Nutritional needs of the Nutritional needs of the chronically illchronically ill

Jana Hermanova3rd Faculty of Medicine

Charles University, Prague

What does it involve?What does it involve?Nutritional intakeEating habitsAltered nutritionNutritional

assessmentNutritional care

planning

Healthy foodsSpecial dietsArtificial feedingNutrition and the

end-of-life care

Factors affecting nutritionFactors affecting nutritionEating habits and food

preferences are the major factors Eating habits are influenced by: developmental stagegenderethnicity and culturebeliefs about foodpersonal preferences

factors influencing food intakefactors influencing food intake(continued)(continued)religious practiceslifestylemedications and therapyhealthalcohol consumptionadvertisingpsychologic factors

Altered nutritionAltered nutritionMalnutrition

undernutrition (BMI < 19)– insufficient nutrient intake

overnutrition – (BMI > 26) – overweight, obese, morbidly obese, (obese people can suffer from undernourishment!)

BMIBMIWeight in kilograms

BMI = ________________

(Height in meters)2

60 kilograms___________ = 26.61.5 x 1.5

Guide for BMI evaluationGuide for BMI evaluation< 16 malnourished16–19 underweight20-25 normal26-30 overweight31-40 moderately to severely

obese> 40 morbidly obese

B. Kozier, 2004

UndernutritionUndernutrition

Causesinadequate food

intakeimproper

digestion and absorption of food – (conditions?)

Related symptomsweight lossweaknessdecreased

functionsdelayed wound

healingprone to infectionimpaired

pulmonary functions

Causes of inability to eatCauses of inability to eatHemiparesisImpaired fine motor skillsVision impairmentAnorexiaSwallowing problemsLack of energyLethargyEnvironmental factors

OvernutritionOvernutritionIncreases the stress on body

organs

Predisposes to chronic problems (e.g. hypertension, diabetes mellitus)

May present complications in providing care

Let’s talk multidisciplinary!Let’s talk multidisciplinary!

NursesDoctorsNutritional therapists Physiotherapists

Asses – plan – intervene – evaluate!

Who is missing?

Ergotherapists/OT

Social workersPsychologists Pharmacists

Nutritional assessmentNutritional assessmentnurse, physician,

dietitian (nutritionist)

components:general appearancenutritional

screeningnursing historyphysical

examinationcalculating

percentage of weight loss

dietary history laboratory data anthropometric

measurement

MinimalNutritionalAssessMinimalNutritionalAssessmentment

Monitoring Monitoring

Care planningCare planningGoals

Maintain optimal status Promote healthy practices Prevent complications of malnutrition Decrease weight Regain weight

InterventionsInterventionsReinforce teaching of the

dietitian/nutritionistCreate an atmosphere that encourages

eatingAssist with eatingMonitor the client’s appetite and intakeAdminister enteral and parenteral

feedingConsult with the physician and

dietitian

““We were only feeding the We were only feeding the patients…”patients…”

“giving a cup of coffee or water can be a spiritual work”

Special dietsSpecial dietsConsistency modifications

Clear liquid – water, tea, broth, clear juices,popsicles, coffee

Full liquid – ice cream, yogurt, cream soups, butter, peanut butter, scrambled eggs

Soft diet – chopped shredded meat, mashed potatoes, canned fruit, pasta

Czech dietary systemCzech dietary system

Special diets0-S tea (clear

liquids)1-S liquid, high

calorie4-S strict low fat9-S diabetic light

Basic diets0 – liquid1 - soft

2 – light3 - regular4 – low fat5 – low residue6 – low protein8 – low calorie9 – diabetic10 – low salt,

light11 – high calorie

Feeding accessories - Feeding accessories - cupscups

Utensils for feeding people Utensils for feeding people with weak grip and other with weak grip and other problemsproblems

Plate guardsPlate guards

When patients cannot eatWhen patients cannot eatMrs. E, 37, has had

her first cycle of treatment for AML. She has not tolerated her treatment very well, has been vomiting a lot, had diarrhea and has developed painful stomatitis…

Mr. H, 59, has suffered from a degenerative muscle disease. He has come to the point that it is very difficult for him to swallow anything…

Enteral feedingEnteral feedingNG nasogastric

tubeNE nasoenteral

tubePEG – percutaneous

endoscopic gastrostomy

PEJ – percutaneous endoscopic jejunostomy

Intermittent ContinuousCyclic

By gravityBy syringe – bolusBy enteral feeding

pump

Aspiration precautions

PEG tube and pumpPEG tube and pump

PEG tubePEG tube

Parenteral feedingParenteral feedingCentral line (CVC)Peripheral line –

limited to a short time and low osmolarity solutions

10 - 20% G (D5W)TPN (all-in-one)Fat emulsion

Continuous feeding

Cyclic feeding

Risks of TPN◦ Infection◦ Occlusion of the

catheter◦ Intestinal disuse

When patients don’t want When patients don’t want to eatto eatMrs. A, 96, on

admission to nursing home states: “I am not going to eat and I do not want you to feed me or use any other means of providing nutrition”

Mrs. B, 78, with deteriorating dementia. Few weeks ago she was interested in finger-foods but recently has been refusing meals and has become combative during feeding attempts

End-of-life care – ethical End-of-life care – ethical considerationsconsiderationsArtificial nutrition – yes or no?What about fluids?Does hunger and thirst hurt?When to withdraw?Who decides?

Thank you for attention Thank you for attention