NURSING NR 228 Nutrition Week 7 edapt nutrition- Nutrition for Gastrointestinal Health

Nutrition for Gastrointestinal Health The human gastrointestinal (GI) system is very complex, and disruptions to this homeostatic environment can lead to inflammation, pain and multiple other GI symptoms. Nutrition significantly impacts your GI health, and some GI disorders may have serious nutritional implications. Almost everyone has had some form of episodic GI symptoms ranging from indigestion, gas, nausea, vomiting, abdominal pain, diarrhea and constipation. Others may have more complicated disorders, such as dysphagia.

Evaluation of a client with gastrointestinal symptoms is holistic and takes a multidisciplinary approach to help separate GI symptoms associated with dietary practices from those related to GI disease or dysfunction.

In this module, we will discuss an overview of nutrition and its impact on GI health, and examples of different nutritional therapies utilized in the management of general gastrointestinal (GI) symptoms. This module will guide you to identify the nutritional needs of individuals with GI disorders and the impact nutrition can have on their overall health.

Anti-Inflammatory Diets Anti-inflammatory diets have been proven to reduce inflammation and identified as having protective qualities. An anti-inflammatory diet consists of which of the following foods? Select all that apply.

Fresh herbs and spices Fruits and vegetables Plant-based proteins (like beans and nuts) Processed grains Non-fatty fish Anti-inflammatory diets contain foods such as fruits and vegetables, whole grains, plant-based proteins (like beans and nuts), fatty fish, and fresh herbs and spices.

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Homeostasis Homeostasis is achieved when there are healthy interactions between gut microbes and their host. When this balance is altered, it can contribute to which of the following disorders?

Probiotic Inflammatory Regulatory Hereditary Healthy interactions between gut microbes and their host are needed to maintain homeostasis. Changes in microbiome structure lead to dysbiosis, which contributes to inflammation.

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Dehydration Dehydration is a concern when vomiting is continual. Vomiting causes a loss of fluid and electrolytes, stressing body functions. Which of the following electrolytes can be depleted? Select all that apply.

Iron Magnesium Sodium Potassium Dehydration is a concern when vomiting is continual. Vomiting causes a loss of fluid and electrolytes (magnesium, potassium, sodium), stressing

body functions. Infants are at high risk for dehydration because their bodies contain a high percentage of fluids.

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Nutrition for GI Health

Food is our main source of energy, and vitamins and trace minerals are essential components of our diet for nutritional health. Without these essential components dietary deficiencies can develop, cause gastrointestinal (GI) symptoms, and complicate GI diseases/disorders.

Common GI symptoms, such as vomiting and diarrhea, disrupts the homeostatic environment of the GI system and can lead to fluid/electrolyte and nutritional deficiencies. Dehydration is a concern with uncontrolled vomiting and diarrhea. The loss of fluid and electrolytes stresses body functions. Infants are at high risk for dehydration because their bodies contain a high percentage of fluids.

Malnutrition is very common in hospitalized clients and has been associated with prolonged hospitalization, longer intensive care unit (ICU) stay, higher hospital costs, and adverse health outcomes (Ukleja, 2018).

Therefore, identifying clients at risk by conducting a nutritional assessment, close monitoring, and prioritizing nutrition interventions have been associated with improved clinical outcomes.

Dimensions of Health Clients can be significantly affected by disruptions in gastrointestinal (GI) health and impacts various dimensions of health.

Physical Health Intellectual Health Emotional Health Social Health Spiritual Health Environmental Health

General Screening for GI Disorders

W hile caring for a client with gastrointestinal (GI) symptoms, the health care provider will conduct a thorough nutritional assessment to determine priority actions and overall plan of care. During the assessment, questions asked include, but are not limited to:  Dietary practices; foods they typically eat and any cultural considerations  If they are taking any medications  Allergies to medications or foods  Changes in appetite or diet  Changes in weight  Difficulty chewing or swallowing, and  Changes in bowel habit such as constipation, diarrhea, rectal bleeding, or dark stools.  Changes in weight can be a key indicator in nutritional health. Assess usual body weight, ideal body weight and present body weight. GI symptoms and disorders will often influence nutritional intake and can lead to malnutrition.

Some medications such as anti-inflammatory medications, aspirin, antibiotics, and opioids can cause nausea, vomiting, diarrhea, constipation, and other GI symptoms. Client's that use laxatives over an extended period of time may start to develop constipation.

Inquire about the client's home environment, such as if they are exposed to any GI symptoms in the home, food and exercise habits, oral hygiene, recent life changes and stress levels, and alcohol, caffeine, and tobacco use Another part of the health history is asking about family history of GI disorders. Has anyone in the family has had any type of GI disorder such as ulcerative colitis, colorectal or gastric cancer, gastroesophageal reflex disease (GERD), peptic ulcers, alcoholism, Crohn’s disease, or celiac disease.

Cultural Considerations Culture can have an impact on gastrointestinal (GI) health. You will explore cultural considerations as part of the dietary assessment. Certain GI disorders are associated more with various ethnic groups.

Culture

Associated GI Disorders

African American

Alcoholism, colorectal cancer, diabetes, helicobacter pylori infection, hepatitis C, obesity

Hispanic

Diabetes, helicobacter pylori infection, hepatitis C, obesity

Japanese

Gastric cancer

Jewish American

Lactose intolerance

Native American

Alcoholism, gallstones, gallbladder cancer

Mexican American

Diabetes, gallstones, gallbladder cancer

Risk for Malnutrition

When assessing an adult client with GI disorders, the healthcare provider recognizes that the client is at risk for malnutrition. To assess the client for malnutrition, which of the following would apply? Select all that apply.

Weight from childhood Usual body weight Ideal body weight Present body weight When reviewing the client's health, it is important to assess the client’s usual body weight, ideal body weight and present body weight. Stomach and intestinal disorders will often influence nutritional intake and impact a client's weight and health status, leading to malnutrition. The childhood weight would not be important at this time.

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General Diagnostics of Gastrointestinal Disorders When clients report various symptoms of a gastrointestinal (GI) disorder, those reported symptoms with be closely evaluated to help determine if it is an upper or lower GI problem. When a health care professional suspects a client is suffering from GI disease or disorder, or if a patient reports unexplained symptoms in their GI tract, technology offers valuable tools. Diagnostic tests and procedures can range from invasive to noninvasive, simple to more complex, and can help health care professionals learn more about the causes, symptoms, and severity of different health conditions.

Nutritional Therapy

Diet is the cornerstone of therapy for gastrointestinal (GI) health, regardless of the symptoms or disorder. Unusual dietary practices, nutritional inadequacies, or food intolerances can lead to GI symptoms or disorders.

Common diets that reduce inflammation in the GI system and are often recommended for individuals experiencing GI symptoms or disorders includes:  Mediterranean  DASH diets These diets offer antioxidant –rich foods which play an essential role to reducing inflammation in the GI system . They also focus on the prevention of various health alterations, to include GI health. The goal is having well-balanced food choices, weight management, and maintaining healthy eating. The DASH diet has a special focus on controlling hypertension, as well.

Why the DASH Diet Works Review the information below on the DASH diet.

Transcript Link

What is the Mediterranean Diet?

“The Mediterranean diet is a generic term based on the traditional eating habits in the countries bordering the Mediterranean Sea. There’s not one standard Mediterranean diet. At least 16 countries border the Mediterranean. Eating styles vary among these countries and even among regions within each country because of differences in culture, ethnic background, religion, economy, geography and agricultural production" (AHA, 2020).

This diet includes:  Plenty of fruits, vegetables, bread and other grains, potatoes, beans, nuts and seeds;  Olive oil as a primary fat source; and  Dairy products, eggs, fish and poultry in low to moderate amounts.

Diets to Decrease Inflammation A diet that reduces inflammation is often recommended for individuals that experience disorders of the gastrointestinal (GI) system. The two diets recommended for this are the:

Dash 1800 ADA Mediterranean Regular diet A diet that reduces inflammation is often recommended for individuals experiencing GI disorders. These diets include the Mediterranean and DASH diets. Both diets focus on weight management, and healthy eating.

The DASH diet has a special focus on controlling hypertension. The 1800 ADA and regular diet do not contain foods that are specifically formulated to reduce inflammation.

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Nutritional Disorders of the Gastrointestinal System Gastrointestinal (GI) disorders can have significant nutritional implications on an individual's health by impacting the individual's ability to chew, swallow, digest, and absorb nutrients, while passing substances on for elimination.

Disorders of the GI tract include those that affect the esophagus, stomach, small intestine, and large intestine (upper and lower GI system). Common

client symptoms include gas, indigestion, nausea and vomiting. GI disorders may include dysphagia, diarrhea, and constipation.

You will learn more about specific disorders in other learning modules, however, let's take a quick look at gas and dysphagia as they are common symptomatic GI disorders that effect nutritional health.

Example - Intestinal Gas and Flatulence Intestinal gas can mean different things to different people. Often identified as:  Excessive bloating-swelling  Belching-release of swallowed air from the stomach  Rectal gas/flatus-as produced by food digestion and fermentation by intestinal bacteria Various functions along the path of digestion can contribute to the production of gas. Following simple diet changes can help to reduce gastrointestinal gas and relieve symptoms. Clients who have gas and

flatulence may have a "full" feeling and may not want to eat, therefore nutritional requirements may be compromised.

Foods that Contribute to Gas Production Once the healthcare provider has determined there is no medical condition causing the excessive gas, an elimination diet can be used to identify and eliminate foods that may be causing the symptoms. Refer to the chart, Foods that Contribute to Gas Production.

Transcript Link Diet can have a significant impact on the production of intestinal gas and flatulence. By identifying, limiting or avoiding the offending foods, one can reduce or eliminate the symptoms.

Flatus An individual is seen in the office for a well visit. When speaking, they express concern that they have had an increase in flatus and asks what they can do to eliminate this. The healthcare provider asks about dietary

practices with knowledge that consumption of which of the following foods could increase gas production? Select all that apply.

Root vegetables Legumes Milk and milk products Fatty foods Most people agree that beans (all types), milk, and milk products may be the worst offenders in causing gas. Other troublesome foods include onions, celery, carrots, raisins, apricots, prune juice, wheat products, and brussel sprouts.

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Example - Dysphagia Dysphagia common gastrointestinal (GI) disorder that effects a client's ability to swallow and can lead to malnutrition. Just like breathing or the beating of the heart, swallowing is an involuntary action that occurs without thought. Systematic screening of the client's ability to swallow, combined with a thorough assessment of their nutritional status is important. If a client is unable to swallow, then there is a great risk for malnutrition.

The goal in the management of clients with this gastrointestinal disorder is to continuously assess their nutritional status, swallowing ability, and make the necessary adjustments to their dietary plan to meet their nutritional requirements. You will learn more about care of a client with dysphagia in another learning module.

In the image on the right, a speech therapist leads a dysphagia patient in exercises to strengthen her swallowing muscles during a home health speech therapy session.

Gastrointestinal Tract Disorders When caring for clients with a disorder of the gastrointestinal (GI) tract, the health care provider would anticipate which of the following conditions? Select all that apply.

Hiatal Hernia Congestive heart failure Dysphagia Esophagitis Conditions that impact the GI tract include dysphagia, vomiting and diarrhea. Congestive heart failure impacts the cardiovascular system.

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Nutritional Deficiencies Today's diets and dietary habits do not often meet the daily recommended requirements as established by Healthy People 2030.

Fruits, vegetables, and whole grains are not a staple in many diets.

Healthcare providers are seeing the impact diet has on the health of the clients we care for; especially the gastrointestinal system which is greatly impacted by nutritional deficiencies.

Healthy People 2030 Take time to review the health people initiative before moving on.

Nutritional Goals Remember, diet and nutritional goals are determined by the specific gastrointestinal (GI) symptoms, disease or disorder. The foods you eat contribute to disruptions in gastrointestinal health and without nutritional intervention can exacerbate into further complications.

Many people eat too much processed food, fast foods, and sugar, and not enough fiber, fruits, and vegetables. "Processed food" includes food that

has been cooked, canned, frozen, packaged or changed in nutritional composition with fortifying, preserving or preparing in different ways.

Poor eating habits, such as eating too quickly or skipping meals, and food insecurities may also contribute to GI problems and nutritional deficiencies. Many digestive problems can be prevented by eating a nutrient-rich, well-balanced diet.

Preventing Malnutrition As individuals age, many factors can impact their swallowing ability. As healthcare providers caring for these individuals, it is important to identify those factors and adjust the dietary plan

to prevent malnutrition.

As individuals age, many factors can impact their swallowing ability. As healthcare providers caring for these individuals, it is important to identify those factors and adjust the dietary plan to prevent malnutrition. Activity plan, oral-pharyngeal and eating assessment do not influence an individual's ability to swallow and lead to malnutrition.

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Complications As an individual ages, the ability to swallow can be impacted. The inability to swallow is known as:

Autoimmune liver disorder Rheumatoid arthritis Dysphagia Lupus Just like breathing or the beating of the heart, swallowing is an involuntary action that occurs without thought. However, as an individual ages, many factors can impact an individual's ability to swallow-causing dysphagia and potentially leading to malnutrition. Lupus, rheumatoid arthritis and autoimmune liver disorder are all autoimmune diseases.

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DASH Diet Preventing malnutrition in clients with gastrointestinal (GI) disorders is a challenge. The client states an understanding of the recommended diets to reduce inflammation when they indicate that the DASH diet has a special focus on controlling:

Arthritis Hypertension Diabetes Cholesterol Diet is the cornerstone of therapy for GI complaints. Unusual dietary practices, nutritional inadequacies, or food intolerances can lead to GI disorders which can affect all other organs and body systems, impacting overall health.

A diet that reduces inflammation is often recommended for individuals experiencing GI disorders. These diets include the Mediterranean and DASH diets. Both diets focus on weight management, and healthy eating.

The DASH diet has a special focus on controlling hypertension. The DASH diet is not formulated to control diabetes, arthritis or cholesterol.

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Flatulence You are speaking with a client who is complaining of an excessive flatulence. When reviewing the client's dietary intake, you identify that which of the following food might be responsible for causing the excessive flatulence?

Meat Potatoes Cauliflower Applesauce Cauliflower is a gas producing food that relates in flatulence. Meat, potatoes and applesauce do not increase gas production.

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Problem Foods An individual is seen in the office for a well visit. When speaking, they express concern that they have had an increase in flatus and asks what they can do to eliminate this. The healthcare provider asks about dietary practices with knowledge that consumption of which of the following foods could increase gas production? Select all that apply.

Most people agree that beans (all types), milk, and milk products may be the worst offenders in causing gas. Other troublesome foods include onions, celery, carrots, raisins, apricots, prune juice, wheat products, and brussel sprouts. Citrus fruits are not specific enough to identify as a troublesome food.

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Healthy Food Options A client has a gastrointestinal (GI) disorder. Which of the following foods can lead to a further inflammation and nutritional deficiencies in the gastrointestinal system?

Foods

Healthy Options

Unhealthy Options

salad fish beans green beans

ice cream french fries frozen dinner donuts

Many people eat too much processed food, fast foods, and sugar and not enough fiber, fruits and vegetables. French fries, frozen dinner, ice cream, and donuts are unhealthy options and can further lead to inflammation.

Fiber, fruits and vegetables are needed to prevent nutritional deficiencies.

Poor eating habits contribute to GI problems and nutritional deficiencies.

Many digestive problems can be prevented by eating a nutrient-rich, wellbalanced diet.

Your response is correct!

DASH Diet You are providing client teaching related to the DASH diet. Which of the following statements made by the client is correct regarding this type of diet?

"It offers antioxidant-rich foods which helps decrease inflammation.”

"It limits fiber in my diet to prevent complications.”

"It provides various options for processed foods.”

"It will completely resolve my hypertension.”

DASH diet offer antioxidant-rich foods which play an essential role to reducing inflammation in the gastrointestinal (GI) system. They also focus on the prevention of various health alterations, to include GI health. The goal is having well-balanced food choices, weight management, and maintaining healthy eating. The DASH diet has a special focus on controlling hypertension, however, will not necessarily completely resolve it.

Your response is correct!

Cultural Considerations Culture can have an impact on gastrointestinal health. Which of the following gastrointestinal (GI) disorders are closely associated with which ethnic group?

Hispanic Diabetes

Japanese Gastric cancer

Jewish American Lactose intolerance

Native American Gallstones

Hispanics have a greater incidence of diabetes, Japanese gastric cancer, Jewish Americans lactose intolerance, and Native American's gallstones.

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GI Alteration – Helicobacter pylori Which of the following ethic groups have an increased incidence of helicobacter pylori infections based upon ethnicity? Select all that apply.

Jewish American African American Mexican American Hispanic Both Hispanics and African Americans have a higher incidence of helicobacter pylori infections based upon ethnicity. Jewish Americans have a high incidence of lactose intolerance and Mexican Americans have a higher incidence of diabetes, gallstones, and gallbladder cancer.

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Dysphagia Disorders of the gastrointestinal (GI) tract can impact nutritional health.

When people think of GI disorders, swallowing difficulties are not the first thing that comes to mind; but complications with swallowing can have a great impact on a client's nutritional status. Dysphagia is a swallowing disorder that causes difficulty or pain while swallowing or attempting to swallow. In this unit, we will be exploring the:  Possible causes of dysphagia  Warning signs of dysphagia  Feeding strategies of clients with dysphagia

Dysphagia Individuals with dysphagia often exhibit which of the following symptoms?

Select all that apply.

Coughing or choking when eating or drinking Bringing food back up (regurgitation) Persistent drooling of saliva Unexpected weight loss.

Sensation of food getting stuck in the throat or chest Individuals with dysphagia may avoid eating and drinking due to a fear of choking, which can lead to malnutrition and dehydration. Clients with dysphagia may exhibit the following symptoms; coughing or choking when eating or drinking; sensation of food getting stuck in the throat or chest; persistent drooling of saliva; bringing food back up (regurgitation); and/or unexpected weight loss.

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Solid Food Consistencies What are the three levels of solid food consistencies?

Liquid Pureed Advanced Mechanically Altered The three levels of solid food consistencies are:  Pureed: foods are totally pureed to a smooth, homogenous consistency.

 Mechanically altered: soft-textured, moist foods that are easily chewed.  Dysphagia advanced: near-normal textured foods; excludes crunchy, sticky, or very hard foods.

Liquid is not a solid food consistency.

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Liquid Consistencies What are the four levels of liquid consistencies?

Honeylike Pureed Spoon-thick Thin Nectarlike The four levels of liquid consistencies are:  Thin: all unthickened beverages and supplements.  Nectarlike: liquids thicker than water but thin enough to sip through a straw.  Honeylike: liquids that can be eaten with a spoon but do not hold their shape.  Spoon-thick: liquids thickened to pudding consistency that need to be eaten with a spoon.

Pureed is a solid food consistency.

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Swallowing Phases Review

Swallowing is a complex series of events characterized by three basic phases:  Oral phase  Pharyngeal phase  Esophageal phase Impairments in swallowing can have a profound impact on intake and nutritional status, and greatly increase the risk of aspiration.

Phases of Swallowing What are the three phases of swallowing?

Latent Oral phase Esophageal phase Pharyngeal phase

The three phases of swallowing are oral, pharyngeal, and esophageal. The term latent does not relate to a swallowing phase.

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Types of Dysphagia Dysphagia is a swallowing disorder that causes difficulty or pain while swallowing or attempting to swallow. Difficulty in swallowing can be caused by:  Structural dysphagia (which results from changes to the actual structure of your esophagus)  Esophageal motility (movement) issues  Structural Dysphagia  Esophageal Motility Structural Dysphagia which results from changes to the actual structure of your esophagus can be caused from:  Obstruction  Inflammation  Edema  Surgery

Meal Planning A client has been diagnosed with dysphagia. When planning a meal for the client, the family should consider which of the following solid food consistencies? Select all that apply.

Ground Mashed Minced Liquid A client has been diagnosed with dysphagia. When planning a meal for the client, the family should consider minced, mashed, and ground solid food.

Liquid is not considered a solid food consistency.

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Food Textures Match the food textures below to their proper definitions.

Food that is moist, soft-textured, and easily formed into a rounded ball in the mouth (bolus). Meats are ground or minced into pieces no larger than a quarter inch; all pieces are moist, and stick together slightly.

Ground

Foods that are soft and moist naturally or after cooking.

Minced

Cooked food, usually vegetables, fruits or legumes, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid.

Pureed

Foods cooked into a smooth, evenly textured mixture.

Mashed

Solid food textures can be identified as:  Minced – foods that are soft and moist naturally or after cooking.  Mashed – foods cooked into a smooth, evenly textured mixture.  Ground – food that is moist, soft-textured, and easily formed into a rounded ball in the mouth (bolus). Meats are ground or minced into pieces no larger than a quarter inch; all pieces are moist and stick together slightly.  Pureed – cooked food, usually vegetables, fruits or legumes, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid.

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Liquid Consistencies The four levels of liquid consistencies are:  Thin: unthickened beverages and supplements.  Nectarlike: liquids thicker than water but thin enough to sip through a straw.  Honeylike: liquids that can be eaten with a spoon but do not hold their shape.  Spoon-thick: liquids thickened to pudding consistency that need to be eaten with a spoon.

Individualized Care Thin liquids may be thickened to facilitate swallowing and decrease the risk of aspiration. No two patients with dysphagia are alike. Therefore, diet must be individualized according to the swallowing ability and personal

food preferences of the patient. Food must be served in a form that fits the specific anatomic and functional needs of the patient.

Liquid Consistencies Match the four levels of liquid consistency to their definitions below.

Liquids thicker than water but thin enough to sip through a straw.

Nectarlike

Liquids thickened to pudding consistency that need to be eaten with a spoon.

Spoon-thick

Unthickened beverages and supplements.

Thin

Liquids that can be eaten with a spoon but do not hold their shape.

Honeylike

The four levels of liquid consistencies are:  Thin: unthickened beverages and supplements.  Nectarlike: liquids thicker than water but thin enough to sip through a straw.  Honeylike: liquids that can be eaten with a spoon but do not hold their shape.  Spoon-thick: liquids thickened to pudding consistency that need to be eaten with a spoon.

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Aspiration Precautions When clients are diagnosed with dysphagia, there are specific recommendations for feeding to avoid aspiration. These recommendations are listed below:  Position individual upright, bent slightly forward, with the chin tucked and head tilted forward.  Eliminate distractions so the individual can focus all attention on the meal.  The feeding assistant should sit at or below patient's eye level while feeding.  Avoid asking them to talk while eating.  Instruct not to use liquids to clear the mouth of foods. Liquids should be used only after they have cleared food from the mouth.  Encourage frequent dry swallows or coughing to help clear food from the mouth between bites.  Encourage small bites (1 teaspoon solid food or about 10-15 mL liquid), especially if the individual's ability to manage food is impaired.

 Allow adequate time (for example, 20-30 minutes) to eat.  Use spoons rather than cups; individuals have less difficulty taking food and liquid this way.  A straw may be used by some to drink liquids and thinned foods.  While eating, check for voice quality. A wet or gurgled voice indicates food may be resting on the vocal cords.

During meals, supervision is necessary to prevent or minimize swallowing problems. Individuals should be reevaluated regularly to determine whether any changes need to be made in the consistency of fluids or food.

Sometimes they eat too quickly and then choke when trying to swallow.

Staff can observe and supervise while they eat to remind them to complete the swallowing sequence before taking the next bite of food.

Aspiration Precautions Mrs. Robinson was diagnosed with dysphagia and will be going home. The family asks for further direction in what they can do to help prevent

complications, such as aspiration. The health care provider would educate the client and family to do which of the following? Select all that apply.

Eliminate distractions so they can focus all attention on the meal.

Position them upright, bent slightly forward, with the chin tucked and head tilted forward.

Avoid asking them to talk while eating.

Allow adequate time (for example, 20-30 minutes) for them to eat.

Encourage larger bites to finish the meal as quickly as possible.

To prevent complications such as aspiration, they should be instructed to: Position self-upright, bent slightly forward, with the chin tucked and head tilted forward; Eliminate distractions so the individual can focus all attention on the meal; Avoid asking the individual to talk while eating.; Encourage small bites (1 teaspoon solid food or about 10-15 mL liquid), not large bites. The individual's ability to manage food is impaired. Allow adequate time (for example, 20-30 minutes) for them to eat. Encourage smaller bites not larger bites.

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Feeding Techniques Various feeding techniques may facilitate safe swallowing:  Serve small, frequent meals to help maximize intake.  Encourage patients with dysphagia to rest before mealtime.

Postpone meals if the patient is fatigued.  Give mouth care immediately before meals to enhance the sense of taste.

Living with Dysphagia Living with dysphagia can be hard for the person with the diagnosis; but it can also be difficult for their family and friends. Meals together might be missed as the individual with dysphagia is embarrassed to eat in front of others or is fearful of choking.

Beyond the Blender Creating meals that are nutritious, delicious, and easy to prepare can be a challenge. Beyond the Blender is a cookbook developed with the special dietary needs of those with a diagnosis of dysphagia.

Phases of Swallowing Swallowing occurs in three phases. Identify the location of each phase below.

Swallowing occurs in three phases: (A) Voluntary or oral phase. The tongue presses food against the hard palate, forcing it toward the pharynx. (B) Involuntary, pharyngeal phase. Early: wave of peristalsis forces a bolus between the tonsillar pillars. Middle: soft palate draws upward to close posterior nares and respirations cease momentarily. Late: vocal cords approximate, and the larynx pulls upward, covering the airway and stretching the esophagus open. (C) Involuntary, esophageal phase.

Relaxation of the upper esophageal (hypopharyngeal) sphincter allows the peristaltic wave to move the bolus down the esophagus.

It is the involuntary, pharyngeal phase not voluntary, pharyngeal phase.

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Mechanical Conditions and Dysphagia The healthcare provider is speaking to a group of elderly individuals about dysphagia. Which of the following are mechanical conditions that could cause dysphagia? Select all that apply.

Surgery of the throat Inflammation Obstruction Edema The healthcare provider is speaking to a group of elderly individuals about dysphagia. The health care provider would advise the individuals that obstruction, inflammation, edema, and surgery of the throat could cause dysphagia.

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Dysphagia The healthcare provider is speaking to a group of elderly individuals about dysphagia. Which of the following are neurological conditions that could cause dysphagia? Select all that apply.

Cerebral palsy Facial fractures Traumatic brain injury Multiple sclerosis Cerebrovascular accident Amyotrophic lateral sclerosis (ALS) Myasthenia gravis The healthcare provider is speaking to that same group of elderly individuals about dysphagia and is now focusing on the neurological conditions that could cause dysphasia. These include amyotrophic lateral sclerosis (ALS), myasthenia gravis, cerebrovascular accident, traumatic brain injury, cerebral palsy, Parkinson’s disease, and multiple sclerosis.

Fractures of the bone (i.e. facial fractures) are not neurological conditions.

Your response is correct!

Goals of Nutrition Therapy Once a diagnosis of dysphagia has been established, the goal of nutrition therapy is to modify the texture of foods and/or the viscosity of liquids to enable the client to achieve adequate nutrition and hydration while decreasing the risk of aspiration. Solid foods may be minced, mashed, ground, or pureed and thin liquids may be thickened to facilitate swallowing and decrease the risk of aspiration.

You want to decrease the risk of aspiration.

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Pureed Diet The health care provider is concerned about Mr. Harpers nutritional status. A review of the electronic health record (EHR) identifies a prescription for a pureed diet. The provider recalls the items on Mr. Harpers dinner tray and realizes that the foods provided were not in alignment with the pureed diet.

Drag the foods that should be on a pureed diet. Choose only the foods that do not require further processing.

Pureed Diet Regular Diet Hamburger Applesauce Pudding Soup (tomato, cream of chicken) Broccoli

Pudding Soup (tomato, cream of chicken)

Yogurt

Yogurt

French Fries

Applesauce

Clients with dysphagia may avoid eating and drinking due to a fear of choking, which can lead to malnutrition and dehydration. Some clients with dysphagia have problems swallowing certain foods or liquids, while others can't swallow at all. The goal of nutrition therapy for dysphagia is to modify the texture of foods and/or viscosity of liquids to enable the client to achieve adequate nutrition and hydration while decreasing the risk of aspiration. Pudding, soup, yogurt and applesauce are appropriate on a pureed diet.

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Feeding Techniques Various feeding techniques may facilitate safe swallowing. Drag the appropriate steps listed below into the right column.

Potential Steps Serve small, frequent meals to help maximize intake

Appropriate Steps Encourage patients with dysphagia to rest before mealtime

Lower head of bed to improve swallowing ability

Encourage patients with dysphagia to rest before mealtime Give mouth care immediately before meals

Serve small, frequent meals to help

to enhance the sense of taste

maximize intake

Postpone meals if the patient is fatigued Serve small, frequent meals to help maximize intake

Give mouth care immediately before meals to enhance the sense of taste Postpone meals if the patient is fatigued

Various feeding techniques may facilitate safe swallowing:    

Serve small, frequent meals to help maximize intake.

Encourage patients with dysphagia to rest before mealtime.

Postpone meals if the patient is fatigued.

Give mouth care immediately before meals to enhance the sense of taste.

Lowering the head of bed does not improve swallowing ability and increases the risk of aspiration.

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Dysphagia Case Study: Mr. Harper The healthcare professional is reviewing the nurse’s note. Click to highlight the findings that would require follow-up.

Dinner arrived. The health care professional planned time to assess Mr. Harper's mealtime ritual. Upon entering the room, the health care professional found the tray out of patient reach . The healthcare professional movedthe tray to the bedside , uncoveredand openedall the items on the dinner tray.

Mr. Harper showed no interest in eating. Upon encouragement from the healthcare professional, the client picked up the spoon. The professional noted that he hadtremors while trying to pick up the spoon and had difficulty coordinating movement of the spoon to the tray to gather food and then to the mouth.

Once Mr. Harper could place the food in his mouth, upon swallowing, he immediately startedto cough . When speaking with Mr. Harper, he indicated that he has a sensation that food was stuck in his throat.

His voice was“gurgly” or wet sounding . Mr. Harper put down the spoon, pushed his food away, and verbalized that he is not hungry.

Clients with dysphagia often exhibit the following symptoms:

    

Coughing or choking when eating or drinking Sensation of food getting stuck in the throat or chest Persistent drooling of saliva Bringing food back up (regurgitation) Unexpected weight loss

Patients with dysphagia may feel panic at mealtime and avoid eating with others.

Your response is correct!

Provider Interventions Case Study: Mr. Harper Drag the correct phrase from the choices below to fill in each blank found in the following sentences: The healthcare provider realizes that Mr. Harper is struggling to eat.

Because of the tremors, he is struggling to pick up and maneuver the spoon. To support Mr. Harper in his ability to feed himself, the healthcare provider can use adaptive eating devices such as built-up utensils and mugs with spouts, if indicated

. The healthcare provider also witnessed Mr. Harper coughing after taking a bite of food. The nurse can also take steps to decrease the risk of aspiration. To reduce the risk of aspiration, the provider can place the client in an upright or high Fowler’s position and encourage small bites and thorough chewing

.

The healthcare provider realizes that Mr. Harper is struggling to eat.

Because of the tremors, he is struggling to pick up and maneuver the spoon. To support Mr. Harper in his ability to feed himself, the health care provider can use adaptive eating devices such as built-up utensils and mugs with spouts, if indicated. The healthcare provider also witnessed

Mr. Harper coughing after taking a bite of food. The healthcare provider can also take steps to decrease the risk of aspiration. To reduce the risk of aspiration, the healthcare provider can place the patient in an upright or high Fowler’s position and encourage small bites and thorough chewing. You would want to decrease distractions during mealtime so the individual can focus on swallowing.

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Diarrhea and Constipation Gastrointestinal (GI) disorders can produce significant nutritional problems. In many situations, diet is the foundation of therapy. Diarrhea and constipation are intestinal motility disorders that can disrupt nutritional health. We will explore these GI alterations and nutrition considerations within this learning module.

Dumping Syndrome An individual with dumping syndrome is complaining of cramping 10 minutes after completing their lunch. The health care provider would recognize that these symptoms are occurring in the early

phase.

Clients in the early phase of dumping syndrome (occurring 10 to 20 minutes after a meal) experience fullness, cramps, nausea, and diarrhea.

Late phase clients exhibit advanced symptoms (occurring 2 to 3 hours after a meal) which include hypoglycemia. Latent and postictal are not applicable to dumping syndrome.

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Fiber When caring for a client with constipation, it is important to emphasize adequate intake of fiber. Very large amounts of fiber may result in bezoars

.

Very large amounts of fiber may result in bezoars. Bezoars are a solid mass of indigestible material that accumulates in your digestive tract, sometimes causing a blockage. Large amounts of fiber does not cause diarrhea, nausea or gastric reflux.

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Dumping Syndrome When caring for an individual diagnosed with dumping syndrome, the healthcare provider should instruct the client to:

Consume liquids between meals Consume only a liquid diet Thicken liquids Add ice to all fluids Clients with dumping syndrome should not consume liquids with meals, rather, they should consume liquids between meals. Thickened liquids, liquid diet and ice added to fluids are not required.

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Intestinal Gas and Flatulence Intestinal gas can mean different things to different people. Often identified as:  Excessive bloating-swelling  Belching-release of swallowed air from the stomach  Rectal gas/flatus-as produced by food digestion and fermentation by intestinal bacteria

Foods that Contribute to Gas Production Once the healthcare provider has determined there is no medical condition causing the excessive gas, an elimination diet can be used to identify and remove foods that may be causing the symptoms. Diet can have a significant impact on the production of intestinal gas and flatulence. By identifying, limiting or avoiding the offending foods, one can reduce or eliminate the symptoms. Refer to the chart, Foods that Contribute to Gas Production.

Transcript Link

Flatus Which of the following foods could increase gas production? Select all that apply.

Fatty foods Milk and milk products Legumes

Root vegetables Most people agree that beans (all types), milk, and milk products may be the worst offenders in causing gas. Other troublesome foods include onions, celery, carrots, raisins, apricots, prune juice, wheat products, and brussel sprouts.

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Constipation Constipation is generally described as having fewer than three bowel movements a week. Chronic constipation is infrequent bowel movements or difficult passage of stools that persists for several weeks or longer.

Constipation most commonly occurs when waste or stool moves too slowly through the digestive tract or cannot be eliminated effectively from the rectum, which may cause the stool to become hard and dry. Chronic constipation has many possible causes.

Factors that may increase your risk of chronic constipation include: Being an older adult Being a woman Being dehydrated Eating a diet that's low in fiber Getting little or no physical activity Taking certain medications, including sedatives, opioid pain medications, some antidepressants or medications to lower blood pressure  Having a mental health condition such as depression or an eating disorder      

Constipation Risk As a healthcare provider, you are aware that being a woman and an older adult increase the risk for constipation.

Studies have also shown that women tend to have a slightly slower colon transit time than men, resulting in a higher chance of developing constipation.

Many age-related problems (e.g., decreased mobility, comorbid medical conditions, increased use of medications with a side effect profile that includes constipation, and changes in diet) may contribute to the increased prevalence of constipation in older adults.

Adequate fluid intake does not increase risk of constipation and being a man has no impact as well.

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Clinical Manifestations of Constipation Clinical manifestations (i.e. signs and symptoms) of chronic constipation include: Passing fewer than three stools a week Having lumpy or hard stools Straining to have bowel movements Feeling as though there's a blockage in your rectum that prevents bowel movements  Feeling as though you can't completely empty the stool from your rectum  Needing help to empty your rectum, such as using your hands to press on your abdomen and using a finger to remove stool from your rectum    

Constipation Causes and Treatment Review the following infographic for some constipation causes and treatment suggestions.

Constipation Care Recommendations

Constipation means having less than 3 stools per week. The normal bowel pattern for clients varies from 3 times/day to every 3 days. Stools that are passed are hard and dry, which can be difficult and painful to expel.

Increasing water intake is helpful for prevention of constipation – approximately 8-10 glasses per day. Including fiber rich foods like whole grains, fruits, and vegetables. Chronic constipation can be distressing.

Care recommendations for clients experiencing constipation include:  Increase fiber intake in diet to provide roughage and ease stool passage.  Use stool softeners, laxatives, and probiotics to aid in avoiding constipation.  Use medications such as opioids, sparingly, and in conjunction with other methods to prevent constipation.  Encourage the client to walk and become more active.  Avoid skipping meals and form an eating routine.  Listen to the body’s cues for bowel movements and avoid stress which can decrease gastrointestinal (GI) motility.

References Grodner, M., Escott-Stump, S., & Dorner, S. (2020). Nutritional foundations and clinical applications: A nursing approach (7th ed.). Elsevier.

Who is at Risk for Constipation?

As a healthcare provider, you are speaking with an individual about their bowel habits. The provider identifies a client is exhibiting the signs and symptoms of chronic constipation when they verbalize that they are experiencing which of the following symptoms? Select all that apply.

Passing fewer than three stools a week Having lumpy or hard stools Straining to have bowel movements Consuming adequate amounts of fiber

Signs and symptoms of chronic constipation include:  Passing fewer than three stools a week  Having lumpy or hard stools  Straining to have bowel movements Consuming adequate amounts of fiber helps to prevent constipation.

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Nutritional Considerations – Fiber According to the American Heart Association, the average daily fiber intake should be 25 to 30 grams a day. However, the average dietary intake of fiber among adults in the United States is estimated to be 15 grams a day. The lack of dietary fiber lends itself to increased risk for constipation. The inclusion of fruits, vegetables, legumes, beans, grains, and cereals are easy ways to increase fiber and reduce the risk for constipation.

The types of fiber found in food are water-soluble and water insoluble.

Each has different properties and characteristics.

Soluble Dissolved in water Water-soluble fibers absorb water during digestion.

They increase stool bulk and may decrease blood cholesterol levels.

Soluble fiber can be found in fruits (such as apples, oranges and grapefruit), vegetables, legumes (such as dry beans, lentils and peas), barley, oats and oat bran.  Includes plant pectin and gums    

Insoluble Does not dissolve in water.

Water-insoluble fibers remain unchanged during digestion.

They promote normal movement of intestinal contents.

Insoluble fiber can be found in fruits with edible peel or seeds, vegetables, whole grain products (such as whole-wheat bread, pasta and crackers), bulgur wheat, stone ground corn meal, cereals, bran, rolled oats, buckwheat and brown rice.  Includes plant cellulose and hemicellulose    

References University of California San Francisco. (2020). Increasing fiber intake. https://www.ucsfhealth.org/education/increasing-fiberintake#:~:text=The%20American%20Heart%20Association %20Eating,about%20half%20the%20recommended%20amount

Who is at Risk for Constipation?

When discussing soluble vs insoluble fiber consumption with a client, the healthcare provider is able to confirm client understanding when they verbalize: Soluble

fiber dissolves in water.

Insoluble

fiber does not dissolve in water.

Soluble fiber dissolves in water. Insoluble fiber does not dissolve in water.

High fiber and low fiber are diets.

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Diarrhea Diarrhea is loose, watery stools three or more times a day. Diarrhea may be acute, persistent or chronic:  Acute diarrhea is a common problem that typically lasts 1 or 2 days and goes away on its own.  Persistent diarrhea lasts longer than 2 weeks and less than 4 weeks.  Chronic diarrhea lasts at least 4 weeks. Chronic diarrhea symptoms may be continual or may come and go.

Diarrhea has been linked to the following causes:    

Intolerance to foods Difficulty absorbing fats Tolerance to medications Medical treatments

It is important that one identifies the underlying cause of diarrhea and takes action to control the impact it has on their health and nutritional well-being.

Diarrhea

Diarrhea may cause dehydration, which means your body lacks enough fluid and electrolytes to work properly. Your body loses more fluid and electrolytes in loose stools than solid stools.

Diarrhea may also cause malabsorption. If people do not absorb enough nutrients from the food they eat, they may become malnourished. Certain conditions that cause chronic diarrhea—such as infections, food allergies, intolerances, and certain digestive tract problems—may also cause malabsorption.

The focus of nutritional support when a client is experiencing diarrhea is:  Drink 8-10 cups of fluid per day, like water, broth, half-strength juice, weak tea, or electrolyte replacement drinks.  Eat Small frequent meals during the day; progress to regular diet  Limit fried or fatty foods  Limit foods with high sugar content  Enteral or parenteral fluids may be necessary  Try sources of soluble fiber to help firm up stool.

The primary objective of feeding should always be to minimize the adverse effects of the illness on nutritional status. A secondary objective is to promote normal intestinal mucosal renewal, absorptive and digestive functions.

Nutrition therapy for diarrhea is based on the cause. In severe cases, the patient may be advised to restrict oral intake to allow the gastrointestinal (GI) tract to rest; however, it is usually unnecessary to withhold feedings.

Nutritional Support for Diarrhea Recommendations for clients experiencing diarrhea are highlighted below. Click on each icon to learn more about liquids, eating smaller meals, and additional food recommendations.

Types of Diarrhea Mrs. Johnson has been admitted to the hospital with a diagnosis of dehydration. When taking a health history, Mrs. Johnson verbalizes that she has been experiencing diarrhea for the last six weeks. Based on this information, the healthcare provider would document that the client has chronic diarrhea.

Mrs. Johnson is experiencing chronic diarrhea. Diarrhea may be acute, persistent or chronic:

 Acute diarrhea is a common problem that typically lasts 1 or 2 days and goes away on its own.  Persistent diarrhea lasts longer than 2 weeks and less than 4 weeks.  Chronic diarrhea lasts at least 4 weeks. Chronic diarrhea symptoms may be continual or may come and go.

Obstructive is related to diarrhea that is experienced when there is an obstruction.

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Nutritional Deficiencies

When caring for an older client who experiences diarrhea secondary to dumping syndrome, which of the following deficiencies could occur?

Select all that apply.

Vitamin B12 Creatinine

Iron Vitamin D Protein Older patients who experience dumping syndrome often display deficiencies in iron, vitamin B12, protein, and vitamin D. Creatinine is a measurement of kidney function.

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Nutritional Considerations A healthcare provider is educating students on items that may have a laxative effect. Which item would be included on this list?

Hot dogs Alcohol Pizza Eggs Food items such as eggs, pizza, and hot dogs do not have a laxative effect.

Alcohol increases gut motility, therefore acting as a laxative.

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Laxatives A healthcare provider is prescribing a laxative that will cause the stool to absorb water and swell. Which type of laxative has these properties?

Stimulant Emollient Lubricant Bulk-forming

Emollients lubricate the stool. Lubricants soften the stool, making it easier to pass. Stimulants promote peristalsis by irritating the intestinal mucosa or stimulating nerve ending in the intestinal wall.

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Flatulence You are speaking with a client who is complaining of an excessive flatulence. When reviewing the client's dietary intake, you identify that which of the following food might be responsible for causing the excessive flatulence?

Beans Potatoes Meat Applesauce Beans are gas producing foods that relate to flatulence. Meat, potatoes and applesauce do not increase gas production.

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Problem Foods Which of the following foods can increase gas production? Select all that apply.

Pineapple Milk Oranges Legumes Onions

Many people agree that beans, legumes, milk, and milk products may be the worst offenders in causing gas. Other troublesome foods include onions, celery, carrots, raisins, apricots, prune juice, wheat products, and brussels sprouts. Citrus fruits are not specific enough to identify them as a troublesome food.

Many people agree that beans, legumes, milk, and milk products may be the worst offenders in causing gas. Other troublesome foods include onions, celery, carrots, raisins, apricots, prune juice, wheat products, and brussels sprouts. Citrus fruits are not specific enough to identify them as a troublesome food.

Fluid Recommendations The healthcare provider is planning to educate a client on recommendations for fluid intake when experiencing diarrhea. Which recommendations are appropriate to include? Select all that apply.

Avoid milk products Choose very hot drinks Limit high caffeine Drink liquids during meals Select fruit juices like apple or orange The healthcare provider would make the following recommendations to a client with diarrhea.  Drink liquids 30 minutes before or after meals.  Limit use of apple juice, which may aggravate diarrhea (especially in children).  Electrolyte solutions (Gatorade, Pedialyte, etc.) may be prescribed with medical advisement to replenish lost sodium and potassium.  Avoid foods during periods of severe diarrhea that are:

 Very hot—which might increase natural movement of the intestines  High in caffeine—such as coffee, colas, or chocolate  Avoid milk products. Milk products contain lactose, a natural sugar that may not be digested properly.

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Dietary Considerations – Constipation While caring for a client with constipation, the nurse is evaluating the meal tray delivered from dietary services. Which food is appropriate?

Salad with tomatoes Grilled chicken breast Canned peaches in syrup White toast with jelly For clients with constipation, it is important to include high fiber foods like whole grains, vegetables, and fruits. The canned peaches have a high sugar content. The white toast is low in fiber. Grilled chicken is high in protein.

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Diarrhea A healthcare provider is teaching an older adult about appropriate foods to eat with diarrhea. The client mentions that the foods below are their favorites. Which food should the provider encourage the client to eat?

Puffed cereal Chocolate Dry toast Pears Recommended solid food consumption include starting with the BRAT diet which consist of foods that are low in fiber (bananas, rice, applesauce, dry toast, crackers) with diarrhea. Sugary foods will increase diarrhea.

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Nursing Application: Nutrition for Gastrointestinal Health Adequate nutrition consists of the ingestion and utilization of water, essential nutrients, vitamins and minerals to maintain and sustain health and wellness. Gastrointestinal (GI) health affects all other body systems.

As nurses, it is essential assess clients' nutritional wellbeing, identifying the factors that influence nutritional outcomes and direct the care provided based on the findings. This module will guide you in the care for individuals facing nutritional deficits related to alterations in gastrointestinal health.  Describe the nurse’s role in assessing the impact of gastrointestinal disorders on the client’s well-being.  Differentiate nutritional deficits that occur as a result of GI disorders.  Assess a client’s level of distress based upon GI symptoms.  Explain nursing diagnoses related to GI disorders.  Plan, implement, and evaluate care for clients with dietary needs related to GI disorders.

Dimensions of Health Nurses will recognize and analyze cues of a gastrointestinal (GI) disorder as discussed within the dimensions of health. Identify which dimension of health applies to each statement.

Weight loss and nutrient deficiencies in addition to the pathology of the disease itself.

Physical Health

Poorly managed symptoms lead to decreased self-esteem and well-being.

Emotional Health

See the client holistically and provide strategies such as meditation and spiritual support.

Spiritual Health

Finding appropriate facilities to use the restroom while in public, at work, or school can decrease a client’s sense of wellness.

Environmental Health Intellectual Health Social Health

The six dimensions of health impacted by disorders of the GI tract are physical, intellectual, emotional, social, and spiritual. The physical dimension is most affected due to long lasting symptoms providing distress, nutritional deficits, and stress. Intellectual dimension is challenged with the often-rigorous adherence to diet and treatment.

Emotional health can be taxed when clients struggle to accept the diagnosis and/or physical limitations or changes. To address the social dimension, the nurse should provide strategies to help the client understand the challenging new physical ramifications like colostomies, dumping, etc. Spiritual health may be enhanced by using yoga, meditation, or other related strategies to focus on the mind-body connection and environmental health is finding appropriate facilities.

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Gastrointestinal Disorders All gastrointestinal (GI) disorders require some level of nutrition

therapy, which is personalized

to meet the needs of each patient.

All GI disorders require some level of nutrition therapy, which is individualized to meet the needs of each patient. Nutritional therapy should not be generalized or nonspecific, rather personalized for each client. Medications are not necessary for all conditions.

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Constipation The nurse is caring for a client with a constipation. The client verbalizes understanding of their disease process when they identify that constipation consists of? Select all that apply.

Passing fewer than three stools a week Straining to have bowel movements Lumpy, or hard stools Passing more than 3 stools per week Thin, liquid stools Clinical manifestations include, passing fewer than three stools a week; gas or flatulence; having lumpy or hard stools, and straining to have bowel movements.

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Six Dimensions of Gastrointestinal Health When a client experiences a Gastroinestinal (GI) disorder, it is essential that the nurse begin to recognize cues: Identify relevant data to the clinical situation. This is part of nursing assessment. It is also important to understand the profound, holistic impact from not only a GI perspective, but an alteration in elimination as well. When completing the assessment, identify data encompassing the 6 dimensions of health (Grodner et. al., 2020).

Physical Health Intellectual Health Emotional Health Social Health Spiritual Healh Environmental Health

Cultural Considerations You have learned that culture can have an impact on gastrointestinal health as well. Remember, certain Gastrointestinal (GI) disorders may have higher prevalence with various ethnic groups. While caring for diverse clients, cultural awareness is essential. The following diseases can be seen in any population, but may be more common based on geographic location, social structure, socioeconomic class, and many other variables.

Culture

Associated GI Disorders

African Colorectal cancer, diabetes, obesity American Hispanic

Diabetes, obesity

Japanese

Gastric cancer

Jewish Lactose intolerance American Native Gallstones, gallbladder cancer American Mexican Diabetes, gallstones, gallbladder cancer American

Cultural Influences on Gastrointestinal Data Culture can influence illness, health care, and health outcomes. For each culture listed across the top, select some common health disorders which are more likely with the group.

African American

Hispanic

Gallstones Colorectal cancer

x

Diabetes

x

Gallbladder cancer

Native American

Mexican American

x

x

x

x

x

Common health disorders that are more likely with each group include: African American  Colorectal cancer  Diabetes  Obesity Hispanic  Diabetes  Obesity Japanese  Gastric cancer Jewish American

x

 Lactose intolerance Native American  Gallstones  Gallbladder cancer Mexican American  Diabetes  Gallstones  Gallbladder cancer



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Social Determinants of Health The 5 social determinants of health are important to consider when assessing gastrointestinal (GI) alterations, and developing a holistic plan of care.

Click on each + sign below to learn more.

References U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion.

(2020). Social determinants of health (2020): Healthy people 2030. https://health.gov/healthypeople/objectives-and-data/social-determinants-health

Client Support

The nurse is speaking to a group of clients with a diagnosis of chronic diarrhea. A client expresses difficulty with acceptance of dietary or physical limitations. Which tips should the nurse include? Select all that apply.

Consider hospitalization Peer case management Recovery education Support groups Dietary consult and education Many clients struggle with acceptance of dietary or physical limitations; nurses can refer patients to GI disorder support groups as an additional therapeutic strategy. Referring to a dietician may also be beneficial to discuss possible dietary options and tips to help with support. Recovery education, peer case management, and considering hospitalization do not apply.

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Nutritional Assessment

Many Gastrointestinal (GI) disorders have significant nutritional implications. In many situations, diet is the cornerstone of therapy for GI complaints. GI disorders influence overall health by affecting how nutrients are absorbed by the different organs and body systems.

During assessment, ask specific questions regarding:  The client’s diet  Cultural and religious influences and restrictions in dietary intake.  Foods that exacerbate or alleviate any symptoms that are reported.

Gaining information to assess nutrient intake can be challenging, as evidenced in the link below. However, nurses can perform a detailed, holistic assessment that covers the social determinants of health outlined in Healthy People. Additional serum tests can provide detailed evidence of nutrient intake as well as electrolyte levels to evaluate hydration status.

When GI disorders and nutritional deficiencies are identified, healthcare professionals often make recommendations for nutritional supplements, diets, and nutritional interventions to reduce additional variances in health. Early identification of patients at risk by nutritional assessment

and early initiation of nutrition interventions have been associated with improved clinical outcomes

Nutrient Status Assessment Take time to review the Nutrient Status Assessment in Individuals and Populations for Health Aging. Be sure to carefully review table 1 – limitations of current strategies to assess nutrient intake.

Alterations in Gastrointestinal Health Review the following GI health alterations.  Dysphagia  Diarrhea  Constipation

Alterations in Gastrointestinal Health Review the following GI health alterations.  Dysphagia  Diarrhea  Constipation

Transcript Link

Alterations in Gastrointestinal Health Review the following GI health alterations.  Dysphagia  Diarrhea  Constipation

Transcript Link

Gastrointestinal Absorption

When caring for clients with a gastrointestinal (GI) disorder, it is important for the healthcare provider to identify that these disorders influence overall health by affecting how nutrients

are absorbed by the different organs and body systems.

GI disorders affect how nutrients are absorbed in the different organs.

Absorption of medications, electrolytes and fluids can also be affected; however, the GI disorder is primary. The other influences are secondary.

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Focused History – Recognizing Cues Clients who have gastrointestinal problems often present with nonspecific symptoms. Review each symptom below.

Abdominal Pain Pain is one of the body’s ways to indicate that something isn’t quite right.

Use the PQRST mnemonic to evaluate. (P-Pain, Q-Quality, R- Radiation, SSeverity, T-Time) Clients who have gastrointestinal problems often present with non-specific symptoms. Review each symptom below.

Changes in Appetite Has the client had a change in appetite? Some conditions cause the client to increase their intake while others result in decreased appetite and ingestion.

Previous Clients who have gastrointestinal problems often present with non-specific symptoms. Review each symptom below.

Changes in Bowel Habits Establish the client’s normal bowel habits (frequency, consistency, urgency, constipation, etc.) and evaluate for changes.

Previous Clients who have gastrointestinal problems often present with non-specific symptoms. Review each symptom below.

Swallowing Problems Changes in age (elderly have decreased saliva) or other diagnoses (multiple sclerosis, cerebrovascular accident, etc.) can cause difficulty swallowing. An in-depth swallowing evaluation can be performed by a speech therapist if needed.

Previous Clients who have gastrointestinal problems often present with nonspecific symptoms. Review each symptom below.

Food Intolerance Is the client able to eat all foods as desired? Do some foods lead to GI upset or discomfort? Has the client had a change in the ability to tolerate certain types of food or food in general?

Clients who have gastrointestinal problems often present with non-specific symptoms. Review each symptom below.

Nausea and/or Vomiting GI symptoms that are often seen with many disorders include nausea and vomiting due to some sort of GI disturbance. Symptoms can range from mild, occasional nausea to chronic, constant nausea and vomiting.

Previous Clients who have gastrointestinal problems often present with nonspecific symptoms. Review each symptom below.

Changes in Weight Has the client recently had a change in weight? An increase or decrease in weight can be related to GI illness.

GI Assessment As with all nursing care, assessment of the gastrointestinal system is completed in a logical sequence by a nurse, using the nursing process and clinical judgment to:  Identify actual and potential health risks, and  Provide interventions that promote health.

Cultural, genetic, developmental, and lifestyle influences all contribute to gastrointestinal health and should be included in screening for disease, identifying priorities of care, and providing health education that promote optimal health for each client.

Diagnosis of Client Needs – Prioritizing Hypotheses Formulating nursing diagnoses (by analyzing cues & prioritizing hypotheses) depends on the information obtained in the assessment and aids in the clinical judgment and decision-making process. Various reasons can cause the client to have gastrointestinal symptoms. Possible nursing diagnoses include:  Constipation (or risk for) due to decreased gastrointestinal (GI) motility, medications, disease process, etc.  Diarrhea due to increased GI motility, medications, disease process, etc.  Bowel incontinence due to surgical intervention, disease process, etc.  Fatigue related to nutritional deficits/chronic disease/current life stage (pregnancy, teenager, etc.)  Imbalanced nutrition: less than body requirements  Nutritional deficiency due to lack of access to food, intake of nutrient poor foods, etc.  Fluid volume deficit due to nausea, vomiting, and/or diarrhea  Ineffective individual coping strategies due to stressful situations, recent diagnoses, etc.  Ineffective adolescent eating dynamics due to psychosocial complications  Ineffective child eating dynamics due to lack of access to food, loss of appetite, medications, etc.  Ineffective infant eating dynamics due to decreased breast milk, no access to formula, cleft palate, medications, prematurity, etc.

Prioritization of Care A patient comes in to the emergency department with nausea, vomiting and loose, watery stool every hour for the last 24 hours. His mucous membranes are dry, states being dizzy when standing, and is tachycardic.

He admits being recently diagnosed with a stomach problem but unable to recall the name of it. You have fully assessed and evaluated your client and established a plan of care. Next, you must prioritize the nursing

diagnoses within the plan of care. Which of the following nursing diagnoses is priority for this client?

Imbalanced nutrition: less than body requirements.

Fatigue related to nutritional deficits and chronic disease.

Bowel incontinence due to disease process.

Fluid volume deficit due to nausea, vomiting, and diarrhea.

Constipation due to decreased GI motility and disease process.

Based upon the assessment findings (recognizing and analyzing cues) of nausea, vomiting, loose, clear stools (diarrhea), and tachycardia, the client is having fluid volume deficit. Fluid deficit is priority based upon the clinical situation. The client does not have constipation and does not report any bowel incontinence issues. Fatigue and imbalanced nutrition are secondary to an alteration in GI health, however fluid volume deficit is priority and should be addressed first.

Your response is correct!

Planning for Gastrointestinal Alterations The BRAT diet is one solution to use in a patient with gastrointestinal (GI) health. The BRAT diet consists of eating bananas, rice, applesauce, and toast.

B

R

A

T Here are some other solutions and plan interventions for clients with alterations in GI health:  Advocate for client testing to determine cause of symptoms.  Evaluate electrolytes and hydration status using labs, orthostatic vital signs, and other pertinent assessment data.  Provide client teaching for dietary strategies to prevent additional GI upset.  Obtain a stool sample for culture and sensitivity and other parasites and digestive abnormalities.  Determine client specific needs based on age and developmental stage (ex: infant – essential nutrients in formula and baby foods).  Encourage strategies for hydration if unable to tolerate food.  Evaluate the effect of symptoms on physical, intellectual, emotional, social, and spiritual health.  Teach strategies to deal with physical ramifications such as dumping syndrome, colostomies, etc.  Establish assistance for stressful situations and life changes (ex: counseling, have client speak with healthcare provider about medications, etc.).  Provide activities and establish a plan for clients who are unable to eat due to medical conditions (ex: stretching, hand weights, etc.).

 Establish dietary plan for each client – detailed information on portion control, moderation, focusing on healthier alternatives, etc.

Can be used for clients with excessive or inadequate intake.  Determine and educate client on nutritional resources in the area for access to food like food banks, church food pantries, government assistance, etc. to meet dietary needs despite economic ability.  Encourage adherence and explain importance of any diet prescribed and consult nutritional therapist if needed.

Fluid Recommendations The nurse has provided teaching on recommendations for fluid intake when experiencing diarrhea. The client demonstrates an understanding when they can identify which of the following fluids to drink if they have diarrhea? Select all that apply.

Avoid milk products Drink very hot drinks Limit high caffeine Drink apple juice Drink electrolyte solutions The healthcare provider would make the following recommendations to a client with diarrhea.  Limit use of apple juice, which may aggravate diarrhea (especially in children).  Electrolyte solutions (Gatorade, Pedialyte, etc.) may be prescribed with medical advisement to replenish lost sodium and potassium.  Avoid foods during periods of severe diarrhea that are:  Very hot—which might increase natural movement of the intestines  High in caffeine—such as coffee, colas, or chocolate

 Avoid milk products. Milk products contain lactose, a natural sugar that may not be digested properly.

Your response is correct!

Unfolding Case Study

Mr. Rodgers, an 80-year-old, recently had surgery to remove a portion of his stomach related to cancer. He was discharged after the procedure but has returned 3 days later with nausea, vomiting and diarrhea. The client is diagnosed with dehydration.

Question 1 / 6 Which of the following health concerns alerts the nurse based upon alterations in gastrointestinal function?

Probiotic misuse Nutritional deficiencies Constipation

Medication compliance The nurse will need to minimize the adverse effects of the diarrhea on nutritional status and correct nutritional deficiencies. The nurse has recognized and analyzed cues that that Mr. Rodgers is having a nutritional imbalance due to vomiting and diarrhea. There is no history related to probiotic misuse, noncompliance with medications, or constipation.

Your response is correct!

Unfolding Case Study

Mr. Rodgers, an 80-year-old, recently had surgery to remove a portion of his stomach related to cancer. He was discharged after the procedure but has returned 3 days later with nausea, vomiting and diarrhea. The client is diagnosed with dehydration.

Question 2 / 6 Which of the following nursing interventions are priority?

Contacting radiology for abdominal x-ray

Fluid/electrolyte interventions Meal planning Consulting a registered dietitian With a client having vomiting and diarrhea, correcting any fluid and electrolyte imbalances, as part of nutritional deficiencies, is what is needed first. This is prioritizing hypotheses, ranking interventions based upon priority. Meal planning, consulting with a dietitian, or contacting radiology are not priority nursing actions at this time.

Your response is correct!

Unfolding Case Study

Mr. Rodgers, an 80-year-old, recently had surgery to remove a portion of his stomach related to cancer. He was discharged after the procedure but has returned 3 days later with nausea, vomiting and diarrhea. The client is diagnosed with dehydration.

Question 3 / 6 After determining that Mr. Rodgers needs fluid and electrolyte nutritional intervention, the nurse must prioritize the nursing diagnoses within the

plan of care. Which of the following nursing diagnoses is priority for this client?

Imbalanced nutrition: less than body requirements Fluid volume deficit due to nausea, vomiting, and diarrhea Fatigue related to nutritional deficits and chronic disease Bowel incontinence due to disease process Based upon the assessment findings (recognizing and analyzing cues) of nausea, vomiting, and diarrhea, the nurse has prioritized hypotheses that Mr. Rodgers is having fluid volume deficit. Fluid deficit is priority based upon the clinical situation. The client does not report any bowel incontinence issues. Fatigue and imbalanced nutrition are secondary to an alteration in GI health, however fluid volume deficit is priority and should be addressed first.

Your response is correct!

Unfolding Case Study

Mr. Rodgers, an 80-year-old, recently had surgery to remove a portion of his stomach

related to cancer. He was discharged after the procedure but has returned 3 days later with nausea, vomiting and diarrhea. The client is diagnosed with dehydration.

Question 4 / 6 Mr. Rodgers has not reported any nausea, vomiting or diarrhea for over 24 hours. Mr. Rodgers puts his call light on requesting to see the healthcare provider. He reports being "so hungry" and audible bowel sounds in all quadrants are present.

Which of the following diet orders would the nurse anticipate?

Regular diet Clear liquids Remain NPO Pureed diet The focus of nutritional support when a client is experiencing diarrhea is drinking 8-10 cups of fluid per day, like water, broth, half-strength juice, weak tea, or electrolyte replacement drinks; eat small frequent meals during the day and progress to regular diet. Clear liquids is preferred when reintroducing a diet to promote normal intestinal mucosal renewal and absorptive and digestive functions. The nurse is generating solutions and has determined starting with a clear diet is optimal to meet the expected outcome for hydration and nutritional support. Then, advance diet as tolerated. No indication for pureed diet or to remain on NPO status.

Your response is correct!

Unfolding Case Study

Mr. Rodgers, an 80-year-old, recently had surgery to remove a portion of his stomach related to cancer. He was discharged after the procedure but has returned 3 days later with nausea, vomiting and diarrhea. The client is diagnosed with dehydration.

Question 5 / 6

This nurse is carrying out the prescribed clear liquid diet order. The meal tray has been delivered by the dietary team and the nurse is assisting Mr. Rodgers with meal tray set-up. Which of the following phases of the clinical judgement measurement model (CJMM) is the nurse implementing?

Analyzing cues Generating solutions Prioritize hypotheses Taking action The nurse is taking action to implement the clear liquid diet order. The nurse has already taken the other steps in the clinical judgement and decision-making process.

Your response is correct!

Unfolding Case Study

Mr. Rodgers, an 80-year-old, recently had surgery to remove a portion of his stomach related to cancer. He was discharged after the procedure but has returned 3 days later with nausea, vomiting and diarrhea. The client is diagnosed with dehydration.

Question 6 / 6

Prior to discharge, the nurse is teaching Mr. Rodgers about appropriate foods to eat if the diarrhea returns. Mr. Rodgers is worried about dehydration and rehospitalization. Which of the following foods recalled by Mr. Rodgers is the best evidence of effective client teaching?

"I will start with sips of water, apple juice, and ginger ale.”

"I will only take my ondansetron as needed for diarrhea.”

"I will take sips of milk and eat dry toast.”

"I will not drink anything until I talk with my doctor.”

Mr. Rodgers is starting with clear liquids such as water, clear juices, and ginger ale. Drinking fluids, starting with small sips, can help prevent dehydration from diarrhea. Then move to the BRAT diet as tolerated. Mr. Rodgers can recall the clear liquid diet as priority; therefore, the evaluation of client teaching was effective (evaluate outcomes).

Ondansetron is a medication used for nausea, but Mr. Rodgers do not inquire about nausea. Avoid milk products. Milk products contain lactose, a natural sugar that may not be digested properly and can increase diarrhea. This would put the client at risk for dehydration.

Your response is correct!

Analyzing Cues A client with diarrhea asks why it is important to avoid sugars and sweets.

What the appropriate response by the nurse?

“Sugars and sweets provide empty calories, so they should be limited in everyone’s diet.”

“Excess water is drawn into the intestines with sugary foods and causes cramping and diarrhea.”

“Sugar makes blood glucose levels increase; hyperglycemia is a complication of diarrhea.”

“Avoiding sugars and sweets helps ensure that they will not displace the intake of protein, which you need for healing.”

Clients with diarrhea should avoid sugars and sweets because they contribute to a high osmolar load when the gastric contents enter the intestine. This will cause more diarrhea. Sugars and sweet are full of calories, hyperglycemia is not a complication of diarrhea, and sugar does not displace protein in the body.

Your response is correct!

Constipation While caring for a client with constipation, the nurse is evaluating the meal tray delivered from dietary services. Which food is appropriate?

Canned peaches in syrup White toast with jelly Grilled chicken breast Salad with tomatoes

For clients with constipation, it is important to include high fiber foods like whole grains, vegetables, and fruits. The canned peaches have a high sugar content. The white toast is low in fiber. Grilled chicken is high in protein.

Your response is correct!