Principles of nutrition therapy & the role of the nurse

Principles of nutrition therapy & the role of the nurse Diet Therapy: NURS 2018

Objectives At the end of this presentation students will be able to: • Describe the nutritional intake of persons who are institutionalized • Explain the basis for determining the therapeutic nutritional requirements of individuals • Use the concept of diet therapy in planning menus for patients • Identify ways of incorporating dietary management in nursing care plans • Describe the role of nurse in providing nutritional care to institutionalized individuals

Factors affecting nutritional requirement and intake • Individual differences exist which impact nutritional requirements they include: • Age • Gender • General condition • Health disorder • Nutritional status • Soci-economic background

Factors affecting nutritional requirement and intake • Emotional and cultural factors are very important in determining food intake. • The cultural pattern of three meals will impact dietary choice. • Animal experiments have shown that habitual factors such as three meals per day have great influence on dietary pattern and choices • Dietary information may affect early choices which has implications for later life; in respect of NCDs and excesses

Factors affecting nutritional requirement and intake • Appetite may be adequate for selection of a nutritionally acceptable diet under certain circumstances • Selection of food on the basis of nutritional principles is more reliable and is recommended • There are normal variations in food intake in relation to • age, • sex, • environmental temperature, • and caloric expenditure

Factors affecting nutritional requirement and intake • Age- higher caloric and micronutrient requirement needed to support : • growth and development; • bone and muscle mass development • Sex- BMR is increased with higher muscle mass • higher in adults compared with older adults who have sarcopenia; • higher in males than females

Factors affecting nutritional requirement and intake • Reports have suggested that decrease in appetite occurs when environmental temperature has reached a point at which maintenance of body temperature is difficult • Caloric expenditure increases both the requirement for more calories and usually the appetite (thus intake) • Illness and disease- though this may decrease appetite in some instances- the actual micronutrient and caloric requirements may be higher

Factors affecting nutritional requirement and intake • Factors causing increased intake • Cystic fibrosis of the pancreas • Hyperthyroidism • Diabetes mellitus • Epinephrine-producing tumors of the adrenal medulla • Pts on ACTH, adrenal cortical steroids, androgens, estrogens, and isoniazide. • Tumors of the hypothalamic regions of the brain

Factors affecting nutritional requirement and intake • Factors causing reduced intake • Dietary deficiency of any essential nutrient • Acute and chronic febrile illnesses, • Debilitating illnesses such as rheumatoid arthritis and ulcerative colitis, • Hepatic and renal diseases, • Hypothyroidism

Hospitalized people • Nutrition care in hospitals is aimed at the role that nutrition plays in any acute process occurring during hospitalization as well as long-term goals. • Nutrition services include food service and clinical nutrition • Medical nutrition therapy is the assessment and treatment of illness or disease that relates to nutritional care.

Hospitalized people • Malnutrition risk increases in the hospitalized client because of factors that decrease dietary intake, increase nutrient losses and lead to increased metabolic needs • The provision of specialized nutrition support in the form of enteral or parenteral nutrition should be done after careful consideration of the indicators, risks and benefits of treatment • Palliative nutrition care involves providing hydration and nutrition in accordance with client centered decisions particularly in end of life care.

Hospitalized people • Hospital patients usually spend most of their time in bed. • Their needs for energy are therefore lower than those of active persons of the same sex, age and weight. • However, some may have increased nutritional requirements. These include • patients who entered hospital undernourished; • those who are pregnant or lactating or have recently had a baby; • and those with diseases that require a special diet or extra nutrients.

Hospitalized people • The nurse is a vital member of the interdisciplinary health care team providing nutrition support and care. • One of the key processes in clinical nutrition in nutritional assessment which includes anthropometric and clinical measures of assessment.

Hospitalized people • The nurse is a vital member of the interdisciplinary health care team providing nutrition support and care. • One of the key processes in clinical nutrition is nutritional assessment which includes anthropometric and clinical measures of assessment.

Psychological Impact of Illness • Being ill may have severe psychological impact on health and result in several health care conditions suited to the NANDA list: • Emotional needs- caregiver role strain, sadness, anxiety, fear • Ability to cope:- impaired coping, anticipatory grieving, depression, social isolation • Institutional setting:- powerlessness

Illness:- Impact on food behaviour • Illness and institutionalization may impact negatively on dietary intake as they may impair:- • Appetite- smells, appearance of food, texture may differ from what was consumed at home • Acceptance and Rejection of foods:- pain, nausea, drowsiness, physical disabilities (temporary and permanent) may affect the willingness to accept or reject food • Failure to eat:- the same conditions affecting acceptance may also affect and result in failure to eat

Nutritional Needs of the hospitalized patient • The nutritional status of a patient at admission has implications for the management and outcome of the condition. Some nutritional issues that have negative impact on outcome and management are:- • Undernutrition • Loss of lean body mass • Prolonged admission • These have negative impact • Co-morbidity • Opportunistic infections • Length of stay • Mortality

Nutritional Needs of the hospitalized patient • Basis of determining needs Tucker & Dauffenbach, 2011

Nutritional Needs of the hospitalized patient • Basis for determining needs

Disadvantages of estimating energy requirements • Estimating energy needs just based on weight may be erroneous as the ratio of active lean body mass to total weight is not constant- thus a DEXA scan or a bioelectrical impedance may be useful. • (Duggan and Golden, 2007)

Nutritional Needs of the hospitalized patient • Basis for determining needs Based on Nitrogen balance studies the normal Nitrogen requirements range from 105mg N/kg/d to 132mg N/kg/d for nitrogen equilibrium- losses= intake • NB. 1g protein= 6.25mg N • Thus 0.105gN * 6.25= 0.65g Protein/kg/d & 0.132gN * 6.25= 0.83kg Protein/kg/d - which is two sd units of the mean of 0.65 • Thus normal protein requirement for nitrogen balance is 0.65 to 0.83 g/kg/d • Protein requirements should be 10%- 15% of total energy intake/d • (Smith, 2007)

Nutritional Needs of the hospitalized patient • The tools that are important in determining the needs of hospitalized patients include • Nutritional assessment including – anthropometry, biochemical tests and clinical assessment • Medical diagnosis:- this is often a multiplier in energy determination • Dietary history which provides an analysis of usual intake

Prescribed nutritional therapy • There are several ways that the hospitalized patient may be supported nutritional. The method of dietary delivery is dependent on: • Anorexia due to illness- weakens due to illness or surgery; cancer; eating disorders • Swallowing disorders:- presence of gag reflex; Cerebrovascular motor neuronal, esophageal stricture • Gastric stasis, gastroparesis- post op; ICU • Inability to take sufficient orally- burns, trauma, Inflammatory bowel disease

Nutrition as part of the Nursing Care Plan • Analysis of food- The nurse identifies, type, amount, preparation styles, likes and dislikes • Plan and implement diet instruction:- in collaboration with the dietician/nutritionist and based on patient needs the nurse prepares the patient for discharge and wellness maintenance and in primary settings • Identify follow-up care needs- HTN, Renal, DM, HIV/AIDS clinic along with dietary referral • Other assistance- Social Worker, Path programmes, advise regarding gyms, recovery groups

References • Duggan, M., & Golden, B. (2007). Deficiency diseases. In C. Geissler & H. Powers (Eds.), Human Nutrition (11th Ed.) (pp 517-536). Edinburgh, UK: Elsevier Churchill Livingstone. • Smith, R. C. (2007). Nutritional support for hospitalized patients. In J. Mann & A. S. Truswell (Eds.), Essentials of human nutrition (pp 33-52). New York, USA: Oxford University Press. • Tucker, S. & Dauffenbach, V. (2011). Nutrition and diet therapy for nurses. Boston, USA: Pearson.

Principles of nutrition therapy & the role of the nurse