1. LaFleur Brooks’ Health Unit Coordinating
7th edition
Chapter 12
Nutritional Care Orders

2. The Nutritional Care Department and Types of Diets
Lesson 12.1
The Nutritional Care Department and Types of Diets
Define the terms listed in the vocabulary list.
Write the meaning of the abbreviations in the abbreviations list.
Explain the importance of communicating diet changes and patient food allergies to the nutritional care department.
Discuss the methods that may be used by the health unit coordinator (HUC) to order a late tray for a patient.

3. The Nutritional Care Department and Types of Diets (cont’d)
Lesson 12.1
The Nutritional Care Department and Types of Diets (cont’d)
Discuss two eating disorders and other factors that a doctor would need to consider when ordering a hospitalized patient’s diet.
List three groups of diets that may be ordered for the hospitalized patient.
List five consistency changes that can be made to a standard diet and explain what is included in each.

4. The Nutritional Care Department and Types of Diets (cont’d)
Lesson 12.1
The Nutritional Care Department and Types of Diets (cont’d)
List four diet options that may be selected for the patient who has started on clear liquids and has an order for diet as tolerated and explain how the selection would be made.
Identify two diets that may be requested by patients.
Identify five therapeutic diets that the patient’s doctor may order.

5. Communication with the Nutritional Care Department
New diet or changes to existing diet:
If EMR with computer physician order entry (CPOE) is being used:
The physician orders are entered directly into the patient’s electronic record, and the dietary order is automatically sent to the nutritional care department.
If paper charts are used:
The health unit coordinator (HUC) communicates the order by computer to the nutritional care department.
The computer order entry to the nutritional care department also allows the HUC to enter other options, such as a dietary consult.
If the computer system is unavailable, the diet is ordered via a written downtime requisition and is later entered into the computer to maintain a record.

6. Communication with the Nutritional Care Department, cont'd
Patients are given menus with next day's menu choices.
Some hospitals have diet aids interview patients for menu selections to save on paper.
Patient choices are entered on a laptop computer.
All dietary information, including orders for tube feedings, allergies, limit fluids, and calorie count, must be sent to the nutritional care department so necessary adjustments will be made when the patient's tray is prepared.
The dietician maintains a record on each patient (usually on computer), which is updated with each order received.

7. Food Allergies
A patient's food allergy and/or food intolerance MUST be communicated to the nutritional care department.
Food allergies can:
Cause minor discomforts, such as hives or upset stomach, if mild
Severe reactions can produce life-threatening changes (tree nuts, peanuts, fish).
Food allergies are usually communicated upon admission to hospital.
"NFKA" indicates patient has no known food allergies.
Life-threatening change in circulation and bronchioles is called anaphylactic shock.

8. Ordering Late Food Trays
The HUC must communicate with the nutritional care department (by or telephone) when ordering a diet for a patient who has completed a procedure or test that requires him to be NPO.
Note: Some hospital nutritional care departments require that all diet orders be submitted in writing via computer.
"NPO" means nothing by mouth.
Late admissions may also need to have a “late” food tray ordered.

9. A Nutritional Care Department Requisition
If the computer system is unavailable, order the diet from the nutritional care department by written “down-time” requisition. The diet order is later entered into the computer to maintain a record.

10. Eating Disorders
Many factors to consider when ordering diet for hospitalized patients:
Anorexia nervosa
Bulimia
Obesity
Dehydration
Inability to swallow, chew, and/or ingest food
The doctor may also order between-meal dietary supplements or snacks for patients as needed.
Hospitals are required to have updated diet manuals with recommended dietary allowances.

11. Three Diets Ordered for the Hospitalized Patient
Standard Diets
Regular diet and diets that vary in consistency or texture of foods (from clear liquid to solid). No restrictions or modifications.
Therapeutic Diets
Foods served are modified to vary in caloric content, level of one or more nutrients, bulk, or flavor.
Tube Feedings
Administration of enteral nutrition or liquefied nutrients into the stomach, duodenum.
Therapeutic diets must be ordered by a doctor.
See Table 12-1 for description and purposes of common hospital diets.

12. Types of Diets that Vary in Food Texture or Consistency
Clear Liquid: broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, and popsicles
Full Liquid: clear diet + smooth-textured dairy products, custards, refined cooked cereals, vegetables, and all fruit juices
Pureed: most foods including meats, vegetables, and fruits can be processed (cooked and blended) to a pureed (smooth) consistency.
A regular diet, also called general, house, routine, and full, is planned to provide good nutrition and consists of all items in the four basic food groups.
An order sent for a liquid diet must indicate clear or full so the nutritional care personnel know what to send the patient.

13. Types of Diets that Vary in Food Texture or Consistency, cont'd
Mechanical Soft: addition of ground or finely diced meats, cheese, rice, potatoes, pancakes, light breads, cooked vegetables and canned fruits, soups, or peanut butter
Soft: combines foods described with nonirritating, easily digestible foods and modified fiber content
Regular: no restrictions, unless specified
Some diets are used as a transitional step until patients can tolerate the next level of diet.

14. Diet as Tolerated (DAT)
The nurse can determine and select the consistency of the patient’s diet as the patient’s condition improves.
The patient’s diet will be advanced from clear liquid to:
Full liquid
Soft
Mechanical soft
Regular
These diets may also be called progression diets.

15. Patient-Requested Diets
Many patients have food preferences that are based on their culture or religion.
This information is used in conjunction with therapeutic or consistency requirements to prepare their food. Examples:
Vegetarian diet
Kosher diet
See Box 12-1 for various religious dietary restrictions.

16. Patient-Requested Diets, cont'd
Vegetarian diets: a plant-based diet that limits or excludes animal foods
Several types of vegetarian diets are available.
Kosher diets: adhere to the dietary laws of Judaism
A kosher diet involves certain categories of animals and the manner in which food is processed.

17. Therapeutic Diets
These diets are modified to vary in caloric content and vary levels of one or more nutrients.
Common therapeutic diets:
ADD diet (attention-deficit disorder diet)
Bland diet
BRAT diet
Soft or low-residue diet
Low-cholesterol, low-protein, and low-sodium diets
Calorie-restricted diets
See pages for descriptions of each type of diet.\
An order modifying a nutrient or number of calories would not change the consistency of the diet.

18. Therapeutic Diets, cont'd
Common therapeutic diets, cont'd:
High-fiber diets
Diabetic diets
Renal diets
Cardiac Prudent diet
High potassium
Hypoglycemic diet
There are a wide variety of additional therapeutic diets.
Instructor Note: You may want to go back and review Table 12-1 again with students.

19. Therapeutic Diets, cont'd
For patients who have difficulty eating or swallowing (dysphagia):
Level I (most restricted)–unable to safely swallow food
Level II (moderate dysphagia)–minimal amount of easily chewed foods
Level III–patient is beginning to chew: mechanically soft diet
Level IV (least restricted)–can chew soft textures and swallow liquids
There is also a special postoperative diet for gastric bypass procedure. See p. 199 in the text.

20. Tube Feeding and Parenteral Nutrition
Lesson 12.2
Tube Feeding and Parenteral Nutrition
Discuss the reasons a patient would require a tube feeding and list three methods of administering tube feedings.
List three items an HUC may need to order when transcribing an order for tube feeding.

21. Tube Feeding and Parenteral Nutrition (cont’d)
Lesson 12.2
Tube Feeding and Parenteral Nutrition (cont’d)
Explain the purpose of the doctors’ orders force fluids, limit fluids, and calorie count and discuss the importance of sending all doctors’ orders regarding a patient’s diet or modifications to a patient’s diet to the nutritional care department.
Discuss the importance of sending total parenteral nutrition (TPN) orders to the pharmacy in a timely manner.

22. Tube Feedings
Tube feedings (gavage) are ordered for patients who have ingestion problems due to:
Difficulty swallowing
Unable to eat sufficient nutrients
Cannot absorb nutrients from the foods they eat
Tube feeding is the direct administration of liquefied nutrients into the gastrointestinal system.

23. Tube Feedings, cont'd
The administration of enteral nutrition or liquefied nutrients into the:
Stomach
Duodenum
Jejunum
Through a tube inserted through the:
Nose (a nasogastric or nasoenteral tube)
Opening in the abdominal wall (gastrostomy, duodenostomy, or jejunostomy)
Types of nasogastric or naso-enteral tubes used for feedings include Entron, Dobbhoff, and Levin.

24. A Nasogastric Feeding Tube
Some of the commercially prepared formulas, including Isocal HN, Deliver 2.0, Ultracal HN Plus, Pulmocare, Jevity, Boost High Nitrogen, Boost Plus, Respalor, or Magnacal, may be ordered for tube feedings.

25. A Gastrostomy Feeding
Percutaneous endoscopic gastrostomy is a procedure performed to insert a tube through the abdominal wall into the stomach under endoscopic guidance.

26. Administration of Tube Feeding
Tube feedings are administered in three ways:
Bolus (intermittent): involves infusing a formula over a short time with a syringe or with the use of an enteral feeding bag
Continuous: requires the use of a mechanical feeding infusion pump (called an enteral feeding pump or a Kangaroo pump) to control the rate of infusion
Cyclic: infused over eight-to-16 hours during the day or night
Daytime feedings are recommended for patients who have a greater chance of aspiration or tube dislodgment if using cyclic method.

27. Administration of a Bolus Through a Syringe
Used to administer 300 to 400 mL of formula over a short time (10 minutes) with a syringe.

28. An Enteral Feeding Pump with Tubing for Continuous Feeding
A mechanical feeding infusion pump (called an enteral feeding pump or a Kangaroo pump) used to control the rate of infusion
The usual procedure involves infusing 300 to 400 mL every three-to-six hours over a 30- to 60-minute period with the use of an enteral feeding bag.

29. Transcribing a Tube Feeding Order
The HUC may need to order:
An enteral feeding set which includes bags and tubing
A specific sized nasogastric tube (if necessary)
Formula
Feeding infusion pump
An x-ray to verify placement (if necessary)
Several types of formulas and other preparations are available to meet nutritional needs for different disease states. More than 50 medical food products are available, and changes are constantly made as new knowledge is acquired.
See page 201 for examples of a typical doctors' orders for tube feedings.

30. Other Dietary Orders
The following pertains to the intake of foods and liquids, not orders for a specific type of diet:
Force Fluids: to encourage the patient to drink more fluids for hydration or rehydration purposes
Limit Fluids: restriction of fluids is usually ordered for patients who are retaining fluids (a condition known as edema) because of a disease process.
NPO: usually ordered after major surgery or during a critical illness
The HUC would send the order for force fluids to the nutritional care department, so more fluids would be included on the patient’s trays.
All orders must be sent to the nutritional care department to update the patient’s dietary record, so a tray would not be prepared for the patient.

31. Other Dietary Orders, cont'd
Intake of foods and liquids, cont'd:
Sips and Chips: patient may have only sips of water and ice chips.
Dietician to consult: request that the registered dietitian discuss the diet with the patient or teach the patient about the diet
Calorie Count: ordered to document the quantities and types of food consumed by the patient for further nutritional evaluation by the dietitian
The order for calorie count needs to be sent to the nutritional care department.
The nurse who is caring for the patient needs to be notified, and it may be required to prepare a form on which the patient’s caloric intake will be recorded.

32. Parenteral Nutrition
This provides nutrients to patients who are unable to receive food via the digestive tract.
All nutrients are prepared by the pharmacist under sterile conditions, not by dietary department.
Total parenteral nutrition (TPN)
Partial parenteral nutrition (PPN)
Intravenous hyperalimentation
The complex composition of a TPN solution requires a written doctor’s order (usually preprinted with details that are filled in by the physician). Printed or written orders are still required in many facilities even if CPOE is used for the majority of other orders.
Nutrients prepared by pharmacist include carbohydrates, proteins, fats, water, electrolytes, vitamins, and minerals.

33. Parenteral Nutrition, cont'd
Three types of parenteral nutrition, cont'd:
Total parenteral nutrition (TPN): provision of all necessary nutrients
Partial parenteral nutrition (PPN): contains some essential nutrients injected into a vein to supplement other means of nutrition, usually a partially normal diet of food
Intravenous hyperalimentation: administration of nutrients by intravenous feeding, especially to individuals unable to take in food through the alimentary tract
TPN is administered through central or peripheral venous catheters depending on the type of solution.

34. Changes in Total Parenteral Nutrition (TPN) Orders
Need to be sent to the pharmacy as soon as possible:
TPN is very expensive and is customized for each patient.
If prepared before the changes are received, the already prepared formula must be discarded.
Usually the pharmacy will call the nursing unit prior to mixing a patient’s TPN to ensure that there are no changes.