Chapter 17 Nutritional Care

1. 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

2. OBJECTIVES: • Define the therapeutic process • Describe the collection & analysis of nutritional information • Describe the planning & implementation of nutritional care • Identify the evaluation of nutritional care

3. Nutritional Care • 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

4. Setting and Focus of Care • 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

5. Setting and Focus of Care • 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

6. Phases of the Care Process • Collecting information • Identifying problems • Planning care • Implementing care • Evaluating and recording results

7. Collecting and Analyzing Nutrition Information Nutrition Assessment

8. Nutrition Assessment • ABCD approach: • Anthropometry • Biochemical tests • Clinical observation • Dietary evaluation • Anthropometric Measurements – are the physical measurements of the human body used for health assessment

9. Nutrition Assessment • 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

10. Nutrition Assessment Biochemical Tests: • Include: • Plasma Proteins (serum albumin, prealbumin, hemoglobin) • Help detect protein and iron deficiencies • Liver enzymes • BUN, Serum electrolytes • Cr • CBC • Fasting glucose

11. Nutrition Assessment • 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

12. Nutrition Assessment Clinical Observations: • Clinical signs of nutritional status • Physical examination • Inspection of skin for edema, turgor, nail integrity, abdominal exam, BS, and lungs.

13. Nutrition Assessment • Dietary Evaluation: • Specific food history obtained using three-day food record. • Nutritional Supplements • Food allergies, intolerances • Activity level

14. Nutrition Diagnosis • “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.

15. Nutrition Diagnosis • 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.

16. Analysis • 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

17. Nutrition Intervention • 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

18. Nutrition Intervention • 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

19. Nutrition Intervention • 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

20. Nutrition Intervention • Personal adaptation – Successful nutritional therapy can occur only when the diet is personalized. • Accomplished by planning withthe patient or family • Four areas: • Personal needs • Disease • Nutrition therapy • Food plan

21. Mode of Feeding • Routine “house” diets: • A schedule based on a cycle menu • Basic modifications in texture ranging from clear liquid  full liquid soft food regular diet

22. Mode of feeding • Clear liquid • Clear broth, bouillon, Sprite, fruit juice, gelatin, popsicles • Full liquid • Milk, yogurt, ice cream, pudding

23. Mode of Feeding • Routine House Diets cont. • Soft • Pasta, soft bread, potatoes, cooked and soft fruits • Regular • Any foods

24. Mode of Feeding • 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

25. Mode of Feeding • 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

26. Evaluation of Nutritional Care • 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 diet or feeding method on the illness or the patient’s situation?

27. Evaluation of Nutritional Care • 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?

28. Drug Interactions • 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

29. Drug Interactions • 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

30. Drug interactions

31. Drug-Herb Interactions • 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

32. Drug-herb interactions