1. METABOLISM Ma. Tosca Cybil A. Torres, RN, MAN MTCAT '09

2. Definition of Terms: Metabolism- all biochemical reactions within the body. Basal Metabolic rate- energy requirement of an awake person at rest Energy needed at a person’s lowest level of cellular function Nutrients- any ingested chemical that is used for growth, repair and maintenance of the body. Catabolism- breakdown of complex structures into simpler forms. Anabolism- process by which simpler molecules combine to build more complex structures. MTCAT '09

3. Gastrointestinal System MTCAT '09

6. digestion is completed in the small intestine , and most nutrients are absorbed in this part of the GIT

7. the large intestine serves primarily to absorb water and electrolytes and to eliminate the waste products of digestion through the fecesMTCAT '09

9. teeth - for initial breakdown of food to small particles

11. salivary glands – moisten food and mucous membranes and begin carbohydrate digestion

12. tongue – to push the food to the pharynx to initiate swallowingMTCAT '09

14. lined with mucous membrane – secretes mucoid substance for protection

15. the bolus of food arrives at the cardiac sphincter of the stomach w/in 5-10 secs. after ingestion

16. the lower esophageal sphincter (LES) prevents reflux of food in the stomach back into the lower esophagusSwallowing (deglutition) 3 phases: 1.) tongue forces the bolus of food into the pharynx 2.) the food moves into the upper esophagus 3.) the food moves down into the stomach * Food is prevented from passing into the trachea by closing of the trachea (epiglottis) and the opening of the esophagus MTCAT '09

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22. Gastrointestinal Tract Digestive Function of the Stomach: Pepsin – needed for protein digestion HCL acid – aids in pre-digestion of food MTCAT '09

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26. vermiform appendix – has no function , near the ileocecal valve

27. anus – anal opening, is controlled by a smooth muscle internal sphincter and a striated muscle external sphincter

28. chymeis propelled toward the anus by peristalsis, also mixes the intestinal contents

29. in the colon, the feces is pushed forward by mass movements – stimulated by gastrocolic reflexes initiated when food enters the duodenum from the stomach

30. Defecation reflex

31. when feces enter the rectum and cause distention of wall of the rectum  send impulses to the sacral segment of the spinal cord – then back to the colon, sigmoid and rectum  initiate relaxation of the internal anal sphincter  relaxation or contraction of external anal sphincter (voluntary control)MTCAT '09

34. in the center of the villi are capillaries, veins, small arteries for absorption of nutrients into the blood vessel system

35. 90% of absorption occurs within the small intestines by active transport or diffusion

36. amino acids, monosaccharides, Na+, Ca++ are transported by active transport w/ the expenditure or use of energy

37. other nutrients, fatty acids and H2O – diffuse passively across the cell membrane

38. reabsorption of H2O, electrolytes and bile occurs mainly in the ascending colonMTCAT '09

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42. intestinal bacteria synthesize Vit. K  required for production of clotting factors II (Prothrombin), VII, IX,XMTCAT '09

43. PHYSIOLOGY OF DIGESTION AND ABSORPTION Digestion: physical and chemical breakdown of food into absorptive substances. Initiated in the mouth where food mixes with saliva and starch is broken down. Food then passes into the esophagus where it is propelled into the stomach. In the stomach, food is processed by gastric secretions into a substance called chyme.

44. In the small intestine, carbohydrates are hydrolyzed to monosaccharides, fats to glycerol, and fatty acids and proteins to amino acids to complete the digestive process. When chyme enters the duodenum, mucus is secreted to neutralize hydrochloric acid; in response to release of secretin, pacreas releases bicarbonate to neutralize acid chyme. Cholecystokinin and pancreozymin (CCK- PZ) are also produced by duodenal mucosa; stimulate contraction of the gall bladder along with relaxation of the sphincter of Oddi (to allow bile to flow from the common bile duct into the duodenum, and stimulate release of pancreatic enzymes.

45. NUTRITION Nutrition is the sum of all interactions between an organism and the food it consumes. MTCAT '09

46. 6 MAJOR CLASSES OF NUTRIENTS WATER 2.5 L Macronutrient CHO 125-175 g. LIPIDS 80-100 g. PROTEIN 44-60 g. MINERALS 0.05-3,300 mg. Micronutrient VITAMINS 0.002-60 mg.

48. Lean people contain more water than obese people

50. Digestion (CHO) Desired end product of CHO are monosaccharides (Glucose, fructose, galactose) Major enzymes: Ptyalin (salivary amylase) Pancreatic amylase MTCAT '09

51. Metabolism (CHO) Storage and conversion Stored either as glycogen or fat Glycogen Large polymer of glucose Process of glycogen formation----GLYCOGENESIS Stored mostly in the liver and skeletal muscles Glucose that cannot be stored as glycogen are stored as fat MTCAT '09

52. Glycogenolysis Breakdown of glycogen to reform glucose for use of cells Activated by GLUCAGON and EPINEPHRINE When blood glucose concentration falls alpha cells (pancreas) secrete glucagon  stimulates glycogenolysis mainly in the liverliver delivers glucose to the bloodstream elevate blood glucose level SNS stimulated  adrenal medulla releases epinephrine stimulates glycogenolysis in both the liver and muscle cells release energy needed during sympathetic stimulation MTCAT '09

53. Gluconeogenesis Process of forming of glucose from protein (amino acids) and fat reserves Occurs in the liver Only up to 60% of CHON can be coverted into glucose MTCAT '09

54. Essential Nutrients PROTEIN (CHON) Organic substances composed of amino acids Amino acids are the most important components of protein. Essential for synthesis of body tissue in growth, maintenance and repair. It is responsible for muscle contraction and motility of cilia and flagella. Yields 4 kcal/g RDA is 44 to 60 g depending on age and sex. Multiply your wt. in lbs x 0.37 = e RDA Category: Essential amino acids Those that cannot be manufactured in the body and must be supplied as part of the diet Non essential amino acids Can be manufactured in the body MTCAT '09

55. Digestion (CHON) start in the stomach pepsin – breakdown of proteins to polypeptides small intestines trypsin – breakdown of polypeptides into peptides and amino acids MTCAT '09

56. Metabolism (CHON) Storage Absorbed by active transport through the small intestine into the portal blood circulation CHON is “stored” as body tissue Body cannot actually store CHON for future use. MTCAT '09

57. Essential Nutrients LIPIDS Organic substances that are greasy and insoluble in water but soluble in alcohol or ether. Fats are lipids that are solid in room temperature Oil are lipids that are liquid in room temperature Fatty acids basic structural unit of most lipids MTCAT '09

58. Digestion (LIPIDS) Starts in the stomach digested mostly in the small intestine by bile, pancreatic lipase and enteric lipaseEnd product are glycerol, fatty acids, and cholesterol reassembled in the intestinal cells into triglycerides and cholesterol esters (cholesterol w/ fatty acids) converted by the small intestine and liver to LIPOPROTEINS for transportation MTCAT '09

59. Lipoproteins Lipoproteins- made up of various lipids and a protein Classification High-density lipoproteins (HDL) contains the highest concentrations of CHON (50%) Low-density lipoprotein (LDL) contains very high concentration of cholesterol Very-low-density lipoprotein (VLDL)contains little protein but high concentrations of triglycerides and moderate concentrations of phospholipids and cholesterol MTCAT '09

60. Storage (LIPIDS) Store in 2 major tissues: Adipose tissue (fat depot) Stores triglycerides until needed for energy Insulator Liver MTCAT '09

62. Vitamin classification: Water-soluble vitamins Cannot be stored in the body body needs daily supplementation Vitamin C, Vitamin B-complex Fat-soluble vitamins Can be stored in the body vit E and K with limitation Daily supplementation is not absolutely necessary Vitamin A, D, E, K MTCAT '09

63. Minerals Inorganic elements essential to the body because of their role as catalysts in biochemical reactions. CLASSIFICATION Macrominerals. When the daily requirement is 100 mg or more Microminerals. When the daily requirement is less than 100 mg. MTCAT '09

64. FOUNDATIONS OF AN ADEQUATE DIET Food Guide Pyramid - 1992 Recommended Daily Allowance – 1943 – level of intake of essential nutrients considered to be adequate to meet the nutritional needs of healthy people Other Dietary Guidelines (1990) Eat a variety of food Choose a diet low in fat, saturated fat and cholesterol. Choose a diet with plenty of vegetables, fruits and grain products. Use sugar in moderation. Use salt in moderation. If you drink, do so in moderation.

65. The Food Pyramid GRAINS VEGETABLES FRUITS OILS MILK MEAT & BEANS

68. Iron can be given after 4 mos.

69. Toddlers and Preschoolers

70. Growth rate slows during toddler years (1 to 3)

71. Needs fewer calories but an increase amount of protein in relation to body weight.

74. Socioeconomic Status

75. Personal Preference

76. Psychological Factor

77. Alcohol and drugs

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83. Assessing Nutritional Status“ABCD Approach” Anthropometric measurement Biochemical Data Clinical signs Dietary History

84. ANTHROPOMETRY System of measurement of the size and make up of the body and specific body parts. INCLUDE: Weight* Height BMI = wt. in kg/ (ht in meter) 2 20-25% Normal 27.5-30% Mild Obesity 30-40% Moderate Above 40% Severe Wrist circumference Mid upper arm circumference (MAC) Triceps skin fold (TSF)

85. Height and weight should be obtained on hospital admission. Weigh daily. Wrist measurement is used to estimate the client’s body frame. Height in cm divided by wrist circumference= frame size N value= >10.4 to 10.9cm (small), 10.4 – 9.6 (Medium),< 9.6 (large)

86. MAC determines muscle wasting. Measured at the mid point of the arm. N values = 28.3 men, 28.5 women Skinfold measurement determine fat content of subcutaneous tissue. N values = 12.5 cm men, 18 cm women Other areas measured biceps, scapula and abdominal muscles

87. Biochemical Data Hgb & Hct indices Serum albumin Transferrin (blood protein that binds with iron) Total lymphocyte count Nitrogen balance Creatinine excretion

88. Clinical Signs Clinical Signs Indicative of Nutritional Status Hair- dull, brittle, depigmented, easily plucked Face- skin dark over cheeks and under eyes, skin flaky, face swollen Eyes- Eye membranes pale, dry (xeropthalmia), Bitot’s spots, increased vascularity, cornea, soft (kerotomalcia) Lips- swollen and puffy (cheilosis), angular lesions at corners of mouth (angular fissures) Tongue- smooth appearance, swollen, beefy red, sores, atrophic papillae

89. Clinical signs Teeth- Cavities, mottled appearance (fluorosis), malpositioned Gums-spongy, bleed easily, marginal redness, recession Glands- thyroid enlargement (simple goiter) Skin- rough, dry, flaky, swollen, pale, pigmented, lack of fat under skin Nails- spoon shaped, ridged Skeleton- poor posture, beading of ribs, bowed legs or knock legs Muscles- flaccid, poor tone, wasted, underdeveloped Extremities- weak and tender, presence of edema Abdomen- swollen Nervous system- decrease in or loss of ankle and knee reflexes

90. Dietary History It considers the quantity and quality of food intake and also frequency of consumption of certain food items in order to determine the current or customary intake of nutrients.

92. The client is asked to keep a record of food actually consumed over a period of time, varying from 3 to 7 days.

94. The subject is asked to recall all food eaten during the previous day and to estimate the quantities of food consumed.

97. Hunger – triggered by low blood glucose level

98. Appetite – sight, smell, and thought of food

100. Diagnosing Altered nutrition: more than body requirements Altered nutrition: less than body requirements Activity intolerance Constipation Diarrhea Knowledge deficit Self-esteem disturbance Potential for impaired skin integrity MTCAT '09

101. IMPLEMENTATION Stimulating Appetite(depending on the medical condition) Serve food in pleasant and attractive manner Mouth care Position comfortably Promote comfort Relieve pain Adequate ventilation and humidity Remove unsightly articles Check very tight or very loose clothing Remember that color affects appetite to eat. Environment – curtain the unit of patients on NPO Diet Therapist Special Diets Hospital Diets Diet therapy in disease management

106. Alternative Feeding: Enteralhyperalimentation- delivery of nutrients directly to the GI tract. Short- term- esophagostomy; nasogastric tube Long- term- gastrostomy; jejunostomy Indications of NGT: Gavage- to deliver nutrients and medication; for feeding purposes Lavage- to irrigate the stomach Decompression- to remove stomach contents or air MTCAT '09

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108. SKILLS: NGT Insertion PURPOSES OF NGT INSERTION: To provide feeding (gastric gavage) To irrigate stomach ( gastric lavage) For decompression (drainage of gastric content) To administer medication.

109. INSERTION Inform the patient and explain the procedure. Place in high- Fowler’s Measure length of NGT to be inserted (NEX technique) = 50 cm. Lubricate tube with water soluble lubricant. To reduce friction. Do not use oil. Hyperextend the neck, gently advance the tube toward the nasopharynx. Tilt the patient’s head forward once the tube reaches the oropharynx, and ask to swallow as the tube is advanced. Secure the NGT by taping it to the bridge of the client’s nose, after checking the position of the tube placement.

111. Assess tube placement and patency.

112. Introduce 5-20ml of air into the NGT and auscultate at the epigastric area, gurgling of sound is heard.

113. Aspirate gastric content, which is yellowish or greenish in color.

114. Immense tip of tube in water, no bubbles should be produced.

115. Measure the pH of the aspirated fluid which should be acidic.

116. Ask the client to speak or hum

117. Observe the client for coughing or choking.The most effective method of checking the NGT is radiograph verification then, checking pH of aspirated gastric content.

119. Introduce feeding slowly. To prevent flatulence, crampy pain and or reflex vomiting.

120. Height of feeding is 12 inches above the tube’s point of insertion into the client. This allows slow introduction of feeding.

121. Instill 60 ml of water into the NGT after feeding. To cleanse the lumen of the tube.

122. Clamp the NGT before all of the water is instilled. To prevent entry of air into the stomach.

123. Ask client to remain in Fowler’s position or in slightly elevated right lateral position for at least 30 min. To prevent potential aspiration of feeding.

124. Do after care of equipment.

128. Teaching Patients Self-Care Demonstration of the tube feeding begins by showing the patient how to check for residual gastric contents before the feeding. All feedings are given at room temperature or near body temperature. For a bolus feeding, the nurse shows the patient how to introduce the liquid into the catheter by using a funnel or the barrel of a syringe. The receptacle is tilted to allow air to escape while the liquid is being instilled initially. As the funnel or syringe fills with liquid, the feeding is allowed to flow into the stomach by gravity by holding the barrel or syringe perpendicular to the abdomen. Raising or lowering the receptacle to no higher than 45 cm (18 in) above the abdominal wall regulates the rate of flow.

129. Teaching Patients Self-Care A bolus feeding of 300 to 500 mL usually is given for each meal and requires 10 to 15 minutes to complete. The amount is often determined by the patient's reaction. If the patient feels full, it may be desirable to give smaller amounts more frequently. The patient and caregiver must understand that keeping the head of the bed elevated a minimum of 45 degrees for at least 1 hour after feeding facilitates digestion and decreases the risk of aspiration. Any obstruction requires that the feeding be stopped and the physician notified.

131. Teaching Patients Self-Care The patient or caregiver is instructed to flush the tube with 30 to 50 mL of water after each bolus or medication administration and to also flush the tube daily to keep it patent. The patient and caregiver are made aware that the tube is marked at skin level to provide the patient with a baseline for later comparison. They are advised to monitor the tube's length and to notify the physician or home care nurse if the segment of the tube outside the body becomes shorter or longer.

133. Solution and administration equipment should be changed every 24 hours

134. Dressing changes every 48-72 hrs with antibiotic ointment to catheter insertion

135. Medication is never administered in a TPN line

136. Observe for complications

137. Infection

138. Venous thrombosis

139. HyperglycemiaMTCAT '09

140. Evaluation MTCAT '09