Therapeutic Diets Applied Nutrition and Dietics in BSc Nursing

Applied

Nutrition and dietics

1. Therapeutic Diets

2. Therapeutic Diets Modifications of 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

3. Therapeutic Diet Patient’s appetite may be affected by anorexia or loss of appetite, weakness, illness, loneliness, self-pity and other factors Use patience and tact to convince patient to eat food Understand purpose of diet and provide simple explanations to patient

4. Definition A therapeutic diet is a meal plan that controls the intake of certain foods or nutrients. It is usually a modification of a regular diet which is normally prescribed by a physician and planned by a dietician.

5. Examples of common therapeutic diets Gluten-free diet Clear Liquid diet Full Liquid diet Diabetic (Calorie controlled) diet No concentrated sweet diet Low fat diet Sodium restricted(no added salts) diet Renal diet High fiber diet

6. Objectives of therapeutic diet To maintain a good nutritional status. To correct nutrient deficiencies which may have occurred due to the disease. To afford rest to the whole body or to the specific organ affected by the disease.

7. Objectives continue…. To adjust the food intake to the body’s ability to metabolize the nutrients during the disease. To bring about changes in the body weight whenever necessary. To educate the patient regarding the need for adherence to prescribed diet.

8. Principles of therapeutic diet Diet should be based on a normal diet. It should fulfill the necessary food requirement in the simplest way. It should be planned according to the patient’s likes and dislikes, religion and constraints.

9. Principles continue…. Complete knowledge of the disease should be gathered so that required changes in the diet should be done. Possible duration of the disease should be considered (acute & chronic).

10. Indications of therapeutic diet To maintain, restore & correct nutritional status. To decrease calories for weight control. To provide extra calories for weight gain. To balance amounts of carbohydrates, fat and protein for control of diabetes. To provide a greater amount of a nutrient such as protein.

11. Continue… To decrease the amount of a nutrient such as sodium. To exclude foods due to allergies or food intolerance. To provide texture modifications due to problems with chewing &/or swallowing.

12. Factors to consider in planning therapeutic diets The underlying diseased condition which requires a change in the diet. The possible duration of the disease. The factors in the diet which must be altered to overcome these conditions. The patients tolerance for food by mouth. Also the patient’s economic status, his food preferences, his occupation and time of meals should be considered.

13. Modifications of therapeutic diets Quantitative Modification Qualitative Modification Restriction of nutrients Ex. sodium in hypertension Change in consistency Ex. clear liquid diet Excess of nutrients Ex. tuberculosis, where increased protein & energy are required Rearrangements of meals Increasing frequency of meals or omission of foods Ex. energy which demands complete exclusion of the foods the person is allergic to.

14. Modification based on consistency These diets are used in the treatment of gastro intestinal tract. These diets can range from a very low residue diet to a very high fiber diet. Routine hospital diets are as follows.

15. Clear liquid diet:- In this diet, small amounts of fluids (usually 30-60ml) are served at frequent intervals(2hrs) to replace fluid and electrolytes and also t relieve thirst. Composed mainly of water, carbohydrates and some electrolytes. Provide only 400-500kcal,5gms protein, negligible fat & 100-120gms carbohydrates. Ex. juices without pulp, broth and jell-O.

16. Indications for clear fluid diet Pre-operative patients ex.: preparation for bowel surgery. Prior to colonoscopic examination. Post-operative patients. Acute illness & infections as in acute gastro intestinal(GI) disturbances such as acute gastroenteritis. As the first step in oral alimentation of a nutritionally debilitated person. Temporary food intolerance. To relieve thirst. To reduce colonic fecal matter.

17. Full fluid diet:- A full fluid diet includes all foods which are liquid or can be liquefied at room and body temperature. It is free from cellulose and irritating condiments and spices includes creamy fluids. Ex. ice cream, pudding, thinned hot cereal, custard, strained cream soups and juices with pulp. Nutritional composition:1200kcal and 35g protein.

18. Indications for full fluid diet Used post operatively by patients progressing from clear liquids to solid foods. Acute gastritis and infections. Following oral surgery or plastic surgery of face or neck area. In presence of chewing and swallowing dysfunction for acutely ill patients. Patients with oesophageal or stomach disorder who cannot tolerate solid foods owing to anatomical irregularity.

19. Soft Diet A soft diet is used as a transitional diet between full fluid and normal diet. It is nutritionally adequate. It is soft in consistency, easy to chew, made up of simple, easily digested foods, containing limited fiber and connecting tissues and does not contain rich or highly flavored foods. Nutritional composition: 1800kcal and 50g protein. The energy, protein and other nutrients are adjustable according to the individuals need , based on activity, height, weight, sex, age and disease condition.

20. Indications for soft diet Patients progressing from full fluid diet to general diet. Post operative patients unable to tolerate general diet. Patients with mild gastro-intestinal problems. Weak patients or patients with inadequate dentition to handle all foods in a general diet. Diarrhea convalescence. Between acute illness and convalescence. Acute infections.

21. Mechanical soft diet Many people require a soft diet simply because they have no teeth and such a diet is known a mechanical or a dental soft diet. It is not desirable to restrict the patient to the food selection. Following modifications to the normal diet are: Vegetables may be chopped or diced before cooking. Hard raw fruits and vegetables are to be avoided ; tough skins and seeds to be removed.

22. Continue… Nuts and dried fruits may be used in chopped or powdered forms. Meat to be finely minced or ground. Soft breads and chapattis can be given.

23. Indications for mechanical soft diet In cases of limited chewing or swallowing. Patients who have undergone head and neck surgery. Dental problems. Anatomical oesophageal strictures.

24. Normal diet A normal diet is defined as one which consists of any and all foods eaten by a person in health. All the nutrients are supplied in normal amounts in normal diet.

25. Cold semi liquid diets This diet is given following tonsillectomy or throat surgery until a soft or general diet may be swallowed without difficulty. It contains more of cold beverages and luke warm preparations.

26. Blenderized liquid diet This is adopted in conditions of Inadequate oral control. Oral surgery with dysphagia. Wired jaws(blenderized foods can be consumed through small openings) Patients with reduced pharyngeal peristalsis. Routine food is made into liquid pulp and can be prepared using a kitchen blender.

27. Modification in nutrients Modification or change in the nutrient composition of the diet to increase the availability of nutrients to suit the body requirements/limitations of a person.

28. Types of diet based on modification in nutrients:- High calorie diet Low calorie diet High protein diet Low protein diet Fat controlled diet No added salt diet Low sodium diet No concentrated sweets diet Diabetic diet High fiber diet Renal diet

29. High calorie diet:- This is normal diet with an increase in the calorie level to 3000 or more. This is modified in consistency and flavour, according to specific needs. Avoid high-bulk foods ,Avoid high-fat foods such as fried foods, rich pastries, and cheese cake because they digest slowly and spoil appetite These diets are prescribed for Weight loss Fever Hyperthyroidism burns

30. Low calorie diet These diets control calories, carbohydrates, proteins and fat intake in balanced amount to meet the nutritional needs and control blood sugar and weight. 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. Energy value reduced to 1500,1200 or 1000 calories, protein levels 65 to 100gm.

31. These diets are prescribed for reducing body weight in:- Diabetes mellitus Cardiovascular diseases Hypertension Gout Gall bladder disease Preceding surgery

32. High Protein Diet Used to treat malnutrition or to increase muscle mass. High protein diet of 100-125g per day may be prescribed for a variety of conditions like Fever Hyperthyroidism Burns Regular diet with added protein rich foods such as meats, fish, milk, cheese, and eggs. After surgery Diarrhea Elderly Alcoholism

33. Low protein diet A low-protein diet is a diet in which people reduce their intake of proteins. Diet is prescribed to people with kidney or liver disorders.

34. Fat controlled diet It is used to reduce fat levels and/or treat medical conditions like Gall bladder & liver diseases Obesity Certain heart diseases Avoid cream, whole milk, cheese, fats, fatty meats, rich desserts, chocolate, fried foods, salad dressings, nuts, and coconut

35. No added salt(NAS)diet It is a regular diet with no salt packet . Food is seasoned as regular food. Low sodium diet:- Used for pts with hypertension, heart disease, liver disease, kidney disease, and edema. Avoid or limit addition of salt to any food, smoked meats or fish, processed foods, pickles, olives, and processed cheese,canned soups.

36. No Concentrated Sweets(NCS) Diet This is for diabetics when their weight and blood sugar levels are under control It includes regular foods without the addition of sugar. Calories are not counted.

37. Diabetic diet These diets control calories, carbohydrates, protein and fat intake in balanced amounts to meet nutritional needs Control blood sugar levels Control weight Avoid sugar-heavy foods such as candy, soft drinks, desserts, cookies, syrup, honey, condensed milk, sugared gum, jams, and jellies.

38. High fiber diet It is prescribed in the prevention and treatment of gastrointestinal, cardiovascular and metabolic diseases . Fiber rich foods like fruits, legumes, vegetables, whole breads and cereals.

39. Renal diet It is for people having renal/kidney diseases. The diet plan is individualized depending on if the person is on dialysis. The diet restricts sodium, potassium, fluid and protein in specified levels .

40. FEEDING TECHNIQUES Feeding methods depend on the type of disease, pts condition and their tolerance to food. The nutrients can be administered to the patients by special techniques to prevent the nutrient deficiencies.

41. Modes of Feeding Nasogastric Nasoduodenal Nasojejunal Enteral Parenteral Tube feeding Total parenteral nutrition (TPN) Partial parenteral nutrition

42. Enteral Enteral means within or by the way of the gastrointestinal tract. The foods are administered via a tube and hence enteral feeding is also called tube feeding. Tube feeding Tube feeding is advised when the patient is unable to eat but the digestive system is functioning normally.

43. Tube feeding Full fluid diets administered through this route. Tube may be passed through the nose into the stomach( nasogastric ),duodenum ( nasoduodenal ), or jejunum ( nasojejunal) . When there is an obstruction in the oesophagus, enteral feeding is done by passing a tube surgically through an incision in the abdominal wall into the stomach (gastrostomy), duodenum (duodenostomy) or jejunum (jejunostomy).

44. Nasogastric

45. Nasoduodenal

46. Nasojejunal

47. Indications for tube feeding Inability to swallow due to paralysis of muscles of swallowing (diphtheria, poliomyelitis) Unwillingness to eat Persistent anorexia requiring forced feeding Semiconscious or unconscious patients Severe malabsorption requiring administration of unpalatable formula Short bowel syndrome Babies of very low birth weight

48. A satisfactory tube feeding must be Nutritionally adequate Should be well tolerated by the patient Should be easily digestible with no adverse reactions Easily prepared Inexpensive

49. Enteral Nutrition Delivery System The enteral Nutrition is utilised when the patient cannot or will not take adequate oral nutrients. Enteral route is preferred to parenteral Nutrition as the later involves invasive procedures which are more expensive, painful and cause local or systemic infections and sepsis. Following are the routes of access of nutrition.

50. 1.Pharyngostomy and Oesophagostomy It performed in head and neck operations, trauma and tumours of the head and neck. Nursing care for pharyngostomy and oesophagostomy are Clan the stoma site with hydrogen peroxide and distilled water. Keep the area around the stoma dry and clean. Use absolutely sterile met. Check suspected sources for infections around the stoma site. Secure the feeding tube properly to avoid accidental dislodgement.

51. Gastrostomy This procedure is frequently used in patients with mechanical or functional obstructing lesions of head, neck or oesophagus or in neurologically impaired patients.

52. Nursing care for gastrostomy: Apply sterile dressing to minimize swelling or bleeding immediately after surgery. Observe stoma for redness, swelling, necrosis and drainage. Check dressing 8 hourly for gastric leakage which can cause rapid breakage. Assess the position of the tube and secure it properly.

53. Jejunostomy Intra- jejunal feeding eliminates the problem of gastric overload, reflux vomiting and aspiration associated with gastric feeding. Nursing care for jejunostomy: Immediately following placement of jejunostomy tube attach it to the gravity drainage. Irrigate the tube frequently to maintain patiency. Continuous drip method with infusion pump is preferred.

54. Enteral feeds The types of feeds that can be administered through a tube include: Blenderized Food: This is prepared for patients who cannot chew and swallow due to cancer of the oral cavity, larynx or oesophagus. Ordinary food items which cannot be swallowed are cooked well and blenderized to make them liquid for feeding through a nasogastric tube.

55. Polymeric Mixtures: This contain intact protein, fat and carbohydrate of high molecular weight and are thus lower in osmolarity and require normal digestive juices. Elemental Diets: These are commercially predigested mixtures of amino acids, dextrins, sugars, electrolytes, vitamins and minerals with small amounts of fat. They are free of lactose and can be easily administered. These diets are used as alternatives to intravenous feeding.

56. Methods of administration The three common methods of tube feeding administration are : Continuous Drip Intermittent Drip Bolus method

57. Continuous Drip: This is the most common form of administration. The drip rate is adjusted in increments to prevent cramping, nausea, diarrhoea or distension. Feedings are started at 30 to 59 ml/hr every 8 or 12 hrs until the final rate is attained.

58. Intermittent Drip: In this 4-6 feeds are given with regular periods of interruption,e.g.4 hours on and 4 hours off . Bolus method: In this method, large volumes are given in a short time, e.g. 200 ml is administered in a minimum time of ten minutes.

59. Parenteral Nutrition The delivery of nutrients directly through the peripheral or central vein is termed as parenteral nutrition. This can be of two types i.e. Total or supplemental.

60. Total parenteral nutrition (TPN): The total nourishment of increased Nutritional requirements through intravenous feeding has been termed total parenteral nutrition (TPN ). Partial parenteral nutrition: When parenteral nutrition provides 30-50% of the total daily nutrients, it is termed partial parenteral nutrition .

61. Conditions for which parenteral nutrition is given: Gastrointestinal problems Acute renal failure Hepatic failure Congenital anomalies of the gastrointestinal tract Burns

62. Parenteral feed solutions Glucose Emulsified fat Crystalline amino acids Vitamins Electrolytes- sodium, chlorine, phosphorus, potassium, calcium and magnesium. Trace elements- zinc, copper, chromium, manganese and iodine Water

63. Parenteral feeding For a hospitalized patient to be given nutrients parenterally . This gives special attention to the provision of energy nutrients by peripheral or central vein.

64. Total parenteral nutrition(TPN) It is most sophisticated method of nutritional support. It involves feeding the patients with sterile solution or glucose, amino acids and micro-nutrients usually via an indwelling catheter inserted into the large central vein(i.e. superior vena cava). Administered either continuous infusion of nutrient solution round the clock or in cyclic pattern of infusion

65. Parenteral nutrition delivery system Parenteral nutrition is a complex form of therapy designed to provide daily nutritional requirements by the intravenous route. The success of the therapy depends on: Appropriate nutrient prescription Sterile management Catheterization technique Dressing management Continuous patient monitoring

66. Central venous access: Central venous access is required for infusion of hypertonic solution. The veins used are: Subclavian vein Internal jugular vein External jugular vein Peripheral vein Basilic vein Cephalic vein

67. Femoral veins: Careful concentration is given for vein selection. The patient’s clinical situation, anatomic factors, experience and the skill of the physician Femoral and peripheral veins are not widely used for prolonged venous access due to infection and thrombosis.

68. Subclavian is the preferred vein, specially the right side as the pathway to superior vena cava is more direct and the apex of the lung is lower on the right side.

69. Complications of Parenteral Nutrition Delivery System Catheter Occlusion: Initial treatment for catheter occlusion is aspiration of the clot with a syringe. Sterile technique is essential. Sepsis Air Embolism and Hemorrhage Air embolism is a potentially lethal complication related to the use of central venous catheters.

70. Complications of Catheter Insertion Pneumothorax: It is an abnormal collection of air in the pleural space between the lung and the chest wall. Clinical manifestation depends on the size and type of pneumothorax. Typical symptoms include pain, dyspnea and hypoxia.

71. Haemothorax: Arterial trauma by the inserting needle is the usual cause of injury to the vein. Blood collects in the plural space. Chest tubes may be necessary to drain blood.

72. Assignment Write in detail dietary management and one day menu plan for following condition and do group presentation Roll no. 1 to 5:Dietary management in obesity. Roll no. 6 to 10: Dietary management for diabetes mellitus. Roll no. 11 to 15: Dietary management for cardiovascular diseases . Roll no. 16 to 21: Dietary management for underweight.

73. Roll no. 22 to 26: Dietary management for renal diseases. Roll no. 27 to 31: Dietary management for hepatic disorders. Roll no. 32 to 36: Dietary management for constipation. Roll no. 37 to 41: Dietary management for diarrhea. Roll no. 42 to 49: Dietary management for pre-operative and post operative.