Nutrition Care Process (ADIME) Process

A. Assessment of Nutritional Status

Responsibilities and Role of Nurses in Nutritional Care
Observing
Nurse - usually the first person who sees the patient’s eating problems

 has direct communication with the patient

 how well the patient’s eats his food
 what kinds and amounts of food are refused
 the patient’s attitude towards his food are readily determined
 must have a knowledge in diet therapy (food allowed / restriction)
 should immediately forward the diet prescription to the dietary department
 makes sure that the patient is ready to consume the food served on the tray
Listening
Nurse - shows his/her general interest and understanding of the patient

 helps the patient express his/her feelings

 learned from the patient some of his/her favorite foods and dislikes
 explains concerns on foods that cannot be eaten due to ethnic, cultural background and religious
beliefs
 becomes aware of what concerns the patient may have about the diet he will have at home

Reporting
      Nurse – documents and chart all the problems related to food intake
 
Nutritional History
a. Dietary Intake Data
- Dietary Computations: Desirable Body Weight
                                                        Basal Metabolic Rate
                                                        Total Energy Requirement
                                                        Food Exchange List 
b. Nutrient Intake Analysis (NIA)
c. Food Diary
d. Food Frequency
e. 24 hour Recall
 
Physical Assessment
a. Anthropometric Measurements
b. Height and Weight
c. Body Mass Index
d. Body Composition
e. Mid-arm Circumference (MAC)
f. Fat-fold or Skin-fold Thickness
 

 Other Sources of Data

 Malnutrition Universal Screening Tool (MUST)
 Subjective Global Assessment (SGA)
 Mini Nutritional Assessment (MNA)
 Geriatric Nutritional Risk Index (GNRI)
B. Nutrition Diagnosis and Plan of Care
 Nutrition Problems and/or Needs
 Planning the Diet with Cultural Competency
 Resources needed in Planning and Implementing Dietary Regimen

C. Nutrition Intervention
 Food and Nutrient Delivery
 Food Administration
 Oral Nutrition
 Short-term enteral access
 Long-term enteral access

Enteral Nutrition
Tube Feeding

 Provide enteral nutrition for clients who cannot swallow, with esophageal obstruction,
unconscious, and cannot consume oral feeding.
 Rubber – ice; Plastic- warm (Levine-single; Salem sump-double lumen)
  High fowler’s, if contraindicated place right side lying position with head slightly elevated to
prevent aspiration.
 Measure the distance from the tip of the nose to earlobe through the bottom of the xiphoid
process (adult)
 Measure the distance from the tip of the nose to earlobe through the midway of xiphoid
process and umbilicus (children)
 Use water soluble jelly as lubricant
 Offer sips of water and advance tube forward, head bent forward closes the epiglottis and
trachea
 Inject 10 ml of air and auscultate for gurgling sound in the epigastrium.
 Aspirate for residual stomach content (ph 1-3 of yellow to green)
 Immerse tip of the NGT into water and observe for bubbling.
 X-ray confirms
 Flush with 30-60 ml of water after feeding
 If NGT is to removed, instruct client to exhale and remove tube with smooth, continuous
pull

NG TUBE
N- ever give without checking
G- ive warm(room temperature)
T- urn to right side during the feeding for the stomach to empty better  
U- se gravity, never force feeding
B- e sure to aspirate
E- nd with water and chart
Types of Enteral Formulation

1. Ready to Use Formulations

2. Tube feedings – prepared from regular foods
1. Standard tube feeding - fiber free, high in cholesterol, fat and sugar

                                                                   - milk based, sugar and soft cooked eggs

           2. Blenderized tube feeding - soft diet allowances which can be blenderized easily
Complications:
Mechanical

 nasopharyngeal irritations – ice chips

 luminal obstruction – flush, replace tube
 mucosal erosions – reposition tube, ice water lavage, remove tube
 tube displacement – replace tube
 aspiration – discontinue tube feeding

Gastrointestinal
  cramping/distention – change formula, reduce infusion rate
 vomiting/diarrhea – dilute formula, reduce infusion rate
 constipation – promote sufficient, fluids and fibers, encourage patient activity

Metabolic

 hypertonic dehydration – increase water

 cardiac failure – reduce sodium content, fluid restriction
 renal failure – decrease phosphate, magnesium, potassium, CHON restriction, amino acids
solution
 glucose intolerance – reduce infusion rate
 hepatic encephalopathy – decrease amount of CHON

Parenteral Nutrition

1. Peripheral Parenteral Nutrition (PPN) – nutrients are given via small veins, usually in the
arms
2. Total Parenteral Nutrition (TPN) – also called Central Parenteral Nutrition (CPN) or
intravenous hyperalimentation (IVH); nutrients are given centrally into the superior or
inferior vena cava or the jugular vein

 TPN solutions are nutritionally complete based  on the patient’s weight  and
caloric/nutritional needs
 TPN is indicated in clients who need extensive nutritional support over an extended period
like CA and severe malnutrition
 Mixture of dextrose, amino acids, multivitamins, electrolytes and trace of minerals
 The usual site is subclavian vein
 During TPN catheter insertion, Trendelenburg position – to engorge the vein and facilitate
insertion of the vein and prevent air embolism
 The primary purpose of TPN is to administer glucose
 PIC – basilic / cephalic; PPC - subclavian
 Administer TPN at room temperature
 Cold temperature of solution may cause chills
 Consume TPN formula for 24 hours to prevent contamination
 The TPN solution is hypertonic (25-35% of dextrose)
 Use infusion pump to maintain steady infusion this prevents abnormal shifting of fluids from
intracellular compartment to the extracellular compartment (cells shrink)
 If infusion is delayed do not catch up – notify physician for calculation
 Monitor urine and glucose level. Glycosuria is expected.
 The client may need small amount of insulin as prescribed by the physician to prevent
glucose intolerance
 Prevent infection on the catheter site. Infection is the most common complication of TPN.
 If TPN administration is interrupted or discontinued, administer D10W to prevent
hypoglycemia

D. Monitoring Nutritional Status

 Strategies to address Age-related changes affecting Nutrition
  Selected Therapeutic Diets
 Recording and reporting of Nutritional Status

E. Evaluation of Plan of Care

Effectiveness of the plan of care