HLSC-2P92 Lecture 9: Nutritional care process and therapeutic approaches

Health care professionals

- physician, nurses, registered dietitians, pharmacists, etc.
- roles of health care team members vary; team members' responsibilities often overlap
- physicians prescribe diet orders and other instructions related to nutrition care (e.g. referrals for nutrition assessment and dietary counseling)

Nurses

- responsible for administering tube and intravenous feedings
- responsible for nutrition care when facility does not employ registered dietitian

Registered dietitians (RD)

- assess, diagnose, and treat nutrition related problems over the course of disease management

- provide preventative nutrition programs or education

- but cannot change a patient's diet order (e.g. nothing by mouth NPO) which has been ordered and prescribed by the physician

Nutrition screening

- a referral for nutrition care may result from a nutrition screening

- assessment tool that helps identify malnourished patients, or those at risk

- examples: Subjective Global Assessment, MNA (Mini Nutritional Assessment for elderly patients)

What information is included in an nutrition screening?

- admitting diagnosis
- physical measurements and lab test results
- information about nutrition and health status provided by the patient or caregiver

Nutrition care process

a systematic problem solving method that dietetic practitioners use to critically think and make decisions to address nutrition related problems and provide safe, effective, high quality nutrition care

When was the nutrition care process developed?

2002

When was the nutrition care process implemented in Canada?

2006

What are the 4 steps to the nutrition care process?

- nutrition assessment
- nutrition diagnosis
- nutrition intervention
- nutrition monitoring and evaluation

What is the goal of a nutrition assessment?

identify specific nutrition problems

Nutrition diagnosis format

PES statement
P = problem
E = etiology
S = signs and symptoms

What is the purpose of nutrition intervention?

actions designed to alleviate nutrition problem

Step 1: nutrition assessment

•Foundation of the Nutritional Care Process
•Collect information to evaluate nutritional status and needs
•Differing causes of malnutrition require an understanding of the interaction with factors affecting nutritional status prior to intervention

what does nutrition assessment consist of?

- subjective data
- objective data
- Anthropometric data
- biochemical data
- physcial data
- medical history
- diet history
- engergy and protein requirements

subjective data

•obtained during interviews
•from patient, family members, significant others
•interviewer's observations

objective data

-anthropometric data
-biochemical data
-physical data
-medical history
-diet history

what does anthropometric data include:

•Height and weight
-body weight changes
- usual body weight
- ideal body weight
-cricumfrance

hieght and weight

•Height and weight
-infants and children
•apply to growth curves
•poor growth an indicator of malnutrition
-adults
•calculate BMI = weight in kg/(height in m)2
•assess nutrient and energy needs

body weight changes

-monitored over time
-some conditions result in fluid retention (weight gain) which may mask weight loss
-body weight can be expressed as a percentage of usual body weight (%UBW) or ideal body weight (%IBW)

usual body weight

-compare current weight with the weight that is generally maintained

-%UBW=(current weight)/(usual weight)×100

ideal body weight

•Ideal body weight
-compare current weight with the weight that would be associated with a healthy BMI (e.g. 22)

-%IBW=(current weight)/(ideal weight)×100

circumfrance

-infants and children
•head circumference
•infant brain growth and malnutrition in children up to 3 years old
-adults
•circumferences of waist and limbs
•evaluate body fat and muscle mass

biochemical data

•Analysis of blood and urine samples
-Contain nutrients, proteins, and metabolites that reflect various aspects of nutrition and health status (e.g. C-reactive protein for malnutrition)
•Several factors e.g. fluid imbalances can influence test results
-Makes interpretation difficult
•Useful together with other tools for patient assessment

physcial data

•Most physical signs of malnutrition are nonspecific and can reflect many causes
•Diet history and laboratory data typically needed as support
•Signs of malnutrition appear mostly in tissues where cells are rapidly replaced
-hair
-skin
-digestive tract
•Hydration status
-Fluid imbalances may accompany some illnesses
-Medications can also affect
-Recognizing physical signs of dehydration and fluid retention is critical
•Functional assessments
-Protein-energy malnutrition (PEM) and zinc deficiency can depress immunity, which can be tested by measuring skin response to antigens that cause redness and swelling when immune function is adequate
-Muscle weakness due to loss of muscle tissue can be assessed by testing hand grip strength

diet history

•Some objective information will not be on medical records
•Comprehensive record of past dietary practices
•Determine nutritional adequacy
•Helpful to develop nutritional care plan
•Different methods
-24 hour recall
-food frequency questionnaire
-food record
-direct observation

diet hisorty: 24 hour recall

recall all foods and beverages consumed over the past 24 hours

pros
-not dependent on literacy or education level of respondent
-interview "unannounced" so as not to interfere with food choices
-accurate short-term food intake
-results are obtained quickly; method is relatively easy to conduct
cons
-reliant on memory
-food items may be omitted (attached stigma)
-portion sizes might not be reported accurately
-over or underestimation of food intake is common
-skill of interviewer affects outcome
-represents a single day, seasonal variation not addressed

diet histroy: food frequency questionnaire

-survey of foods and beverages routinely consumed over a period of time (often a 1-year period, retrospective)
-may be qualitative, semi-quantitative

food frequency questionaire cons

•cons
-reliant on memory
-misses short-term and recent food intake changes
-serving sizes difficult to be evaluated by respondent
-common foods only, related to general population

food frequency questionnaire pros

pros
-estimates long-term food intake, so day-to-day and seasonal variability should not affect the results
-reflective of a general dietary intake
-questionnaire "unannounced" so as not to interfere with food choices
-low cost

diet histroy: food record

-written account of diet consumed over a specified period of time; usually several consecutive days

FOOD RECORD PROS

•pros
-not dependent on memory
-accurate short-term food intake
-sometimes useful for controlling intake

FOOD RECORDS CONS

•cons
-process could potentially influences intake
-underreporting and portion sizes errors are common
-requires literacy and the physical ability to write
-seasonal changes not addressed

DIET HISTORY: DIRECT OBSERBVATION

-written account of foods and beverages consumed over a specified period of time
-clinician records dietary items a patient is given; subtracts amounts remaining after meals are completed
-possible only in controlled environment (long-term care facilities, large scale intervention studies)

direct observation pros

•pros
-not dependent on memory
-does not interfere with food intake
-evaluate acceptability of a prescribed diet

direct observation cons

•cons
-labor intensive
-limited applicability, dependent on situation; possible only in residential situations

energy and protein requirements

-energy imbalance leads to obesity (excess) or wasting (insufficient)
-protein imbalance leads to wasting (insufficient)
-many illnesses associated with protein-energy malnutrition (PEM)
•Needs can be measured or predicted

energy requirments

•Energy needs predicted
-for a healthy population
•Estimated Energy Requirement (EER) equations
-for a clinical population use selected equations for estimating resting metabolic rate (RMR) (sex, weight, and age specific)
•Harris-Benedict
•Mifflin-St. Jeor
- Adjust RMR value with a stress factor appropriate to medical problem

nutrition diagnosis

•Identification and labelling of a client problem for which nutrition-related activities provide the primary intervention

example of diagnosis

-Unintentional weight loss (problem) related to insufficient caloric intake (etiology) as evidenced by 7 kg weight loss or 10% UBW in the past few months (signs/symptoms)

planning stage

-prioritize
•multiple diagnoses, must order for importance and urgency
•order of response, client preference, impact on other problems
•
-identify goals/outcome measures
•e.g. consuming less than 7% of total daily kcal from saturated fats (goal) by decreasing the daily dietary intake of saturated fats or by substituting one type of fat-based spread with another (outcome measures)
- plan
•selection of appropriate interventions
•must be based on science and supported by research (evidence-based)

implementing stage

•Implementing stage
-action phase (putting theory into practice)
-must be compatible with the client

nutrition monitoring and evaluation

•Determine the effectiveness of a nutritional care plan and if client goals and outcomes are being met
•Monitor, measure and evaluate progress at designated dates
-disease, treatment, or patient situation changes - nutrition care plan must be flexible
-goals not met or outcome measures not acceptable - revisit and redesign nutrition care plan if things are not working

nutrition eductation

-Tailored to person's age, literacy, and cultural background
-Can be provided in group sessions or one-on-one

dietary adjustments

•Implement the nutritional plan through differing nutritional support methods
-Regular diet
-Modified diet with altered texture or consistency
•altered texture or consistency
•modified nutrient
-Nothing by mouth
-Specialized nutritional support (enteral and parenteral nutrition)

regular diets

•Standard diet (includes all foods) formulated to meet individual needs based on age, height, weight, activity level and medical condition
•Most common in long-term care facilities and hospitals designed by RDs and based on DRI
•Can be changed to satisfy individual preferences

modified diets

•When standard or regular diets can not meet energy and nutrient needs
•Different diets based on modification, composition and/or approach
-altered nutrient/energy density
-modified texture and consistency

modified diet: altered nutrients

•Altered nutrients
-condition/disease/disorder-specific
-short- or long-term modification

modified diet: modified texture and consistancy

-mechanically altered diets (e.g. mashed, minced, ground, puree) for dysphagia (impaired swallowing)
- -blenderized liquid diets for minimal GI stimulation (transition between clear liquid and solid food diets)
- clear liquid diets (leave minimal residue in GI tract

enteral nutritition

-provision of nutrients using GI tract (stomach or intestine)
-oral supplements and tube feedings

parenteral nutrition

- intravenous provision of nutrients, bypassing the GI tract
- used when GI tract cannot be used

types of enteral nutrition

- oral supplements
- tube feeding
-formulas
- transition to table food

oral supplements

•Appropriate for patients too weak or debilitated to consume meals
•Nutrient-dense formulas, milkshakes, fruit drinks, and snack bars
-Similar products sold in pharmacies and grocery stores for home use
•Taste is an important consideration
Helps promote acceptance

candidates for tube feeding

•Medical conditions that may indicate tube feeding
-Severe swallowing disorders
-Impaired motility or obstructions in the upper GI tract
-Certain types of intestinal surgeries
-Little or no appetite for extended periods
-Mechanical ventilation
-Mental incapacitation due to confusion, neurological disorder, or coma

contraindications for tube feeding include:

•Contraindications for tube feedings include:
-Severe GI bleeding
-Fistulas
-Vomiting or diarrhea
-Severe malabsorption

•Enteral nutrition may also be contraindicated if the expected need for nutrition support is less than 5 to 7 days in a malnourished patient or less than 7 to 9 days in an adequately nourished patient

transnasal: nasogastric

-most common route for patients with normal GI function
-easiest to insert and confirm placement
-least expensive method
-But risk of tube migration to the small intestine; highest risk of aspiration, a common complication of enteral feedings in which substances from the GI tract are drawn into the lungs, potentially leading to pneumonia.

trasnasal: nasoduodenal/nasojejunal

-lower risk of aspiration
-enteral feeding even with conditions that prevent gastric feeding
-lower risk of aspiration in compromised patients
-But tubes are more difficult to insert and maintain than nasogastric tubes; risk of tube migration to the stomach

tube entersostomy

•Direct route to the GI by passing the tube through the abdominal wall
•Surgical incision or needle puncture
•Used for long-term feeding (>4 weeks) or iftransnasal not possible due to obstruction
•Gastrostomy and Jejunostomy

gastrostomy

-most common method for long term use in patients with normal stomach emptying
-easier insertion than other enterostomies
-But moderate risk of aspiration in high-risk patients

jejunostomy

-lowest risk of aspiration
-allows for earlier feeding during severe stress
-enteral feeding even with conditions that prevent gastric feeding
-But most difficult insertion procedure

tube feeding routes

- -transnasal
- orgastic
- enterostomy

- Gastric feedings (nasogastric and gastrostomy routes) preferred whenever possible
-More easily tolerated
-Less complicated to deliver than intestinal feedings because the stomach controls the rate at which nutrients enter the intestine
Avoid in patients with high risk ofaspiration

feeding tubes

•tubes should be soft and flexible
•Variety of lengths and diameters
•Selection based on patient's age, size, feeding route, and formula viscosity

types of enteral formulas

-standard
-elemental
-specialized
-modular

standard

-Standard (polymeric, contain mostly intact proteins and polysaccharides and provided to individuals who can digest and absorb nutrients without difficulty)

elemental

Proteins and carbohydrates are partially or fully broken down to fragments and prescribed for patients with compromised or absorptive functions

specialized forumals

-Specialized formulas (disease-specific, for patients with specific illness e.g. liver, kidney diseases)\

modular forumals

-Modular formulas
•Created from individual macronutrient preparations in the hospital and thus contain specific nutrient combinations; for patients with unique nutrient needs

formula selection factors

•Formula selection factors
-GI function (e.g. a patient with impaired GI tract may require an elemental formula)
-Nutrient and energy needs
-The need for fiber modifications (low or high fiber needs)
-Individual tolerances
•Food allergies and sensitivities

close feeding

connect pre-packaged formula to feeding tube

open feeding

-open feeding
•transfer formula from package to feeding container
•increased risk of environmental contamination

Bolus

-bolus (rapid administration at meal times, delivery of prescribed volume, about 250 ml to 500 ml of formula in fewer than 15 minutes)

intermittent

large amounts of formula, about 250ml to 400ml of formula over 30 min to 40 min, several times daily

continuous

-continuous (pumped at a controlled feeding rate, smaller amounts continuously over an 8- to 24-hour period)

transition to table foods

•Volume of formula is tapered off as condition improves
•Gradual shift to oral diet
-Individuals receiving continuous feedings switched to intermittent feedings (gradual decrease of enteral feeding)
•Oral intake should supply about two-thirds of nutrient needs before tube feedings discontinued

parenteral nutrition: 3 catagories

•Administer nutrients through the vein (intravenous)
•Critically ill patients
Gastrointestinal function is inadequate

parenteral canaditics

•Short-bowel syndrome
•Severe pancreatitis
•Malabsorption disorders
•GI obstructions
•Major trauma
•Critical illness
•Bone marrow transplant
•High risk of aspiration

parenteral nutrition -formula characteristics

•Major trauma
•Critical illness
•Bone marrow transplant
•High risk of aspiration
-•Customized formulations to meet patients' nutrient needs
•Highly individualized
-May be recalculated on daily basis until patient's condition stabilizes
•Typically contain
-amino acids
-carbohydrate
-lipids
-fluids
-vitamins and minerals

administration

•Multidisciplinary nutrition support team of health care professionals
-physician
-nurse
-dietitian
-pharmacist
-
•Goal is to safely and effectively deliver nutrition to the patient with the fewest complications

venous access

Two main access sites:
1. Peripheral: Located in the hand or forearm
- Used to deliver limited amounts for short periods of time
2. Central: Large diameter veins near the heart
-Can supply all of a patient's nutrient need for longer periods of time

peripheral parenteral nutrition (PPN)

•administered through peripherally inserted central catheter (PICC)
•can only provide limited amounts of energy and protein
-Peripheral veins can be damaged by overly concentrated solutions
-Used most often in patients who do not have high nutrient needs or fluid restrictions
•Lower risk of insertion (doesn't require MD) thus increased availability and decreased cost
•Used for short-term administration (less than 2 weeks)
•Rotation of vein sites may be necessary to avoid damaging veins

total parenteral nutrition (TPN)

•Total Parenteral Nutrition (TPN) administered through central venous catheter (CVC)
•Bedside surgical procedure for long-term feeding; preferred for long-term parenteral nutrition
•Inserted directly into a large central vein or into central vein via peripheral vein
•Central access can reliably meet complete nutrient requirements
-Provides nutrient-dense solutions for patients with high nutrient needs or fluid restrictions

Administering Parenteral Nutrition

•Insertion and care of intravenous catheters
•Administration of parenteral solutions
-Continuous administration over 24 hours (continuous parenteral nutrition)
-Cyclic administration for 8- to 14-hour period only (cyclic parenteral nutrition)
•Monitoring patient condition, nutritional status, complications

progression to end goal

•Some require parenteral support for life but most move to oral diet
•Dependent on a number of factors
-overall health and medical condition
-length of time on parenteral support
-follow-up treatment
-GI function
•Patient must have adequate GI function before parenteral nutrition can be tapered off and enteral feedings / oral diet will begin