1. Diet Therapy and Assisted Feeding
Chapter 27
Diet Therapy and Assisted Feeding
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

2. Goals of Diet Therapy Treat and manage disease
Prevent complications and restore health
Specific diet for each patient is prescribed on the physician’s order sheet
Patients can have nutritional goals met after a thorough diet assessment
Some patients may need assistance with feeding
Energy needs diminish with age—metabolic rate and activity decrease, indicating that calorie requirement is reduced.
Some patients have unrestricted diets similar to the meals they eat at home.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

3. Patients Needing Feeding Assistance
Patients with paralysis of the arms
Patients with visual impairment
Patients with intravenous lines in their hands
Severely impaired or weak patients
Confused patients
Feeding may be delegated to a nursing assistant or family member
Patient’s food and fluid intake should be closely monitored and documented.
Weight gain/loss, percentage of meals eaten, and ability to tolerate diet should also be documented.
Diet can be modified for more effective therapy; should be discussed with patient, physician, and dietitian.
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4. Figure 27-1: Assisting with feeding
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

5. Postoperative Patient
Should be well-nourished preoperatively to facilitate postoperative healing and recovery
Preoperative patients are usually NPO 6 to 8 hours before the procedure
Postoperative patients progress from a clear liquid to full liquid diet
May progress to a soft diet before attempting a general or regular diet
What foods are included in a clear liquid diet? Full liquid? Soft diet?
NPO status reduces risk of vomiting while under anesthesia and decreases threat of aspiration.
When are solid foods added to the patient’s diet? (when patient can tolerate them without nausea, vomiting, or abdominal discomfort)
Liquids should be warm or cold, not tepid.
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6. Foods Allowed on a Liquid Diet
Clear liquids
Grape, apple, cranberry juices
Strained fruit juices
Vegetable broth
Carbonated water
Clear, fruit-flavored drinks
Tea, coffee
Gelatin and ices
Clear candies
Popsicles
Clear broth
Full liquids
Milk and milk beverages
Yogurt, eggnog, pudding
Custard and ice cream
Puréed meat, vegetables in cream soups
Vegetable juices
Sweetened plain gelatin
Cooked refined cereals
Strained or blended gruel
All other beverages
Cream
Clear liquid diets do not meet the nutritional requirements for health and healing.
Full liquid diets can be used to meet long-term dietary needs.
What foods are allowed in a soft diet?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

7. Postoperative Patient
Liquid diet is usually started when bowel sounds return
Presence or absence of bowel sounds is determined by auscultation
Goal is to have low-residue, easily digested foods
A liquid diet decreases risk of abdominal discomfort, nausea, and vomiting
Patient may progress to soft diet before advancing to regular
Check patient’s swallowing reflexes.
Check for bowel sounds and distention.
Encourage ice chips 4 hours before first meal.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

8. Anorexia Nervosa
Mental disorder characterized by refusal to maintain a normal weight and fear of becoming obese
Patient may refuse to eat despite being extremely underweight
If not corrected, may be fatal
Treatment is:
Nutritional intervention
Counseling
Mainly occurs in teenage girls and young women, less frequently in teenage boys.
Patients avoid high-calorie foods and exercise excessively.
May require hospitalization, as well as tube feeding or TPN.
Collaboration among patient, family, physician, nurse, dietitian, and mental health professional is very important for treatment.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

9. Bulimia
Eating disorder characterized by episodic binge eating followed by behaviors to prevent weight gain; e.g., purging, fasting, using laxatives
Patients aware of their behavior and often feel ashamed
Treatment is:
Nutritional counseling
Psychological counseling
Usually involves young adults, primarily women.
Characterized by bingeing and purging.
Patients with bulimia are usually aware and ashamed of their behavior, which makes it easier to treat.
What other health problems are caused by anorexia and bulimia?
What are the proper nursing interventions for anorexic and bulimic patients?
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10. Obesity
Excessive accumulation of fat, not just being overweight according to height and weight scales
Incidence in United States is increasing
65% of Americans are overweight
Approximately 30% are obese
Mildly obese: 20% to 30% above ideal body weight
Morbidly obese: At least 100 lb above ideal body weight
What are the common disorders linked to obesity? (cardiovascular disease, stroke, kidney disease, diabetes, arthritis, emotional disorders)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

11. Obesity (cont’d) Contributing factors
Genetics, environment, poor eating habits, lack of knowledge about good nutrition, body physiology, age, and gender
Goal of diet therapy is to improve health and quality of life
Must expend more energy than is consumed through intake of calories
Obesity is not merely being overweight. It is an excessive accumulation of fat that causes stress on vital organs.
Surgical intervention for obesity is popular, but complicated and high-risk.
Psychological interventions and support groups are effective.
What other factors can be included in diet therapy?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

12. Pregnancy
Nutritional status before and during pregnancy can influence health status of mother and fetus
Weight gain should be 2 to 4 lb for the first trimester and 1 lb/week during the second and third trimesters
Recommended—no caloric increase in the first trimester, then 300 calories/day for the second and third trimesters
Nutritional state of pregnant patients is affected by:
previous health status of the mother.
nausea and vomiting in the first trimester.
appetite, which may be emotional and physical.
access to food of proper nutritional value.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

13. Substance Abuse Abuse of alcohol and other drugs
Interferes with food intake by decreasing appetite and decreasing financial resources for food
May lead to impaired absorption of nutrients
Thiamine deficiency is seen in alcohol abuse
Discuss the signs and symptoms of liver damage caused by substance abuse.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

14. Substance Abuse (cont’d)
Patients with a history of substance abuse should have dietary counseling
Treatment
Fluid and electrolyte supplements
Vitamin and mineral supplements (particularly thiamine)
High-calorie, high-carbohydrate diet
Dietary fat restriction if liver function impaired
What role does the nurse play in treatment of substance abuse?
What nursing interventions are appropriate for substance abuse patients?
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15. Cardiovascular Disease
Includes diseases of the blood vessels, hypertension, myocardial infarction, and congestive heart failure
Focused on reduction of fat and sodium intake to decrease atherosclerosis
Cholesterol, three types:
High-density lipoprotein
Low-density lipoprotein
Very-low-density lipoprotein
Sodium: 1 teaspoon salt contains 2300 mg sodium
Many foods in their natural state contain sodium; sodium, rather than salt, must be limited.
Describe atherosclerosis and how it affects the body.
What foods contain large amounts of saturated fat? (red meat, eggs, high-fat dairy products)
What foods help lower cholesterol? (vegetable oils, low-fat dairy products, fish, poultry)
Discuss the advantages of the DASH diet.
What other suggestions can the nurse provide to help patients prevent cardiovascular disease?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

16. Diabetes Mellitus
Disturbance of the metabolism of carbohydrates and the use of glucose by the body
Two main types
Type 1: insulin dependent (juvenile onset)
Type 2: non–insulin dependent (adult onset)
Higher risk in African Americans and Hispanics
Factors to consider for diabetic dietary management:
Types and quantity of foods eaten and insulin supply.
If food intake is more than the patient can metabolize, ketosis may occur.
If food intake is insufficient, patient can become malnourished and be in danger of insulin shock.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

17. Diabetes Mellitus (cont’d)
Diet therapy to control carbohydrate intake to maintain serum glucose at 75 to 115 mg/dL
Patients should avoid large amounts of carbohydrates in one meal
Meals should contain 45% to 60% carbohydrates, 20% to 25% protein, and 20% to 25% fat
Calories restricted if patient is overweight
Carbohydrates should be complex
In calculating a diabetic diet, consider the following factors:
Sex, age, height, and weight
Employment and activity
General health status
Dietary likes and dislikes
Cultural background
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

18. Diabetes Mellitus (cont’d)
Diabetic patients are at higher risk for:
Cardiovascular disease
Hypertension
Kidney disease
Blindness
Stroke
Dietary counseling is essential
Patient should eat at prescribed intervals throughout the day.
Diet should provide a steady supply of carbohydrates in relation to insulin supply.
Teach the patient to plan menus and meals.
Teach the importance of weight control, skin care, exercise, and infection prevention.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

19. HIV/AIDS HIV/AIDS patients often have: Therapy is aimed at:
Severe diarrhea
Profound weight loss
Muscle wasting
Therapy is aimed at:
Replacement of fluids and electrolytes
Weight gain
Replacement of lost muscle mass
Maintaining the immune system
Why is HIV/AIDS a socially, psychologically, and physiologically complex disease?
Describe the function of the immune system.
Loss of appetite, nausea, and vomiting can interfere with diet therapy.
Diet therapy may delay the onset of AIDS.
Gastric tube feedings or TPN may be required.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

20. Nasogastric and Enteral Tubes
Usually a temporary measure to provide nutritional support
Check tube placement prior to feeding or administering medications
Irrigate to ensure it is patent
Nasogastric and enteral tubes provide needed nutrition and medications.
These are the lifelines used to provide life-giving nutrition for patients.
Treat tubes with care and respect because without them, the patient will not be able to have needed nutrition.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

21. Nasogastric and Enteral Tubes (cont’d)
Reasons for use
Dysphagia following stroke
Inflammatory bowel disease
Decompression of the stomach before or after surgery
Obtaining gastric specimens for analysis
Gastric feeding or lavage
Administration of medications
Insertion and care (Review Skill 27-2)
Review the anatomy involved in insertion of nasogastric and enteral tubes.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

22. Figure 27-2: Nasogastric tube
Review the parts of the tubes and proper methods of caring for them.
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23. Figure 27-2: Duodenal tube
Review the parts of the tubes and proper methods of caring for them.
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24. Figure 27-2: Gastrostomy tube
Review the parts of the tubes and proper methods of caring for them.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

25. Figure 27-2: Jejunostomy tube
Review the parts of the tubes and proper methods of caring for them.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

26. Percutaneous Endoscopic Gastrostomy Tubes
Generally used when a patient requires long-term nutritional support
Tube placement should be checked every shift and before feeding or administering medication
Before feeding or administering medications, amount of residual fluid in the stomach should be assessed
Review the technique and procedures for inserting gastric tubes.
Review tube-feeding techniques and procedures.
How frequently should the tubes be removed and replaced?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

27. Types of Feeding Tubes
Plastic nasogastric tubes: can be used for lavage, tube feeding, and administering medications
Small-bore silicone  feeding tubes: usually used only for tube feeding
Percutaneous endoscopic gastrostomy (PEG) tube and jejunostomy tube: used for tube feeding and administering medication  
Review the technique and procedures for inserting gastric tubes.
Review tube-feeding techniques and procedures.
How frequently should the tubes be removed and replaced?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

28. Figure 27-3: Nasogastric and enteral feeding tubes
Review the parts of the tubes and proper methods of caring for them.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

29. Feeding Pumps
Continuous feeding effective for patients who cannot tolerate large amounts of fluids at one time
Intermittent feeding beneficial for patients who are able to feed themselves or when beginning to reintroduce oral feeding
Amount of tube feeding is prescribed by the physician; ranges from 8 to 12 oz per feeding
Feeding pumps are often used for long-term nutritional support or for patients who cannot tolerate large volumes of feeding formula at one time.
These patients usually have limited gastric capacity because of the nature and stage of illness (for example, intestinal blockage from cancer).
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

30. Total Parenteral Nutrition
A method of delivering total nutrition through a catheter placed in a large central vein
High concentrations of carbohydrates main source of energy
Started slowly to allow the body to adjust to the high level of glucose concentration and the hyperosmolality
Used for patients on long-term therapy for:
Burns, intestinal obstruction, inflammatory bowel disease, AIDS, cancer (chemotherapy)
Before administering TPN, the nurse should:
check for patient drug allergies.
make sure the solution is clear and free from floating material.
gently squeeze the bag or check the container for leaks.
check the insertion site for leakage and signs of infection.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.