Diet Therapy and Assisted Feeding

Diet Therapy and Assisted Feeding
Chapter 27 Diet Therapy and Assisted Feeding Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Theory
Identify the nurse’s role related to diet therapy and special diet. Compare and contrast a full liquid with a clear liquid diet. Explain the different dietary modification levels: puréed, mechanically altered, advanced, and regular. Describe health issues related to nutrition. List disease processes that may benefit from diet therapy. Clinical Practice Use therapeutic communication with a patient who needs a special diet. Develop a teaching plan for nutritional therapy. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Goals of Diet Therapy Treat and manage disease
Prevent complications and restore health Specific diet for each patient is prescribed on the physician’s order sheet Patients can have nutritional goals met after a thorough diet assessment Some patients may need assistance with feeding Energy needs diminish with age—metabolic rate and activity decrease, indicating that calorie requirement is reduced. Some patients have unrestricted diets similar to the meals they eat at home. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Patients Needing Feeding Assistance
Patients with paralysis of the arms Patients with visual impairment Patients with intravenous lines in their hands Severely impaired or weak patients Confused patients Feeding may be delegated to a nursing assistant or family member Patient’s food and fluid intake should be closely monitored and documented. Weight gain/loss, percentage of meals eaten, and ability to tolerate diet should also be documented. Diet can be modified for more effective therapy; should be discussed with patient, physician, and dietitian. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 27-1: Assisting with feeding
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Postoperative Patient
Should be well-nourished preoperatively to facilitate postoperative healing and recovery Preoperative patients are usually NPO 6 to 8 hours before the procedure Postoperative patients progress from a clear liquid to full liquid diet May progress to a soft diet before attempting a general or regular diet What foods are included in a clear liquid diet? Full liquid? Soft diet? NPO status reduces risk of vomiting while under anesthesia and decreases threat of aspiration. When are solid foods added to the patient’s diet? (when patient can tolerate them without nausea, vomiting, or abdominal discomfort) Liquids should be warm or cold, not tepid. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Foods Allowed on a Liquid Diet
Clear liquids Grape, apple, cranberry juices Strained fruit juices Vegetable broth Carbonated water Clear, fruit-flavored drinks Tea, coffee Gelatin and ices Clear candies Popsicles Clear broth Full liquids Milk and milk beverages Yogurt, eggnog, pudding Custard and ice cream Puréed meat, vegetables in cream soups Vegetable juices Sweetened plain gelatin Cooked refined cereals Strained or blended gruel All other beverages Cream Clear liquid diets do not meet the nutritional requirements for health and healing. Full liquid diets can be used to meet long-term dietary needs. What foods are allowed in a soft diet? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Postoperative Patient
Liquid diet is usually started when bowel sounds return Presence or absence of bowel sounds is determined by auscultation Goal is to have low-residue, easily digested foods A liquid diet decreases risk of abdominal discomfort, nausea, and vomiting Patient may progress to soft diet before advancing to regular Check patient’s swallowing reflexes. Check for bowel sounds and distention. Encourage ice chips 4 hours before first meal. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Anorexia Nervosa Mental disorder characterized by refusal to maintain a normal weight and fear of becoming obese Patient may refuse to eat despite being extremely underweight If not corrected, may be fatal Treatment is: Nutritional intervention Counseling Mainly occurs in teenage girls and young women, less frequently in teenage boys. Patients avoid high-calorie foods and exercise excessively. May require hospitalization, as well as tube feeding or TPN. Collaboration among patient, family, physician, nurse, dietitian, and mental health professional is very important for treatment. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Bulimia Eating disorder characterized by episodic binge eating followed by behaviors to prevent weight gain; e.g., purging, fasting, using laxatives Patients aware of their behavior and often feel ashamed Treatment is: Nutritional counseling Psychological counseling Usually involves young adults, primarily women. Characterized by bingeing and purging. Patients with bulimia are usually aware and ashamed of their behavior, which makes it easier to treat. What other health problems are caused by anorexia and bulimia? What are the proper nursing interventions for anorexic and bulimic patients? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Obesity Excessive accumulation of fat, not just being overweight according to height and weight scales Incidence in United States is increasing 65% of Americans are overweight Approximately 30% are obese Mildly obese: 20% to 30% above ideal body weight Morbidly obese: At least 100 lb above ideal body weight What are the common disorders linked to obesity? (cardiovascular disease, stroke, kidney disease, diabetes, arthritis, emotional disorders) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Obesity (cont’d) Contributing factors
Genetics, environment, poor eating habits, lack of knowledge about good nutrition, body physiology, age, and gender Goal of diet therapy is to improve health and quality of life Must expend more energy than is consumed through intake of calories Obesity is not merely being overweight. It is an excessive accumulation of fat that causes stress on vital organs. Surgical intervention for obesity is popular, but complicated and high-risk. Psychological interventions and support groups are effective. What other factors can be included in diet therapy? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Pregnancy Nutritional status before and during pregnancy can influence health status of mother and fetus Weight gain should be 2 to 4 lb for the first trimester and 1 lb/week during the second and third trimesters Recommended—no caloric increase in the first trimester, then 300 calories/day for the second and third trimesters Nutritional state of pregnant patients is affected by: previous health status of the mother. nausea and vomiting in the first trimester. appetite, which may be emotional and physical. access to food of proper nutritional value. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Substance Abuse Abuse of alcohol and other drugs
Interferes with food intake by decreasing appetite and decreasing financial resources for food May lead to impaired absorption of nutrients Thiamine deficiency is seen in alcohol abuse Discuss the signs and symptoms of liver damage caused by substance abuse. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Substance Abuse (cont’d)
Patients with a history of substance abuse should have dietary counseling Treatment Fluid and electrolyte supplements Vitamin and mineral supplements (particularly thiamine) High-calorie, high-carbohydrate diet Dietary fat restriction if liver function impaired What role does the nurse play in treatment of substance abuse? What nursing interventions are appropriate for substance abuse patients? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disease
Includes diseases of the blood vessels, hypertension, myocardial infarction, and congestive heart failure Focused on reduction of fat and sodium intake to decrease atherosclerosis Cholesterol, three types: High-density lipoprotein Low-density lipoprotein Very-low-density lipoprotein Sodium: 1 teaspoon salt contains 2300 mg sodium Many foods in their natural state contain sodium; sodium, rather than salt, must be limited. Describe atherosclerosis and how it affects the body. What foods contain large amounts of saturated fat? (red meat, eggs, high-fat dairy products) What foods help lower cholesterol? (vegetable oils, low-fat dairy products, fish, poultry) Discuss the advantages of the DASH diet. What other suggestions can the nurse provide to help patients prevent cardiovascular disease? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diabetes Mellitus Disturbance of the metabolism of carbohydrates and the use of glucose by the body Two main types Type 1: insulin dependent (juvenile onset) Type 2: non–insulin dependent (adult onset) Higher risk in African Americans and Hispanics Factors to consider for diabetic dietary management: Types and quantity of foods eaten and insulin supply. If food intake is more than the patient can metabolize, ketosis may occur. If food intake is insufficient, patient can become malnourished and be in danger of insulin shock. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diabetes Mellitus (cont’d)
Diet therapy to control carbohydrate intake to maintain serum glucose at 75 to 115 mg/dL Patients should avoid large amounts of carbohydrates in one meal Meals should contain 45% to 60% carbohydrates, 20% to 25% protein, and 20% to 25% fat Calories restricted if patient is overweight Carbohydrates should be complex In calculating a diabetic diet, consider the following factors: Sex, age, height, and weight Employment and activity General health status Dietary likes and dislikes Cultural background Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diabetes Mellitus (cont’d)
Diabetic patients are at higher risk for: Cardiovascular disease Hypertension Kidney disease Blindness Stroke Dietary counseling is essential Patient should eat at prescribed intervals throughout the day. Diet should provide a steady supply of carbohydrates in relation to insulin supply. Teach the patient to plan menus and meals. Teach the importance of weight control, skin care, exercise, and infection prevention. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

HIV/AIDS HIV/AIDS patients often have: Therapy is aimed at:
Severe diarrhea Profound weight loss Muscle wasting Therapy is aimed at: Replacement of fluids and electrolytes Weight gain Replacement of lost muscle mass Maintaining the immune system Why is HIV/AIDS a socially, psychologically, and physiologically complex disease? Describe the function of the immune system. Loss of appetite, nausea, and vomiting can interfere with diet therapy. Diet therapy may delay the onset of AIDS. Gastric tube feedings or TPN may be required. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 1 Diabetes mellitus is a disturbance of carbohydrate metabolism. Which two ethnic backgrounds are at greatest risk of developing diabetes? Whites and African Americans Whites and Hispanics African Americans and Hispanics African Americans and Asians Answer: 3 Rationale: The incidence of diabetes mellitus is increasing at an alarming rate in the United States. Although all ethnic backgrounds are at risk of developing diabetes, African Americans and Hispanics are at greatest risk of developing this disease. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 2 Bill is a recently diagnosed HIV patient. Both Bill and his partner Pat are present for the nurse’s discharge teaching regarding diet. Which of the following is true regarding diet therapy in HIV patients? Patients should be referred to a dietitian within the first year of diagnosis. Emphasis should be placed on carbohydrate intake. Patients should be encouraged to eat three full meals a day. Research suggests that diet therapy can be a factor in delaying full-blown AIDS. Answer: 4 Rationale: Research suggests that diet therapy can be a factor in delaying the onset of full-blown AIDS. HIV patients should be referred to dietitians as soon as possible. Emphasis should be placed on protein intake, and meals should consist of small, frequent meals instead of three full meals. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 3 Gabrielle’s patient is admitted with a diagnosis of alcohol abuse. She is assessing her patient for any nutritional deficits. Which deficiency is often present with alcohol abuse? Niacin Thiamine Potassium Sodium Answer: 2 Rationale: Thiamine deficiency is often present with alcohol abuse. Medical treatment often includes a diet that is high in calories and high in carbohydrates. Diets also usually include fluid and electrolyte supplements and vitamin and mineral supplements, especially thiamine. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Theory
Verbalize the rationale for assisted feedings and tube feedings. List the steps for the procedure to insert, irrigate, and remove a nasogastric tube. Clinical Practice Demonstrate insertion, irrigation, and removal of a nasogastric tube. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Nasogastric and Enteral Tubes
Usually a temporary measure to provide nutritional support Check tube placement prior to feeding or administering medications Irrigate to ensure it is patent Nasogastric and enteral tubes provide needed nutrition and medications. These are the lifelines used to provide life-giving nutrition for patients. Treat tubes with care and respect because without them, the patient will not be able to have needed nutrition. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Nasogastric and Enteral Tubes (cont’d)
Reasons for use Dysphagia following stroke Inflammatory bowel disease Decompression of the stomach before or after surgery Obtaining gastric specimens for analysis Gastric feeding or lavage Administration of medications Insertion and care (Review Skill 27-2) Review the anatomy involved in insertion of nasogastric and enteral tubes. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 27-2: Duodenal tube

Figure 27-2: Gastrostomy tube

Figure 27-2: Jejunostomy tube

Percutaneous Endoscopic Gastrostomy Tubes
Generally used when a patient requires long-term nutritional support Tube placement should be checked every shift and before feeding or administering medication Before feeding or administering medications, amount of residual fluid in the stomach should be assessed Review the technique and procedures for inserting gastric tubes. Review tube-feeding techniques and procedures. How frequently should the tubes be removed and replaced? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 4 Sienna’s patient is having difficulty swallowing. Her doctor has ordered a gastrostomy tube. Sienna explains to her patient that a gastrostomy tube is a tube placed: through the nose into the stomach. directly into the stomach. directly into the intestines. directly into the veins. Answer: 2 Rationale: A gastrostomy tube is a tube placed directly into the stomach. A nasogastric tube is placed into the stomach through the nose. A jejunostomy tube is a tube placed into the intestines. An intravenous line is placed directly into the veins. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Theory Discuss the procedure for tube feeding.
Identify medical rationale and nursing care for a patient receiving peripheral parenteral nutrition (PPN) and total parenteral nutrition (TPN). Understand the possible complications associated with modified diets, tube feedings, PPN, and TPN. Clinical Practice Demonstrate feeding a patient through a nasogastric tube or percutaneous endoscopic gastrostomy (PEG) tube. Know your facility’s policies, procedures, and protocols for nutrition-related problems and complications with tube feedings. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Types of Feeding Tubes Plastic nasogastric tubes: can be used for lavage, tube feeding, and administering medications Small-bore silicone feeding tubes: usually used only for tube feeding Percutaneous endoscopic gastrostomy (PEG) tube and jejunostomy tube: used for tube feeding and administering medication Review the technique and procedures for inserting gastric tubes. Review tube-feeding techniques and procedures. How frequently should the tubes be removed and replaced? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 27-3: Nasogastric and enteral feeding tubes

Feeding Pumps Continuous feeding effective for patients who cannot tolerate large amounts of fluids at one time Intermittent feeding beneficial for patients who are able to feed themselves or when beginning to reintroduce oral feeding Amount of tube feeding is prescribed by the physician; ranges from 8 to 12 oz per feeding Feeding pumps are often used for long-term nutritional support or for patients who cannot tolerate large volumes of feeding formula at one time. These patients usually have limited gastric capacity because of the nature and stage of illness (for example, intestinal blockage from cancer). Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Total Parenteral Nutrition
A method of delivering total nutrition through a catheter placed in a large central vein High concentrations of carbohydrates main source of energy Started slowly to allow the body to adjust to the high level of glucose concentration and the hyperosmolality Used for patients on long-term therapy for: Burns, intestinal obstruction, inflammatory bowel disease, AIDS, cancer (chemotherapy) Before administering TPN, the nurse should: check for patient drug allergies. make sure the solution is clear and free from floating material. gently squeeze the bag or check the container for leaks. check the insertion site for leakage and signs of infection. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 5 As a nurse, when taking care of a patient with a nasogastric tube, you should remember all of the following except: that tube placement should be checked at least every shift and before every feeding. to elevate the head of the bed 15 degrees before feedings and leave it up for 30 to 60 minutes after the feeding. that the amount of the tube feeding is prescribed by the physician. to record intake and output. Answer: 2 Rationale: Elevate the head of the bed 30 to 90 degrees before feedings. Leave the head of the bed up for 30 to 60 minutes after the feedings. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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