Capítulo 11 – La Embarazada

Toxoplasma gondi - a causa de excreta de gato; ocasiona retardación mental, epilepsia,

ceguera.

Recomendaciones para náuseas y vómitos – agua de limón, galletas saladas.

Although proper nutrition before and during pregnancy cannot guarantee a successful

pregnancy outcome, it does profoundly affect fetal development and birth.

A healthy diet based on MyPlate food patterns is recommended before, during, and after

pregnancy, with few modifications.

All women of childbearing age who are capable of becoming pregnant are urged to consume

400 µg of synthetic folic acid daily—through fortified foods or supplements—to reduce the

risk of neural tube defects. The most critical period for the development of neural tube

defects is the first month after conception when a woman may not even know she is pregnant.

Screening for iron deficiency anemia should occur prior to conception. Women should be

encouraged to consume adequate heme iron, calcium, essential fatty acids, and iodine. The

potential risks of using dietary supplements should be discussed.

Ideally, women should attain a healthy weight prior to conception.

Weight gain recommendations during pregnancy are based on a woman’s BMI: 25 to 35

pounds for women of normal weight, 28 to 40 pounds for underweight women, 15 to 25

pounds for overweight women, and 11 to 20 pounds for obese women.

The recommended pattern of weight gain for normal-weight women is 1.1 to 4.4 pounds in

the first trimester and approximately 1 pound/week for the rest of pregnancy. This pattern is

adjusted up or down for women who are not within their healthy weight range at the time of

conception.

Calorie requirements do not increase during the first trimester. In the second trimester,

calorie needs increase by 340 cal/day and in the third trimester by 452 cal/day.

A woman who eats a varied diet with adequate calories should be able to meet her increased

need for vitamins and minerals through food alone except for iron. Iron supplements are

recommended. Folic acid requirements increase to 600µg during pregnancy; supplements

and/or fortified foods can provide this amount. Multivitamin and minerals are recommended

for specific situations, such as during iron deficiency, for women carrying two or more

fetuses, and when intake is poor.

Women are urged to avoid alcohol before and during pregnancy because a safe level is not

known.

The consequences of foodborne illness can be devastating for a developing fetus. Pregnant

women are urged to take precautions to avoid foodborne illness.

Pregnant women are advised to limit their caffeine intake to 300 mg/day or less—the

equivalent of approximately 2 cups of coffee. Caffeine is associated with LBW but not with

birth defects.

Nonnutritive sweeteners are safe to use during pregnancy with the amounts specified by the

FDA.

Herbal supplements should not be used during pregnancy because their safety has not been

tested during pregnancy or lactation.

Women are advised to limit their intake of predatory fish and to heed local advisories for fish

consumption to limit their exposure to methylmercury. Mercury poisoning in a fetus can

result in developmental delays, cerebral palsy, seizures, and mental retardation.

Pregnant woman should engage in moderate physical activity for at least 30 min/day on

most days of the week. Safe activities include those that do not have a risk of fall or require

lying down in the supine position after the second trimester of pregnancy.

Diabetes, gestational hypertension, and maternal PKU are maternal health conditions that

can greatly impact fetal development and the course of pregnancy. Women with these

conditions must be closely monitored.

A screening preformed at the first prenatal visit can identify women at potential nutritional

risk during pregnancy and provides baseline data for ongoing monitoring. Adequacy of

weight gain is related to adequacy of calorie intake.

Nutrition counseling should be initiated early in prenatal care and continue throughout the

pregnancy. It should stress the importance of appropriate weight gain, ways to improve

overall intake, and the benefits of breastfeeding.

Breastfeeding is recommended for the first 12 months of life. In addition to being uniquely

suited to infant growth and development, it imparts other significant benefits to both infant

and mother.

Almost all women are capable of breastfeeding.

The healthy diet recommended during pregnancy should be continued during lactation.

Although more calories are needed during lactation than pregnancy once lactation is well

established, women can eat less than the total calories needed and mobilize calories stored as

fat to help regain pre-pregnancy weight.

Thirst is a reliable indicator of fluid need for most women during lactation.

Generally, when maternal intake of nutrients is inadequate, the quantity, not the quality, of

breast milk is diminished.

In the postpartum period, attaining a healthy BMI is important for avoiding obesity and its

health risks later in life.

FALSE - The amount of weight a woman gains during pregnancy is an important indicator

of fetal growth. However, adequate weight gain during pregnancy cannot by itself ensure the

delivery of a normal-birth-weight infant.

FALSE - Obese women should gain 11 to 20 pounds during pregnancy. It is not known how

much weight severely obese women should gain during pregnancy.

TRUE - Fortified cereals are a significant source of folic acid. In fact, the recommended

amount of folic acid could easily be exceeded with fortified cereal.

TRUE - Both inadequate and excessive maternal weight gain during pregnancy are

associated with overweight or obesity in the offspring later in life.

FALSE - The RDA for calcium does not increase during pregnancy because calcium

absorption greatly increases. Calcium needs can be met with the equivalent of 3 cups of milk

daily.

FALSE - Pregnant and lactating women as well as women who may become pregnant are

advised to eliminate only shark, swordfish, king mackerel, and tilefish from their

diets; white albacore tuna should be limited to 6 oz/week, and other fish and shellfish can be

consumed in amounts up to 12 oz/week as long as any one particular type of fish is not eaten

more than once a week. Local advisories about fish caught in local waters should also be

heeded.

TRUE - Calorie requirements do not increase until the second trimester, and even then, the

increase is small: an additional 340 calories for the second trimester and an additional 452

calories in the third trimester.

TRUE - Lactation increases calorie recommendations by 500 for the first 6 months of

breastfeeding and by 400 for the second 6 months. Women may eat fewer calories than this

and still produce enough milk by mobilizing calories stored as fat.

TRUE - An inadequate maternal intake of nutrients decreases the quantity of breast milk

produced, not the quality.

TRUE - Thirst is a good indicator of the need for fluids except among women who live in a

dry climate or exercise in hot weather.

Preguntas

A woman trying to become pregnant was told by her physician to take a daily supplement

containing 400 µg of folic acid. She asks why a supplement is better than eating folic acid

through food. Which statement is the nurses’ best response?

a. “There are few natural sources of folate in food.”

b. “Synthetic folic acid in supplements and fortified foods is better absorbed, more

available, and a more reliable source than the folate found naturally in food.”

c. “Folate in food is equally as good as folic acid in supplements. It is just easier to take it

in pill form and then you don’t have to worry about how much you’re getting in food.”

d. “If you are sure that you eat at least five servings of fruits and vegetables every day,

A woman who was at her healthy weight when she got pregnant is distraught by her 5-pound

weight gain between 20 and 24 weeks of gestation. At this point in her pregnancy, her weight

gain is right on target. What is the nurse’s best response?

a. "A 5-pound per month weight gain at this point in your pregnancy is normal."

b. “Although it is considerably less than the recommended amount, it is not a cause for

concern. Just be sure to follow your meal plan next month so you get enough calories and

nutrients.”

c. “I recommend you write down everything you eat for a few days so we can identify

where the problem lies.”

d. “A 5-pound weight gain in 1 month at this point in your pregnancy may be a sign that

you are at risk of preeclampsia. You should cut back on the ‘extras’ in your diet to limit

your weight gain for next month.”

Which of the following conditions are associated with a high-risk pregnancy? Select all that

apply.

a. Prepregnancy BMI of 20

b. Prepregnancy BMI of greater than 25

c. Maternal age of 30

d. Pregnancies spaced less than 18 months apart

At her first prenatal visit, an overweight woman asks how much weight she should gain

during the course of her pregnancy. What is the nurse’s best response?

a. “You should not gain any weight during your pregnancy. You have adequate calorie

reserves to meet all the energy demands of pregnancy without gaining additional weight.”

b. “You should try to gain less than 15 pounds.”

c. “Aim for a 15- to 25-pound weight gain.”

d. “The recommended weight gain for your weight is 25 to 35 pounds.”

Which of the following statements indicates that the pregnant woman understands the

recommendations about caffeine intake during pregnancy?

a. “I have to give up drinking coffee and cola.”

b. “I will limit my intake of coffee to about 2 cups a day and avoid other sources of

caffeine.”

c. “As long as I don’t drink coffee, I can eat other sources of caffeine because they don’t

contain enough to cause any problems.”

d. “Caffeine is harmless during pregnancy, so I am allowed to consume as much as I

want.”

What nutrient is not likely to be consumed in adequate amounts during pregnancy so a

supplement is recommended?

a. Iron b. Calcium c. Vitamin B12 d. Vitamin C

A woman at 5 weeks of gestation is complaining of nausea throughout the day. What should

the nurse recommend?

a. Small, frequent meals of easily digested carbohydrates

b. Small, frequent meals that are high in protein

c. A liquid diet until the nausea subsides

d. A low fiber intake

Which of the following statements is true?

a. “Women who breastfeed almost always achieve their pregnancy weight at 6 weeks

postpartum.”

b. “Weight loss during lactation is not recommended because it lowers the quantity and

quality of breast milk produced.”

c. “Breastfeeding women do not have to increase their intake by the full amount of

calories it ‘costs’ to produce milk because they can mobilize fat stored during preg-

nancy for some of the extra energy required.”

d. “Women do not need to increase their calorie intake at all for the first 6 months of

breastfeeding because they can use calories stored in fat to produce milk.”

Capítulo 12 – El Niño An optimal diet supports normal growth and development within calorie and nutrient

guidelines.

Because of varying rates of growth and activity, nutritional requirements are less precise

for children and adolescents than they are for adults.

Exclusive breastfeeding is recommended for the first 6 months of life. Breastfeeding

should continue up to the age of 1 year.

Iron-fortified infant formula is an acceptable alternative or supplement to breastfeeding.

The biggest hazard of formula feeding is overfeeding.

Adequacy of growth (height and weight) is the best indicator of whether or not an

infant’s intake is nutritionally adequate.

Complementary foods should not be introduced before the infant is developmentally

ready, usually around 6 months of age. Iron-fortified infant cereal is traditionally the first

food introduced. New foods should be introduced one at a time for a period of 5 to 7 days

so that any allergic reaction can be easily identified.

Nutritional guidelines on how to achieve optimal nutritional intakes for toddlers do not

exist. Infants and toddlers are at low risk of nutrient deficiencies, yet their diets may

already be beginning to be high in added sugars and fats and low in fruits and vegetables.

Parents are the primary gatekeepers of their children’s nutritional intake. They should

make healthy foods available and not introduce foods into their children’s diet that have

no value other than calories.

The food groups most likely to be consumed in inadequate amounts by children and

adolescents are fruits, vegetables, whole grains, and dairy products, increasing their risk

of inadequate intakes of calcium, potassium, fiber, and other nutrients.

The Dietary Guidelines for Americans, 2010 are intended for all Americans age 2 years

and older.

Compared to breakfast eaters, youth who skip breakfast eat less vitamins and minerals,

have lower academic performance, frequently eat unhealthy snacks, and are more likely

to be overweight.

Overweight and obesity among youth are a major public health concern. Children suffer

greater social and psychological effects of obesity than adults. Disorders common in

adults who are overweight, such as glucose intolerance, type 2 diabetes, hypertension,

hyperlipidemia, and metabolic syndrome, may also develop in children who are

overweight. Childhood overweight may increase the risk of insulin resistance, stroke,

cardiovascular disease, and renal failure in adulthood. All children are targets for obesity

prevention beginning at birth.

Adolescents may have unhealthy eating habits that increase their risk of poor pregnancy

outcome, such as a high intake of sugar and inadequate intakes of iron and folate.

TRUE - The amount of calories and protein needed per unit of body weight is greater for

infants than for adults because growth in the first year of life is more rapid than at any

other time in the life cycle (excluding the fetal period).

TRUE - If breastfeeding is discontinued before the infant’s first birthday, it should be

replaced with iron-fortified infant formula. Cow’s milk is not recommended before the

age of 1 year.

FALSE - Iron is the nutrient of most concern when solids are introduced into the diet.

TRUE - Overfeeding is a potential problem with early introduction of solid foods

because young infants are unable to communicate satiety, the feeling of fullness.

TRUE - The risk of nutrient deficiencies among American toddlers is negligible.

However, the risks of overfeeding and eating empty calories are real.

FALSE - The Dietary Guidelines for Americans, 2010 are intended for all Americans

over the age of 2 years.

TRUE - Milk can displace the intake of iron-rich foods, increasing the risk of iron

deficiency.

TRUE - Children who regularly skip breakfast have lower intakes of vitamins and

minerals than children who normally eat breakfast.

TRUE - An overweight child is more likely to develop complications of adult

overweight, such as diabetes, hypertension, and metabolic syndrome.

TRUE - Among 2- to 18-year-olds, the intake of empty calories far exceeds empty

calorie allowance for all age–sex groups.

Preguntas:

Which statement indicates the mother understands the nurse’s instructions about

breastfeeding?

a. “Breastfeeding should only last 5 minutes on each breast.”

b. “Sometimes babies cry just because they are thirsty, so a bottle of water should be

offered before breastfeeding begins to see if the infant is just thirsty.”

c. “The longer the baby sucks the less milk I will have for the next feeding.”

d. “The first breast offered should be alternated with each feeding.”

A mother asks why toddlers shouldn’t drink all the milk they want. Which of the following is

the nurse’s best response?

a. “Consuming more than the recommended amount of milk can displace the intake of

iron-rich foods from the diet and increase the toddler’s risk of iron deficiency anemia.”

b. “Consuming more than the recommended amount of milk increases the risk of milk

allergy.”

c. “Too much milk can lead to overhydration.”

d. “Consuming more than the recommended amount of milk will provide too much

protein.”

The nurse knows her instructions about introducing solids into the infant’s diet have been

effective when the mother states

a. “Babies should be introduced to solid foods at 1 to 3 months of age.”

b. “New foods should be given for 5 to 7 days so that allergic responses can be easily

identified.”

c. “Infants are more likely to accept infant cereal for the first time if it is mixed with

breast milk or formula and given from a bottle.”

d. “The appropriate initial serving size for solids is 1 to 2 tbsp.”

Which of the following would be the best snack for a 2-year-old?

a. Popcorn b. Banana slices c. Fresh cherries d. Raw celery

Which groups are adolescents most likely to eat in inadequate amounts? Select all that apply.

a. Whole grains b. Vegetables c. Fruits d. Meat

The client asks if her 10-year-old daughter needs a weight loss diet. Which of the following

would be the nurse’s best response?

a. “Rather than a diet at this age, you should just forbid her to eat sweets and empty

calories.”

b. “Because prevention of overweight is more effective than treatment, you should start

to limit her calorie intake by only serving low-fat and artificially sweetened foods.”

c. “Ten-year-old girls are about to enter the growth spurt of puberty, and it is natural for

her to gain weight before she grows taller. Diets are not recommended for children,

although healthy eating and moderation are always appropriate.”

d. “She needs extra calories for the upcoming growth spurt, so you should be encouraging

her to eat more than she normally does.”

Calorie and nutrient requirements during adolescence

a. Are higher than during adulthood because of growth and developmental changes.

b. Peak early and then fall until adulthood is reached.

c. Are lower than during childhood.

d. Cannot be generalized because individual variations exist.

Nutrients most likely to be deficient in an adolescent’s diet are

a. Vitamin A and folate

b. Protein and vitamin C

c. Zinc and phosphorus

d. Iron and calcium

Capítulo 13 – Adulto Mayor

Riesgos que promueven desarrollar desnutrición:

o Consumo inadecuado de los grupos de alimentos. Los mayores de 70 años tienen

una ingesta promedio menor de Vit E, Magnesio, fibra, calcio y potasio.

o Pérdida de apetito y anorexia. Pérdida de peso que afecta la masa muscular y

densidad ósea. Movilidad reducida y cambios neuropsicológicos.

Aging begins at birth and ends in death. Exactly how and why aging occurs is not known.

Good eating habits developed early in life promote health in old age.

As a group, older adults are at risk for nutritional problems because of changes in physiology

(including changes in body composition, gastrointestinal tract, metabolism, central nervous

system, renal system, and the senses), changes in income, changes in health, and

psychosocial changes.

Older adults represent a heterogeneous population that varies in health, activity, and

nutritional status. Generalizations about nutritional requirements are less accurate for this age

group than for others.

Generally, calorie needs decrease, but the need for nutrients stays the same or increases with

aging. Requirements increase for calcium and vitamin D. Older adults need to obtain their

RDA for vitamin B12 from the synthetic form found in supplements or fortified foods. The

DRI for sodium decreases due to the decrease in calorie requirement. The RDA for iron in

women decreases when menses stops.

MyPlate for Older Adults is designed to help community-dwelling older adults consume a

healthy diet based on the Dietary Guidelines for Americans, 2010 (see Fig. 13.2). Nutrient-

dense fruits and vegetables, whole and fortified grains, low-fat and nonfat dairy milk and

dairy products, lean proteins, and liquid vegetable oils are depicted on a dinner plate to show

variety and proportion. Physical activity is featured at the top of the placemat to illustrate that

normal daily activities count; a variety of fluids occupy a place next to the dinner plate.

Generally, older adults do not consume enough vitamin E, magnesium, fiber, calcium,

potassium, and probably vitamin D. They should be encouraged to eat more whole grains,

dark green and orange fruits and vegetables, legumes, and milk and milk products.

Screening for nutritional problems is appropriate for all older adults and in all settings.

Screening is essential so that timely nutrition intervention can be instituted.

Weight loss is the most effective dietary strategy against osteoarthritis. The benefits of

weight loss and exercise combined are greater than when either method is used alone.

Benefits include improvements in physical function and quality of life.

Even interventions begun late in life can slow or halt bone loss characteristic of osteoporosis.

The equivalent of three glasses of milk is needed to meet calcium requirement in older adults.

Calcium supplements may be necessary to achieve the recommended amount. Other nutrients

important for bone health include vitamin D, vitamin A, vitamin K, magnesium, vitamin C,

and phytoestrogens.

Sarcopenia is the loss of muscle mass and strength that occurs with aging. It is not inevitable

and can be reversed with resistance training (alzar pesas) and adequate protein intake

(1.2g/kg). Se recomienda que consuman 25 a 30 g de proteína de alta calidad al día, el

equivalente de 3 a 4 onzas de pescado o ave.

The treatment of obesity in older adults is not without risk. Weight loss can be

counterproductive if it comes from a loss of muscle and bone, not fat. For many older adults,

malnutrition presents more of a risk than overweight.

Many known risk factors for Alzheimer disease (AD) are similar to those for CHD

(Coronary Heart Disease).

o Homocisteína elevada, hipercolesterolemia, alta presión sanguínea, diabetes y

sobrepeso.

o Bajo estudio están el uso de Vit. E, Selenio, Vit. C y Omega-3 (DHA).

o Comer una dieta saludable de frutas, verduras, cereales integrales y pescados; 2

servicios de pescado/semana.

o El Alzheimer causa una disminución en la habilidad de alimentarse y comer.

Ahogamiento.

Long-term care residents are at risk for malnutrition. Preventive efforts should focus on

maintaining an adequate calorie and protein intake. Honor special requests, encourage food

from home, and provide assistance with eating as needed.

Goals of diet intervention for older adults are to maintain or restore maximal independent

functioning and to maintain quality of life. Restrictive diets may not be appropriate for older

adults and may actually promote malnutrition; they should be used only when a significant

improvement in health can be expected.

A liberal diet approach may help prevent malnutrition and improve quality of life.

Pressure ulcers increase the need for calories, protein, and other nutrients. Increasing nutrient

density without increasing the volume of food served may be the most effective method of

delivering additional nutrients. Between-meal supplements may also be needed to maximize

intake.

TRUE – 74% of adults age 65 years and older rated their health as good or better during the

period 2004–2006. Self-assessment of health status is important because poor ratings

correlate with higher risks of mortality (Federal Interagency Forum on Aging-Related

Statistics, 2012).

TRUE - In general, calorie needs in older adults decrease due to a decrease in lean body

mass and physical activity while the need for other nutrients stays the same or increases.

FALSE - The AI for water does not change for men or women from the age of 19 years

onward. Older adults have a blunted sense of thirst, yet if they are healthy, normal drinking

and eating habits are considered adequate to guide fluid intake.

TRUE - Older adults do not need more vitamin B12 than younger adults, but their ability to

absorb the natural form of B12 from food may be impaired. Adults over the age of 50 years

are urged to consume the RDA for vitamin B12 from fortified foods or supplements to ensure

adequacy.

FALSE - Most older adults consume adequate amounts of iron. In fact, they are cautioned

against consuming supplements that contain iron so as not to exceed the upper limit for iron.

FALSE - Although loss of lean body mass is a normal consequence of aging, muscle mass

can be replaced with resistance exercises and a diet adequate in protein.

TRUE - Weight loss in older adults is associated with functional limitations, nursing home

admissions, and mortality.

FALSE - While it is true that peak calcium retention—the period when calcium intake has

the greatest impact on bone density—occurs between the ages of 4 and 20 years, the

efficiency of absorption decreases with age, so the AI for calcium for older adults is higher

than that of younger adults.

FALSE - The prevalence of malnutrition or dehydration among residents of long-term care

facilities is from 23% to 85%.

TRUE - A major cause of under nutrition among long-term care residents is loss of appetite.

Monitoring of intake is essential to identify problems early, before a down- hill spiral

develops.

Preguntas

A 68-year-old man who has steadily gained excess weight over the years complains that it is

too late for him to make any changes in diet or exercise that would effectively improve his

health, particularly the arthritis he has in his knees. Which of the following would be the

nurse’s best response?

a. “You’re right. You should have made changes long ago. You cannot benefit from a

change in diet and exercise now.”

b. “It is too hard for older people to change their habits. You should just continue what

you’ve been doing and know that it’s a quality of life issue to enjoy your food.”

c. “It may not help to change your diet and exercise, but it certainly wouldn’t hurt. Why

don’t you give it a try and see what happens?

d. “It is not too late to make changes, and losing weight through diet and exercising are

more effective at relieving arthritis pain than either strategy is alone. And older people

often are better at making lifestyle changes than are younger adults.”

The nurse knows her instructions about vitamin B12 are effective when the client verbalizes

he will

a. Consume more meat.

b. Consume more fruits and vegetables.

c. Eat vitamin B12–fortified cereal.

d. Drink more milk.

A client complains that she is not eating any more than she did when she was 30 years old

and yet she keeps gaining weight. Which of the following would be the nurse’s best

response?

a. “As people get older, they lose muscle mass, which lowers their calorie requirements,

and physical activity often decreases too. You can increase the number of calories you

burn by building muscle with resistance exercises and increasing your activity.”

b. “You may not think you are eating more calories but you probably are because the

only way to gain weight is to eat more calories than you burn.”

c. “Weight gain is an inevitable consequence of getting older related to changes in your

body composition. Do not worry about it because older people are healthier when they

are heavier.”

d. “You need fewer calories now than when you were 30. The only way to lose weight is

to eat less than you are currently eating.”

A mineral likely to be consumed in inadequate amounts by older adults is

a. Iron b. Potassium c. Zinc d. Sodium

The best dietary advice for the possible prevention of Alzheimer disease is to

a. Consume a high-fiber diet.

b. Eat a heart healthy diet of fruits, vegetables, whole grains, and seafood.

c. Take a multivitamin every day.

d. Avoid foods with a high glycemic index.

Risk factors for malnutrition in older adults include (select all that apply)

a. A decrease in food intake in the last 3 months due to loss of appetite

b. Weight loss

c. Acute disease

d. Neuropsychological problems

e. Impaired mobility f. BMI of 23

Older adults doing resistance exercises to rebuild lost muscle may also need to increase their

intake of what nutrient to achieve their objective?

a. Calories b. Carbohydrate c. Protein d. Iron

Which of the following may help promote the intake of a resident in long-term care? Select

all that apply.

a. Use simple verbal prompts to eat.

b. Provide three meals a day; avoid snacks.

c. Minimize noise and distractions in the dining room.

d. Offer finger foods.

e. Honor individual preferences; solicit input from resident and family.