Illness Nutrition Care Chapter 14 Nutrition Diet Therapy

Illness & Nutrition Care Chapter 14 Nutrition & Diet Therapy (7 th Edition)

Nutrition in Health Care Nutrition & Diet Therapy (7 th Edition)

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 longterm dietary modification Nutrition & Diet Therapy (7 th Edition)

Responsibility for Nutrition Care • Physician—prescribes diet orders & other aspects of nutrition care – Critical pathways outline • Nurses, registered coordinated, dieticians, other health comprehensive plan for professionals identify specific diagnoses, treatments, procedures problems, suggest strategies, provide – Implementation requires all members of nutritional services • Cooperative effort of multidisciplinary health care team – Roles of team members often overlap Nutrition & Diet Therapy (7 th Edition)

Responsibility for Nutrition Care • 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 Nutrition & Diet Therapy (7 th Edition) • 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

Responsibility for Nutrition Care • 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 Nutrition & Diet Therapy (7 th Edition) • 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 Nutrition & Diet Therapy (7 th Edition)

Information collected for nutrition screen Nutrition & Diet Therapy (7 th Edition)

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 Nutrition & Diet Therapy (7 th Edition) • 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 & Diet Therapy (7 th Edition)

Nutrition Assessment Nutrition & Diet Therapy (7 th Edition)

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 Nutrition & Diet Therapy (7 th Edition)

Nutrition & Diet Therapy (7 th Edition)

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 Nutrition & Diet Therapy (7 th Edition)

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 5 th percentile may be cause for concern Nutrition & Diet Therapy (7 th Edition) • 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) Nutrition & Diet Therapy (7 th Edition)

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 Nutrition & Diet Therapy (7 th Edition)

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 & retinolbinding protein Nutrition & Diet Therapy (7 th Edition) • Other routine tests with nutritional implications – Hematology (RBC, Hb, Hct) – Chemistry (Alb) – Serum enzymes (Ck, AST, ALT) – Serum electrolytes (Na, K) – Glucose (glu, Hb. A 1 C) – Blood urea nitrogen (BUN) and Creatinine (Cr)

Physical Examination • Most physical signs of malnutrition are nonspecific—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 Nutrition & Diet Therapy (7 th Edition) • Physical signs of malnutrition are often evident in parts of the body where cells are replaced at a rapid rate

Implementing Nutrition Care Nutrition & Diet Therapy (7 th Edition)

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 Nutrition & Diet Therapy (7 th Edition)

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) Nutrition & Diet Therapy (7 th Edition) • Diet order – Physician has primary responsibility for prescribing appropriate diet – Orders must be precise to avoid confusion (2 g. Na 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 – – Fever Mechanical ventilation Restlessness (psychiatric) Presence of open wounds • 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 • Energy needs for critical care patients usually range 25 -30 kcalories per kg body weight daily—often exceeding 2000 kcalories Nutrition & Diet Therapy (7 th Edition)

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 Nutrition & Diet Therapy (7 th Edition) • 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 Nutrition & Diet Therapy (7 th Edition)

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 Nutrition & Diet Therapy (7 th Edition)

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 Nutrition & Diet Therapy (7 th Edition) • • • 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 Nutrition & Diet Therapy (7 th Edition) • 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 Nutrition & Diet Therapy (7 th Edition) • 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