Elena Kuchler BSN, RD, MHA.

 The Joint Commission on Hospital Accreditation has guidelines in place to provide appropriate care to all patients admitted into a hospitalized setting.  The Dietitian assesses all patients within the first hours of admission and must recommend a course of action if a patient is NPO greater than 72 hours upon admit.

 Different patient population require different modes of nutrition. Most patients will be Rx’d a regular diet that consist of three meals daily.  The American Dietetic Association includes the ‘Dietary Guidelines for Americans’ that dictate the necessary requirements for health promotion and disease prevention.  These include: Low fat, low sugar, high fiber, low salt, alcohol in moderation, exercise daily, and no smoking.

 This Diet RX will not meet a patients nutritional requirements.  It is designed to last no longer than three days as it does not provide enough calories to meet patient’s nutritional requirements for healing.  USES: To rest bowel and GI tract or to progress slowly from surgery.  Components: Clear juices, broth and water

 Although diet Rx may provide more calories, it is also not recommended for long term use as it is not sufficient in fiber.  USES: To progress the gut after long periods of rest and to provide more calories as it includes Milk, and cream soups.   Be mindful of lactose intolerant patients.  Lactose free high protein drinks are available.

 These Diet Rx are designed to help patients recovering from CVA’s, (cerebral vascular accidents or strokes) as they may have dysphagia (difficulty swallowing).  These diets may have the same amount of food: blended, pureed, or mechanically modified for ease of chewing and swallowing.  This diet will meet the patient’s nutritional requirements.

 Diabetic Diet Rx: The Dietitian uses the patients ideal body weight to determine the ideal calorie level for the patient.  1800 ADA is a typical diabetic diet that consist of 1800 calories and includes between meal and bedtime snacks to help keep blood sugars stable.  Carbohydrates are counted to ensure blood sugars stay within normal limits. Patients on these diets typically have blood glucose levels checked ac and hs (before meals and bedtime)

 Patients with elevated BUN and Creatine will require a restriction in the nutrients that may cause kidneys to work harder.  This Diet is designed to reduce the workload of the kidney.  Typically this diet is low in Protein, potassium, sodium, and fluid.  Protein metabolizes to amino acids which is further broken down to urea and nitrogen. If the Kidneys are unable to rid the blood of the toxic waste, than blood levels will elevate and a modification of nutrients will be implemented to prevent damage to the kidneys.

 USE IT OR LOSE IT’ This is the guideline and the standard of care message. If a patient has a functioning gut (bowel sounds are present), it is always recommended to use the Gastrointestinal system if warranted.  Tube Feedings Enteral Nutrition is another term used for tube feeding. If a patient is unable to swallow due to a brain injury etc, the Dietitian recommends a feeding by Nasal gastric (NG) or if anticipated long term/ PEG tube (percutaneous endogastric)

 Tube feeding: If anticipated short term use nasal gastric feeding as it is easily inserted and removed. Long term Feeding, PEG, a surgical procedure placing a tube in the gut to directly add liquid nutrition into the stomach. Patients are usually unable to swallow: Stroke, dysphagia, or any patient at risk for aspiration pneumonia would be a candidate for this type of feeding.

 GASTRIC RESIDUALS: any substance not digested after two hours of feeding.  Place syringe into PEG site and pull back until gastric contents no longer fill syringe, if amount is less than 60ml (this number changes per facility policy and procedure manual) may continue to feed patient.  If gastric residuals are too high, TF may be decreased, not discontinued, until tolerance is achieved.

 INDICATED WHEN A PATIENT DOES NOT HAVE A FUNCTIONING GUT.  Used by administering nutrients that have already been “broken down” to Glucose, Amino Acids, and Lipids (or respectively known as CHO, PRO and FAT).  These nutrients, Glucose, Amino Acids and Lipids, are infused at a determined rate through a Central Line to provide patients’ with nutrition who do not have a functioning GI tract.

 Depending on the Diagnosis and prognosis of the patient, the family, doctors, patient, and dietitian determine what type of feeding is required.  If a patient will be unable to swallow for a short period of time a nasal gastric feeding will be recommended as the risk of infection for not using the gut, or keeping Patient NPO is increased during the acute phase of illness.  Patients’ requiring long term feeding due to lack of ability to swallow may have surgical placement of a feeding tube.  Only when a patient has no gut function, is TPN recommended as it has been shown to cause hyperglycemia, insulin resistance, and Pancreatic/liver problems.

 Nursing requires a lot of skill especially Assessment Skills!  When you recognize a patient with untreated HTN or DM, it is recommended to refer these patients to a dietitian. Lifestyle and diet changes are the FIRSTLINE approach to care of these patients prior to Rx treatment.  Last note of consideration…Nutrition is the first step to well being. Overweight leads to obesity which leads to HTN, Hyperlipidemia, DM, Renal failure and Cancer. All, if not most of all disease today is related to nutrition. Preventing illness with adequate nutrition is considered the standard now instead of treatment approach.