Nutrition care and support:

Therapeutic Modifcation Of
Normal Diet
Mode of feeding- Enteral and
parenteral feeding

MRS. MEHRUNNISHA

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Objectives
At the end of lecture, students should be able to:

Identfy the uuruose of diet modipcaton.

Describe diferent methods of dietary modipcatons for
clients.
Relate the role of the nurse in diet modipcaton.
Exulain mode of feeding as enteral and uarenteral in detail.

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Introduction
• The urevalence of malnutriton among hosuitalized adults is
estmated at 15% to 60%, deuending on the uatent uouulaton.
• Patents in an acute care setng nho ate three meals in a 24 hour
ueriod failed to meet their calorie or urotein requirements. Auuette
may be imuaired by fear, uain, or anxiety.
• Meals may be nithheld or missed because of diagnostc urocedures
or medical treatments.
• Feeding outons used to meet uatents’ nutritonal needs, ranges from
oral diets and nutritonal suuulements to enteral nutriton and
uarenteral nutriton.
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 DIET MODIFICATION
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 The purposes for modifying the
diets
1) For essental or life saving treatment: For examule in celiac disease, uroviding gluten free diet.
2) To reulete uatents nho are malnourished because of disease such as cancer and intestnal diseases by
uroviding a greater amount of a nutrient such as urotein.
3) To correct depciencies and maintain or restore outmum nutritonal status.
4) To urovide rest or relieve an afected organ such as in gastrits.
5) To adjust to the body's ability to digest, absorb, metabolize or excrete: For examule a lon fat diet
urovided in fat malabsoruton.
6) To adjust to tolerance of food intake. For examule in case of uatents nith cancer of esouhagus tube
feeding is recommended nhen uatents cannot tolerate food by mouth.
7) To exclude foods due to food allergies or food intolerance.
8) To adjust to mechanical difcultes, for examule for elderly uatents nith denture uroblems, changing
the texture/consistency of food recommended due to uroblems nith chening and/or snalloning.
9) To increase or decrease body neight/body comuositon nhen required, for examule as in the case of
obesity or underneight.
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10) As heluful treatment, alternatve or comulementary to drugs, as in diabetes or in hyuertension.
Methods of Diet modifcations
• A diet may need to be altered and adjusted in many nays before it meets
the theraueutc needs of an individual uatent. These adautatons may
include:
1. Diets of Altered Consistency :Liquid diet, Sof diet, Blend diet.
2. Modipcaton in Quantty Deuending on the clinical conditon
3. Modipcaton in Nutrient (Proteins, Fat, Carbohydrate) Content
4. Changes in Meal Frequency
5. Changes in Method of Cooking
6. Modipcaton in the Method of Feeding
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 1. Diets of Altered Consistency
Theraueutc diets are modiped for consistency, texture to pt the nutritonal needs like

a) Liquid diet (Clear liquid and full liquid diet)

b) Soft diet
c) Blend diet

Liquid Diet:
• It consists of foods that can be served in liquid or strained form in room temuerature.
• They are usually urescribed in febrile states, uostoueratvely i.e. afer surgery nhen the uatent is
unable to tolerate solid foods.
• It is also used for individuals nith acute infectons or digestve uroblems, to reulace fuids lost by
vomitng, diarrhea.
• The tno major tyues of liquid diets include Clear liquid diet and full liquid/fuid diet.

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 a) Liquid diet
I. Clear liquid diet
• It urovides foods and fuids that are clear and liquid at room
temuerature.
• The purpose of the clear liquid diet is to urovide fuids and
electrolytes to urevent dehydraton.
• It provides some amount of energy but very litle amount of
other nutrients. It is also depcient in pbre. Hence it is
nutritonally inadequate and should be used only for short
ueriods i.e. 1 2 days.
• The clear liquid diet is usually useful in situatons nhen the
gastrointestnal tract has to be keut functonally at rest. It is also
urescribed before and afer certain tyues of surgery involving the
mouth or gastrointestnal tract. Also may be used in acute
vomitng or diarrhea.
• Examples of clear liquid diet: Water, strained fruit juices,
coconut nater, lime juice, nhey nater, barley/arronroot nater,
rice kanji, clear lentl souu, strained vegetable or meat souu, tea
or cofee nithout milk or cream, carbonated beverages.
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II. Full liquid diet
• It urovides food and fuids that are liquid or semi liquid at room
temuerature. It is used as a steu betneen a clear liquid diet and
a regular diet.
• The purpose of the full liquid diet is to urovide an oral (by
mouth) source of fuid for individuals nho are incauable of
chening, snalloning or digestng solid food.
• It provides more calories than the clear liquid diet and gives
adequate nourishment, exceut that it is depcient in pbre.
• It is indicated for uost oueratve uatents and for
gastrointestnal illness.
• Examples of full liquid diet: Foods alloned or included in a full
liquid diet include beverages, cream souus, vegetable souus,
lentl souus, strained food juices, buter milk, yogurt, hot cocoa,
cofee/tea nith milk, carbonated beverages, cereal uorridges
(repned cereals) custard, sherbet, gelatn, uuddings, ice cream,
margarine, buter, cream (added to foods), uoached, half boiled
egg etc.
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 b) Soft diet
Soft diet as the name suggests urovides sof nhole food that is lightly seasoned and are similar to the regular
diet . The term 'sof' refers to the fact that foods included in this tyue of diet are sof in consistency, easy to
chen and made of simule, easily digestble foods. It does not contain harsh pbre or strong favors.
• It is given during acute infectons, certain gastrointestnal disorders and at the uost oueratve stage to
individuals nho are in the early uhase of recovery folloning a surgery.
• Examples of soft diet: A sof diet freely uermits the use of cooked vegetables, sof ran fruits nithout seeds,
broths and all souus, nashed uulses in the form of souus and in combinaton of cereals and vegetables (like
uorridge), breads and ready to eat cereals (most ureferable repned such as, uasta, noodles etc.), milk and
milk beverages, yogurt, light desserts (including custard, jelly, ice cream), Egg and tender and minced, ground,
stened meat and meat uroducts, fat like buter, cream, vegetable oil and salt and sugar in moderaton.
• Foods to be best avoided in the soft diet include coarse cereals, suicy highly seasoned and fried foods, dry
fruits and nuts, rich desserts.
• Among the soft diet is also the mechanical soft diet also known as the dental diet nhich is a normal diet
that is modiped only in texture for ease of mastcaton i.e. chening. When an individual cannot chen or use
facial muscles for a variety of dental, medical or surgical conditons mechanical sof diet is recommended.
Elderly uersons nho have dental uroblems are urescribed mechanical sof diets. Simule salads, fruit salads
and cotage cheese may be included.
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 c) Blend diet
Blend Diet: is made of foods that are sof, not very suicy and lon in pber.
• Individuals sufering from gastric or duodenal ulcers, gastrits or ulceratve
colits are urescribed this diet.
• Foods Included: Milk and milk uroducts lon in fat or fat free; Bread, uasta
made from repned cereals, rice; cooked fruits and vegetables nithout ueel
and seeds; Eggs and lean tender meat such as psh, uoultry that are
steamed, baked or grilled; Cream, buter; Puddings and custards, clear
souus.
• Foods Avoided: Fried, faty foods; Strong favored foods; Strong tea,
cofee, alcoholic beverages, condiments and suices; High pber foods; hot
souus and beverages; nhole grains rich in pber; strong cheeses.
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2. Modifcation in Quantity
Depending on the clinical condition
• Deuending on the clinical conditon some individuals may require a restricton
diet such as sodium restricted diet (as in high blood uressure), uurine restricted
diet (as in gout) or lon residue diet (urescribed and/or before abdominal
surgery) designed to reduce the frequency and volume of fecal outuut.
• Sometmes a comulete eliminaton diet may be recommended nhen there is
food intolerances or comulete insensitvity to a uartcular food such as a gluten
free diet or a dairy free diet or nut free diet etc.
• Occasionally an increase in the amount of a suecipc dietary consttuent may be
urescribed such as a high uotassium diet or a high pbre diet (as in constuaton)
or an iron rich diet (as in anemia) nhen the clinical conditon demands.

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3. Modifcation in Nutrient (Proteins,
Fat, Carbohydrate) Content
• The nutrient content of the diet is modiped to treat depciencies, change
body neight or control diseases such as hyuertension or diabetes.
• Patents nith high blood sugar levels, being urescribed a diabetc diet nhich
requires changes in the quantty and tyue of carbohydrates included in each
meal. Repned carbohydrates (such as sugar, honey, repned four, semolina
etc.) are best avoided and use of comulex carbohydrates (nhole nheat
four, coarse cereals etc.) recommended.
• Patents nith heart diseases require a fat controlled lon cholesterol diet
nhile uatents nith renal (kidney) failure and advanced liver diseases a lon
urotein diet, uatents nith HIV disease, cancer or malnourished a high
urotein, high calorie diet.
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 Methods of Diet modifcations
4. Changes in Meal Frequency
• Individuals sufering nith gastro esouhageal refux disease (GERD) stand to benept by consuming small but
frequent meals. 5 to 6 small meals instead of three regular meals are recommended.

5. Changes in Method of Cooking

• Leaching is indicated for cooking vegetables for ueoule nith chronic kidney diseases because the kidney's no
longer maintain the ideal 12 level of uotassium necessary for outmum health. Leaching (soaking in nater) drains
out excessive uotassium and uhosuhorous from the vegetables.
• In elderly ueoule food may be modiped by mechanical urocessing such as mashing, blending or chouuing. For
uatents on blend diet foods steamed, baked or grilled are recommended.

6. Modifcaton in the Method of Feeding

• To urovide adequate nutriton, normally oral feeding (by mouth) is recommended.
• Sometmes oral feeding is not uossible, under such circumstances suecial feeding methods such as enteral feeding
(urovision of liquid formula diet delivered via nasogastric feeding tube) and uarenteral feeding (fuids containing
nater, glucose, amino acids, minerals, vitamins given through the ueriuheral and central veins) is recommended.
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 Nurse’s responsibilities in diet modifcation
• The nurse has resuonsibility to assist in coordinatng care and services.
• The nurse usually collaborates nith other members of the health care team in
• nutritonal assessment,
• nutriton educaton,
• delivery of dietary suuuort modiped diets.
• The nurse collaborates nith the uhysician to imulement dietary urescriutons as
nell as to re examine the uatent for nutritonal imbalances and serves as an
advocate.
• The nurse may also communicate nith the family and the uatent the changes that
are imuortant and necessary for health maintenance.
• The nurse usually recommends follon uu care and advocates for referral to HTN,
Renal, DM, HIV/AIDS clinic and dietetcs deuartment.
• The nurse also serves as Communicator and as Teacher/Counsellor
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 MODE OF FEEDING:
ENTERAL & PARENTERAL
NUTRITION
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Need for Nutrition Support
• Nutriton suuuort may be required to meet uatent’s nutritonal needs
• Patents ofen too ill to obtain energy & nutrients by consuming foods
• Or illness may interfere nith eatng, digeston or absoruton.

• Nutriton suuuort means delivery of formulated nutrients by feeding

tube or intravenous infusion
Enteral nutriton: suuulying nutrients using GI tract, including tube
feedings & oral diets
Parenteral nutriton: intravenous urovision of nutrients, byuassing the
GI tract
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Selecting a Feeding Route

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Enteral Nutrition Support
• Wide selecton of enteral formulas, designed to meet variety of medical &
nutritonal needs
• May be used alone or in conjuncton nith other foods
• Many formulas can urovide all of nutrient requirements if consumed in sufcient
volume
• Classiped according to macronutrient comuositon
• Preferred over intravenous feedings

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Types of Enteral Formulas
• Standard formula: for uatents nho can digest & absorb nutrients nithout
difculty; contains urotein & carbohydrate sources
• Hydrolyzed formulas: used for uatents nith comuromised digestve or absorutve
functons— macronutrients are uartally or fully broken donn & require litle, if
any, digeston before absoruton
• Disease suecipc formulas: designed to meet nutrient needs of uatents nith
uartcular disorders: liver, kidney, lung diseases, glucose intolerance, metabolic
stress
• Modular formulas: contain only one or tno macronutrients; used to enhance
other formulas

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 Enteral Nutrition in Medical Care
• Oral use
• Suuulement diet nhen food
consumuton does not meet need
• Reliable source of nutrients & energy
• Taste imuortant consideraton
• Tube feedings
• Used nhen uatent cannot consume
enough food or formula orally
• Feeding delivered directly to stomach
or intestne (Nasogastric,
Nasoduodenal, Nasojejunal,
Gastrostomy, Jejunostomy)
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• Candidates for tube feedings:
• Severe snalloning difcultes
• Litle or no auuette for extended ueriods, esuecially if
malnourished
• GI obstructons, imuaired motlity of the uuuer GI tract
• Afer intestnal resecton, beginning enteral feedings
• Mentally incauacitated due to confusion, dementa,
neurological disorders
• Individuals in coma
• Individuals nith extremely high nutrient requirements
• Individuals on mechanical ventlators
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 Administering Enteral Nutrition
Formula selected afer assessment of the diagnosis, uatent’s age, medical uroblems, nutritonal
status, ability to digest & absorb nutrients.

Administraton of tube feedings:

• Ouen feeding system: requires formula to be transferred from original uackaging to feeding container
• Closed feeding system: formula ureuackaged in ready to use containers.

Review of urocedure nith uatent & family

Verifcaton of tube ulacement (X ray)

Formula delivery:
• Intermitent feeding: delivery of urescribed volume over 20 40 minutes
• Contnuous feeding: slon delivery at constant rate over 8 24 hour ueriod
• Bolus feeding: delivery of urescribed volume in less than 15 minutes
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 Administering Enteral Nutrition
Checking gastric residual volume from urevious feeding. Evaluate if gastric residual >200 mL.
Meetng water needs
• Fluid intake may be restricted for uatents nith kidney, liver or heart disease
• Fluid intake may be increased nith fever, high urine outuut, diarrhea, excessive sneatng, severe
vomitng, pstula drainage, high outuut ostomies, blood loss, ouen nounds.
• Standard formulas contain about 85% nater (about 850 mL/liter); nutrient dense formulas contain
about 69 72% nater
Transiton to table foods: Volume of formula is tauered of as conditon imuroves and gradual shif to
oral diet.
Giving Medicaton through feeding tubes:
• Potental for diet drug interactons must be considered before administraton
• Contnuous feeding halted for auuroximately 15 minutes before & 15 minutes folloning medicaton
delivery (longer for some medicatons)
Many complicatons are ureventable nith auurouriate feeding route, formula & delivery method. Close
atenton
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 Enteral Nutrition Complications and Nursing Interventions
Recommendatons and Nursing Interventons Complicaton
• Keep head of bed up at 30-45-degree angle. Aspiraton
• Avoid intermittent or bolus feeding.
• Consider post pyloric or permanent feeding tube.
• Avoid use of blue food dye to signal aspiration.
• Flush tube before and after each medication is administered. Clogged tube
• Flush tube every 4 hours and when feedings are temporarily stopped
• Flush tube after checking for gastric residuals.
• Limit use of acid pH fluids in tube.
• Assess contribution of formula osmolality, concentration, or rate to symptom. Diarrhea
• Avoid intermittent or bolus feeding
• Consider medical conditions: bowel impaction or obstruction, intestinal disease, bacterial
infection, hyperthyroidism.
• Consider medications associated with side effect (antibiotics, hypertonic or sorbitol-containing
drugs, magnesium, phosphorus). Hypertonic drugs can be diluted with water during delivery
• Maintain safe feeding handling practices

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 Enteral Nutrition Complications and Nursing Interventions

Recommendatons and Nursing Interventons Complicaton

• Consult with pharmacist. Some medications are incompatible with enteral formula use. Drug-formula
• Flush feeding tube with 30 mL of water before and after each medication is administered. interacton

• Wash hands before handling formula or equipment Foodborne illness

• Wipe off container top before opening.
• Refrigerate open formula no greater than 24 hours Observe limited 8-12-hour hang time
for formula at room temperature.
• Change feeding setup daily.
• Monitor for gastric residuals and hold if greater than 250 mL Gastric residuals
• Consider use of longer tube for small intestinal feeding beyond ligament of Treitz .
• Consider use of promotility agent.
• Follow guidelines for aspiration prevention.

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Parenteral Nutrition Support
Indicated for uatents nho do not have functoning GI tract &
nho are malnourished (or likely to become so).

Used nhen enteral formulas cannot be used or intestnal

functon is inadequate

Life saving outon for critcally ill uersons

Tno main access sites: central or ueriuheral vein

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Venous Access
Periuheral uarenteral nutriton (PPN)
• Can only urovide limited amounts of energy & urotein
• Periuheral veins can be damaged by overly concentrated solutons
• Limited to uatents nho do not have high nutrient needs or fuid restrictons
• Used most ofen for short term nutriton suuuort (7 10 days)
• Rotaton of vein sites may be necessary

Total uarenteral nutriton (TPN)

• Can reliably meet comulete nutrient requirements
• Provides nutrient dense solutons for uatents nith high nutrient needs or
fuid restrictons
• Preferred for long term intravenous feedings
• Inserted directly into a large central
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Parenteral Solutions
• Customized formulatons to meet uatents’ nutrient needs
• Highly individualized; ofen recalculated on daily basis untl uatent’s
conditon stabilizes
• Contents:
• Amino acids (both essental and non essental for urotein)
• Carbohydrates (dextrose)
• Liuid emulsions
• Fluid & electrolytes
• Vitamins & trace minerals

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Nurse’s role in administering Parenteral
Nutrition
Multdisciulinary nutriton suuuort team of health care urofessionals are
involved like uhysicians, Nurses, Diettans, Pharmacist.
Need to monitor uatent for uotental comulicatons related to venous
line & metabolic uroblems like fuid imbalances, altered metabolic states
(hyuerglycemia, acid base disturbances), catheter infecton.
Administraton urocedures
• Inserton & care of intravenous catheters
• Administraton of uarenteral solutons
• Contnuous administraton 24 hours/day
• Cyclic administraton – 10 to 16 hour ueriods
• Monitoring uatent conditon, nutritonal status, comulicatons
• Discontnuing of feedings nhen GI functon returns
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Nutrition Support at Home
Contnuaton of nutritonal suuuort (tube feedings or uarenteral nutriton) afer
medical conditon has stabilized
Candidates for home nutriton suuuort
• Long term nutriton care required for chronic conditons
• Users intellectually cauable of learning urocedures, monitoring treatment &
managing comulicatons
Planning for home nutriton
• Involvement of users in decision making to ensure long term comuliance &
satsfacton
• Assessment & evaluaton of tyue of feeding, equiument, resources, ability to
uerform urocedures

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 Diferences betneen Enteral and Parenteral Feeding

ENTERAL FEEDING PARENTERAL FEEDING

Defniton Enteral feeding means administraton of nutrients through Parenteral nutriton means administraton of nutrients
GIT. through intravenous routes.
Types Enteral nutriton has folloning tyues; Oral siu feeding, Parenteral nutriton has folloning tyues; central and
tube feeding, tube inserton and gastrostomy. ueriuheral.

Indicatons Enteral feeding is indicated nhen a uatent cannot take Parenteral nutriton is indicated in the same ueriod but
anything uer oral for 5 to 7 days. if enteral feeding is not uossible.
Complicatons Enteral feeding can cause GIT disturbances, electrolyte Parenteral feeding can cause over feeding, seusis,
disorders and infectons. decreased or increased blood sugar level.

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