Interventions to Promote Nutrition

Overview of the Anatomy and Physiology of the Digestive System

·         The GIT is composed of 2 general parts:

ü  Main GIT: Mouth – Esophagus – Stomach – Small intestines – Large Intestines – Rectum

ü  Accessory Glands: Salivary gland, Liver, Gallbladder, Pancreas

·         Food and Fluid Regulatory Center: HYPOTHALAMUS

·         DIGESTION

-process by which food is broken down for the body to use in growth, development, healing and
prevention of diseases

·         ABSORPTION

-process by which digested CHO, CHON, fats, minerals and vitamins are actively and passively
transported into organs and tissues

·         METABOLISM

-process by which nutrients are converted to energy to support cellular growth and repair

·         NUTRITION

- study of nutrients and the processes by which they are used by the body

Ø  MACRONUTRIENTS

1.    Carbohydrates

2.    Protein-

3.    Fats

Ø  MICRONUTRIENTS

1.    Vitamins

2.    Minerals

Ø  CALORIE (KILOCALORIE)

                   -1 g (CHO) - 4 CAL

                   - 1 G (CHON) - 4 CAL

                   - 1 G (FAT) - 9 CAL

Variable affecting Caloric Needs

1. Age and growth

2. Gender (higher BMR in males)

3. Climate (cold=higher BMR)

4. Sleep (lower BMR)

5. Activity

6. Fever

7. Illness

Review of Vitamins

Fat-soluble Vitamins:

·         These vitamins are unaffected by normal temperature and methods of food preparation.

·         Are found in the fats and oils of foods.

·         Are stored in the liver and in the fatty tissues of the body for long periods.

Water-soluble Vitamins:

·         These vitamins are easily affected by cooking process and exposure to air.

·         The body cannot store them in large amounts as the kidneys filter out any extra coming from
the diet.

Taxonomy Medical Name Sources Deficiency

A Retinol (animal) All yellow Xerophthalmia- Night blindness
orange
Carotene fruits and
(Plants) vegetables

B1 Thiamine Rice, Wernicke’s encephalopathy

chicken,
fish, nuts ·         Decreased level of
consciousness due to increased
intracranial pressure

·         Severe Body fatigue

B2 Riboflavin Eggs, Ariboflavinosis
eggplant,
coconut Cheilosis—Cracking at the side of the
lips

B3 Niacin/ Legumes, Pellagra

Nicotinic Acid/ root crops,
Nicotinamide cassava, 3 signs of pellagra
avocado
1.    Dementia

2.    Dermatitis

3.    Diarrhea

B5 Pantothenic Malunggay ·         Poor mental performance

, all meat
·         Stanted growth

·         No energy or body malaise

·         Liver failure (if severe)

B6 Pyridoxine Same as Microcytic anemia- the presence of

B2 small, often hypochromic, red blood
cells

Peripheral neuritis- conditions that

result when nerves that carry messages
to and from the brain and spinal cord
from and to the rest of the body are
damaged or diseased

·         Paresthesia

·         Paralysis

B7 Biotin Corn, Burning feet syndrome- also known

aubergine, as Grierson-Gopalan syndrome, is a set
pork of symptoms in which the feet often
become uncomfortably hot and painful.
B9 Folic acid/ Milk Neural tube defect- are birth defects of
Folate the brain, spine, or spinal cord.

B12 Cyanocobalamin All Pernicious Anemia- condition in

(Only absorbed vegetable, which the body can't make enough
in the intestines) all meat healthy red blood cells because it
doesn't have enough vitamin B12.

C Ascorbic Citrus Weak immune system

Scurvy, poor wound healing

D Calciferol Dried Fish, Osteomalacia, rickets

Milk,
Anchovies,
sardines

E Tocopherol Vegetable Dry skin, comedones (skin-colored,

oil, nuts, small bumps (papules) frequently
atis found on the forehead and chin of
those with acne), sagged skin

K Phytomenadione Liver, Bleeding

/ passion
Aquamenadione fruit

H Inactivated Same as b7 Burning feet syndrome

Biotin

Review of Minerals

ASSESSMENT OF NUTRITIONAL STATUS

1.    ANTHROPOMETRIC MEASUREMENTS

·         height

·         weight (best indicator of nutritional status)

·         Skin folds (Fat folds)

·         Arm Muscle circumference

·         Body Mass Index = wt in kg / (ht in meter) 2

·         BMI result:

        20-25%----- Normal

        27.5-30%--- Mild Obesity

        30-40%----- Moderate Obesity

        Above 40%- Severe Obesity

2.    Biochemical data

·         Hgb and Hct indices

·         -Serum Albumin

·         -Nitrogen Balance

·         -Creatinine Excretion

3.    Clinical signs

- hair, skin, tongue, mucous membrane, abdominal girth

4.    Dietary History

- 24 hr diet recall; 72 hr diet recall

MEASURES TO STIMULATE APPETITE

1. Serve food in pleasant and attractive manner

2. Place patient in a comfortable position (SF/HF to prevent aspiration)

3. Provide good oral hygiene measures

4. Promote comfort

5. Remember that color affects color

6. Engage in pleasant conversation

7. Assist weak patient in feeding

NURSING INTERVENTIONS FOR NAUSEA AND VOMITING

1. Position conscious clients in SF or HF position; unconscious patients in lateral position to prevent

aspiration

2. Provide good oral hygiene measures

3. Suction the mouth as needed if the client is unable to expel vomitus

4. Relieve nausea by offering the client:

- ice chips

- hot tea with lemon/ lime

- hot ginger ale

- dry toast or crackers

- cold cola beverage

5. Replace loss fluid by hydration and IV therapy

6. Observe for potential complications:

a. DEHYDRATION

- Thirst (first sign)

- dry mouth and mucous membrane

- warm, flushed, dry skin

- fever, tachycardia, low bp

- weight loss

- sunken eyeballs

- oliguria

- dark, concentrated urine

- high urine SG

- poor skin turgor

- altered LOC

- elevated BUN, Crea

-elevated Hct

b. Acid-base balance

    Metabolic Alkalosis: excessive vomiting

    Metabolic Acidosis: excessive diarrhea

7. Administer antiemetic as ordered by the physician for vomiting

·         Metoclopramide (Plasil)

·         Trimethobenzamide (Tigan)

·         Promethazine (Phenergan)

·         Prochlorperazine maleate (Compazine)

Therapeutic Diet

·         Normal diet that is modified to treat or cure diseases;

·         Therapeutic = treat or cure

·         Diet -food or beverages ingested for a special reason

Dietitian

·         specialist in dietetics

·         performs therapeutic and preventive roles

·         works with both ill and healthy people

Nutritionist

·         a specialist in the study of nutrition concerned with the study of nutrients, how nutrients are
used in the body and relationship between diet, health, and disease.

TYPES OF BASIC AND THERAPEUTIC DIETS

1.  Regular / Standard / House Diet

·         for patients who doesn’t have special needs or dietary modification

·         Omitted: foods that produce flatus (cabbage), highly seasoned, and fried foods

2.  Diet as Tolerated (DAT)

·         when patient’s appetite, ability to eat, and tolerance for food may change

·         ex. 1st post op day patient may be given clear liquid. If no nausea occurs, normal intestinal
motility returned (active bowel sounds, passes gas, and feels like eating) diet may be advanced to
full liquid or regular diet

3.  Cold Liquid Diet

·         Purposes: Blood Clotting

o   Post tonsillectomy

o   Post thyroidectomy

o   Post adenoidectomy

o   Post dental extraction

·         Cold Foods allowed

o   Plain ice cream (vanilla)

o   Sherbet

o   Cold milk

o   Cold Traditional Iced Tea

4.  Liquid Diets

CLEAR LIQUID FULL LIQUID

Purpose Ø  Initial diet after complete Ø  Intermediate diet between clear
bowel rest to: liquid & soft diet

o   prevent and correct Ø  Foods that melt or liquefy at

dehydration body temp

o   relieve thirst Ø  To provide additional

calories to clients who are unable
o   minimize gastric stimulation to tolerate solid foods.

Ø  Provides fluid and Ø  Indications

carbohydrates (sugar)
o   unable to tolerate solid or semi-
Ø  Short – term diet for 24 – 36 solid foods
hrs
o   GIT disturbances
Ø  Indications:
o   burns and illness
o   post surgery

o   acute inflammatory of GIT

(diarrhea, gastroenteritis,
pancreatitis)

o   burns and illness

Foods Ø  water, coffee (decaf/regular), Ø  all in clear liquid diet
allowed tea
Ø  milk and milk drinks
 Ø  carbonated drinks
Ø  fat free strained bouillon or
broth (soup stock)
Ø  clear or diluted fruit juices
(apple, grape, cranberry)
Ø  popsicles
Ø  gelatin
Ø  hard candy
Foods Ø  Dairy products and milk
not
allowed Ø  Fruit juices with pulp
5.  Modified Consistency Diets
SOFT DIET
Purpose Ø  diet after full liquid
Ø  easily chewed and digested
Ø  low – residue or low fiber diet semi-solid consistency
Indications
o   chewing and swallowing
difficulties
o   stroke patient
o   mandibular fractures, broken
jaw
Foods Ø  all foods in liquid diet
Ø  eggs (in pudding and custards)
Ø  plain ice cream, sherbet
Ø  yogurt
Ø  orange juice
Ø  vegetable juices
Ø  cream, butter, margarine,
smooth peanut butter
Ø  strained cream soups
PUREED DIET
Ø  Modification of soft diet
Ø  Any food that is added with
water and blended to produce a
Ø  To supply nutrition to clients
with NGT or gastrostomy tubes
(osterized feeding – food is placed
into a sterile bottle and discarded
after 24hrs)
Indications
o   mobility or refused food as
obstruction of esophagus
o   Anorexia nervosa
o   Severe burns
o   Comatose
Ø  pureed and blended foods
allowed

Ø  lean, tender, cooked, minced

ground meat, poultry, and fish
(chopped / shredded)

Ø  scrambled egg, omelet,

poached eggs, cottage cheese,
and mild cheeses

Ø  low fiber fruits without skin

and seeds (banana, mango,
sectioned orange, papaya)

Ø  low fiber cooked chopped

vegetables (mashed potato,
carrots, chayote, squash)

Ø  Rice, Pasta, soft bread, soft

cake, bread pudding
Foods long fibers, hard fried foods,
not highly seasoned, foods with
allowed skin/nuts/seeds, raw and gas
forming fruits and vegetables
(apple, beans, cabbage, celery,
onions, cherries, coconut, egg
plant, melons, onions, wheat)
 

6. Content – Modified Diets

High – Fiber or Sodium Restricted Diabetic Diet

High Residue
Purpose Ø  To prevent and Ø  To treat Ø  To control blood
treat constipation cardiovascular, renal, sugar level
and diverticulitis and liver disorder
Ø  Diet varies with
individual, severity of
diseases type and
extent of insulin
therapy received.
Foods Ø  fruits (apples, Ø  Fresh fruits and Ø  Balanced diet
allowed oranges) vegetables
Ø  Use dietary list
Ø  vegetables Ø  NO CANNED exchange
(broccoli, carrots, products, seafoods, and
corn) dairy products o   1 cup rice = 1 half
burger
Ø  whole grain
 (cereals, wheat, o   1 egg = ¼ cottage
grain) cheese

o   1 tsp margarine = 2

tsp mayonaise
7.        Electrolyte Reinforced Diets

High Potassium High Calcium High Phosphorous

Purpose Ø  To maintain Ø  To provide rigidity Ø  To treat
skeletal and cardiac and structure to bones hypophosphotemia
muscle activity

Foods Ø  Coffee Ø  Dairy and milk Ø  Soft drinks

allowed products
Ø  Milk Ø  Chocolate
Ø  Green leafy
Ø  Meat vegetables Ø  Milk

Ø  Fruits (banana, Ø  Small fish with

cantaloupe, bones
avocado, raisins,
strawberry) Ø  Tuna

Ø  Vegetables Ø  Sardines

1.    Bland Diet

Ø  Diet to allow stomach lining to heal (doesn’t stimulate gastric secretion)

Ø  Indications

o   diarrhea

o   indigestion

o   gastritis

o   gall bladder disease

o   ulcer

Ø  Foods Allowed

o   mild flavour

o   soft and smooth in texture

Ø  Not Allowed

o   Fibrous, hard meats, herbs and spices, coffee, tea, citrus fruits, very hot and cold beverages

o   strong flavoured vegetables (cabbage, onion, leek, cauliflower, turnip)

 2.    Candidiasis Diet

Ø  Free of:

o   Fruits

o   Fermented Foods

o   Sugar

o   Yeast

3.    Acid – Ash Diet

Ø  To alkalinize urine

Ø  To soothe irritated bladder or urethra

Ø  Foods: Citrus fruits and vegetables

Ø  Not Allowed: Prune juice and cranberry juice (both produce acidic urine)

4.    Ash – Acid Diet

Ø  For UTI – to acidify urine

Ø  Give protein, meat, poultry

 5.  Culture Related Diets (Religion and Their Dietary Practices) 

HALAL KOSHER VEGAN Mormon Protestant Roman

s s Catholic

Purpos To maintain To maintain To maintain (The (Greek

e dietary dietary dietary Church Orthodox)
requirement requirements requirement of Jesus
s of Muslim of Jewish s Christ of
Clients Clients of Seventh the latter
(Islamic) (Judaism/Jewis Day day saint)
h Faith) Adventist
Clients
Foods No pork Kosher foods Full No No dairy Fasting
can’t be Vegetarian Coffee, Products before
prepared using Alcohol, and meat communio
 No gelatin the utensils that diet Tea during n
was prepared in Fasting
No alcohol a non – kosher and during
food Holy Week
May lead to No pork
VB12
deficiency
Milk and meat
are not eaten
together but may
be eaten 6 – 12 No coffee,
hrs apart alcohol, tea,

Enteral Feeding

·         Enteral nutrition is administered to prevent or correct malnutrition and associated

complications.  It provides adequate nutrition via the gastrointestinal tract, through the delivery of
complete supplementary formulas.

·         Indications

o   Patient unable to swallow

o   Patient unable or unwilling to consume adequate nutrition orally

o   The patient must have a functioning GI tract

·         Contraindications

o   Malfunctioning GI tract (i.e. short gut syndrome, severe acute pancreatitis)

o   Mechanical obstruction

o   Prolonged ileus

o   Severe GI bleed

o   Severe diarrhea/intractable vomiting

o   GI tract fistula

o   TPN should be considered instead for patients with contraindications.

·         Route of Administration
     There are five routes of administration available for enteral feeding. The route of administration
will be determined by the predicted therapy, recovery time and/or disability.

1.    Nasogastric (nose into stomach)

·         This route is used most frequently due to ease of placement of the tube.  This is for short-
term enteral feeding (usually less than or equal to 8-12 weeks).

2.    Nasoduodenal (nose into duodenum)

·         This route bypasses the stomach and administers feeding directly into the small bowel.  The
main advantage of this route is less risk of aspiration and is used if gastric emptying is impaired.

3.    Nasojejuenal (nose into jejunum)

·         This route bypasses the stomach and administers feeding directly into the small bowel. The
main advantage of this route is less risk of aspiration and is used if gastric emptying is impaired.

4.    Gastrostomy (feeding tube inserted through abdominal wall into stomach)

·         This is the preferred method for long-term enteral feeding. Preferred for patients who have
an intact gag reflex, have normal emptying of gastric and duodenal contents and whose stomach is
not involved in the primary disease.

5.    Jejunostomy (feeding tube is inserted through abdominal wall into jejunum)                           

·         This route is used for long-term enteral feeding for patients with impaired gastric emptying.

 NASOGASTRIC TUBE (NGT)

- commonly used tube: LEVIN TUBE

Purposes:

·         -to provide feeding (gastric gavage)

·         -to irrigate stomach (gastric lavage)

·         -For decompression

·         -administration of meds

·         -administer supplemental fluid

·         Insertion procedure:

1. Inform patient and explain procedure.

2. Place in HF position to facilitate insertion.

3. Measure length of tube to be inserted starting from the tip of the nose to the tip of the earlobe,
to the xiphoid process).
4. Lubricate tip of catheter with water-soluble lubricant to reduce friction. Oil based lubricant may
cause lipid pneumonia.

5. Hyperextend the neck and gently advance the catheter toward the nasopharynx.

6. Tilt the patient’s head forward once the tube reaches the oropharynx (throat)and ask the patient
to swallow or sip fluid as tube is advanced.

7. Secure the NGT by taping it to the bridge of the nose after checking the tube’s placement.

  Administering Tube Feeding (gastric gavage)

1. Position pt in SF

2. Assess tube placement and patency

     - introduce 5-20 ml of air into NGT and auscultate at the epigastric area. Gurgling sound
indicates patency

     -aspirate gastric content (yellowish/greenish)

     -immerse tip of the tube in water, no bubbles should be produced

     -measure pH of aspirated fluid (acid)

     Note: the most effective method of checking the NGT placement is radiograph    verification.

3. Assess residual feeding contents. To assess absorption of the last feeding, should be less than
50ml.

4. Introduce feeding slowly to prevent flatulence, cramping and vomiting.

5. Height of tube should be 12 inches above insertion point.

6. Instill 30-60 ml of water into the NGT after feeding to cleanse the lumen of the tube.

7. Clamp the NGT to prevent entry of air into the stomach.

8. Maintain Fowler’s position for at least 30 mins to prevent aspiration.

9. Document 

Potential Side Effects

SIDE EFFECT REASON ACTIONS

DIARRHEA ·         Feedings are ·         Do not stop
administered too quickly feedings unless
specifically ordered
·         The patient has a by the physician.
lactose intolerance (All
formulas at WOHC are ·         Investigate
 SIDE EFFECT REASON ACTIONS
lactose free) potential causes and
notify the physician
·         A contaminated and dietician.
formula is administered
(e.g. formula is hung too
long in sun or tubing not
cleansed properly. )

·         Use of antibiotics
may lead to overgrowth
of C. difficile toxin
leading to frequent loose
stools.

·         Protein
malnutrition
(hypoalbuminemia)

·         Malabsorption
states

·         Lack dietary
fibre.
NAUSEA/VOMITING/ ·         Feedings are
BLOATING administered too
quickly.
·         Intolerance to
concentration and/or
volume exists.
·         If vomiting
occurs, stop feeding,
turn patient to the
side, assess need for
suctioning and notify
physician and
dietician.

·         Reduced gastric
motility associated with
gastric retention.

·         Feedings are too

cold

·         Paralytic ileus

·         Obstruction
CONSTIPATION ·         Inadequate bulk ·         Reassess fluid
in the diet status and activity
level
·         Associated with
medication therapy ·         Notify
physician and
·         Reduced dietician
 SIDE EFFECT REASON ACTIONS
gastrointestinal motility

·         Associated with
decreased level of
activity

·         Inadequate fluid
intake

·         Advanced age
MECHANICAL ·         Skin and/or ·         Hypoallergenic
mucosal irritation tape

·         Pressure against ·         Change

nares of nose dressings once per
day with Normal
Saline

·         Secure taping
of tube
 

Parenteral Nutrition

             Parenteral nutrition, or intravenous feeding, is a method of getting nutrition into your body
through your veins. Depending on which vein is used, this procedure is often referred to as either
total parenteral nutrition (TPN) or peripheral parenteral nutrition (PPN).

             This form of nutrition is used to help people who can’t or shouldn’t get their core nutrients
from food. It is often used for people with:

·         Crohn’s disease

·         cancer

·         short bowel syndrome

·         ischemic bowel disease

·         It also can help people with conditions that result from low blood flow to their bowels.