Nutritional Support and the
Occupational Therapist's Role
(acute care; hyperalimentation; nutritional care; services, occupational
therapy)
Ilene G. Malamud
Nutrition, although important, is
often overlooked during hospitaliza-
tion. At Grant Hospital of Chicago,
a nutritional support team is trained
in recognizing, assessing, and man-
aging nutritional disorders. The oc-
cupational therapist member of this
team works to enhance patients'
functional independence physically
and emotionally. Knowledge of nu-
trition is necessary for all health
professionals when dealing with the
total person.
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N utrition is often ignored dur-
ing a patient's hospitaliza-
tion. Butterworth (1) states that
"one of the largest pockets of un-
recognized malnutrition in Amer-
ica, and Canada too, exists not in
rural slums or urban ghettos, but
in the private rooms and wards of
big city hospitals" (p. 4). A nutri-
tional support team is trained in
recognizing, assessing, and treating
nutritional disorders commonly
caused by illness. Illness can result
in anorexia and increased nutri-
tional demands. Yet nutritional
support can lead to a decreased
hospital stay by helping to prevent
postoperative medical complica-
tions. This article will outline basic
terminology, various diagnoses in-
dicating hyperalimentation, the
team approach, and the specific
role of the occupational therapist
on the nutritional support team.
To prevent and treat malnutri-
tion, health professionals must be
aware of various modes of nutri-
tional support. Increased knowl-
edge about nutrition will help the
therapist recognize nutritional
needs and manage patients appro-
priately. There are two basic types
of nutritional support: enteral and
parenteral. The type chosen de-
pends on factors such as the disease
The American Journal of Occupational Therapy
process, the number of calories re-
quired daily, the condition of the
patient's gastrointestinal tract, the
length of time nutritional support
is needed, and the patient's level of
cooperation.
Enteral Nutrition
The administration of enteral
nutrition requires the use of a func-
tional gastrointestinal tract. En-
teral nutrition may be as basic as
an individualized diet complete
with adequate calories, protein, vi-
tamins, and minerals to maintain
or replete a pa tien t' s n u tri tional
stores, and it may include commer-
cially prepared nutritional supple-
ments. On a more complex level, a
nasogastric or nasojejunal tube
may be inserted, or a permanent
feeding tube such as a gastrostomy
or jejunostomy may be required.
With the availability of the gas-
trointestinal tract, conditions that
indicate enteral route include cen-
tral nervous system disorder, dys-
Ilene G. Malamud, OTRIL, is Di-
rector of Occupational Therapy,
Lake Shore Nursing Center, Chi-
cago, IL 60626. At the time of this
study, she was an occupational ther-
apist at Grant Hospital, Chicago.
343
 phagia, and anorexia. Contraindi-
cations include diseases where
bowel rest is needed, obstruction is
possible, or aspiration is feared.
The enteral route, which is safest
and most efficient, may be the
long-term goal for nutritional sup-
port even when it is not the method
used initially.
Parenteral Nutrition
Nutrition administered through
an intravascular route is referred
to as parenteral nutrition. Paren-
teral hyperalimentation can be
either partial parenteral nutrition
(PPN) through a peripheral vein or
total parenteral nutrition (TPN) or
central vein hyperalimentation us-
ing a central vein. Indications for
parenteral nutrition include oncol-
ogy patients receiving chemother-
apy and/or radiation resulting in
gastrointestinal side effects; pa-
tients with disorders of the gas-
trointestinal tract (i.e., obstruction,
the need for bowel rest); high-risk,
pre- and postoperative patients;
and severe trauma patients. These
patients have to be built up nutri-
tionally and either cannot or
should not take in adequate nutri-
tion via the enteral route.
PPN is used in patients with
slight to moderate nutritional def-
icits and is often used in conjunc-
tion with oral feedings. Intrave-
nous (I V) lines are usually placed
in a patient's upper extremity, and
the rate of flow of the fluid in the
lines is carefully monitored by an
infusion device. Patients with poor
venous access or patients who need
nutritional support for an ex-
tended length of time are not good
candidates for PPN. However,
PPN can be an effective supple-
mental measure for increasing a
patient's daily calories.
With TPN, an IV catheter is sur-
gically inserted into the subclavian
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or internal jugular vein and
threaded to the superior vena cava.
TPN is considered when a patient
has a nonfunctioning gastrointes-
tinal tract, requires total bowel
rest, is unable to eat for an ex-
tended period of time, or when
PPN is not adequate to meet a pa-
tient's caloric needs. As with PPN,
ensuring proper infusion of this
highly concentrated solution is es-
sential. TPN can provide patients
with their total daily caloric needs
during these times of stress.
The Team Approach
Patients with various illnesses, in-
cluding cancer, Crohn's disease, ul-
cerative colitis, liver failure, pan-
creatitis, cardiac disease, and gen-
eral anorexia caused by illness, are
followed by the nutritional support
team. At Grant Hospital, the nutri-
tional support team includes a di-
rector (a credentialed, hyperali-
mentation physician) who is also
chief of surgery, two nurse clini-
cians, a clinical dietician, two clini-
cal pharmacists, an occupational
therapist, and a physical therapist.
The team began officially in Jan-
uary 1981, although it was started
informally in 1979. Occupational
therapy has been involved with
the nutritional support team ap-
proximately since 1980, attending
meetings and medical rounds and
treating patients followed by the
team. The team approach offers
continuity of care to patients and
team members. Goals are initially
The goals ot the nutritional support team are initially
directed toward stabiliZing the patient's nutritional and
medical status, then toward improving function and
endurance. When appropriate, discharge plans are also
made.
directed toward stabilizing the pa-
tient's nutritional and medical sta-
tus, then toward improving func-
tion and endurance. When appro-
priate, discharge plans are also
made.
The Role of the Occupational
Therapist
The occupational therapist on
the nutritional support team does
not work with all the patients who
are followed by the team; however,
most are referred to occupational
therapy for evaluation. Occupa-
tional therapy may not be appro-
priate for patients in deep coma or
for patients who have unstable
medical conditions.
With illness or injury, individuals
face intrapersonal losses, such as an
altered body image and a weaken-
ing of the self-concept, as well as
physical losses, such as decreased
mobility, lack of control over inti-
mate physical functioning, and the
inability to meet all their needs by
themselves (2). Occupational ther-
apy offers patients goal-directed ac-
tivity to increase their functional
mobility and self-care abilities.
Patients' anxieties may be com-
pounded when they are faced with
surgery, feeding tube replacement,
TPN, or PPN. Psychological prob-
lems may emerge during hospitali-
zation; pain, fear, and change in
medical status will influence moti-
vation and activity tolerance. Pa-
tients may attempt to avoid activity
because they are generally decon-
 ditioned from prolonged illness
and bedrest. They may be fearful
of movement with TPN or want to
overprotect the extremity receiv-
ing a PPN infusion. When precau-
tions are followed, such as watch-
ing TPN sites for redness or swell-
ing and allowing no stress on IV
sites, patients should have no prob-
lems participating in activities.
Emotional support is critical at this
time.
A program of individualized ac-
tivity should be instituted if nutri-
tional intake is used appropriately,
and it should result in increased
strength and endurance. Physical
activity or exercise enhances the
synthesis of protein into . keletal
muscle. Because the body doe not
store protein, unused calories are
stored only as fat or, to a lesser
extent, carboh drales (3, 4). he
effects of acti ity or exercise are
d monstrated by increased muscle
bulk (versus fat) and improved en-
durance.
Evaluation
The patient's current is
assessed befor therapy is initiated.
Areas evaluated include funClion
in activities of daily living (ADL),
mobility and exercise tolerance,
gross and fine hand strength and
coordination, perceptual/visual
motor problems, and functional
psychological status.
Through an interview, informa-
tion is gathered about the patient's
family support and home environ-
ment, occupational/work situation,
leisure activities, and cUITellt re-
sponse to illness. The evaluations
aid in understanding the patient's
physical and emotional condition
during hospitalization and allow
the therapist t develop appropri-
ate treatment goals in conjunction
with team members (5).
Treatment
Patients are engaged in activities
suited to their individual needs,
which can be upgraded with
changes in status. Examples in-
clude exercise programs, ADL
skills (using the precautions for
TPN and PP ), leisure time plan-
ning, and prescribing adaptive
equipment or teaching energy con-
servation techniques. Attaining
functional independence is the ul-
timate goal 8f treatment, and pa-
tients are encouraged to take an
active rol in treatment planning.
"Occupational therapy provides in-
tervelllion to all viate dysfunctio!O
and to main 'ain the highest I vel
of function in all aspects of living
throuah purposeful activity" (6, p.
27).
Prevention
As health professionals, 0 cupa-
tional therapists should b come
aware of patients at nutritional
risk. Subjectively, a patient may
complain of a poor appetite or
\oveakl ess. Objective measures in-
cI Ide weight loss, tests and proce-
dure that I' quire a patient to have
nothing by mouth, nonh aling
wounds, smallllluscle '\-'asting (t m-
por I. thenar, al d hypothel ar
wasting), and a long hospital stay.
If a patient demonstrates any of
these problems, a nutritional as-
sessment may be in order. Early
r cognition and tr atm l1l of nu-
tritional problem' can prevent de-
bilitation.
The early occupational therapy intervention occurred at the
patient's bedside and included the use of oral-facial
hygiene, grooming, bed mobility, and range-of-motion
exercises to increase the patient's upper extremity strength
and endurance.
Case Study
The following case study illus-
trates the occupational therapist's
role in caring for a nutritional sup-
port patient. H.V. was a 31-year-
old male with an admission diag-
nosis of chronic phlegmonous pan-
creatitis secondary to a I5-year his-
tory of alcohol abuse. H.V. lived
alone and had been employed as a
maintenance worker. Hisjob often
included bending, reaching, and
lifting activities, and demanded
substantial endurance.
During the early phase of his ad-
mission, the patient remained crit-
ically ill with a poor prognosis for
survival. He suffered renal failure,
pneumonia, and eventually under-
went a near-complete pancreatec-
tomy.
The patient was followed by the
nutritional support team upon ad-
mission. The indicated means of
nutritional support was TP . Ap-
proximately one month after ad-
mission, the patient's prognosis im-
proved, and referrals to occupa-
tional therapy and physical therapy
were initiated. Upon evaluation by
the occupation I therapist assigned
to th nutritional support team, the
following conditions were noted:
• pain and difficulty in bed mo-
bility (due to abdominal drain, nu-
merous IVs, and weakness);
• upper extremity muscle
strength 3/5 (fair) with tremor sec-
ondary to weakness;
• grasp strength of 32 Ibs in his

The American Journal of Occupational Therapy 345

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 right upper extremity and 28 lbs
in his left;
• poor self-image and minimal
avocational interests;
• activity tolerance limited to 10
minutes at minimal levels; and
• dependence in self-care.
The early occupational therapy
intervention occurred at the pa-
tient's bedside and included the use
of oral-facial hygiene, grooming,
bed mobility, and range-of-motion
exercises to increase the patient's
upper extremity strength and en-
durance. Within 2 weeks his toler-
ance of activity increased to 40
minutes, and treatment in the oc-
cupational therapy clinic ensued.
Occupational therapy and physical
therapy closely coordinated the pa-
tient's schedule to pace his periods
of exertion and rest evenly. During
the remaining 6 weeks of his acute
care hospitalization, physical ther-
apy treatment addressed general
physical conditioning using pro-
gressive resistance exercises, while
occupational therapy treatment in-
cluded more extensive self-care
training, upper extremity strength-
ening, and standing tolerance us-
ing functional activities and home-
346 May 1986, Volume 40, Number 5
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maker trammg. (Note that under
the existing practice of shortened
length of stay, this patient would
probably have been transferred to
the rehabilitation unit for the re-
mainder of his care.) The patient
was involved in selecting his goals
and choosing his treatment activi-
ties.
At the end of his hospitalization,
he was independent in self-care
skills, and his endurance was
greatly improved. During his ther-
apy sessions, he often vented his
fears concerning his alcohol de-
pendence and uncertain career
prospects. He was referred for out-
patient substance abuse counseling
and, although unable to return di-
rectly to work, he was hopeful that
in a short time he would return to
light duty. His participation in
therapy demonstrated how much
his strength and endurance im-
proved.
Conclusion
Nutrition is an important area of
health care, and increased knowl-
edge and immediate attention to
nutritional problems may lead to
decreased hospital stays. The team
approach to nutritional support
promotes continuity of care and
problem solving. The occupational
therapist's role on this team is to
increase the patient'S self-care
skills, monitor the patient'S activity
level, and provide psychosocial
support during nutritional ther-
apy. Recognition of nutritional dis-
orders and proper follow-up by the
team will aid in caring for the total
person.
REFERENCES
I. Butterworth GE: The skeleton in the
hospital closet. Nutrition Today Marchi
April: 4, 1974
2. Kutner B: Milieu therapy in rehabilita-
tion medicine. } Rehabil 34:14-17,
1968
3. Krause M. Mahan K: Food, Nutrition
and Diet Therapy. Philadelphia: Saun-
ders, 1979
4. Kaminski M, Winborn A: Nutritional
Assessment Guide. Chicago: Abbott
Pharm. 1978
5. Malamud I: Occupational therapists
working with hyperalimentation pa-
tients in a hospital selling. Nutritional
Support Services 2:42, 1982
6. Hopkins H, Smith H: Willard and
Spackman's Occupational Therapy. Phil-
adelphia: Lippincoll, 1978