Chapters 8-10

Regular Diet

• For clients with no dietary restrictions. The diet is adjusted to meet age specific needs throughout the life cycle.

• Modify to accommodate individual preferences, food habits, and ethnic values

Clear Liquid Diet

• Foods or fluids that have no residue and are liquid at room temperature.

• Primarily to prevent dehydration & relieve thirst, consists of water & carbohydrates.

• Requires minimal digestion, leaves minimal residue, & is non-gas-forming.

• Nutritionally inadequate and should not be used long-term

• Include: Water, tea, coffee, fat-free broth, carbonated beverages, clear juices, ginger ale, & gelatin.

Indications for a clear liquid diet

Acute illness, reduction of colon fecal material prior to certain diagnostic tests & procedures, acute GI disorders, and some post-op recovery.

Full Liquid Diet

Foods liquid at room temp.

• plain ice cream & strained cereals

• all liquids and milk, juice, and soup

• any kind of liquid (coffee with creamer, ice cream, orange juice)

Indications for a full liquid diet

Transition from liquid to soft diets, post-op recovery, acute gastritis, febrile conditions, and intolerance of solid foods.

Blenderized liquid (pureed) diet

• Liquids/foods are pureed to liquid form.

• Composition & consistency of pureed diet varies, depending on client’s needs.

• Modify with regard to calories, protein, fat, or other nutrients based on dietary needs.

• Adding broth, milk, gravy, cream, soup, tomato sauce, or fruit juice to foods in place of water provides additional calories and nutritional value.

• Each food is pureed separately to preserve individual flavor.

indications for a blenderized or pureed diet

Clients who have chewing or swallowing difficulties, oral or facial surgery, and wired jaws.

Soft (bland, low fiber) Diet

• Whole foods that are low in fiber, lightly seasoned, and easily digested.

• Food supplements or snacks in between meals add calories.

• Predisposes clients to constipation.

• Selections vary & can include smooth, creamy, or crisp textures.

  • Raw fruits and vegetables, coarse breads & cereals, beans, & other potentially gas-forming foods are excluded.

Indications for a soft diet

Clients transitioning between full liquid and regular diets, and those who have acute infections, chewing difficulties, or GI disorders.

Mechanical Soft Diet

• Regular diet is modified in texture. Composition is altered for specific
  nutrient needs.

• Foods that require minimal chewing before swallowing (ground meats, canned fruits, softly cooked vegetables).

• Butter, gravies, sugar, or honey can be added to increase calorie intake.

• Excludes harder foods (dried fruits, most raw fruits and vegetables, foods
  containing seeds and nuts).

indications for a mechanical soft diet

Include limited chewing ability; dysphagia, poorly fitting dentures, and clients who are edentulous (without teeth); surgery to the head, neck, or mouth; and strictures of the intestinal tract.

Dysphagia Diet

• Prescribed when swallowing is impaired (following a stroke).

• Manifestations are drooling, pocketing food, choking, or gagging.

• LEVELS OF SOLID TEXTURES:
  • Level 1: Pureed
  • Level 2: Mechanically altered
  • Level 3: Advanced.

• Hard, sticky foods are eliminated.

Level 1 in dysphagia diets

• Pureed

• Totally pureed to smooth consistency with pudding-like texture (pureed fruits, vegetables, meats, soups, scrambled eggs, pudding, custard, applesauce)

Level 2 in dysphagia diets

• Mechanically altered.

• Soft-textured, moist, semi-solid foods easily chewed & swallowed (ground meat served with gravy, tuna salad, well- moistened pancakes/syrup, poached eggs, soft canned or cooked fruit)

Level 3 in dysphagia diets

• Advanced

• Near-normal textured foods that are moist (moist tender meats or casseroles, breads that are not crusty, moist potatoes, soups, rice, and stuffing)

Levels of liquid consistencies

thin, nectar-like, honey-like, spoon-thick

thin liquid

Non-restrictive. Consists of all unthickened beverages and supplements (clear juices, frozen yogurt, ice cream, milk, soda, and broth)

Nectar-like

Liquids thin enough to sip through a straw but thicker than water. Consistency of a heavy syrup (nectars, cream soups, buttermilk, and thin milkshakes)

Honey-like

Liquids that do not maintain their shape when poured but are thickened. They can be eaten with a spoon but cannot be sipped through a straw (honey, tomato sauce, and yogurt)

Spoon-thick

Liquids thickened to maintain their shape and need to be eaten with a spoon (pudding, custard, hot cereals).

Nursing Assessment/Data Collection done by nurses

• Assessments include daily weights, prescribed lab tests, & evaluation of nutritional & energy needs & response to diet therapy.

• Observe and document nutritional intake.

• Perform a calorie count to determine caloric intake and to evaluate adequacy.

• Provide education and support for diet therapy.

• A prescription for a diet as tolerated permits preferences while taking into consideration ability to eat.

• Assess for hunger, appetite, & nausea when planning appropriate diet, & consult with a dietitian.

• Dietary intake is progressively increased (from nothing by mouth to clear liquids to
  regular diet) following a major surgery.

• Assess for the return of bowel function (as evidenced by auscultation of BS & the
  passage of flatus) before advancing a client’s diet.

low fiber/low residue diet

• Supplies foods least likely to form obstruction when the intestinal tract is narrowed by inflammation or scarring or when GI motility is slowed

• Used for inflammatory bowel disease, partial obstructions of the GI tract, gastroenteritis, diarrhea, or other gastrointestinal disorders

• Included foods: white bread, refined cooked cereals, cooked potatoes without skins, white rice, and refined pasta.

• Foods to limit or avoid: raw fruits (except bananas), vegetables, nuts
  and seeds, plant fiber, and whole grains.

• Dairy products should be limited to two servings a day.

High fiber/high residue diet

• Used for constipation, IBS when primary symptom is alternating constipation
  & diarrhea, and asymptomatic diverticular disease.

• Provides 25-38 g daily.

• Volume and weight are added to the stool, speeding the movement of undigested materials through the intestine.

• Foods included: fruits and vegetables and whole-grain products.

• Increase gradually and provide adequate fluids to reduce abdominal cramps, bloating, diarrhea, and dehydration.

• Gas-forming foods should be limited

  • Gas-forming foods include: Apples, Artichokes, Beans, Bran, Broccoli,
    Brussels sprouts, Cabbage, Milk, Nuts, Onions, Wheat, Yeast

cardiac diet

• Indicated for atherosclerosis, DM , hyperlipidemia, HTN, MI, nephrotic
  syndrome, & renal failure.

• Reduces the risk of heart disease.

• Plant-based diets associated with lower risk of coronary vascular disease (CVD).

• Restrict total, cholesterol, and fats.

• Educate on diet choices.

atherosclerosis

• build-up of plaque in and on the artery walls causing them to narrow

• can cause MI’s and strokes

Arteriosclerosis 

blood vessels that carry blood and nutrients from the heart to the body become thick and stiff (lose elasticity)

Dietary Approaches to Stop Hypertension (DASH) diet

• to prevent & control HTN, hypercholesterolemia, and obesity

• 1500-2300 mg of sodium/day

• 6 oz/day or less of lean meat

• 3-4 servings a day of seeds and nuts

• Includes: fruits, vegetables, whole grains, low-fat dairy, meat, fish, poultry, nuts, and beans

• Limits: sugar-sweetened foods & beverages, red meat, sodium, and fats

Fat Restricted Diet

• Used to reduce symptoms of abd. pain, steatorrhea, flatulence, & diarrhea.

• Used with malabsorption disorders, pancreatitis, gallbladder disease, &
  GERD (Gastroesophageal reflux).

• Restrict total amount of fat, including saturated, trans, polyunsaturated,
  and monounsaturated.

• Clients with malabsorption may also have difficulty tolerating fiber and
  lactose.

• Vitamin and mineral deficiencies may occur in clients with diarrhea or
  steatorrhea.

High calorie, high protein diet

• Used for severe stress, burns, wound healing, cancer, HIV, chronic obstructive

• Whole milk/milk products, peanut butter, nuts & seeds, beef, chicken, fish, pork, &
  eggs).

• Encourage snacks between meals, such as milkshakes, instant breakfasts, and nutritional supplements.

• Calorie counts assist in determining total nutritional intake and can identify a deficit or excess intake.

carbohydrate consistent diet

• Clients with DM, hypoglycemia, hyperglycemia, and obesity

• Focuses on maintaining consistent carb, fat, & protein intake each day & with each meal; it is also known as “carb counting.”

• The Diabetes Plate Method may also be recommended

Diabetes plate method

• Fill half the plate with nonstarchy vegetables (broccoli, spinach, asparagus).

• Fill a quarter of the plate with lean protein foods.

• Fill a quarter of the plate with complex carbohydrate foods. (sweet potatoes, quinoa, brown rice, bananas, peas, chickpeas)

• Drink water or a low-calorie drink.

Sodium Restricted Diet

• Used for TN, heart failure, renal disease, cardiac disease, and liver disease

• The AHA recommends no more than 2,300 mg/day, moving toward a limit of 1,500 mg/day

• Encourage fresh foods rather than processed foods.

• Canned, frozen, instant, smoked, pickled, & boxed foods contain higher
  amounts of this

Considerations for Sodium Restricted Diet

• Teach/read nutritional labels regarding sodium content per serving.

• Effervescent medications contain significant amounts of sodium; these include medications that contain the active ingredient sodium bicarbonate or sodium citrate.

• Salt substitutes may be used; most salt substitutes contain large amounts of potassium and should not be used by clients with renal disease.

Protein Restricted Diet

• Used for renal disease and end-stage liver disease

• Provide enough to maintain nutritional status but not an amount that will allow the buildup of waste products from protein metabolism (40 to 60 g of protein daily).

• The higher the restriction, the more important it becomes that all protein in the diet contain all essential amino acids.

• Special low-protein products, such as pastas, bread, cookies, wafers, and gelatin made with wheat starch, can improve energy intake and add variety to the diet.

• Vegetables and fruits contain some protein and, for very-low-protein diets, these foods must be calculated into the diet.

• Foods are limited from the milk, meat, bread, and starch groups.

Renal Diet

For acute kidney injury or chronic kidney disease and for those requiring hemodialysis or peritoneal dialysis

hemodialysis

a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer able to do so

peritoneal dialysis

• a treatment for kidney failure that uses the lining of the abdomen (peritoneum) as a filter to remove waste products and excess fluid from the blood

• clients usually have diets prescribed that are less restrictive with fluid and protein intake than those on hemodialysis.

Nursing Considerations for Patients on a Renal Diet

• Controlled amounts of protein, sodium, phosphorus, calcium, potassium, and fluids may be prescribed; may also need modification in fiber, cholesterol, and fat based on individual requirements

• Most clients receiving dialysis need to restrict fluids.

• Monitor weight daily as a priority, because weight is an important indicator of fluid status.

Potassium Modified Diet

• Low __________ indicated for hyperkalemia (may be caused by impaired renal function)

• High _________ indicated for hypokalemia (GI losses - diarrhea, vomiting)

Foods low in potassium

applesauce, green beans, cabbage, lettuce, peppers, grapes, blueberries, cooked summer squash, cooked turnip greens, pineapple, and raspberries

Foods high in potassium

fruits (bananas, apricots, orange juice, cantaloupe, and tomatoes), vegetables (potatoes, spinach, and broccoli), milk, legumes, and salt substitutes. 

Normal blood value for potassium

3.5-5 mEq/L

cardiac; hyperkalemia or hypokalemia can cause dysrhythmias, which can be life threatening.  

If potassium is too high or too low – we would want to monitor the patients
_____________________ status by utilizing a EKG because _______________.

low purine diet

• Used for gout, kidney stones, and elevated uric acid levels

• Foods to restrict include anchovies, herring, mackerel, sardines, scallops, organ meats, gravies, meat extracts, wild game, goose, and sweetbreads.

purine

A precursor for uric acid, which forms stones and crystals

High-iron diet

• Used for clients with anemia

• Replaces iron deficit from inadequate intake or loss.

• Includes organ meats, meat, egg yolks, whole-wheat products, dark green leafy vegetables, dried fruit, and legumes.

• Vitamin C enhances absorption of this; dairy inhibits it

Nasoenteric Tubes

• Short-term (less than 3 to 4 weeks).

• Nasogastric (NG) tubes

• Nasoduodenal tubes

• Nasojejunal tubes

Nasogastric Tubes (NG)

Passed through the nose to the stomach.

Nasoduodenal tubes

• Pass from the nose through the stomach and end in the duodenum.

• Used in clients who are at risk for aspiration or who have delayed gastric emptying (gastroparesis)

Nasojejunal tube

• Pass from the nose through the stomach and end in the jejunum

• Used in clients who are at risk for aspiration or who have delayed gastric emptying (gastroparesis)

Enteral Nutrition

• Commercial formula administered by tube into stomach or small intestine

• Most closely utilize the body’s own digestive and metabolic routes.

• Can augment an oral diet or be the sole source of nutrition.

• Must have at least a partially functioning GI system

• Contraindicated if GI tract is nonfunctional (paralytic ileus or intestinal obstruction).

• Administered with conditions that hinder nutritional status.

• Administered if neuromuscularly impaired and cannot chew or swallow food.

• Delivery method depends on type and location of the feeding tube, type
  of formula administered, and the client’s medical status and GI function.

gavage feeding

• EN or _________________ for infants when too weak for sucking, unable to coordinate swallowing, & lacks a gag reflex.

• Implemented to conserve energy when an infant is attempting to breast feed or bottle feed, but becomes fatigued, weak, or cyanotic.

ostomies

• Used if requiring long-term enteral feeding, high risk for aspiration or when a nasal obstruction makes insertion through the nose impossible.

• It is a surgically created opening (stoma), used to deliver feedings directly into the stomach or intestines

Gastrostomy

• Are endoscopically or surgically inserted into the stomach.

• Checking for residual is more difficult with this device because of the close proximity of the button on the skin.

• Are generally well-tolerated bc the stomach chamber holds and releases feedings in a physiologic manner that promotes effective digestion.

  • As a result, dumping syndrome is usually avoided

dumping syndrome

when formula moves too quickly from the stomach into the small intestine

nursing actions for dumping syndrome

decrease flow rate or total volume of formula, change the formula, or increase the volume of free water to prevent constipation

Jejunostomy tubes

Are surgically inserted into the jejunal portion of the small intestine (jejunum).

Enternal Feeding Methods

• Continuous infusion method

• Cyclic feeding

• Intermittent tube feeding

Continuous infusion method

• Administered at a continuous rate over 24-hr period.

• Recommended for critical pts. bc of association with smaller residual volumes, & a lower risk of aspiration and diarrhea.

• Pumps help ensure consistent flow rates.

• Feeding tubes should be flushed with 20-50 mL of warm water q4 hr to maintain tube patency and provide hydration.

• Check facility policy regarding withholding feedings for high gastric
  residual volume (GRV)

Cyclic feeding

Continuous rate for 8 -20 hr, often during sleeping hours. Often used for
transition from total EN to oral intake.

Intermittent tube feeding

• Every 4-6 hr in equal portions of 250 -400 mL, typically over a 30- to 60-min time frame, usually by gravity drip or an electronic pump.

• Often used for noncritical clients, home tube feedings, and clients in rehabilitation.

• Feeding resembles normal pattern of nutrient intake.

• Facilities might require measurement prior to initiating the feeding and held if the amount is greater than the amount stated in facility policy or prescription.

Nursing Care for Enteral Nutrition

• Returning residual prevents electrolyte and fluid imbalance.

• Head of bed at least 30º during feedings & 30 to 60 min after to lessen risk of aspiration.

• Administer feeding solution at room temperature to decrease GI discomfort.

• Do not heat in a microwave, can result in uneven temps within the solution.

• Monitor daily weights and I&O.

• Obtain gastric residuals every 4 to 6 hr.

• Monitor electrolytes, blood urea nitrogen, creatinine, minerals, and complete blood count.

Medications and Enteral Nutrition

• When appropriate, administer medications through a feeding tube.

• Feeding should be stopped prior to administering medications.

• The tubing should be flushed with water (15 to 30 mL) before & after med. & between each med if more than one is administered.

• More water can be required following some medications (suspensions).

• Medications should only be dissolved in water.

• Liquid medications should be used when possible.

Complications with Enteral Nutrition

• Constipation, diarrhea, cramping, pain, abdominal distention, dumping syndrome, N&V

• Dumping syndrome occurs r/t rapid emptying of formula into small intestine,
  resulting in a fluid shift.

  • Manifestations include dizziness, rapid pulse, diaphoresis, pallor, and lightheadedness

• Metabolic complications

  • Dehydration, hyperglycemia, electrolyte imbalances, fluid overload, refeeding syndrome, rapid weight gain

• Food poisoning

Nursing actions if there are GI complications with enteral nutrition

• Consider a change in formula.

• Decrease the flow rate or total volume of the infusion.

• Increase the volume of free water if constipated.

• Administer the EN at room temperature.

• Take measures to prevent bacterial contamination

Nursing actions for metabolic complications with enteral nutrition

• Provide adequate amounts of free water.

• Restrict fluids if fluid overload occurs.

• Monitor electrolytes, blood glucose, and weights.

• Monitor respiratory, cardiovascular, and neurologic status.

• Administer insulin per prescribed protocol for hyperglycemia.

refeeding syndrome

a life-threatening complication when nutrition is reintroduced to malnourished patients, leading to a shift in fluids and electrolytes.  

nursing actions for food poisoning with enteral nutrition

Prevent bacterial contamination.

• Wash hands before handling formula or enteral products.

• Clean equipment and tops of formula cans.

• Use closed feeding systems.

• Cover and label unused cans with the client’s name, room number, date, and time of opening.

• Refrigerate unused portions promptly for up to 24 hr.

• Replace the feeding bag, administration tubing, and any equipment used to mix the formula every 24 hr.

Parenteral Nutrition

• Used when GI tract is not functioning, or not able to physically or psychologically consume sufficient nutrients orally or enterally.

• Based upon nutritional needs and anticipated duration of therapy, can be given as either total parenteral nutrition (TPN) or peripheral parenteral nutrition (PPN)

total parenteral nutrition (TPN)

• Provides a nutritionally complete solution to be used when caloric needs are very high or when long-term therapy is indicated.

• A method of feeding bypassing the GI tract

  • It can only be administered in a central vein.

• It contains all the calories and nutrients a person requires

• Can be administered 24 hours or cyclically over 12-18 hours

TPN is made up of…

• carbohydrates, protein, fat, electrolytes, minerals, vitamins, trace minerals, water

• mix of macro & micronutrients

• Macro: dextrose, liquid emulsions (soybean oil), amino acids (protein)

• Micro: electrolytes, trace minerals, and vitamins

What TPN is used for

• Patients who do not have a functioning GI tract or who have disorders requiring a complete bowel reset

• Bowel obstruction, Crohn’s disease, Ulcerative colitis, severe diarrhea, unable to eat for more than 5-7 days

adverse affects of TPN

• metabolic abnormalities, infection risks, or venous access

• refeeding syndrome

• hyperglycemia

• serum electrolyte abnormalities

• central line associated bloodstream infections

• venous thrombosis

• vascular injury