NURS 225: Nutrition in Health and Disease

NURS 225: Nutrition in Health and Disease

2017

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Topic # 1: HCG Diet

Part I, Criteria # 1: Identification of Nutrients

According to the Dudek (2016), the RDAs represent the average daily-recommended

intake to meet the nutrient requirements of 97% to 98% of healthy individuals by life stage and

gender. When estimating the nutritional needs of people with health disorders, health

professionals use the RDA’s as a starting point and adjust them according to the individual’s

need (Dudek, 2013). Even though HCG is a hormone injection program, there are extremely

strict and limited food choice to their diet plan such as: 500 calories limit per day, no cosmetic

products that contain fat in them, 2 small apples are not an expectable exchange for 1 apple.

Table 1 below lists some foods that patients are allowed to choose from for daily intake

(Simeons, 2016).

Table 1 The Original HCG Diet Protocol by Dr. Simeons

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Due to such strict rules and limitation on food selection, patients would end up with deficiency in

two important macronutrients such as carbohydrate and fat. As we can see, if we plug in some

foods from Table 1 above into MyFitnessPal website we would end up with 509 calories, which

is very close to what the HCG program requires (Lose weight with MyFitnessPal. Retrieved

from http://www.myfitnesspal.com/). However, if we look at the amount of carbohydrate

remaining, it is obvious that patients only consume 50% of their daily-recommended calories.

Carbohydrate is a macronutrient that is important in providing energy for the daily living.

Clearly, patients using HCG program are very limited on fat consumption. According to

example below, if we follow The Original HCG Diet Protocol by Dr. Simeons, we would end up

with only 5 grams from fat when the daily-recommended intake is 40 grams. Fats come in

multiple different forms. While some are bad and should be limited, some are essential for the

body; therefore, limiting the amount of fat consumption to almost completely nothing is not a

good diet plan. On the other side, this program provides a very sufficient amount of protein to

the patients. As we can see from Table 2 below, patient fulfilled the amount of daily-

recommended requirement, 60 grams, with the additional 4 grams. This might be also the key

element to the program that claims that by injecting HCG, patients will not feel hungry. It might

be because the high amount of protein patients consume that make them feel less hungry.

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Table 2 Patient Food Diary from MyFitnessPal Showing Daily Intake Goals versus RDAs.

Part I, Criteria # 2: RDA Approval Analysis

As mentioned previously, Recommended Dietary Allowances (RDAs) is the average

daily dietary intake level sufficient to meet the nutrient requirement of 97% to 98% of healthy

individuals in a particular life stage and gender group (Dudek, 2013). Even though the amount of

intake varies on the individual, HCG program still provides patient with very little in

micronutrients such as calcium, potassium, iron, fiber, sodium, vitamin A, and vitamin C.

However, out of these nutrients, there are five nutrients that the diet is very deficient in: sodium,

potassium, calcium, vitamin A, and iron. These 5 nutrients are not even at 50% of the daily-

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recommended intake. Sodium plays an important role in fluid and electrolyte balance. Even

though deficiency is rare, patient can experience nausea, dizziness, and/or muscle cramps

(Dudek, 2013). Potassium is also important in fluid and electrolyte. It also has nerve impulse

transmission function and skeletal and cardiac muscle activity. Deficiency will lead to muscle

weakness, anorexia, confusion, and irregular heartbeats (Dudek, 2013). Calcium involves in bone

and teeth formation, blood clotting, nerve transmission, contraction and relaxation of muscles,

and blood pressure regulation. Deficiency in this mineral can lead to impaired growth in children

and osteoporosis in adults (Dudek, 2013). Vitamin A is very important in formation of visual

purple, normal growth and development of bones and teeth, healthy skin and hair, and also

important in immune function. Deficiency can result in ceases of bone growth, dry skin, decrease

saliva production, and impair immune system (Dudek, 2013). Last but not least, iron is very

important in transporting oxygen. Iron in foods exists in two forms: heme iron, found in meat,

fish, and poultry, and nonheme iron, found in plants such as grains, vegetables, legumes, and

nuts. The majority of iron in the diet is nonheme iron (Dudek, 2013).

Part 2, Criteria 1# Nutrition and Pathophysiology

Cystic fibrosis is a genetic disorder where the individual inherits one defective gene

(mutation of the transmembrane conductance regulator gene [CFTR] located on chromosome 7)

from each parent and is “characterized by abnormally thick mucus secretions from the epithelial

surfaces that results in progressive lung disease, pancreatic insufficiency and dysfunction of the

gastrointestinal and genitourinary systems”. Due to the CFTR’s inability to function properly

leads to obstruction of the ducts and glands of affected organs such as the lungs and pancreas,

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digestive tract, liver, skin and reproductive organs (Nahikian-Nelms, Sucher, & Lacey, 2016, pp.

650).

Patients with cystic fibrosis, enzymes are suppressed and unable to reach the small

intestines related to pancreatic insufficiency secondary to obstructed ducts. These patients will

show symptoms such as abdominal distention; frequent bowel movements that are oily, bulky,

and foul smelling; and even with normal appetite will present with poor growth pattern,

decreased muscle mass and decreased subcutaneous tissue. These patients, both children and

adults, are also at risk for electrolyte imbalance and dehydration due to excessive sweating in hot

weather and fever related to the increased levels of chloride and sodium in their sweat. Other

complications that occur because of the disease process include varices and cirrhosis of the liver

with portal hypertension; cystic fibrosis related diabetes (10% to 15% of adults of adults) with

subsequent clinical complications is acquired. Also, patients with cystic fibrosis have a higher

risk of infection (mainly Staphylococcus aureus and Pseudomonas aeruginosa) due to defective

or impaired cilia action, which can lead to the inability to clear mucus from the lungs due to the

defective regulation of the respiratory tract. The major cause of death (more than 95% of

patients) with cystic fibrosis patients is pulmonary insufficiency, which in turn leads to

pulmonary failure (Nahikian-Nelms, Sucher, & Lacey, 2016, pp. 650).

To prevent nutritional deficiencies, maintain nutritional status, and maximize growth of

patients with cystic Fibrosis, early detection is of the utmost importance. Some of these

diagnostic tests to help with early detection include DNA analysis of the CFTR gene to confirm

mutation, pancreatic function tests, pulmonary function tests, and a sweat chloride test (usually

done during the newborn screening). “Common nutrition diagnostic labels for cystic fibrosis

include inadequate energy intake, inadequate oral intake, increased energy needs, malnutrition,

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less than optimal intake of fats, inappropriate intake of types of carbohydrates, inconsistent

carbohydrate intake, inadequate vitamin and mineral intake, altered GI function, altered

nutrition-related laboratory values, underweight, unintended weight loss, self-monitoring deficit,

limited adherence to nutrition-related recommendations, and poor nutrition quality of life”

(Nahikian-Nelms, Sucher, & Lacey, 2016, pp. 653). Most studies show that cystic fibrosis

patients have vitamin and mineral deficiencies including Vitamin A, Vitamin D, Vitamin E, and

Iron and Zinc (mostly children and adolescence). Although Vitamin A deficiency is common, it

also can be misleading because during an infection or an acute illness a patient’s the serum

plasma Vitamin A levels may be decreased. Due to the increased prevalence of bone fractures

and osteoporosis, Vitamin D needs to be monitored carefully to ensure they are receiving the

right amount because studies have also shown that CF patients still have low levels of Vitamin D

concentrations despite intake of supplements (Nahikian-Nelms, Sucher, & Lacey, 2016, pp. 651-

652).

Part 2, Criteria # 2: Medical and Nutrient Related Interventions and Dietary Needs

Timely interventions and accurately assessing their nutritional status is very important

because many cystic fibrosis patients may present with multiple nutritional diagnoses at any

given time related to the complexity of their disease. Every treatment plan for CF patients will

vary from patient to patient but, also usually include the “following components; airway

clearance techniques; oral, inhaled and nebulized medications; nutrition therapies; and a fitness

plan” (Cystic fibrosis Foundation, n.d.); and nutritional-related medication management with

Pancreatic Enzyme Therapy.

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“Because a significant number of individuals with CF have pancreatic insufficiency,

malabsorption of dietary fat, protein, fat-soluble vitamins, and other nutrients often occurs…

Individuals with CF are prescribed pancreatic enzyme supplements. These enzymes are

specifically formulated with an enteric coating that allows for better absorption into the

duodenum. The target dose is 1500 to 2500 unit’s lipase/kg… [and the] FDA has issued a rule

requiring manufacturers of pancreatic enzyme supplements to obtain approval for their products

[because of the inconsistencies in the formulation].” With this new FDA ruling in place,

Pancreatic enzyme supplements, like any new drug, must go through the same standards of

testing before being distributed to the public (Nahikian-Nelms, Sucher, & Lacey, 2016, p. 652).

Cystic fibrosis patients, especially with pancreatic insufficiencies, need adequate intake

of calories to help with development and growth and these needs will vary based on each

individual and their nutritional status. These patients usually need 1 ½ to 2 times that amount

calories than someone without cystic fibrosis and “if an individual has significant growth

deficits, lung disease, or malabsorption, energy requirements may be significantly increased

(110%–200% of the RDA for age)”. Usually caloric intake is never restricted or minimized due

to the majority of CF patients have difficulty gaining or maintaining their weight (Nahikian-

Nelms, Sucher, & Lacey, 2016, p. 652). Cystic fibrosis patients have trouble absorbing fats

related to pancreatic insufficiency and in turn they have trouble absorbing fat-soluble vitamins

such as Vitamin A, Vitamin D, Vitamin E and Vitamin K, which are critical for normal growth.

Besides taking these fat-soluble vitamins as supplements they need to ensure they consume

appropriate amount of water-soluble vitamins, such as; Vitamin C and the B-complex vitamins

(to include biotin and pantothenic acid, and folic acid) (Cystic fibrosis Foundation, n.d.).

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One treatment recommended for cystic fibrosis patients include Airway clearance, which

allows the mucus that is thick and viscous to loosen up and dislodge from their lungs allowing

for better oxygenation, improve lung function and helps decrease the risk of lung infections.

Some techniques include: coughing or huffing; chest physiotherapy (including percussion with

cupped hands or equipment can be prescribed and ordered through various manufacturers).

Along with these Airway clearance techniques, usually cystic fibrosis patients are on long term

bronchodilators (usually nebulized) that can result in abdominal pain and anorexia,

corticosteroids, antibiotics like ciprofloxacin may have delayed absorption when taken with dairy

products, mucus thinners, and “CFTR (cystic fibrosis transmembrane conductance regulator)

modulator therapies. [They] are designed to correct the function of the defective protein made by

the CF gene and there are currently [only] two FDA-approved CFTR modulators: ivacaftor

(Kalydeco®) and lumacaftor/ivacaftor (Orkambi®)” (Cystic fibrosis Foundation, n.d.).

Part 3, Criteria # 1 Nutrient Calculations

Our patient is a 22-year-old female who is 5’5″ (65 inches) and 112 pounds (50.9 kg).

BMI

Using this calculation, the patient’s BMI is 18.6 and according to the Quick Bite

Interpreting BMI Chart, the patient’s BMI barely meets the Healthy Weight, which ranged from

18.5 to 24.9 (Dudek 2014, p. 7). “The 2002 Nutrition Consensus Report states that there is no

perfect method to estimate the calorie needs of a person with CF” (Nahikian-Nelms, et al., 2016,

p.652).

112/ 65 X 65 (4225) = 0.0265 X 703 = 18.6 BMI

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Since the patient’s BMI falls under the Healthy Weight category to estimate her caloric

needs we will use the equation for a healthy adult, which is (weight in kg) x (30 kcal/kg). Using

this calculation, we estimate that her calorie intake needs would be roughly be 1527 kcal. The

BMI plus activity and food intake is the calculation documented below.

112 X 10 = 1120 X 0.20 (activity) = 224 + 1120 = 1344 X 0.1(food) = 134 + 1344 =

1478 calories/day

CHO

For carbohydrate intake, should be individualized and “should be monitored to achieve

glycemic control. Although carbohydrate is not restricted, patients should be taught to distribute

carbohydrate calories throughout the day and to avoid concentrated carbohydrate loads”

(Nahikian-Nelms, et al., 2016, p.653).

1478 X 0.45 = 665 calories then/by 4calories/gram = 166 grams/day

1478 X 0.65 = 960 calories then/by 4 calories/gram = 240 grams/day,

Daily range 665-960 calories/day from CHO, 166 – 240 grams/day,

PRO

Protein intake, recommended intake is roughly 1.5 to 2.0 times the Daily Recommended

Intake (DRI) for that age (Nahikian-Nelms, et al., 2016, p.653). “The Recommended Dietary

Allowance (RDA) for protein for healthy adults is 0.8 g/kg” and “the Acceptable Macronutrient

Distribution Range (AMDR) for protein for adults is 10% to 35% of total calories” (Dudek 2014,

p. 54). With a caloric intake of 1527 kcal, minimum protein intake of 10% and protein equaling 4

kcals/gram, for a healthy patient would need a minimum intake of roughly 38.2 grams. Since a

cystic fibrosis patient needs 1.5 to 2.0 times the normal intake of protein, at a minimum a cystic

fibrosis patient would need 57.3 grams to 76.4 grams of protein per day.

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112 lb. / 2.2 kg/lb. = 50.9 kg. X 0.8 gm/kg = 40.7 grams protein daily, healthy person

Or

40.7 grams X 1.5 times as much, requirement = 61grams/day protein X 4 calories/gram =

244 calories/day

40.7 grams X 2 times as much, requirement = 81.4 grams/day X 4 calories/gram = 326

calories/day

Daily range 244 – 326 calories/day, or 61 – 81 grams/day

FAT

For patients with cystic fibrosis , there is no restriction on fat intake because it is essential

for weight maintenance. Unlike the 25% to35% recommended fat intake for the normal

population, cystic fibrosis patients require a greater fat intake of 35% to 40 % of total kcal

(Nahikian-Nelms, et al., 2016, p.653). With a caloric intake of 1527 kcal, maximum fat intake of

40% and fats equaling 9 kcals/grams, the patient would need a minimum intake of roughly 67.9

grams of fat per day.

2839 X 0.35 = 568 calories then/by 9 calories/gram = 63 grams/day

2839 X 0.40 = 994 calories then/by 9 calories/gram = 110 grams/day

Daily range 568 – 994 calories/day, or 63 – 110 grams/day

Part 3, Criterion #2 SMART Goals and Patient Care Plan

SMART Goal # 1: Patient will make a menu for two days, 3 meals/day with a heme rich protein

food in two meals, menus will be discussed at the end of the shift. Patient was able to plan six

meals with four containing heme rich proteins. Goal met SMART Goal # 2: Patient will consume

75% of 2 meals during this 12—hour shift. Goal met patient consumed 100% of breakfast and

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75% of lunch. SMART Goal # 3: Patient will consume a serving of probiotic rich food, (yogurt)

daily by end of shift. Goal met, patient consumed a Greek yogurt for lunch.

Patient is a 22-year-old female who’s 5’5” (65 inches) and 112 pounds (50.9 kg), BMI of 18.6

who was diagnosed with cystic fibrosis at two years old. She came to the ER complaining that she has

trouble breathing. Her blood pressure is 130/86, heart rate 92 beats per minute, temperature of 98.8

degrees Fahrenheit, and oxygen saturation at 88% in room air. Patient denies any history of smoking or

illicit drug use and occasionally has an alcoholic drink. Patient states that she is still taking

Ciprofloxacin after having pneumonia about two weeks ago.

As an RN caring for a person with cystic fibrosis, there are many roles and duties that one

must be responsible for. An RN must ask the patient if they have any type of food allergies.

There are no particular foods that an adult with cystic fibrosis should really avoid, but you must

take precautions before giving food that a patient may be allergic to. The RN must assess the

patient for low protein by obtaining the serum prealbumin and globulin levels. Patient teaching

would include the importance of maintaining a high protein, fat diet with a daily consumption of

probiotics (Jafir, 2014). Listen to the patient and what she likes to eat, thus avoiding any

ethnocentricism. Give the patient different options of high protein meals to choose from in order

to effectively gain the nutrients needed. Advise the patient to consider what foods she prefers

that are easy to chew that are also high in protein, and fat.

The plan for maintaining nutritional balance throughout the shift was implemented by first

collaborating with the nutritionist to aid in planning a food menu that tailored the patient’s needs,

making sure to accommodate the patient’s appetite. After the menu was provided, the patient decided on

eat hot cereal, with scrambled eggs, and whole wheat toast for breakfast, lunch included Greek yogurt,

butter lettuce salad and fruit, and for dinner roasted chicken, mashed potatoes with gravy, and edamame.

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Patient was asked what kind of high protein foods she would like to eat at home and replied with

chicken, salmon, and steak. Patent airway was ensured before feeding by checking gag reflex and her

ability to swallow. Suction was also readily available by her bedside. I monitored the patient’s protein

by obtaining labs and assessing her total protein, albumin, prealbumin and globulin levels.

Due to thick and sticky mucus build up in the lungs, it is very important that the RN

check the patient’s airways because it can suddenly get clogged. The nurse must auscultate

breath sounds and recognize wheezing, crackles, or rhonchi. Assess the patient’s air way and

ensure a patent passage. Teach the patient how to perform effective coughing and deep breathing

techniques daily in order to help the secretion of sputum. Other duties include physiotherapy to

aid in secretion of the mucus. The patient should be in a comfortable position with the head

elevated in a semi-fowler position. Thick, sticky mucus also makes it easier for bacteria to

colonize into the lungs so the RN must assess the patient for any lung infections. This may also

result in the patient preferring softer foods, for ease of eating and swallowing. The nurse must

check labs such as blood tests for WBC and platelet count, ABGs, sputum culture, as well a chest

x-ray. The thick mucus can also block tubes or ducts in the pancreas (George & Hazle, 2016).

The thick mucus can lead to malnutrition due to digestive enzymes not being able to reach the

small intestine.

Educate the patient in the importance of physical exercise and how it helps with

improving GI motility and respiratory muscles (George & Hazle, 2016).

During patient teaching, she showed willingness to learn as she stated that she learns better if I

demonstrated techniques. Patient showed understanding as she demonstrated effective coughing and

deep breathing techniques, preparation of meal plans and protein sources. She stated that she will

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practice these techniques daily to excrete her sputum. She also understood to take her antibiotics

throughout the entire time it is prescribed (Miller & Stoeckel, 2016).

References

Cystic fibrosis Foundation. (n.d.). Treatments and therapies [website]. Retrieved

https://www.cff.org/Living-with-CF/Treatments-and-Therapies/

Dudek, S. G. (2014). Nutrition essentials for nursing practice (7th ed.). Philadelphia, PA:

Wolters Kluwer Health/Lippincott Williams & Wilkins.

George, C., & Hazle, L. (2016). Cystic fibrosis: Nurses act as a healthcare provider, advocate

and educator for CF patients. Advance Healthcare Network for Nurses. Retrieved from

http://nursing.advanceweb.com/Continuing-Education/CE-Articles/Cystic-Fibrosis.aspx

Miller, M. A., & Stoeckel, P. R. (2016). Client education: Theory and practice (2nd ed.).

Burlington, MA: Jones & Bartlett Learning.

MyFitnessPal (n.d.). Lose weight with MyFitnessPal. Retrieved from

http://www.myfitnesspal.com/

Nahikian-Nelms, M., Sucher, K., & Lacey, K. (2016). Nutrition therapy and pathophysiology

(3rd ed.). Boston, MA: Cengage Learning.

Simeons, W. (2016). The original HCG diet protocol & menu by Dr. A. T. W. Simeons: An

overview. Retrieved from https://hcgdietinfo.com/Diet-HCG