Vwpe4j0vm - NUTRITON DIAGNOSIS AND PLAN OF CARE 2

NUTRITION DIAGNOSIS
AND PLAN OF CARE

CALAYAN EDUCATIONAL FOUNDATION INC.
DR. FELIPE A. MERANO
PROFESSOR
REFERENCE: NUTRITION AND DIET THERAPY BY LUTZ & PRZYTULSKI

What is your dietary plan?
NURSING CARE PLAN (ADPIE)
ASSESSMENT: (Subjective & Objective Data)
DIAGNOSIS: (NANDA)
PLANNING: (Goals / Objectives)
IMPLEMENTATION / INTERVENTION (Rationale)
EVALUATION
PLANNING AND DIET WITH CULTURAL
COMPETENCY
Cultural Difference:
 Religion & Beliefs
 Family Background
 Cultural & Family Origin
 Cultural & Family Tradition
 Acquired & Inherited Lifestyle
RESOURCES NEEDED IN PLANNING
AND IMPLEMENTING DIETARY REGIMEN
ASSESSMENT
NUTRITIONAL HISTORY
 Dietary Intake Data
 Nutrient Intake Analysis (NIA)
 Food Diary
 Food Frequency
 24-Hour Recall
 Dietary Intake Data

 Isthe collection of information of foods and
dietary supplements intake that will assess the
accurate and reliable intake estimation.
Intake of foods is also used to craft dietary
guidance and evaluate the risks associated
with food-borne hazards / diseases.
 Nutrient Intake Analysis (NIA)

 Isthe process of analysing nutrient intake of
an individual to make food choices to nourish
and optimize health and to define level of
nurtiture in an individual for a given criterion
of nutritional adequacy.
Food Diary
 Subjects
record all food and beverages
consumed over three consecutive days (two
weekdays and one weekend day).
 Theconsumed items can be measured using a
scale or other household items, such as
measuring cups or spoons, or estimated using a
portion-size guide.
Food Diary
Trained staff must provide detailed
instructions on how to record intake and
the completed records need to be
entered into a software program, such as
Nutrition Data System for Research (NDSR),
for analysis.
24 Hours Recall

 Subjectsare asked to report all foods and
beverages consumed in the past 24 hours. This
can be done via telephone or face-to-face
interview.
 Trainedstaff must conduct the interview to
prompt for details, such as cooking methods and
portion sizes. The data needs to be entered into a
software program, such as NDSR, for analysis.
24 Hours Recall

Automated self- administered 24-hour
recall technique is also now available at
http://riskfactor.cancer.gov/tools/instrum
ents/asa24/
 Food Frequency Questionnaire (FFQ):

 Subjects report how frequently certain food and
beverage items were consumed over a specific
period of time (typically 1 year). Most FFQ versions
ask portion size questions of every food item, as well
as general questions about common cooking
practices (e.g. type of fat typically added while
cooking).

 Most FFQs are available in paper or electronic
format and take about 1 hour to complete.
Computerized software programs calculate nutrient
intake by multiplying the reported frequency of
each food by the amount of nutrient in a serving of
that food. There are no data entry requirements for
the study team.

 FFQs are usually validated for a period of 6 months
or 1 year and repeat administration is not
recommended for a period shorter than 6 months.
 ANTHROPOMETRIC MEASUREMENTS  Malnutrition Universal Screening

 Height & Weight Tool (MUST)
 BMI  Subjective Global Assessment
 Body Composition
(SGA)
 Mini Nutritional Assessment (MNA)
 Mid-arm Circumference (MAC)
 Geriatric Nutritional Risk Index
 Fat Fold or Skin Fold Thickness
(GNRI)
FOOD AND NUTRIENT DELIVERY
 FOOD SERVICES IN HEALTH CARE FACILITIES

HAVE TWO (2) MAJOR FUNCTIONS
The preparation and delivery of meals to
clients and,
The nutritional care of clients
FOOD AND NUTRIENT DELIVERY
NUTRITIONAL CARE OF CLIENTS

Assessing the client’s need for nutrients
Delivering nutrients to the client
Monitoring the client’s nutrient intake
Counselling the client about nutritional
needs
ASSESSMENT
Height, Weight, BMI, and Weight History

Laboratory Test Values
Food Intake Information
Potential Food-Drug Interactions
Mastication and Swallowing Ability
Ability to Feed Independently
Bowel and Bladder Functions
ASSESSMENT
Presence of Pressure Ulcers

Food Allergies and Intolerance
Factors affecting Nutritional Status
Determination of body status
Presence of Physical Stress
Learning barriers
ASSESSMENT
Factors affecting Nutritional Status

Food Preferences
Cultural Beliefs
Religious Beliefs
ASSESSMENT
Presence of Physical Stress

Severe Burns
Trauma
Infection
Surgery
ASSESSMENT
Learning barriers
Hearing Inability to follow instructions
Mobility Cultural and Religious Barriers
Language barriers Learning Disability
Vision Learning Readiness
Speech Preferred learning style
Reading & Writing Skills
DIET ORDERS
Itis a written nutritional needs of client

prescribed by the physician.
The nurse cannot serve or administer
client’s diet without written diet orders.
Diet orders must be based on diet
manual of the institution.
Example: NPO, SOFT DIET, LIQUID DIET
SPECIAL DIET
The purpose of a special diet or

modified diet is to restore or maintain a
client’s nutritional status by manipulating
one or more of the following aspects of
the diet
ASPECTS OF SPECIAL DIET
 Nutrients
such as protein, calcium, iron, sodium,
potassium, and vitamin K, may be increased,
decreased, or eliminated
 Kilocalories may be either restricted or increased.
 Texture
or consistency of foods may be an issue.
Example: Surgery & Communicable Disease
 Useof seasoning such as pepper may be restricted or
eliminated.
NUTRIENTS AND DISEASES
CONDITIONS NUTRIENTS SPECIAL DIET

MALNUTRITION NUTRIENTS INCREASE
OBESITY FATS DECREASE

HEMORRHOID ELIMINATE
HOT SPICY FOOD
KIDNEY DISEASE PROTEIN CONTROL
QUIZ ON SPECIAL DIET

1. HYPOGLYCEMIA SUGAR / GLUCOSE
2. HYPOCALCEMIA CALCIUM
3. OSTEOPOROSIS CALCIUM
4. OSTEOPOROSIS VITAMIN D
5. HYPERTENSION SALT

6. DIABETES
7. ABDOMINAL
SURGERY
8. DENGUE DARK COLOR FOOD
9. ANEMIA
10. BURN
CONDITIONS NUTRIENTS/FOOD SPECIAL DIET

11. DUODENAL ULCER FOOD & NUTRIENTS
12. CACHEXIA
FOOD & NUTRIENTS
13. DIARRHEA OILY FOOD
14. HYPOKALEMIA BANANA
15. GLOMERULONEPHRITIS PROTEIN

ANSWERS

HYPOGLYCEMIA SUGAR / GLUCOSE
HYPOCALCEMIA CALCIUM
OSTEOPOROSIS CALCIUM
OSTEOPOROSIS VITAMIN D
HYPERTENSION SALT
ANSWERS

DIABETES SUGAR / GLUCOSE
ABDOMINAL
FOOD
SURGERY
DENGUE DARK COLORED FOOD
ANEMIA IRON
BURN
ELECTROLYTES
CONDITIONS NUTRIENTS/FOOD SPECIAL DIET

DUODENAL ULCER FOOD & NUTRIENTS
CACHEXIA
FOOD & NUTRIENTS
DIARRHEA OILY FOOD
HYPOKALEMIA BANANA
GLOMERULONEPHRITIS PROTEIN
COMMON DIET ORDERS
 NPO  LOW SALT LOW FAT

 CLEAR LIQUID  LOW SODIUM DIET
 GENERAL LIQUID  TOTAL PARENTERAL
 SOFT DIET NUTRITION
 BRAT DIET
 LOW PURIEN DIET
IMPORTANCE OF NUTRITIONAL CARE
MALNUTRITION associated with acute and

chronic disease is common in hospital
setting.
It is one of the most common conditions
affecting the care of hospitalized clients.
METHODS OF NUTRIENT DELIVERY
1. ORAL DELIVERY
2. ENTERAL TUBE FEEDING
3. PARENTERAL FEEDING
1. ORAL DELIVERY
The most common methods of nutrient delivery but
may be affected with the following conditions:
a. Iatrogenic Malnutrition
b. Induced Malnutrition
1. IATROGENIC MALNUTRITION – It is a form of

malnutrition due to routine hospital practices such as
extended periods of food or nutrient deprivation
because of treatments, diagnostic procedures,
therapy and rehabilitation.
2. INDUCED MALNUTRITION – Is a results of physician’s
order or institutional policy due to diagnostic
procedures, surgical operation & other treatment
1. ORAL DELIVERY considerations:

a. Selective or Non-Selective. Ex. No Red Meat
b. Eating Environment
c. Assisted Feeding VS Self Feeding
d. Assisting Disabled Client
e. Supplemental Feeding
SUPPLEMENTAL FEEDING:
a. MODULAR SUPPLEMENTS
b. INTACT OR POLYMERIC FORMULAS
c. ELEMENTAL OR PREDIGESTED FORMULAS
d. DISEASE-SPECIFIC FORMULAS
a. MODULAR SUPPLEMENTS
a. Contains only one nutrient designed for client
who require the addition of only one nutrient.
Example: Moducal, Nutrisource CHO, Microlipid,
Amino Acids.
b. INTACT OR POLYMERIC FORMULAS
a. Used when the gastrointestinal tract is functional
and the client needs all the essential nutrients in a
specified volume. Example: ENSURE, SUSTACAL,
c. ELEMENTAL OR PREDIGESTED FORMULAS
a. The nutrients in this formulas are easier to digest or
already partially digested. It is rapidly digested
and apt to be present in the small intestine in
higher concentration. Example: FLEXICAL, VITAL,
VIVONEX
d. DISEASE-SPECIFIC FORMULAS
a. The nutrients in this formulas are designed for
clients with specific metabolic problems.
Example: Liver Disease – Hepatic Aid, Travasob
Hepatic, Pulmonary – Respalor, Pulmocare

a. Second way of delivering nutrients to
clients. With some medical conditions,
oral feeding is impossible, insufficient, or
impractical. NGT Feeding – Naso-Gastric
Tube Feeding

b. It can be commercially prepared or can
be prepared by client or significant
others to be less expensive.

c. Indications of Tube Feeding.
1. Mechanical Difficulties that make chewing or
swallowing is impossible or difficult.
2. Intestinal Disease that cannot digest or absorb
food adequately.

c. Indications of Tube Feeding.
3. Client refuses to eat or cannot eat
4. Client is unable to consume a sufficient
amount of food because of clinical condition
2. ENTERAL TUBE FEEDING consideration:

a. Gastro Intestinal Function g. Administration of
b. Tube Placement Medication
c. Contamination h. Monitoring of Tube-Fed
d. Administration Client
e. Potential Complication i. Home Enteral Nutrition
f. Osmolality

a. Gastro Intestinal Function
The GIT (Gastrointestinal Tract) should always
be used to the extent possible. Oral supplements
should be considered before tube feeding ; tube
feeding should always be considered before
intravenous feeding

b. Tube Placement
Feeding Tubes can enter the body through the
nose or through a surgical made opening. NGT,
Nasoduodenal (ND) Tube, Nasojejunal (NJ) Tube,
Ostomy, Colostomy, Esophagostomy,
Gastrostomy
LEFT COLOSTOMY

b. Tube Placement
Nursing primary responsibility is to monitor the risk of
Regurgitation and Aspiration.
Regurgitation is the back flow of feeding leading to the
lungs & cause infection.
Aspiration – is the state whereby susbstance has been
drawn up into the nose, throat or lungs.

c. Contamination
Unfortunately, Tube Feeding provide an excellent
environment for the growth of microorganism. When the
tube feeding becomes contaminated with bacteria, the
client receiving feeding may become ill and they suffer
from GI problems such as nausea, vomiting or diarrhea.

d. Administration
CONTINUOUS FEEDING
INTERMITTENT FEEDING
BOLUS FEEDING
CONTINUOUS FEEDING
It is always recommended for formulas delivered
directly into the small intestine.
Infusion Pump is necessary for precise control of
a continuous feeding.
INTERMITTENT FEEDING
Means giving a 4-6 hours volume of feeding solution
over 20-30 minutes. Clients tolerate intermittent
feedings much better than bolus feedings because
these feedings more closely approximate normal
eating behavior. The tube needs to be flushed after
each feeding to minimize bacterial growth and
prevent contamination.
BOLUS FEEDING
Means giving a 4-6 hours volume of feeding solution
within a few minutes. Client is fed only 4 to 6 times per
day. Feeding given by this method are frequently
poorly tolerated, with clients complaining of
abdominal discomfort, nausea, fullness, and cramping.
ENTERAL FEEDING POTENTIAL COMPLICATION (e)

1. Mechanical – Tube Irritation, Tube Obstruction, Aspiration
and Regurgitation & Tube Displacement.
2. Gastrointestinal – Cramping, Distention, Bloating, Gas pains,
Nausea, Vomiting, Diarrhea
3. Metabolic – Dehydration, Overhydration, Hyperglycemia,
Hypernatrimia, Hyponatremia, Hypophopatemia,
Hypercapnia, Hyperkalemia, Hypokalemia
ENTERAL FEEDING Consideration:

f. OSMOLALITY
1. The osmolality of the solution is based on the
number of dissolved particles in the solution.
The greater the number of particles, the higher
the osmolality. - Concentration
Osmosis
Movement of fluid from and area of lower solute
concentration to an area of higher solute
concentration
Diffusion
Movement of molecules and ions from an area of
higher concentration to an area of lower
concentration

g. Administration of Medication:
Nurses responsibilities are
• to maintain the 10 Rights of Drug Administration
• To Monitor the potential food-drug interaction
• To minimize or prevent complication

h. Monitoring the Tube-Feed Client:
Nurses Responsibility are
* to maintain the Nutritional Status
* Fluid and Electrolytes Balance
* Gastrointestinal Balance

i. Home Enteral Nutrition:
Nurses Responsibility are
* Health Teaching prior to Discharge
* Home Health Care Services coordination
* Collaboration and Support

a. Gastro Intestinal Function g. Administration of
b. Tube Placement Medication
c. Contamination h. Monitoring of Tube-Fed
d. Administration Client
e. Potential Complication i. Home Enteral Nutrition
f. Osmolality
2. PARENTERAL FEEDING
Nutrients are delivered to the client
through the veins (intravenously) is the
third means of feeding.
a) Peripheral Parenteral Nutrition (PPN)
b) Total Parenteral Nutrition (TPN)
2. Peripheral Parenteral Nutrition (PPN)

Feeding via vein away from the center of
the body in peripheral veins.
3. Total Parenteral Nutrition (PPN)
Feeding via central vein particularly in
subclavian or jugular vein

It is an effective method of nutritional support
for clients with mild to moderate nutritional
deficiencies who are unable to receive
enteral nutrition or for whom the central
venous route is inaccessible or undesirable.

Indicated in clients who are/have:
a. expected to be NPO for 5 days
b. inadequate GI Function to last 5-7 days
c. making transition to oral or tube feeding

Indicated in clients who are/have:
d. central venous access in contraindicated
e. malnourished and expected to be NPO for 7 days
f. energy and protein requirements that can be met
with PPN (1800 kcalories per day or less)
3. Total Parenteral Nutrition (PPN)

Potential candidates are clients who are
anticipated to require nutritional support for
longer than 10 days or who have an
increased requirement for energy such as
clients who have:
3. Total Parenteral Nutrition (PPN) INDICATIONS

a. need preoperative preparation but are
severely malnourished.
b. postoperative surgical complications
c. inflammatory bowel disease
d. inadequate oral intake or malabsorption.
DIET THERAPY
Diet Therapy
System of food intake

Usual foods and drinks regularly consumed
Food prescribed, regulated, or restricted in
kind and amount for therapeutic or other
purposes
Diet Therapy
THERAPY
Treatment of physical,
mental, or behavioral
problems that is meant
to cure or rehabilitate
somebody
Diet Therapy
To maintain good
nutritional status
Diet Therapy
Correct deficiencies that

may have occurred
Diet Therapy
Afford rest to the whole body or to certain organs that may be affected by the disease
Diet Therapy
Bring about changes to the body weight whenever necessary
Diet Therapy
General Diets
Diets Modified in Consistency
Diets Modified in Composition
General Diets
Alsocalled as
Regular Diet
General Diets
 Normal diet planned to provide the recommended daily allowances for

essential nutrients
 Designed to meet the caloric needs of a bedridden patient whose
condition does not require any dietary modification
Diets Modified in Consistency
A regular diet altered to meet

specific body requirements
under different conditions of
health or disease.
 Customized the level of
thickness or smoothness of a
food
Diets Modified in Composition
Dietof an individual that was modified by

content
Example: Calories, CHO, PRO, Fat, or
specific nutrient
Diets Modified in Composition
Therapeutic Diets
Therapeutic Diets
 Modificationsof normal diet used to improve specific

health conditions
 Normally prescribed by doctor and planned by
dietician
 May change nutrients, caloric content and/or texture
 May seem strange and even unpleasant to the
patient
Therapeutic Diets
 Patient’s
appetite may be affected by anorexia or loss
of appetite, weakness, illness, loneliness, self-pity and
other factors
 Usepatience and tact to convince patient to eat
food
 Understandpurpose of diet and provide simple
explanations to patient
Therapeutic Diets
 Regular diet  Fatrestricted (low-fat)

 Liquid diet diet
 Soft diet  Sodium restricted diet
 Diabetic diet  Protein diet
 Calorie controlled diet  Bland diet
 Low cholesterol diet  Low residue diet
Regular Diet
 Balanced diet usually used for ambulatory
patients
 At times is has a slightly reduced caloric
content
 Foods such as rich desserts, cream sauces,
salad dressings and fried foods may be
decreased or omitted
Liquid Diets
 Nutritionally
inadequate and should only be used for
short periods of time
 Uses:
 After surgery or a heart attack
 Pts with acute infections or digestive problems
 To replace fluids lost by vomiting or diarrhea
 Before some Xrays of digestive tract
Liquid Diets
2 types
Clear liquid diet
Water, apple or grape juice, fat-free broths, plain gelatin,
popsicles, ginger ale, tea, coffee
Full liquid diet
Everything on clear liquid diet plus strained soups and
cereals, fruit and vegetable juices, yogurt, hot cocoa,
custard, ice cream, pudding, sherbet, and eggnog
Soft Diet
 Similar to regular diet but foods must require
little chewing and be easy to digest
 Avoid meat and shellfish with tough connective
tissue, coarse cereals, spicy foods, rich desserts,
fried foods, raw fruits and veggies, nuts, and
coconuts
Soft Diet
Uses:
Aftersurgery
Patients with infections
Digestive disorders or chewing problems
Diabetic Diet
 Usedfor pts with diabetes mellitus (body does not
produce enough insulin to metabolize carbohydrates)
 Diet contains exchange lists
 Goods are grouped according to type, nutrients, and
calories
 Pts
are allowed a certain number of items from each
exchange list according to individual needs
Diabetic Diet
 Avoidsugar-heavy foods such as candy, soft drinks,
desserts, cookies, syrup, honey, condensed milk,
sugared gum, jams, and jellies
 New trend is to count only carbs as blood sugar levels
are most affected by carbs
 Pt
then takes an amount of insulin based upon
amount of carbs eaten
Calorie Controlled Diet
Low-Calorie Diet
Used for pts who are overweight

Avoid or limit high calories foods such as:
Butter, cream, whole milk, cream soups or
gravies, sweet soft drinks, alcoholic beverages,
salad dressings, fatty meats, candy and rich
desserts
Calorie Controlled Diet
High-Calorie Diet
 Usedfor pts who are underweight, or who have
anorexia nervosa, hyperthyroidism, or cancer
 Extra proteins and carbs are included
 Avoid
high-bulk foods such as green salads,
watermelon and fibrous fruits
 Avoid high-fat foods such as fried foods, rich pastries,
and cheese cake because they digest slowly and
spoil appetite
Low Cholesterol Diet
 Restricts foods containing cholesterol
 Used for pts with atherosclerosis and heart disease
 Limitfoods high in saturated fats such as beef, liver,
pork, lamb, egg yolk, cream, cheese, natural
cheeses, shellfish, whole milk, and coconut and palm
oil products
Fat Restricted or Low-Fat Diet
Used for pts with gallbladder and liver

disease, obesity, and certain heart diseases
Avoid cream, whole milk, cheese, fats,
fatty meats, rich desserts, chocolate, fried
foods, salad dressings, nuts, and coconut
Sodium Restricted Diet
(Low Sodium or Low Salt Diet)
 Used for pts with cardiovascular diseases such

as hypertension or congestive heart disease,
kidney disease, and edema
 Avoid or limit addition of salt to any food,
smoked meats or fish, processed foods, pickles,
sauerkraut, olives, and processed cheeses
High Protein Diet
 Usedfor children and adolescents who need
additional growth, pregnant or lactating women,
before and/or after surgery, pts suffering from burns,
fevers, or infections
 Regular diet with added protein rich foods such as
meats, fish, milk, cheese, and eggs
Low Protein Diet
Used for pts with certain kidney diseases

and for certain allergic conditions
Regular diet with limited or decreased
protein rich foods
Bland Diet
 Consists
of easily digested foods that do not irritate
the digestive tract
 Used for pts with ulcers and other digestive diseases
 Avoidcoarse foods, fried foods, highly seasoned
foods, pastries, raw fruits and veggies, alcohol,
carbonated beverages, nuts, coffee, tea, smoked
and salted meats and fish.
Low Residue Diet
 Used for pts with digestive and rectal diseases

such as colitis or diarrhea
 Eliminates or limits foods high in bulk or fiber
such as raw fruits and veggies, whole grains
and cereals, nuts, seeds, beans and peas,
coconut, and fried foods

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NUTRITION DIAGNOSIS

AND PLAN OF CARE

REFERENCE: NUTRITION AND DIET THERAPY BY LUTZ & PRZYTULSKI

ASSESSMENT: (Subjective & Objective Data)

 Dietary Intake Data

 Nutrient Intake Analysis (NIA)

24 Hours Recall

24 Hours Recall

 Food Frequency Questionnaire (FFQ):

 Food Frequency Questionnaire (FFQ):

 Food Frequency Questionnaire (FFQ):

 ANTHROPOMETRIC MEASUREMENTS  Malnutrition Universal Screening

 BMI  Subjective Global Assessment

 FOOD SERVICES IN HEALTH CARE FACILITIES

NUTRITIONAL CARE OF CLIENTS

Height, Weight, BMI, and Weight History

Presence of Pressure Ulcers

Factors affecting Nutritional Status

Presence of Physical Stress

Itis a written nutritional needs of client

The purpose of a special diet or

CONDITIONS NUTRIENTS SPECIAL DIET

OBESITY FATS DECREASE

CONDITIONS NUTRIENTS SPECIAL DIET

CONDITIONS NUTRIENTS SPECIAL DIET

CONDITIONS NUTRIENTS/FOOD SPECIAL DIET

14. HYPOKALEMIA BANANA

15. GLOMERULONEPHRITIS PROTEIN

CONDITIONS NUTRIENTS SPECIAL DIET

CONDITIONS NUTRIENTS SPECIAL DIET

CONDITIONS NUTRIENTS/FOOD SPECIAL DIET

 NPO  LOW SALT LOW FAT

MALNUTRITION associated with acute and

1. IATROGENIC MALNUTRITION – It is a form of

1. ORAL DELIVERY considerations:

2. ENTERAL TUBE FEEDING

2. ENTERAL TUBE FEEDING

2. ENTERAL TUBE FEEDING

2. ENTERAL TUBE FEEDING

2. ENTERAL TUBE FEEDING consideration:

2. ENTERAL TUBE FEEDING consideration:

2. ENTERAL TUBE FEEDING consideration:

2. ENTERAL TUBE FEEDING consideration:

2. ENTERAL TUBE FEEDING consideration:

2. ENTERAL TUBE FEEDING consideration:

ENTERAL FEEDING POTENTIAL COMPLICATION (e)

ENTERAL FEEDING Consideration:

ENTERAL FEEDING Consideration:

ENTERAL FEEDING Consideration:

ENTERAL FEEDING Consideration:

2. ENTERAL TUBE FEEDING consideration:

2. Peripheral Parenteral Nutrition (PPN)

2. Peripheral Parenteral Nutrition (PPN)

2. Peripheral Parenteral Nutrition (PPN)

2. Peripheral Parenteral Nutrition (PPN)

3. Total Parenteral Nutrition (PPN)

3. Total Parenteral Nutrition (PPN) INDICATIONS

System of food intake

Correct deficiencies that

 Normal diet planned to provide the recommended daily allowances for

A regular diet altered to meet

Dietof an individual that was modified by

 Modificationsof normal diet used to improve specific