Illness & Nutrition Care

1. Illness & Nutrition Care Chapter 14 Nutrition & Diet Therapy (7th Edition)

2. Nutrition in Health Care Nutrition & Diet Therapy (7th Edition)

3. Effects of Illness on Nutrition Status • Relationship between nutrition & illness is complex • Medical problems can alter nutrient needs & result in malnutrition • Reduction in food intake • Interference with digestion & absorption • Alteration of nutrient metabolism & excretion • Increase metabolic stress & energy needs • Poor nutrition can affect course of disease & body’s response to treatment • Dietary changes required for acute illness usually temporary; chronic illnesses may require long-term dietary modification Nutrition & Diet Therapy (7th Edition)

4. Cooperative effort of multidisciplinary health care team Critical pathwaysoutline coordinated, comprehensive plan for specific diagnoses, treatments, procedures Implementation requires all members of team Roles of team members often overlap Physician—prescribes diet orders & other aspects of nutrition care Nurses, registered dieticians, other health professionals identify problems, suggest strategies, provide nutritional services Responsibility for Nutrition Care Nutrition & Diet Therapy (7th Edition)

5. Registered dietitian (RD) Food & nutrition expert Role includes Conduct nutrition assessment Diagnose nutritional problems Develop, implement & evaluate nutrition care plans Plan & approve menus Provide nutrition education May manage food services in health care institution Registered dietitian has academic & professional requirements to qualify for RD credential conferred by American Dietetic Association Qualifications include Bachelor’s degree in nutrition or dietetics Supervised internship Successful completion of national examination Responsibility for Nutrition Care Nutrition & Diet Therapy (7th Edition)

6. Nurses Interact closely with patients Identify those who would require nutrition services Screen for nutrition problems; participate in nutrition assessments Provide direct nutrition care Participate as member of nutrition support team Registered dietetic technicians Work in partnership with registered dietitian Assist in implementation & monitoring of nutrition services Other health professionals Include Pharmacists Physical therapists Occupational therapists Speech therapists Social workers Nursing assistants Home health care aides Responsibility for Nutrition Care Nutrition & Diet Therapy (7th Edition)

7. Nutrition Screening • Assessment tool that helps to identify malnourished patients, or those at risk • Information includes • Admitting diagnosis • Information on medical record • Physical measurements & lab test results • Responses of patient or caregiver during initial interview or assessment Nutrition & Diet Therapy (7th Edition)

8. Information collected for nutrition screen Nutrition & Diet Therapy (7th Edition)

9. Systematic approach to medical nutrition therapy (MNT-nutrition care that includes dx. nutr. problems, rx. Diets and providing counseling); There are 4 interrelated steps: 1. Assessment Collection of information needed to evaluate patient’s nutrition status & dietary needs Information gathered from variety of sources 2. Nutrition diagnosis Individual nutrition problem Includes specific problem, etiology, signs & symptoms Diagnoses may change over course of illness 3. Nutrition intervention Actions designed to alleviate nutrition problem Includes goals & desirable outcomes Dietary changes, nutrition education, change in medication 4. Nutrition monitoring & evaluation Determination of effectiveness of nutrition care plan Goals & outcomes are compared with earlier assessment data & diagnoses Plan of care is modified, based on evaluation Nutrition Care Process Nutrition & Diet Therapy (7th Edition)

10. Nutrition Care Process Nutrition & Diet Therapy (7th Edition)

11. Nutrition Assessment Nutrition & Diet Therapy (7th Edition)

12. Historical Information • Information about patient’s nutrition status & nutrient needs • Identifies personal preferences that need to be considered in nutrition care plan • Information gathered from patient or caregiver, or from medical record • Includes • Medical history • Social history • Diet history Nutrition & Diet Therapy (7th Edition)

13. Nutrition & Diet Therapy (7th Edition)

14. Food Intake Data • Use of combination of methods to obtain information regarding food intake • 24-hour recall: detailed description of foods & beverages consumed in a 24-hour period are outlined; may reflect typical day • Food frequency questionnaire: written survey of food consumption during specific period of time, including those relevant to patient’s medical condition • Food record: written account of food consumed during specified period; usually over several consecutive days • Direct observation: observation of meal trays or shelf inventories; used to conduct kcalorie counts Nutrition & Diet Therapy (7th Edition)

15. Measures of body size that can reveal problems related to overnutrition & protein-energy malnutrition Height (or length) & weight; BMI Percentage of body fat Circumferences of head (in children), waist & limbs Anthropometric assessment in infants & children Used to evaluate growth patterns Usually plotted on growth charts Growth patterns below 5th percentile may be cause for concern Anthropometric assessment in adults Routinely measured during illness Changes must be evaluated carefully Unintentional weight loss may indicate malnutrition Weight gain may result from fluid retention In assessing significance of change, must consider rate as well as amount Including skin fold measurements & limb circumference can help identify changes in body composition that need to be addressed in treatment plan Anthropometric Data Nutrition & Diet Therapy (7th Edition)

16. Calculating %Ideal Body Wt (IBW) Nutrition & Diet Therapy (7th Edition)

17. Biochemical Analyses (Labs) • Provide information about PEM, vitamin & mineral status, fluid & electrolyte balance, organ function • Include analysis of blood & urine samples • Different factors can influence test results, making interpretation difficult • Variety of tests usually required to diagnose nutrition problems Nutrition & Diet Therapy (7th Edition)

18. Plasma proteins Help in assessment of protein status May fluctuate for other reasons Values must be considered with other data Tests include Total protein Albumin Transferrin Prealbumin & retinol-binding protein Other routine tests with nutritional implications Hematology (RBC, Hb, Hct) Chemistry (Alb) Serum enzymes (Ck, AST, ALT) Serum electrolytes (Na, K) Glucose (glu, HbA1C) Blood urea nitrogen (BUN) and Creatinine (Cr) Biochemical Analyses Nutrition & Diet Therapy (7th Edition)

19. Most physical signs of malnutrition are non-specific—can reflect many causes Nutrient deficiencies Fluid imbalances Functional impairments related to nutritional problems Clinical signs of deficiencies may be reflected in Skin, hair & nails Eyes Lips, mouth & gums Physical signs of malnutrition are often evident in parts of the body where cells are replaced at a rapid rate Physical Examination Nutrition & Diet Therapy (7th Edition)

20. Implementing Nutrition Care Nutrition & Diet Therapy (7th Edition)

21. Dietary Modifications • Energy & nutrient needs are met by standard (regular)diet; modified diet is prescribed when different texture is needed or when certain foods need to be eliminated because of a condition. • Diets altered by • 1. Changing consistency & texture of foods: used for patients with chewing or swallowing impairments • Mechanically altered • Blenderized liquid • Clear liquid • 2. Altering nutrient content: may relieve symptoms of disease, preventing or reversing malnutrition • Fat-restricted • Fiber-restricted • High-kcalorie, high-protein • Need to be adjusted to satisfy individual preferences & tolerances Nutrition & Diet Therapy (7th Edition)

22. Diet manuals Include detail of specific foods to include or exclude in modified diet May be compiled from resources from American Dietetic Association Alternative feeding routes Used in situations where nutrient needs are high, patient appetite is poor, or patient is unable to meet nutrient needs orally Tube feedings: delivery of nutritionally-complete formulas through tube placed into stomach or intestine or nasogastric (temp) Intravenous feedings: delivery of nutrients via the vascular system; may be used when patient’s condition prohibits use of GI tract to deliver nutrients (PPN, TPN) Diet order Physician has primary responsibility for prescribing appropriate diet Orders must be precise to avoid confusion (2gNa instead of “low sodium”) Often done in consultation with dietitian or nurse Nothing by mouth (NPO) Restriction of any food, beverages, medications by mouth Commonly used during acute illness or diagnostic tests involving GI tract Dietary Modifications Nutrition & Diet Therapy (7th Edition)

23. Determining Energy Requirements • Energy needs affected by patient's • Health problem • Treatments • Current nutrition status • Activity level • Gender, height, weight, and age • Several methods can be used to calculate energy requirements • Calculation based on medical problem, activity level & stress level • In critical patients, needs increased further due to • Fever • Mechanical ventilation • Restlessness (psychiatric) • Presence of open wounds • Energy needs for critical care patients usually range 25-30 kcalories per kg body weight daily—often exceeding 2000 kcalories Nutrition & Diet Therapy (7th Edition)

24. Nutrition care plan often involves dietary modifications & nutrition education Plan should be compatible with desires & abilities of the patient Long-term dietary intervention—must take into account current food habits, lifestyle & degree of motivation Determine individual’s readiness to change Emphasize what to eat, rather than what not to eat Suggest only one or two changes at a time Dietary counseling requires sensitivity to cultural orientation, educational background, & motivation for change Approaches to Nutrition Care Nutrition & Diet Therapy (7th Edition)

25. Approaches to Nutrition Care • Nutrition education • Allows patients to learn about dietary factors that affect their medical condition • Should be tailored to patient’s age, level of literacy, cultural background • Learning style should be considered • Discussion, supplemented with written materials • Visual examples • One-on-one or group sessions • Follow-up sessions to assess learning • Other tools • Sample menus • Diet analysis software • Informational packages Nutrition & Diet Therapy (7th Edition)

26. Documenting Nutrition Care • All nutrition care is described in medical record • SOAP note • Subjective information obtained in interview with patient or family; includes main symptoms & complaints • Objective information available from nutrition screening or assessment data; includes biochemical analyses, anthropometric tests, physical exams • Assessment includes brief evaluation of subjective & objective data; includes diagnosis of nutrition problem • Plan describes recommendations, dietary prescriptions, special equipment, nutrition education, referrals Nutrition & Diet Therapy (7th Edition)

27. Loss of appetite common among patients in hospitals or other medical care facilities Result of medical condition, treatment, emotional distress Can be affected by medications & other treatments that alter taste perceptions Nurses & dietetic technicians have central role in helping patients to eat Helping patients to eat Empathize with patient Motivate patient Help patient select foods he likes & mark menus appropriately Suggest foods that require little effort to eat Help patient prepare for meal Check patient’s tray to confirm correct diet & food selections Help with eating (open milk container, etc) Try to solve eating problems Take a positive attitude toward hospital foods Improving Food Intake Nutrition & Diet Therapy (7th Edition)

28. New field which includes the study of dietary effects on gene expression Research suggests that some dietary factors may have effect (helpful or harmful) in people with particular genetic variations Genome: full complement of genetic material in the chromosomes of a cell A DNA microarray allows researchers to monitor the expression of thousands of genes simultaneously Nutrition in Practice—Nutritional Genomics Nutrition & Diet Therapy (7th Edition)

29. Single-gene disorders Seriously disrupt metabolism & require significant dietary or medical intervention Include PKU Sickle-cell anemia Multigene disorders Usually sensitive to number of environmental influences, including diet & lifestyle Tend to develop over many years, allowing modification of diet & lifestyle Disease & risk factors involve assortment of genes Nutrition in Practice—Nutritional Genomics Nutrition & Diet Therapy (7th Edition)