Learning Deck 6 Nutrition Care Process Implementation

1 John 3:18
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Nutrition Care Process: • My little children, let us not love in word or in
tongue, but in deed and in truth.
Implementation
Chapter 8
1 2
Planning Implementation
• Maintain or restore optimal nutritional status • Collaboration

• Promote healthy nutritional practices • Primary care provider
• Nutritionist
• Prevent complications associated with malnutrition
• Nurses in the hospital:
• Decrease weight or regain specified weight • Reinforce
• Provide an atmosphere to encourage eating
• Assist in feeding
• Monitor the client’s appetite and the food intake
• Administer and enteral and parenteral feedings
• Consult and report nutritional problems that arise
3 4
Implementation Assisting in Special Diet

• Nurses in the community: • Diets are altered for the following reasons:
• Health education • a special examination or surgery
• Nurses in the home setting: • increase or decrease weight
• Nutritional screens • restore nutritional deficits
• Refer clients at risk • allow an organ to rest and promote healing
• Instruct clients about parenteral and enteral feeding • Diets are modified:
• Nutrition counseling • texture, kilocalories, specific nutrients, seasonings, or
consistency.
5 6
1

• Implementing • Clear Liquid Diet
• Assisting with Special Diets • Indication: After surgeries or in acute stages of
• Diets maybe modified through: texture, kilocalories, specific infection
nutrients, seasonings, or consistency • Short term diet (24 of 36 hours)
• Clear Liquid Diet (short term: 24-36 hours)
• Full Liquid Diet
• Supplies fluids and carbs but very low on protein, fat,
vitamins and minerals
• Soft Diet
• Relieves thirst, prevent dehydration, and minimize
• Diet as Tolerated
• Modification for Disease stimulation of GIT
7 8
• Full Liquid Diet • Soft Diet

• Indication: For client with GI disturbances or cannot • Indication: For clients with difficulty chewing and
tolerate solid/semi-solid foods swallowing
• Contains more on milk • Low-residue diet containing very few uncooked foods
• Monotonous • Pureed diet (modification type)
• Low in iron, protein and calories
9 10
• Diet as Tolerated • Modification for Disease

• Indication: For clients with appetite, ability to eat, and • Indication: For clients with special needs regarding
tolerance for certain foods are changing their sickness
11 12
2
Implementing: Specialized
Specialized Diets (cont’d)
Diets (cont’d)

• ADA - American Diabetic Association • Vegetarian
• Balanced meals based on total calories and • The vegan diet excludes all meat and animal products
carbohydrate counting (45-60 grams/meal) • The lacto vegetarian diet includes plant foods plus dairy
• Cardiac products
• Limited fat (<30% of calories), Saturated fats < 7% of • The lacto-ovo vegetarian diet includes plant foods,
daily calories, ↓ Na+ dairy and eggs
• Renal
• Low protein, ↑ carbohydrates, ↓ Na+, ↓ K+, controlled
fluid intake
13 14
Dietary Approaches to Stop

Specialized Diets (cont’d) Hypertension (DASH)
• Vegetarian • High in:

• Nutrients vegetarians may need to focus on including • calcium, magnesium, potassium, and fiber
protein, iron, calcium, zinc & vitamin B12
• Low in:
• What combinations of plant proteins provide COMPLETE
• sodium and fat
proteins?
15 16
Implementing (cont’d)
• Dysphagia
• Older clients, clients with stroke, cancer (r/t radiation
to head & neck), cranial nerve dysfunction
• Gear instructions to individual
• Stimulating appetite
• Assisting clients with meals
• Special community nutritional services (e.g., Meals on
Wheels)
17 18
3
Implementing: Nasogastric
Implementing: Enteral Nutrition
Tube

• Enteral – through the GI system
• Enteral access devices
• Nasogastric tube
• Nasoenteric (nasointestinal) tube
• Gastrostomy and jejunostomy devices
• Percutaneous endoscopic gastrostomy (PEG)
• Percutaneous endoscopic jejunostomy (PEJ)
19 20
Figures Skill 47-1 Measuring the

appropriate length to insert a nasogastric Figures Skill 47-1 Taping a nasogastric
tube to the bridge of the nose.
tube.
21 22
Figures Skill 47-1 Swallowing Figure 47–16 Placements for enteral access: A,
for nasoenteric/ nasointestinal tubes; B, for
closes the epiglottis.
gastrostomy and jejunostomy tubes.
23 24
4
Figure 47-17 Percutaneous endoscopic Figure 47-18 Percutaneous endoscopic
gastrostomy (PEG) tube jejunostomy (PEJ) tube

25 26
Implementing: Enteral
Figure 47-19 Low profile gastrostomy Feedings
feeding tube
27 28
Implementing: Testing Feeding Implementing: Testing Feeding

Tube Placement Tube Placement
• Initially, tube placement confirmed by radiography • To verify placement before feedings, at intervals
and tube marked with indelible ink at exit point • Aspirate GI secretions
from nose; length of visible tubing documented • Measure pH of aspirated fluid
• Auscultate epigastrium while injecting 5-20 mL of air
• Confirm length of tube insertion with insertion mark
29 30
5
Implementing: Enteral
Figure 47-20 An enteric feeding pump
Feedings

• Administer
• Intermittent – 300 – 500 mL per feeding over 30 minute
period; usually administered room temp
• Continuous – administered over 24 h with infusion
pump; usually administered cold
• Refeeding syndrome
• Open system or closed system
31 32
Figure 47-20 (continued) Using a Figure 47-20 (continued) Feeding set tubing with
calibrated plastic bag to administer a tube drip chamber
(Ross Products Division, Abbott Laboratories.

feeding Used with permission.)
33 34
Figure 47-20 (continued) Using the barrel Implementing: Managing

of a syringe to administer a tube feeding Clogged Feeding Tubes
• Clogged tubes must be removed and reinserted;

prevention is key
• Flush with at least 30 mL water before, between,
and after each medication is instilled; do not add
meds to formula or to each other as precipitates
may form
35 36
6
Implementing: Managing Implementing: Parenteral
Clogged Feeding Tubes Nutrition

• First, reposition client to release kink in tubing • Total parenteral nutrition (TPN) or IV
• If still blocked, flush and aspirate with water hyperalimentation
• Hypertonic, so injected only into high-flow central veins
repeatedly
• Used in clients with severe malnutrition, severe burns,
bowel disease disorders, acute renal failure, hepatic
failure, metastatic cancer, major surgeries (NPO 5 days)
37 38
Implementing: Parenteral Implementing: Parenteral

Nutrition Nutrition (cont’d)
• Total parenteral nutrition (TPN) or IV • TPN (cont’d)

hyperalimentation • Infusions started gradually to prevent hyperglycemia;
• Carries risk of infection and fluid/electrolyte glucose levels monitored
imbalances • Discontinued gradually to prevent hyperinsulinemia and
• Requires surgical aseptic technique, frequent lab hypoglycemia
monitoring for TPN modification
39 40
Implementing: Parenteral
Evaluating
Nutrition (cont’d)
• Peripheral parenteral nutrition (PPN) • The goals established in the planning phase are
• Less concentrated solution, can provide lipids but evaluated according to specific desired outcomes
associated with phlebitis
• Used more to prevent than to correct nutritional
imbalance
• Enteral or parenteral can be provided at home
41 42
7
Evaluating
• If the outcomes are not achieved, the nurse should

explore the reasons
• Cause of problem identified? Outcomes realistic?
• Family included and supportive?
• Client’s preferences considered?
• Do symptoms cause loss of appetite?
• Anything interfering with digestion or absorption?
43

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1 John 3:18

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• Maintain or restore optimal nutritional status • Collaboration

Implementation Assisting in Special Diet

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• Full Liquid Diet • Soft Diet

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• Diet as Tolerated • Modification for Disease

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Dietary Approaches to Stop

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• Vegetarian • High in:

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Figures Skill 47-1 Measuring the

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gastrostomy and jejunostomy tubes.

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Implementing: Testing Feeding Implementing: Testing Feeding

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(Ross Products Division, Abbott Laboratories.

Figure 47-20 (continued) Using the barrel Implementing: Managing

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• Clogged tubes must be removed and reinserted;

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Implementing: Parenteral Implementing: Parenteral

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• Total parenteral nutrition (TPN) or IV • TPN (cont’d)

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• If the outcomes are not achieved, the nurse should

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