principles of nutrition therapy & the role of the nurse

Principles of nutrition therapy & the role of the nurse

Diet Therapy: NURS 2018

ObjectivesAt the end of this presentation students will be

able to: Describe the nutritional intake of persons who

are institutionalizedExplain the basis for determining the

therapeutic nutritional requirements of individuals

Use the concept of diet therapy in planning menus for patients

Identify ways of incorporating dietary management in nursing care plans

Describe the role of nurse in providing nutritional care to institutionalized individuals

Factors affecting nutritional requirement and intakeIndividual differences exist which

impact nutritional requirements they include:

AgeGenderGeneral conditionHealth disorderNutritional statusSoci-economic background

Factors affecting nutritional requirement and intake

Emotional and cultural factors are very important in determining food intake.

The cultural pattern of three meals will impact dietary choice.

Animal experiments have shown that habitual factors such as three meals per day have great influence on dietary pattern and choices

Dietary information may affect early choices which has implications for later life; in respect of NCDs and excesses


Appetite may be adequate for selection of a nutritionally acceptable diet under certain circumstances

Selection of food on the basis of nutritional principles is more reliable and is recommended

There are normal variations in food intake in relation to

age, sex, environmental temperature, and caloric expenditure


Age- higher caloric and micronutrient requirement needed to support :◦growth and development; ◦bone and muscle mass development

Sex- BMR is increased with higher muscle mass◦higher in adults compared with older

adults who have sarcopenia;◦ higher in males than females


Reports have suggested that decrease in appetite occurs when environmental temperature has reached a point at which maintenance of body temperature is difficult

Caloric expenditure increases both the requirement for more calories and usually the appetite (thus intake)

Illness and disease- though this may decrease appetite in some instances- the actual micronutrient and caloric requirements may be higher


Factors causing increased intake

Cystic fibrosis of the pancreas

Hyperthyroidism

Diabetes mellitus

Epinephrine-producing tumors of the adrenal medulla

Pts on ACTH, adrenal cortical steroids, androgens, estrogens, and isoniazide.

Tumors of the hypothalamic regions of the brain


Factors causing reduced intake

Dietary deficiency of any essential nutrient

Acute and chronic febrile illnesses,

Debilitating illnesses such as rheumatoid arthritis and ulcerative colitis,

Hepatic and renal diseases,

Hypothyroidism

Hospitalized peopleNutrition care in hospitals is aimed at the

role that nutrition plays in any acute process occurring during hospitalization as well as long-term goals.

Nutrition services include food service and clinical nutrition

Medical nutrition therapy is the assessment and treatment of illness or disease that relates to nutritional care.

Hospitalized peopleMalnutrition risk increases in the hospitalized

client because of factors that decrease dietary intake, increase nutrient losses and lead to increased metabolic needs

The provision of specialized nutrition support in the form of enteral or parenteral nutrition should be done after careful consideration of the indicators, risks and benefits of treatment

Palliative nutrition care involves providing hydration and nutrition in accordance with client centered decisions particularly in end of life care.

Hospitalized peopleHospital patients usually spend most of their time

in bed.

Their needs for energy are therefore lower than those of active persons of the same sex, age and weight.

However, some may have increased nutritional requirements. These include ◦ patients who entered hospital undernourished; ◦ those who are pregnant or lactating or have recently

had a baby;◦ and those with diseases that require a special diet or

extra nutrients.

Hospitalized peopleThe nurse is a vital member of the

interdisciplinary health care team providing nutrition support and care.

One of the key processes in clinical nutrition in nutritional assessment which includes anthropometric and clinical measures of assessment.

Hospitalized peopleHospital patients usually spend most of

their time in bed. Their needs for energy are therefore lower

than those of active persons of the same sex, age and weight.

However, some may have increased nutritional requirements. These include ◦patients who entered hospital undernourished; ◦ those who are pregnant or lactating or have

recently had a baby;◦and those with diseases that require a special

diet or extra nutrients.

Hospitalized peopleThe nurse is a vital member of the

interdisciplinary health care team providing nutrition support and care.

One of the key processes in clinical nutrition in nutritional assessment which includes anthropometric and clinical measures of assessment.

Hospitalized peopleHospital patients usually spend most of

their time in bed. Their needs for energy are therefore lower

than those of active persons of the same sex, age and weight.

However, some may have increased nutritional requirements. These include ◦patients who entered hospital undernourished; ◦those who are pregnant or lactating or have

recently had a baby;◦and those with diseases that require a special

diet or extra nutrients.

Hospitalized peopleNutrition care in hospitals is aimed at

the role that nutrition plays in any acute process occurring during hospitalization as well as long-term goals.



Hospitalized peopleThe nurse is a vital member of

the interdisciplinary health care team providing nutrition support and care.

One of the key processes in clinical nutrition is nutritional assessment which includes anthropometric and clinical measures of assessment.

Psychological Impact of IllnessBeing ill may have severe

psychological impact on health and result in several health care conditions suited to the NANDA list:

Emotional needs- caregiver role strain, sadness, anxiety, fear

Ability to cope:- impaired coping, anticipatory grieving, depression, social isolation

Institutional setting:- powerlessness

Illness:- Impact on food behaviour

Illness and institutionalization may impact negatively on dietary intake as they may impair:-◦Appetite- smells, appearance of food, texture

may differ from what was consumed at home◦Acceptance and Rejection of foods:- pain,

nausea, drowsiness, physical disabilities (temporary and permanent) may affect the willingness to accept or reject food

◦Failure to eat:- the same conditions affecting acceptance may also affect and result in failure to eat

Nutritional Needs of the hospitalized patientThe nutritional status of a patient at admission

has implications for the management and outcome of the condition. Some nutritional issues that have negative impact on outcome and management are:-◦ Undernutrition◦ Loss of lean body mass◦ Prolonged admission

These have negative impact◦ Co-morbidity◦ Opportunistic infections◦ Length of stay ◦ Mortality

Nutritional Needs of the hospitalized patient

Basis of determining needsPredictive Equation

Formulae

Harris-Benedict (males)

66.45 +13.75 * wt + 5 * ht - 6.75 * age

Harris-Benedict (females)

655.09 + 9.56 * wt + 1.84 * ht - 4.67 * age

Mifflin-St. Jeor (males)

9.99 * wt+6.25* ht - 4 .92 * age + 5

Mifflin-St. Jeor (females)

9.99 * wt + 6.25 * ht – 4.92 * age - 161

WHO (males) [18-30 years]

15.3 * wt + 679

WHO (females) [18-30 years]

14.7 * wt + 496Tucker & Dauffenbach, 2011

Nutritional Needs of the hospitalized patientBasis for determining needs

EER by gender FormulaeFemales 354- (691* age) + PA * (9.36 * wt +

726 * ht)Males 662- (9.53 * age) + PA * (15.91 * wt +

539 * ht)

Activity Activity Factor (PA)Sedentary 1Light active 1.16Active 1.31Very active 1.56

Disadvantages of estimating energy requirementsEstimating energy needs just

based on weight may be erroneous as the ratio of active lean body mass to total weight is not constant- thus a DEXA scan or a bioelectrical impedance may be useful.

(Duggan and Golden, 2007)

Nutritional Needs of the hospitalized patientBasis for determining needsBased on Nitrogen balance studies the normal

Nitrogen requirements range from 105mg N/kg/d to 132mg N/kg/d for nitrogen equilibrium- losses= intake

NB. 1g protein= 6.25mg NThus 0.105gN * 6.25= 0.65g Protein/kg/d &

0.132gN * 6.25= 0.83kg Protein/kg/d - which is two sd units of the mean of 0.65

Thus normal protein requirement for nitrogen balance is 0.65 to 0.83 g/kg/d

Protein requirements should be 10%- 15% of total energy intake/d

(Smith, 2007)

Nutritional Needs of the hospitalized patient

The tools that are important in determining the needs of hospitalized patients include

Nutritional assessment including – anthropometry, biochemical tests and clinical assessment

Medical diagnosis:- this is often a multiplier in energy determination

Dietary history which provides an analysis of usual intake

Prescribed nutritional therapy

There are several ways that the hospitalized patient may be supported nutritional. The method of dietary delivery is dependent on: ◦Anorexia due to illness- weakens due to

illness or surgery; cancer; eating disorders◦Swallowing disorders:- presence of gag

reflex; Cerebrovascular motor neuronal, esophageal stricture

◦Gastric stasis, gastroparesis- post op; ICU◦Inability to take sufficient orally- burns,

trauma, Inflammatory bowel disease

Nutrition as part of the Nursing Care Plan

Analysis of food- The nurse identifies, type, amount, preparation styles, likes and dislikes

Plan and implement diet instruction:- in collaboration with the dietician/nutritionist and based on patient needs the nurse prepares the patient for discharge and wellness maintenance and in primary settings

Identify follow-up care needs- HTN, Renal, DM, HIV/AIDS clinic along with dietary referral

Other assistance- Social Worker, Path programmes, advise regarding gyms, recovery groups

ReferencesDuggan, M., & Golden, B. (2007). Deficiency

diseases. In C. Geissler & H. Powers (Eds.), Human Nutrition (11th Ed.) (pp 517-536). Edinburgh, UK: Elsevier Churchill Livingstone.

Smith, R. C. (2007). Nutritional support for hospitalized patients. In J. Mann & A. S. Truswell (Eds.), Essentials of human nutrition (pp 33-52). New York, USA: Oxford University Press.

Tucker, S. & Dauffenbach, V. (2011). Nutrition and diet therapy for nurses. Boston, USA: Pearson.

principles of nutrition therapy & the role of the nurse

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