MODULE V

Clinical Nutrition and Diet Therapy

Lesson 1: Nutrition Care Process

Lesson 2: Diet Modification and Diet Therapy

Module V Nutrition and Diet Therapy, 1st Semester AY 2022-2023

 MODULE V
CLINICAL NUTRITION AND DIET THERAPY

INTRODUCTION

This module will introduce the process used for providing nutrition care
and the implementation of nutrition care in clinical practice, and the principles
and objectives of diet therapy.

LEARNING OBJECTIVES

After studying the module, you should be able to:

1. Assess the nutritional status of a given client using relevant

parameters and appropriate nutritional assessment tools
2. Formulate relevant nutrition diagnosis.
3. Implement safe and quality interventions with the client to address
the nutritional needs, problems, and issues.
4. Provide health education in nutrition and diet therapy to targeted
clientele.
5. Document nutritional status accurately and comprehensively.
6. Identify the most common therapeutic diets used in clinical care.

DIRECTIONS/ MODULE ORGANIZER

There are two lessons in the module. Read each lesson carefully then
answer the exercises/activities to find out how much you have benefited from
it. Work on these exercises carefully and submit your output to your instructor
or to the CCHAMS Office.

In case you encounter difficulty, discuss this with your instructor during
the face-to-face meeting. If not contact your instructor at the CCHAMS office.

Good luck and happy reading!!!

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Lesson 1

Nutrition Care Process

NUTRITION CARE PROCESS

• A systematic problem-solving method that dietetics professionals use to
critically think and make decisions to address nutrition-related problems and
provide safe and effective quality nutrition care.
• Composed of Assessment, Diagnosis, Intervention, and Monitoring and
Evaluation (ADIME)
• It provides a consistent structure and framework for nutrition professionals to
use to provide individualized care for patients.
• Nurses are intimately involved in the care process and often identify nutrition
needs within the nursing diagnosis.

Health Care Team

• In the area of nutrition care, the following are involved:
o Registered Dietician
▪ carries the major responsibility of medical nutrition therapy
▪ The dietitian determines nutrition needs, plans and manages
nutrition therapy, evaluates the plan of care, and documents
results
o Physician and support staff
▪ Physician prescribes diet orders (or nutrition prescriptions)
▪ The team may include some or all of the following members:
nurse, dietitian, physical therapist, occupational therapist,
speech therapist, respiratory therapist, radiologist, physician
assistant, kinesiotherapist, pharmacist, and social worker
o Nurse
▪ Nurses are in a unique position to provide additional nutrition
support by referring patients to the dietitian when necessary
▪ They are in the closest continuous contact with hospitalized
patients and their families, which is important to ensure the
most beneficial health care approach.
▪ Nurse helps to develop, support, and carry out the plan of care
determined by the dietician.
• Successful nutrition care depends on the close collaboration of the dietitian
and the nurse.

Nutrition Screening
• A brief assessment of health-related variables to identify patients who are
malnourished or at risk for malnutrition.
• The information collected in a nutrition screening may include the admitting
diagnosis, physical measurements and test results obtained during the

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 admission process, relevant signs and symptoms, and information about
nutrition and health status provided by the patient or caregiver
• Subjective Global Assessment
o evaluates a person’s risk of malnutrition by ranking key variables of the
medical history and physical examination
o These variables are each given an A, B, or C rating:
▪ A: Well nourished: if no significant loss of weight, fat, or muscle
tissue and no dietary difficulties, functional impairments, or GI
symptoms; also applies to patients with recent weight gain and
improved appetite, functioning, or medical prognosis
▪ B: Moderate malnutrition: if 5 to 10 percent weight loss, mild
loss of muscle or fat tissue, decreased food intake, and digestive
or functional difficulties that impair food intake; the B
classification usually applies to patients with an even mix of A,
B, and C ratings
▪ C: Severe malnutrition: if more than 10 percent weight loss,
severe loss of muscle or fat tissue, edema, multiple GI
symptoms, and functional impairments
• Other nutrition screening tools:
o Malnutrition Screening Tool (MST)
o Malnutrition Universal Screening Tool (MUST)

PHASES OF THE NUTRITION CARE PROCESS

I. NUTRITION ASSESSMENT
• involves the collection and analysis of health-related information in order to
identify specific nutrition problems and their underlying causes
• includes ABCDE of assessment, which stands for A – anthropometric, B –
biochemical, C – clinical, D – dietary, and E – energy needs
• At the conclusion of the gathering of nutrition assessment data, health care
providers must distinguish relevant from irrelevant data, validate the data, and
then determine whether there is a need to obtain additional information.

A. Anthropometric Assessment
• Height
• Desirable Body Weight (DBW) or Ideal Body Weight (IBW)
o Hamwi Formula – short cut to determining ideal body weight
for adults
▪ IBW for males: 106 pounds for 5 feet plus 6 pounds
per inch over 5 feet
▪ IBW for females: 100 pounds for 5 feet plus 5 pounds
per inch over 5 feet
▪ Add 10% for large frame. Subtract 10% for small frame
▪ Percent IBW = current weight/ideal weight x 100
▪ Interpretation:
• A weight of 20% or more above ideal body
weight due to accumulation of body fat, is an
indication of obesity
• A weight of 20% or less below ideal weight is
an indication of possible nutritional risk

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 ▪ Percent of Weight Loss = Usual weight – present
weight/ usual weight x 100
• Unplanned and/or recent weight loss of 10% in
a period of 30 days is a risk factor for
malnutrition, while weight loss exceeding 20%
is a high risk factor for surgical patients.
• BMI
A healthy body weight typically falls within a BMI range of
o
18.5 to 25
o (BMI is further discussed in Module 3)
• Head Circumference
o helps to assess brain growth and malnutrition in children up
to 3 years of age
o Head circumference values can also track brain development
in premature and small-for-gestational-age infants
o To measure, the tape is placed just above the eyebrows and
ears and around the occipital prominence at the back of the
head.
• Body Composition
o The dietitian may measure various aspects of body size and
composition to determine relative levels of lean tissue
compared to fat mass.
▪ Fat-fold or Skin-fold Thickness – measured with
caliper
• Waist Circumference
o Waist circumference assessment and waist-to-height ratio
are important considerations for both overweight and
normal-weight individuals, because they indicate the risk for
chronic diseases (e.g., type 2 diabetes, cardiovascular
disease, hypertension, cancer, overall mortality), even
among individuals of normal weight.
o waist circumference should be < 102 cm for men and < 88 cm
for women
• Mid-arm Circumference (MAC)
o gives an indication of body protein reserves and helps to
detect protein malnutrition
B. Biochemical (Laboratory) Assessment
• Advantage
o Can detect early sub clinical status of nutrient deficiency
o Can identify specific nutrient deficiency
o Objective tests, independent of the emotional and subjective
factors that usually affect the investigator or reliability of
the patient’s recollection
• Disadvantage
o Expensive and time-consuming
o Standards could vary with wide range
o There may be problems with interpreting results
• Examples of biochemical tests pertinent to nutrition include, but are
not limited to, the following:

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 o Plasma proteins: serum albumin and prealbumin evaluate for
protein status
o Liver enzymes: evaluate liver function
o Blood urea nitrogen and serum electrolytes: evaluate renal
function
o Urinary urea nitrogen excretion: estimate nitrogen balance
o Creatinine height index: evaluate protein tissue breakdown
o Complete blood count: evaluate for anemia
o Fasting glucose: evaluate for hyper- and hypoglycemia
o Total lymphocyte count: evaluate immune function
C. Clinical Assessment
• nutritional physical examinations to assess patients for signs and
symptoms consistent with malnutrition or specific nutrient
deficiency
o Techniques in physical examination:
▪ Inspection- Systematic visual inspection
▪ Auscultation- Using a stethoscope and naked ear to
identify deviations from standard sounds
▪ Palpation- Examination of the body using touch
▪ Percussion- Use of sound to distinguish deviations
from standard sounds created by presence of body
organs and cavities
• also includes medical history like past surgeries, previous diagnoses,
disorders of the family members
• Advantages
o Can be performed in a large no. of individuals in a short
period of time
o Less expensive
o Other staff may perform PE, given the proper training
• Disadvantages
o Deficiencies may not be clearly manifested
o Overlapping of deficiency states
o Bias of the observer
o Reliability of patients recollection

CLINICAL SIGNS THAT SUGGEST NUTRIENT IMBALANCE

Area of Concern Possible Deficiency Possible Excess
HAIR
Dull, dry, and brittle Protein
Easily plucked, with no pain Protein
Hair loss Protein, zinc, biotin Vitamin A
Flag sign (i.e., loss of hair pigment in Protein, copper
strips around the head)
HEAD AND NECK
Bulging fontanel (in infants) Vitamin A
Headache Vitamin A, D
Epistaxis (i.e., nosebleed) Vitamin K
Thyroid enlargement Iodine
EYES

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Conjunctival and corneal xerosis (i.e., Vitamin A
dryness)
Pale conjunctivae Iron
Blue sclerae Iron
Corneal vascularization Vitamin B2
MOUTH
Cheilosis or angular stomatitis (i.e., Vitamin B2
lesions at the corners of the mouth)
Glossitis (i.e., red, sore tongue) Niacin, folate, vit B12,
and other B vit
Gingivitis (i.e., inflamed gums) Vitamin C
Hypogeusia or dysgeusia (i.e., poor sense Zinc
of taste or distorted taste)
Dental caries Fluoride
Mottling of teeth Fluoride
Atrophy of papillae on tongue Iron, B Vitamins
SKIN
Dry or scaly Vit. A, Zinc, Essential Vit. A
fatty acids (EFAs)
Follicular hyperkeratosis (resembles Vit. A, EFAs, B Vit.
gooseflesh)
Eczematous lesions Zinc
Petechiae or ecchymoses Vitamin C and K
Nasolabial seborrhea (i.e., greasy, scaly Niacin, vit B12, B6
areas between the nose and lip)
Darkening and peeling of skin in areas Niacin
exposed to sun
Poor wound healing Protein, Zinc, vit C
NAILS
Spoon shaped (Koilonychia) Iron
Brittle and fragile Protein
HEART
Enlargement, tachycardia, or failure B1
Small heart Energy
Sudden failure or death Selenium
Arrhythmia Magnesium, Potassium,
Selenium
Hypertension Calcium, Potassium Sodium
ABDOMEN
Hepatomegaly Protein Vitamin A
Ascites Protein
MUSCULOSKELETAL EXTREMETIES
Muscle wasting (especially in the temporal Energy
area)
Edema Pro, vit B
Calf tenderness Vit B1 or C, biotin, Se
Beading of ribs or “rachitic rosary” in a Vit C, D
child
Bone and joint tenderness Vit C, D, Ca, P

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Knock knees, bowed legs, or fragile bones Vit D, Ca, P, Cu
NEUROLOGIC
Paresthesias (i.e., pain and tingling or Vit B1, B6, B12, biotin
altered sensation in the extremities)
Weakness Vit C, B1, B6, B12,
energy
Ataxia and decreased position and Vit B1, B12
vibratory senses
Tremor Magnesium
Decreased tendon reflexes Vit B1
Confabulation or disorientation Vit B1, B12
Drowsiness and lethargy Vit B1 Vit A, D
Depression Vit B1, biotin, B12

D. Dietary Assessment
• Food intake data
• Methods commonly used as well as each method’s advantages and
disadvantages are discussed in the table below.

Method Description Advantages Disadvantages

24-hour Guided interview • Results are not • Process relies on
dietary in which the dependent on literacy memory.
recall foods and or educational level • Underestimation and
beverages of respondent. overestimation of food
consumed in a • Interview occurs after intakes are common.
24-hour period food is consumed, so • Food items that cause
are described in method does not embarrassment
detail. influence dietary (alcohol, desserts) may
choices. be omitted.
• Results are obtained • Data from a single day
quickly; method is cannot accurately
relatively easy to represent the
conduct. respondent’s usual
• Method does not intake.
require reading or • Seasonal variations may
writing ability. not be addressed.
• Skill of interviewer
affects outcome.
Food Written survey of • Process examines long- • Process relies on
frequency food consumption term food intake, so memory.
questionnair during a specific day-to-day and • Food lists often include
e period of time, seasonal variability common foods only.
often a 1-year should not affect • Serving sizes are often
period. results. difficult for
• Questionnaire is respondents to
completed after food evaluate without
is consumed, so assistance.
method does not • Calculated nutrient
influence food choices. intakes may not be

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 • Method is inexpensive accurate.
to administer. • Food lists for the
general population are
of limited value in
special populations.
• Method is not effective
for monitoring short-
term changes in food
intake.
Food record Written account • Process does not rely • Recording process itself
of food consumed on memory. influences food intake.
during a specified • Recording foods as • Underreporting and
period, usually they are consumed portion size errors are
several may improve accuracy common.
consecutive days. of food intake data. • Process is time-
Accuracy is • Process is useful for consuming and
improved by controlling intake burdensome for
including weights because keeping respondent; requires
or measures of records increases high degree of
foods. awareness of food motivation.
choices. • Method requires
literacy and the
physical ability to
write.
• Seasonal changes in
diet are not taken into
account.
Direct Observation of • Process does not rely • Process is possible only
observation meal trays or on memory. in residential
shelf inventories • Method does not situations.
before and after influence food intake. • Method is labor
eating; possible • Method can be used intensive.
only in to evaluate the
residential acceptability of a
facilities. prescribed diet.

E. Energy Needs Assessment

• The prediction equations most commonly used in clinical practice
are as follows:
1. Mifflin-St. Jeor
• most accurate in estimating basal metabolic rate (BMR)
• Men: RMR = (9.99 × wt in kg) + (6.25 × ht in cm) − (4.92
× age in yr) + 5
• Women: RMR = (9.99 × wt in kg) + (6.25 × ht in cm) −
(4.92 × age in yr) − 161
1. Harris-Benedict
• was found to systematically overestimate basal energy
expenditure (BEE) by at least 5%

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 •Men: RMR = 66.47 + (13.75 × wt in kg) + (5.0 × ht in cm)
− (6.75 × age in yr)
• Women: RMR = 665.09 + (9.56 × wt in kg) + (1.84 × ht in
cm) − (4.67 × age in yr)
2. Owen
• underestimates RMR about 21% of the time and
overestimates RMR 6% of the time
• Men: RMR = 879 + (10.2 × wt in kg)
• Women: RMR = 795 + (7.18 × wt in kg)

II. NUTRITION DIAGNOSIS AND PLAN OF CARE

• involves the identification and labeling of an existing nutrition problem that
the food and nutrition professional is responsible for treating independently
• Nutrition diagnoses are organized into the following three categories:
o Intake: Too much or too little of a food or nutrient compared with
actual or estimated needs; inadequate, excessive, or inappropriate are
used to describe the specific nutrient or substance that is altered
o Clinical: Nutrition problems that relate to medical or physical
conditions like problems in swallowing, chewing, digestion, absorption,
and maintaining appropriate weight
o Behavioral and environmental: Knowledge, attitudes, beliefs, physical
environment, access to food, and food safety
• A nutrition diagnosis statement will have three distinct and concise elements:
Problem, Etiology, and the Signs/symptoms (PES)
o Problem: may include nutrient deficiencies (e.g., iron-deficiency
anemia) or underlying disease that requires a modified diet (e.g., renal
disease, liver disease)
o Etiology: causes or contributing risk factors are identifiable factors that
are directly leading to the stated problem
o Sign/Symptoms: accumulation of subjective and objective changes in
the patient’s health status that indicate a nutrition problem and that
are the results of the identified etiology
▪ Within a nutrition diagnostic PES statement, the signs and
symptoms should be preceded by the words as evidenced by
• Examples:
o Excessive caloric intake (problem) related to frequent consumption of
large portions of high-fat meals (etiology) as evidenced by average
daily intake of calories exceeding recommended amount by 500 kcal
and 12-pound weight gain during the past 18 months (signs).
o “Inadequate energy intake (P) related to changes in taste and appetite
(E) as evidenced by average daily kcal intake 50% less than estimated
recommendations (S)”

III. NUTRITION INTERVENTION

• Nutrition interventions are “purposefully planned actions designed with the
intent of changing a nutrition-related behavior, risk factor, environmental
condition, or aspect of health status for an individual, target group, or the
community at large.”

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 • Objectives of the care plan are client-driven, thus focusing attention on
personal needs and goals as well as on the identified requirements of medical
care for the patient.
• The nutrition intervention strategies are organized into four categories:
o Food and/or Nutrient Delivery
▪ Personalized/individualized needs can be achieved through
exploring the following areas with the family:
1. Personal needs: What personal desires, concerns, goals,
or life situation needs must be met?
2. Disease: How does the patient’s disease or condition
affect the body and its normal metabolic functions?
3. Nutrition therapy: Prioritize diagnoses on the basis of
urgency, impact, and resources. How and why must the
diet change to meet the needs created by the patient’s
particular disease or condition?
4. Food plan: How do these necessary nutritional
modifications affect daily food choices? Write a nutrition
prescription that is focused on the etiology to meet these
needs.
▪ Mode of Feeding:
1. Oral Nutrition
2. Enteral Nutrition
o a mode of feeding that makes use of the
gastrointestinal tract through oral or tube feeding
o When a patient’s gastrointestinal tract is
functioning but he or she cannot consume food
orally, enteral feeding is an option
3. Parenteral Nutrition
o a mode of feeding that does not make use of the
gastrointestinal tract but that instead provides
nutrition support via the intravenous delivery of
nutrient solutions
o If patients are unable to tolerate any nutrient
delivery into the gastrointestinal tract, parenteral
nutrition therapy is considered

(Further discussion of the modes of feeding will be in Lesson 2 of this

module.)

o Nutrition Education
▪ A formal process to instruct or train a patient/client in a skill
▪ Impart knowledge to help patients/clients voluntarily manage or
modify food, nutrition and physical activity choices, and
behavior to maintain or improve health
o Nutrition Counseling
▪ A supportive process that is characterized by a collaborative
counselor-patient relationship to promote health
▪ Sets priorities, establishes goals, and creates individualized
action plans that acknowledge and foster responsibility for self-
care to treat an existing condition

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 o Coordination of Nutrition Care
▪ Consultation with, referral to, or coordination of nutrition care
with other health care providers, institutions, or agencies that
can assist with the treatment or management of nutrition-
related problems.

IV. NUTRITION MONITORING AND EVALUATION

• identifies patient outcomes relevant to the nutrition diagnosis and the
intervention plan
• The three components of this process are as follows:
1. monitor progress,
2. measure outcomes, and
3. evaluate outcomes
• Outcome measures include the following categories:
1. Food-/nutrition-related history outcomes
▪ Food and nutrient intake
▪ Food and nutrient administration
▪ Medication, complementary/alternative medicine use
▪ Knowledge and beliefs
▪ Availability of food and supplies
▪ Physical activity, nutrition quality of life
2. Anthropometric measurement outcomes
▪ Height
▪ Weight
▪ Body mass index
▪ Growth pattern indices and percentile ranks
▪ Weight history
3. Biochemical data, medical tests, and procedure outcomes
▪ Lab data (e.g., electrolytes, glucose) and tests (e.g., gastric
emptying time, resting metabolic rate)
4. Nutrition-focused physical finding outcomes
▪ Physical appearance ▪ Appetite
▪ Muscle and fat wasting ▪ Affect
▪ Swallow function
• Efficacy of the care plan is assessed, and changes are made, if necessary.
• If changes are not necessary and the patient’s goals have been satisfied, the
dietitian may discharge the patient from nutrition services at this point.

DOCUMENTING NUTRITION CARE

• Each step of the nutrition care process must be documented in the patient’s
medical record
• ADIME format
o Using this format, the nutrition care plan is recorded as follows:
▪ Assessment. The assessment section summarizes relevant
assessment results, such as the medical problem, historical
information, height, weight, BMI, laboratory test results, and
relevant symptoms.
▪ Diagnosis. The diagnosis section lists and prioritizes the nutrition
diagnoses.

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 ▪ Intervention. The intervention section describes treatment goals
and expected outcomes, specific interventions, and the patient’s
responses to nutrition care.
▪ Monitoring and Evaluation. The monitoring and evaluation section
records the patient’s progress, changes in the patient’s condition,
and adjustments in the care plan.
• SOAP Format
o The letters represent the types of information included in each section:
Subjective, Objective, Assessment, and the Plan for care.
▪ Subjective information is obtained in an interview with the patient
or caregiver and includes the chief medical problem and relevant
symptoms.
▪ Objective information includes nutrition screening or assessment
data, such as the results of anthropometric and laboratory tests and
the physical examination.
▪ Assessment section contains a brief evaluation of the subjective and
objective data and provides concise diagnoses of the nutrition
problems.
▪ Plan includes recommendations that can help solve the problem,
including the nutrition prescription, plan for nutrition education and
counseling, and referrals to other professionals or agencies.

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Lesson 2

Diet Modification and Diet

Therapy

CLINICAL NUTRITION
• focuses on the nutritional management of individuals or group of individuals
with established disease condition
• deals with issues such as altered nutritional requirements associated with the
disease, disease severity and malnutrition and many such issues

DIETETICS
• The branch of medicine concerned with how food and nutrition affects human
health comprising the rules to be followed for preventing, relieving or curing
disease by diet.
• deals with feeding individuals based on the principles of nutrition
• the science and art of human nutritional care

CLINICAL DIETETICS
• the application of dietetics in a hospital or health care institutional setting

DIET THERAPY
• a branch of dietetics concerned with the use of food for therapeutic purpose
• The purpose of diet therapy is to restore or maintain an acceptable nutritional
status of a patient. This is accomplished by modifying one or more of the
following aspects of the diet:
o Basic nutrient(s) o Texture or consistency
o Caloric contribution o Seasoning

Principles and Objectives of Diet Therapy

1. To increase or decrease body weight
2. To maintain a state of positive health and good nutritional status
3. To ensure adequate nutrition for all age groups and physical conditions
4. To correct nutrient deficiency that may occur
5. To prevent chronic degenerative processes and diseases
6. To adjust food intake to the body’s ability to metabolize the nutrient e.g.
carbohydrate modification in diabetes mellitus

THERAPEUTIC DIET
• a qualitative/quantitative modified version of a normal regular diet which has
been tailored to suit the changing nutritional needs of patient/individual and
are used to improve specific health/disease condition
• Some common examples of therapeutic diets 3 include clear liquid diet,
diabetic diet, renal diet, gluten free diet, low fat diet, high fiber diet

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Normal/ General Diet
• a balanced diet which meets the nutritional needs of an individual/patient
o Balanced diet is defined as one which contains a variety of foods in such
quantities and proportions that the need for energy, proteins, vitamins,
minerals, fats and other nutrients is adequately met for maintaining
health and well being.
• given when the individual's medical condition does not warrant any specific
modification
• provides approximately 1600 to 2200Kcal, and contain around 180 to 300g
carbohydrates, 60 to 80g of fat and 40 to 70 g of protein

Modification of Normal Diet

The reasons for modifying the diets may include:

• For essential or lifesaving treatment: For example in celiac disease, providing
gluten free diet
• To replete patients who are malnourished because of disease such as cancer
and intestinal diseases by providing a greater amount of a nutrient such as
protein
• To correct deficiencies and maintain or restore optimum nutritional status
• To provide rest or relieve an affected organ such as in gastritis
• To adjust to the body's ability to digest, absorb, metabolize or excrete: For
example a low fat diet provided in fat malabsorption
• To adjust to tolerance of food intake. For example in case of patients with
cancer of esophagus tube feeding is recommended when patients cannot
tolerate food by mouth
• To exclude foods due to food allergies or food intolerance
• To adjust to mechanical difficulties, for example for elderly patients with
denture problems, changing the texture/consistency of food recommended due
to problems with chewing and/or swallowing
• To increase or decrease body weight/body composition when required, for
example as in the case of obesity or underweight
• As helpful treatment, alternative or complementary to drugs, as in diabetes or
in hypertension
Significance of Modified/Therapeutic Diet
• it is useful in managing the disease condition
• it promotes resistance to disease condition
• is preventive or supplemental treatment

Types of Modified/Therapeutic Diet

A. Diets of Altered Consistency
a. Liquid Diet
• consists of foods that can be served in liquid or strained form in
room temperature
• usually prescribed in febrile states, postoperatively i.e. after
surgery when the patient is unable to tolerate solid foods
• used for individuals with acute infections or digestive problems,
to replace fluids lost by vomiting, diarrhea
• Clear Liquid Diet

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 o provides foods and fluids that are clear and liquid at
room temperature
o purpose is to provide fluids and electrolytes to prevent
dehydration
o provides some amount of energy but very little amount of
other nutrients; is nutritionally inadequate and should be
used only for short periods i.e. 1-2 days
o contains 600 to 900Kcal, 120 to 200g carbohydrate,
minimal fat 5 to 10g protein and small amount of sodium
and potassium (electrolytes)
o useful in situations when the gastrointestinal tract has to
be kept functionally at rest
o Examples of clear liquid diet: Water, strained fruit juices,
coconut water, lime juice, whey water, barley/arrowroot
water, rice kanji, clear dal soup, strained vegetable or
meat soup, tea or coffee without milk or cream,
carbonated beverages, ice pops, plain gelatin
• Full Liquid Diet
o provides food and fluids that are liquid or semi liquid at
room temperature
o used as a step between a clear liquid diet and a regular
diet
o purpose of the full liquid diet is to provide an oral (by
mouth) source of fluid for individuals who are incapable
of chewing, swallowing or digesting solid food
o provides more calories than the clear liquid diet and gives
adequate nourishment, except that it is deficient in fiber
o An average full liquid diet can provide approximately
1000 to 1800 calories and 50 to 65g of protein and
adequate minerals and vitamins
o Examples of full liquid diet: Foods allowed or included in
a full liquid diet include beverages, cream soups,
vegetable soups, strained food juices, lassi/butter milk,
yogurt, hot cocoa, coffee/tea with milk, carbonated
beverages, cereal porridges (refined cereals) custard,
sherbet, gelatin, puddings, ice cream, eggnog,
margarine, butter, cream (added to foods), poached, half
boiled egg
b. Soft Diet
• provides soft whole food that is lightly seasoned and are similar
to the regular diet
• does not contain harsh fiber or strong flavors
• provides a transition between a liquid and a normal diet i.e.
during the period when a patient has to give up a full liquid diet
but is yet not able to tolerate a normal diet
• given during acute infections, certain gastrointestinal disorders
and at the post-operative stage to individuals who are in the
early phase of recovery following a surgery

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 • can be nutritionally adequate (providing approximately 1800-
2000 calories, 55-65g protein) provided the patient is able to
consume adequate amount of food
• Examples of soft diet: A soft diet freely permits the use of
cooked vegetables, soft raw fruits without seeds, broths and all
soups, washed pulses in the form of soups and in combination of
cereals and vegetables, breads and ready-to-eat cereals (most
preferable refined such as pasta, noodles etc.), milk and milk
beverages, yogurt, light desserts (custard, jelly, ice cream), egg,
tender and minced, ground, stewed meat and meat products, fat
like butter, cream, vegetable oil and salt and sugar in
moderation
• Foods to be best avoided in the soft diet include coarse cereals,
spicy highly seasoned and fried foods, dry fruits and nuts, rich
desserts.
• Mechanically Soft Diet
o a normal diet that is modified only in texture for ease of
mastication i.e. chewing
o for individuals who cannot chew or use facial muscles for
a variety of dental, medical or surgical conditions and
elderly persons who have dental problems
o The food in mechanical soft diet is similar to the soft diet
and may be full liquid, chopped, pureed or regular food
with soft consistency
c. Bland Diet
• made of foods that are soft, not very spicy and low in fiber
• consists of foods which are mechanically, chemically and
thermally non-irritating i.e. are least likely to irritate the
gastrointestinal tract
• for individuals suffering from gastric or duodenal ulcers, gastritis
or ulcerative colitis
• Foods Included: Milk and milk products low in fat or fat free;
Bread, pasta made from refined cereals, rice; cooked fruits and
vegetables without peel and seeds; Eggs and lean tender meat
such as fish, poultry that are steamed, baked or grilled; Cream,
butter; Puddings and custards, clear soups.
• Foods Avoided: Fried, fatty foods; Strong flavored foods; Strong
tea, coffee, alcoholic beverages, condiments and spices; High
fiber foods; hot soups and beverages; whole grains rich in fiber;
strong cheeses.
B. Modification in Quantity
a. Restriction Diet
• Sodium restricted diet – for patients with high blood pressure
• Purine restricted diet – for patients with gout
• Low residue diet - prescribed and/or before abdominal surgery
b. Elimination Diet - recommended when there is food intolerances or
complete insensitivity to a particular food
• gluten free diet
• dairy free diet

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 • nut free diet
c. increase in the amount of a specific dietary constituent
• high potassium diet – for high blood pressure
• high fiber diet – for constipation
• iron rich diet – for anemia
C. Modification in Nutrient (Proteins, Fat, Carbohydrate) Content
a. diabetic diet
• for patients with high blood sugar
• Refined carbohydrates are avoided; complex carbohydrates are
recommended
b. fat controlled low cholesterol diet
• for patients with heart disease
c. low protein diet
• for patients with renal failure and advanced liver disease
d. high protein, high calorie diet
• for HIV, cancer, and malnourished patients
e. weight reduction diet
• for overweight and obese patients
D. Changes in Meal Frequency
a. Small but frequent meals
• For individuals suffering with gastro-esophageal reflux disease
(GERD)
• Pregnant women experiencing nausea and vomiting
E. Changes in Method of Cooking
a. Leaching (soaking in water)
• indicated for cooking vegetables for people with chronic kidney
diseases because the kidney's no longer maintain the ideal 12
level of potassium necessary for optimum health
• drains out excessive potassium and phosphorous from the
vegetables
b. In elderly people food may be modified by mechanical processing such
as mashing, blendrizing or chopping
c. For patients on bland diet foods steamed, baked or grilled are
recommended.
F. Modification in the Method of Feeding
a. Enteral Feeding
• provision of nutrients using the gastrointestinal (GI) tract,
usually refers to the use of tube feedings, which deliver
nutrient-dense formulas directly to the stomach or small
intestine via a thin, flexible tube
• used only for patients with functional GI tract
• Candidates for Tube Feedings:
o Severe swallowing disorders
o Impaired motility in the upper GI tract
o GI obstructions and fistulas that can be bypassed with a
feeding tube
o Certain types of intestinal surgeries
o Little or no appetite for extended periods, especially if
the patient is malnourished

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 o Extremely high nutrient requirements
o Mechanical ventilation
o Mental incapacitation due to confusion, neurological
disorders, or coma
• Contraindications
o severe GI bleeding
o high-output fistulas
o intractable (not easily managed/controlled) vomiting or
diarrhea
o severe malabsorption
• Routes (Defined and compared in the table below.)
o Orogastric - tube is inserted into the stomach through
the mouth. This method is often used to feed infants
because a nasogastric tube may hinder the infant’s
breathing.

TUBE FEEDING ROUTES

Insertion Method or Advantages
Feeding Site
Transnasal Does not require surgery or
(a transnasal feeding incisions for placement;
tube is one that is tubes can be placed by a
inserted through the nurse or trained dietitian.
nose)
1. Nasogastric Easiest to insert and confirm
(tube is placed into the placement; least expensive
stomach via the nose) method; feedings can often
be given intermittently and
without an infusion pump.
2. Nasoduodenal and Lower risk of aspiration in
nasojejunal compromised patients;
(tube is placed into the allows for earlier tube
duodenum or jejunum feedings than gastric
via the nose) feedings during acute stress;
may allow enteral feedings
even when obstructions,
fistulas, or other medical
conditions prevent gastric
feedings.
Tube enterostomies Allow the lower esophageal
(an opening into the GI sphincter to remain closed,
tract through the reducing the risk of
abdominal wall) aspiration; more comfortable
than transnasal insertion for
long-term use; site is not
visible under clothing.
1. Gastrostomy Allow the lower esophageal
[An opening into the sphincter to remain closed,
Disadvantages
Easy to remove by
disoriented patients; long
term use may irritate the
nasal passages, throat, and
esophagus.
Highest risk of aspiration in
compromised patients; risk
of tube migration to the
small intestine.
More difficult to insert and
confirm placement; risk of
tube migration to the
stomach; feedings require
an infusion pump for
administration.
Tubes must be placed by a
physician or surgeon;
general anesthesia may be
required for surgically
placed tubes; risk of
complications from the
insertion procedure; risk of
infection at the insertion
site.
Tubes must be placed by a
physician or surgeon;

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stomach through which reducing the risk of general anesthesia may be
a feeding tube can be aspiration; more comfortable required for surgically
passed. A nonsurgical than transnasal insertion for placed tubes; risk of
technique for creating a long-term use; site is not complications from the
gastrostomy under local visible under clothing. insertion procedure; risk of
anesthesia is called infection at the insertion
percutaneous site.
endoscopic gastrostomy
(PEG)]
2. Jejunostomy Lowest risk of aspiration; Most difficult insertion
[An opening into the allows for earlier tube procedure; most costly
jejunum through which feedings than gastrostomy method; feedings require an
a feeding tube can be during critical illness; may infusion pump for
passed. A nonsurgical allow enteral feedings even administration.
technique for creating a when obstructions, fistulas,
jejunostomy is called or medical conditions
percutaneous prevent gastric feedings.
endoscopic jejunostomy
(PEJ). The tube can
either be guided into
the jejunum via a
gastrostomy or passed
directly into the
jejunum (direct PEJ)]

• Types of Enteral Formulas

o Standard formulas
▪ enteral formulas that contain mostly intact
proteins and polysaccharides
▪ Also called polymeric formulas
▪ Blenderized formulas
- enteral formulas that are prepared by
using a food blender to mix and puree
whole foods
o Elemental formulas/Hydrolyzed/Chemically
Defined/Monomeric Formulas
▪ 1-3 kcal/ml; enteral formulas that contain
proteins and carbohydrates that are partially or
fully hydrolyzed
o Specialized formulas
▪ 1-2 kcal/ml; enteral formulas for patients with
specific illnesses
▪ Also called disease-specific or specialty formulas
o Modular formulas
▪ 3-8 kcal/ml; enteral formulas prepared in the
hospital from modules that contain single
macronutrients; used for people with unique
nutrient needs
• Selection of Formula

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 o factors considered when choosing a formula are shown in
the image on the next page
• Feeding tubes
o Feeding tubes are made from soft, flexible materials
(such as silicone or polyurethane) and come in a variety
of lengths and diameters
o The outer diameter of a feeding tube is measured in
French units, in which each unit equals 1/3 millimeter;
thus, a “12 French” feeding tube has a 4-millimeter
diameter (12* 1/3 mm =4 mm)
o Double-lumen tubes allow a single tube to be used for
both intestinal feedings and gastric decompression, a
procedure in which the stomach contents of patients with
motility problems or obstructions are removed by suction.

Selection of Formula

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 • Methods of Delivery
o intermittent: delivery of about 250 to 400 milliliters of
formula over 30 to 45 minutes
o continuous: slow delivery of formula at a constant rate
over an 8- to 24-hour period
o bolus: delivery of about 250 to 500 milliliters of formula
over a 5- to 15-minute period
• Tube Feeding Complications
o Insertion: nasal damage, variceal bleeding
o PEG/PEJ Insertion: bleeding; intestinal /colonic
perforation
o Post-insertion trauma: discomfort, erosions, fistula,
strictures
o Displacement: tube falls out, bronchial administration of
feed
o Reflux: esophagitis, aspiration
o GI Intolerance: nausea, pain, bloating, diarrhea
o Metabolic: refeeding syndrome, hyperglycemia, fluid
overload, electrolyte disturbance
• Nursing Considerations
o When beginning enteral feedings:
▪ protocols should be reviewed carefully before
working with patients
▪ patient tolerance must be considered when
adjusting formula delivery rates
▪ Assess the abdomen by auscultating for bowel
sounds and palpating for rigidity, distension, and
tenderness.
o On an ongoing basis:
▪ monitor patient for gastric distension, nausea,
bloating, and vomiting
▪ Stop the infusion and notify the provider if the
patient experiences acute abdominal pain,
abdominal rigidity, or vomiting.
o After feeding:
▪ measure the gastric residual volume, or the
volume of formula and GI secretions remaining in
the stomach after feeding
▪ experts recommend that feedings be withheld and
an evaluation be conducted if the gastric residual
volume exceeds 500 milliliters
b. Parenteral Feeding
• provides nutrients intravenously to patients who do not have
sufficient GI function to handle enteral feedings
• Usually used for severely malnourished patients undergoing
chemotherapy and major surgery
• The primary purpose of the method is to maintain a positive
nitrogen balance.
• TPN also aims at:

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 o Keeping the patient’s nutrition at a healthy state.
o Preserving muscle mass; thus, lessening body fat.
o Managing proper metabolism.
o Sustaining continuous circulation inside the body.
• Candidates for Parenteral Nutrition (conditions)
o Intractable vomiting or diarrhea
o Severe GI bleeding
o Intestinal obstructions or fistulas
o Paralytic ileus (intestinal paralysis)
o Short bowel syndrome (a substantial portion of the small
intestine has been removed)
o Bone marrow transplants
o Severe malnutrition and intolerance to enteral nutrition
• Access sites:
o Peripheral veins – Peripheral Parenteral Nutrition (PPN)
▪ smaller, peripheral vein is used
▪ used most often in patients who require short-
term nutrition support (less than 2 weeks) and
who do not have high nutrient needs or fluid
restrictions
▪ limited to 900 milliosmoles per liter because
peripheral veins are sensitive to high nutrient
concentrations
o Central veins – Central/Total Parenteral Nutrition (TPN)
▪ Use of superior vena cava or subclavian vein
▪ PICC – Peripherally Inserted Central Catheter
- less invasive and lower in cost
- a less invasive and low-cost central line
access that is inserted in the basilic vein,
with the tip in the superior vena cava or
right atrium
• Components of Parenteral Solutions
o Amino acids
▪ amino acid concentrations in commercial solutions
To convert range from 3 to 20 percent
nutrient o Carbohydrates
concentrations to ▪ provided in the form dextrose monohydrate which
grams per gives 3.4 kcalories per gram
milliliter: ▪ concentrations greater than 10 percent are usually
• 10% amino acid used only in TPN solutions
solution = 10 g o Lipids
▪ supply essential fatty acids
amino acids/100
▪ available in 10, 20, and 30 percent solutions,
mL
containing 1.1, 2.0, and 3.0 kcalories per
• 10% dextrose milliliter, respectively
solution = 10 g ▪ may supply 20 to 30 percent of total kcalories
dextrose o Fluids and electrolytes
monohydrate/100 ▪ include sodium, potassium, chloride, calcium,
mL magnesium, and phosphate
o Vitamins and Trace Minerals

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 ▪ All vitamins are usually included in parenteral
solutions, although a preparation without vitamin
K is available for patients using warfarin therapy
▪ trace minerals typically added to parenteral
solutions include chromium, copper, manganese,
selenium, and zinc
▪ Iron is often excluded because it can destabilize
parenteral solutions that contain lipid emulsions;
therefore, special forms of iron may need to be
injected separately.
• Parenteral formulations
o total nutrient admixture (TNA)/ 3-in-1 solution/an all-in-
one solution
▪ contains dextrose, amino acids, and lipids
o 2-in-1 solution
▪ Excludes lipids
• Methods of Administering Parenteral Nutrition
o Continuous Parenteral Nutrition
▪ infused continuously over 24 hours
o Cyclic Parenteral Nutrition
▪ For long-term parenteral nutrition, infusions are
given 10- to 14-hour periods per day
• Potential Complications
o Catheter-Related
▪ Air embolism
▪ Blood clotting at catheter tip
▪ Clogging of catheter
▪ Dislodgment of catheter
▪ Improper placement
▪ Infection, sepsis
▪ Phlebitis
▪ Tissue injury
o Metabolic
▪ Electrolyte imbalances
▪ Gallbladder disease
▪ Hyperglycemia, hypoglycemia
▪ Hypertriglyceridemia
▪ Liver disease
▪ Metabolic bone disease
▪ Nutrient deficiencies
▪ Refeeding syndrome
- a condition that sometimes develops when
a severely malnourished person is
aggressively fed; characterized by
electrolyte and fluid imbalances and
hyperglycemia.
• Nursing Considerations:
o Discard all unused, cloudy, or sedimented fluids.
o Do not add drugs and other mixtures to a solution
containing protein.

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 o Refrigerate solutions until they are used.
o Be aware that dates should be on tube feedings, and that
they should not be given past 24 hours of date.
o Be alert for signs of gas, regurgitation, cramping, and
diarrhea, and be prepared to intervene.
o Take necessary precautions when using nutrient solutions
because they are excellent sources for bacterial growth.
o Be especially alert for signs of hypo- or hyperglycemia
when TPN is used and intervene if necessary.
o Assist the patient in adjusting to an alternate feeding
method. Many patients experience stress due to fear and
concern of unfamiliar feeding methods.
o Encourage and practice good oral hygiene measures with
the patient, even though he or she is not eating by
mouth.
o Encourage early ambulation, which makes use of the
muscles and increases the use of calcium and protein.
Physical activity also raises morale.

Selecting a Feeding Route

Module V Page 187

 MODULE SUMMARY

This module has 2 lessons which discussed clinical nutrition and diet therapy.
Lesson 1 tackled nutrition care process as the foundation of nutrition therapy.
Lesson 2 discussed diet therapy which consisted
Congratulations! You have just studied Module V. Now you are ready to
evaluate how much you have benefited from your reading by answering the summative
test. Good Luck!!!

SUMMATIVE TEST

Multiple Choice

1. For a patient who is at high risk of 4. A difference between continuous and

aspiration and is not expected to be intermittent feedings is that
able to eat table foods for several continuous feedings:
months, an appropriate placement a. require an infusion pump.
of a feeding tube might be: b. allow greater freedom of movement.
a. nasogastric. c. are more similar to normal patterns
b. nasoenteric. of eating.
c. gastrostomy. d. are associated with more GI side
d. jejunostomy. effects.

2. In selecting an appropriate enteral 5. A patient needs 1800 milliliters of

formula for a patient, the primary
consideration is:
a. formula osmolality.
b. the patient’s nutrient needs.
c. availability of infusion pumps.
d. formula cost.
3. An important measure that may
prevent bacterial contamination in
tube feeding formulas is:
a. nonstop feeding of formula.
b. using the same feeding bag and
tubing each day.
c. discarding opened containers of
formula not used within 24 hours.
d. adding formula to the feeding
container before it empties
completely.
formula a day. If the patient is to
receive formula intermittently
every four hours, how many
milliliters of formula will she need
at each feeding?
a. 225
b. 300
c. 400
d. 425
Enumeration
1. What are the steps in nutrition care
process? Define each step.
2. What are the different therapeutic
diets used in clinical care? Which
patients benefit from these types of
therapeutic diet?

Module V Page 188

 Laboratory Activity
I. Using the following assessment data, develop a nutrition care plan. (Use NANDA or
other NCP reference books)
Subjective:
Patient reports excessive snacking at work, little exercise, recent weight gain
of 10 lb in past year; willing to attempt 5% weight loss and dietary/lifestyle changes to
reduce LDL-C before trying statin medication

Objective:
Height: 6’1”
Weight: 268 lb
BMI: 35.4, obesity II
Total cholesterol: 288 mg/dL
Waist circumference: 45”
LDL-C: 214 mg/dL;
HDL-C: 48 mg/dL
EER: 2725 kcal
Triglycerides: 132 mg/dL
Diet order: Weight reduction; heart-healthy diet

Assessment:
Abdominal obesity; dietary recall indicates ~3700 kcal intake per day and diet
high in fat, saturated fat, trans fat

Nutrition Diagnosis/Plan:
Nutrition Intervention:

Module V Nutrition and Diet Therapy, 1st Semester AY 2022-2023