illness & nutrition care

Nutrition & Diet Therapy (7th Edition)

Illness & Nutrition Care

Chapter 14


Nutrition in Health Care


Effects of Illness on Nutrition Status

• Relationship between nutrition & illness is complex– Medical problems can alter nutrient needs & result in

malnutrition• Reduction in food intake• Interference with digestion & absorption• Alteration of nutrient metabolism & excretion• Increase metabolic stress & energy needs

– Poor nutrition can affect course of disease & body’s response to treatment

• Dietary changes required for acute illness usually temporary; chronic illnesses may require long-term dietary modification


Responsibility for Nutrition Care

• Cooperative effort of multidisciplinary health care team– Critical pathways

outline coordinated, comprehensive plan for specific diagnoses, treatments, procedures

– Implementation requires all members of team

– Roles of team members often overlap

• Physician—prescribes diet orders & other aspects of nutrition care

• Nurses, registered dieticians, other health professionals identify problems, suggest strategies, provide nutritional services



• Registered dietitian (RD)– Food & nutrition expert– Role includes

• Conduct nutrition assessment

• Diagnose nutritional problems

• Develop, implement & evaluate nutrition care plans

• Plan & approve menus• Provide nutrition

education• May manage food

services in health care institution

• Registered dietitian has academic & professional requirements to qualify for RD credential conferred by American Dietetic Association

• Qualifications include– Bachelor’s degree in

nutrition or dietetics– Supervised internship– Successful completion of

national examination



• Nurses– Interact closely with

patients• Identify those who would

require nutrition services• Screen for nutrition

problems; participate in nutrition assessments

• Provide direct nutrition care

– Participate as member of nutrition support team

• Registered dietetic technicians– Work in partnership with

registered dietitian– Assist in implementation &

monitoring of nutrition services

• Other health professionals– Include

• Pharmacists• Physical therapists• Occupational therapists• Speech therapists• Social workers• Nursing assistants• Home health care aides


Nutrition Screening

• Assessment tool that helps to identify malnourished patients, or those at risk

• Information includes– Admitting diagnosis– Information on medical record– Physical measurements & lab test results– Responses of patient or caregiver during

initial interview or assessment


Information collected for nutrition screen


Nutrition Care Process• Systematic approach to

medical nutrition therapy (MNT-nutrition care that includes dx. nutr. problems, rx. Diets and providing counseling);

There are 4 interrelated steps:• 1. Assessment

– Collection of information needed to evaluate patient’s nutrition status & dietary needs

– Information gathered from variety of sources

• 2. Nutrition diagnosis– Individual nutrition problem– Includes specific problem,

etiology, signs & symptoms– Diagnoses may change over

course of illness

• 3. Nutrition intervention– Actions designed to alleviate

nutrition problem– Includes goals & desirable

outcomes– Dietary changes, nutrition

education, change in medication

• 4. Nutrition monitoring & evaluation– Determination of

effectiveness of nutrition care plan

– Goals & outcomes are compared with earlier assessment data & diagnoses

– Plan of care is modified, based on evaluation


Nutrition Care Process


Nutrition Assessment


Historical Information

• Information about patient’s nutrition status & nutrient needs

• Identifies personal preferences that need to be considered in nutrition care plan

• Information gathered from patient or caregiver, or from medical record

• Includes– Medical history– Social history– Diet history


Food Intake Data• Use of combination of methods to obtain

information regarding food intake– 24-hour recall: detailed description of foods & beverages

consumed in a 24-hour period are outlined; may reflect typical day

– Food frequency questionnaire: written survey of food consumption during specific period of time, including those relevant to patient’s medical condition

– Food record: written account of food consumed during specified period; usually over several consecutive days

– Direct observation: observation of meal trays or shelf inventories; used to conduct kcalorie counts


Anthropometric Data• Measures of body size that

can reveal problems related to overnutrition & protein-energy malnutrition– Height (or length) & weight;

BMI– Percentage of body fat– Circumferences of head (in

children), waist & limbs• Anthropometric assessment

in infants & children– Used to evaluate growth

patterns – Usually plotted on growth

charts – Growth patterns below 5th

percentile may be cause for concern

• Anthropometric assessment in adults– Routinely measured during

illness– Changes must be evaluated

carefully• Unintentional weight loss may

indicate malnutrition• Weight gain may result from

fluid retention• In assessing significance of

change, must consider rate as well as amount

– Including skin fold measurements & limb circumference can help identify changes in body composition that need to be addressed in treatment plan


Calculating %Ideal Body Wt (IBW)


Biochemical Analyses (Labs)

• Provide information about PEM, vitamin & mineral status, fluid & electrolyte balance, organ function

• Include analysis of blood & urine samples• Different factors can influence test results,

making interpretation difficult• Variety of tests usually required to

diagnose nutrition problems


Biochemical Analyses

• Plasma proteins– Help in assessment of

protein status– May fluctuate for other

reasons– Values must be

considered with other data

– Tests include• Total protein• Albumin• Transferrin• Prealbumin & retinol-

binding protein

• Other routine tests with nutritional implications– Hematology (RBC, Hb, Hct)– Chemistry (Alb)– Serum enzymes (Ck, AST,

ALT)– Serum electrolytes (Na, K) – Glucose (glu, HbA1C)– Blood urea nitrogen (BUN)

and Creatinine (Cr)


Physical Examination• Most physical signs of

malnutrition are non-specific—can reflect many causes– Nutrient deficiencies– Fluid imbalances– Functional impairments

related to nutritional problems

• Clinical signs of deficiencies may be reflected in– Skin, hair & nails– Eyes– Lips, mouth & gums

• Physical signs of malnutrition are often evident in parts of the body where cells are replaced at a rapid rate


Implementing Nutrition Care


Dietary Modifications• Energy & nutrient needs are met by standard

(regular)diet; modified diet is prescribed when different texture is needed or when certain foods need to be eliminated because of a condition.

• Diets altered by– 1. Changing consistency & texture of foods: used for

patients with chewing or swallowing impairments• Mechanically altered • Blenderized liquid• Clear liquid

– 2. Altering nutrient content: may relieve symptoms of disease, preventing or reversing malnutrition

• Fat-restricted• Fiber-restricted• High-kcalorie, high-protein

• Need to be adjusted to satisfy individual preferences & tolerances


Dietary Modifications• Diet manuals

– Include detail of specific foods to include or exclude in modified diet

– May be compiled from resources from American Dietetic Association

• Alternative feeding routes– Used in situations where nutrient

needs are high, patient appetite is poor, or patient is unable to meet nutrient needs orally

• Tube feedings: delivery of nutritionally-complete formulas through tube placed into stomach or intestine or nasogastric (temp)

• Intravenous feedings: delivery of nutrients via the vascular system; may be used when patient’s condition prohibits use of GI tract to deliver nutrients (PPN, TPN)

• Diet order– Physician has primary

responsibility for prescribing appropriate diet

– Orders must be precise to avoid confusion (2gNa instead of “low sodium”)

– Often done in consultation with dietitian or nurse

• Nothing by mouth (NPO)– Restriction of any food,

beverages, medications by mouth

– Commonly used during acute illness or diagnostic tests involving GI tract


Determining Energy Requirements

• Energy needs affected by patient's– Health problem– Treatments– Current nutrition status– Activity level– Gender, height, weight, and age

• Several methods can be used to calculate energy requirements• Calculation based on medical problem, activity level & stress level• In critical patients, needs increased further due to

– Fever– Mechanical ventilation– Restlessness (psychiatric)– Presence of open wounds

• Energy needs for critical care patients usually range 25-30 kcalories per kg body weight daily—often exceeding 2000 kcalories


Approaches to Nutrition Care

• Nutrition care plan often involves dietary modifications & nutrition education

• Plan should be compatible with desires & abilities of the patient

• Long-term dietary intervention—must take into account current food habits, lifestyle & degree of motivation– Determine individual’s

readiness to change– Emphasize what to eat,

rather than what not to eat– Suggest only one or two

changes at a time

• Dietary counseling requires sensitivity to cultural orientation, educational background, & motivation for change


Approaches to Nutrition Care

• Nutrition education– Allows patients to learn about dietary factors that affect

their medical condition– Should be tailored to patient’s age, level of literacy,

cultural background– Learning style should be considered

• Discussion, supplemented with written materials• Visual examples• One-on-one or group sessions• Follow-up sessions to assess learning

– Other tools• Sample menus• Diet analysis software• Informational packages


Documenting Nutrition Care

• All nutrition care is described in medical record• SOAP note

– Subjective information obtained in interview with patient or family; includes main symptoms & complaints

– Objective information available from nutrition screening or assessment data; includes biochemical analyses, anthropometric tests, physical exams

– Assessment includes brief evaluation of subjective & objective data; includes diagnosis of nutrition problem

– Plan describes recommendations, dietary prescriptions, special equipment, nutrition education, referrals


Improving Food Intake• Loss of appetite common

among patients in hospitals or other medical care facilities– Result of medical

condition, treatment, emotional distress

– Can be affected by medications & other treatments that alter taste perceptions

• Nurses & dietetic technicians have central role in helping patients to eat

Helping patients to eat• Empathize with patient• Motivate patient• Help patient select foods he

likes & mark menus appropriately

• Suggest foods that require little effort to eat

• Help patient prepare for meal• Check patient’s tray to

confirm correct diet & food selections

• Help with eating (open milk container, etc)

• Try to solve eating problems• Take a positive attitude

toward hospital foods


Nutrition in Practice—Nutritional Genomics

• New field which includes the study of dietary effects on gene expression

• Research suggests that some dietary factors may have effect (helpful or harmful) in people with particular genetic variations

• Genome: full complement of genetic material in the chromosomes of a cell

• A DNA microarray allows researchers to monitor the expression of thousands of genes simultaneously


Nutrition in Practice—Nutritional Genomics

• Single-gene disorders– Seriously disrupt

metabolism & require significant dietary or medical intervention

– Include• PKU• Sickle-cell anemia

• Multigene disorders– Usually sensitive to

number of environmental influences, including diet & lifestyle

– Tend to develop over many years, allowing modification of diet & lifestyle

– Disease & risk factors involve assortment of genes

illness & nutrition care

Documents

editionnutrition diet

nutrition problems

nutrition illness

nutrition statusrelationship

nutrition carenursesinteract

nutrition servicesscreen

nutrition care plansplan

complexmedical problems