nutrition care 1. nurses and dietitians provide support and personalized care registered...

Nutrition Care

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Nurses and dietitians provide support and personalized care

Registered dietitians (RDs) carry major responsibilities▪ Plan, Implement, and Evaluate

Teamwork of dietician-nurse-physician▪ Patient-Centered Care

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Nurse helps dietician to develop, support, and carry out the nutrition plan of care

Nurse also acts as coordinator, advocate, interpreter, teacher and counselor

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Nursing Process = AssessmentDiagnosisPlanningImplementationEvaluation

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Nutrition assessmentNutrition diagnosisNutrition planning and interventionNutrition monitoring and evaluationNurse & Dietician

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Nutrition assessment Anthropometric data (age, gender, ht, wt,

BMI) Biochemical tests (lab tests – chemistry,

glucose, liver, renal, lipid) Diet evaluations (appetite, intake, allergies,

intolerances, activity level, mode of eating) Medications Clinical observations (includes physical

exam)

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Nutrition assessment Anthropometric measurements▪ Weight▪ Weigh patients at consistent times – same time each

day▪ Weigh patients without shoes in light indoor clothing.▪ Ask about recent weight loss or gain.

▪ Height▪ Use fixed measuring stick on wall or moveable

measuring rod on platform clinic scale.▪ Have patient stand as straight as possible with no

shoes or cap.

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Measuring height in an infant

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Nutrition assessment Dietary evaluation ▪ History▪ Usual intake, current intake, restrictions,

modifications (use 24-hour recall and food diaries)

Support system, living situation Nutrition supplements, vitamin or mineral

supplements Food allergies, intolerances Usual activity level

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Nutrition assessment Observations▪ Clinical signs of nutrition status

Physical examination – skin integrity, skin turgor, edema, nail integrity, lung sounds, bowel sounds, vital signs

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Nutrition diagnosis Problem Etiology Signs and symptoms

Example; excessive caloric intake due to large portions, high fat meals

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Nutrition intervention Disease modification Personal adaptation (diet change is

personalized) Mode of feeding▪ Oral feeding▪ Assisted oral feeding▪ Enteral feeding▪ Parenteral feeding

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Nutrition monitoring and evaluation Nutrition goals (are they being met ?) Changes (should diet plan be altered ?) Ability to follow diet More information or resources needed Does the patient and/or family

understand dietary care plan and changes

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Oral Feeding▪ Preferred method of feeding, Self vs. Assisted

Assisted Oral Feeding Nurse, Nursing Assistant, family member Allow patient to feed self as much as

possible Have tray securely placed in front of pt. Offer small amounts Do not rush the feeding Offer liquids w/ straw, between solid bites Wipe pt. mouth with napkin Warn pt. about hot foods 14

Enteral feeding▪ Feeding via tube directly into GI tract (NG or

PEG tube)▪ Tube feeding

Continuous Intermittent Bolus

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Nutrients are delivered to the client via central vein.

Candidates are anticipated to require TPN for longer than 10 days.

Indications: Patients with post-op surgical

complications. Patients with inflammatory bowel disease. Patients with inadequate oral intake or malabsorption.

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TPN Protocols include: A slow start A strict schedule Close monitoring Instructions for increasing volume Maintenance of a constant rate Instructions for a slow withdrawal(Clients needs are determined by

physician/ dietician and solution is made in pharmacy).

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Patient needs to be watched carefully for shifts in electrolytes and fluids.

Requires Vital signs every 4 to 8 hours.

Daily weights Serum electrolytes, glucose,

creatinine, blood urea nitrogen levels, daily for 5 days then twice a week.

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Refer to handout Regular diet Clear liquid diet Full liquid diet Mechanical soft diet Pureed diet Diabetic, Renal, Cardiovascular diets Low-purine, Low residue, Gluten-free Kosher

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Regular (house) diet▪ Most foods allowed, no restrictions▪ Should avoid spicy, heavily seasoned foods

Clear Liquid diet▪ Used to reduce amt. fecal material in colon▪ To empty digestive system before

colonoscopy or abdominal surgery▪ To treat inflammatory bowel disease▪ Refer to handout for foods allowed

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REGULAR DIET CLEAR LIQUID DIET

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Full liquid diet▪ Used when conditions require easy to swallow & digest foods

Used for pts. w/ difficulty chewing Refer to handout for foods allowed

Mechanical Soft Diet▪ Used for patients w/ difficulty chewing

and/or swallowing, edentulous pt.▪ Refer to handout for foods allowed

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FULL LIQUID DIET MECHANICAL SOFT DIET

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Pureed Diet▪ Diet is modified in consistency so that food

does not have to be chewed, easy to swallow▪ Foods must be of pudding-like consistency▪ Refer to handout for foods allowed

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Diabetic DietWhat is diabetes ? Disorder of

glucose metabolism▪ Normally, CHO foods eaten…..breakdown in

GI tract…..absorbed into bloodstream as glucose….glucose transported in body….used as energy ▪ Insulin helps to move glucose from

bloodstream INTO cells▪ With diabetes, these processes occur

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Diabetes (continued)▪ Insulin produced in pancreas▪ Diabetics do not produce enough insulin or

cannot effectively use the insulin produced▪ Type I (more severe, usually early onset)▪ Type II (adulthood, 90-95% have Type II)▪ Gestational diabetes (during pregnancy)▪ Hypoglycemia – low blood glucose▪ Hyperglycemia – high blood sugar

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Diabetes (continued) Insulin: hormone produced by the

pancreas that attaches to insulin receptors on cell membranes, allows absorption of glucose into the cell

Normal blood glucose = 70-110 (preferably less than 100)

Sources of blood glucose: diet and glycogen stores

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Diabetic Diet *refer to handout

▪ Diet used to control blood glucose level ▪ Recommendations from ADA▪ Space meals and snacks throughout entire

day to avoid hypo- and hyperglycemia▪ Choose foods based upon low glycemic index▪ Diet consists of complex carbohydrates, high

fiber foods, omega 3 & 6 fatty acids▪ Avoid high-fat content foods

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Goals of care Maintain optimal nutrition Avoid symptoms Prevent complications

Basic elements of diabetes management:healthy diet, physical exercise, medications (oral and/or insulin)

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Diabetic Diet recommendations:▪ CHO consume more than 130 gm/day

Utilize glycemic index High fiber foods important (25-30 gm/day)

▪ Fat 25-30% total cals, less than 7% from saturated fats▪ Protein 15-35% total cals

Carbohydrate counting: used to balance carb intake w/ insulin usage

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Carbohydrate counting:▪ Patients must count total number of carbs in

a meal ▪ Then pt. must inject appropriate amount of

insulin to process the carbs▪ Patient must have knowledge on how to

count carbs per meal !!!▪ Patient education is a MUST !!!

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Sample Breakfast Menu: Cooked oatmeal, 1 cup 25 gm White toast, 2 slices 25 gm Jam, 1 tablespoon 13 gm Milk 2%, 1 cup 13 gm Orange, 1 medium 15 gm Coffee, 1 cup 0 gm Sugar packet, 1 4 gm

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Sample Breakfast Menu: Oatmeal, 1 cup 25 gm (1/2 = 12.5 gm) Toast, 2 slices 25 gm (1 slice = 12.5) Jam, 1 13 gm (none = 0) Milk, 1 cup 13 gm (all = 13 gm) Orange, 1 15 gm (none = 0) Coffee, 1 cup 0 gm (all = 0) Sugar packet, 1 4 gm (all = 4gm)

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Kidney disease = kidneys cannot filter waste products from the body (such as urea, ammonia, electrolytes, phosphorus and excess water)- may require hemodialysis- diet modification is a MUST !!!- major causes = diabetes, HTN

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Renal Diet Avoid excess protein intake, may need to

reduce protein to 0.6 – 0.7 g/kg (compared to normal intake of 0.8 g/kg)

Carbs & fats must provide sufficient calories !!!

Sodium usually needs to be restricted, especially w/ HTN and edema (swelling)

Potassium is restricted in most patients Phosphorus must be restricted Multivitamin (renal) may be necessary Fluid restriction may be necessary

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Coronary heart disease: ***Major cause = atherosclerosis,

associated w/ elevated cholesterol and lipids

Atherosclerosis: formation of fats and cholesterol that develop into hardened plaques in lining of major blood vessels (ie, coronary arteries)

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Dietary recommendations for reducing CV risk:

1. 30 min. exercise 2. Diet rich in vegetables & fruits3. Eat fish 2-3 x/week4. Choose whole-grain, high-fiber5. Limit saturated & trans fats &

cholesterol6. Alcohol in moderation 7. Choose foods w/ little or NO salt8. Select low-fat or fat free dairy products

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“The Colors of Salt”White: NaCl, MSG (preservatives)Black: Soy sauceRed: KetchupYellow: MustardGreen: Pickles, relishOrange: Cheese (except cottage)Brown: Soups (except homemade),

gravyPink: Lunchmeats, hot dogs, burgers

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“low salt” alternatives not ok – contain NaCl

Mrs. Dash products okSea Salt = saltDiet Rite – sodium free sodaDASH diet – dietary avoidance of salt

to improve HTN, low Na, low fat

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AHA guidelines▪ Total fat 25-35% (of total

calories)▪ Saturated fat Less than 7%▪ Carbohydrates 50-60%▪ Protein 15% or less▪ Cholesterol 200mg or less▪ Fiber 20-30 gm

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Bananas, rice, applesauce, toast, tea For pts. w/ GI upset & diarrhea Not recommended for pediatric patients

anymore – nutritionally incomplete – follow regular diet of tolerable foods

High fiber foods better for diarrhea, also coconut water and rice water

Important to hydrate to maintain fluid balance

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Refer to handout▪ Low Residue Diet▪ Low Purine Diet▪ Kosher Diet▪ Gluten-free Diet

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Small, frequent mealsAvoid high fat foodsAvoid alcohol, caffeine, smoking

Heartburn, reflux, hiatal hernia, peptic ulcer disease