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

Illness & Nutrition Care
Chapter 14
Nutrition & Diet Therapy (7th Edition)
Nutrition in Health Care
Nutrition & Diet Therapy (7th Edition)
Effects of Illness on Nutrition
Status
• Relationship between nutrition & illness is
complex
– Medical problems can alter nutrient needs & result in
malnutrition
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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 (7th Edition)
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
Nutrition & Diet Therapy (7th Edition)
• Physician—prescribes
diet orders & other
aspects of nutrition
care
• Nurses, registered
dieticians, other
health professionals
identify problems,
suggest strategies,
provide nutritional
services
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 (7th 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 (7th Edition)
• Other health professionals
– Include
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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
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Admitting diagnosis
Information on medical record
Physical measurements & lab test results
Responses of patient or caregiver during
initial interview or assessment
Nutrition & Diet Therapy (7th Edition)
Information collected for nutrition screen
Nutrition & Diet Therapy (7th 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 (7th 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 (7th Edition)
Nutrition Assessment
Nutrition & Diet Therapy (7th 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 (7th Edition)
Nutrition & Diet Therapy (7th 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 (7th 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 5th
percentile may be cause for
concern
Nutrition & Diet Therapy (7th 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 (7th 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 (7th 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
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Total protein
Albumin
Transferrin
Prealbumin & retinolbinding protein
Nutrition & Diet Therapy (7th Edition)
• 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 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 (7th 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 (7th 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 (7th 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 (7th Edition)
• 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
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Health problem
Treatments
Current nutrition status
Activity level
Gender, height, weight, and age
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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 (7th 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 (7th 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
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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 (7th 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 (7th 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 (7th Edition)
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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 (7th 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 (7th 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