Chapter 17 Nutritional Care

Nutritional support is fundamental in the successful treatment of disease

Nutritional support is often the primary therapy

This chapter focuses on:◦ the comprehensive care of the patient’s

nutritional needs as provided by the RD and◦ the nursing role in the care process in identifying

nutritional needs within the nursing diagnosis

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Define the therapeutic process Describe the collection & analysis of nutritional information

Describe the planning & implementation of nutritional care

Identify the evaluation of nutritional care

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Key concepts◦Valid health care is centered on the

patient and his or her individual needs◦Comprehensive health care is best

provided by a team of various health professionals and support staff persons

◦A personalized health care plan, evaluation, and follow-up care guides actions to promote healing and health

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Nurses and dietitians provide essential support and personalized care.◦Patients need personal advocates in a

maze of complex medical technology that can be confusing

Registered Dietitian (RD) carries major responsibility “medical nutrition therapy” – i.e. for determining individual nutritional therapy needs and plan of care

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Nurses are in the closest continuous contact with patients and their families. Real partnership with patients and caretakers essential to valid care.◦ Coordinate the patient’s special services and

treatments◦ Consult and make referrals as needed◦ Interprets and explains the plan of care to the

patient◦ Teacher and counselor

Nutritional care must be person-centered.◦ Needs must constantly be updated with the

patient’s status

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Collecting information

Identifying problems

Planning care Implementing care Evaluating and

recording results

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Nutrition Assessment

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ABCD approach: ◦Anthropometry◦Biochemical tests◦Clinical observation◦Dietary evaluation

Anthropometric Measurements – are the physical measurements of the human body used for health assessment

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Three types of measurements are common:◦ Weight – preferably

before breakfast, without shoes, in light indoor clothing

◦ Height – stand as straight as possible without shoes or cap

◦ Body composition – to determine fat vs muscle

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Biochemical Tests: Include:

◦Plasma Proteins (serum albumin, prealbumin, hemoglobin) Help detect protein and iron deficiencies

◦Liver enzymes◦BUN, Serum electrolytes◦Cr◦CBC◦Fasting glucose

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Protein metabolism Basic 24-hour urine tests measures byproducts of

protein metabolism – Cr, Urea Nitrogen Elevated levels may indicated excess breakdown of body

tissue

◦ Immune system integrity Determines lymphocyte count

◦ Skeletal system integrity Status of bone integrity and possible osteoporosis

◦ Gastrointestinal function: lab and x-ray Evaluate for peptic ulcer disease and malfunctions along

GI tract

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Clinical Observations:◦Clinical signs of

nutritional status◦Physical

examination◦Inspection of skin

for edema, turgor, nail integrity, abdominal exam, BS, and lungs.

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Dietary Evaluation: Specific food

history obtained using three-day food record.◦Nutritional

Supplements◦Food allergies,

intolerances◦Activity level

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“Identification and labeling an actual occurrence, risk of, or potential for developing a nutrition problem that dietetics professionals are responsible for treating independently”

Nutrition diagnosis will change as the patient’s nutrition needs change.

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Example:◦ Excessive caloric intake related to frequent

consumption of large portions of high-fat meals as evidenced by (AEB) average daily intake of calories exceeding recommended amount by 500 kcals and 12 pound weight gain during the past 18 months.

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The “nutritional problem” is identified in the nutrition diagnostic statement◦ May include nutritional deficiencies or

underlying disease requiring a special modified diet

Etiology: Identify cause or contributing factors. ◦ Correctly identifying the cause is the only way to

design an intervention plan adequately

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Nutrition care and teaching include an appropriate food plan with examples of food choices, food buying, and food preparation

Everyday emotions have a significant influence on food intake and choices

Influence of economic needs

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Diet therapy based on patient’s normal nutritional requirements◦ Any therapeutic diet is only a modification of

normal nutritional needs◦ Only modified as an individual’s specific condition

requires

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Disease modifications – Nutritional components of the normal diet may be modified in 3 ways:◦ Energy – total kcals may be increased or

decreased

◦ Nutrients – modified in amount or form

◦ Texture

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Personal adaptation – Successful nutritional therapy can occur only when the diet is personalized.

Accomplished by planning with the patient or family

Four areas:◦Personal needs◦Disease ◦Nutrition therapy◦Food plan

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Routine “house” diets: ◦ A schedule based on

a cycle menu◦ Basic modifications

in texture ranging from clear liquid full liquid soft food regular diet

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Clear liquid◦ Clear broth, bouillon,

Sprite, fruit juice, gelatin, popsicles

Full liquid◦ Milk, yogurt, ice

cream, pudding

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Routine House Diets cont.

Soft◦ Pasta, soft bread,

potatoes, cooked and soft fruits

Regular◦ Any foods

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Oral feeding – preferred for as long as possible

Assisted oral feeding – nurse may have to help feed or cut up meat, butter bread, etc.◦make use of plate guards, special utensils,

etc. to promote independence Enteral feeding

◦Small tube placed through patient’s nasal cavity; runs down back of throat into either stomach or small intestine; may also use a “g-tube” for more permanent placement

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Parenteral nutrition – for those who cannot tolerate food or formula through the GI tract◦ Peripheral vein

feeding (short term)◦ Central vein feeding

(long term)◦ Intralipids

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Evaluated in terms of nutritional diagnosis and treatment objectives

Continues through period of care, stops at the point of discharge

General considerations◦ Nutritional goals – effect of the dietor feeding method on the illness or the patient’s situation?

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◦ Required changes – is it necessary to change the type of food or feeding equipment, environment for meals, counseling procedures, or types of learning activities for nutrition education?

◦ Ability to follow diet – Does any hindrance or disability prevent the patient from following the treatment plan?

◦ Resources - Do the patient and family understand all the self-care instructions provided? Connection with community resources available?

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Gathering information about all drug use is essential to the care process◦Includes over-the-counter drugs, prescribed

drugs, alcohol, “street drugs” Drug-food interactions

Increasing or decreasing the effect of a drug and adversely affect health

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Drug-nutrient interactions Reactions occur when prescription drugs

are taken in combination with over-the-counter vitamin and mineral supplements.

Drug-herb interactions Is the least defined of drug interactions Some herbs have clinically documented

medicinal properties May affect key enzymes involved in

metabolism

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Examples: Ginkgo biloba- Aspirin, warfarin (Coumadin),

ticlopidine (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine)

St. John's wort-Antidepressants Ephedra-Caffeine, decongestants,

stimulants Ginseng-Warfarin Kava-Sedatives, sleeping pills,

antipsychotics, alcohol

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