PhDr. Natália Beharková, Ph.D., Mgr. Dana Soldánová
Nutrition
a basic human need
Nutritional status assessment
anthropometrical examination (weight, height, BMI, waist circumference measurement, measurement of the circumference of the muscles on the non-dominant arm, measurement of skin fold thickness)
biochemical markers – blood and urine examination
clinical indicators – body constitution, symptoms of malnutrition, hydration status
nutritional history – eating habits
Nutritional care
provided by nutrition team, multidisciplinary team – dietitian, nurse, doctor, hospital attendant, health care assistant, hospital catering provider
dietitian – performs nutritional diagnostics, solves nutritional problems, consults a doctor, suggests and evaluates nutritional measures
nurse – recognizes, monitors and solves nutritional problems
doctor – performs nutritional screening at admission, assesses nutritional status, orders dietary measures and solves nutritional problems
hospital attendant, health care assistant – assists with food distribution, monitors food consumption
food service – personalizes the diet according to the patient's needs
Dietary system
Diet
Part of the treatment regime
food individualized according to the doctor's orders
requirements – food has energy and biological value, is harmless in hygienic-epidemiologic sense, and is tasty, diverse, warm, and aesthetically pleasing
Basic Diets
Diet number
Diet designation
Energy kJ
Indication
0
full – liquid
6 000
short-term administration; after oral cavity surgery; pharyngeal and oesophageal diseases, swallowing disorders; after tonsillectomy, jaw injuries or dental operations
1
pureed
9 500
chest and swallowing disorders (seniors, conditions after radiotherapy and chemotherapy); acute attack of gastric and duodenal ulcer disease; injuries and surgical procedures in oral cavity, throat or oesophagus
2
soft
9 500
gastric and duodenal diseases; after heart attack; skin diseases; allergies
3
regular
9 500
all foods, no restrictions
4
fat-modified
9 500
diseases of the liver, gallbladder and pancreas
5
low-residue
9 500
inflammatory bowel disease; intestinal surgery; diarrhoea after radiotherapy and chemotherapy
6
low-protein
9 500
kidney disease
8
slimming
5 300
overweight, obesity
9
diabetic (consistent carbohydrate diet)
individual
diabetes mellitus
10
low-sodium
9 500
hypertension; swelling; heart and blood vessel diseases
normal diet, composition and consistency adjusted for the toddlers
13
children's food (age under 15)
9 500
normal diet, modified to children
14
selective diet
9 500
malnutrition; cachexia; mental anorexia, bulimia; selection of meals according to patient's wishes (provided by the nutrition therapist)
* diet No. 7 (low-cholesterol) – is no longer included in the dietary system as of 2008 (every diet should have low cholesterol content)
Special diets
Diet number
Diet designation
Indication
0-S
tea
tea in sips
1-S
liquid high-nutritional
chest and swallowing disorders + need of increased energy intake (seniors; conditions after radiotherapy and chemotherapy; injuries and surgical procedures in oral cavity, throat or oesophagus
4-S
strict fat limitations
acute hepatitis; acute gallbladder inflammation; after cholecystitis; after cholecystectomy; after starving in pancreatitis
9-S
diabetic soft
diabetes mellitus with concomitant diseases of the digestive tract
W
warfarin
when treated with warfarin, diet with vitamin K excluded (no green leafy vegetables)
KVM
vanillylmandelic acid
when measuring vanillylmandelic acid content, fruits, vegetables and fruit juices are excluded
Standardized dietary procedures
Diet number
Diet designation
Indications
BLP
gluten-free
celiac disease; sprue
BL
lactose-free
lactose intolerance
P
pancreatic
gradual alimentation after pancreatitis
OK
occult bleeding diet
before examination of occult (hidden) bleeding from GIT
Enteral nutrition
administration of pharmaceutically prepared nutritional products
purpose – maintaining good nutritional status, improving nutritional status
proper functioning of gastrointestinal tract is an essential precondition here
products containing individual (single) nutrients or all components of nutrition
Principles
explain to the patient the reasons for and the method of administration; patient drinks in small sips during the day – prevention of diarrhoea and nausea
specially prepared sipping products – for a patient with non-healing wounds, oncological diseases, or dietary restrictions (Diasip for diabetes mellitus patients; Nutridrink Juice Style for fat-free nutrition; Nutridrink Multi Fibre for patients needing fibre, etc.)
product temperature – according to the patient (colder sipping reduces nausea, promotes appetite)
oncological patients during chemotherapy – alternate only two flavours to prevent aversion to flavours; useful in cases of nausea due to chemotherapy
Nasogastric tube (NG)
Provides nutrition
nutritionally and chemically defined products are used
a thin polyurethane or silicone tube is inserted
Leave the tube inside for maximum 4–6 weeks; after 14 days a replacement or change of position is recommended to prevent pressure ulcers.
NG tube for gastric decompression
inserting a thick PVC tube
suction of stomach contents (monitoring the character and amount of secretions)
gastric lavage in case of intoxication
short-term (up to 7 days)
NG tube positioning – prevention of pressure ulcers
Contraindications of NG tube use
anatomical obstructions; acid burning of oesophagus; severe mucosal bleeding; risk of perforation of the oesophagus and stomach
Nasogastric tube insertion
competence – general nurse without professional supervision, according to the doctor's indication, for conscious patients 10 years and older
1) Preparation of the patient
semi-Fowler's (low Fowler's) position
Blow the patient's nose.
Assess nostril space.
Remove and store dental prosthesis.
Instruct the patient to breathe through the nose, swallow, then breathe out.
position the patient – semi-Fowler's position – first have patient raise head, then after tube has passed through nasopharynx, have patient lower head. Patient takes a breath, then swallows (we advance the nasogastric tube during swallowing), then breathes out. Breathing and swallowing cycles to be repeated up to the indicated length on the NG tube). If the patient feels sick during insertion of NG tube, interrupt the procedure, let him/her take breath, make lessening the patient's anxiety a priority
the correct length – from the xiphoid process of the sternum behind ear and to the tip of the nose, mark on the NG tube
local anaesthesia – Mesocain gel
NG tube can be stored in the freezer for approximately 30 minutes before insertion for easier insertion.
3) Verify the correct location
auscultation – stethoscope on the xiphoid process of the sternum, inject 30 mL of air with Jeanette syringe – audible air bubbling
Examine the pH of the aspirated gastric content by using pH indicators, physiological range 0–4; when introduced into the respiratory tract, the content has straw colour, pH 6–8.
X-ray control
4) Details recorded in the documentation
Removal of the nasogastric tube
on the basis of a doctor's orders
undesired removal by the patient
Before removal, clamp the NG tube according to the doctor's orders (e.g. one hour before removal or one day before; observe the patient – flatulence, belching, nausea, etc.).
Insufflate 30 – 50 mL of air to prevent residue in NG tube.
Instruct the patient – take a deep breath, hold breath, pull NG tube out.
Record details in the documentation.
Administering enteral nutrition
Bolus administration
between 6 am – 10 pm for 2–3 hours, Jeanette syringe, 150–300 mL of prescribed enteral formula
overnight break
room-temperature nutrition
patient in semi-Fowler's position
aspiration of the stomach content, over 100 mL skip the following dose, return the aspirated content back to the stomach (contains gastric juices)
adequate speed and pressure of delivery
Flush the tube with boiled water and close for 30 minutes, the patient should be in semi-Fowler's position after administration.
nutrition to the jejunum under sterile conditions (reduced risk of regurgitation, vomiting, aspiration)
pharmaceutical nutritive products, nutritionally and chemically defined (Fresubin, Nutrison, Isosource)
feeding by a pump for enteral nutrition
continuous 24-hour administration, or with an overnight break
tube is flushed regularly with half-normal saline solution or sterile water (at least 20 mL three times a day, always when feeding is interrupted and always when it is started again)
feeding may be provided for several months, even at home (by patient or relatives)
inserted by a doctor with nurse assistance
Percutaneous endoscopic gastrostomy (PEG)
insertion of tube into the stomach through the abdominal wall with use of endoscope
for long-term enteral nutrition (over 6 weeks)
feeding bolus or continuously (as with NGT)
rebandaging of the wound, tube rotation
feeding for several months can be provided at home (by patient or relatives)
Insertion of the tube into the jejunum through the abdominal wall using an endoscope.
nutrition into the jejunum under sterile conditions
for long-term enteral nutrition (over 6 weeks)
pharmaceutical nutritional products, nutritionally and chemically defined (Fresubin, Nutrison, Isosource)
feeding by a pump for enteral nutrition
continuous 24-hour administration, or with an overnight break
the tube is flushed regularly with sterile half-normal saline or sterile water
rebandaging of the wound
feeding for several months, can be provided at home (by patient or relatives)
Parenteral nutrition
method of delivering nutrients out of the digestive tract into the vascular system (directly into the bloodstream) – peripheral venous catheter, central venous catheter, venous port
used for patients with dysfunctional digestive tract
can be combined with enteral nutrition
not a physiological route of nutrient administration
Purpose
Ensuring the satisfactory nutritional state of the patient and the satisfactory state of his/her internal environment.
Methods of administration
To a peripheral vein
short-term nutritional support
risk of phlebitis
solutions for hydration treatment (water, electrolytes)
additional energetic intake – 5% Glucose
supplementation of proteins and vitamins
To a central vein
long-term nutritional support
concentrated solutions without risk of phlebitis
application to the subclavian vein
application to the jugularis vein (end of the catheter in the superior vena cava)
application to a venous port
Systems of administration
multiple bottle system – single nutritional components in bottles (an obsolete system)
all in one system – all nutritional components in one bag, the most frequently used
All-in-one bag
bags prepared by manufacturer – the contents of the chambers are mixed just prior to the application
bags prepared in the pharmacy according to the individual needs of the patient
cyclically administered with an overnight break
Disadvantages of parenteral nutrition
permanent venous access (risk of infection)
unnatural way of eating (bypasses the digestive tract)
risk of overdose
impairment of the intestinal mucosa (atrophy, decrease in local immunity
high price
Literature
Jirkovský D. a kol. Ošetřovatelské postupy a intervence: učebnice pro bakalářské a magisterské studium, Praha, Czechia: Motol University Hospital, 2012. s. 389-411. ISBN: 978-80-87347-13-3
Krišková, A. a kol. Ošetrovateľské techniky – metodika sesterských činností. Martin, Slovakia: Osveta, 2006. pp. 179-220. ISBN 80-8063-202-2