Nutrition Assessment and Dietary Intake

Nutrition Assessment

• Diet and health history are important aspects, including factors influencing nutrition, drug-nutrient interactions, patient preferences, and any cultural or religious restrictions.
• Screening is a part of nutritional assessment.
• Physical assessment includes observing any signs related to nutritional status and checking for dysphagia.

Assessment

• The patients nutrition knowledge should be assessed.
• Understanding patient diet involves a 3-7 day food diary.
• Cultural and religious background and personal food preferences are important to sociocultural considerations.
• Socioeconomic status impacts nutritional options.
• Social history covers patients alcohol, tobacco, and illegal substance use.
• Psychological factors should be considered.
• Review a patient's prescription and OTC drugs and supplements.

Dietary Intake and Food Preferences

• Determine the types of food the patient prefers.
• Ask about the number of meals they consume daily.
• Inquire about any dietary restrictions due to religious or cultural reasons.

Unpleasant Symptoms

• Ask about foods triggering indigestion, gas, or heartburn.

Allergies

• Determine if the is the patient allergic to any foods.
• Determine the type of reaction they experience.
• Ask how food allergies are treated.

Taste, Chewing, and Swallowing

• Ask if the patient wears dentures.
• Determine if the patient has difficulty swallowing.

Appetite and Weight

• Check for any recent changes in appetite.

Factors Influencing Nutrition

• Environmental factors include being able to access full-service grocery stores and the high cost of healthy food.
• Wide availability of fast food increases its intake with fewer nutritious options.
• Lack of accessibility to safe places to exercise also contributes to poor nutrition.
• Transportation and fixed incomes should be considered as socioeconomic factors.

Developmental Factors: Infants to School Age

• Solid foods and formula or Breast feeding are dietary options.

Developmental Factors: Adolescents

• An increase in metabolic demands for growth.
• Consumption of essential vitamins, like calcium, iron, iodine, and B complex vitamins, is needed.
• Onset of eating disorders like anorexia and bulimia can develop.

Developmental Factors: Young & Middle Adulthood

• Reduction of nutrient demands.
• Pregnancy increases need for folic acid, calcium.
• Lactation increases needs protein, calcium, and vitamins A & C.

Developmental Factors: Older Adults

• Age-related changes include loss of teeth, reduced saliva production, atrophy of epithelial cells, and decreased sense of thirst, leading to a dehydration risk.
• Reduced gag reflex and decrease in esophageal and colonic peristalsis can impact nutrition.

Drug-Nutrient Interactions

• Analgesics like Tylenol decrease bodies absorption of food.
• Antidepressants like SSRIs can cause taste alteration and anorexia.
• Antihypertensives like Labetalol can create taste alterations and weigh gain.
• Bronchodilators like Albuterol can lead to appetite stimulant.
• Anticoagulants like Warfarin are K antagonists.
• Diuretics such as Lasix decrease drug absorption with food.
• Laxatives like mineral oil have an affect fat soluble vitamins.
• Potassium Replacements decrease Vitamin B12.
• Antiarrhythmics like Amiodarone cause taste alterations.
• Antibiotics like Bactrim decrease folic acid.

Cultural Restrictions

• Influence the meaning of food, with "good" and "bad" associations.
• Special dishes when ill.
• Enhance interpersonal relationships.
• There are also racial and ethnic differences, such as lactose intolerance in Asian Pacific, African, Native American, Mexican American, and Middle Eastern groups.

Religious Restrictions

• Muslim: No pork, alcohol, caffeine, includes Ramadan fasting from sunrise to sunset, requires ritualized methods for animal slaughtering.
• Christianity: Some baptists have minimal or no alcohol consumption, lent and meatless days for catholics.
• Hinduism: Avoids meats and alcohol.
• Judaism: Prohibits pork and mixing milk or dairy products with meat dishes.
• Church of Christ of Latter-Day Saints: Abstains from alcohol, tobacco, and caffeine.

Alternative Food Diets

• Vegans avoid all animal products including dairy and eggs.
• Ovo-lacto vegetarians eat eggs and dairy but no meats.
• Lacto vegetarians eat dairy but no meats or eggs.
• Pescatarians eat fish and shellfish, but no meats.
• Medical diets include casein and gluten-free diets and ketogenic diets for epilepsy.

Nutritional Screening

• Used to identify malnutrition risk or determine patients at risk.
• Mini nutritional assessment can done with standardized tools.
• Anthropometric measurements include BMI and ideal body weight.
• unintentional weightloss
• modified dietds
• altered nutritional systems

Laboratory Tests

• Can determine nutritional status.
• Blood Protein Plasma:
  • Prealbumin
  • Albumin
  • Retinol-Binding
• Used to identify specific diseases
• Liver enzymes: LFTs
• Kidney function: GFR

Physical Examination

• Alertness helps determine level of malnutrition
• Weight for height, age, body build should be normal
• Patient should be erect and can show indicators such as sagging shoulders, sunken chest or humped back
• Muscles should be well-developed, firm, good tone, with some fat under skin
• Attention span should be good, nor irritable or restless w/ normal reflexes and psychological stability
• Good appetite and digestion, normal regular elimination, no palpable organs or masses
• Normal beats, rhythm with normal blood pressure
• Endurance, sleeps well, vigorous
• Hair is healthy, and not plucked

Nursing Interventions: Acute Care

• Therapeutic diets.
• Medical nutrition therapy.
• Promoting appetite.
• Assisting with oral feedings.
• Enteral tube feedings.

Nursing Interventions: Assistance

• Therapeutic diets and medical nutrition therapy are considerations.
• Promoting the patients appetite.
• Assisting with oral feedings and treatment for dysphagia.
• Enteral Tube Feedings assistance.

Nursing Interventions: Teaching

• Patient teaching for health promotion.

Types of Therapeutic Diets: Clear Liquid

• Includes clear, fat-free broth, bouillon, coffee, tea, carbonated drinks, and clear fruit gelatin.

Types of Therapeutic Diets: Full Liquid

• Includes any liquids with smooth textures, such as dairy products (ice cream), blended creamed soups, custards, and refined cooked cereal.

Types of Therapeutic Diets: Pureed/Thickened Liquids

• Includes clear and full liquids, with the addition of scrambled eggs, pureed meats and vegetables, and mashed potatoes.

Types of Therapeutic Diets: Mechanical Soft

• Includes ground or finely diced meats, flaked fish, cottage cheese, rice, and potatoes.

Types of Therapeutic Diets: Soft/Low Residue

• Includes of low-fiber, easily digested foods, pasta, casseroles, moist tender meats, and canned cooked fruits and vegetables.

Types of Therapeutic Diets: High Fiber

• Includes fresh uncooked fruits, steamed vegetables, bran oatmeal, and dried fruits.

Types of Therapeutic Diets: Low Sodium

• Restrictions includes: 4 g (no added salt), 2 g, 1 g, or 500 mg.

Types of Therapeutic Diets: Low Cholesterol

• Diets which limit approximately 300 mg/day.

Types of Therapeutic Diets: Diabetic

• ADA recommendations include balanced intake of carbohydrates, fats, and proteins.

Types of Therapeutic Diets: Gluten

• Eliminates wheat, oats, rye, barley and their derivatives.

Types of Therapeutic Diets: Regular

• Involves no restrictions unless specified.

Promoting Appetite

• The environment should have on strong odors, include oral hygiene to remove any unpleasant tastes, and promote the patients comfort.
• Smaller, more frequent meals might be needed.
• Medications for appetite stimulation, insulin, glucocorticoids, thyroid hormones, taste modifiers or psychotropic drugs should be considered.
• Social activity and consulting a dietician is helpful.

Oral Feedings

• Its important to Maintain independence and dignity for patients.
• Verbal coaching is great for encourgament.
• Risk for aspiration should be assessed and Oral suctions at bedside.
• Look for: -decreased alertess -poor gag reflex -difficulty managing saliva.
• Consult SLP if needed

Decrease Aspiration Risk

• Provide 30 minute rest periods before eating
• Posture to be in upright seated position at 90 degrees, with Head flex slightly
• Feed on the stronger side of mouth with 1/2 to 1 tsp amounts
• Remain upright position for at least 30-60 minutes after meal
• Have patient swallow twice to clear pharynx
• Inspect mouth for pocket of food

Dysphagia

• Defined as difficulty swallowing, due to neurological, muscular, obstruction type of disorders.

Dysphagia: Warning Signs

• Coughing during eating.
• Change in a patients voice tone or quality after swallowing.
• Abnormal movements of mouth, tongue, and lips.
• Slow, weak, imprecise, or uncoordinated speech.
• Abnormal gag reflex.
• Delayed swallowing, be ware of silent aspiration
• Leads to malnutrition and aspiration pneumonia

Oral Feedings: Dysphagia Patient

• Liquid diets should vary in thickness:
  • Thin (low viscosity), Nectar-like (medium viscosity), Honey-like, Spoon-thick.
• Feed slowly, smaller size bites.
• Matching speeding the feeding to the patients readiness.
• Allow thorough chewing and swallowing before taking another bite.
• Remove food immediately if the patient is coughing or choking begins & suction.

Oral Feedings: Visual deficits

• Blind patient with impaired vision can benefit for:
• Maintain independence.
• Identify food location on meal plate – clock format.
• Use constant plate setup for every meal with adaptive equipment.

GI Intubation: Temporary Tubes

• Nasogastric (NG).
• Small bore Dobhoff (weighted).
• Nasojejunostomy (NJ).
• Nasoduodenal (ND).

GI Intubation: Permanent Tubes

• Gastronomy and Jejunostomy are surgicaly created tubes.

GI Intubation – NG Purposes

• An enteral feeding or medication admin.
• Decompression is removal of secretions and gaseous substances. -Used Salem Sump, Levin, Miller-Abbott tube
• Compression is internal pressure via inflated balloon prevents hemorrhage.
• Sengstaken-Blakemore is a tube used
• Lavage is performed to the stomach for bleeding, poisoning, or gastric dilation.
• Levin, Ewald, Salem Sump tube used

GI Intubation

• Place patient in high Fowler's position (90 degrees).
• Determine length and mark with tape distance from tip of the nose to earlobe to xyphoid process of sternum.
• Give patient small sips of water during insersion.
• Flex patient's head toward chest when it passess the nasopharynx.
• have the patient to mouth breathe and cough

GI Intubation - Management

• pH strips and X-rays are method of checking for placement.
• Minimizing discomfort with Oral care.
• Routine Flushing tubes prevent blockage.
• Replacement Frequency is dependent on type of tube.

Oral Medication through an Enteral tube

• To Verify is: location of the tube being stomach or jejunum.
• Compatibility of location with medication I.e., Fe dissolves and absorbs in the stomach.
• Flushing tube amount between 15ml-30ml of sterile water.
• Clamping enteral tube for 30-60 minutes.
• Liquid preparation NOT available: tablet or capsule dilute in sterile water but DO NOT use tap water

Enteral Feedings: Indications

• Its intended for patients who are unable to swallow but possess a function.
• Enteral or Short term tubes such as: Nasogastric, Jejunal, gastric reflux risk.
• Gastronomy or Jejunal are called Long term (>4 weeks)

Enteral Feedings

• Continuous and are measured in Rate: mL/hr.
• Intermittent or Bolus Rate: amount Qh.

Enteral Feeding

• Warm tube up to room temperature
• Patient position will have to elevated at 45 degrees or use Trentelenburg for those who must be flat.
• Verify NGT prior to feeding and start with full strength
• Increase 8/12hr as tolerated
• Signs of GRV
• High: GRV
• n/v/d
• GI cramping

Gastric Residual Volume

• Indicates delayed emptying
• Can be identified by medications or disease
• Performed Q4hr of before each feeding.
• with 10-30ml through the tube
• Volume to exceed 250ml.
• If so, risk for aspiration and STOP feeding!
• Medications can be added : Metoclopramide and erythromycin.

Enteral Feedings: Complications

• Pulmonary aspiration:
  • The patient must maintain high fowlers position
  • Tube feeding must be verified and repositioned.
• Diarrhea:
  • Formula must be diluted, delivered continuously/
  • consult health care provider
  • do not hang longer than 4/8 hrs
• Constipation:
  • select a formula containing fiber -Tube occulussion:
  • Use medication in liquid form before administering.

Learn about nutrition assessment, dietary intake, and food preferences. This includes diet and health history, physical assessments, patient knowledge, and sociocultural factors that impact nutritional options. Also reviewed are any prescription and OTC drugs and supplements.