Brief Clinical Nutrition

Author: Lysen Lucinda K.
Publisher:
Publish Date: 2003-01-01
Features: [Excerpt:]
1.3.5.9 Nose: Nasal and External Examination
(1) Observe the shape of the nose, secretions, patency, deviation of the nasal septum, and condition of the nasal mucosa.
(2) Note any substances expelled from the nose, including their color and composition.
(3) Have the examinee tilt their head slightly backward to inspect the nasal cavity, noting whether it is patent. If not, it may affect the passage of a nasogastric tube.
(4) The nasal mucosa should be pink.
1.3.5.10 Chin
Examine the opening and closing of the lower jaw, its lateral movement, and the condition of the parotid glands. The upper and lower front teeth should be aligned. The lower jaw should move freely from side to side without clicking sounds, which is important for assessing chewing ability. Check for enlargement of the parotid gland in front of the ear.
1.3.5.11 Lips
Inspect the color, symmetry, and any damage of the lips. The lips should be pink, symmetrical, and undamaged.
1.3.5.12 Tongue
Examine the symmetry, color, moisture, and texture of the tongue. Have the patient stick out their tongue to observe it. If the tongue is centered without deviation or tremors, it is considered symmetrical. The tongue should have a pale pink color and appear moist. The tongue may appear slightly rough due to the presence of taste buds.
1.3.5.13 Buccal Mucosa
(1) Inspect the color, moisture, and any damage of the buccal mucosa.
(2) In Caucasians, the oral mucosa is typically pink or red, while in Black individuals, it may appear slightly blue. The mucosa should appear smooth, moist, and undamaged.
(3) Check the gag reflex: Use a tongue depressor to touch the posterior pharyngeal wall to elicit a gag reflex.
1.3.5.14 Teeth
Examine the color, condition of repair, presence of missing or inflamed teeth. The teeth should be white, well-aligned, free of stains, and free of inflammation.
1.3.5.15 Gums
Inspect the color, moisture, and condition of the gums. The gums should be pink, moist, undamaged, and free of calculus.
1.3.5.16 Neck
(1) Check for jugular vein distension, thyroid condition, submandibular gland, and presence of feeding tubes.
(2) The jugular veins should be straight and not distended. When examining the thyroid, stand behind the patient, place the right hand between the trachea and sternocleidomastoid muscle, and have the patient perform a swallowing motion. Repeat this on the left side. During swallowing, the thyroid should rise slightly without hard lumps or new growths.
(3) Note any feeding tubes.
1.3.5.17 Chest
(1) Examine the fullness of the chest muscles and the frequency, rhythm, and amplitude of breathing.
(2) Auscultate breath sounds; they should be clear.
(3) The chest should have well-developed muscles with adequate fat reserves; breathing frequency should be within the normal range (approximately 16–20 breaths per minute in adults), with a regular rhythm and amplitude.
(4) Breath sounds should be clear during auscultation.
3.3.4.1 Stress and Disease Effects on Blood Glucose Control
(1) Stress and disease increase the levels of counterregulatory hormones.
(2) When peripheral glucose utilization decreases, hepatic glucose production increases.
(3) Peripheral insulin resistance often complicates treatment, leading to difficult-to-control hyperglycemia.
(4) Reduced food intake during illness results in suboptimal blood glucose control.
3.3.4.2 Diabetic Ketoacidosis
(1) Diabetic ketoacidosis is a life-threatening complication common in IDDM, possibly due to insufficient insulin efficacy when counterregulatory hormones rise.
(2) Fatty acid oxidation increases ketone bodies (ketones: pyruvate β-hydroxybutyrate).
(3) Its osmotic diuresis leads to dehydration, electrolyte imbalance, and metabolic acidosis. Without treatment, it can harm cardiovascular and renal functions.
(4) Treatment involves insulin and fluid/electrolyte replacement.
3.3.4.3 Diabetic Nonketotic Hyperosmolar Coma
(1) This is a complication of NIDDM, more common in patients with severe current illness.
(2) The insulin secreted in the body can still prevent acidosis.
(3) Characteristics include extremely high blood glucose (>600 mg/dL), serum osmolality >330 mOsm/kg body weight, mild acidosis with serum bicarbonate >20 meq/L, and lethargy in patients.
(4) Treatment involves insulin, fluid, and electrolyte replacement. Rapid diagnosis and treatment are crucial due to a mortality rate as high as 50%.
3.3.4.4 Hypoglycemia
(1) Overzealous insulin use can cause hypoglycemia.
(2) Other causes include delayed meals after insulin administration.
(3) Repeated severe hypoglycemia can damage the nervous system.
3.3.4.5 Neuropathy
(1) Delayed gastric emptying or gastroparesis is seen in 45–75% of diabetic patients.
(2) Some patients with gastroparesis may be asymptomatic, while others may experience acute exacerbations alternating with asymptomatic periods.
(3) Medications: erythromycin, metoclopramide, domperidone, pantoprazole.
(4) Small bowel rest and parenteral nutrition are rarely needed; nasogastric tubes can often provide enteral nutrition.
3.4.1.5 Adaptation
Providing enteral nutrition can effectively maintain the nutritional function of the gastrointestinal mucosa. During the growth and healing period after intestinal resection or injury, supplying energy specifically suited for the digestive tract—such as arginine for enterocytes and short-chain fatty acids for colonocytes—helps achieve adaptation.
3.4.1.6 Immune Barrier
The gastrointestinal mucosal barrier prevents bacterial adhesion and protects against their toxins. If the barrier is not maintained normally, its function is compromised, increasing the permeability of the digestive tract.
3.4.2 Nutritional Complications of Gastrointestinal Disorders
The evaluation of patients with gastrointestinal diseases should include the following aspects:
(1) Chief Complaints:
- Ask about symptoms such as stomach pain, heartburn, vomiting, or abnormal bowel movements.
- Onset time, duration, severity.
- Factors that worsen symptoms.
- Factors that relieve symptoms.
(2) Medical History:
- Oral, pharyngeal, abdominal, and rectal history.
- Chronic gastrointestinal diseases, such as ulcerative colitis.
- Primary diseases, including neurological conditions affecting the tongue, mouth, pharynx, or stomach, as well as conditions like diabetes, hypothyroidism, and constipation.
- Food allergies.
- History of gastrointestinal surgery, especially resections.
- History of vitamin, mineral supplements, laxatives, and mineral oil intake.
(3) Family History:
- Chronic intestinal inflammation, ulcerative colitis, colon cancer, gallbladder disease, alcoholism, or gastric ulcer history.
(4) Psychosocial History:
- Assess the status of emotional complications, including self-perception complications.
(5) Activities of Daily Living and Functional Status:
- Detailed nutritional history.
- Changes in appetite.
- Ability to purchase and prepare food.
- Special dietary restrictions.
- Ability to exercise regularly.
- History of alcohol and smoking.
- Dental history.