Principles of nutrition therapy & the role of the nurse Diet Therapy: NURS 2018

Objectives At the end of this presentation students will be able to: Describe the nutritional intake of persons who are institutionalized Explain 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 intake Individual differences exist which impact nutritional requirements they include: Age Gender General condition Health disorder Nutritional status Soci-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

Factors affecting nutritional requirement and intake 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

Factors affecting nutritional requirement and intake 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

Factors affecting nutritional requirement and intake 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 affecting nutritional requirement and intake 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 affecting nutritional requirement and intake 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 people Nutrition 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 people Malnutrition 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 people Hospital 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 people Nutrition 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 people Malnutrition 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 people The 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 people Hospital 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 people Nutrition 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 people Malnutrition 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 people The 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 people Hospital 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 people Nutrition 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 people Malnutrition 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 people The 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 Illness Being 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 patient The 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 needs Predictive Equation Formulae Harris-Benedict (males) * wt + 5 * ht * age Harris-Benedict (females) * wt * ht * age Mifflin-St. Jeor (males)9.99 * wt+6.25* ht * age + 5 Mifflin-St. Jeor (females)9.99 * wt * ht – 4.92 * age WHO (males) [18-30 years] 15.3 * wt WHO (females) [18-30 years] 14.7 * wt Tucker & Dauffenbach, 2011

Nutritional Needs of the hospitalized patient Basis for determining needs EER by genderFormulae Females354- (691* age) + PA * (9.36 * wt * ht) Males662- (9.53 * age) + PA * (15.91 * wt * ht) ActivityActivity Factor (PA) Sedentary1 Light active1.16 Active1.31 Very active1.56

Disadvantages of estimating energy requirements Estimating 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 patient Basis for determining needs Based 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 N Thus 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

References Duggan, M., & Golden, B. (2007). Deficiency diseases. In C. Geissler & H. Powers (Eds.), Human Nutrition (11 th Ed.) (pp ). 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.