Chapter 22

1. Chapter 22 Diet and Clients with Special Needs

2. Objectives • Describe body’s reactions to stress and relate them to nutrition • Explain special dietary needs of surgical and burn clients • Discuss enteral and parenteral nutrition (continues)

3. Objectives • Explain special dietary needs of clients with fever and infection • Explain special dietary needs of clients with AIDS

4. Homeostasis • State of physical balance • Balance upset when body experiences trauma of surgery, severe burns, or infections • Body activates hypermetabolic response to physical stress • Must replace nutrients, fluids, and calories

5. The Surgical Client • Surgery always stressful to client • If elective, evaluate and improve nutritional status before surgery • For overweight clients, improved nutritional status may include weight reduction before surgery whenever possible (continues)

6. The Surgical Client • Clients usually NPO after midnight night before surgery • Prevents regurgitation and aspiration of stomach content during surgery • In most cases, IV solutions given after surgery (continues)

7. The Surgical Client • Solutions contain water, 5 to 10 percent dextrose, electrolytes, vitamins, and medications as needed • Adults after surgery need 35 to 45 caloriesper kg • Maximum calories supplied by solutions create calorie deficit (continues)

8. The Surgical Client • Caloric intake must be increased as soon as possible • High-protein diet may be recommended • Extra minerals and vitamins needed • When peristalsis returns, ice chips may be given • Followed by clear liquid diet (continues)

9. The Surgical Client • Progress to regular diet depends on type of surgery • Some clients may need parenteral or enteral feedings

10. Stop and Share • Consider the following scenario: • Your client weighs 192 pounds and has just had major surgery. How many calories will he require in a 24-hour period? (continues)

11. Stop and Share • First, calculate his weight in kilograms • 192 pounds  2.2 kg per pound = 87.27 kg • Next, multiply his weight in kg by number of kg per pound to get range • 87 kg x 35 calories per kg = 3,045 • 87 kg x 45 calories per kg = 3,915 • He needs 3,045 to 3,915 calories per day

12. Dumping Syndrome • May occur following gastric surgery • Symptoms: • Dizziness, weakness, cramps, vomiting, and diarrhea shortly after eating • Cause: • Food moves too quickly from stomach into small intestine (continues)

13. Dumping Syndrome • Prevention: • Eat diet high in protein and fat • Restrict carbohydrates • Reintroduce complex carbohydrates gradually • Limit fluids to 4 oz at meals • Total daily food should be served as several small meals to avoid overloading stomach

14. The Client Receiving Enteral Nutrition • Bring nutrients directly into digestive tract • Tube feedings may be necessary • Due to unconsciousness, surgery, stroke, severe malnutrition, or extensive burns (continues)

15. The Client Receiving Enteral Nutrition • Nasogastric (NG) tube inserted through nose and into stomach or small intestine • Gastrostomy (opening into stomach) or jejunostomy (opening into jejunum) may be done surgically if feeding needed for longer than six weeks (continues)

16. The Client Receiving Enteral Nutrition • Numerous commercial formulas available for tube feeding: • Polymeric formulas • For clients who can digest and absorb nutrients normally • Elemental or hydrolyzed formulas • For clients who have limited ability to digest or absorb nutrients • Modular formulas • Can be used as supplements or for developing customized formulas for certain clients (continues)

17. The Client Receiving Enteral Nutrition • Methods of administration: • Continuous • Ongoing during 16- to 24-hour period • Intermittent • At night with food eaten during day • Bolus • Given during 15-minute period

18. Possible Complications with Enteral Nutrition • Osmolality of liquid substance • Number of particles per kg of solution • When formula with high osmolality reaches intestine, body may draw fluid from blood to dilute formula • Weakness and diarrhea can occur (continues)

19. Possible Complications with Enteral Nutrition • Aspiration in lungs can occur • Causing pneumonia • Tube may become clogged, or client may pull tube out (continues)

20. Possible Complications with Enteral Nutrition • Placement of tube should be checked initially with x-ray • Then with gastric pH before each use • Keep head of bed elevated

21. The Client Receiving Parenteral Nutrition • Provision of nutrients intravenously • Used if gastrointestinal tract not functional or if normal feeding not adequate • TPN or hyperalimentation • Parenteral nutrition used to provide total nutrition (continues)

22. The Client Receiving Parenteral Nutrition • Peripheral vein used for nutrient solutions needed for two weeks or less • Central vein used for TPN needed for extended period of time • High blood flow facilitates quick dilution of highly concentrated TPN • Reducing risk of phlebitis and thrombosis

23. Possible Complications withParenteral Nutrition • Infection at site of catheter can cause infection of blood • Sepsis • Bacterial or fungal infections can develop in solution • Abnormal electrolyte levels, phlebitis, or blood clots can occur

24. The Client with Burns • Enormous losses of fluids, electrolytes, and proteins in cases of serious burns • Fluids and electrolytes replaced by IV therapy immediately to prevent shock • Glucose not included in these fluids for first two to three days after burn • Reduces risk of hyperglycemia

25. Nutrition Therapy for Clients with Burns • High-protein, high-calorie diet • Vitamin replacement: • Vitamin C and zinc for healing • Vitamin B for metabolism of extra nutrients • Vitamin A for immune system and epithelial tissues • Sufficient fluids needed to maintain kidney function

26. The Client with Infections • Fever • Hypermetabolic state • Each degree of fever on Fahrenheit scale raises BMR by 7 percent • If extra calories not provided, body uses sources of stored energy (continues)

27. The Client with Infections • Increase protein, mineral, and vitamin intake • Need extra liquid to replace losses

28. The Client with AIDS • HIV invades T cells • WBCs that protect body from infections • When T cells cannot function normally, body has no resistance to opportunistic infections (continues)

29. The Client with AIDS • Opportunistic infections caused by other microorganisms present • But do not affect people with healthy immune systems • HIV infection ultimately leads to AIDS • Incurable • Fatal (continues)

30. The Client with AIDS • Clients diagnosed as HIV positive should have baseline nutrition and diet assessment • Healthful diet may delay onset of AIDS • Unhealthful eating habits can be corrected at early stage of disease • Future nutritional needs should be explained (continues)

31. The Client with AIDS • Clients with AIDS experience serious protein-energy malnutrition (PEM) • Thus, body wasting • Also known as wasting syndrome • Results in hypoalbuminemia and weight loss • When possible, give medications after meals to reduce chance of nausea (continues)

32. The Client with AIDS • Sores in mouth or esophagus can make eating painful • Soft foods may be better tolerated • Taste can be affected • Avoid spicy, highly acidic, and extremely hot or cold foods (continues)

33. The Client with AIDS • Additional sugar and flavoring may increase acceptability of liquid supplements • Due to nausea and diarrhea, sufficient fluids essential • Tube feeding may be necessary if client has difficulty swallowing or simply cannot eat

34. Stop and Share • Consider the following scenario: • You are teaching a class about methods to improve the appetite of a client with AIDS. Name some of the methods. (continues)

35. Stop and Share • Give medications after meals • Offer soft food • Avoid spicy, acidic, and extremely hot or cold foods • Serve frequent, small meals (continues)

36. Stop and Share • Add sugar and flavorings to liquid supplements • Take advantage of good days and offer any tolerated food • Talk with client to help ease concerns about finances, family, and friends

37. Conclusion • Surgery, burns, fevers, and infections • Traumas that cause body to respond in hypermetabolic manner • Response creates need for additional nutrients at same time injury causes loss of nutrients (continues)

38. Conclusion • Care must be taken to provide extra fluids, proteins, calories, vitamins, minerals, and carbohydrates as needed • When surgery elective, improve nutritional status before surgery • When food cannot be taken orally, use enteral or parenteral nutrition