QUIZ 4: Modified Diets & Clinical Nutrition

Types of Modified Diets (6)

Clear Liquid

Full Liquid

Blenderized Liquids (Pureed)

Soft (Bland, Low Fiber) Diet

Mechanical Soft

Dysphagia Diet

Blenderized Liquids (Pureed) Diet

Consistency varies

Purpose: Chewing and swallowing difficulties

Nutritionally adequate

Soft (Bland, low-fiber) Diet

Whole foods, low is fiber, easily digested

Smooth, creamy, non-gas forming

Mechanical Soft Diet

Regular diet that is modified in texture

Minimal chewing

Excludes harder foods

Full Liquid Diet

More variety, still liquid at room temperature

Nutritionally inadequate

Transition from liquids

Ice cream, strained cereal, pureed vegetables

Clear Liquid Diet

No residual and liquid at room temperature

Prevent dehydration

Nutritionally inadequate

Water, tea, broth, juices etc.

Dysphagia Diet

Prescribed when swallowing is impaired (following a stroke)

HOB 90 degrees

Double swallow

Chin to chest

Levels of Liquid Consistencies

Level 0: Thin

Level 4: Extremely Thick

Levels of Solid Textures

Level 3: Liquidized

Level 7: Easy to Chew

Enteral Feeding (EN)

Used when a client cannot consume adequate nutrients and calories orally but has a gastrointestinal (GI) system that functions at least partially

Contraindication: GI tract nonfunctional

Consists of commercial formula administered through a tube into the stomach

Can be the sole source of nutrition or can be used to augment an oral diet.

Feed whenever possible

Ensure HOB remains 30 degrees for 30-60 mins after

Manifestations of Dysphagia (4)

Drooling

Pocketing food

Choking

Gagging

Nasoenteric tubes (4)

Nasogatric

Nasoduodenal

Nasojujenal (ends in l

Enteric Feedings (4)

Standard (proteins)

Hydrolyzed (proteins)

Disease Specific (proteins)

Modular formulas (proteins

Enteric Delivery Methods (4)

Continuous

Cyclic

Intermittent

Bolus

Parenteral Feeding

Used when GI is NOT working

TPN or PPN

Hypervolemia concern: Fluid restriction = Higher concentration (carbs)

Hyperglycemia: Lower concentration (carbs)

Dextrose less than 10% is for short-term use only

Do not feed whenever possible

TPN (Total Parenteral Nutrition)

Nutritionally complete

Located in central vein

Used when hypertonic (>10% dextrose, up to 70%) is needed

PPN (Peiperhal Parenteral Nutrition)

Short-term, incomplete nutrition due to low dextrose (<10%, 2.5-10%)

Fats (Lipids)

Make up 10-30% of parenteral formula

Protein (Amino Acids)

Make up 3-20% of parenteral formula

Determined by requirements + liver and kidney function

Heparin

Added to parenteral formula to prevent fibrin buildup on the catheter tip

IV MEDICATION CONTRAINDICATION

Administering through a PN IV line or port

Enteral Feeding (Preparation)

HOB 30 degrees

Maintain patency

Verify tube placement

Verify bowel sounds

Check residuals Q4-6

Dehydration concern (prepare free water)

Start slow; increase slow

Obtain baseline (height, weight, BMI, labs, GI function, dietician referral for calorie/energy needs)

Enteral Feeding (Ongoing Care)

Flush w/ 15-30mL water before, between and after meds

Monitor gastric residuals and tube site

Discontinue when client consumes 2/3 of protein and calorie needs orally for 3-5 days

When weaning/transitioning, stop EN 1 hour prior to eating

Increase up to 6 small meals/day

Goal: 500-750/day and feed at night before totally discontinuing

Enteral: GI Complications

Constipation, diarrhea, cramping, pain, N/V
Dumping syndrome (dizziness, rapid pulse, diaphoresis, pallor)

Enteral: GI Complications (Nursing Action)

Consider changing the formula

Decrease formula, Increase free-water

Formula at room temperature

Enteral: Mechanical Complications

Tube misplacmeent, dislodgment, aspiration, irritation, clogging

Parenteral: Mechanical Complications

Catheter misplacement, pneumothorax, air embolus, obstruction, bolus infusion

Parenteral: Infection & Sepsis

Fever and elevated WBC’s

Result from contamination

Refeeding syndrome

Resulting from the body quickly changing from a catabolic to anabolic state. Results in fluid and electrolyte imbalance.

Enteral: Mechanical Complications (Nursing Action)

Confirm placement prior to feeding

Elevate HOB 30 degrees or higher

Bolus over 15 min.

Flush tube with 30mL water every 4 hours

Check residuals every 4-6 hours

Do not mix formula with meds

Enteral: Metabolic Complications

Dehydration, hyperglycemia, electrolyte imbalance, Fluid overload, Refeeding syndrome (starvation state to feeding- can be fatal)

Parenteral: Metabolic Complications

Hyper/hypoglycemia, Electrolyte imbalance, dehydration, fluid overload

Enteral: Metabolic Complications (Nursing Action)

Consider changing the formula to Isotonic

Increase or decrease free-water

Monitor Electrolytes, Glucose and daily weight

Treat symptoms

Enteral: Foodborne Contamination

Bacterial contamination of formula

Enteral: Foodborne Contamination (Nursing Action)

Wash hands before

Clean equipment

Use closed feeding systems.

Cover and label open cansReplace the feeding bag, tubing, and any equipment every 24 hr.

Fill generic bags with only 4 hr worth of formula.

Parenteral Feeding (Ongoing Care)

Fluid balance, flow

Examine solution, verify solution with second RN

Aseptic and sterile technique (changing central line)

Change bag and tubing Q24H

Parenteral Feeding (Nursing Actions)

Introduce enteral substances to prevent GI atrophy

Should be discontinued as soon as possible to avoid potential complications.

Discontinuation should be done gradually to avoid rebound hypoglycemia.

Gradual transition, once discontinued.

Educate the client and family home administration

Specific Pareneteral Nursing Actions

•Monitor for manifestations of infection.

•Use strict aseptic technique when setting up the IV tubing, changing the site dressing, and accessing or deaccessing the IV access.

•Change the PN bag and tubing set at least every 24 hr

•Monitor blood glucose .

•Administer sliding scale insulin or add to the TPN
  Dextrose for hypoglycemia

•Monitor daily weights, I&O, and oral intake of nutrients.

•Notify the provider of weight gain greater than 1 kg/day.

•Titrate lipids to weight changes

Nutritionally inadequate

Liquid diet

Clear liquid diet

Duodenal and jejunal feedings tubed are used for clients with risk for what underlying concern?

Risk of aspiration

Risk of respiratory depression

Risk of kidney disease

Risk of aspiration

Cyclic

A continuous rate of a block of time

No more than 4 hours if exposed to air

Intermittent

Administered every 4 to 6 hours in equal portions

Continuous

Administered at a continuous rate over a 24hr period

No formula poured inside bag (closed system; no air exposure)

Residuals

If more than half the total administered, call the provider to slow or hold the feeding. GI tract cannot digest the total within expected parameters