Complex client Exam 1 complete

OVERWEIGHT

BMI>30

Increased need for nutition

sepsis, trauma, burns, protracted fever

mechanically altered diets

Used when clients have difficulty chewing/swallowing usually due to poor dentition, oral/facial surgeries, and/or illnesses such as dementia, a stroke/TIA, or developmental delays

Pureed diet

• Foods are blended to almost liquid form

• Think baby food

• Clients who consume this type of diet are at high risk for nutritional decline

Mechanical Soft diet

• Foods are chopped or ground (i.e. ground beef, shredded chicken, scrambled eggs)

• Any food that is easy to chew (restrict nuts, raw fruits/veggies, seeds)

level 1 dysphagia diet

Pureed

level 2 dysphagia diet

•Mechanically altered

•“soft-textured, moist, semi-solid”

level 3 dysphagia diet

•Advanced

•“near normal textured foods”

•Casseroles, no crust on breads, soups, rice, stuffing, mashed potatoes

thin liquid

•Normal consistency of beverages/foods/soups

nectar consistency

•Consistency of heavy syrup

•Will drip off of a spoon

honey consistencies

•Consistency of honey

•Can almost be eaten with a spoon

•Other examples: yogurt, tomato sauce

spoon/pudding consistency

•Must be eaten with a spoon

clear liquid diet

• Anything you can “see” through

• Prescribed due to requires minimal digestion or prior to certain procedures

• Examples: broth, jello, clear juices (no pulp), soft drinks, coffee, tea, water

Full liquid diet

• Consists of food liquid at room temp

• Usually ordered as a transition to a soft diet or regular diet, for post op recovery, or any risk of intolerance of solid foods

• Examples: everything in a clear liquid diet plus milk, yogurt, supplements (Boost, Ensure, ect.), soups, vegetable/fruit juices, ice cream, sherbet, strained cereals, pudding

Cardiovascular Disease diet

•Recall on LDL and HDL cholesterols

•Nutrition Prevention Strategies

•Low-Fat, Low Cholesterol, No Added Salt Diet

•Keep total amount of cholesterol below 200mg

•Increase intake of fiber and omega-3 fatty acids

•Watch for folate, B6, and B12 deficiencies>increased risk!

•Exercise of course

•Weight management

•Smoking cessation

•If MI occurred, they may need to limit caffeine intake

Hypertension diet

•DASH diet

•Keep sodium intake to <2300mg/day *1500mg is goal

•High potassium, high calcium

•Salt substitutes

•Foods naturally high in sodium

Heart Failure diet

•Low Sodium intake <2,000mg/day

•Small, frequent meals

•Monitor fluids

•Increase protein intake

•DASH diet could be used

The body needs iron, vitamin B 12, and folic acid to

produce RBCs

Add Vitamin C

increases absorption of iron

increase iron intake

sources=meat, fish, poultry, tofu, dried beans/peas, whole grains, dried fruit, iron fortified foods

Increase vitamin B12 foods

sources=fish, meat, poultry, eggs, milk

Increase folic acid intake

sources=green leafy vegetables, dried peas/beans, seeds, OJ, cereals/breads ***may still have to supplement***

constipation

•Assess potential causes

•Encourage exercise

HIGH FIBER DIET!!!!!!!!

•Dark green leafy veggies, whole grain foods like cereals, raw fruits/veggies

•Supplement

•Look at meds

•Try to avoid use of laxatives

Diarrhea

WATCH FOR ELECTROLYTE LOSSES

MAY NEED A HIGH FIBER DIET

•Consult RD if diarrhea is food related or caused by enteral feedings

Dysphagia

•Inability to swallow due to neurological disorder, inflammation, or obstruction

•RD and Speech Therapy need to be consulted if it’s suspected

•RD can work with nursing and ST to decide on the best texture or liquid consistency for the patient

•Watch out for dry mouth so provide adequate mouth care

•Client should be in High-Fowler’s for meals

•May need assistive feeding devices

•Allow adequate time to eat and encourage small bites and to chew thoroughly

Position for feedings in pt with dysphagia

High-Fowler’s

Dumping syndrome

•Occurs when a portion of the stomach is surgically removed

•Can happen 15 min-3 hrs min after eating

•Watch out for hypoglycemia due to rise in insulin levels

•Small, frequent meals

•Consult RD for diet education

• EAT PROTEIN AND FAT AT EACH MEAL

• NO SUGARY DENSE FOOD

•Lie down for 20-30 min after meals

•Look out for vitamin deficiencies (Iron, B12)

Dumping syndrome diet

• protein and fat each meal

• no sugary dense food

GERD Diet

•Usually due to hiatal hernia, obesity, pregnancy, smoking, some meds, and genetics

•Risk=adenocarcinoma of esophagus, Barret’s esophagus

•Teach client to not lie down 2 hrs or less after eating a meal

•Suggest to not wear tight-fitting clothing

• AVOID LARGE MEALS NEAR BEDTIME AND MAY NEED TO AVOID TRIGGER FOODS LIKE CITRUS FRUITS/JUICES, SPICY FOODS, CARBONATION

•Encourage weight loss if overweight

• THESE FOODS CAN LOWER ESOPHAGEAL SPHINCTER PRESSURE: FATTY FOODS, ALCOHOL, CHOCOLATE, NICOTINE PRODUCTS, PEPPERMINT/SPEARMINT

Foods to avoid for GERD

citrus fruits/juices, spicy foods, carbonation

These foods and lower esophageal sphincter pressure:

fatty foods, alcohol, chocolate, nicotine products, peppermint/spearmint

acute gastritis

•excessive use of NSAIDs, bile reflux, ingestion of strong acid or alkali substance, complication of radiation therapy, complication of a trauma

chronic gastritis

•presence of ulcers, H. Pylori, autoimmune disorders, poor diet, meds, reflux of pancreatic secretions and bile into stomach

s/s of gastritis

•abdominal pain/discomfort, belching, vomiting, HA, lethargy, nausea, hiccupping, heartburn, vomiting, bleeding, hematemesis

Bland diet for gastritis

CONSULT RD FOR DIET EDUCATION HERE IF NECESSARY

Prevention of gastritis

MODIFY DIET, REDUCE STRESS, AVOID ETOH AND NSAIDS, MEDS

Gastritis prevention

•Avoid eating frequent meals>increases gastric secretions

•No smoking

•Watch out for coffee, black pepper, spicy foods, and caffeine

•Peptic Ulcer Disease (PUD)

•Erosion of mucosal layer of stomach or duodenum

•H.Pylori or NSAIDs may be the culprit

•Eating can temporarily relieve pain

•S/S: dull/gnawing pain, burning sensation in back or low midepigastric area, heartburn, constipation, vomiting, bloating, urea breath, tarry stools

• AVOID FREQUENT MEALS AND SNACKS> INCREASES GASTRIC SECRETIONS

• AVOID COFFEE, NSAIDS ETOH, CAFFEINE, ASA, TOBACCO PRODUCTS, BLACK PEPPER, SPICY FOODS

Avoid for PUD

• FREQUENT MEALS AND SNACKS> INCREASES GASTRIC SECRETIONS

• COFFEE, NSAIDS ETOH, CAFFEINE, ASA, TOBACCO PRODUCTS, BLACK PEPPER, SPICY FOODS

Ileostomies& colostomies

•Maintain fluid and electrolytes

•s/p surgery, liquids only then advance based on client tolerance

•Diet should be high in fluids and soluble fiber (think oatmeal, bran, peas, apples, strawberries, barley)

•Avoid gassy foods (broccoli, cabbage, beans, carbonated beverages)

•Avoid nuts, raw carrots, popcorn due risk for blockage

•Limit foods that produce odor (garlic, eggs, fish)

•Need adequate protein and calories to heal stoma site

•If not healing well>consult RD

diet for ileostomies and colostomies

•Diet should be high in fluids and soluble fiber (think oatmeal, bran, peas, apples, strawberries, barley)

•Avoid gassy foods (broccoli, cabbage, beans, carbonated beverages)

•Avoid nuts, raw carrots, popcorn due risk for blockage

•Limit foods that produce odor (garlic, eggs, fish)

Diverticulosis

just the presence of diverticula

Diverticulitis-

•inflammation due to fecal matter trapped in diverticula

•DIVERTICULOSIS & DIVERTICULITIS s/s

abdominal pain, N/V, constipation OR diarrhea, fever

Prevention of •DIVERTICULOSIS & DIVERTICULITIS

HIGH FIBER DIET

During acute diverticulitis

CLEAR LIQUID DIET UNTIL INFLAMMATION DECREASES THEN HIGH FIBER, LOW FAT DIET
NO SEEDS OR HUSKS

IBD Diet

LOW FIBER DIETS AND BASED ON WHAT THE CLIENT CAN TOLERATE

LOW RESIDUE, HIGH PROTEIN, HIGH CALORIE DIET WITH MVI

IBD s/s

•N/V, abdominal cramps, fever, fatigue, anorexia, weight loss, steatorrhea

IBD

•Crohn’s or Ulcerative Colitis

•Have periods of exacerbation and remission

•S/S: N/V, abdominal cramps, fever, fatigue, anorexia, weight loss, steatorrhea

• LOW FIBER DIETS AND BASED ON WHAT THE CLIENT CAN TOLERATE

  LOW RESIDUE, HIGH PROTEIN, HIGH CALORIE DIET WITH MVI

•If severe, may need TPN-RD will follow

•If client struggling to gain weight or food intolerances, consult RD

Pancreatitis

•Inflammation of pancreas

• TO REDUCE PANCREATIC SECRETIONS, THE CLIENT MUST NPO WITH NG TUBE TO SUCTION

•If client continues to be NPO for >3 days, TPN will need to be initiated. Consult RD!

•Chronic>follow low fat, high protein, high carb diet

• TO REDUCE PANCREATIC SECRETIONS,

• THE CLIENT MUST NPO WITH NG TUBE TO SUCTION

general considerations for nutrition for renal disorders

•Think back to patho

•Watch client’s weight

•Encourage adherence to any type of fluid restriction

•Monitor urine output and for constipation

•Be prepared to explain why dietary changes are necessary or consult RD for further education

•Provide support

AKI diet

•Rapid decline in kidney function due to some sort of insult

•Watch out for lab changes and fluid overload

•Diet is individualized based on type of AKI and underlying cause and dialysis

•Need adequate calories to handle stress

•Fluids are restricted to client’s daily UOP plus 500 ml during oliguric phase, they increase during diuretic phase

•Protein:

•Dialysis=1-1.5 g/kg

•Nondialysis = 0.6-1.0 g/kg

•Restrict potassium to 60-70 mEq/day when on HD

•Sodium:

•Dialysis: 1-3 g/day

•Nondialysis: 1-4 g/day

Protein for AKI

•Dialysis=1-1.5 g/kg

•Nondialysis = 0.6-1.0 g/kg

Restrict potassium to 60-70 mEq/day

when on HD

Sodium for AKI

•Dialysis: 1-3 g/day

•Nondialysis: 1-4 g/day

NEPHROTIC SYNDROME

•Results in increased excretion of serum protein into the urine

•Prolonged loss leads to malnutrition, anemia, and vit D deficiency

•Goals: minimizing edema, replacing lost nutrients, minimizing kidney damage, controlling HTN, and preventing muscle catabolism

•Protein: 0.7-0.8 g/kg/day

•2-3 g Sodium/day

•Carbs should provide majority of calories

•Keep total fat 30% of total calories

•MVI

NEPHROLITHIASIS

•Kidney stones

•Patients with ileostomies are at increased risk

•Increase fluids!

•Limit animal proteins, sodium, ETOH, and caffeine

•Low potassium can contribute to stone formation

•Limit high oxalate foods: spinach, rhubarb, beets, nuts, chocolate, tea, wheat bran, and strawberries

•For uric acid stones limit high purine foods: lean meats, organ meats, whole grains, legumes

Carbs for DM

•Limit simple carbs

•Minimum of 130g/day for brain function

•45-65% of total calories

Fats for DM

•Saturated Fat should be less than 7% of total calories

•Limit trans fats to less than 1%

•Limit cholesterol to 200-300mg/day

•Consume at least 2 servings of polyunsaturated fats

Fiber for DM

•Promote adequate intake for effective carb metabolism

•14g per 1,000 calories

Protein for DM

•15-20% of total caloric intake

•Only reduce if kidney failure present

Considerations for DIET WITH DM

•Encourage clients to eliminate all tobacco use

•ETOH should be consumed with a meal or immediately after due to hypoglycemic effects

•Artificial sweetners are acceptable except for Saccharin in pregnancy

•RD will work with client to build an individualized meal plan based on nutritional needs

•Client will learn how to count carbs and about the exchange list

•Encourage exercise

•Encourage weight loss if necessary

•Teach how to self monitor

•Clients will require a lot of education and support!

Immunosuppression diet

• HIGH RISK FOR PROTEIN-CALORIE MALNUTRITION AND BODY WASTING

• •Adverse effects of treatments can compromise nutritional status

  •Body’s demands are increased

  • TEACH CLIENT ABOUT POTENTIAL FOOD SOURCES OF BACTERIA (RAW FRUITS/VEGGIES, UNDERCOOKED MEAT/POULTRY/EGGS

  •Wash fruits and veggies

  •Refrigerate foods ASAP

  •Monitor BMI, weight, labs

  •Assist client to make realistic goals for nutrition and food consumption

  •Look at quality of life

immunosupression diet

• TEACH CLIENT ABOUT POTENTIAL FOOD SOURCES OF BACTERIA (RAW FRUITS/VEGGIES, UNDERCOOKED MEAT/POULTRY/EGGS

• HIGH RISK FOR PROTEIN-CALORIE MALNUTRITION AND BODY WASTING

Cancer prevention

•Consume at least 14 g per 1000 calories of fiber per day

•No tobacco products

•Eat at least 5 servings of fruits and veggies especially high in Vitamins A, C, and cruciferous veggies

•Consume whole grains not processed

•Avoid anything smoked, pickled, or cooked with charcoal/on the grill

•Consume poly and monounsaturated fats

•Limit ETOH consumption

Nutrition therapy for cancer

•High risk for anorexia, increased metabolism, and negative nitrogen balance

•Systemic effects result in poor food intake, increased nutrient and energy needs, and catabolism of body tissues

•Consult RD to create individualized plan for client

•Calorie needs vary but usually require 25-35 kcal/kg body weight

•Protein: 1.0-2.5 g/kg body weight per day

•Maybe need MVI

•Encourage clients to eat more on “good” days

•NUTRITIONAL SUPPLEMENTS

•Increase calorie and protein density in foods

•If client has dysphagia, consult both RD and ST and thicken foods

HIV/AIDS Diet

•Nutrient Requirements are INCREASED

•Individualized plan based on:

•Increased caloric needs: 37-55 kcal/kg body weight/day

•High protein diet: 1.2-2.0 g/kg body weight/day

•MVI

•Decreased intake due to anorexia, N/V/D

•Nutritional findings include rapid weight loss, GI problems, inadequate intake, increased nutrient needs, food aversions, fad diets, and supplements

•May need enteral feedings or TPN

•Encourage small, frequent meals with high cal, high protein foods

•Poor nutritional status leads to other infections

•HIV-associated wasting = 10% or more weight loss in 30 days or less

•Fluids, fluids, fluids

specific diet for HIV and AIDS

•Increased caloric needs: 37-55 kcal/kg body weight/day

•High protein diet: 1.2-2.0 g/kg body weight/day

HIV-associated wasting =

10% or more weight loss in 30 days or less

Early satiety and anorexia

• EAT SMALL AMOUNTS OF HIGH PROTEIN, HIGH CAL FOODS

• •Avoid food odors

  •Do not fill up on low cal foods like broth, roughage, ect

  •Eat cool or room temp foods

  •Eat more in AM

Mouth Ulcers and Stomatitis

•Use soft toothbrush

•Avoid alcohol mouthwashes

•Omit spicy, dry, or coarse foods

•Cold or room temp foods

•Try straws

•Replace meals with High Protein, High Cal drinks

•Well-fitting dentures

Fatigue

•Eat large, calorie-dense meal when energy is at its highest

•Use easy to prepare foods

•Meal delivery service

Taste alterations/ Thick Saliva

•Try adding foods that are tart

•Eat small, frequent meals

•Use sauces and seasonings

•Use plastic utensils for eating

•Suck on mints, chew gum, or candy

Nausea, vomiting

•Eat cold or room temp foods

•Try high-carb, low fat foods

•Avoid fried foods

•Do not eat before chemo or radiation

•Take meds

•Sit up for 1 hr after meal

Diarrhea

•Need adequate intake of fluids

•Avoid high ropughage foods

•Consume foods high in pectin to bulk up stool

•Limit caffeine, hot or cold drinks, and fatty foods

ENTERAL NUTRITION

•Used when a client cannot consume adequate nutrients orally and maintains a fully functioning GI system

•NO EN if ileus or obstruction present!

•Consists of a commercial formula that will go through the stomach or small intestine

•Can replace diet supplement oral diet

•RD needs to be consulted!!

Nasogastric (NG)-

•through nose and into stomach

Nasoduodenal (ND)-

- through nose and into duodenum

Nasojejunal (NJ)-

through nose and into jejunum

ND and NJ used for

high aspiration risk clients

Gastrostomy-

Gastrostomy-

Jejunostomy-

tube surgically inserted into jejunal portion of small intestine

FORMULAS (most provide 1.0-1.2 kcal/ml)

•The higher the calorie the formula is, the less water it contains

•High Cal formula may require additional free water

•Standard formulas are usually low residue so these are good to start off with

•Hydrolyzed formulas are residue free

Standard enteral nutrition

•Composed of whole proteins or protein isolates

•Require functioning GI tract

•Available in High Protein, High Cal, Fiber-Enriched, and Disease specific formulas

•Good for patients with constipation

Hydrolyzed enteral nutrition

•a.k.a. Elemental

•Composed of PARTIALLY DIGESTED protein peptides and amino acids

•Good for clients with partially functioning GI tracts or those who have absorption/digestive issues (IBD, liver failure, CF, pancreatic disorders, impaired immune systems)

•Have High Cal, High Protein option

Continuous Infusion- enteral nutrition

•Formula is given at a continuous rate over a 24 hour period

•Use infusion pumps

•Good for ICU clients

•Check residuals q 4-6 hours

•Flush tube q 4 hours to maintain patency

•If residual over 500ml or more than what policy states, HOLD feeding and RETURN the residual

Cyclic enteral nutrition

•Formula given at continuous rate over 8-12 hours

•Good for clients who eat orally too

Intermittent enteral nutrition

•Formula is given usually every 4-6 hours

•Usually 250-400ml of formula over 30-60 min time frame

•Check residuals prior to starting feed

Bolus enteral nutrition

•250-400ml of formula usually administered by large syringe in 15-30 min time frame

•Given 4-6 times daily

•Great for clients who participate in rehab or for home feeding

•DO NOT BOLUS INTO JEJUNUM OR DUODENUM

Preparing the Client for enteral nutrition

Tube placement should be checked by X-ray or KUB

Check bowel sounds

Check residuals ever 4-6 hours

Notify MD if large residual continues

HOB at least at 30 degrees

Begin with small volume then increase volume in increments

Give feeding at ROOM TEMP

Ongoing Care enteral nutrition

Monitor daily weights and I&Os

Check lytes and labs

Monitor tube site

Monitor character and frequency of BMs

When giving meds, stop TF, dissolve meds in water, flush tube with 15-30 ml of water before and after meds

Interventions enteral nutrition

Wean as oral intake increases, work with RD

NPO clients need ORAL CARE

Mechanical needs for enteral feedings and actions

Elevate HOB at least 30 degrees

Flush tube every 4 hours

Do not mix meds with formula

Unclog tube with 30-50 ml of warm water

Metabolic actions for enteral feedings

Provide plenty of free water

Consider changing formula-talk with RD

If overload, hold back fluids

Monitor labs and cardiac/respiratory issues

May need insulin

Refeeding syndrome

Potentially fatal!!!

Occurs when client in starvation state is started on EN or TPN

Refeeding syndrome actions

Monitor client for changes in cardiac, respiratory, neurological status>NOTIFY MD

Monitor lytes

Food poisoning from enteral nutrition

Bacterial contamination of formula

WASH HANDS

Replace feeding bag, administration tubing, and any equipment used to mix formula every 24 hours

TPN

•Used when a client’s GI tract is not functioning

•Provides a nutritionally complete solution through a client’s IV

•Designed for long-term support

•Can only be given through Central Line

•PPN (Peripheral Parental Nutrition)-given through a peripheral vein, limited in nutritional value, for short term support

•RD or PharmD will be on the nutrition support team coming up with the TPN solutions

•Components of TPN

•Carbohydrates or Dextrose

•Higher dose given to clients on fluid restrictions

•Electrolytes, vitamins, trace elements

•Amounts added depending on blood chemistry values and physical findings

•Lipids (fats)

•Will come 10%, 20%, or 30% based on needs

•Made up of safflower or sunflower oil and egg phospholipids

•Can be added, piggybacked, or given intermittently

•Protein

•Mixture of essential and nonessential amino acids

•3.5-15% concentrations

•Insulin or Heparin can also be added