Chapter 10 Diet and Nutrition Section 1 Section

Chapter 10 Diet and Nutrition

• • • Section 1 Section 2 Section 3 Section 4 Section 5 Introduction Hospital Diets Nutrition Assessment Diet nursing Special diet nursing

Section 1 Introduction • Body Requirement for Nutrients §carbohydrate §fats organic §protein §vitamins §minerals §water The human body and foods are made of the same materials, arranged in different ways. Energy-yielding nutrients

How Diet Relates to Health and disease? Balanced diet Rational nutrition §Support growth, maintenance, and repair of the body §Improve immunity §Prevent and treat diseases

Conversel y a poor diet vmalnutrition Ødeficiencies Øimbalances Øexcesses vchronic disease Øheart disease Ødiabetes Øsome kinds of cancer Øadult bone loss, etc.

Food Guide Pyramid: A Guide to Daily Food Choices fats, 25 g milk, 100 g; Beans, 50 g meat, 50～ 100 g; fish, 50 g eggs, 25～ 50 g vegetable, 400～ 500 g fruit, 100～ 200 g grains, 300～ 500 g

Section 2 Hospital Diets • Basic Diets • Therapeutic Diets • Test Diets

Basic Diets Basic diets are the foundation of the other diets. • • General diet Soft diet Semi-liquid diet Liquid diet

General diet • Clients with normal digestive and absorptive function, with normal temperature, and those during the process of recovery or without diet limit. • Reference--Balanced nutrition, easily digested, not stimulating, 3 meals a day with total energy of 2200 -2600 kcal/d, and protein of 70 -90 g/d.

Soft diet • Clients having difficulty in chewing, or gastrointestinal function disorders, elders, infants and those during postoperative recovery. • Reference--Balanced nutrition, easily chewed, not stimulating, soft food such as noodle, steamed bread, vegetables, well-cooked mince meat, 3 -4 meals a day with total energy of 2200 -2400 kcal/d and protein of 60 -80 g/d.

Semi-liquid diet • Clients with fever, oral diseases or gastrointestinal disorders or having difficulty in chewing and swallowing, or those during postoperative period. • Reference--Not stimulating, easily chewed and swallowed, semi-liquid food such as rice porridge, noodle, bean-curd and dumpling, small frequent meals with fixed quantity of each staple food, 5 meals recommended a day with total energy of 1500 -2000 kcal/ d and protein of 50 -70 g/d.

Liquid diet • Clients with hyperthermia, oral diseases, acute inflammation, having difficulty in swallowing, acute gastrointestinal disturbances, or those in critical conditions, during postoperative period. • Reference--Easily swallowed and digested liquid food such as milk, bean milk, fruit juice, only for temporary use because of insufficient energy, 6 -7 meals a day 200 -250 ml each time with total energy of 836 -1195 kcal/ d and protein of 40~50 g/ d.

Therapeutic Diets • Therapeutic diets are based on the basic diets and used as treatment by adjusting total energy and certain nutrients.

Therapeutic Diets High energy diet High protein diet Low salt diet Salt free and low sodium diet Low fat diet Low cholesterol diet Low residue or residue free diet High food fiber diet

High energy diet • Clients with diseases of high consumption of energy; such as tuberculosis, large area burns, liver diseases, and hyperthyroidism. • Reference--In addition to basic diet, 2 more meals are added a day such as milk, bean milk, egg, cake, chocolate, with total energy of 3000 kcal/d.

High protein diet • Clients with long-term consumptive diseases, malnutrition, anemia, burns, malignancy, nephritic syndrome, hypoprotein, and those before or after operation, in pregnancy, and lactation. • Reference--In addition to basic diet , high-protein food such as meat, fish, egg, beans are added with total amount of protein 1. 5 -2 g/ (kg．d), < 120 g/d and total energy of 2500 -3000 kcal/ d.

Low protein diet • Clients who need limited protein intake, such as acute nephritis, uremia, and hepatic coma. • Reference--Limited protein intake with total amount of protein < 40 g/d for adult. (20 -30 g/ d according to conditions)

Low salt diet • Clients with hypertension, congestive heart failure, ascites, aura eclampsia, chronic nephritis. • Reference--Restricted salt in cooking and diet, with total amount of salt < 2 g/ d for adult except for natural sodium in food. Pickled food is forbidden.

Salt free and low sodium diet • Same as those of low salt diet, in addition to severe edema clients. • Reference--No salt in cooking except for natural sodium in food, with no more than 0. 5 g/d, High-sodium food and medicine is forbidden.

Low fat diet • Clients with hepatic, cystic, and pancreatic diseases, hypercholesterolemia, arteriosclerosis, coronary heart disease and obesity. • Reference--Restricted oil and forbidden fat, and fried food. with total fat amount <50 g/ d.

Low cholesterol diet • Clients with arteriosclerosis, hypertension, coronary heart disease, high serum cholesterol levels. • Reference--High-cholesterol food such as animal’s brain, viscera, yolk are restricted with total cholesterol amount<300 mg/ d.

Low residue or residue free diet • Clients with diarrhea, enteritis, typhoid, dysentery, and those after gastrointestinal operation, Gastroesophageal varication, rectum and anus operation. • Reference--High fiber food is forbidden or restricted. Hard food with smashed bones is forbidden.

High food fiber diet • Clients with constipation, obesity, diabetes, and hyperlipidemia. • Reference--High fiber food are recommended.

Test Diets(diagnostic diets ) Test diets are used to help diagnosis and insure accurate testing by adjusting the contents of diets in special time. Occult test diet Cholecystography test diet Creatinine test diet 131 I thyroid uptake test diet, etc.

Occult blood test diet • The three-day test diet is used for preparation of occult blood test to assist the diagnosis of gastrointestinal bleeding. • The client who is going to have the test is forbidden during this period any food that can lead to a false positive result, such as meat, poultry, medicine and food rich in iron, and green vegetables. The test sample will be taken on the forth day.

Cholecystography test diet • The test is used in diagnosing gallbladder disease, bile duct disease and hepatic bile duct disease. • Before the test day, the client should have high fat diet for lunch and fat free, low protein, high carbohydrates diet for supper, followed by contrast after which food and water are absolutely forbidden until the morning of the test day. • The client should not have breakfast on the test day. After the first X-ray examination, the client can have a high fat meal (fat 25 -50 g) if the gall bladder develops well. In 30 minutes the client can have the second X-ray examination.

Creatinine test diet • The three-day test is used. to check the kidney filtration function. During this period, meat, poultry, fish, tea, and coffee are absolutely forbidden, and protein intake is also limited to the total amount of protein<40 g/d. The test sample will be taken on the third day.

131 I thyroid uptake test diet • The two-week test is used to check the function of thyroid. During this period, food rich in iodine, such as kelp, jellyfish, shrimp, iodized salt as well as iodine for skin disinfection are absolutely forbidden.

Section 3 Nutrition Assessment • • Affecting factors Diets status Physical status Laboratory Test

Affecting factors Physical factors psychological factors Sociocultural factors

Physical factors Physiological factors Disease and drug food allergies Age Physical activity Special life cycle status Pathological factors

Sociocultural factors • • • Economic Situation Lifestyle Personal Preference Environment Knowledge About Nutrition

Diets status Ø Meals time Ø Category and amount of Food intake • Changes in appetite • eating patterns • Influencing factors (impaired chewing or swallowing)

Physical status • Physical Examination • Anthropometric Measurements

Physical Examination Area of Examination General appearance and vitality Apathetic, look tired, easily fatigued Skin Dry, flaky or scaly; pale or pigmented; lack of subcutaneous fat Nails Brittle, pale, ridged or spoon-shaped Hair Dry, dull, sparse, loss of color, brittle Eyes Pale or red conjunctiva, dryness, soft cornea, dull Lips Swollen, red cracks at side of mouth cornea Tongue Swollen, beefy red or magenta colored; smooth appearance; decrease or increase in size Gums Spongy, swollen, inflamed; bleed easily Muscles Underdeveloped, wasted, soft Signs of Malnutrition Clinical Signs of Malnutrition

Anthropometric Measurements • Height and weight • skin fold thickness • arm circumference，AC

Height and weight The standard of IBW • IBW (kg) = [height(cm) – 100] × 0. 9 • IBW (kg) = height(cm) – 105 Calculating percent of weight loss or gain • %weight loss ＝IBW－CBW / IBW× 100% • %weight gain ＝ CBW－IBW/ IBW× 100% normal : ± 10 %

Body Mass Index(BMI) BMI = weight(kg) / height(m 2) The normal range: 18. 5~22. 9 overweight : 23~27. 9 obesity: ≥ 28 WHO

The BMI values have two major drawbacks: they fail to indicate ü how much of the weight is fat; ü where that fat is located.

deep within the central abdominal area of the body The fat lying deep within the body’s abdominal cavity may pose an especially high risk to health.

skin fold thickness lean middling fat male ＜ 10 mm 10~40 mm ＞ 40 mm female ＜ 20 mm 20~50 mm ＞ 50 mm the triceps skinfold About half of the fat in the body lies directly beneath the skin.

Laboratory Test • Serum Proteins • Urinary Tests • Total Lymphocyte Count

Section 4 Diet nursing Ø Diet administer • Arrange the client's diet according to the diet orders. Ø Meals care

Meals care Pre- Meals care During Meals care Post- Meals care

Pre- Meals care v. Diet education v. Preparation ♣ Environment ♣ client Stimulating the Appetite

Stimulating the Appetite • Relieving illness symptoms that depress appetite prior to mealtime. • Providing familiar food that the client likes. • Avoiding unpleasant or uncomfortable treatments immediately before or after a meal. • Providing a tidy, clean environment. • Encouraging or providing oral hygiene for clients before mealtime • Reducing psychological stress.

During Meals care § Check the type of diet. Do not give an incorrect diet for clients. § Assist clients who cannot help themselves to remove the food. § For a blind client, identify the placement of food as you would describe the time on a clock. soup (12 ) vegetables(9) vegetables (3 ) rice (6 )

Post- Meals care § replace the food covers and give the client care. § note how much and what the client has eaten and the amount of fluid taken. If the client's intake and output of fluid is being recorded, nurse should record. § Pay attention to the fasting client especially on shift.

Section 5 Special diet nursing ♣ Enteral Nutrition (EN) *Tube feeding *Elemental diets ♣ Parenteral Nutrition (PN)

tube feeding nasogastric gavage – is a medical approach to maintain clients’ nutrition and ensure treatment by inserting a tube to gastrointestinal duct via nasal cavity, through which fluid food, water, and medicine are infused.

Elemental diets • Elemental diet is a purified food whose chemical composition is definite and it contains all the required nutrients of human body. ♣ severe burn and trauma ♣ digestive tract fistula ♣ the nutritional support of pre-operation and post-operation ♣ non-infectious diarrhea ♣ malabsorption and malnutrition, etc.

Purpose Elemental diet could achieve the Therapeutic and adjunctive therapy effect for the severely ill patients.

Administration fractional infusion intermittent infusion continuous infusion

Complications • • Mechanical complications Infectious complications Gastrointestinal tract complications Metabolic complications

Notes to nursing • It should be initially offered in a small amount and can be increased gradually at a low and slow pace when patients are tolerated well then stabilize the prescription, dosage and transfusion rate. • Follow sterile procedure and prevent contamination. • Prepared feedings should be stored in refrigerator below 4°C and should be used up in less than 24 h. • The infusion temperature is 41°C～ 42°C, and take it orally in 37°C. • Irrigate the tube with warm water before and after infusion, which prevent tube from obstruction.

Continue ♣ Clients need some necessary lab tests such as blood glucose, urine glucose, blood urea nitrogen, electrolyte. Observe clients' urine and stool, record client's weight, and monitor 24 h intake and output. ♣ Observe the client's response during feeding. When clients have some symptoms such as nausea, vomit, abdominal distention, and diarrhea, nurses should find the reason, adjust infusion rate and temperature, and stop infusion for severe clients. ♣ The feedings is stopped gradually to prevent hypoglycemia.

Parenteral Nutrition (PN) v PN also referred to as total parenteral nutrition (TPN). PN is provided when the gastrointestinal tract is nonfunctional. v PN is administered intravenously through a central venous catheter into the superior vena cava. v Clients who accept PN therapy include those with severe malnutrition, severe burns, bowel disease disorder, acute renal failure, hepatic failure, cancer or major surgeries where nothing may be taken by mouth for more than 5 days.

Nursing care for the client's receiving PN is based on three major nursing goals: • preventing infection; • maintaining the PN system; • preventing complications such as metabolic, electrolyte or fluid balance.

• Observation and nursing during infusion • Monitoring • Prevention of complications and nursing of client with complications

• Complications related to catheterization • Infection • Metabolic complications