Principles of nutrition therapy &

the role of the nurse

Diet Therapy: NURS 3018

 Objectives
At the end of this presentation students will be able
to:
 Describe the nutritional intake of persons who are
institutionalized
 Explain the basis for determining the therapeutic
nutritional requirements of individuals
 Use the concept of diet therapy in planning menus
for patients
 Identify ways of incorporating dietary management
in nursing care plans
 Describe the role of nurse in providing nutritional
care to institutionalized individuals
Factors affecting nutritional
requirement and intake
 Individual differences exist which impact
nutritional requirements they include:
 Age
 Gender
 General condition
 Health disorder
 Nutritional status
 Soci-economic background
 Factors affecting nutritional
requirement and intake

 Emotional and cultural factors are very

important in determining food intake.
 The cultural pattern of three meals will impact
dietary choice.
 Animal experiments have shown that habitual
factors such as three meals per day have great
influence on dietary pattern and choices
 Dietary information may affect early choices
which has implications for later life; in respect of
NCDs and excesses
 Factors affecting nutritional
requirement and intake
 Appetite may be adequate for selection of a
nutritionally acceptable diet under certain
circumstances
 Selection of food on the basis of nutritional
principles is more reliable and is recommended
 There are normal variations in food intake in
relation to
 age,
 sex,
 environmental temperature,
 and caloric expenditure
 Factors affecting nutritional
requirement and intake
 Age- higher caloric and micronutrient
requirement needed to support :
◦ growth and development;
◦ bone and muscle mass development
 Sex- BMR is increased with higher muscle
mass
◦ higher in adults compared with older adults who
have sarcopenia;
◦ higher in males than females
 Factors affecting nutritional
requirement and intake
 Reports have suggested that decrease in
appetite occurs when environmental
temperature has reached a point at which
maintenance of body temperature is difficult

 Caloric expenditure increases both the

requirement for more calories and usually the
appetite (thus intake)

 Illness and disease- though this may decrease

appetite in some instances- the actual
micronutrient and caloric requirements may be
higher
 Factors affecting nutritional
requirement and intake
 Factors causing increased intake

 Cystic fibrosis of the pancreas

 Hyperthyroidism

 Diabetes mellitus

 Epinephrine-producing tumors of the adrenal medulla

 Pts on ACTH, adrenal cortical steroids, androgens,

estrogens, and isoniazide.

 Tumors of the hypothalamic regions of the brain

Factors affecting nutritional
requirement and intake
 Factors causing reduced intake

 Dietary deficiency of any essential nutrient

 Acute and chronic febrile illnesses,

 Debilitating illnesses such as rheumatoid arthritis

and ulcerative colitis,

 Hepatic and renal diseases,

 Hypothyroidism
Hospitalized people
 Nutrition care in hospitals is aimed at the
role that nutrition plays in any acute process
occurring during hospitalization as well as
long-term goals.

 Nutrition services include food service and

clinical nutrition

 Medical nutrition therapy is the assessment

and treatment of illness or disease that
relates to nutritional care.
Hospitalized people
 Hospital patients usually spend most of their time in
bed.

 Their needs for energy are therefore lower than

those of active persons of the same sex, age and
weight.

 However, some may have increased nutritional

requirements. These include
◦ patients who entered hospital undernourished;
◦ those who are pregnant or lactating or have recently had
a baby;
◦ and those with diseases that require a special diet or
extra nutrients.
Hospitalized people
 Nutrition care in hospitals is aimed at the
role that nutrition plays in any acute process
occurring during hospitalization as well as
long-term goals.

 Nutrition services include food service and

clinical nutrition

 Medical nutrition therapy is the assessment

and treatment of illness or disease that
relates to nutritional care.
Hospitalized people
 Malnutrition risk increases in the hospitalized clients
because of factors that decrease dietary intake,
increase nutrient losses and lead to increased
metabolic needs

 The provision of specialized nutrition support in the

form of enteral or parenteral nutrition should be
done after careful consideration of the indicators,
risks and benefits of treatment

 Palliative nutrition care involves providing hydration

and nutrition in accordance with client centered
decisions particularly in end of life care.
Hospitalized people
 The nurse is a vital member of the
interdisciplinary health care team providing
nutrition support and care.

 One of the key processes in clinical

nutrition is nutritional assessment which
includes anthropometric and clinical
measures of assessment.
Hospitalized people
 Hospital patients usually spend most of their
time in bed.
 Their needs for energy are therefore lower
than those of active persons of the same sex,
age and weight.
 However, some may have increased nutritional
requirements. These include
◦ patients who entered hospital undernourished;
◦ those who are pregnant or lactating or have recently
had a baby;
◦ and those with diseases that require a special diet or
extra nutrients.
 Psychological Impact of Illness
 Being ill may have severe psychological
impact on health and result in several health
care conditions suited to the NANDA list:
 Emotional needs- caregiver role strain,
sadness, anxiety, fear
 Ability to cope:- impaired coping,
anticipatory grieving, depression, social
isolation
 Institutional setting:- powerlessness
 Illness:- Impact on food behaviour
 Illness and institutionalization may impact
negatively on dietary intake as they may
impair:-
◦ Appetite- smells, appearance of food, texture may
differ from what was consumed at home
◦ Acceptance and Rejection of foods:- pain, nausea,
drowsiness, physical disabilities (temporary and
permanent) may affect the willingness to accept or
reject food
◦ Failure to eat:- the same conditions affecting
acceptance may also affect and result in failure to
eat
Nutritional Needs of the hospitalized
patient
 The nutritional status of a patient at admission has
implications for the management and outcome of the
condition. Some nutritional issues that have negative
impact on outcome and management are:-
◦ Undernutrition
◦ Loss of lean body mass
◦ Prolonged admission

 These have negative impact on the following:

◦ Co-morbidity
◦ Opportunistic infections
◦ Length of stay
◦ Mortality Risk
 Nutritional Needs of the
hospitalized patient
 Basis of determining needs
Predictive Formulae
Equation
Harris-Benedict (males) 66.45 +13.75 * wt + 5 * ht - 6.75 * age
Harris-Benedict 655.09 + 9.56 * wt + 1.84 * ht - 4.67 * age
(females)
Mifflin-St. Jeor (males) 9.99 * wt+6.25* ht - 4 .92 * age + 5
Mifflin-St. Jeor (females) 9.99 * wt + 6.25 * ht – 4.92 * age - 161
WHO (males) [18-30 15.3 * wt + 679
years]
WHO (females) [18-30 14.7 * wt + 496
years]
Tucker & Dauffenbach, 2011
 Nutritional Needs of the
hospitalized patient
 Basis for determining needs

EER by gender Formulae

Females 354- (691* age) + PA * (9.36 * wt + 726 * ht)
Males 662- (9.53 * age) + PA * (15.91 * wt + 539 * ht)

Activity Activity Factor (PA)

Sedentary 1.2
Light active 1.375
Active 1.55
Very active 1.90
Disadvantages of estimating energy
requirements
 Estimating energy needs just based on
weight may be erroneous as the ratio of
active lean body mass to total weight is
not constant-
◦ thus a DEXA scan or a bioelectrical
impedance may be useful.

 (Duggan and Golden, 2007)

Nutritional Needs of the hospitalized
patient
 Basis for determining needs
Based on Nitrogen balance studies the normal
Nitrogen requirements range from 105mg N/kg/d to
132mg N/kg/d for nitrogen equilibrium- losses=
intake
 NB. 1g protein= 6.25mg N
 Thus 0.105gN * 6.25= 0.65g Protein/kg/d & 0.132gN
* 6.25= 0.83kg Protein/kg/d - which is two sd units
of the mean of 0.65
 Thus normal protein requirement for nitrogen
balance is 0.65 to 0.83 g/kg/d
 Protein requirements should be 10%- 15% of total
energy intake/d
 (Smith, 2007)
 Nutritional Needs of the
hospitalized patient
 The tools that are important in determining
the needs of hospitalized patients include
 Nutritional assessment including –
anthropometry, biochemical tests and
clinical assessment
 Medical diagnosis:- this is often a multiplier
in energy determination
 Dietary history which provides an analysis
of usual intake
Prescribed nutritional therapy
 There are several ways that the hospitalized
patient may be supported nutritional. The
method of dietary delivery is dependent on:
◦ Anorexia due to illness- weakens due to illness
or surgery; cancer; eating disorders
◦ Swallowing disorders:- presence of gag reflex;
Cerebrovascular/motor/neuronal swallowing
defects, esophageal stricture
◦ Gastric stasis, gastroparesis- post op; ICU
◦ Inability to take sufficient feeds orally- burns,
trauma, Inflammatory bowel disease
 Nutrition as part of the Nursing
Care Plan
 Analysis of food- The nurse identifies, type,
amount, preparation styles, likes and dislikes
 Plan and implement diet instruction:- in
collaboration with the dietician/nutritionist and
based on patient needs the nurse prepares the
patient for discharge and wellness maintenance
and in primary settings
 Identify follow-up care needs- HTN, Renal, DM,
HIV/AIDS clinic along with dietary referral
 Other assistance- Social Worker, Path
programmes, advise regarding gyms, recovery
groups
Concept map- elements of MNT
References
 Duggan, M., & Golden, B. (2007). Deficiency
diseases. In C. Geissler & H. Powers (Eds.), Human
Nutrition (11th Ed.) (pp 517-536). Edinburgh, UK:
Elsevier Churchill Livingstone.

 Smith, R. C. (2007). Nutritional support for

hospitalized patients. In J. Mann & A. S. Truswell
(Eds.), Essentials of human nutrition (pp 33-52).
New York, USA: Oxford University Press.

 Tucker, S. & Dauffenbach,V. (2011). Nutrition and

diet therapy for nurses. Boston, USA: Pearson.