NUTRITIONAL CARE PLAN

1. Nutritional care plan

2. It is the substance, procedure , and setting involved in ensuring the proper intake & assimilation of nutrients , especially for hospitalized patient . Objectives To present the components of the nutrition care plan To discuss the different approaches in determining the contents of the nutrition care plan

3. Components of nutrition care plan Nutritional assessment Nutritional requirement Micro &Macro micronutrients Fluid requirement Access: oral, parenteral, or combinations Nutrient formulation Nutrient delivery Monitoring strategies

4. Nutritional Assessment Methods Used Are: A nthropometric Assessment B iochemical Assessment C linical Assessment D ietary Assessment

5. NUTRITIONAL REQUIREMENT

6. Food pyramid:

7. Food pyramid: Education tool that shows the dietary guidelines in easily understood graphic format. Balanced diet : Contains the various food groups of food stuff in the correct proportions. Recommended dietary allowances/intakes : The intake of nutrient derived from diet which keeps nearly all people in good health.

8. Group particulars Body wt Energy Kcal/kg Protein g/kg Fat g/day Calcium Mg/day Iron Mg/day Infants 0-6 months 5.4 108 2 500 6-12 months 8.6 98 1.65 500 Children 1-3yrs 12 102 1.8 25 400 12 4-6 19 89 1.6 25 400 18 7-9 27 73 1.5 25 400 26 Adolescence (boys) 10-12yrs 35.4 62 1.5 22 600 34 girls 10-12yrs 31.5 62 1.8 22 600 19 Boys 13-15yrs 47.8 50 1.5 22 600 41 Girls 13-15yrs 46.7 44 1.4 22 600 28 Boys 16-18yrs 57.1 46 1.4 22 500 50 Girls 16-18yrs 49.9 41 1.2 22 500 30

9. To avoid iron deficiency a woman should consume iron rich food. Iron rich food : roasted bengal gram , rice flakes , cow pea , sirukeerai , mullakeerai , araikerai , manathakkali , sundakai , watermelon ,raisins(dry grapes) , savalai (fish) , beef , liver sheep Group particulars Body wt Energy Kcal/kg Protein g/kg Fat g/day Calcium Mg/day Iron Mg/day Pregnant woman 50 +300 [phone] Lactating 0-6 Month 50 +550 [phone] month 50 +400 [phone]

10. PARTICULARS ENERGY Obese 25kcal/kg body weight Normal weight 30 kcal/kg body weight Underweight 35kcal/kg body weight Preterm baby 60-150kcal/kg/day Prt – 3.4g/kg PEM 150-200kcal/kg body weight Prt-5g/kg Diabetes mellitus IBW*0.9/25-35kcal Acute renal failure 25-30kcal/kg , Prt -0.6-0.8g/kg Chronic real failure 35-50kcal/kg , Prt-0.5g/kg Hemodialysis 35kcal/kg , Prt-1-1.2g/kg Peritoneal dialysis 35kcal/kg , Prt-1.2-1.5g/kg

11. Micronutrients Electrolytes and Minerals (Na,K,Mg,): Na & k -essential to maintain osmotic balance and keep the cells in proper shape Mg - required for cellular metabolism Trace elements : Needed in very minute quantity for proper growth , development and physiology of the organism I - required for the normal function of thyroid gland Zn - co-factor for a no of enzymes Cu -play an important role in iron absorption

12. Cr - lead to impaired glucose tolerance Mn - participate in lipid & CHO metabolism Mo -essential constituent of xanthine and aldehyde oxidases and involved in uric acid metabolism Vitamins: water and fat soluble: Essential for normal growth and nutrition & required in small quantity Vitamin A - necessary for clear vision in dim light Vitamin D - required for bone growth and calcium metabolism Vitamin E -preventing the oxidation of vit-A & β carotene in intestine

13. Vitamin B complex; Thiamine - proper utilization of CHO in the body Riboflavin - essential for several oxidation process inside the cell and concerned with energy and protein metabolism. Nicotinic acid - component of coenzyme in oxidative reactions and concerned with metabolism of CHO,fat,and proteins. Pyridoxine - metabolism of amino acid and conversion of tryptophan to nicotinic acid Folic acid - required for the multiplication and maturation of red calls Vitamin B12 - required for proper functioning of the CNS & metabolism of folic acid. Vitamin-C -required for iron absorption

14. FLUID REQUIREMENT Water need for the function of: Cell life, Chemical and metabolic reactions Regulate body temperature Transport of nutrients, Elimination of waste Formulas Used: For 0 - 10 kg:   weight (kg) x 100 mL /kg/day  For 10-20 kg:  1000 mL + [weight (kg) x 50 ml/kg/day] For > 20 kg:  1500 mL + [weight (kg) x 20 ml/kg/day] Infusion rate = total fluid volume per day ÷ 24 hours Fluid Requirement for renal patient: Urine output + 500ml.

15. Access Oral Enteral nutrition Nasogastric tube PEG / Gastrostomy Jejunostomy PEG-J ( Jejunostomy feeding passed through the PEG) Surgical jejunostomy Parenteral nutrition Peripheral Central

16. Oral feeding: Clear fluid diet (eg.barley water,dhal water,clear stained fruit juice, tea/coffee (without milk),coconut water.) Full fluid diet ( porridge ,dhal soup , dhal payasam , strained juices , cooked& pureed fruits ,milk , milk shakes , lassi , tea , coffee , strained soups , ice cream) Soft diet (maida,all dhals ,juices, vegetables (cooked) , milk & milk product, egg(not fried),minced non veg, kheer , puddings. Regular diet ( normal diet)

17. ENTERAL NUTRITION/TUBE FEEDING D uring acute initial phase of illness exogenous energy 20-25 Kcal/Kg/day D uring recovery phase -30-40 Kcal/Kg/day P rotein intake should be 1.2-1.5 g/Kg/day never exceeding 1.8 g/Kg/day E xcept extreme losses: burns, digestive losses

18. Type of tube feeding: Blended ( blended regular food,) Elemental(low residue diet , lactose free, ready to absorb) Non elemental( low residue with fiber, may contain lactose) Specific nutrient modular( supply single nutrients , good for diet manipulation Disease specific formular ( those have problem in metabolism or oral esophagus.

19. Total parental nutrition For children; Child Calories Amino acid g/kg Lipids g/kg New born 110-125 kcal /kg 2-5 1-3 Older child 100-110 kcal/kg 1.5-3 1-3 Adult Dextrose Amino acid Lipids Total 100ml/hr 25g 4g 110g 2400ml/hr 600g gives 2040 kcal 96g gives 384 550( 500ml) 2974

20. Nutrient Formulation Regular or special diet Oral supplements Enteral nutrition: Standard formulation, Modular formulations Special (elemental or semi-elemental) Parenteral nutrition: Individual (amino acids, fat, dextrose) or 3 in 1 combinations Formulations for peripheral or central route

21. Nutrient Delivery Oral (as in regular intake or as oral supplement) Gastric feeding: Bolus (either manual or with a gravity tube) ––for adequate gastric capacity and function Intermittent or continuous using pumps ––for volume restricted or gastric dysfunction Small intestine feeding: Intermittent or continuous using gravity drip, but with smaller volumes (30smaller 30-80 ml/hour)

22. Monitoring Strategies Fluid balance Complete Blood Count Total Lymphocyte Count mild depletion-1500-1800 moderate -900-1500 severe -less than 900 Serum albumin (value as initial assessment tool, but not as protein build up; frequent determination for issues only, pressure not nutritional)