MEDICAL NUTRITION THERAPY

Classification of modified diets

1. Consistency
 Clear liguid
 Full liquid
 Soft
 Mechanical soft diet
 Light diet
 Pureed diet
 Bland diet
2. Nutrient content
 High fiber
 Low protein
 Na
 Low fat
 Low fiber
3. Quality
 Obesity
 Vomiting
 Diarrhea
 Diabetes
4. Special method of feeding
 Enteral (tube feeding)
 Parental (intravenous fluid)

Diet Modification

Specific diseases or conditions require modifications of natural components of a normal diet.

Each modified diet has a purpose and rationale, and its use is usually determined by the physician or dietician.
✔General diet
✔Regular diet
✔House diet

The general diet is designed to attain or maintain optimal nutritional status in persons. who do not require modified or
therapeutic diets.
 Individual requirements for specific nutrients vary and are adjusted depending on the gender, age, height,
weight and activity level.
 This diet is used to promote health and reduce risks for developing chronic-diet related diseases such as
cardiovascular diseases or cancers.

The regular diet may be made in two ways:

✔Quantitative – modifications in the number or size of meals served or amounts of specific nutrients (e.g small six
feedings, kcalorie-controlled diets)
✔Qualitative – modifications in consistency, texture or nutrients (e.g clear-liquid, full-liquid diets)

“Whatever the kind of meals or modified diets patients receive, acceptance of food is influenced by nursing personnel.”
“It is also possible that acceptance of modified diets may also be influenced by whether patients perceive nutrition to be
an important part of their medical care and recovery.”
Patient education can make a difference in patient acceptability of meals.

Basic Hospital Diets

Clear Liquid Diets – may be used postoperatively or if a patient is scheduled for diagnostic tests. A clear liquid diet
consists of foods that are clear and liquid at room or body temperature.
This is to prevent dehydration and keep colon
contents to a minimum.

Indications:
✔Before/after surgery
✔Prepare bowel for diagnostic tests (colonoscopy,
barium enema, etc)
✔Minimize stimulation of GI tract

Contraindications:
✔should not be used for more than 24 hours
✔inadequate GI function
✔nutrient needs requiring parenteral nutrition

Full Liquid Diets – this consists of foods that are liquid at room temperature. It is used to provide oral nourishment for
patients who have difficulty chewing or swallowing solid foods.

This diet offers more variety and commercial nutritional supplements can be used to supply adequate amounts of
energy and nutrients to make it nutritionally complete.

✔All liquids are allowed.

Indications:
✔Provide oral fluids after surgery
✔Oral or plastic surgery to the face and neck
✔Mandibular fractures
✔Chewing and swallowing difficulties
✔Esophageal or GI strictures
✔Diarrhea

Contraindications:

✔Dysphagia

“When a patient has problems chewing or swallowing, foods can be chopped, ground, mashed and pureed. Consistency
of food can be varied according to the patient’s ability to chew and swallow.”

Soft Diets – these are often used during transition from liquid diets to regular or general diets. This diet has traditionally
been used for patients with mild GI problems.

Regular or General Diets – these are used for patients who do not need dietary restrictions or modifications.

Diet as Tolerated (DAT) – this permits patients’ preferences and situations to be taken into tolerance.
Enteral Nutrition

Anytime the GI tract is used to provide nourishment, the feeding can be referred to as enteral nutrition.

ENTERAL FEEDING BY TUBE

✔when patients are unwillingly able to orally consume nutrients but the GI tract is still functioning, nutrients can be
provided via feeding tubes placed into the alimentary tract.

Tube Feeding the Infant or Child

✔Assure them that the children can still be cuddled and can play without interfering with the tube nourishment.
✔Be sure to explain the procedures to the
children as well.
✔ Dolls or stuffed animals can be used to explain how tube feeding helps to speed the healing process.

Types of Formulas

a. Standard-Intact Formulas (Polymeric Formula)

These are composed of intact nutrients that require a functioning GI tract for digestion and absorption of nutrients.

These can be categorized into blenderized food products, milk-based products, high- kcalorie and lactose free products,
and normocaloric lactose free products.

b. Elemental Formulas ( Predigested or Hydrolyzed Formulas)

These are composed of partially or fully hydrolyzed nutrients that can be used for patients with partially functioning GI
tract or those who have impaired capacity to digest foods or absorb nutrients.

 These products are lactose-free.

 Thet are not palatable

c. Modular Formulas
These are not nutritionally complete by themselves because they are single macronutrients such as glucose polymers,
protein or lipids.

They are added to foods or other enteral products when nutritional needs cannot be met.

d. Specialty Formulas
These products are designed to meet specialized nutrient demands for specific disease states such as diabetes, renal or
liver failures, pulmonary disease or HIV/AIDS.

Successful use of enteral feedings depends on:

✔Patient’s condition
✔Availability of access for feeding
✔Patient’s tolerance of chosen enteral formula

Feeding Routes

Feeding routes involves considerations of different factors:

✔patient’s medical status govern the length of feeding tube
✔anticipated length of time that tube feeding may be required dictates whether the feeding tube should be surgically
placed
✔if feeding tube will be used for short duration,
nonsurgical placement can be made

1. Nasogastric – passed through the nose to stomach.

2. Nasoduodenal - passed from nose to duodenum
1. Nasojejunal – passed through nose to jejunum
2. Esophagotomy – surgically inserted into the neck and extends to Stomach
3. Gastrostomy- surgically inserted into stomach
4. Jejunostomy - surgically inserted into small Intestine

Method of Administration

Tube feedings can be administered by three methods:

1.Continuous Feeding – This method provides controlled delivery of a prescribed volume of formula at a constant rate
over a continuous period using an infusion pump.

This preferred especially when feeding into the small intestine because it is similar to typical gastric emptying.

2. Intermittent Infusion –It involves delivering total quantity of formulas needed for a 24-hour period in 3 to 6 equal
feedings. Each feeding is usually delivered by gravity during a 30 to 90-minute period.

This method represents a more normal pattern but most patients do not tolerate if the pattern is too rapid

3. Bolus Feeding –It involves infusing volume of formula by gravity or syringe over a short period of time.

This method requires minimal equipment and time but is associated with increased potential for aspiration,
regurgitation and GI side effects.

Parenteral Nutrition

 This is the provision of energy and nutrients intravenously.

 When infused into a large-diameter vein, such as the superior vena cava or subclavian, parenteral nutrition is
called central parenteral nutrition (CPN) or total parenteral nutrition (TPN).
 When a smaller, peripheral vein is used (usually in the forearm), parenteral nutrition is called peripheral
parenteral nutrition.
 Because of serious complications that may occur in TPN, this should be preserved for severely malnourished
patients undergoing chemotherapy and major therapy.

Components of Parenteral Nutrition Solutions

Parenteral solutions contain the same nutrients and components you would expect to find in any enteral nutrition
source.

It typically contains:

✔Water
✔Amino acids
✔Dextrose
✔Electrolytes
✔Vitamins and trace elements
✔Fat is also included, by means of piggyback administration
Carbohydrates
 The most common carbohydrate used in PN is dextrose monohydrate. Used as an energy source, it yields
3.4kcal/g because of its hydrated form.
 Higher glucose concentrations are useful when a patient’s fluids need to be restricted.
 Lower concentrations are often used to help control hyperglycemia.
 Concentrations greater than 10% are hypertonic and must be given via central parenteral nutrition.

Amino Acids
 Protein is provided in PN solutions as a mixture of essential and nonessential amino acids that are available with
or without added electrolytes.
 Amino acids solutions are available for specialized protein needs such as renal failure, liver failure, stress and
trauma.
 Fats
 IV lipid emulsions are used as concentrated energy source and to prevent development of essential fatty acid
deficiency.
 Lipid emulsions have been delivered peripherally using a piggyback system.

Baseline serum triglyceride level should be confirmed before administration of IV lipid emulsions and should be
monitored according to institutional policy.

If a lipid profile is ordered on a patient receiving lipids, the patient should not have received lipid emulsion for the
12hours before blood is drawn.

Total Nutrient Admixtures

 When lipid emulsions are added to dextrose and amino acid mixtures, the resulting solution is called three-in-
one-mixture.

Advantage:
✔It allows lipid infusion over 24 hours, decreasing carbon dioxide production and reducing hepatic accumulation of fat
induced by long-term glucose use.

Electrolytes
Electrolytes and minerals are essential for normal body function.

Vitamins
 Adult and pediatric multivitamin formulations
for IV use are available commercially.
 Vitamin K is not included in adult preparations and must be given either intramuscularly or as an IV injectable
added to the PN solution.

Peripheral Parenteral Nutrition

 PN solutions administered via peripheral veins must be isotonic to prevent damage to the vein.
 Isotonic PN solutions usually contain 5% to 10% dextrose (final concentration) and 3% to 5% amino acids, plus
electrolytes, vitamins and minerals.
 These nutrient components can only provide a
limited amount of kcalories and protein.

✔PPN is most often used in situations where only short-term nutrition support is needed in nonhypermetabolic
conditions.

Complications
Technical Complications
 Pneumothorax
 Malposition of catheter
 Subclavian artery puncture
 Carotid artery puncture
 Catheter embolism
 Air embolism
 Catheter obstruction
 Thrombosis

Metabolic Complications
 Hyperglycemia
 Hypoglycemoa
 Hyperkalemia
 Hypocalcemia
 Hypophastemia

Septic Complications
 Catheter-related sepsis
 Septic thrombosis

Transitional Feedings

 A period of adjustment, or weaning, is necessary before discontinuing nutritional support or when converting
from one form of nutritional support to another.
 Patients in TPN usually have decreased appetites and may take 1 to 2 weeks before they feel hungry.
 Long periods of PN without enteral feeding results in atrophy of GI tract.

✔Before weaning from PN, assessment of GI functionis recommended to prevent GI problems.

✔Assess the patient’s swallowing ability before offering oral feedings.
✔Full liquids are usually given first, followed by pureed or soft foods.
✔Tube feedings should be stopped at least 1 hour before and after mealtime to promote appetite.