best meet
the introduction of solid foods.
nutrient needs.
● Additionally, nurses should provide education and ● Snacks or desserts that are high in sugar, fat, or sodium
references for the client regarding each of the
should be avoided.
assessments listed above. ● Children are at an increased risk for choking until
4 years of age.
● Avoid foods that are potential choking hazards. Always
provide adult supervision during snack and mealtimes.
During food preparation, cut small, bite‑sized pieces
that are easy to swallow to prevent choking. Do not
allow the child to engage in drinking or eating during
play activities or while lying down.

NUTRITIONAL CONCERNS/RISKS Iron deficiency anemia
Lead poisoningis a risk for children younger than 6 years

Iron
of age because they frequently place objects in their
● Iron deficiency anemia is the most common nutritional mouths that can contain lead and have a higher rate of
deficiency disorder in children. intestinal absorption.
● Lean red meats provide sources of readily ● Feed children at frequent intervals because more lead is
absorbable iron. absorbed on an empty stomach.
● Consuming vitamin C (orange juice, tomatoes) with ● Inadequate intake of calories, calcium, iron, zinc, and
plant sources of iron (beans, raisins, peanut butter, phosphorous can increase susceptibility.
whole grains) will maximize absorption.
● Milk should be limited to the recommended quantities
(24 oz) because it is a poor source of iron and can SCHOOL‑AGE CHILDREN: 6 TO 12 YEARS
displace the intake of iron‑rich foods.
Vitamin D
NUTRITION GUIDELINES
● School‑age children generally grow 2 to 3 inches in
● Vitamin D is essential for bone development.
height and gain approximately 5 to 6 lb/year.
● Recommended vitamin D intake is the same (5 mcg/day) ● Following MyPlate recommendations, the diet should
from birth through age 50. Children require more vitamin
provide variety, balance, and moderation.
D because their bones are growing. ● Young athletes need to meet energy, protein, and
● Milk (cow, soy) and fatty fish are good sources of
fluid needs.
vitamin D. ● Educate children to make healthy food selections.
● Sunlight exposure leads to vitamin D synthesis. ● Children enjoy learning how to safely prepare
Children who spend large amounts of time inside
nutritious snacks.
(watching TV, playing video games) are at an increased ● Children need to learn to eat snacks only when hungry,
risk for vitamin D deficiency.
not when bored or inactive.
● Vitamin D assists in the absorption of calcium into
the bones.
NUTRITIONAL CONCERNS/RISKS
Not eating breakfastoccurs in about 10% of children.
PRESCHOOLERS: 3 TO 6 YEARS ● Optimum performance in school is dependent on a
nutritious breakfast.
NUTRITION GUIDELINES ● Children who regularly eat breakfast tend to have an
age‑appropriate BMI.
● Preschoolers generally grow 2 to 3 inches in height and
gain approximately 5 to 6 lb/year. Overweight/obesityaffects at least 20% of children.
● Preschoolers need to consume 13 to 19 g/day of ● Greater psychosocial implications exist for children
complete protein. than adults.
● If the preschooler consumes foods from all five food ● Overweight children tend to be obese adults.
groups and height and weight are within expected ● Prevention is essential. Encourage healthy eating habits,
reference ranges, supplemental vitamins/minerals decrease fats and sugars (empty‑calorie foods), and
might not be needed. increase the level of physical activity.
● Preschoolers tend to dislike strong‑tasting vegetables ● A weight‑loss program directed by a provider is indicated
(cabbage, onions), but like many raw vegetables that are for children who are overweight, or obese if they have
eaten as finger foods. comorbidity. Otherwise, efforts are directed at maintaining
● Food jags (ritualistic preference for one food) are weight so the BMI will normalize as height increases.
common and usually short‑lived. ● Praise the child’s abilities and skills.
● MyPlate guidelines are appropriate, requiring the lowest ● Never use food as a reward or punishment.
number of servings per food group.
● Food patterns and preferences are first learned from
the family, and peers begin influencing preferences and NURSING ASSESSMENT/DATA
habits at around 5 years of age. COLLECTION AND INTERVENTIONS
Nursing assessments should include the parent’s knowledge
NUTRITIONAL CONCERNS/RISKS base of the child’s nutritional requirements, and nutritional
Concernsinclude overfeeding; intake of high‑calorie, concerns with regard to age. Nurses should provide education
high‑fat, high‑sodium snacks, soft drinks, and juices; and for the parent and child about nutritional recommendations.
inadequate intake of fruits and vegetables.
● Be alert to the appropriate serving size of foods (1 tbsp
per year of age).
● Avoid high‑fat and high‑sugar snacks.
● Encourage daily physical activities.

● Can switch to skim or 1% low‑fat milk after
2 years of age.

Adolescence Dieting
● The stigma of obesity and social pressure to be thin can
● The rate of growth during adolescence is second only to lead to unhealthy eating practices and poor body image,
the rate in infancy. Nutritional needs for energy, protein, especially in females.
calcium, iron, and zinc increase at the onset of puberty ● Males are more susceptible to using supplements and
and the growth spurt. high‑protein drinks in order to build muscle mass and
● The female adolescent growth spurt usually begins at 10 improve athletic performance. Some athletes restrict
or 11 years of age, peaks at 12 years, and is completed by calories to maintain or achieve a lower weight.
17 years. Female energy requirements are less than that ● Eating disorders can follow self‑imposed crash diets for
of males, as they experience less growth of muscle and weight loss.
bone tissue and more fat deposition.
Eating disorders(anorexia nervosa, bulimia nervosa,
● The male adolescent growth spurt begins at 12 or 13 years
binge eating disorder) commonly begin during
of age, peaks at 14 years, and is completed by 21 years.
adolescence. These disorders are discussed further
● Eating habits of adolescents are often inadequate in
in the MENTAL HEALTH REVIEW MODULE, CHAPTER 19:
meeting recommended nutritional intake goals.
EATING DISORDERS.
Adolescent pregnancy
NUTRITIONAL CONSIDERATIONS ● The physiologic demands of a growing fetus
compromise the adolescent’s needs for their own
● Energy requirements average 2,000 cal/day for a
unfinished growth and development.
12‑ to 18‑year‑old female and 2,200 to 2,800 cal/day for ● Inconsistent eating and poor food choices place the
a 12‑ to 18‑year‑old male.
adolescent at risk for anemia, pregnancy‑induced
● The USDA reports that the average U.S. adolescent
hypertension, gestational diabetes, premature labor,
consumes a diet deficient in folate, vitamins A and E,
miscarriage, and delivery of a newborn of low birth weight.
iron, zinc, magnesium, calcium, and fiber. This trend is
more pronounced in females than males.
Diets of adolescents generally exceed recommendations
NURSING ASSESSMENT/DATA
●
for total fat, saturated fat, cholesterol, sodium, and sugar.

● Nursing assessments should include a determination of
NUTRITIONAL RISKS the following in the adolescent.
◯ Typical 24‑hr food intake
Eating and snacking patternspromote essential ◯ Weight patterns, current weight, and body mass
nutrient deficiencies (calcium, vitamins, iron, fiber) and

index (BMI)
overconsumption of sugars, fat, and sodium. ◯ Attitude about current weight
● Adolescents tend to skip meals, especially breakfast, and
◯ Use of nutritional supplements, vitamins,
eat more meals away from home.

and minerals
● Foods are often selected from vending machines, ◯ Medical history and use of prescription medications
convenience stores, and fast food restaurants. These ◯ Use of over‑the‑counter medications
foods are typically high in fat, sugar, and sodium. ◯ Use of substances (marijuana, alcohol, tobacco)
● Carbonated beverages can replace milk and fruit juices ◯ Level of daily physical activity
in the diet with resulting deficiencies in vitamin C, ● Assess for findings of an eating disorder. This
riboflavin, phosphorous, and calcium.
can include an evaluation of the adolescent’s
Increased need for iron laboratory values.
● Females 14 to 18 years of age require 15 mg/day of iron ● Nursing assessments should include strategies that
to support expansion of blood volume and blood loss promote health for the adolescent.
during menstruation. ◯ Educate the adolescent on using MyPlate to meet
● Males 14 to 18 years of age require 11 mg/day of iron to energy and nutrient needs with three regular meals
support expansion of muscle mass and blood volume. and snacks.
◯ Stress the importance of meeting calcium needs by
Inadequate calcium intakecan predispose the adolescent

including low‑fat milk, yogurt, and cheese in the diet.
to osteoporosis later in life. ◯ Educate the adolescent on how to select and prepare
● During adolescence, 45% of bone mass is added.
nutrient‑dense snack foods: unbuttered, unsalted
● Normal blood‑calcium levels are maintained by drawing
popcorn; pretzels; fresh fruit; string cheese;
calcium from the bones if calcium intake is low.
smoothies made with low‑fat yogurt, skim milk, or
● Adolescents require at least 1,300 mg/day of calcium,
reduced‑calorie fruit juice; and raw vegetables with

which can be achieved by three to four servings from
low‑fat dips.
the dairy food group. ◯ Encourage participation in vigorous physical activity
at least three times per week.

◯ Refer pregnant adolescents to the Women, Infant, and
Children (WIC) nutrition subsidy program.

◯ Provide individual and group counseling for
adolescents who have findings of eating disorders.

Adulthood and BALANCED DIET AND NUTRIENT NEEDS
older adulthood MyPlate suggests the following daily food intake for adults
and older adults who get less than 30 min of moderate
● A balanced diet for all adults consists of 45% to 65% physical activity most days. (7.3)
carbohydrates and 20% to 35% fat (with 10% or less from
Grains: Select whole grains.
saturated fats).
● The recommended amount for protein is unchanged in Vegetables: Select orange and dark green leafy vegetables.
adults and older adults. However, many nutrition experts
Fruits: Select fresh, dried, canned, or juices. Avoid fruits
believe that protein requirements increase in older adults.
with added sugar.
● Older adults need to reduce total caloric intake. This is due
to the decrease in basal metabolic rate that occurs from Make half your plate vegetables and fruits.
the decrease in lean body mass that develops
Milk, yogurt, and cheese group: One cup of milk or plain
with aging.
yogurt is equivalent to 1 ½ oz of natural cheese or 2 oz
● Reduced caloric intake predisposes the older adult for
processed cheese.
development of nutrient deficiencies.
● Older adults can have physical, mental, and social changes Protein foods group: Includes meat, fish, poultry,
that affect their ability to purchase, prepare, and digest dry beans, eggs, soy products, seeds, and nuts. One
foods and nutrients. ounce‑equivalent equals 1 oz meat, fish, or poultry (baked,
● Dehydration is the most common fluid and electrolyte grilled, broiled); ¼ cup cooked beans; 1 egg; 1 tbsp peanut
imbalance in older adults. Fluid needs increase with butter; or ½ oz nuts or seeds. Use lean meats.
medication‑induced fluid losses. Some disease processes
Oils: Use vegetable oils (except palm and coconut). One
necessitate fluid restrictions.
tbsp of oil equals 3 tsp equivalent; 1 tbsp equals 2 ½ tsp
● BMI should be between 18.5 and 24.9. There is an
dietary intake; and 1 oz nuts equals 3 tsp oils (except
increased risk for both overweight and underweight
hazelnut, which equals 4 tsp).
older adult clients. Overweight adults are more prone to
hypertension, diabetes mellitus, and stroke. Discretionary calories: 132 to 362 discretionary calories
are permitted per day. These add up quickly and can be
from more than one food group.
NUTRITIONAL CONCERNS Minerals: Calcium requirements increase for older adults
● A 24‑hr dietary intake is helpful in determining the as the efficiency of calcium absorption decreases with age.
need for dietary education.
Vitamins: Vitamins A, D, C, E, B6, and B12 can be decreased
● Older adults can have oral problems (ill‑fitting dentures,
in older adults. Supplemental vitamins are recommended.
difficulty chewing or swallowing), and a decrease in
salivation or poor dental health.
● Older adults have decreased cellular function and
reduced body reserves, leading to decreased absorption
of multiple vitamins and minerals as well as reductions
in insulin production and sensitivity.
● Older adults have a decreased lean muscle mass.
Exercise can help to counteract muscle mass loss.
● The loss of calcium can result in
decreased bone density in older adults.
7.3 MyPlate recommendations for adults

MALES FEMALES
19 TO 31 TO 19 TO 31 TO
30 YEARS 50 YEARS 51+ YEARS 30 YEARS 50 YEARS 51+ YEARS
Calories 2,400 2,200 2,000 2,000 1,800 1,600

1
Fruits 2 cups 2 cups 2 cups 2 cups 1 ½ cups
½ cups
Vegetables 3 cups 3 cups 2 ½ cups 2 ½ cups 2 ½ cups 2 cups
Grains 8 oz 7 oz 6 oz 6 oz 6 oz 5 oz
Protein 6 ½ oz‑eq 6 oz‑eq 5 ½ oz‑eq 5 ½ oz‑eq 5 oz‑eq 5 oz‑eq
Milk 3 cups 3 cups 3 cups 3 cups 3 cups 3 cups
Oils 7 tsp 6 tsp 6 tsp 6 tsp 5 tsp 5 tsp

Source: United States Department of Agriculture. ChooseMyPlate.gov.
Retrieved December 22, 2015, from www.choosemyplate.gov

REGULAR EXERCISE FLUID INTAKE
● All adults should exercise at a moderate or vigorous ● The long‑held standard of consuming eight 8‑oz glasses
pace for at least 150 min per week. Adults who cannot of liquid per day has been tempered by evidence that
do 150 min of moderate activity should be as physically dehydration is not imminent even when less than 64 oz
active as tolerated. of fluid is consumed.
● Moderate activities include gardening/yard work, golf, ● Solid foods provide varying amounts of water, making it
dancing, and walking briskly. possible to get adequate fluid despite low beverage intake.
● The loss of lean muscle mass is part of normal aging ● For healthy adults, it is generally acceptable to allow
and can be decreased with regular exercise. The loss of normal drinking and eating habits to provide needed fluids.
lean muscle can be associated with a decrease in total ● Encourage water and natural juices, and discourage
protein and insulin sensitivity. drinking only soda pop and other liquids that have caffeine.
● Regular exercise can improve bone density, relieve
depression, and enhance cardiovascular and
respiratory function. NURSING ASSESSMENT/DATA
Nursing assessments should include a dietary profile
POTENTIAL EFFECT OF PHYSICAL,
●
of the adult or older adult. Medical history, medication

MENTAL, AND SOCIAL CHANGES regimen, mobility, social practices, mental status, and
● Diseases and treatments can interfere with nutrient and financial circumstances are important components of
food absorption, and utilization. the assessment.
◯ Aging adults are at an increased risk for developing ● Nurses should provide education about dietary practices
osteoporosis (decreasing total bone mass and for the adult and older adult, while additionally
deterioration of bone tissue). Adequate calcium and providing referrals to registered dietitians and
vitamin D intake with regular weight‑bearing community agencies when needed.
exercise is important for maximizing bone density.
◯ Musculoskeletal concerns, such as arthritis, cause
pain that can interfere with the purchase and

preparation of foods.
◯ Dementia can make shopping, storing, and cooking
food difficult.
● Medications can cause electrolyte losses.
● Loss of smell and vision interfere with the interest in
eating food.
● Older adults can have difficulty chewing, in which case
mincing or chopping food is helpful. They can have
difficulty swallowing food, and thickened liquids can
decrease the risk for aspiration.
● Social isolation, loss of a partner, and mental
deterioration can cause poor nutrition in adult and older
adult clients. Encourage socialization and refer to a
senior center or program.
● A fixed income can make it difficult for older adults to
purchase needed foods. Refer to food programs, senior
centers, and food banks. Meals on Wheels programs are
available for housebound older adults.

1. A nurse at a community center is providing A community health nurse is teaching a group of

guardians the importance of adequate vitamin D
nutrition counseling for a group of older adult
intake for children. Use the ATI Active Learning
clients. Which of the following information should
Template: Basic Concept to complete this item.
the nurse include? (Select all that apply.)
A. Increase protein to 50% of daily calories. UNDERLYING PRINCIPLES
B. The need for vitamins and minerals can increase. ●
Explain why vitamin D is important for children.
C. Up to 35% of daily calories should come from fat. ●
Identify at least two sources of vitamin D.
D. At least 45% of daily calories should
come from carbohydrates.
E. Fruits and vegetables should make
up one-third of each meal.
2. A nurse is assessing a 6‑month‑old infant who has a

lactose intolerance. Which of the following findings
should the nurse expect? (Select all that apply.)
A. Abdominal distention
B. Flatus
C. Hypoactive bowel sounds
D. Occasional diarrhea
E. Visible peristalsis
3. A nurse is educating the parents of a toddler about

appropriate snack foods. Which of the following foods
should the nurse include? (Select all that apply.)
A. Graham crackers
B. Apple slices
C. Raisins
D. Jelly beans
E. Cheese cubes
4. A nurse is teaching a group of clients who are pregnant

about iron‑rich foods. Which of the following foods
should the nurse include? (Select all that apply.)
A. Beans
B. Fish
C. Dairy products
D. Lean red meats
E. Apples
5. A school nurse is teaching a group of adolescents about

healthy snack food choices. Which of the following
foods should the nurse include? (Select all that apply.)
A. Carrot sticks with low‑fat dip
B. Cheese and crackers
C. Unbuttered popcorn
D. French fries
E. Hot dog

1. A. Protein requirements do not increase Using the ATI Active Learning Template: Basic Concept
during older adulthood. UNDERLYING PRINCIPLES
B. CORRECT: Age-related changes can reduce the ●
Vitamin D is essential for the development of healthy
body’s ability to absorb vitamins and minerals. bones. It is important in children because their bones
C. CORRECT: Adult clients should obtain 20% are newly formed and continually growing.
to 35% of daily calories from fat. ●
Vitamin D aids in the absorption of calcium into the bones. Sunlight
D. CORRECT: Adult clients should obtain 45% to
exposure, milk (cow’s, soy), and fatty fish are sources of vitamin D.
65% of daily calories from carbohydrates.
E. Fruits and vegetables should make up one-half of each meal. NCLEX® Connection: Health Promotion and Maintenance,
NCLEX Connection: Health Promotion and Maintenance,
® Aging Process
2. A. CORRECT: Abdominal distention is a finding

associated with a lactose intolerance.
B. CORRECT: Flatus is a finding associated
with a lactose intolerance.
C. Hypoactive bowel sounds are not associated
D. CORRECT: Occasional diarrhea is a finding
associated with a lactose intolerance.
E. Visible peristalsis is not associated
Aging Process
3. A. CORRECT: Graham crackers are appropriate

snack foods for toddlers.
B. CORRECT: Apple slices are appropriate
C. Raisins are difficult to chew and pose a choking hazard.
D. Jelly beans are difficult to swallow, pose a choking
risk, and are high in sugar content.
E. CORRECT: Cheese cubes are appropriate
Aging Process
4. A. CORRECT: Iron‑rich foods include beans.

B. CORRECT: Iron‑rich foods include fish.
C. Dairy products are not rich in iron.
D. CORRECT: Iron‑rich foods include lean red meats.
E. Apples are not rich in iron.
Ante/Intra/Postpartum and Newborn Care
5. A. CORRECT: Carrot sticks with low‑fat ranch

dip are a healthy snack selection.
B. CORRECT: Cheese and crackers are
a healthy snack selection.
C. CORRECT: Unbuttered popcorn is a healthy snack selection.
D. French fries are not a healthy food choice
because they are high in fat.
E. Hot dogs are not a healthy food choice because
they are high in sodium and fat.
Aging Process

NCLEX® Connections

Manage the client’s nutritional intake.
Provide client nutrition through tube feedings.
Evaluate side effects of client tube feedings and intervene, as needed.
Monitor the client's nutritional status.
Pharmacological and Parental Therapies

TOTAL PARENTERAL NUTRITION (TPN)
Administer parenteral nutrition and evaluate client response.
Apply knowledge of nursing procedures and psychomotor
skills when caring for a client receiving TPN.
Reduction of Risk Potential

LABORATORY VALUES: Compare client laboratory
values to normal laboratory values.
POTENTIAL FOR ALTERATIONS IN BODY SYSTEMS

Identify client potential for skin breakdown.
Identify client potential for aspiration.

CHAPTER 8
UNIT 2 CLINICAL NUTRITION Full liquid diet
CHAPTER 8 Modified Diets ● Consists of foods that are liquid at room temperature
including plain ice cream and strained cereals. Some
facilities include pureed vegetables.
Offers more variety and nutritional support than a clear
Therapeutic nutrition is the role of food and
●
liquid diet but might require supplementation of protein

nutrition in the treatment of diseases and and calories if used more than 3 days.
Indications include a transition from liquid to soft
disorders. The basic diet becomes therapeutic
●
diets, postoperative recovery, acute gastritis, febrile

when modifications are made to meet client conditions, and intolerance of solid foods.
Use cautiously with clients who have dysphagia
needs. Modifications can include increasing or
●
(difficulty swallowing) unless liquids are thickened

decreasing caloric intake, fiber, or other specific appropriately.
Many dietary manuals have removed the full liquid diet,
nutrients; omitting specific foods; and modifying
●
so it might be used infrequently.

the consistency of foods.
Blenderized liquid (pureed) diet
It is important to remember, however, that food ● Consists of liquids and foods that are pureed to
meets both physiological and psychological liquid form.
The composition and consistency of a pureed diet varies,
needs and should be a pleasant experience for
●
depending on the client’s needs.

the hospitalized client. Nurses should ● Modify with regard to calories, protein, fat, or other
nutrients based on the dietary needs of the client.
collaborate with the dietitian for nutritional or ● Adding broth, milk, gravy, cream, soup, tomato sauce, or
dietary concerns. fruit juice to foods in place of water provides additional
calories and nutritional value.
● Each food is pureed separately to preserve
TYPES OF MODIFIED DIETS individual flavor.
● Indications include clients who have chewing or
Regular diet (normal or house diet) swallowing difficulties, oral or facial surgery, and
wired jaws.
● Indicated for clients who do not need dietary
restrictions. The diet is adjusted to meet age specific
Soft (bland, low‑fiber) diet
needs throughout the life cycle.
● Many health care facilities offer self‑select menus for ● Contains whole foods that are low in fiber, lightly
regular diets. seasoned, and easily digested.
● Modify the regular diet to accommodate individual ● Food supplements or snacks in between meals
preferences, food habits, and ethnic values. add calories.
● Food selections vary and can include smooth, creamy, or
Clear liquid diet crisp textures. Raw fruits and vegetables, coarse breads
and cereals, beans, and other potentially gas‑forming
● Consists of foods or fluids that have no residue and are
foods are excluded.
liquid at room temperature. ● Indications include clients transitioning between
● Primarily to prevent dehydration and relieve thirst,
full liquid and regular diets, and those who
the diet consists of water and carbohydrates. This diet
have acute infections, chewing difficulties, or
requires minimal digestion, leaves minimal residue, and
gastrointestinal disorders.
is non‑gas‑forming. It is nutritionally inadequate and ● Predisposes clients to constipation.
should not be used long‑term.
● Indications include acute illness, reduction of colon
fecal material prior to certain diagnostic tests and
procedures, acute gastrointestinal disorders, and some
postoperative recovery.
● Acceptable foods are water, tea, coffee, fat‑free
broth, carbonated beverages, clear juices, ginger ale,
and gelatin.
NUTRITION FOR NURSING CHAPTER 8 Modified Diets 51

Mechanical soft diet NURSING ASSESSMENT/DATA
● A regular diet that is modified in texture. The diet
composition is altered for specific nutrient needs. ● Ongoing assessment parameters include daily weights,
● Includes foods that require minimal chewing before prescribed laboratory tests, and an evaluation of a
swallowing (ground meats, canned fruits, softly client’s nutritional and energy needs and response to
cooked vegetables). diet therapy.
● Butter, gravies, sugar, or honey can be added to increase ● Observe and document nutritional intake. Perform a
calorie intake. calorie count if needed to determine caloric intake and
● Excludes harder foods (dried fruits, most raw fruits and to evaluate adequacy.
vegetables, foods containing seeds and nuts). ● Provide education and support for diet therapy.
● Indications include limited chewing ability; dysphagia, ● A prescription for a diet as tolerated permits a client’s
poorly fitting dentures, and clients who are edentulous preferences while taking into consideration the client’s
(without teeth); surgery to the head, neck, or mouth; ability to eat. Assess the client for hunger, appetite, and
and strictures of the intestinal tract. nausea when planning the most appropriate diet, and
consult with a dietitian.
Dysphagia diet ● Dietary intake is progressively increased (from nothing
by mouth to clear liquids to regular diet) following a
● Prescribed when swallowing is impaired (following
major surgery. Nurses should assess for the return of
a stroke).
bowel function (as evidenced by auscultation of bowel
● Manifestations of dysphagia are drooling, pocketing
sounds and the passage of flatus) before advancing a
food, choking, or gagging.
client’s diet.
LEVELS OF SOLID TEXTURES
● Level 1: Pureed. Foods are totally pureed to a smooth
consistency with a pudding‑like texture (pureed fruits,
vegetables, meats, soups, scrambled eggs, pudding,
custard, applesauce).
● Level 2: Mechanically altered. Soft‑textured, moist,
semi‑solid foods that are easily chewed and swallowed
(ground meat served with gravy, chicken or tuna salad,
well‑moistened pancakes with syrup, poached eggs, soft
canned or cooked fruit).
● Level 3: Advanced. Near‑normal textured foods that are
moist (moist tender meats or casseroles, breads that are
not crusty, moist potatoes, soups, rice, and stuffing).
Hard, sticky foods are eliminated.
LEVELS OF LIQUID CONSISTENCIES

● Thin: Non‑restrictive. Consists of all unthickened
beverages and supplements (clear juices, frozen yogurt,
ice cream, milk, soda, and broth).
● Nectar‑like: Liquids that are thin enough to sip through
a straw but thicker than water. Consistency of a heavy
syrup (nectars, cream soups, buttermilk, and thin
milkshakes).
● Honey‑like: Liquids that do not maintain their shape
when poured but are thickened. They can be eaten with
a spoon but cannot be sipped through a straw (honey,
tomato sauce, and yogurt).
● Spoon‑thick: Liquids thickened to maintain their shape
and need to be eaten with a spoon (pudding, custard,
hot cereals).
52 CHAPTER 8 Modified Diets CONTENT MASTERY SERIES

1. A nurse is caring for a client following an A nurse is planning care for a newly admitted client
appendectomy who has a postoperative who has a prescription for a regular diet. Use the ATI
prescription that reads “discontinue NPO Active Learning Template: Basic Concept to complete
status; advance diet as tolerated.” Which of the this item to include the following sections:
following are appropriate for the nurse to offer
UNDERLYING PRINCIPLES: Identify the
the client initially? (Select all that apply.)
indication for a regular diet.
A. Applesauce
NURSING INTERVENTIONS
B. Chicken broth
●
Identify at least two assessments that are
C. Sherbet
appropriate to determine the need for dietary
D. Wheat toast modifications to the regular diet.
E. Cranberry juice ●
Identify at least two nursing actions that are appropriate
to monitor the client’s response to diet therapy.
2. A nurse is caring for a client who is to receive a Level
2 dysphagia diet due to a recent stroke. Which of the
following dietary selections is most appropriate?
A. Turkey sandwich
B. Poached eggs
C. Peanut butter crackers
D. Granola
3. A nurse is performing dietary needs assessments

for a group of clients. A blenderized
liquid diet is appropriate for which of the
following clients? (Select all that apply.)
A. A client who has a wired jaw due
to a motor vehicle crash
B. A client who is 24 hr postoperative following
temporomandibular joint repair
C. A client who has difficulty chewing
due to oral surgery
D. A client who has hypercholesterolemia
due to coronary artery disease
E. A client who is scheduled for a
colonoscopy the next morning
4. A nurse is caring for a client who has multiple

sclerosis and requires liquids with honey‑like
thickness. Which of the following foods can the
client consume without adding a thickening agent?
A. Ice cream
B. Yogurt
C. Buttermilk
D. Cream of chicken soup
5. A nurse is assisting a client who has a prescription

for a mechanical soft diet with food selections.
Which of the following are appropriate selections
by the client? (Select all that apply.)
A. Dried prunes
B. Ground turkey
C. Mashed carrots
D. Fresh strawberries
E. Cottage cheese
NUTRITION FOR NURSING CHAPTER 8 Modified Diets 53

1. A. Applesauce is appropriate once the client’s Using the ATI Active Learning Template: Basic Concept
diet begins to advance. It is not appropriate as
UNDERLYING PRINCIPLES: A regular diet is indicated
an initial postoperative selection.
for clients who do not need dietary restrictions.
B. CORRECT: Chicken broth is a clear liquid, which is appropriate
as an initial selection for a client who is postoperative. NURSING INTERVENTIONS
C. Sherbet is appropriate once the client’s diet
Assessments to determine the need for dietary modification
begins to advance. It is not appropriate as
an initial postoperative selection.
●
Individual preferences
D. Wheat toast is appropriate once the client’s
●
Food habits
diet begins to advance. It is not appropriate ●
Ethnic values or practices
as an initial postoperative selection. Assessments to monitor the client’s response to diet therapy
E. CORRECT: Cranberry juice is a clear liquid, ●
Obtain daily weight
which is appropriate as an initial selection
for a client who is postoperative.
●
Monitor laboratory values
●
Monitor energy level
®
●
Observe and document nutritional intake
Evaluate understanding of diet therapy
2. A. A Level 2 diet requires foods that are moist and semi‑solid. Illness Management
A turkey sandwich would be too dry, and breads are not
allowed on the Level 2 diet. This would be an appropriate
choice for a client receiving a regular diet.
B. CORRECT: A Level 2 diet requires foods that are
moist and semi‑solid, such as a poached egg.
C. A Level 2 diet requires foods that are moist and
semi‑solid. Peanut butter crackers are too sticky and
dry for a Level 2 diet. This would be an appropriate
choice for a client who is receiving a regular diet.
D. A Level 2 diet requires foods that are moist and
semi‑solid. Granola is too hard and crunchy
for a client receiving a Level 2 diet.
NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures
3. A. CORRECT: A blenderized liquid diet is appropriate

for a client who has a wired jaw.
B. CORRECT: A blenderized liquid diet is appropriate
for a client following oral surgery.
C. CORRECT: A blenderized liquid diet is appropriate
for a client who has difficulty chewing.
D. The client’s history does not indicate a
need for a blenderized liquid diet.
E. A client who is scheduled for a colonoscopy should receive
a clear liquid, rather than a blenderized liquid, diet.
NCLEX® Connection: Reduction of Risk Potential,
Potential for Alterations in Body Systems
4. A. Identify ice cream as a thin liquid that can place

the client at risk for aspiration.
B. CORRECT: Identify yogurt as a honey‑like liquid, because
it can be eaten with a spoon but not sipped with a straw.
This client can also safely receive spoon‑thick liquids.
C. Identify buttermilk as a nectar‑like liquid that
can place the client at risk for aspiration.
D. Identify cream of chicken soup as a nectar‑like liquid
that can place the client at risk for aspiration.
5. A. Dried fruits are excluded from a mechanical soft

diet due to potential chewing difficulty.
B. CORRECT: Ground meats require minimal
chewing before swallowing and are therefore
appropriate for a mechanical soft diet.
C. CORRECT: Mashed carrots require minimal
chewing before swallowing and are therefore
D. Fresh strawberries are excluded from a mechanical soft
diet due to seeds and potential chewing difficulty.
E. CORRECT: Cottage cheese requires minimal
chewing before swallowing and is therefore
54 CHAPTER 8 Modified Diets CONTENT MASTERY SERIES

CHAPTER 9
UNIT 2 CLINICAL NUTRITION ENTERAL FEEDING ROUTES
CHAPTER 9 Enteral Nutrition A client’s medical status and the anticipated length of
time that a tube feeding will be required determine the
type of tube used.
Enteral nutrition (EN) is used when a client Nasoenteric tubes

cannot consume adequate nutrients and calories Nasoenteric tubes are short‑term (less than 3 to 4 weeks).
orally, but has a gastrointestinal (GI) system that ● Nasogastric (NG) tubes are passed through the nose to
the stomach.
functions at least partially. EN is contraindicated ● Nasoduodenal tubes pass from the nose through the
when the GI tract is nonfunctional (paralytic ileus stomach and end in the duodenum.
Nasojejunal tubes pass from the nose through the
or intestinal obstruction).
●
stomach and end in the jejunum.

Nasoduodenal and nasojejunal tubes are used in clients
EN is administered when a client has a condition
●
who are at risk for aspiration or who have delayed

(burns, trauma, prolonged intubation, eating gastric emptying (gastroparesis).
For an infant, a feeding tube is inserted from the nares
disorders, radiation therapy, chemotherapy, liver
●
or mouth into the stomach. This flexible tube can

or renal dysfunction, infection, inflammatory remain taped in place for up to 30 days.
bowel disease) that hinders nutritional status. Ostomies

EN is also administered when a client is Ostomies are placed for clients requiring long‑term enteral
neuromuscularly impaired and cannot chew or feeding, who are at high risk for aspiration or when a
nasal obstruction makes insertion through the nose
swallow food. impossible. An ostomy is a surgically created opening
(stoma); ostomies can be used to deliver feedings directly
EN feeding or gavage feeding for an infant is into the stomach or intestines.
used when an infant is too weak for sucking,
Gastrostomy tubes are endoscopically or surgically
unable to coordinate swallowing, and lacks a inserted into the stomach.
A percutaneous endoscopic gastrostomy (PEG) tube is
gag reflex. Gavage feeding is implemented to
●
placed with the aid of an endoscope.

conserve energy when an infant is attempting ● An alternative to the PEG tube is a skin‑level gastrostomy
tube, which is known as a low‑profile gastrostomy
to breast feed or bottle feed, but becomes device. It is more comfortable, longer‑lasting, and fully
fatigued, weak, or cyanotic. immersible in water. Checking for residual is more
difficult with this device because of the close proximity of
EN consists of a commercial formula the button on the skin.
Gastrostomy tube feedings are generally well‑tolerated
administered by a tube into the stomach or
●
because the stomach chamber holds and releases feedings

small intestine. Enteral feedings most closely in a physiologic manner that promotes effective digestion.
As a result, dumping syndrome is usually avoided.
utilize the body’s own digestive and metabolic
Jejunostomy tubes are surgically inserted into the jejunal
routes. EN can augment an oral diet or be the
portion of the small intestine (jejunum).
sole source of nutrition.
ENTERAL FEEDING FORMULAS

● Commercial products are preferred over home‑blended
ingredients because the nutrient composition,
consistency and safety can be better insured.
● Standard and elemental formulas are the two primary
types of enteral feeding formulas available. They are
categorized by the complexity of the proteins included.
● Other formula types include disease-specific (COPD,
kidney disease, immunocompromise) and modular
formulas that typically contain a single nutrient
(protein, carbohydrates, fat).
NUTRITION FOR NURSING CHAPTER 9 Enteral Nutrition 55

Standard formulas ENTERAL FEEDING DELIVERY METHODS
● Also called polymeric or intact, these formulas are The delivery method is dependent on the type and location
composed of whole proteins (milk, meat, eggs) or of the feeding tube, type of formula administered, and the
protein isolates. client’s medical status and GI function.
● They require a functioning gastrointestinal tract.
● Most provide 1 to 2 cal/mL. Continuous infusion method
Formula is administered at a continuous rate over a
Elemental formulas
24‑hr period.
● These formulas are made up of nutrients that are ● Infusion pumps help ensure consistent flow rates.
partially or fully hydrolyzed or broken down. ● This method is recommended for critically ill clients
● These formulas are used for clients who have a because of its association with smaller residual volumes,
partially functioning gastrointestinal tract, or those and a lower risk of aspiration and diarrhea.
who have an impaired ability to digest and absorb ● Many facilities require measuring gastric residual
foods (inflammatory bowel disease, liver failure, cystic volume (GRV) every 4 to 6 hr. Other facilities are
fibrosis, pancreatic disorders, and short-gut syndrome). moving away from this practice, as there is insufficient
● Most provide 1.0 to 1.5 cal/mL. High‑calorie formulas evidence to support it.
provide 1.5 to 2.0 cal/mL. Partially hydrolyzed formulas ● Feeding tubes should be flushed with 20 to 50 mL of
provide other nutrients in simpler forms that require warm water every 4 hr to maintain tube patency and
little or no digestion. provide hydration.
● Check facility policy regarding withholding feedings
PACKAGING for high gastric residual volume (GRV). Typically, the
amount is more than 250 mL on two consecutive
Tube feedings can be packaged in cans or prefilled bags.
measurements for an adult or more than one-fourth the
● Prefilled bags and administration tubing should be
prescribed volume for children.
discarded every 24 hr or according to facility policy,
even if they are not empty.
Cyclic feeding
● Cans can be used to add formula to a generic bag to
infuse via a pump, or for feedings directly from a syringe. ● Formula is administered at a continuous rate for 8 to
20 hr, often during sleeping hours.
Often used for transition from total EN to oral intake.
DETERMINING APPROPRIATE FORMULA
●
Caloric density determines the volume of the formula Intermittent tube feeding
necessary to meet the caloric needs of a client (1.0 to
Formula is administered every 4 to 6 hr in equal portions
1.2 cal/mL).
of 250 to 400 mL, typically over a 30‑ to 60‑min time
Water content in formulas with 1.0 cal/mL should be frame, usually by gravity drip or an electronic pump.
850 mL water per 1 L formula. Higher‑calorie formulas Feeding times can range from 20 to 90 min.
have lower water content. The client might need ● This is often used for noncritical clients, home tube
additional free water to meet hydration needs. feedings, and clients in rehabilitation.
● Feeding resembles normal pattern of nutrient intake.
Osmolality of the formula is determined by the amount of ● Facilities might require measurement prior to initiating
dissolved particles of sugars, amino acids, and electrolytes.
the feeding and held if the amount is greater than the
● Osmolality is increased if the formula contains more
amount stated in facility policy or prescription.
digested protein.
Hydrolyzed or partially hydrolyzed (predigested)
Bolus feeding
●
formulas are higher in osmolality than standard

formulas. They are also lactose‑free. A variation of intermittent feeding using a large syringe
attached to the feeding tube. A large volume of formula
Fiber and residue content
(700 mL maximum, usual volume is 250 to 400 mL) is
● Standard formulas are low in residue which makes
administered over a short period of time (5 to 30 min) four
them less likely to produce abdominal distention or gas.
to six times daily.
These products are optimal for clients who have been on ● The rate of administration for a premature or small
bowel rest, are postoperative following bowel surgery, or
infant should be no greater than 5 mL every 10 min, and
have GI related disease processes. Hydrolyzed formulas
10 mL/min in older infants and children.
are considered residue-free. ● Bolus feedings are delivered directly into the stomach;
● Standard formulas that are enriched with fiber are
they are contraindicated for tubes placed into the
recommended for clients who have constipation or
jejunum or duodenum. They can be poorly tolerated and
diarrhea to normalize bowel movements.
can cause dumping syndrome.
The presence of other nutrients include fats and
carbohydrates, which can be modified according
to a client’s disease processes (respiratory disease,
malabsorption, diabetes mellitus, kidney disease).
56 CHAPTER 9 Enteral Nutrition CONTENT MASTERY SERIES

Online Video: Enteral Tube Feeding
NURSING ACTIONS ONGOING CARE

● Monitor daily weights and I&O.
PREPARATION OF THE CLIENT ● Obtain gastric residuals every 4 to 6 hr.
● Monitor electrolytes, BUN, creatinine,
● Prior to instilling enteral feeding, tube placement
minerals, and CBC.
should be verified by radiography. The tube should then ● Monitor the tube site for manifestations of infection or
be marked with indelible ink or adhesive tape where it
intolerance (pain, redness, swelling, drainage).
exits the nose and documented. ● Monitor the character and frequency of
● Measure the tube each shift and prior to each feeding to
bowel movements.
ensure the tube has not migrated. Aspirating gastric ● When appropriate, administer medications through a
contents and measuring pH levels are not considered
feeding tube.
reliable methods of verifying initial placement. ◯ Feeding should be stopped prior to
● Verify the presence of bowel sounds.
administering medications.
● To maintain feeding tube patency, it is flushed routinely ◯ The tubing should be flushed with water (15 to 30 mL)
with warm water.

before and after the medication is administered,
● Check gastric residuals if required by the facility,
and between each medication if more than one
typically every 4 to 6 hr. In some cases, policy or
is administered.
prescription will indicate whether to return the contents ◯ Medications should only be dissolved in water.
to the client’s stomach or to hold or reduce feedings. ◯ Liquid medications should be used when possible.
◯ The volume that indicates a need for intervention
■ For an infant or child, the volume of water to flush
for adults ranges from 100 to 500 mL in a

is 1.5 times the amount predetermined to flush an
single measurement, or at least 250 mL on two
unused feeding tube of the same size.
consecutive checks. ■ More water can be required to flush the tubing
◯ Returning residual contents to the stomach
following some medications (suspensions).

prevents electrolyte and fluid imbalance. However,
returning large volumes could increase the risk
for complications. INTERVENTIONS
● The head of the bed should be elevated at least 30º ● Weaning occurs as oral consumption increases. Enteral
during feedings and for at least 30 to 60 min afterward
feedings can be discontinued when the client consumes
to lessen the risk of aspiration.
two‑thirds of protein and calorie needs orally for
● Burp the infant following the feeding if the infant’s
3 to 5 days.
condition allows. ● A client who is NPO will require meticulous oral care.
● Begin with a small volume of full‑strength formula. ● A client can require nutritional support service at home
Increase volume in intervals as tolerated until the
for long‑term EN. A interprofessional team comprised of
desired volume is achieved.
a nurse, dietitian, pharmacist, and the provider
● Administer the feeding solution at room temperature to
monitors the client’s weight, electrolyte balance, and
decrease gastrointestinal discomfort.
overall physical condition.
● Do not heat formulas in a microwave as this can result ● Transitioning from EN to an oral diet requires the
in uneven temperatures within the solution.
client to receive adequate nutrition as food items
BASELINE PARAMETERS are reintroduced.
● Obtain height, weight, and body mass index. ◯ Begin the transition process by stopping the EN for
● Monitor blood urea nitrogen (BUN), albumin, 1 hr before a meal.

hemoglobin, hematocrit, glucose, and electrolyte levels. ◯ Slowly increase the frequency of the meals until the
● A registered dietitian will work with the provider to client is eating up to six small meals daily.
evaluate nutritional and energy needs. ◯ When oral intake equals 500 to 750 cal/day, the
● Verify gastrointestinal function. Dysfunction of the GI continuous tube feeding is administered only during
tract can indicate a need for alternate forms of nutrition. the night.

COMPLICATIONS Metabolic complications
Include dehydration, hyperglycemia, electrolyte
Gastrointestinal complications
imbalances, fluid overload, refeeding syndrome, rapid
● Constipation, diarrhea, cramping, pain, abdominal weight gain
distention, dumping syndrome, nausea, and vomiting.
NURSING ACTIONS
● Dumping syndrome occurs due to rapid emptying of ● Provide adequate amounts of free water.
the formula into the small intestine, resulting in a fluid ● Consider changing formula to one that is isotonic.
shift. Manifestations include dizziness, rapid pulse, ● Restrict fluids if fluid overload occurs.
diaphoresis, pallor, and lightheadedness. ● Monitor electrolytes, blood glucose, and weights.
NURSING ACTIONS ● Monitor respiratory, cardiovascular, and
● Consider a change in formula. neurologic status.
● Decrease the flow rate or total volume of the infusion. ● Administer insulin per prescribed protocol
● Increase the volume of free water if constipated. for hyperglycemia.
● Administer the EN at room temperature.
● Take measures to prevent bacterial contamination. Refeeding syndrome
A potentially fatal complication that occurs when a client
Mechanical complications
who is in a starvation state is started on enteral nutrition.
Tube misplacement or dislodgement; aspiration; irritation The risk is greater with parenteral nutrition than enteral.
and leakage at the insertion site; irritation of the nose,
esophagus, and mucosa; and clogging of the feeding tube. Food poisoning
NURSING ACTIONS Can result due to bacterial contamination of formula
● Confirm tube placement prior to feedings.
NURSING ACTIONS: Prevent bacterial contamination.
● Elevate the head of the bed at least 30º during ● Wash hands before handling formula or enteral products.
feedings and maintain the client in this position ● Clean equipment and tops of formula cans.
for approximately 60 min following completion of ● Use closed feeding systems.
the feeding. ● Cover and label unused cans with the client’s name,
● Administer bolus feedings over a period of 15 to 30 min.
room number, date, and time of opening.
● Flush the tubing with 15 to 30 mL of warm water every ● Refrigerate unused portions promptly for up to 24 hr.
4 hr for continuous infusion, after measuring gastric ● Replace the feeding bag, administration tubing, and any
residual, before and after bolus feedings, and between
equipment used to mix the formula every 24 hr.
each medication administration. ● Fill generic bags with only 4 hr worth of formula.
● Unclog tubing using gentle pressure with 30 to 50 mL
warm water in a 60 mL piston syringe. Carbonated
beverages are not approved for fixing a clogged tube.
Commercially-made products are available and have
been shown to effectively dissolve clotted formula.
● Do not mix medications with the formula.

1. A nurse is discussing the use of a low‑profile A nurse is providing information to a client on complications
gastrostomy device with the guardian of a child that can occur when administering an enteral nutrition.
who is receiving an enteral feeding. Which of the What information should the nurse include in the teaching?
following is an appropriate statement by the nurse? Use the ATI Active Learning Template: Basic Concept
to complete this item to include the following.
A. “The device is usually comfortable for children.”
B. “Checking residual is much easier with this device.” RELATED CONTENT: Identify three complications. List
C. “This access requires less maintenance two nursing interventions for each complication.
than a traditional nasal tube.”
D. “Mobility of the child is limited with this device.”
2. A nurse is teaching a client who is starting continuous

feedings about the various types of enteral
nutrition (EN) formulas. Which of the following
should the nurse include in the teaching?
A. Formula rich in fiber is recommended
when starting EN.
B. Standard formula contains whole protein.
C. Hydrolyzed formula is recommended
for a full‑functioning GI tract.
D. The high‑calorie formula has
increased water content.
3. A nurse is instructing a client on how to administer

cyclic enteral feedings at home. Which of the
following information should the nurse include?
A. “Give a feeding every 6 hours.”
B. “Set the feeding up before you go to bed.”
C. “Weigh yourself daily.”
D. “Flush the tube with a carbonated
beverage to dislodge clogs.”
E. “Ensure your head is elevated to 15
degrees during administration.”
4. A nurse is administering bolus enteral feedings

to a client who has malnutrition. Which
of the following are appropriate nursing
interventions? (Select all that apply.)
A. Verify the presence of bowel sounds.
B. Flush the feeding tube with warm water.
C. Elevate the head of the bed 20°.
D. Administer the feeding at room temperature.
E. Instill the formula over 60 min.
5. A nurse is preparing to administer intermittent

enteral feeding to a client. Which of
the following are appropriate nursing
interventions? (Select all that apply.)
A. Fill the feeding bag with 24 hr worth of formula.
B. Discard feeding equipment after 24 hr.
C. Place any unused formula in open
cans in the refrigerator.
D. Flush the feeding tube every 4 hr.
E. Elevate the head of the client’s bed
for 15 min after administration.

1. A. CORRECT: The gastrostomy device is more Using the ATI Active Learning Template: Basic Concept
comfortable for children because of the close RELATED CONTENT
proximity of the button on the skin.
B. Checking for residual is more difficult with this device Gastrointestinal disturbance
because of the close proximity of the button on the skin. ●
Increase the amount of free fluid if constipated.
C. Instruct the guardian to provide regular stoma care, ●
Consider a change to formula with enriched fiber if constipated.
and give information about flushing the tube. ●
Decrease the flow rate if cramping occurs.
D. The mobility of the child is increased because of ●
Give the formula at room temperature.
the close proximity of the button on the skin.
Feeding tube obstruction
●
Flush the tubing with 15 to 30 mL of warm water every 4 hr.
●
Flush before and after feedings and medication.
●
Use a piston syringe with 50 mL of warm water to unclog the tubing.
2. A. Residual‑free formula without fiber is recommended ●
Carbonated beverages are not approved
when starting EN to minimize abdominal to clear clogged enteral tubes.
distention from increased flatus.
B. CORRECT: A standard formula contains whole protein (milk, Food poisoning
meat, eggs) and requires a full‑functioning GI tract.
●
Wash hands before handling the formula or equipment.
C. Hydrolyzed formula is recommended for a partially ●
Clean tops of formula containers.
functioning digestive tract or for those who have ●
Cover and refrigerate formula up to 24 hr.
impaired ability to digest and absorb foods. ●
Replace the feeding bag and administration tubing every 24 hr.
D. Formula high in calories is low in water content.
NCLEX® Connection: Basic Care and Comfort, Complications of Diagnostic Tests/Treatments/Procedures
3. A. Include this instruction for a client who is

prescribed intermittent feedings.
B. CORRECT: Many clients administer cyclic
feedings during sleeping hours, so they are free
during the daytime to do other things.
C. CORRECT: The client should obtain a daily
weight while receiving enteral nutrition.
D. Have the client notify the provider if the tube is clogged
to obtain a commercial remedy to dislodge the tube.
E. Tell the client to elevate the head 30º or
more during administration.
4. A. CORRECT: Verify the presence of bowel sounds prior to a

bolus feeding to ensure the bowel is functioning.
B. CORRECT: Flush the feeding tube to ensure patency
before administering a bolus feeding.
C. Elevate the client’s head of bed at least 30° prior to a
bolus feeding to decrease the risk of aspiration.
D. CORRECT: Administer the bolus feeding at room
temperature to prevent abdominal cramping.
E. Instill the formula in a shorter time
period, typically 5 to 30 min.
5. A. The feeding bag should be filled with only enough formula

for 4 hr to prevent bacterial contamination.
B. CORRECT: Feeding equipment, such as the bag holding
the formula and the tubing, should be discarded
every 24 hr to prevent bacterial contamination.
C. CORRECT: The unused portion of formula should be
refrigerated up to 24 hr to prevent bacterial contamination.
D. CORRECT: Flushing the feeding tube
every 4 hr maintains patency.
E. Elevate the head of the client’s bed for 30 to 60 min
following administration to prevent aspiration.

CHAPTER 10
UNIT 2 CLINICAL NUTRITION Lipids (fats) are available in concentrations of 10%, 20%,
Total Parenteral and 30%. Lipids are formulated from a combination of

CHAPTER 10 soybean oil and/or safflower oil, and egg phospholipids,
Nutrition which gives lipids a milky or opaque appearance.

● IV lipids are contraindicated for clients who have severe
hyperlipidemia, severe hepatic disease, or an allergy to
soybean oil, eggs, or safflower oil.
Parenteral nutrition (PN) is used when a client’s ● Lipid emulsion provides the needed calories when
dextrose concentration must be reduced due to fluid
gastrointestinal tract is not functioning, or when restrictions or persistent hyperglycemia. They also
a client cannot physically or psychologically correct or prevent essential fatty acid deficiency.
Lipid emulsion provides the calories without increasing
consume sufficient nutrients orally or enterally.
●
the osmolality of the PN solution.

Based upon the client’s nutritional needs and ● Total nutrient admixtures are available that combine
lipids into the PN solution containing dextrose
anticipated duration of therapy, PN can be and amino acids, rather than administering the
given as either total parenteral nutrition (TPN) or solutions separately. Not all facilities use this
three‑in-one solution.
peripheral parenteral nutrition (PPN). ◯ Three-in-one infusions reduce body carbon dioxide
production and buildup of fat in the liver.

TPN provides a nutritionally complete solution.
Protein is provided as a mixture of essential
It can be used when caloric needs are very high,
and nonessential amino acids and is available in
when long-term therapy is indicated, or when concentrations of 3% to 20%. The client’s estimated
requirements and liver and kidney function determine the
the solution to be administered is hypertonic
amount of protein provided.
(composed of greater than 10% dextrose). It can
Other substances can be added to the PN solution by
only be administered in a central vein. pharmacy services.
● Insulin can be added to reduce the potential
PPN is administered for up to 14 days into a for hyperglycemia.
Heparin can be added to prevent fibrin buildup on the
peripheral vein. It is nutritionally incomplete
●
catheter tip.
because it has a low dextrose content. It is ● Glutamine, antioxidants, prebiotics, or probiotics might
be prescribed based on individual client needs.
indicated for clients who require short‑term
nutritional support with fewer calories per day. ! Administering any IV medication through
a PN IV line or port is contraindicated.
The solution must be isotonic and contain no
more than 10% dextrose and 5% amino acids. INDICATIONS
COMPONENTS OF PARENTERAL DIAGNOSES

NUTRITION SOLUTIONS ● TPN is commonly used in clients who need intense
PN includes amino acids, dextrose, electrolytes, vitamins, nutritional support for an extended period of time,
and trace elements in sterile water. Fats (lipids) including clients undergoing treatment for cancer,
are added to the parenteral solution or given as an bowel disorders, those who are critically ill, and those
intermittent infusion. suffering from trauma or extensive burns, as these
conditions are associated with high caloric requirements.
Carbohydrate or dextrose solutions are available ● PPN can be used when the client is unable to consume
in concentrations of 2.5% to 10% for PPN and up to
enough calories to meet metabolic needs or when
70% for TPN.
nutritional support is needed for a short time.
● A higher concentration of dextrose is often prescribed
● Clients can receive PN at home as nutrition replacement
for a client on fluid restrictions.
or to supplement nutrition. Typically, the client will
● A lower‑dextrose concentration can be used to help
have a tunneled catheter, and feedings can occur while

control hyperglycemia.
the client sleeps.
Electrolytes, vitamins, and trace elements are essential
for normal body functions. The amounts added are
dependent upon the client’s blood chemistry values
DESIRED THERAPEUTIC OUTCOMES
and physical findings, which are used to determine the ● Improved nutritional status
quantity of electrolytes. Additional vitamin K can be added ● Weight maintenance or gain
to the PN solution. ● Positive nitrogen balance
NUTRITION FOR NURSING CHAPTER 10 Total Parenteral Nutrition 61

EVIDENCE SUPPORTING EFFECTIVENESS ● Monitor for “cracking” of TPN solution. This occurs if
the calcium or phosphorous content is high or if
● Daily weight: Maintenance of baseline or gain of up
poor‑salt albumin is added. A “cracked” TPN solution
to 1 kg/day
has an oily appearance or a layer of fat on top of the
● Increases in prealbumin level (expected reference range
solution and should not be used.
of 15 to 36 mg/dL) ● Verify the prescription of the PN solution with a second
● Blood urea nitrogen level within the expected reference
nurse prior to administration.
range (10 to 20 mg/dL) ● If the PN solution is prepared and stored in the
refrigerator, allow it to come to room temperature for
1 hr prior to administering it.
CONSIDERATIONS ● Maintain strict aseptic techniques to reduce the risk of
infection. The high dextrose content of PN contributes
PREPARATION OF THE CLIENT to bacterial growth.
● Use sterile technique when changing central line dressing
● Prior to initiating PN, review the client’s weight, BMI,
and tubing. Change the bag and IV tubing for the dextrose
nutritional status, diagnosis, and current laboratory
solution every 24 hr unless facility policy differs. With
data. This can include CBC, blood chemistry profile,
intermittent IV lipid infusions, ensure the solution does
PT/aPTT, iron, total iron‑binding capacity, lipid profile,
not hang more than 12 hr to prevent microbial growth.
liver function tests, electrolyte panel, BUN, prealbumin ● Ensure lipid infusion is stopped 12 hr prior to obtaining a
and albumin level, creatinine, blood glucose, and
blood specimen for triglycerides to ensure accurate results.
platelet count.
● Assess the client’s educational needs.
● Use an electronic infusion device to prevent the NURSING ACTIONS
accidental overload of a solution. ● Ask the provider about giving some enteral substance
● A micron filter on the IV tubing is required when
during long-term PN administration, such as diluted juice,
administering PN solution. This filter is not added to
to prevent atrophy of the gastrointestinal tract.
the IV tubing when administering a lipid emulsion. ● PN should be discontinued as soon as possible to avoid
● Evaluate for allergies to soybeans, safflower, or eggs if
potential complications, but not until the client’s enteral
lipids are prescribed.
or oral intake can provide 60% or more of estimated
caloric requirements.
ONGOING CARE ! Discontinuation should be done gradually
Nursing care is focused on preventing complications to avoid rebound hypoglycemia.
through consistent monitoring. Specific monitoring ● During transition, the client will need enteral or oral
guidelines vary among health care facilities.
nutrition. Oral nutrition usually begins with clear
● Parameters can include I&O, daily weights, vital signs,
liquids that are low in fat or substances that might
pertinent laboratory values (e.g., electrolytes), and
irritate the client’s gastrointestinal tract. The client
evaluation of the client’s underlying condition. This
might not have an appetite for 1 to 2 weeks, so PN
data is used to determine the client’s response to
infusion will need to continue until the client can take
therapy, whether the formulation of the solution is
in adequate calories through other means.
correct, and to prevent nutrient deficiencies or toxicities. ● Educate the client and family regarding home PN,
● Monitor blood and urine glucose as prescribed and per
including aseptic preparation and administration
facility guidelines. Sliding scale insulin can treat or
techniques, blood glucose monitoring, and criteria to
prevent hyperglycemia, or regular insulin can be added
evaluate for complications.
to the PN solution.
● Monitor flow rate carefully.
◯ Administering the solution too slowly will fail to meet COMPLICATIONS
the client’s nutritional needs.
Infection and sepsisare evidenced by a fever or elevated
◯ Administering the infusion too rapidly can cause
WBC count. Infection can result from contamination of

hyperosmolar diuresis, which can lead to dehydration,
the catheter during insertion, contaminated solution, or a
hypovolemic shock, seizures, coma, and death.
long‑term indwelling catheter.
◯ To avoid hypoglycemia, an IV of dextrose 10% to
20% in water is administered if the PN solution Metabolic complicationsinclude hyperglycemia,

is unavailable. hypoglycemia, hyperkalemia, hypophosphatemia,
◯ Do not attempt to increase the rate of the PN solution hypocalcemia, dehydration (related to hyperosmolar
to “catch up.” Hyperglycemia, hyperosmolar diuresis, diuresis resulting from hyperglycemia), and fluid overload
and fluid overload can occur if the PN solution is (as evidenced by weight gain greater than 1 kg/day and
increased when available. edema).
62 CHAPTER 10 Total Parenteral Nutrition CONTENT MASTERY SERIES

Mechanical complicationsinclude catheter misplacement Application Exercises
resulting in pneumothorax or hemothorax (evidenced
by shortness of breath, diminished or absent breath
sounds), arterial puncture, catheter embolus, air embolus,
1. A nurse is planning care for a client who has a new
prescription for peripheral parenteral nutrition (PPN).
thrombosis, obstruction, and bolus infusion due to
Which of the following actions should the nurse
incorrectly set or malfunctioning electronic pumps. include in the plan of care? (Select all that apply.)
Refeeding syndromeoccurs when the body rapidly changes A. Examine trends in weight loss.
from catabolic (seen in starvation states) to anabolic B. Review prealbumin finding.
metabolism when nutrition is started. It is characterized by C. Administer an IV solution of 20% dextrose.
fluid and electrolyte imbalances (potassium, magnesium,
D. Add a micron filter to IV tubing.
phosphate). Manifestations include shallow respirations,
confusion, seizures, weakness, cardiac rhythm changes, fluid E. Use an IV infusion pump.
retention, and acidosis.
2. A charge nurse is providing information about fat
NURSING ACTIONS emulsion added to total parenteral nutrition (TPN) to a
group of nurses. Which of the following statements by
● Monitor for manifestations of fever, chills, increased the charge nurse are appropriate? (Select all that apply.)
WBCs, and redness around the catheter insertion site. A. “Concentration of lipid emulsion
● Use strict aseptic technique when setting up the IV can be up to 30%.”
tubing, changing the site dressing, and accessing or B. “Adding lipid emulsion gives the
deaccessing the IV access. Change the PN bag and tubing solution a milky appearance.”
set every 24 hr or per facility protocol. C. “Check for allergies to soybean oil.”
● Monitor blood glucose per prescription or facility policy.
D. “Lipid emulsion prevents essential
● Administer sliding scale insulin or plan for insulin to be
fatty acid deficiency.”
added to the TPN solution to treat hyperglycemia.
E. “Lipids provide calories by increasing
● Plan to administer additional dextrose to
the osmolality of the PN solution.”
treat hypoglycemia.
● Monitor daily weights, I&O, and oral intake of nutrients.
● Notify the provider of weight gain greater than 1 kg/day. 3. A charge nurse is teaching a group of nurses about
● Anticipate a decrease in the concentration of the medication compatibility with TPN. Which of the
solution, rate of administration, or volume of lipid following statements should the charge nurse make?
emulsion to treat weight gain. A. “Use the Y‑port on the TPN IV tubing
to administer antibiotics.”
B. “Regular insulin can be added to the TPN solution.”
Active Learning Scenario C. “Administer heparin through a
port on the TPN tubing.”
A nurse is teaching a client about complications that can
D. “Administer vitamin K IV bolus via
occur when receiving total parenteral nutrition (TPN).
a Y‑port on the TPN tubing.”
What should the nurse include in the teaching? Use
the ATI Active Learning Template: Basic Concept
to complete this item to include the following. 4. A nurse is preparing to administer lipid emulsion and
notes a layer of fat floating in the IV solution bag.
RELATED CONTENT: Identify three complications of TPN.
Which of the following actions should the nurse take?
Describe two nursing actions related to each complication.
A. Shake the bag to mix the fat.
B. Turn the bag upside down one time.
C. Return the bag to the pharmacy.
D. Administer the bag of solution as it is.
5. A nurse is caring for a client who is receiving

TPN through a central venous access device,
but the next bag of solution is not available for
administration at this time. Which of the following
is an appropriate action by the nurse?
A. Administer 20% dextrose in water IV
until the next bag is available.
B. Slow the infusion rate of the current
bag until the solution is available.
C. Monitor for hyperglycemia.
D. Monitor for hyperosmolar diuresis.
NUTRITION FOR NURSING CHAPTER 10 Total Parenteral Nutrition 63

1. A. CORRECT: Examining trends in weight loss will Using the ATI Active Learning Template: Basic Concept
help to evaluate the outcome of PPN.
RELATED CONTENT
B. CORRECT: Reviewing the prealbumin finding will determine
nutritional deficiency over a short period of time. Infection and sepsis
C. An IV solution of 20% dextrose is administered ●
Monitor for manifestations of fever, chills, increased
only as TPN using a central vein. WBCs, and redness around catheter insertion site.
D. CORRECT: A micron filter is always used ●
Use aseptic technique when setting up the IV tubing
when infusing PN solution. and accessing or deaccessing the port.
E. CORRECT: An IV infusion pump is always used to regulate ●
Use sterile technique when changing central line dressing and tubing.
the flow and provide accurate delivery of the PN solution. ●
Change the PN bag and tubing set every
NCLEX® Connection: Pharmacological and Parenteral Therapies, 24 hr or per facility protocol.
Total Parenteral Nutrition (TPN)
Hyperglycemia
●
Administer sliding scale insulin or plan for insulin
2. A. CORRECT: Lipid emulsion is available in 10%, to be added to the TPN solution.
20%, and 30% concentrations depending upon the ●
Monitor blood glucose.
client’s carbohydrate and caloric needs.
Hypoglycemia
B. CORRECT: The lipid emulsion is formulated from
safflower and/or soybean oils and egg phospholipid,
●
Inform the provider and plan to give additional dextrose.
making the solution appear milky.
●
Monitor frequent blood glucose.
C. CORRECT: Lipid emulsion is formulated from safflower Weight gain greater than 1 kg/day
and/or soybean oil and egg phospholipid. The nurse ●
Inform the provider and anticipate a decrease in the concentration,
should check for allergies to these ingredients. rate of administration or volume of lipid emulsion.
D. CORRECT: Lipid emulsion is used for additional ●
Monitor the client’s intake of oral nutrients.
calories as concentrated energy and to prevent
essential fatty acid deficiency. NCLEX® Connection: Pharmacological and Parenteral Therapies,
E. Lipids provide the calories needed without Nutrition and Oral Hydration
increasing osmolality of the PN solution.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
3. A. Administering any IV medication through a Y‑port

on the TPN line is contraindicated.
B. CORRECT: Regular insulin may be added to the
TPN solution to decrease hyperglycemia.
C. Heparin may be added to the TPN solution to
decrease clot formation in the cannula, but it is not
injected directly into a port on the TPN tubing.
D. Vitamin K can be added to the TPN solution, but it should
not be administered IV bolus through the TPN IV line.
4. A. Shaking the bag is not an appropriate action

because “cracking” of the solution has occurred
and it should not be administered.
B. Turning the solution upside down does not resolve
the problem because cracking of the TPN has
occurred and it should not be administered.
C. CORRECT: Returning the solution to the pharmacy is an
appropriate action by the nurse because cracking of the
solution has occurred and it should not be administered.
The pharmacist and provider will need to adjust the
formulation of the solution to prevent cracking.
D. Administering the solution as it is would not be an
appropriate nursing action because cracking of the
solution has occurred. Infusion of a cracked solution
can lead to fat or particulate embolisms.
5. A. CORRECT: Administering 20% dextrose in water IV until the

TPN solution is available will prevent hypoglycemia.
B. Decreasing the rate of the TPN solution is not an appropriate
action because the decreased rate can cause hypoglycemia.
C. The client should be monitored for hypoglycemia
when the TPN solution is not infusing and
adequate glucose is not provided.
D. Monitor the client for hyperosmolar diuresis when
the TPN solution has infused too fast.
64 CHAPTER 10 Total Parenteral Nutrition CONTENT MASTERY SERIES

NCLEX® Connections
Health Promotion and Maintenance

HEALTH PROMOTION/DISEASE PREVENTION
Identify risk factors for disease/illness.
Educate the client on actions to promote/
maintain health and prevent disease.
HEALTH SCREENING: Perform targeted screening assessments.
HIGH-RISK BEHAVIORS: Assist the client to identify

behaviors/risks that may impact health.

ELIMINATION: Assess and manage client
with an alteration in elimination.

Provide nutritional supplements as needed.
Evaluate the impact of disease/illness on the nutritional status of a client.
Physiological Adaptation
ALTERATIONS IN BODY SYSTEMS: Implement interventions
to address side/adverse effects of radiation therapy.
ILLNESS MANAGEMENT: Educate the client about managing illness.
FLUID AND ELECTROLYTE IMBALANCES: Manage the

care of the client with a fluid and electrolyte imbalance.
Reduction of Risk Potential

POTENTIAL FOR ALTERATIONS IN BODY SYSTEMS:
Identify client potential for aspiration.
SYSTEM SPECIFIC ASSESSMENTS: Assess the client

for signs of hypoglycemia or hyperglycemia

CHAPTER 11
UNIT 3 ALTERATIONS IN NUTRITION Low socioeconomic status and lack of access
CHAPTER 11 Barriers to The lack of money to purchase healthy foods or foods
Adequate Nutrition
required for a specific diet can be a barrier to maintaining
a proper diet.
● Nutritious foods (fresh fruit, vegetables) tend to be more
expensive than canned and boxed foods.
Canned, boxed, and processed foods (lunch meats and
Many individuals have difficulty consuming a
●
frozen meals) are usually high in calories and salt,

nutritional or prescribed diet due to factors that and often contain a higher fat, sodium, and simple
carbohydrate content. These are poor choices for clients
create a barrier. Medical, psychological, and on calorie‑ or sodium‑restricted diets.
social factors can all create nutritional barriers. ● The lack of money to purchase necessary food can lead
to malnutrition or obesity if canned and boxed foods
Approximately 30% to 50% of clients in acute are selected.
care facilities are malnourished upon admission ● The lack of transportation to grocery stores is a barrier if
the client does not have a car or is not licensed to drive.
or during part of their hospital stay. ● Food deserts occur in low-socioeconomic areas where a
person lives more than 1 mile from a food source in the
It is important for nurses to recognize these urban area, or more than 10 miles in a rural area.
factors as nutritional education will be ineffective NURSING CARE
if a client lacks the necessary resources to follow ● Refer the client to a dietitian who can discuss food
options and substitutions that are appropriate.
through on recommendations. ● Instruct the client that frozen fruits and vegetables can
be an affordable option, and are maintained longer in
the freezer.
NUTRITIONAL BARRIERS AND Educate clients on how to read food labels to be aware of
●
nutritional, caloric, and sodium values of the food they

are consuming.
Poor dentition ● Contact social services regarding the client’s access to
Poor dentition (dental caries, poorly fitting dentures) is a food. Investigate the availability of a nutrition program
potential problem for clients across the lifespan. that provides a meal for clients within a
● Children who do not have access to dental care or tools community.
(toothbrush, toothpaste) can have caries that impair the
ability to chew. Cognitive disorders
● Adults who have lost teeth or have teeth that need
Cognitive disorders (dementia, Alzheimer’s disease [AD])

removal or repair have an impaired ability to chew.
can have a significant impact on nutritional status.
● After an adult has teeth removed, it can be difficult to
● Clients who have dementia or AD can experience
adjust to dentures.
impairments in memory and judgment, making
NURSING CARE shopping, food selection, and food preparation difficult.
● School screenings can help identify children who need ● As dementia and AD progress, clients might refuse to
dental attention, and can facilitate the referral process. eat or choose a small selection of food that might not
● Provide children with information about healthy snacks provide adequate nutrition.
that are low in sugar.
NURSING CARE
● Advise children and adults to limit consumption of ● If the client lives independently, encourage shopping with
processed carbohydrates, which can stick to teeth and
a friend or family member and following a shopping list.
increase the risk for dental caries. ● Monitor for vitamin and mineral deficits, and evaluate
● Encourage children and adults to use a fluoridated tooth
the need for nutritional supplements.
paste and have fluoride applied to their teeth. ● Contact social services regarding the availability of food
● Perform a basic dental screening for clients admitted to
or meal delivery to the client’s home.
acute or long‑term care facilities to identify issues that ● If the client lives in a care facility, provide a menu with
can affect the ability to properly eat.
minimal but nutritious options.
● Consult a dietitian or nutritionist to assist with meal ● Serve meals at the same time and in the same location
and diet planning, as well as for recommendations on
surrounded by the same people. Keep environmental
nutritional supplements.
distractions to a minimum.
● Provide snacks in between meals if mealtime intake
is inadequate.
● Cut food into small pieces if the client has difficulty
chewing food. Remind the client to chew and then
swallow. Lightly stroking the chin and throat can help
promote swallowing.
NUTRITION FOR NURSING CHAPTER 11 Barriers to Adequate Nutrition 67

Altered sensory perception ● Thicken thin fluids with a commercial thickener to the
prescribed consistency of thin, nectar-like, honey-like,
Clients who have an alteration in vision, smell, or taste
or spoon-thick.
can find it difficult to feed themselves or can find ● Allow adequate time for assisting the client who has
food unpalatable.
dysphagia to eat. Have the client rest before meals.
● Clients who have decreased vision might need ● Teach clients who aspirate easily due to surgical
assistance shopping for food on a regular basis, and
alteration of their throat or upper tracheal structures to
with food preparation.
tuck their chins when swallowing. Arching the tongue
● Clients in a health care or long‑term care facility might
in the back of the throat can help close off the trachea.
need help with tray setup and location of food on the tray.
● Clients who have an altered sense of smell have an Mechanical fixation of the jaw
altered sense of taste.
Disorders of the jaw requiring surgery include facial
● Clients who smoke might have a diminished sense of smell.
trauma and reconstruction.
● Clients receiving chemotherapy and other types of ● After fractured bones are realigned, the client’s upper
medications can experience taste alterations such

and lower jaw might be wired together.
as a metallic taste in their mouth, masking the real ● The jaw can be immobilized for several weeks.
taste of food. ● The client is generally placed on a liquid diet during
● Clients receiving radiation to the head and neck can
this period.
experience altered or loss of taste (mouth blindness).
NURSING CARE
NURSING CARE ● Encourage the intake of fluids.
● Encourage the client who has decreased vision to ● Help the client determine where to insert a straw
consider shopping with a friend or family member, or
through the space between the jaws.
have groceries delivered to the house. ● Work with the dietitian to develop a liquid meal plan
● Contact social services regarding availability of food or
that includes the necessary nutrients.
meal delivery to the client’s home.
Recommend to the client who has a food aversion to
Lack of knowledge and misinformation
●
eat foods that are served cool, as they are typically less
about nutrition
aromatic and are less likely to precipitate nausea.
● Suggest consuming foods that are spicy or tangy to Clients can be subject to overnutrition, undernutrition, and
compensate for the decreased sense of taste. the ingestion of an inadequate intake of essential nutrients.
● Recommend sucking on hard candies, mints, or chewing ● Clients might not have basic knowledge about nutrition.
gum to counteract an unusual taste in the mouth. ● Information about nutrition can be confusing
● Instruct the client to avoid ingestion of empty or misleading.
calories. If an increase in calories and fluid is desired, ● Clients can be drawn to fad diets (which are generally
milkshakes, juice, and supplements are good options. unhealthy) because quick results are promised.
● Clients can be misled by false advertising.
Impairment in swallowing
NURSING CARE
Clients who have neurologic disorders (Parkinson’s ● Encourage clients to use dietary guidelines available from
disease, cerebral palsy, stroke) or had a surgical procedure government and health associations (MyPlate
done on their mouth, throat, epiglottis, or larynx can have [www‌.‌choosemyplate‌.‌gov], American Heart Association,
difficulty managing food and swallowing without choking. Office of Disease Prevention and Health Promotion Dietary
● Clients who have a neurologic disorder affecting the Guidelines [https://health.gov/dietaryguidelines]).
muscles in the mouth and throat are at risk for aspiration ● Assist clients in locating community resources that
due to delayed swallowing and/or inadequate mastication. provide education on nutrition.
● Clients who have a history of oral cancer might have had ● Assess dietary intake.
part of their lip, tongue, and/or soft palate removed. This ● Instruct clients on how to read nutrition fact labels.
significantly affects the ability to masticate and coordinate ● Encourage the client to keep a journal of dietary intake.
the development of a bolus of food prior to swallowing. ● Provide clients with information on foods that are
● The larynx and epiglottis prevent food from entering healthy and portion sizes.
the trachea. Clients who have had partial or total ● Warn clients that advertisements can be fraudulent.
removal of these can easily aspirate food and fluids,
Medical conditions
unless special precautions are taken.
NURSING CARE ● Clients who have medical conditions (cancer, COPD,
● Continually monitor clients who are at risk for burns, severe trauma, or HIV/AIDS) are at increased risk
aspiration during meals, and have suction equipment for malnutrition due to anorexia, nausea, or stomatitis
immediately available. related to treatments, increased metabolic demands, or
● Consult a dietitian regarding an appropriate diet for the the inability to consume a diet.
client. The National Dysphagia diet includes three levels ● Clients who are undergoing diagnostic testing that
of solid textures. require NPO status are potentially at risk.
◯ Level 1: Pureed ● Clients who have comorbidities resulting in
◯ Level 2: Mechanically altered polypharmacy are at risk for malnutrition and
◯ Level 3: Advanced medication nutrient interactions.
68 CHAPTER 11 Barriers to Adequate Nutrition CONTENT MASTERY SERIES

NURSING CARE Active Learning Scenario
● Monitor diet prescriptions and laboratory results,
particularly for clients who are NPO or are receiving A nurse is providing dietary teaching for a client who
clear or full liquid diets for more than 24 hr. Refer the requests assistance for weight loss. The client states,
client to a dietitian for a complete evaluation of “I’ve tried several fad diets but they don’t work for me.”
nutritional status. Use the ATI Active Learning Template: Basic Concept to
● Monitor clients who have comorbidities for interactions complete this item to include the following sections.
between medications and nutrition. Refer the client to
a pharmacist for a thorough evaluation of medication UNDERLYING PRINCIPLES: Identify
the client’s barrier to nutrition.
interactions and the impact upon nutritional intake.
● Offer several small meals or snacks through the day NURSING INTERVENTIONS: Identify at least four
instead of three large meals if the client cannot tolerate interventions to address this client’s barrier to
large amounts at once. nutrition and to promote healthy weight loss.
● Provide oral care prior to and following meals.
● Discourage the use of alcohol‑based mouthwashes for
clients who have stomatitis.
● Provide liquid supplements between meals to increase
nutrient intake.
1. A nurse is caring for several clients in an extended 4. A nurse is caring for a client who is transitioning
care facility. Which of the following clients is the to an oral diet following a partial laryngectomy.
highest priority to observe during meals? Which of the following actions should the nurse
A. A client who has decreased vision take to reduce the client’s risk for aspiration?
B. A client who has Parkinson’s disease A. Request to have the client’s oral
medications provided in liquid form.
C. A client who has poor dentition
B. Instruct the client to follow each bite
D. A client who has anorexia of food with a drink of water.
C. Encourage the client to tuck the
2. A nurse is planning care for a client who is receiving chin when swallowing.
treatment for malnutrition. The client is scheduled D. Consult the dietitian about providing
for discharge to their home where they live alone. the client with a thin liquid diet.
include in the plan of care? (Select all that apply.)
A. Consult social services to arrange 5. A nurse is planning care for a client who has mechanical
home meal delivery. fixation of the jaw following a motorcycle crash.
B. Encourage the client to purchase include in the plan of care? (Select all that apply.)
nonperishable boxed meals.
A. Thicken liquids to honey consistency.
C. Advise the client to purchase frozen
fruits and vegetables. B. Educate the client about the use
of a nasogastric tube.
D. Recommend drinking a supplement
between meals. C. Assist the client to use a straw to drink liquids.
E. Educate the client on how to read nutrition labels. D. Ensure that the client receives ground meats.
E. Encourage intake of fluids between meals.
3. A nurse is providing teaching for a client who has a

new diagnosis of hypertension and a prescription
for a low‑sodium diet. Which of the following
client statements indicate an understanding
of the teaching? (Select all that apply.)
A. “I should select organic canned vegetables.”
B. “I need to read food labels when
grocery shopping.”
C. “I will stop eating frozen dinners for lunch at work.”
D. “I know that deli meats are usually high in sodium.”
E. “I can refer to the American Heart Association’s
website for dietary guidelines.”
NUTRITION FOR NURSING CHAPTER 11 Barriers to Adequate Nutrition 69

1. A. Observation of a client who has decreased vision is necessary Using the ATI Active Learning Template: Basic Concept
to evaluate the client’s need for assistance. However, this UNDERLYING PRINCIPLES: The client’s barrier to nutrition is lack
client is not the highest priority to observe during meals. of knowledge and misinformation about nutrition. This barrier
B. CORRECT: A client who has Parkinson’s disease is at must be acknowledged to promote adequate nutrition.
risk for aspiration. Due to this safety risk, this client is
the highest priority to observe during meals. NURSING INTERVENTIONS
C. Observation of a client who has poor dentition is ●
Encourage the client to use dietary guidelines such as MyPlate.
necessary to evaluate the client’s need for assistance ●
Assist the client in locating community resources that provide
or a modified diet. However, this client is not the education and nutrition to support healthy nutrition and weight loss.
highest priority to observe during meals. ●
Advise the client that fad diets are generally
D. Observation of a client who has anorexia is necessary unhealthy and often include false advertising.
to evaluate the client’s intake. However, this client is ●
Perform an assessment of dietary intake.
not the highest priority to observe during meals. ●
Encourage the client to keep a journal of dietary intake.
NCLEX® Connection: Safety and Infection Control, Accident/ ●
Provide the client with information on
Error/Injury Prevention healthy foods and portion sizes.
NCLEX® Connection: Health Promotion and Maintenance, Health
2. A. CORRECT: Consult social services to arrange home Promotion/Disease Prevention
meal delivery to promote adequate nutrition.
B. Boxed foods are usually high in calories and salt and are
therefore not recommended to promote adequate nutrition.
C. CORRECT: Advise the client to purchase frozen fruits
and vegetables to promote adequate nutrition.
D. CORRECT: Recommend a supplement between
meals to promote adequate nutrition.
E. CORRECT: Educate the client on how to read
food labels to promote adequate nutrition.
Illness Management
3. A. Canned foods, even if organic, are usually high

in sodium and are therefore a poor choice for a
client on a sodium‑restricted diet.
B. CORRECT: Reading food labels provides the client with
information about the food’s sodium content.
C. CORRECT: Frozen dinners are usually high in
sodium and are therefore a poor choice for a
D. CORRECT: Deli meats are usually high in
sodium and are therefore a poor choice for a
E. CORRECT: The American Heart Association is a recommended
health association for continued client education on dietary
guidelines related to cardiac disorders such as hypertension.
Illness Management
4. A. Providing medications in liquid form does not

decrease the risk for aspiration.
B. Drinking thin liquids, such as water,
increases the risk for aspiration.
C. CORRECT: Tucking the chin when swallowing helps to
close off the trachea and reduces the risk for aspiration.
D. Thick, rather than thin, liquids help
reduce the risk for aspiration.
Complications of Diagnostic Tests/Treatments/Procedures
5. A. Mechanical fixation of the jaw does not cause dysphagia.

It is not necessary to thicken the client’s liquids.
B. Mechanical fixation of the jaw does not indicate
the need for a nasogastric tube.
C. CORRECT: Recommend the use of a straw to drink
liquids. Help the client determine where to insert the
straw through the space between the jaws.
D. Mechanical fixation of the jaw indicates the need
for a liquid diet rather than ground meats.
E. CORRECT: The client who has a mechanical fixation of
the jaw will have the jaws wired shut and is only able to
consume liquids. Encourage supplemental and nutrient‑rich
liquids to maintain adequate hydration and nutrition.
70 CHAPTER 11 Barriers to Adequate Nutrition CONTENT MASTERY SERIES

CHAPTER 12
UNIT 3 ALTERATIONS IN NUTRITION Metabolic syndrome
CHAPTER 12 Cardiovascular The presence of three of the five following risk factors.
and Hematologic
● Abdominal obesity
◯ MALES: greater than or equal to 40‑inch waist
Disorders FEMALES: greater than or equal to 35‑inch waist

◯
◯ For Asian and non-European clients who have lived
predominantly outside the U.S., use population- or

country-specific definitions.
Nurses must have an awareness of nutritional ● Triglycerides greater than or equal to 150 mg/dL or
taking medications to treat high triglyceride levels
needs for clients who have cardiovascular ● Low HDL or taking medications to lower HDL-C
and hematologic disorders. It is important ◯ MALES: less than or equal to 40 mg/dL
FEMALES: less than or equal to 50 mg/dL
to explore dietary needs with the client and
◯
● Increased blood pressure or taking an

recommend modifications related to the antihypertensive medication
◯ Systolic greater than or equal to 130 mm/Hg
disease process. Understanding the role of ◯ Diastolic greater than or equal to 85 mm/Hg
primary and secondary prevention is essential to ● Fasting blood glucose greater than or equal to 100 mg/dL
or taking medication to control blood glucose levels
successful treatment.
Cardiovascular diseases are the leading cause of ANEMIAS

Iron deficiency anemia
death in the U.S. Coronary heart disease (CHD)
RISK FACTORS
is the single leading cause of death. ● Blood loss, deficient iron intake from diet, alcohol use
disorder, malabsorption syndromes, gastrectomy
Metabolic increase caused by pregnancy,
●
adolescence, infection
MANIFESTATIONS
Coronary heart disease ● Fatigue
Hypercholesterolemia leads to atherosclerosis, a process ● Lethargy
of damage and cholesterol deposits on the blood vessels ● Pallor of nail beds
of the heart. Atherosclerosis is the cause of many ● Intolerance to cold
cardiovascular disease complications (myocardial ● Headache
infarction, kidney failure, ischemic strokes). ● Tachycardia
High‑density lipoprotein (HDL) cholesterol is “good”
! Children who have low iron intake can
●
cholesterol because it removes cholesterol from the body

experience short attention spans and display poor
tissue and takes it to the liver. Levels greater than or
intellectual performance before anemia begins.
equal to 60 mg/dL for males and 70 mg/dL or greater for
females provide some protection against heart disease. Vitamin B12 deficiency anemia (macrocytic)
● Low‑density lipoprotein (LDL) cholesterol is “bad”
RISK FACTORS: Lack of meat or dairy consumption, small
cholesterol because it transports cholesterol out of the
bowel resection, chronic diarrhea, diverticula, tapeworm,
liver and into the circulatory system, where it can form
excess of intestinal bacteria
plaques on the coronary artery walls. The optimal range
for LDL is less than 130 mg/dL. MANIFESTATIONS
● Optimal total cholesterol level is less than 200 mg/dL. ● Pallor
● Jaundice
RISK FACTORS ● Weakness
● NON-MODIFIABLE: increasing age, male sex, family ● Fatigue
history of early CHD
● MODIFIABLE: high LDL cholesterol, low HDL cholesterol, GASTROINTESTINAL FINDINGS
consuming a diet high in saturated fat, hypertension, ● Glossitis (inflamed tongue)
diabetes mellitus, metabolic syndrome, obesity, ● Anorexia
sedentary lifestyle, nicotine use disorder ● Indigestion
● Weight loss
NEUROLOGIC FINDINGS
● Decreased concentration
● Paresthesia (numbness) of hands and feet
● Decreased proprioception (sense of body position)
● Poor muscle coordination
● Increasing irritability
● Delirium
NUTRITION FOR NURSING CHAPTER 12 Cardiovascular and Hematologic Disorders 71

Folic acid deficiency anemia ◯ Avoid trans fat, which increases LDL. Partially
hydrogenated products contain trans fat.
RISK FACTORS: Poor nutritional intake of foods containing ◯ Increase consumption of oily fish (tuna,
folic acid (green leafy vegetables, citrus fruits, dried bean,

salmon, herring).
nuts), malabsorption syndromes (Crohn’s disease), certain ◯ Read labels.
medications (anticonvulsants and oral contraceptives) ● Encourage the client to consume a high‑fiber diet.
MANIFESTATIONS ◯ Soluble fiber lowers LDL.
● Fatigue ◯ Oats, beans, fruits, vegetables, whole grains, barley,

● Pallor and flaxseed are good sources of fiber.
● Glossitis ● Encourage the client to exercise.
● Irritability ◯ Instruct the client regarding practical methods for
● Diarrhea increasing physical activity. (Encourage the client to

take the stairs rather than the elevator.)
Findings of folic acid deficiency anemia ◯ Provide the client with references for local
mimic those for vitamin B12 deficiency anemia
exercise facilities.
except for the neurologic manifestations. ● Instruct the client to stop all use of tobacco products.
● The recommended lifestyle changes represent a
significant change for many clients.
NUTRITIONAL GUIDELINES AND ◯ Provide support to the client and family.
NURSING INTERVENTIONS ◯ Encourage the client’s family to participate in the
changes to ease the transition for the client.

Coronary heart disease ◯ Explain why the diet is important.
PREVENTATIVE NUTRITION ◯ Aid the client in developing a diet that is
● Consuming a diet that is limited in trans fats, saturated complementary to personal food preferences and
fats, and cholesterol can reduce the risk of developing lifestyle. A food diary can be helpful.
CHD. The Therapeutic Lifestyle Change (TLC) diet is ◯ Instruct the client that occasional deviations from the
designed to be a user‑friendly eating guide to encourage diet are reasonable.

dietary changes.
● Daily cholesterol intake should be less than 200 mg. Hypertension
● Conservative use of red wine can reduce the risk of ● Hypertension is a significant risk factor for developing
developing CHD.
CHD, myocardial infarction, kidney disease, and stroke.
● Increasing fiber and carbohydrate intake, avoiding ● Hypertension is a sustained elevation in blood pressure
saturated fat, and decreasing red meat consumption can
greater than or equal to 140/90 mm Hg for clients under
decrease the risk for developing CHD.
the age of 60, 150/90 mm Hg for those older than 60.
● Increased intake of omega‑3 fatty acids found in fish,
flaxseed, soy beans, canola, and walnuts reduces the RISK FACTORS FOR PRIMARY HYPERTENSION: family
risk of coronary artery disease. history, hyperlipidemia, smoking, obesity, physical
● Homocysteine is an amino acid. Elevated homocysteine inactivity, high sodium intake, low potassium intake,
levels can increase the risk of developing CHD. excessive alcohol consumption, stress, and aging.
Deficiencies in folate and vitamins B6 and B12 increase African‑American people have the highest prevalence of
homocysteine levels. hypertension. A client’s risk of hypertension increases
after menopause.
THERAPEUTIC NUTRITION
● Secondary prevention efforts for CHD are focused on THERAPEUTIC NUTRITION
lifestyle changes that lower LDL. These include a diet ● The Dietary Approaches to Stopping Hypertension
low in cholesterol and saturated fats, a diet high in (DASH) diet is a low‑sodium, high‑potassium,
fiber, exercise and weight management, and cessation of high‑calcium diet that has proven to lower blood
nicotine use. pressure (systolic and diastolic) and cholesterol.
● Daily cholesterol intake should be less than 200 mg/day. ◯ Decrease sodium intake (initially a daily intake of less
Saturated fat should be limited to less than 7% of daily than 2,300 mg is recommended, and should gradually
caloric intake. be decreased to 1,500 mg for maximum benefit).
● To lower cholesterol and saturated fats, instruct the ◯ Foods high in sodium include canned soups and
client to do the following. sauces, potato chips, pretzels, smoked meats,

◯ Trim visible fat from meats. seasonings, and processed foods.
◯ Limit red meats and choose lean meats ◯ Include low‑fat dairy products to promote
(turkey, chicken). calcium intake.

◯ Remove the skin from meats. ◯ Include fruits and vegetables rich in potassium
◯ Broil, bake, grill, or steam foods. Avoid frying foods. (apricots, bananas, tomatoes, potatoes).
◯ Use low‑fat or nonfat milk, cheese, and yogurt. ● Limit alcohol intake.
◯ Use spices in place of butter or salt to season foods. ● Encourage the client to read labels and educate the
◯ Use liquid oils (olive or canola) in place of oils that are client about appropriate food choices.
high in saturated fat (lard, butter). ● Other lifestyle changes include exercising, weight loss,
and smoking cessation.
72 CHAPTER 12 Cardiovascular and Hematologic Disorders CONTENT MASTERY SERIES

Heart failure SOURCES OF IRON
● Meat
Heart failure is characterized by the inability of the ● Fish
heart to maintain adequate blood flow throughout the ● Poultry
circulatory system. It results in excess sodium and fluid ● Tofu
retention, and edema. ● Dried peas and beans
RISK FACTORS: CHD, arrhythmias, previous MI, ● Whole grains
valve disorders, hypertension, obesity, diabetes, ● Dried fruit
metabolic syndrome ● Iron‑fortified foods
◯ Infant formula (alternative or supplement
to breastfeeding)
● Reduce sodium intake to less than 3,000 mg per day for ◯ Infant cereal (usually the first food introduced
mild-to-moderate heart failure and less than 2,000 mg/

to infants)
day for severe heart failure. ◯ Ready‑to‑eat cereals
● Monitor fluid intake (and possibly restrict 2 L/day).
● Increase protein intake to 1.12 g/kg. VITAMIN C: Facilitates the absorption of iron
● Use small, frequent meals that are soft, (promote consumption).
easy‑to‑chew foods.
! Medicinal iron toxicity is the leading cause of
accidental poisoning in small children and can lead
Myocardial infarction
to acute iron toxicity.
● A myocardial infarction (MI) occurs when there is an
NATURAL SOURCES OF VITAMIN B12
inadequate supply of oxygen to the myocardium. ● Fish
● After an MI, it is necessary to reduce the myocardial ● Meat
oxygen demands related to metabolic activity. ● Poultry
● Risk factors are the same as for CHD. ● Eggs
THERAPEUTIC NUTRITION ● Milk
● A liquid diet is best for the first 24 hr after
People older than 50 years are urged to
the infarction.
consume most of their vitamin B12 requirement
● Caffeine should be avoided because it stimulates the
from supplements or fortified food.
heart and increases heart rate.
● Small, frequent meals are indicated. People who follow a vegan diet
● Counsel the client about recommendations for a need supplemental B12.
heart‑healthy diet.
FOLIC ACID SOURCES
Green leafy vegetables
Anemia
●
● Dried peas and beans

Anemia results from either a reduction in the number ● Seeds
of red blood cells (RBCs) or in hemoglobin, the ● Orange juice
oxygen‑carrying component of blood. Anemia can result ● Cereals and breads fortified with folic acid
from a decrease in RBC production, an increase in RBC
If the client is unable to obtain an adequate supply
destruction, or a loss of blood.
of folic acid, supplementation can be necessary.
● The body requires iron, vitamin B12, and folic acid to
produce red blood cells.
● Iron deficiency anemia is the most common nutritional
disorder in the world. It affects approximately 10% of
the U.S. population, especially older infants, toddlers,
adolescent females, and pregnant clients.
● From childhood until adolescence, iron intake tends to
be marginal.
● Pernicious anemia is the most common form of vitamin
B12 deficiency. It is caused by lack of intrinsic factor, a
protein that helps the body absorb vitamin B12.

1. A nurse is teaching a client about dietary A nurse is providing teaching to a client who has hypertension.
recommendations to lower high blood What should the nurse include in the teaching? Use
pressure. Which of the following statements the ATI Active Learning Template: System Disorder to
by the client indicates understanding? complete this item to include the following sections.
A. “My daily sodium consumption ALTERATION IN HEALTH (DIAGNOSIS)

should be 3,000 milligrams.”
CLIENT EDUCATION: Describe the Dietary
B. “I should consume foods low in potassium.”
Approaches to Stopping Hypertension (DASH) diet
C. “My limit is three cigarettes a day.” and four nutrition teaching points to include.
D. “I should consume low‑fat dairy products.”
2. A nurse is teaching a client about high‑fiber foods

that can assist in lowering LDL. Which of the following
foods should the nurse include? (Select all that apply.)
A. Beans
B. Cheese
C. Whole grains
D. Broccoli
E. Yogurt
3. A community health nurse is assessing a client

who reports numbness of the hands and feet for
the past 2 weeks. This finding is associated with
which of the following nutritional deficiencies?
A. Folic acid
B. Potassium
C. Vitamin B12
D. Iron
4. A nurse is reviewing a client health record that

includes a report of abdominal obesity and
laboratory findings of elevated blood glucose and
elevated triglycerides. These findings meet the
criteria of which of the following conditions?
A. Anemia
B. Metabolic syndrome
C. Heart failure
D. Hypertension
5. A nurse is providing teaching to a client

who has vitamin B12 deficiency. Which of the
following foods should the nurse instruct the
client to consume? (Select all that apply.)
A. Meat
B. Flaxseed
C. Beans
D. Eggs
E. Milk

1. A. Daily sodium consumption should be 2,300 mg or Using the ATI Active Learning Template: System Disorder
less. This assists with lowering systolic and diastolic ALTERATION IN HEALTH (DIAGNOSIS): Hypertension is a sustained
blood pressures as well as cholesterol. elevation in blood pressure greater than or equal to 140/90 mm Hg in
B. Foods high in potassium should be encouraged. clients less than age 60 and 150/90 mm Hg in those older than 60.
This assists with lowering systolic and diastolic
blood pressures as well as cholesterol. CLIENT EDUCATION
C. Smoking cessation should be encouraged. Smoking can ●
The DASH diet is a low‑sodium, high‑potassium, high‑calcium diet
increase blood pressure and should be avoided. that has been proven to lower blood pressure and cholesterol.
D. CORRECT: Low‑fat dairy products should be encouraged. ●
Lower sodium intake (daily intake of less
They promote calcium intake and assist with lowering systolic than 2,300 mg) is recommended.
and diastolic blood pressures as well as cholesterol. ●
Foods high in sodium include canned soups and sauces, potato
NCLEX® Connection: Basic Care and Comfort, chips, pretzels, smoked meats, seasonings, and processed foods.
Include low‑fat dairy products to promote calcium intake.
●
Include fruits and vegetables rich in potassium
(apricots, bananas, tomatoes, potatoes).
2. A. CORRECT: Beans are high in fiber and should ●
Limit alcohol intake.
be included in the teaching.
B. Cheese is high in calcium and should not NCLEX® Connection: Physiological Adaptation, Illness
be included in the teaching. Management
C. CORRECT: Whole grains are high in fiber and
should be included in the teaching.
D. CORRECT: Broccoli is high in fiber and
should be included in the teaching.
E. Yogurt is high in calcium and should not
be included in the teaching.
3. A. Pallor, glossitis, and gastrointestinal distress are

manifestations associated with folic acid deficiency.
B. Irritability, decreased respirations, muscle
weakness, and gastrointestinal distress are
manifestations associated with hypokalemia.
C. CORRECT: Numbness of the hands and feet are
manifestations associated with vitamin B12 deficiency.
D. Fatigue, lethargy, pallor of nail beds, and intolerance to cold
are manifestations associated with iron deficiency anemia.
4. A. Fatigue, lethargy, pallor of nail beds, and intolerance to

cold are manifestations associated with anemia.
B. CORRECT: Weight gain in the abdomen, elevated
blood glucose, and elevated triglycerides are
manifestations associated with metabolic syndrome.
C. Shortness of breath, fluid retention, and fatigue are
manifestations associated with heart failure.
D. Headaches, tiredness, and dizziness are
manifestations associated with hypertension.
5. A. CORRECT: Meat is a food source that

is high in vitamin B12.
B. Flaxseed is a good source of fiber.
C. Beans are a good source of folic acid.
D. CORRECT: Eggs are a food source that is high in vitamin B12.
E. CORRECT: Milk is a food source that is high in vitamin B12.

CHAPTER 13
UNIT 3 ALTERATIONS IN NUTRITION NUTRITIONAL GUIDELINES AND
CHAPTER 13 Gastrointestinal NURSING INTERVENTIONS
Disorders General gastrointestinal considerations

● Monitor gastrointestinal parameters.
◯ Weight and weight changes
◯ Laboratory values
Nurses must gain an awareness of nutritional ◯ Elimination patterns
needs for clients who have gastrointestinal ◯ I&O
Low‑fiber diets avoid foods that are high in residue

(GI) disorders. It is important to explore
●
content (whole‑grain breads and cereals, raw fruits

dietary needs with the client and recommend and vegetables).
◯ Diets low in fiber reduce the frequency and volume of
modifications in relationship to the disease fecal output and slow transit time of food through the
process. Understanding the role of primary digestive tract.
◯ Low‑fiber diets are used short‑term for clients who
and secondary prevention is essential to have diarrhea or malabsorption syndromes.

successful treatment. ● High‑fiber diets focus on foods containing more than
5 g of fiber per serving. A diet high in fiber helps:
Nutrition therapy for gastrointestinal disorders ◯ Increase stool bulk.
◯ Stimulate peristalsis.
is generally aimed at minimizing or preventing ◯ Prevent constipation.
manifestations. In some conditions (celiac ◯ Protect against colon cancer.
disease), nutrition is the only treatment. For Nausea and vomiting

some GI disorders, nutrition therapy is the ● Potential causes of nausea and vomiting include
foundation of treatment. decreased gastric acid secretion; decreased
gastrointestinal motility; allergy to food(s); bacterial
or viral infection; increased intracranial pressure; liver,
ASSESSMENT/DATA COLLECTION pancreatic, and gall bladder disorders; and adverse
effects of some medications.
● Determine whether the client is experiencing any of ● The underlying cause of nausea and vomiting should be
the following.
investigated. Assessing the appearance of the emesis
◯ Difficulty chewing or swallowing
will aid in diagnosis and treatment (coffee‑ground

◯ Nausea, vomiting, or diarrhea
emesis indicates the presence of blood; pale green

◯ Bloating, excessive flatus, occult blood, steatorrhea,
indicates bile).
abdominal pain or cramping, abdominal distention, ● Once manifestations subside, begin with clear
pale, sticky bowel movements
liquids followed by full liquids, and advance the diet
◯ Changes in weight, eating patterns, or bowel habits
as tolerated.
● Determine whether the client uses the following. ● Easy‑to‑digest, low‑fat carbohydrate foods (crackers,
◯ Tobacco
toast, oatmeal, pretzels, plain bread, bland fruit) are

◯ Alcohol
usually well‑tolerated.
◯ Caffeine
◯ Over‑the‑counter medications to treat GI NURSING ACTIONS
conditions (many can have GI complications or be ● Promote good oral hygiene with tooth brushing, mouth
contraindicated with GI conditions) swabs, mouthwash, and ice chips.
◯ Nutritional supplements ● Elevate the head of the bed.
◯ Herbal supplements for GI conditions or other ● Serve foods at room temperature or chilled.
problems (some clients do not consider them to
CLIENT EDUCATION
be medications, so they do not mention them to ● Avoid hot and spicy foods.
the provider) ● Avoid liquids with meals, as they promote a feeling
of fullness.
● Avoid high‑fat foods if they contribute to nausea
because they are difficult to digest.
NUTRITION FOR NURSING CHAPTER 13 Gastrointestinal Disorders 77

Anorexia Diarrhea
● Anorexia is defined as a lack of appetite. It is a common ● Diarrhea can cause significant losses of potassium,
finding for numerous physical conditions and is an sodium, and fluid, as well as nutritional complications.
adverse effect of certain medications. It is not the same ● Common causes of diarrhea include emotional and
as anorexia nervosa. physical stress, gastrointestinal disorders, malabsorption
● Anorexia can lead to decreased nutritional intake and disorders, infections, and certain medications.
subsequent protein and calorie deficits. ● Low-fiber diets might be recommended on a short-term
basis to decrease bowel stimulation.
NURSING ACTIONS ● Nutrition therapy varies with the severity and duration of
● Decrease stress at meal times.
diarrhea. A liberal fluid intake to replace losses is needed.
● Collect data regarding adverse effects of medications.
Administer medications to stimulate appetite.
Dysphagia
●
● Assess and modify environment for unpleasant odors.

● Remove items that cause a decrease in appetite ● Dysphagia is an alteration in the client’s ability to swallow.
(soiled linens, garbage, emesis basins, bedpans, used ● Causes include obstruction, inflammation, and certain
tissues, clutter). neurologic disorders.
● Assess and manage anxiety and depression. ● Modifying the texture of foods and the consistency of
● Provide small, frequent meals and avoid high‑fat foods to liquids can enable the client to achieve proper nutrition.
help maximize intake. Beverages should be held at least ● Dry mouth can contribute to dysphagia. Evaluate
30 min before and after meals to prevent the client from medications being taken to determine if this is a
feeling full before adequate intake of calories from food. potential adverse effect.
● Provide liquid supplements between meals to improve ● Clients who have dysphagia should be referred to a
protein and calorie intake. speech therapist for evaluation.
● Ensure that meals appear appealing. Serve larger meals ● Dietary modifications are based on the specific
early in the day. swallowing limitations experienced by the client.
● Assess for changes in bowel status (increased gastric ● Nutritional supplements are beneficial if nutritional
emptying, constipation, diarrhea). intake is deemed inadequate.
● Position to increase gastric motility.
NURSING ACTIONS
● Provide mouth care before and after meals. ● Clients who have dysphagia are at an increased risk of
aspiration. Place the client in an upright or high‑Fowler’s
Constipation
position to facilitate swallowing.
● Clients who have constipation have difficult or ● Provide oral care prior to eating to enhance the client’s
infrequent passage of stools, which can be hard and dry. sense of taste.
● Causes include irregular bowel habits, psychogenic factors, ● Allow adequate time for eating, use adaptive
inactivity, chronic laxative use, obstruction, medications, eating devices, and encourage small bites and
GI disorders (irritable bowel syndrome [IBS]), pregnancy, thorough chewing.
or secondary to genital/rectal trauma (sexual abuse or
CLIENT EDUCATION
childbirth), and inadequate consumption of fiber and fluid. ● Pills should be taken with at least 8 oz of fluid (can be
● Encourage exercise and a diet high in fiber (25 g/day for
thickened) to prevent medication from remaining in
females and 38 g/day for males), and promote adequate
the esophagus.
fluid intake to help alleviate constipation. ● Avoid thin liquids and sticky foods.
● If caused by medication, a change in the medication
might be necessary.
Dumping syndrome
NURSING ACTIONS
Normally, the stomach controls the rate in which
● Determine onset and duration of past and present
nutrients enter the small intestine. When a portion of
elimination patterns, what is normal for the client,
the stomach is surgically removed, the contents of the
activity levels, occupation, dietary intake, and stress levels.
stomach are rapidly emptied into the small intestine,
● Collect data about past medical and surgical history,
causing dumping syndrome.
medication use (OTC, herbal supplements, laxatives, ● Early manifestations typically occur 10 to 20 min
enemas, and prescriptions), presence of rectal pressure
after eating. Early manifestations include a sensation
or fullness, and abdominal pain.
of fullness, abdominal cramping, nausea, diarrhea,
● Encourage client to gradually increase daily intake of fiber.
and vasomotor manifestations (faintness, syncope,
CLIENT EDUCATION diaphoresis, tachycardia, hypotension, flushing).
● Increase fluid intake to 64 oz/day unless contraindicated. ● Late manifestations occur 1 to 3 hr after eating. Late
● An increase in fiber intake is the preferred treatment for manifestations include diaphoresis, weakness, tremors,
constipation. Avoid chronic use of laxatives. anxiety, nausea, and hunger.
● Manifestations resolve after intestine is emptied.
However, there is a rapid rise in blood glucose and
increase in insulin levels immediately after the intestine
empties. This leads to hypoglycemia.
78 CHAPTER 13 Gastrointestinal Disorders CONTENT MASTERY SERIES

NURSING ACTIONS ● Manifestations include abdominal pain or discomfort
● Monitor clients receiving enteral tube feedings and report (can be relieved by eating), headache, lethargy, nausea,
manifestations of dumping syndrome to the provider. anorexia, hiccuping (lasting a few hours to days),
● Monitor the client for vitamin and mineral deficits (iron heartburn after eating, belching, sour taste in mouth,
and vitamin B12). vomiting, bleeding, and hematemesis (vomiting of blood).
● Acute recovery typically occurs in 1 day, but can take 2
CLIENT EDUCATION
to 3 days. The client should eat a bland diet when able to
● Consume small, frequent meals.
tolerate food. IV fluid replacement therapy is indicated if
● Consume protein and fat at each meal.
the condition persists.
● Avoid food that contains concentrated sugars and ● When the condition occurs due to ingestion of strong
restrict lactose intake.
acids or alkalis, dilution and neutralization of the causal
● Plan to consume liquids 1 hr after meals or between
agent is needed. Avoid lavage and emetics due to
meals (no sooner than 30 min after eating).
potential perforation and esophageal damage.
● Lie down after meals to delay gastric emptying. If reflux
is a problem, try a reclining position. CHRONIC MANAGEMENT: Modify diet, reduce and
manage stress, avoid alcohol and NSAIDs. If condition is
Gastroesophageal reflux disease persistent, the provider will prescribe an H2 receptor
antagonist (famotidine).
● Gastroesophageal reflux disease (GERD) occurs as the
result of the abnormal reflux of gastric secretions up the NURSING ACTIONS: Monitor for vitamin deficiency,
esophagus. This leads to indigestion and heartburn. especially of vitamin B12.
● Factors that contribute to GERD include hiatal hernia,
CLIENT EDUCATION
obesity, pregnancy, smoking, some medications, ● Avoid eating frequent meals and snacks, as they
and genetics.
promote increased gastric acid secretion.
● Long‑term GERD can cause serious complications, ● Avoid alcohol, cigarette smoking, aspirin and other
including adenocarcinoma of the esophagus and
nonsteroidal anti‑inflammatory drugs (NSAIDs), coffee,
Barrett’s esophagus.
black pepper, spicy foods, and caffeine.
● Manifestations include heartburn, retrosternal burning,
painful swallowing, dyspepsia, regurgitation, coughing,
Peptic ulcer disease
hoarseness, and epigastric pain. Pain can be mistaken
for a myocardial infarction. ● Peptic ulcer disease (PUD) is characterized by an erosion
of the mucosal layer of the stomach or duodenum. This
CLIENT EDUCATION
can be caused by a bacterial infection with H. pylori or
● Avoid situations that lead to increased abdominal
the chronic use of NSAIDs (aspirin, ibuprofen).
pressure, such as wearing tight‑fitting clothing. ● Some clients who have PUD do not experience
● Avoid eating for 3 hr before lying down.
manifestations. Others report dull, gnawing pain,
● Elevate the body on pillows instead of lying flat and
burning sensation in the back or low midepigastric area,
avoid large meals and bedtime snacks.
heartburn, constipation or diarrhea, sour taste in mouth,
● Attempt weight loss if overweight or obese.
burping, nausea, vomiting, bloating, urea present in
● Avoid trigger foods (citrus fruits and juices, spicy foods,
breath, and tarry stools. Eating can temporarily relieve
carbonated beverages).
pain. Anemia can occur due to blood loss.
● Avoid items that reduce lower esophageal sphincter ● For PUD caused by H. pylori, the provider prescribes
pressure (fatty foods, caffeine, chocolate, alcohol,
triple therapy (a combination of antibiotics and acid
cigarette smoke, all nicotine products, peppermint and
reducing medications) to be taken for 10 to 14 days.
spearmint flavors).
CLIENT EDUCATION: Avoid coffee, alcohol, caffeine,
Acute and chronic gastritis aspirin and other NSAIDs, cigarette smoking, black pepper,
and spicy foods.
● Gastritis is characterized by inflammation of the gastric
mucosa. The gastric mucosa is congested with blood and
Lactose intolerance
fluid, becoming inflamed. There is a decrease in acid
produced and an overabundance of mucus. Superficial ● Lactose intolerance results from an inadequate supply of
ulcers occur, sometimes leading to hemorrhages. lactase in the intestine, the enzyme that digests lactose.
● Acute gastritis occurs with excessive use of NSAIDs, bile ● The enzyme that converts lactose into glucose, and
reflux, ingestion of a strong acid or alkali substance, as galactose is absent or insufficient. Manifestations
a complication of radiation therapy, or as a complication include distention, cramps, flatus, and osmotic diarrhea.
of trauma (burns; food poisoning; severe infection; liver, ● Small amounts (4 to 6 oz) of milk taken during meals
kidney, or respiratory failure; major surgery). can be tolerated.
● Chronic gastritis occurs in the presence of ulcers ● Some dairy products (yogurt, aged cheeses) are low in
(benign or malignant), Helicobacter pylori, autoimmune lactate and can be better tolerated.
disorders (pernicious anemia), poor diet (excessive
NURSING ACTIONS: Monitor for vitamin D and calcium
caffeine, excessive alcohol intake), medications
deficiency.
(alendronate, perindopril), and reflux of pancreatic
secretions and bile into stomach.

NURSING ACTIONS Inflammatory bowel disease (IBD)
● Avoid or limit intake of foods high in lactose (milk, soft ● Crohn’s disease (regional enteritis) and ulcerative colitis
cheese, ice cream, cream soups, sour cream, puddings,
are chronic, inflammatory bowel diseases characterized
coffee creamer).
by periods of exacerbation and remission.
● Ask the provider about the use of a lactase enzyme. ● Manifestations include nausea, vomiting, abdominal
cramps, fever, fatigue, anorexia, weight loss, steatorrhea,
Ileostomies and colostomies
and low‑grade fever.
An ostomy is a surgically created opening on the surface ● Nutrition therapy is focused on providing nutrients in
of the abdomen from either the end of the small intestine forms that the client can tolerate.
(ileostomy) or from the colon (colostomy). ● A low‑residue, high‑protein, high‑calorie diet with
● Fluid and electrolyte maintenance is the primary vitamin and mineral supplementation is prescribed
concern for clients who have ileostomies during exacerbation to minimize bowel stimulation.
and colostomies. Fluid and electrolyte imbalances are corrected with IV
● The colon absorbs large amounts of fluid, sodium, fluids or oral replacement fluids.
and potassium. ● Enteral nutrition can be prescribed during exacerbations,
● Nutrition therapy begins with liquids only and is slowly especially if the client is reluctant to eat. Because
advanced based upon client tolerance. parenteral nutrition is more costly with a relatively
similar benefit, it is not used unless enteral nutrition is
NURSING ACTIONS: Provide emotional support to clients
ineffective or contraindicated.
due to the risk of altered body image. ● When the client is not experiencing an exacerbation,
CLIENT EDUCATION the diet can be broadened based on the client’s specific
● Consume a diet that is high in fluids (at least 1.9 to 2.4 L disease process and triggers.
[64 to 80 oz] per day) and soluble fiber.
Additional therapy
● Avoid foods that cause gas (beans, eggs, carbonated ● Complementary therapies including vitamin C and herbs
beverages), stomal blockage (nuts, raw carrots, popcorn),
(flaxseed)
and foods that produce odor (eggs, fish, garlic). ● Yoga, hypnosis, and breathing exercises
● Increase intake of calories and protein to promote ● Sedatives
healing of the stoma site. ● Antidiarrheal and antiperistaltic agents
● Aminosalicylate medications and corticosteroids to
Diverticulosis and diverticulitis

reduce inflammation
Diverticula are pouches protruding through the muscle of ● Immunomodulators to alter the immune response and
the intestinal wall, usually from increased intraluminal prevent relapse
pressure. They occur anywhere in the colon, but usually ● Surgery when other treatments are not effective
in the sigmoid colon. Unless infection occurs, diverticula
CLIENT EDUCATION: Avoid intake of substances that cause
cause no problems.
or exacerbate diarrhea, and avoid nicotine.
● Diverticulosis is a condition characterized by the
presence of diverticula.
Cholecystitis
● Diverticulitis is inflammation that occurs when fecal
matter becomes trapped in the diverticula. ● Cholecystitis is characterized by inflammation of
● Manifestations of diverticulitis include abdominal pain, the gallbladder.
nausea, vomiting, constipation or diarrhea, and fever, ● The gallbladder stores and releases bile that aids in the
accompanied by chills and tachycardia. digestion of fats.
● The client receives antibiotics, anticholinergics, and ● Manifestations include pain, tenderness, and rigidity
analgesics. Clients who have severe manifestations are in upper right abdomen. Pain can radiate to the right
admitted to the hospital and dehydration is treated with shoulder or midsternal area. Nausea, vomiting, and
IV therapy. Opioid analgesics are administered for pain. anorexia also can occur. If the gallbladder becomes filled
Complications (peritonitis, bowel obstruction, abscess) with pus or becomes gangrenous, perforation can result.
can warrant surgical intervention. ● In clients who have large stones or inability to control the
● A high‑fiber diet can prevent diverticulosis and condition with diet modifications, surgery is required.
diverticulitis by producing stools that are easily passed, ● Pancreatitis and liver involvement can result from
thus decreasing pressure within the colon. uncontrolled cholecystitis.
● During acute diverticulitis, a clear liquid diet is ● Fat intake should be limited to reduce stimulation of
prescribed until inflammation decreases, then a the gallbladder.
high‑fiber, low‑fat diet is indicated. ● The diet is individualized to the client’s needs
● Clients require instruction regarding diet adjustment and tolerance.
based on the need for an acute intervention or
preventive approach.

Pancreatitis ● Treatment for celiac disease is limited to avoiding gluten.
However, eliminating gluten, which is found in wheat, rye
● Pancreatitis is an inflammation of the pancreas, which
and barley, is difficult because it is found in many prepared
can be acute or chronic. In 70% of the acute cases, alcohol
foods. Clients must read food labels carefully in order to
use and gallstones are major causes. Chronic pancreatitis
adhere to a gluten‑free diet. Some gluten‑free products are
can result from acute pancreatitis that does not resolve.
unappealing to clients, and many are more expensive than
● The pancreas is responsible for secreting enzymes
other products. Prognosis is good for clients who adhere to
needed to digest fats, carbohydrates, and proteins.
a gluten‑free diet.
● Nutritional therapy for acute pancreatitis involves
reducing pancreatic stimulation. The client is prescribed NURSING ACTIONS
nothing by mouth (NPO), and a nasogastric tube is ● Monitor for complications including bleeding (bruising)
inserted to suction gastric contents. due to inadequate vitamin K intake, manifestations of
● TPN can be used until oral intake is resumed. anemias (iron, folate, vitamin B12), and manifestations
● Nutritional therapy for chronic pancreatitis usually of osteoporosis.
includes a low‑fat, high‑protein, and high‑carbohydrate ● Collaborate with a dietitian to assist with food selection
diet. It can include providing supplements of vitamin C and label reading.
and B‑complex vitamins.
CLIENT EDUCATION
Eat foods that are gluten‑free (milk, cheese, rice, corn,
Liver disease
●
eggs, potatoes, fruits, vegetables, fresh meats and fish,

● The liver is involved in the metabolism of most nutrients. dried beans).
● Disorders affecting the liver include cirrhosis, hepatitis, ● Read labels on processed products. Gravy mixes, sauces,
and cancer. cold cuts, soups, and many other products have gluten
● Malnutrition is common with liver disease. as an ingredient.
● Protein needs are increased to promote a positive ● Read labels and research nonfood products (lipstick,
nitrogen balance and prevent a breakdown of the body’s communion wafers, vitamin supplements), which also
protein stores. can have gluten as an ingredient.
● Carbohydrates are generally not restricted, as they are an
important source of calories. Bariatric surgery
● Caloric requirements might need to be increased based
This is considered the most effective treatment for
on an evaluation of the client’s stage of disease, weight,
managing obesity and related conditions. Benefits include
and general health status.
reduction of diabetes mellitus, hypertension, dyslipidemia,
● Multivitamins (especially vitamins B, C, and K) and
and mortality rates as well as improved quality of life.
mineral supplements might be necessary. ● Bariatric surgery works best in combination with
● Alcohol, nicotine, and caffeine should be eliminated.
diet and lifestyle changes. Nutritional counseling is
essential. Protein intake of 60 g/day is required to
Celiac disease
prevent protein-calorie malnutrition.
● Celiac disease is also known as gluten‑sensitive ● CLIENT EDUCATION: Dramatic changes in food intake
enteropathy, celiac sprue, and gluten intolerance. and regular physical activity will be necessary for
● It is a chronic, inherited, genetic disorder with successful long‑term weight control.
autoimmune characteristics. Clients who have celiac
Adjustable gastric bandingrestricts stomach capacity
disease are unable to digest the protein gluten. They
to 15 to 30 mL with an inflatable band that encircles the
lack the digestive enzyme DPP‑IV, which is required to
uppermost portion of the stomach, similar to a belt to
break down the gluten into molecules small enough to
create an outlet that can be adjusted as needed.
be used by the body. In celiac disease, gluten is broken ● CLIENT EDUCATION
down into peptide strands instead of molecules. The ◯ Diet will gradually increase from liquids to pureed to
body is not able to metabolize the peptides. If untreated,
soft foods.
the client will suffer destruction of the villa and the ◯ Chew foods thoroughly, slowly, and in small amounts.
walls of the small intestine. Celiac disease can go
undiagnosed in both children and adults. Roux‑en‑Y gastric bypass: Ingested food bypasses 95%
● Manifestations vary widely. Children who have celiac of the stomach, the duodenum, and a small portion of
disease have diarrhea, steatorrhea, anemia, abdominal the proximal jejunum. Weight loss is achieved through
distention, impaired growth, lack of appetite, and malabsorption and dumping syndrome and the altering of
fatigue. Typical manifestations in adults include the hormone ghrelin which decreases hunger.
diarrhea, abdominal pain, bloating, anemia, steatorrhea, ● Possible postoperative complications include
and osteomalacia. anastomotic leaks, internal hernias, GI bleeding, stomal
stenosis, gallstones.
● Micronutrient deficiencies are common long term.
Sleeve gastrectomyis a procedure in which a longitudinal

portion of the stomach is removed to create a “sleeve”
effect. This reduces production of the hormone ghrelin,
which decreases hunger.

1. A nurse is teaching a client who is recovering A nurse is providing instructions to the guardian of a
from pancreatitis about following a low‑fat child who has lactose intolerance. What should the nurse
diet. Which of the following foods should the include in the teaching? Use the ATI Active Learning
nurse recommend? (Select all that apply.) Template: System Disorder to complete this item.
A. Ribeye steak CLIENT EDUCATION

B. Oatmeal ●
Describe the underlying cause of lactose intolerance.
C. Ice cream ●
Identify two manifestations of lactose intolerance.
D. Canned peaches ●
Identify three foods the child should
E. Pretzels limit or eliminate from their diet.
2. A nurse is teaching a client who has constipation

about a high‑fiber, low‑fat diet. Which of
the following food choices by the client
indicates understanding of the teaching?
A. Peanut butter
B. Peeled apples
C. Hardboiled egg
D. Brown rice
3. A nurse is assessing a client who is postoperative from

a gastric bypass and who just finished eating a meal.
Which of the following findings are manifestations
of dumping syndrome? (Select all that apply.)
A. Bradycardia
B. Dizziness
C. Dry skin
D. Hypotension
E. Diarrhea
4. A nurse is collecting data from a client who has peptic

ulcer disease (PUD). Which of the following findings
should the nurse expect? (Select all that apply.)
A. Steatorrhea
B. Anemia
C. Tarry stools
D. Epigastric pain
E. Swollen lymph nodes
5. A nurse is instructing a client who has celiac disease

about foods to avoid. Which of the following
foods should the nurse include in the teaching?
A. Potatoes
B. Graham crackers
C. Wild rice
D. Canned pears

1. A. Ribeye steak is not a low‑fat food source. Using the ATI Active Learning Template: System Disorder
B. CORRECT: Oatmeal is a source of easily
CLIENT EDUCATION
digested carbohydrate that is low in fat.
C. Ice cream is not a low‑fat food source.
●
The underlying cause of lactose intolerance is an inadequate
D. CORRECT: Canned peaches are a source of easily level of lactase. The enzyme that converts lactose into
digested carbohydrate that is low in fat. glucose and galactose is absent or insufficient.
E. CORRECT: Pretzels are a source of easily
●
Manifestations
digested carbohydrate that is low in fat. Abdominal distension
◯

® Cramps
◯
Nutrition and Oral Hydration Flatus

◯
Diarrhea
◯
●
Foods to limit or avoid include milk, soft cheese,
2. A. Peanut butter is high in fat. ice cream, cream soups, puddings.
B. Unpeeled fruit is a better source of fiber.
C. Egg yolk is high in fat. NCLEX® Connection: Physiological Adaptation,
D. CORRECT: Brown rice is a good source Illness Management
of fiber and is low in fat.
NCLEX® Connection: Basic Care and Comfort, Elimination
3. A. Tachycardia due to a decrease in circulating volume

is a manifestation of dumping syndrome.
B. CORRECT: When a portion of the stomach is no longer
available to serve as a reservoir, a large amount of food
is rapidly dumped into the small intestine, and fluid shifts
from general circulation into the intestine. Dizziness
occurs due to a decrease in circulating volume.
C. Sweating is a manifestation of dumping syndrome.
D. CORRECT: Hypotension occurs due to a
decrease in circulating volume.
E. CORRECT: Diarrhea from increased peristalsis is
a manifestation of dumping syndrome.
4. A. Steatorrhea is a clinical finding in the

presence celiac disease.
B. CORRECT: Iron deficiency anemia due to
blood loss is a clinical finding of PUD.
C. CORRECT: Tarry stools due to intestinal
bleeding is a clinical finding of PUD.
D. CORRECT: Epigastric pain described as a gnawing or
burning sensation is a clinical manifestation of PUD.
E. Swollen lymph nodes are a clinical manifestation of
many conditions and infections, but not of PUD.
5. A. Potatoes are gluten‑free and a good choice

for a client who has celiac disease.
B. CORRECT: Graham crackers are made from wheat
flour. A client who has celiac disease should avoid
products that are made from wheat flour.
C. Wild rice is gluten‑free and a good choice
for a client who has celiac disease.
D. Fruits and vegetables without a sauce are gluten‑free and
are good choices for a client who has celiac disease.

CHAPTER 14
UNIT 3 ALTERATIONS IN NUTRITION End‑stage kidney disease (ESKD) manifestations include
Renal Disorders fatigue, decreased alertness, anemia, decreased urination,

CHAPTER 14 headache, and weight loss.
Acute kidney injury (AKI) m anifestations include a decrease

in urination, decreased sensation in the extremities, swelling
Nurses must understand nutritional needs of clients
of the lower extremities, and flank pain. It is characterized
who have renal disorders. It is important to explore by rising blood levels of urea and other nitrogenous wastes.
dietary needs with the client and recommend Nephrotic syndrome’s most pronounced manifestations
are edema and high proteinuria. Other manifestations
modifications related to the disease process.
include hypoalbuminemia, hyperlipidemia, and blood
Understanding the role of primary and secondary hypercoagulation.
prevention is essential to successful treatment. Kidney stones a re characterized by sudden, intense pain
that is typically located in the flank and is unrelieved by
The kidneys have two primary functions: position changes as the stone moves out of the kidney
pelvis and down the ureter. Diaphoresis, nausea, and
maintaining blood volume and excreting waste
vomiting are common, and there can be blood in the urine.
products. Other functions include the regulation The majority of kidney stones are made of calcium oxalate.
of acid‑base balance, blood pressure, calcium

and phosphorous metabolism, and red blood NUTRITIONAL GUIDELINES AND
cell production. Kidney damage and/or loss of NURSING INTERVENTIONS
kidney function have profound effects on the General renal considerations
client’s nutritional state. Urea is a waste by‑product ● Monitor kidney parameters for clients who have
renal disorders.
of protein metabolism, and urea levels rise with ◯ Nurses should monitor weight daily or as prescribed.
kidney disease. Monitoring protein intake is critical. Weight is an indicator of fluid status, which is a
primary concern.
Short‑term kidney disease requires nutritional ◯ Monitor fluid intake, and encourage compliance with
fluid restrictions.
support for healing rather than dietary ◯ Nurses should monitor urine output. Placement of an
restrictions. Dietary recommendations are indwelling urinary catheter might be necessary for
accurate measurement.
dependent upon the stage of kidney disease. ◯ Monitor for manifestations of constipation. Fluid
restrictions predispose clients to constipation.

Nutritional considerations included in this chapter ● Explain why dietary changes are necessary. Alterations
are for chronic kidney disease and end‑stage in the intake of protein, calories, sodium, potassium,
phosphorus, and other vitamins are required.
kidney disease, acute kidney injury, nephrotic ● Provide support for the client and family.
syndrome, and nephrolithiasis (kidney stones).
Chronic kidney disease (stages 1 to 4)
Referral to and consultation with a registered ● Stages 1 to 4 are predialysis and characterized by
dietitian to determine calories, protein, and increasing blood creatinine levels and a decreasing
glomerular filtration rate (GFR).
other nutrients is essential for the client to
decrease the risk of malnutrition. ● Goals of nutritional therapy
◯ Slow the progression of CKD.
Control blood glucose and hypertension.

◯
◯ Help preserve remaining kidney function by limiting
Chronic kidney diseaseis distinguished by an the intake of protein, which results in decreased
increase in blood creatinine. Manifestations phosphorus levels.
include fatigue, back pain, and appetite changes. ● Restricting phosphorus intake slows the progression of
It is a progressive disorder, characterized by five stages. kidney disease. High levels of phosphorus contribute to
● Stage 1: at risk for CKD calcium and phosphorus deposits in the kidneys.
● Stage 2: mild CKD ● Protein restriction is essential for clients who have
● Stage 3: moderate CKD stage 1 to 4 CKD.
● Stage 4: severe CKD ◯ Slows the progression of kidney disease.
● Stage 5: CKD requiring dialysis or transplant for ◯ Too little protein results in the breakdown of body
survival (end-stage kidney disease) protein. Carefully determine protein intake.
NUTRITION FOR NURSING CHAPTER 14 Renal Disorders 85

DIETARY RECOMMENDATIONS ● Vitamin D deficiency occurs as the kidneys are unable to
● Restrict sodium intake to maintain blood pressure. convert vitamin D to its active form.
● Restrict potassium intake to prevent hyperkalemia. ◯ This alters the metabolism of calcium, phosphorus,
● The recommended daily protein intake is 0.8 to and magnesium, leading to hyperphosphatemia,
1.0 g/kg/day of ideal body weight. hypocalcemia, and hypermagnesemia.
◯ Protein restrictions are decreased as the disease ◯ Calcium supplements will likely be required because
progresses to ESKD, and to decrease the workload on foods high in phosphorus (which are restricted) are
the kidneys. also high in calcium.
◯ High biologic value proteins are recommended for
clients who have CKD to prevent catabolism of muscle Acute kidney injury
tissue. These proteins include eggs, meats, poultry,
AKI is an abrupt, rapid decline in kidney function caused by
game, fish, soy, and dairy products.
trauma, sepsis, poor perfusion, or medications, and usually
● Limit meat intake to 5 to 6 oz/day for most males and
is reversible. AKI can cause hyponatremia, hyperkalemia,
4 oz/day for most females.
hypocalcemia, and hyperphosphatemia. Fluid overload
● Limit dairy products to ½ cup per day.
leading to pulmonary edema is a complication of AKI.
● Limit high‑phosphorus foods (peanut butter, dried
peas and beans, bran, cola, chocolate, beer, some whole THERAPEUTIC NUTRITION
grains) to one serving or less per day. ● Diet therapy for AKI is dependent upon the phase of AKI
● Caution clients to use vitamin and mineral supplements and its underlying cause. Protein, calories, fluids, potassium,
only when recommended by a provider. Avoid high and sodium need to be individualized according to the three
protein sports drinks, energy drinks, or meal phases of AKI (oliguric, diuretic, recovery) and whether the
supplements. Avoid herbal supplements that can affect client is receiving dialysis.
bleeding time and blood pressure. ● Recommendation is to consume 20 to 30 cal/kg/day of
body weight in clients who are in any stage of AKI to
End‑stage kidney disease maintain energy and demands of stress.
● Simple carbohydrates, fats, oils, and low‑protein starches
ESKD, or Stage 5 CKD, occurs when the GFR is less than
are included in the diet. Provide nonprotein calories in
15 mL/min and the blood creatinine level steadily rises,
an adequate amount to maintain the client’s weight.
and indicates complete kidney failure. ● Protein intake can increase to 1 to 1.5 g/kg if the client
THERAPEUTIC NUTRITION is receiving dialysis, compared to 0.6 g/kg (40 g/day) for
● The goal of nutritional therapy is to maintain appropriate nondialysis clients.
fluid status, blood pressure, and blood chemistries. ● Potassium and sodium are dependent on urine output,
◯ A low‑protein, low‑phosphorus, low‑potassium, blood values, and if the client is receiving dialysis.
low‑sodium (2 to 3 g/day), fluid‑restricted diet ◯ Potassium is restricted to 60 to 70 mEq/day when
is recommended. on dialysis.
◯ Consume adequate calories (35 kcal/kg of body ◯ Sodium is restricted to 1 to 2 g/day if not receiving
weight) to maintain body protein stores. dialysis, and 2 to 4 g/day if receiving dialysis, which
● Monitor potassium level and replace as needed. Sodium also depends on the phase.
and fluid allowances are determined by blood pressure, ◯ Calcium requirements are less than 2,000 mg daily if
weight, blood electrolyte findings, and urine output. receiving hemodialysis or peritoneal dialysis.
● Achieving a well‑balanced diet based on the above ● Fluids are restricted to the client’s daily urine output
guidelines is difficult. The National Renal Diet provides plus 500 mL during the oliguric phase. Fluid needs are
clients with a list of food choices. increased during the diuretic phase.
● Protein needs increase from 0.6 to 1.0 g/kg before
dialysis to 1.2 to 1.5 g/kg, depending on the type of Nephrotic syndrome
dialysis, once dialysis has begun as protein and amino ● Nephrotic syndrome results in the increased excretion of
acids are lost in the dialysate.
proteins into the urine, resulting in hypoalbuminemia,
◯ Fifty percent of protein intake should come from
edema, hyperlipidemia, and blood hypercoagulation.

biologic sources (eggs, milk, meat, fish, poultry, soy).
Prolonged protein loss leads to protein malnutrition,
● Restrict phosphorus (700 to 1,200 mg/day).
anemia, and vitamin D deficiency.
◯ A high protein requirement leads to an increase in
● Diabetes mellitus, kidney damage due to medications
phosphorus intake.
or chemicals, autoimmune disorders, and infections can
◯ Foods high in phosphorus are milk products, beef
cause nephrotic syndrome.

liver, chocolate, nuts, and legumes.
◯ Phosphate binders (calcium carbonate, calcium
acetate) are taken with all meals and snacks.
86 CHAPTER 14 Renal Disorders CONTENT MASTERY SERIES

THERAPEUTIC NUTRITION Application Exercises
● Nutritional therapy goals include minimizing edema,
replacing lost nutrients, minimizing kidney damage,
1. A nurse is planning care for a client who has ESKD.
controlling hypertension, and preventing protein Which of the following should the nurse include
malnutrition that can lead to muscle catabolism. in the plan of care? (Select all that apply.)
● Dietary recommendations indicate sufficient protein and A. Monitor the client’s weight daily.
low sodium intake.
B. Encourage the client to comply
◯ Adequate amount of protein intake is 0.7 to
with fluid restrictions.
1.0 g/kg/day.
C. Evaluate intake and output.
◯ Soy‑based proteins can decrease protein losses and
D. Instruct the client on restricting

lower blood lipid levels.
calories from carbohydrates.
◯ Low‑sodium diet of 2,000 mg/day can help control
E. Monitor for constipation.

edema and hypertension.
Carbohydrates should provide the majority of the
2.
◯
A nurse is teaching a client who has stage 2

client’s daily calories.
chronic kidney disease about dietary management.
◯ Cholesterol, trans fat, and saturated fats can be Which of the following information should
restricted to assist in controlling high lipid levels. the nurse include in the instructions?
◯ Provide a multiple vitamin supplement to replace loss
A. Restrict protein intake.
of vitamins with protein excretion. Replace loss of
B. Maintain a high‑phosphorus diet.
vitamin D with a supplement as needed.
C. Increase intake of foods high in potassium.
D. Limit dairy products to 1 cup/day.
Nephrolithiasis
● The most common type of kidney stone is made of 3. A nurse is teaching a client about protein needs when
calcium oxalate. on dialysis. Which of the following instructions should
the nurse include in the teaching? (Select all that apply.)
● Contributing factors include inadequate fluid intake,
elevated urine pH, and excess excretion through the A. Consume 35 kcal/kg of body weight
to maintain body protein stores.
kidneys of oxalate, calcium, and uric acid.
● Kidney stone formation is more influenced by the B. Take phosphate binders when
eating protein‑rich foods.
amount of oxalate in the client’s system than calcium.
A client who has an ileostomy has an increased risk of C. Increase biologic sources of protein
(eggs, milk, and soy).
kidney stones.
D. Increase protein intake by 50% of the
PREVENTATIVE NUTRITION: Excessive intake of protein, recommended dietary allowance (RDA).
sodium, calcium, and oxalates (rhubarb, spinach, beets) E. Consume daily protein intake in the morning.
can increase the risk of stone formation.
THERAPEUTIC NUTRITION 4. A nurse is teaching about diet restrictions to a client

who has acute kidney injury and is on hemodialysis.
● Increasing fluid consumption is the primary
Which of the following recommendations
intervention for the treatment and prevention of kidney should the nurse include in the teaching?
stones. Daily fluid intake should be enough to produce
A. Limit calcium intake to 2,500 mg/day.
at least 2 L of urine per day. Drink some fluid before
B. Decrease total fat intake to 45% of daily calories.
bedtime because urine becomes more concentrated at
C. Decrease potassium intake to 60 to 70 mEq/kg.
night. This is particularly important for clients who
D. Limit sodium intake to 4.5 g/day.
have cystine stones, which requires an even greater
daily fluid intake.
● Recommendation for calcium oxalate stone formation 5. A nurse is completing discharge teaching about diet
and fluid restrictions to a client who has a calcium
is to limit animal protein, excess sodium, alcohol, and
oxalate‑based kidney stone. Which of the following
caffeine use. Low potassium can contribute to calcium instructions should the nurse include in the teaching?
stone formation.
A. Reduce intake of spinach.
● Foods high in oxalates include spinach, rhubarb, beets,
B. Decrease broccoli intake.
nuts, chocolate, tea, wheat bran, and strawberries,
C. Increase intake of vitamin C supplements.
and should be limited in the diet. Avoid megadoses
of vitamin C, which increase the amount of D. Limit consumption of purine substances.
oxalate excreted.
● Recommendation for prevention of uric acid stones is to Active Learning Scenario
limit foods high in purines, which include lean meats,
organ meats, whole grains, and legumes. A nurse is reviewing teaching for a client who has
nephrotic syndrome. What information should the
nurse include? Use the ATI Active Learning Template:
System Disorder to complete this item.
ALTERATION IN HEALTH (DIAGNOSIS)

COMPLICATIONS: List three.
CLIENT EDUCATION: Include five teaching points.
NUTRITION FOR NURSING CHAPTER 14 Renal Disorders 87

1. A. CORRECT: Monitoring the client’s daily weight Using the ATI Active Learning Template: System Disorder
assists in determining fluid retention. ALTERATION IN HEALTH (DIAGNOSIS): Nephrotic syndrome is a renal
B. CORRECT: Implementing fluid restriction for disorder in which there is increased excretion of proteins into the urine.
a client helps to slow fluid retention.
C. CORRECT: Evaluating I&O helps to determine COMPLICATIONS
if there is an increase in fluid retention. ●
Hypoalbuminemia ●
Edema ●
Malnutrition
D. Carbohydrates are not restricted for a client who has ESKD. ●
Proteinuria ●
Hyperlipidemia ●
Anemia
E. CORRECT: Constipation often occurs as
CLIENT EDUCATION
a result of fluid restrictions.
●
Increase protein intake to prevent catabolism of muscle tissue.
®
●
Limit sodium intake to control edema and hypertension.
Consume foods low in trans fats and cholesterol.
●
Consume foods high in carbohydrates to increase calorie intake.
2. A. CORRECT: Restricting protein intake decreases the risk for ●
Take a vitamin supplement to replace vitamin
proteinuria and decreases the workload on the kidney. loss that occurs with protein excretion.
B. A diet high in phosphorus is not recommended NCLEX® Connection: Physiological Adaptation, Illness
because it can contribute to calcium and Management
phosphorus deposits on the kidney.
C. Eating foods low in potassium is recommended
because hyperkalemia occurs with kidney disease.
D. Dairy products are a protein and sodium
source, and are limited to 0.5 cup/day.
3. A. CORRECT: To maintain protein stores, the client

should consume 35 cal/kg of body weight.
B. CORRECT: Protein consumption increases phosphorus
intake. Phosphate binders are recommended with meals.
C. CORRECT: Protein intake should include biologic sources of
protein to include eggs, milk, meat, fish, poultry, and soy.
D. CORRECT: The recommended protein intake for
a client on dialysis is 50% greater than the RDA
because amino acids are lost in the dialysate.
E. The client should spread protein intake throughout the day to
prevent excessive intake of phosphorous and potassium.
4. A. The client receiving hemodialysis should limit

calcium intake to less than 2,000 mg/day.
B. The client should limit total fat intake
to 35% of daily calories.
C. CORRECT: The client should limit potassium
intake to 60 to 70 mEq/kg.
D. The client should limit sodium intake to
1 to 4 g/day when receiving dialysis.
5. A. CORRECT: The client should reduce intake of

foods high in oxalate, such as spinach, which
can cause calcium stone formation.
B. Broccoli is high in calcium but does not cause calcium
stone formation and is not restricted in the diet.
C. Large doses of vitamin C supplements can
cause calcium stone formation.
D. Foods that contain purine, such as organ meats and
red wine, cause uric acid stone formation.
88 CHAPTER 14 Renal Disorders CONTENT MASTERY SERIES

CHAPTER 15
UNIT 3 ALTERATIONS IN NUTRITION ASSESSMENT/DATA COLLECTION
CHAPTER 15 Diabetes Mellitus Hypoglycemia is a blood glucose level less than 70 mg/dL.
It results from taking too much insulin, inadequate food
intake, delayed or skipped meals, extra physical activity,
or consumption of alcohol without food.
Glucose is the body’s primary source of ● Manifestations include mild shakiness, mental
energy, and insulin is needed to assist the confusion, sweating, palpitations, headache, lack of
coordination, blurred vision, seizures, and coma.
body in the breakdown of glucose to a form
Hyperglycemia is a blood glucose level above the
that is used for energy. Diabetes mellitus
expected reference range. It results from an imbalance
inhibits the body’s production and/or use of with food, medication, and activity, combined with an
inadequate amount of insulin production or cells that are
insulin. This results in elevated blood glucose
insulin‑resistant.
levels. Complications of diabetes mellitus are ● Infection, other illness, and stress can cause an increase
in blood glucose.
characterized as macrovascular (cardiovascular ● Primary manifestations include polydipsia (excessive
and cerebrovascular disease) or microvascular thirst), polyuria (excessive urination), and polyphagia
(excess hunger and eating). As hyperglycemia
(kidney, nerve, and vision problems). For clients progresses, ketones (which can be detected in the urine
who are pregnant, blood glucose control and other manifestations (hyperventilation [Kussmaul
respirations], dehydration, fruity odor to the breath,
prevents maternal and fetal complications. headache, inability to concentrate, decreased levels of
consciousness, seizures leading to coma) develop.
The nurse assists the client in identifying lifestyle ● The Somogyi phenomenon is morning hyperglycemia
changes necessary to manage diabetes mellitus, in response to overnight hypoglycemia. Providing a
bedtime snack and appropriate insulin dose prevents
including diet and activity level. this phenomenon.
● The dawn phenomenon is an elevation of blood glucose
TYPES OF DIABETES MELLITUS around 0500 to 0600. It results from an overnight release
of growth hormone and is treated by increasing the
Prediabetes amount of insulin provided during the overnight hours.
● Clients who have glucose levels that are elevated above Metabolic syndrome is a cluster of factors that increase
the expected range but below the diagnostic criteria for the risk for diabetes mellitus and cardiovascular
diabetes mellitus are said to have prediabetes. complications. Factors include elevated glucose levels,
● Clients who have prediabetes are encouraged to adopt central obesity, hyperlipidemia, hypertension, and low
lifestyle modifications to prevent the development of levels of HDL cholesterol. The presence of at least 3 factors
diabetes mellitus. indicates metabolic syndrome.
Type 1 diabetes mellitus

Autoimmune disease is triggered by genetic links or a
NUTRITIONAL GUIDELINES AND
●
viral infection.
Damage to or destruction of beta cells of the pancreas
Hypoglycemia
●
results in an absence of insulin production.

● Most often diagnosed before 18 years of age; can occur ● Clients who have hypoglycemia should take 15 to 20 g of
at any age. a readily absorbable carbohydrate.
◯ Two or three glucose tablets (5 g each)
Type 2 diabetes mellitus ◯ Six to ten hard candies
◯ ½ cup (4 oz) juice or regular soda

● Results from genetic and environmental factors ◯ 1 tbsp honey or 4 tsp sugar
● Characterized by altered patterns of insulin secretion and ● Retest the blood glucose in 15 min. If it is less than 70 mg/dL,
decreased cellular uptake of glucose (insulin resistance)
repeat the above steps. Once levels stabilize, have the
client take an additional carbohydrate and protein snack or
Gestational diabetes mellitus (GDM)
small meal, depending on the severity of the hypoglycemic
● Glucose intolerance that is recognized during pregnancy, episode and whether the next meal is more than 1 hr away.
that typically resolves after delivery
● Clients who have a history of GDM have an increased
risk for developing diabetes mellitus type 2 later in life.
NUTRITION FOR NURSING CHAPTER 15 Diabetes Mellitus 89

Hyperglycemia ● Artificial sweeteners are acceptable (sucralose,
aspartame, saccharin, acesulfame, potassium). Sugar
● Clients who have hyperglycemia should do the following.
alcohols (xylitol, mannitol, sorbitol) contain some sugar,
◯ Notify the provider or go to the emergency department
but not as much as natural sweeteners. Sucrose (table

for difficulty concentrating, altered consciousness, or
sugar) can be included in a diabetic diet and should
seizure activity.
be counted in the total calories for the day to ensure
◯ Take medication if forgotten.
antidiabetic medications are sufficient to cover intake.

● Cultural and personal preferences should be considered
GENERAL NUTRITIONAL GUIDELINES in planning food intake.
● According to the American Diabetes Association and the
● Coronary heart disease (CHD) is a frequent cause of
Academy of Dietetics and Nutrition, daily nutritional
death among clients who have diabetes. Clients who
requirements are based on the needs of each client.
have diabetes are encouraged to follow a diet that is ● A dietitian works with the client to develop meal
high in fiber and low in saturated fat, trans fat, and
planning that meets the client’s needs based on healthy
cholesterol to prevent CHD.
food choices. The goal of therapy is to maintain blood
● Dietary intake should be individualized according to the
glucose levels as close to the expected reference range
client’s individual needs, need for weight management,
as possible.
and lipid and glucose patterns. Clients should space food ◯ The dietitian instructs the client on various
intake throughout the day (regular meals and a snack or

dietary methods, including exchange list and
snacks). General guidelines follow.
carbohydrate counting.
◯ Carbohydrates ● Using the Food Lists for Diabetes (formerly called
■ Encourage the client to consume carbohydrates
Exchange Lists) as a guide for meal planning allows for

found in grains, fruits, legumes, and milk. Limit
the incorporation of three basic food groups: protein,
simple carbohydrates, which include refined grains
carbohydrates, and fats.
and sugars. ◯ Each client has a recommended amount of daily
■ Carbohydrates should be 45% to 65% of total daily
exchanges within each group based on the
caloric intake.
client’s needs.
◯ Fats
Clients should eat less saturated and trans fats.

Carbohydrate counting
■
■ Polyunsaturated fatty acids are found in fish. Two
or more servings per week are recommended. Carbohydrate counting focuses on counting total grams
■ Consuming foods enriched with plant sterols or of carbohydrates in each food item. Many clients find it
stanols can reduce LDL cholesterol. easier than exchange lists because of the simplicity and
◯ Fiber flexibility. It does not require the client to learn how much
■ Promote fiber intake (beans, vegetables, oats, whole a portion size is.
grains) to improve carbohydrate metabolism and ● One serving equals 15 g of carbohydrates. Clients are
lower cholesterol. free to choose what carbohydrates to consume, but are
■ Recommendation for fiber intake includes at least encouraged to choose a variety of types and include
14 g per 1,000 calories. consistent amounts of protein and fats in the diet.
◯ Protein: Protein from meats, eggs, fish, nuts, beans, ◯ Foods that contain 15 g of carbohydrates
and soy products should comprise 15% to 20% of total ■ 1 slice of sandwich bread
caloric intake. Reduce protein intake if needed in ■ 1/2 cup cooked pasta
clients who have diabetes and kidney failure. ■ 1/2 cup canned fruit in juice (not syrup)
◯ Sodium: Limit to 2,300 mg/day. ■ 1/4 cup dried fruit
● Encourage clients to eliminate all tobacco use due to the ■ 3 cups raw vegetables
increased risk of cardiovascular disease. ■ 1 1/2 cup cooked vegetables
● Moderate alcohol intake can lower the risk for ■ 4 to 6 snack crackers
cardiovascular disease. Clients should limit daily alcohol ■ 1/2 cup regular ice cream
intake to one alcoholic beverage for females or two ● With basic carbohydrate counting, a client consumes a
for males. specific amount or servings of carbohydrates at each
◯ To avoid hypoglycemia, the client should consume meal and snack.
alcohol with a meal or immediately after a meal. ● With advanced carbohydrate counting, clients calculate
◯ Alcoholic beverages should not replace food intake. mealtime insulin based on the amount of carbohydrates
● Vitamin and mineral requirements are unchanged consumed. Clients must be able to perform basic math
for clients who have diabetes. Supplements are skills and be willing to check their glucose before each
recommended for identified deficiencies. meal to provide a corrective insulin dose, if the glucose
level is too high.
● Clients can exchange carbohydrate selections as long as
the grams of carbohydrates are the same per serving.
Food selections can vary in amount of additional
calories from fat and protein each food can contain.
90 CHAPTER 15 Diabetes Mellitus CONTENT MASTERY SERIES

OTHER NURSING INTERVENTIONS Application Exercises
● Provide instructions to the client on the following, and
discuss these at subsequent appointments. 1. A nurse is talking with a client who has a new diagnosis
◯ Self‑monitoring of blood glucose of diabetes mellitus type 2 and their caregiver. Which
◯ Dietary and activity recommendations of the following sweeteners should the nurse include as
◯ Manifestations and treatment of hypoglycemia and a zero-calorie sweetener option? (Select all that apply.)
hyperglycemia, to include the importance of taking A. Sucrose
medications as prescribed B. Aspartame
◯ Long‑term complications of diabetes C. Mannitol
◯ Psychological implications D. Xylitol
◯ Community organizations and support groups whose E. Sucralose
focus is diabetes
● Children who have diabetes require parental support, 2. A nurse is assessing a client who is has
guidance, and participation. Dietary intake must provide hypoglycemia. Which of the following
for proper growth and development. Altered nutritional findings should the nurse expect?
needs during times of growth and fluctuations in eating A. Fruity breath odor
patterns and activity levels can make management B. Diaphoresis
complicated. C. Ketones in urine
● For older adult clients, ask questions to determine the D. Polyuria
presence of deficits that impede adequate nutrition or
safe medication administration (cognitive impairment,
3. A nurse is caring for a client who has diabetes
vision and hearing changes, altered dentition, anorexia, mellitus and reports feeling shaky and weak.
financial barriers). The client’s blood glucose is 53 mg/dL. Which of
● For pregnant clients, there must be a balance between the following actions should the nurse take?
maternal blood glucose goals and nutritional needs of A. Provide subcutaneous insulin for the client.
pregnancy. Clients might have to monitor blood glucose B. Offer the client 120 mL (4 oz) fruit juice.
more often (up to eight times daily).
C. Give the client IV potassium.
● Teach proper calibration and use of the self‑monitoring
D. Administer IV sodium bicarbonate.
of blood glucose, record keeping, and reporting of levels
to health care provider.
4. A nurse is reinforcing dietary teaching to
CLIENT EDUCATION a client who has type 2 diabetes mellitus.
● Exercise as appropriate and when blood glucose levels Which of the following instructions should
are within an acceptable range. Closely monitor blood the nurse include? (Select all that apply.)
glucose; decreased medication doses might be required A. “Carbohydrates should comprise
with strenuous exercise to prevent hypoglycemia. 55% of daily caloric intake.”
◯ Recommendations for adults who have diabetes mellitus
B. “Use hydrogenated oils for cooking.”
includes exercising at least 3 days/week for 150 min total. C. “You can add table sugar to cereals.”
◯ Adult should not sit for more than 90 min at a time.
D. “Eat something if you choose to drink alcohol.”
● Lose weight if appropriate. It is important for clients who
E. “Use the same portion sizes to
have type 2 diabetes mellitus and have a BMI greater exchange carbohydrates.”
than 25, as it can decrease insulin resistance, improve
glucose and lipid levels, and lower blood pressure.
◯ Successful weight loss programs include
5. A nurse is teaching a group of clients who have
diabetes about meal planning. Which of the following
managing calorie intake, exercising, and making
client statements indicates understanding?
lifestyle modifications.
A. “I will avoid having snacks.”
● Be aware of the timing for antidiabetic medications
in regard to food intake (before or with meals, or B. “I should not eat anything containing sugar.”
regardless of calorie intake). Take medications at the C. “I will not eat fruit canned in syrup.”
appropriate time for maximum therapeutic effect. D. “I will not eat more than 2,800 mg of sodium a day.”
● Perform self‑monitoring of blood glucose. Strict control
of glucose can reduce or postpone complications
(retinopathy, nephropathy, neuropathy). Active Learning Scenario
● Obtain regular evaluations from the provider.
A nurse is reviewing the discharge plan for a client who
has type 1 diabetes mellitus. How should the nurse use
interprofessional care in the plan? Use the ATI Active
Learning Template: System Disorder to complete this item.
INTERPROFESSIONAL CARE: Describe the role

of another member of the health care team.
CLIENT EDUCATION: Describe three teaching points
offered by this member of the health team.
NUTRITION FOR NURSING CHAPTER 15 Diabetes Mellitus 91

1. A. Common table sugar is sucrose, and it contains about Using the ATI Active Learning Template: System Disorder
15 g of carbohydrates per tablespoon. INTERPROFESSIONAL CARE: Dietitian: Development of meal
B. CORRECT: Aspartame is an artificial sweetener that can planning based on healthy food choices to meet the client’s needs.
sweeten foods and beverages without adding calories.
C. Mannitol is a type of sugar alcohol, which has a CLIENT EDUCATION
low amount of calories (1.6 calories/g). ●
Review of exchange list: Incorporate proteins, carbohydrates,
D. Xylitol is a type of sugar alcohol, which has a and fats within each group based on the client’s needs.
low amount of calories (2.4 calories/g). ●
Review of carbohydrate counting: Consider the total
E. CORRECT: Sucralose is an artificial sweetener that can grams of carbohydrates in each food item and the
sweeten foods and beverages without adding calories. quantity needed for each meal and snack.
NCLEX® Connection: Physiological Adaptation, ●
Review information on food labels: Teach how to read food labels
Illness Management to identify amounts of carbohydrates contained in food.
NCLEX® Connection: Physiological Adaptation, Illness Management
2. A. Fruity breath odor is a manifestation of hyperglycemia.
B. CORRECT: A client who has hypoglycemia can
have diaphoresis and cool, clammy skin.
C. Ketones in the urine is a manifestation of hyperglycemia.
D. Polyuria (excessive urination) is a
manifestation of hyperglycemia.
System Specific Assessments
3. A. IV insulin is administered for hyperglycemia.

B. CORRECT: The client has manifestations of
hypoglycemia. Offer the client 15 to 20 g of
carbohydrate, such as 120 mL juice.
C. IV potassium is administered for hypokalemia.
D. IV sodium bicarbonate is administered
for metabolic acidosis.
System Specific Assessments
4. A. CORRECT: Carbohydrates should be 45% to

65% of total daily calorie intake.
B. The client should avoid using hydrogenated oils
for cooking because they contain trans fatty acids
and increase the risk for hyperlipidemia.
C. CORRECT: The client can use table sugar as long as
adequate insulin or other agents are provided to cover the
sugar intake. The client should count the carbohydrates
in the sucrose in the daily carbohydrate count.
D. CORRECT: The client can drink alcohol (one drink/day
for females, two drinks/day for males) but should eat
something to reduce the risk of hypoglycemia.
E. CORRECT: The client can exchange carbohydrates as long as
the total grams of carbohydrates remains the same each day.
Illness Management
5. A. Inform the client that a small snack before bedtime might be

required to prevent hypoglycemia during the night.
B. Instruct the client that it is okay to eat some
foods containing sugar, but in moderation and
included in daily carbohydrate counting.
C. CORRECT: To avoid extra carbohydrate intake, the
client should eat fruit that was canned with water or
juice rather than syrup, honey, or molasses.
D. Instruct the client to limit sodium intake to 2,300 mg/day.
92 CHAPTER 15 Diabetes Mellitus CONTENT MASTERY SERIES

CHAPTER 16
UNIT 3 ALTERATIONS IN NUTRITION ASSESSMENT/DATA COLLECTION
CHAPTER 16 Cancer and ● Current illness and presence of other medical diagnoses
Immunosuppression
● Nutritional habits, food preferences, and restrictions
● Food allergies
Disorders Height, weight, body mass index (BMI), weight trends

●
RISK FACTORS
Nurses should be knowledgeable of Immunosuppression disorders
nutritional needs for clients who have cancer ● Unprotected sex (HIV)
and immunosuppression disorders. Cancer ● Use of contaminated needles (injection substance
use [HIV])
and cancer treatments can affect chewing, ● Use of medications that have immunosuppressive
swallowing, satiety, digestion, taste, appetite, effects (cytotoxic medications, corticosteroids, disease
modifying immunosuppressive medications)
nutrient absorption, use of glucose, and stool ● History of radiation treatment
formation (dependent on type). ● Congenital immune deficiencies
Protein‑calorie malnutrition and body wasting Cancer

are common secondary diagnoses for clients ● Obesity
Excessive fat intake
who have cancer or immunosuppression
●
● Sedentary lifestyle
disorders (HIV/AIDS). Nutritional deficits are ● Consumption of processed meats, red meats,
refined grains
a major cause of morbidity and mortality for ● Excessive alcohol intake
these clients. Adverse effects of treatments ● Family history
History of cigarette smoking
compromise the nutritional status of affected
●
clients. Immunosuppression disorders increase LABORATORY TESTS

the body’s metabolic demands. Alterations Albumin, ferritin, transferrin
in fat storage and metabolism are related to
medications used in treatment of the disorder. NUTRITIONAL GUIDELINES AND
While subcutaneous fat is lost in the face and NURSING INTERVENTIONS
extremities, fatty deposits occur in the liver and Immunosuppression
skeletal muscles. ● Monitor the effectiveness of nutrition (weight, BMI,
laboratory findings).
The goals of nutritional therapy are to minimize ● Assist the client to set realistic goals for nutrition and
the nutritional complications of disease, improve food consumption.
Instruct the client on strategies to manage adverse
nutritional status, prevent muscle wasting,
●
effects of treatment.
maintain weight, promote healing, reduce CLIENT EDUCATION
adverse effects, decrease morbidity and ● Potential food sources of bacteria include raw fruits and
vegetables, and undercooked meat, poultry, or eggs.
mortality, and enhance quality of life and overall Wash fruits and vegetables. Cook foods thoroughly.
effectiveness of treatment therapies. Nutritional Refrigerate perishable foods as soon as possible.
Make food choices based on nutrition recommendations.
plans are individualized for client needs.
●
NUTRITION FOR NURSING CHAPTER 16 Cancer and Immunosuppression Disorders 93

Cancer HIV/AIDS
Excess body fat stimulates the production of estrogen and The body’s response to the inflammatory and immune
progesterone, which can intensify the growth of various processes associated with HIV increases nutrient
cell types and can contribute to breast, gallbladder, colon, requirements. Malnutrition is common and is one cause of
prostate, uterine, and kidney cancers. death in clients who have AIDS.
● HIV infection, secondary infection, malignancies, and
NURSING ACTIONS: Use semisolid, thickened foods for
medication therapies can cause manifestations and
clients who have dysphagia, and instruct them to sit
adverse effects that impair intake and alter metabolism.
upright and tilt their head forward when swallowing. ● Decreased nutrient intake occurs due to physical
CLIENT EDUCATION manifestations (anorexia, nausea, vomiting, diarrhea).
● Eat more on days when feeling better (on “good” days). Psychological manifestations can include depression
● Consume nutritional supplements that are high in and dementia.
protein and/or calories as between‑meal snacks. When ● Nutritional findings include rapid weight loss,
necessary, use as a meal replacement. gastrointestinal problems, inadequate intake,
● Increase protein and caloric content of foods. increased nutrient needs, food aversions, fad diets,
◯ Substitute whole milk for water in recipes. and supplements.
◯ Add milk, cheese, yogurt, or ice cream to dishes. ● Poor nutritional status leads to wasting and fever,
◯ Use peanut butter as a spread for fruits. further increasing susceptibility to secondary infections.
◯ Use yogurt as a topping for fruit. ● HIV‑associated wasting is characterized by unintended
◯ Dip meats in eggs, milk, and bread crumbs weight loss of 10% and at least one concurrent
before cooking. problem (diarrhea, chronic weakness, or fever) for at
● Preventative nutrition least 30 days.
◯ Consume adequate dietary fiber (25 to 38 g/day ● Diarrhea and malabsorption are prominent concerns in
depending on sex and age) to lessen the risk of clients who have AIDS.
colon cancer.
◯ Eliminate tobacco and exposure to loose asbestos to
Therapeutic nutrition
● Creating an individualized plan for the client who has
reduce the risk of lung cancer.
HIV/AIDS is based on reducing unintentional weight loss
◯ Eat at least 2.5 cups of a variety of fruits and
and wasting.
vegetables daily (linked to lowered incidence of many ◯ Increased caloric needs ranges from 37 to 55 cal/kg.
types of cancer and obesity, which affects the risk for ◯ A high‑protein diet is recommended with amounts
cancer development).
varying from 1.2 to 2.0 g/kg/day.
■ Foods high in vitamin A (dark green, red, and
◯ Intake of a multivitamin that meets 100% of the
orange vegetables)
recommended daily servings is sufficient, unless a
■ Foods high in vitamin C (citrus fruits)
specific deficiency is identified.

■ Cruciferous vegetables (broccoli, ● Enteral feedings are used if the client is unable to
cauliflower, cabbage)
consume sufficient nutrients, calories, and fluid.
◯ Consume whole grains rather than processed or ● Liberal fluid intake is extremely important to
refined grains and sugars. Low-fiber foods and
prevent dehydration.
foods high in fat can cause a variety of cancers (lung,
esophageal, pancreatic, oral cavity, cervical, kidney, CLIENT EDUCATION: Consume small, frequent meals
bladder, liver, stomach). that are composed of high‑protein, high‑calorie,
◯ Avoid meat prepared by smoking, pickling, charcoal nutrient‑dense foods.
and grilling, and use of nitrate‑containing chemicals
(possibly carcinogenic).
◯ Consume polyunsaturated and monounsaturated fats
(found in fish and olive oil), which might be beneficial
in lowering the risk of many types of cancer.
◯ Limit alcohol consumption (associated with many
types of cancers).
● Therapeutic nutrition
◯ Cancer can cause anorexia, increased metabolism, and
negative nitrogen balance.
◯ Systemic effects result in poor food intake, increased
nutrient and energy needs, and catabolism of

body tissues.
◯ An individualized plan is based on the following.
■ Increased caloric needs ranging from 25 to 35 cal/kg
(depending on metabolism, activity level, disease

state, and ability to absorb nutrients).
■ Protein needs are increased to 1.0 to 2.5 g/kg.
■ Vitamin and mineral supplementation is based
upon the client’s needs.
94 CHAPTER 16 Cancer and Immunosuppression Disorders CONTENT MASTERY SERIES

COMPLICATIONS Food aversions
CLIENT EDUCATION: Eat foods that are well‑tolerated and
Early satiety and anorexia
liked prior to treatments (chemotherapy, radiation).
CLIENT EDUCATION
● Eat small amounts of high‑protein foods loaded with Taste alterations and thick saliva
calories and nutrients.
CLIENT EDUCATION
● Try to consume food in the morning when ● Try adding foods that are tart (citrus juices).
appetite is best. ● Eat small, frequent meals.
● Avoid food odors. ● Try using sauces and seasonings for added flavor.
● Do not fill up on low‑calorie foods (liquids, broth, ● Use plastic utensils for eating.
high‑roughage foods containing water). ● Suck on mints, candy, or chew gum to remove bad
● Eat cool or room temperature foods.
taste in mouth.
Sweeten meat with apple or cranberry sauce.
Mouth ulcers and stomatitis
●
CLIENT EDUCATION Nausea, vomiting

● Use a soft toothbrush to clean teeth after eating and
CLIENT EDUCATION
at bedtime. ● Eat cold or room‑temperature foods.
● Avoid mouth washes that contain alcohol. ● Try high‑carbohydrate, low‑fat foods.
● Omit acidic, spicy, dry, or coarse foods. ● Avoid fried foods.
● Include cold or room‑temperature foods in the diet. ● Do not eat prior to chemotherapy or radiation.
● Cut food into small bites. ● Take prescribed antiemetic medication.
● Try using straws. ● Sit up for 1 hr after a meal.
● Replace meals with high‑calorie/protein drinks. ● Sip on fluids throughout the day. Try ginger ale or
● Use well‑fitting dentures.
ginger tea.
● Prepare foods that are cooked until tender and soft.
Add gravies, broth, and a variety of mild sauces to
Diarrhea
●
moistened prepared foods.

CLIENT EDUCATION
Fatigue ● Ensure adequate intake of liquids throughout the day to
replace losses.
CLIENT EDUCATION ● Avoid foods that can exacerbate diarrhea (foods high
● Eat a large, calorie‑dense breakfast when energy level is
in roughage).
the highest. ● Consume foods high in pectin to increase the bulk of
● Conserve energy by eating foods that are easy
the stool and to lengthen transition time in the colon.
to prepare. ● Limit caffeine, hot or cold drinks, and fatty foods.
● Use a meal delivery service.

1. A nurse is teaching a client who has cancer A nurse in an oncology clinic is reviewing dietary
about ways to increase protein and calories in management with a group of clients who have cancer
foods. Which of the following actions should and are undergoing treatment. What instructions should
the nurse include? (Select all that apply.) the nurse include in this discussion? Use the ATI Active
Learning Template: System Disorder to complete this item.
A. Use peanut butter as a spread on crackers.
B. Add water in place of milk in soups. CLIENT EDUCATION
C. Top fruit with yogurt. ●
Describe three effects of cancer on nutrition.
D. Dip chicken in eggs before cooking. ●
Describe three nutritional needs.
E. Sprinkle cheese on a baked potato. ●
Describe three activities that promote improved nutrition.
2. A nurse is teaching a community program on

nutritional guidelines for cancer prevention.
Which of the following instructions should
the nurse include? (Select all that apply.)
A. Eat foods high in vitamin A.
B. Add cruciferous vegetables.
C. Increase intake of red meats
D. Use oil high in saturated fat.
E. Consume refined grains.
3. A nurse in an oncology clinic is caring for a client who is

undergoing treatment for cancer and reports difficulty
eating due to inability to taste food. Which of the
following interventions should the nurse recommend?
A. Avoid citrus juices.
B. Use plastic utensils to eat.
C. Eat foods that are warm.
D. Increase foods high in pectin.
4. A nurse is teaching a client who is undergoing

cancer treatment about interventions to manage
stomatitis. Which of the following statements by the
client indicates understanding of the teaching?
A. “I will try chewing larger pieces of food.”
B. “I will avoid toasting my bread.”
C. “I will consume more food in the morning.”
D. “I will add more citrus foods to my diet.”
5. A nurse is collecting data from a client who has

suspected HIV‑associated muscle wasting. Which
of the following findings supports this diagnosis?
A. BMI 26
B. Fecal impaction
C. Report of fever for 30 days
D. Report of high alcohol consumption

1. A. CORRECT: Peanut butter adds calories and Using the ATI Active Learning Template: System Disorder
protein to fruit slices or crackers. CLIENT EDUCATION
B. The client should substitute whole milk, cream,
and/or hard‑boiled eggs to soups and sauces Effects of cancer on nutrition
to increase protein and calories. ●
Causes anorexia
C. CORRECT: Yogurt adds protein and calories to fruit. ●
Increases metabolism
D. CORRECT: Eggs add protein and calories ●
Causes negative nitrogen balance
to chicken, fish, or meat.
E. CORRECT: Cheese adds protein and calories to vegetables. Nutritional needs
●
Increased calories (25 to 35 cal/kg)
●
Increased protein (1 to 2.5 g/kg)
●
Vitamin and mineral supplementation
Activities
2. A. CORRECT: Consuming foods high in vitamin A ●
Eat more on days when feeling better.
(apricots, carrots, leafy green vegetables)
reduces the risk of cancer.
●
Consume nutritional supplements that are high in protein and/
B. CORRECT: Consuming cruciferous vegetables, such as or calories between meals and/or use as meal replacement.
broccoli and cabbage, reduces the risk the risk of cancer.
●
Substitute whole milk for water in recipes.
C. Increased consumption of red meat can ●
Add milk, cheese, yogurt, or ice cream to foods when cooking.
increase the risk for cancer. ●
Add peanut butter and yogurt as a spread/topping on fruits.
D. The use of polyunsaturated and monounsaturated ●
Coat meats in eggs, milk, and bread crumbs before cooking.
fats is beneficial in lowering the risk of many types ●
Treat cancer‑associated complications (early satiety,
of cancer, while foods high in saturated fats are anorexia, mouth ulcers, stomatitis, fatigue, food aversions,
associated with an increased risk of cancer. altered taste, thick saliva, nausea, vomiting, diarrhea).
E. Consuming whole grains reduces the risk for colon cancer.
NCLEX® Connection: Physiological Adaptation, Illness Management
3. A. Add tart foods, such as citrus, to the diet to increase food

taste and reduce the occurrence of a metallic taste.
B. CORRECT: The use of plastic utensils when eating can
enhance taste sensations for the client undergoing cancer
treatment and reduce the occurrence of a metallic taste.
C. Eating cold or room‑temperature foods
improves taste sensation.
D. Add pectin‑rich foods to increase bulk of the stool
and lengthen transition time in the colon.
4. A. The client should be encouraged to cut food into small

pieces to reduce irritation to mucous membranes.
B. CORRECT: Dry, coarse foods such as toast can
worsen the manifestations of stomatitis.
C. This intervention is indicated for the client who
has fatigue due to cancer treatment.
D. Acidic or spicy foods irritate the mucous membranes of
the client who has stomatitis due to cancer treatment.
5. A. A BMI of 26 is within the expected reference range;

a weight loss of at least 10% is one factor required to
diagnose HIV‑associated muscle wasting.
B. Diarrhea is common for a client who has
HIV-associated muscle wasting.
C. CORRECT: Report of fever or other condition
for 30 days, in addition to a specific weight loss,
indicates HIV-associated muscle wasting.
D. Alcohol consumption is not a factor used to
diagnose HIV‑associated muscle wasting.
Alterations in Body Systems

References
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Concepts, process, and practice (10th ed.). Upper Saddle River, NJ: Prentice-Hall.
Burchum, J. R., & Rosenthal, L. D. (2019). Lehne's pharmacology

for nursing care (10th ed.). St. Louis, MO.
Dudek, S. G. (2018). Nutrition essentials for nursing practice

(8th ed.). Philadelphia: Wolters Kluwer.
Grodner, M., Escott-Stump, S., & Dorner, S. (2016). Nutritional foundations and
clinical applications of nutrition: A nursing approach (6th ed.). St. Louis, MO: Mosby
Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of

medical-surgical nursing (14th ed.). Philadelphia: Wolters Kluwer.
Hockenberry, M. J., & Wilson, D. (2015). Wong’s nursing care of

infants and children (10th ed.). St. Louis, MO: Mosby.
Ignatavicius, D. D., Workman, M.L., & Rebar, C. R. (2018). Medical-Surgical nursing:

Concepts for Interprofessional collaborative care. (9th Ed). St. Louis, MO.
Pagana, K. D., & Pagana, T. J. (2018). Mosby’s manual of diagnostic

and laboratory tests (6th ed.). St. Louis, MO: Elsevier.
Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2017). Fundamentals
of nursing (9th ed.). St. Louis, MO: Elsevier.
Touhy, T. A., & Jett, K. F. (2016). Ebersole & Hess’ toward healthy aging:
Human needs and nursing response (9th ed.). St. Louis, MO: Elsevier.
United States Department of Agriculture (USDA). (2013). Sausages and food
safety. Retrieved from https://www.fsis.usda.gov/wps/wcm/connect/fsis-
content/internet/main/topics/food-safety-education/get-answers/food-
safety-fact-sheets/meat-preparation/sausages-and-food-safety/ct_index
U. S. Food and Drug administration. (2016). Food labeling: Revision

of the nutrition and supplement facts labels. https://www.
regulations.gov/document?D=FDA-2012-N-1210-0875
U. S. Food and Drug administration. (2018). Refrigerator & freezer

storage chart. Retrieved from https://www.fda.gov/downloads/
food/foodborneillnesscontaminants/ucm109315.pdf
U. S. Food and Drug administration. (2017). Surplus, salvaged, and

donated foods: Safety tips. Retrieved from https://www.fda.gov/
Food/ResourcesForYou/Consumers/ucm197835.htm
U. S. Food and Drug administration. (2017). Safe food handling: What

you need to know. Retrieved from https://www.fda.gov/downloads/Food/
FoodborneIllnessContaminants/BuyStoreServeSafeFood/UCM440123.pdf
U. S. Food and Drug administration. (2018). Produce: selecting

and serving it safely. Retrieved from https://www.fda.gov/food/
foodborneillnesscontaminants/buystoreservesafefood/ucm114299.htm
NUTRITION FOR NURSING REFERENCES 99

100 REFERENCES CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: Basic Concept
STUDENT NAME______________________________________
CONCEPT_______________________________________________________________________________ REVIEW MODULE CHAPTER____________
Related Content Underlying Principles Nursing Interventions

(E.G., DELEGATION, WHO? WHEN? WHY? HOW?
LEVELS OF PREVENTION,
ADVANCE DIRECTIVES)
ACTIVE LEARNING TEMPLATES Basic Concept A1

A2 Basic Concept CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: Diagnostic Procedure
STUDENT NAME______________________________________
PROCEDURE NAME_____________________________________________________________________ REVIEW MODULE CHAPTER____________
Description of Procedure
Indications CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Interpretation of Findings
Client Education
Potential Complications Nursing Interventions
ACTIVE LEARNING TEMPLATES Diagnostic Procedure A3

A4 Diagnostic Procedure CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: Growth and Development
STUDENT NAME______________________________________
DEVELOPMENTAL STAGE________________________________________________________________ REVIEW MODULE CHAPTER____________
EXPECTED GROWTH AND DEVELOPMENT
Physical Cognitive Psychosocial Age-Appropriate

Development Development Development Activities
Health Promotion
Immunizations Health Screening Nutrition Injury Prevention
ACTIVE LEARNING TEMPLATES Growth and Development A5

A6 Growth and Development CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: Medication
STUDENT NAME______________________________________
MEDICATION___________________________________________________________________________ REVIEW MODULE CHAPTER____________
CATEGORY CLASS_______________________________________________________________________
PURPOSE OF MEDICATION
Expected Pharmacological Action Therapeutic Use
Complications Medication Administration
Contraindications/Precautions
Nursing Interventions
Interactions
Client Education
Evaluation of Medication Effectiveness
ACTIVE LEARNING TEMPLATES Medication A7

A8 Medication CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: Nursing Skill
STUDENT NAME______________________________________
SKILL NAME_____________________________________________________________________________ REVIEW MODULE CHAPTER____________
Description of Skill
Outcomes/Evaluation
Client Education
ACTIVE LEARNING TEMPLATES Nursing Skill A9

A10 Nursing Skill CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: System Disorder
STUDENT NAME______________________________________
DISORDER/DISEASE PROCESS___________________________________________________________ REVIEW MODULE CHAPTER____________
Alterations in Pathophysiology Related Health Promotion and

Health (Diagnosis) to Client Problem Disease Prevention
ASSESSMENT SAFETY
CONSIDERATIONS
Risk Factors Expected Findings
Laboratory Tests Diagnostic Procedures
PATIENT-CENTERED CARE Complications
Nursing Care Medications Client Education
Therapeutic Procedures Interprofessional Care
ACTIVE LEARNING TEMPLATES System Disorder A11

A12 System Disorder CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: Therapeutic Procedure
STUDENT NAME______________________________________
PROCEDURE NAME_____________________________________________________________________ REVIEW MODULE CHAPTER____________
Description of Procedure
Outcomes/Evaluation
Client Education
ACTIVE LEARNING TEMPLATES Therapeutic Procedure A13

A14 Therapeutic Procedure CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: Concept Analysis
STUDENT NAME______________________________________
CONCEPT ANALYSIS_____________________________________________________________________
Defining Characteristics
Antecedents Negative Consequences

(WHAT MUST OCCUR/BE IN PLACE FOR (RESULTS FROM IMPAIRED ANTECEDENT —
CONCEPT TO EXIST/FUNCTION PROPERLY) COMPLETE WITH FACULTY ASSISTANCE)
Related Concepts Exemplars

(REVIEW LIST OF CONCEPTS AND IDENTIFY, WHICH
CAN BE AFFECTED BY THE STATUS OF THIS CONCEPT
— COMPLETE WITH FACULTY ASSISTANCE)
ACTIVE LEARNING TEMPLATES Concept Analysis A15

A16 Concept Analysis CONTENT MASTERY SERIES

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Nutrition for Nursing

REVIEW MODULE EDITION 7.0

Debborah Williams, MSN, RN

Sheryl Sommer, PhD, RN, CNE

INTELLECTUAL PROPERTY NOTICE

Copyright © 2019 Assessment Technologies Institute, LLC. All rights reserved.

REPRINTED MARCH 2021

NUTRITION FOR NURSING I

Director of development: Derek Prater

Project management: Tiffany Pavlik, Shannon Tierney

Coordination of content review: Honey C. Holman, Debborah Williams

Copy editing: Kelly Von Lunen, Bethany Phillips, Kya Rodgers

Layout: Spring Lenox, Maureen Bradshaw, Bethany Phillips

Illustrations: Randi Hardy

Cover design: Jason Buck

Interior book design: Spring Lenox

IMPORTANT NOTICE TO THE READER

II CONTENT MASTERY SERIES

content in this Review Module, regularly ask yourself,

◯ Safety and Infection Control

a clear, succinct manner. ◯ Pharmacological and Parenteral Therapies

Nutritional considerations for specific disorders chapters ◯ Reduction of Risk Potential

include an overview describing nutritional needs of ◯ Physiological Adaptation

clients who have the given disorder. These chapters cover

Manage the client who has an alteration in

NUTRITION FOR NURSING User’s Guide III

As needed updates to the Review Modules are identified,

IV USER’S GUIDE CONTENT MASTERY SERIES

UNIT 1 Principles of Nutrition

Carbohydrates and fiber 3

Minerals and electrolytes 7

CHAPTER 2 Ingestion, Digestion, Absorption, and Metabolism 11

CHAPTER 3 Nutrition Assessment/Data Collection 15

CHAPTER 4 Guidelines for Healthy Eating 21

CHAPTER 5 Food Safety 27

CHAPTER 6 Cultural, Ethnic, and Religious Influences 31

CHAPTER 7 Nutrition Across the Lifespan 37

Pregnancy and lactation 37

Adulthood and older adulthood 44

NUTRITION FOR NURSING TABLE OF CONTENTS V

UNIT 2 Clinical Nutrition

CHAPTER 9 Enteral Nutrition 55

CHAPTER 10 Total Parenteral Nutrition 61

UNIT 3 Alterations in Nutrition

CHAPTER 12 Cardiovascular and Hematologic Disorders 71

CHAPTER 13 Gastrointestinal Disorders 77

CHAPTER 14 Renal Disorders 85

CHAPTER 15 Diabetes Mellitus 89

CHAPTER 16 Cancer and Immunosuppression Disorders 93

Active Learning Templates A1

Growth and Development A5

System Disorder A11

Therapeutic Procedure A13

Concept Analysis A15

VI TABLE OF CONTENTS CONTENT MASTERY SERIES

Health Promotion and Maintenance

ANTE/INTRA/POSTPARTUM AND NEWBORN

HEALTH PROMOTION/DISEASE PREVENTION: Educate the

HEALTH SCREENING: Perform targeted screening assessments.