Nursing Measures Related to Meeting Nutritional Need of Patient

Introduction

 Food is essential for life. The food taken into the body is broken down, absorbed and utilized to produce heat and energy, to build and repair body tissues and to regulate body processes. Nutrition is the study of nutrients in food, how the body uses nutrients, and the relationship between diet, health and disease. Nutrition also focuses on how diseased conditions and problems can be prevented or lessened with a healthy diet. Healthy eating and participation in exercise or other activities are important for healthy life. Sedentary lifestyle, poor meal choices, eating fast food, high cost of healthy food, widespread availability and advertising of less healthy foods and lack of access to safe places to play and exercise are contributing factors to obesity. 

Food also holds symbolic meaning. Giving or taking food is part of ceremonies, social gatherings, holiday traditions, religious events, and the celebration of birth and the mourning of death. Florence Nightingale understood the importance of nutrition, stressing a nurse's role in the science and art of feeding during the mid-1800s. Since then the nurse's role in nutrition and diet therapy has been changed. 

Nutrition: Nutrition is a basic component of health and is essential for normal growth and development, tissue maintenance and repair, cellular metabolism and organ function. Nutrition may be defined as the science of food and its relationship to health.

The human body needs an adequate supply of nutrients for essential functions of cells. Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity. In hospitals, nutrition may refer to the food requirements of patients, including nutritional solutions delivered via an IV (intravenous) or IG (intragastric) tube.

Nutritional Status: Nutritional status is the condition of the body in those respects influenced by the diet; the levels of nutrients in the body and the ability of those levels to maintain normal metabolic integrity. It can be determine by medical history, dilatory history, thysical examination and laboratory investigation. 

Balanced Diet: It is a diet that provides all the essential nutrients in sufficient quantity and in the correct proportions to promote good health. It consists of right amount of essential nutrients such as carbohydrates, proteins, fats, vitamins, minerals, roughage and water required by the body is called balanced diet.

Nutrient: Nutrient is a chemical substance that an organism needs for survival and growth. A nutrient is a chemical substance that comes from the food.

Types of Nutrients

Our body needs different types of nutrients which are:

Macronutrient: Macronutrients are nutrients that provide calories or energy. Macronutrients include carbohydrates, fats, and proteins. They are called macronutrients as they are required in large amounts to fuel the body. Energy is measured in calories and they are essential for the body to grow, repair and develop new tissues, conduct nerve impulses and regulate life process.

Micronutrient: Micronutrients are essential elements needed by life in small quantities. These nutrients include minerals and vitamins..

Carbohydrate: Carbohydrate is the main source of energy in diet. Each gram of carbohydrate gives 4 calories and serves as the main source of fuel (glucose) for the brain, skeletal muscles during exercise, erythrocyte, leukocyte production and cell function of the renal medulla. They are composed of carbon, hydrogen and oxygen. Sugar, syrup, molasses, honey, fruit and milk are excellent sources of simple carbohydrates. Bread, cereal, potatoes, rice, crackers, flour products and legumes contain complex carbohydrates. Carbohydrates are important for oxidizing fats in normal fat metabolism; promoting desirable bacterial growth in the gastrointestinal (GI) tract, which contributes to the synthesis of vitamin K and small amounts of vitamin B12; dietary fiber is a minimal source of energy but plays an essential role in stimulating peristalsis and maintains normal bowel elimination.

Proteins: Proteins are organic compounds composed of polymers of amino acids connected by peptide bonds. They contain carbon, hydrogen, oxygen and nitrogen. Proteins are vital to growth, development, and normal functioning of almost all body systems. They are major constituents of most living cells and body fluids including bones, skin, teeth, muscle, hair, blood, and serum. 1 gram of protein gives 4 calories of heat.

Dietary proteins can be classified as complete, partially complete or incomplete. Good sources of complete proteins are meat, fish, poultry, milk, cheese and eggs.

Sources of incomplete protein are dried peas and beans, peanut, butter, seeds, fruits and vegetables, bread, cereal, rice and pasta. Partially complete proteins contain sufficient amounts of amino acids to maintain life but do not promote growth. 

Fats: Fats, also called lipids, include neutral fats, oils, fatty acids, cholesterol and phospholipids. Fats are organic substances composed of carbon, hydrogen and oxygen. Fat performs many important functions, including cellular transport, insulation, protection of vital organs in the form of padding, provision of energy, energy storage of adipose tissue, vitamin absorption and transport of fat. The energy value of fats is significant; they supply 9 kcl/g of boxidized fat. Fats are classified as saturated or unsaturated; based on chemical differences. Saturated fats have two hydrogen atoms attached to each of the carbon atoms in the carbon atom chain. An unsaturated fat has a single hydrogen atom missing from each of two side by side carbon atoms; as a result a double bond is formed between the two carbon atoms. Most sources of fat contain a combination of saturated and unsaturated fatty acids. Sources of animal fats, especially beef and lamb, generally contain a higher percentage of saturated fatty acids and are harder than vegetable sources of fatty acids. Coconut oil, palm oil and palm kernel oil also are highly saturated. Chicken fat contains a significantly higher percentage of unsaturated fatty acids. Fish and vegetable sources are classified as unsaturated because they contain a higher percentage of unsaturated fatty acids.

Minerals: Minerals are inorganic substances found in nearly all body tissues and fluids. When plant or animal tissue is burned, what remains is ash or mineral matter. Minerals help build body tissues and regulate metabolism. They are further classified into macro-minerals and micro-minerals (or trace minerals). Macro-minerals present in the body include Calcium, Potassium, Iron, Sodium and Magnesium to name a few. Micro-minerals include Copper, Zinc, Cobalt, Chromium and Fluoride. They are mostly co-factors, and are necessary for the function of enzymes in the body, but are needed only in minor quantities. Approximately 4% of the body's mass consists of minerals.

Vitamins: Vitamins are organic compounds that are essential to the body in small quantities for growth, development, maintenance, and reproduction. They work together with enzymes and other substances that are necessary for a healthy life. They do not supply energy, but they assist in the use of energy nutrients. Most vitamins are not synthesized by the body and must, therefore, be supplied by the diet. There are different types of vitamins like vitamin A, B, C, D, E and K. Vitamins are either fat-soluble or water-soluble. Water soluble vitamins include Vitamin B and C. Green leafy vegetables are rich in Vitamin B, whereas Vitamin C is found abundantly in citrus fruits. Fat soluble vitamins are Vitamin A, D, E and K. Green leafy vegetables, milk and dairy products and plant oils provide these vitamins.

Water: Water is a crucial component of the body because cell function depends on a fluid environment. Water composes 60% to 70% of total body weight. The percent of total body water is greater for lean people than obese people because muscle contains more water than any other tissue except blood. Infants have the greater percentage of total body water and older people have the least. In a healthy individual, fluid intake from all sources equals fluid output through elimination, respiration and sweating. An ill person can have an increased need for fluid e.g. with fever or gastrointestinal losses. By contrast, an ill person can also have a decreased ability to excrete fluid e.g. with cardiopulmonary or renal disease, which may lead to the need to restrict fluid intake.

Types of Diet Used in Hospital

Diet is as important as medicine in the treatment of diseases. Various types of diets are prepared in hospitals to suit the patient's condition and meet his nutritional needs. The amount of nutrients diet required for each individuals varies, it depends upon his/her age, sex, current physical status, life style, environment, etc. Nutrition during illness should be adequate to prevent weight loss and weakness.

Therapeutic Diet: A therapeutic diet is a meal plan that controls the intake of certain foods or nutrients it is part of the treatment of medical condition and sometimes called "special diet" that is formulated usually by nutritionists, dieticians, and medical doctors to aid in the healing of the body from certain types of injuries and diseases. Therapeutic treatments involving food are also prescribed for medical conditions that affect the psychological state of the individual as well, such as weakness caused by anorexia, or a loss of appetite. More common conditions that may require a therapeutic diet include a calorie, fat, and sodium-controlled diet to treat such routine conditions as being overweight, having high cholesterol levels, or being borderline diabetes. Severe health conditions often require a therapeutic diet recommended for the short term. A good example of this is the liquid diet that is often prescribed immediately after surgery. The following diets are used in hospital:

Regular/normal/general Diet (full): The regular diet can also be referred to as a general or normal diet. Its purpose is to provide a well-balanced diet and ensure that individuals who do not require dietary modifications receive adequate nutrition. Based on the Dietary Guidelines and the Food Guide Pyramid, it incorporates a wide variety of foods and adequate caloric intake.

Liquid Diet: Liquid diets are used most often as transitional diets when eating resumes after acute illness, surgery. It must be used for the patients who are unable to take or tolerate solid food. Often medical orders are written to begin the patient on a clear liquid diet and advance to another diet as tolerated. The diet would progress from clear liquids to full liquids to a soft diet, then to a normal or modified diet, based on their condition and tolerance. Tolerance of diet can be assessed by absence of nausea, vomiting and diarrhea, absence of feelings of fullness, absence of abdominal pain and distention and feelings of hunger. This diet is given usually to the patient having hyperpyrexia, post-operative patients and patients having gastrointestinal disturbances. Two types of liquid diet are in common use.

• Full liquid diet
• Clear liquid diet loa

Clear Liquid Diet: Clear liquid diets contain only foods that are clear liquids at room or body temperature. It is not an adequate diet as it contains mainly carbohydrate and water. Food in this diet consists of tea, coffee, fat free broth, bouillon, clear juices, carbonated beverages and glucose water. No milk or milk preparation is given in this diet as they may form gas. It is used for first post-operative day.

Full Liquid Diet: Full liquid diet contains all the items on a clear liquid diet, carbohydrates, protein and fat. As a transition between clear liquid and a soft or regular diet, this plan provides easily tolerated foods. The diet includes milk, strained and creamed soups, creamed cereal and fruit and vegetable juices, etc. This is necessary when the patient is unable to swallow solid food or if the patient is fed by intra-gastric or gastrostomy tubes. High calorie, high protein supplements are recommended if a full liquid diet is used for more than 3 days. 

Soft/light Diet: Soft diet is usually regular diet that consists of foods soft in texture, moderately low in fiber, and processed by chopping, grinding or pureeing to be easier to chew. Most milk products, tender meats, mashed potatoes, tender vegetables and fruits and their juices are included in the diet. Soft diets may also be called bland or low fiber diets. However, most raw fruits and vegetables, seeds, nuts and dried fruits are excluded. It is given to provide light and easily digestible food with minimum residue.

Low Residue/Low Fiber Diet: This type of diet tried to limit fiber, a kind of carbohydrate found in some plant-derived foods. The diet limits intake around ten grams of fiber daily and is designed to minimize the frequency and volume of residue in the intestinal tract.

High Fiber Diet: Dietary fiber is found in fruits, vegetables, and grains. Dietary fiber adds 10 bulk to your diet. Because it makes you feel full faster and for longer, it can help you control weight and help with constipation.

Low Caloric Diet: The aim of this diet is to slow steady loss of weight order a period of several weeks or even months. This diet is advised to obese patients. The food stuffs- ghee, butter, sugar, sweets, bread, rice and potatoes are omitted from the diet.

Low Protein Diet: Low protein diet is advised in kidney disease such as nephritis, uremia, etc. In this disease the protein is avoided or given in low moderate types. The food stuffs are milk, eggs, meat, etc. are omitted/restricted according to the prescribed protein intake.

Low Fat Diet: Low fat diet is restricted from the diet for the patient with liver disease and gall- bladder disease. Carbohydrates in the diet should be increased to supply the liver with glycogen to prevent ketosis. No fried food, ghee or butter or other fat is allowed in the diet, only rice, chapattis, breads, fruits, vegetables, etc. The diet usually includes whole wheat breads, lean cuts of meat, skim milk, low-fat cheese products, eggs, vegetables, and other food items prepared without extra fat.

Salt Free Diet: Sodium controlled diets are usually prescribed for the patients with hypertension and for those with excess fluid accumulations. The patients with heart diseases such as hypertension, kidney diseases, etc. are given this type of diet. This is salt restricted diet or low salt diet. The necessity of the restriction should be carefully explained to the patient and relatives. The following foods are limited or avoided such as commercially prepared foods, salt, cheese, pickles, salted chips, biscuits, etc. White milk, fresh or frozen meats, unsalted vegetables and fruits and low sodium foods are included.

Cholesterol-restricted Diet: Lowering blood cholesterol can reduce the risk of heart disease. Cholesterol is found only in foods of animal origin. Certain oats, beans, and fruits are actually effective at lowering cholesterol levels in the body. The diet includes skim milk, lean meats, fruits, vegetables, and whole grain products.

High Protein Diet: It is given to the patient such as operated cases, tuberculosis, accident, burns, etc. The food stuffs contain rich protein are milk and milk preparation, eggs, fish, meat, pulse, beans, soyabeans and ground nuts, etc.

Diabetic Diet: A diabetic diet varies from the patient to patients depending on the type and intensity of the diabetes, the patients' personal history, and individual nutrient needs. Diabetic is a lifelong disease which can be treated but not cured fully. The dietary treatment depends upon the severity of the condition. The diet should be balanced but there should be restriction of carbohydrates e.g. rice, biscuits, sugar, jams, sweats, honey, carrots and sweet potatoes, etc. The total calories required are 20-25% from protein, 40% from carbohydrates and 40% from fat. Diet in Anemia: This type of patient requires the diet which is highly rich in protein, iron and vitamins. The food stuffs recommended are liver, meat, eggs, jiggery, etc.

Diet in Anemia: This type of patient requires the diet which is highly rich in protein, iron and vitamins. The food stuffs recommended are liver, meat, eggs, jiggery, etc.

Vegetarian Diet: This diet varies widely depending on variety of reasons, such as religious preference, ethical belief, fear of contamination with pesticides, and health concerns about cholesterol and saturated fats found in meats. It may include only plant foods-grains, vegetables, and fruits, legumes, nuts, seeds, and vegetables fats.

Renal Diet: A renal diet is carefully planned with special consideration of nutrients, and it is often adjusted as kidney disease progresses. A renal diet may serve the purpose of attempting to slow down the process of renal dysfunction. If dialysis treatments are not being taken, the doctor may restrict protein intake of foods such as potatoes, tomatoes, oranges, and bananas. A phosphorous restriction may limit the intake of milk and dairy products, dried beans and peas, coffee, tea, and "dark-colored" soda beverages.

Factors Affecting Nutrition

Appetite decreases because of:

• Physical and mental fatigue.
• Unpleasant environment and experiences.
• Lack of access to full service grocery stores.
• Bad smell from the mouth of the patient due to poor oral hygiene.
• Lack of assistance in feeding, Use of dirty plate and glass for serving food.
• Hurry, worry and fear, unfamiliar food pattern.
• Psychological factors such as fear, anxiety, depression and pain.
• Persons with chronic G.I. problems/diseases.
• Irregularity of meals, lack of exercises.
• Too short spacing between meals/inappropriate time of feeding.

Appetite can be increased by:

• Attractive serving, too short spacing between meals.
• Considering food preference [likes and dislikes of the individual].
• Physical and mental relaxation [freedom from hurry, worry, pain, stress and fatigue].
• Regularity in eating, pleasant environment [attractive and cheerful atmosphere].
• Exercise.

Nurse's Responsibility in Meeting Nutritional Need of Patient

Adequate nutrition and hydration is vital for good health, from both a physical and psychological perspective, and should be considered a priority by nurses. Nurses are aware that malnourished patients are more likely to have slower wound healing and to develop complications. So prevention of malnutrition can have a positive effect on the patient's outcome. Ensuring that the nutrition and hydration needs of the patients in hospital are met is part of the nurse's role. Actions required by nurses may include:

• Adapt diet instructions individually to the patient's lifestyle, culture, intellectual ability and level of motivation.
• Consider the factors of age, stage of growth and development, disease and finances in planning, ways to meet nutritional requirements.
• Determine the patient's food intake and eating habits.
• Provide information as necessary about the health need for diet modification: weight loss, weight gain, sodium restriction, cholesterol reduction, fluid restriction and so on.
• Ensure that the patients are comfortable and positioned appropriately in preparation for mealtimes.
• Check the patients while eating and drinking regularly and conducting ongoing assessment to identify those who require assistance with their meals is also important.
• Document in care plans and appropriate delegation of nutrition-related tasks to team members, such as healthcare assistants, should also be considered.

Stimulating Appetite

The problem can be caused by digestive disorders, infections, nutritional deficiencies (for instance, zinc deficiency), pain, illness, anxiety and medications tends to affect the patient's appetite. Besides, Loss of control over food choices, the way of food is prepared, when and how food is served and eating alone may do little to encourage normal eating. The following measures may help to stimulate appetite in hospital and home setting:

• Serve small, frequent meals to avoid overwhelming the individual with large amounts of food.
• Encourage to a walk prior to a meal to stimulate appetite.
• Include a moderate amount of fiber in diet when striving to improve a poor appetite.
• Provide encouragement and a pleasant eating environment.
• Try to set a specific time for serving meals. This way, body and brain get familiar to a particular routine for mealtime, thereby causing hunger pangs at the time that is allotted for meals.
• Be supportive.
• Offer favorite foods.
• Schedule procedures and medications at times when they are least likely to interfere with appetite.
• Avoid stress while having meals and eat more when you are hungry.
• Control pain, nausea and any discomfort for eating.

Preparation of the Patient for Meal

• In the hospital, timings of the serving tea, breakfast, lunch, etc. are planned; therefore, the patients who are not receiving hospital diet should be informed about that. They should ask to bring their tea, breakfast, lunch, etc. at that particular timing.
• Observe the patient's nutritional status; take dietary history, find out his/her food preferences, eating problems like chewing, swallowing, etc. and assist the doctor or dietician, if needed, in planning the diet for the patient.
• Prepare the patient for the meal.
• Explain the patient if ordered special food.
• Encourage to wash hand.
• Encourage for oral hygiene.
• Provide comfortable position.
• Place the dish within the patient's reach.
•  Identify food allergies to prevent allergic reaction.
• Encourage the patient to eat by explaining the importance of diet.
• Assist if needed.
• Observe and record if any unusual reaction is present to food.

Preparation of the Environment

• The environment should be pleasant. There should not be any offensive smell, noise, dirt, too much heat or cold in the ward.
• Ward must be clean and tidy.
• Dressing, enema, medication, etc. should not be carried out during meal time. It should be finished one hour prior to meal.
• Offer bedpans or urinals to bed ridden patient about half an hour before serving the food so that the patient will not be disturbed during meal time.
• If the patient can sit, help him to have fowler's position with cardiac table or over bed table.
• Place the towel over the chest and under the chin to protect clothing.
•  Let the patient feed him/herself as far as possible to reduce the patient's feeling of helplessness.
• Remain at bedside until the patient feels comfortable.
• If a patient dies in the ward, the diet should not be distributed before his dead body is shifted.
•  Attend promptly to any complaints concerning food.

Attractive way of Serving Food

Sight and smell has important role in stimulating the appetite and enjoyment of food. Food should be served at correct time. 

• Food for patients must be clean and well-cooked and in covered vessels. It should have pleasant flavors so that the sight and smell increase his appetite.
•  Food should not be too hot or too cold. Hot food should be served as hot and cold as cold. Or food should be served according to their nature.
• Small and frequent meals are preferable for a sick person so food should be served little at a time; when the patient finishes the first serving, and then second serving should be added.
•  Clean water should be provided with meal if needed.
• Food should be clean and well cocked and in a covered pot.
• Encourage the patient to develop a taste to his therapeutic regimen of diet.
• Food should be served at correct time in a pleasant manner and atmosphere. There should be enough spacing between meals because frequent meals may cause indigestion and reduce appetite.
• The patient should have time to chew and taste the food. Never make hurry to the patient.
• Food preference, intolerance or allergy to food, etc. should be taken into consideration. Patient's cultural and religious values should also be considered.
• Be careful not to spill food. Wipe the patient's mouth and chin whenever necessary.
• Wash the patient's hands and make him brush his teeth after meals.

Assisting with Feeding

The loss of independence that comes with the inability to self-feed can be a severe blow to a person's self-esteem. The following measures may help a person maintain dignity while being feed:

• Involve the person as much as possible. Let the patient feed him/herself as far as possible.
• Ask his or her preferences regarding the order of items eaten and the eating pace.
• Place a napkin over the patient's clothes for protection.
• Serve little food at a time.
• Place tray within reach of the patient.
• Remain at bedside until the patient feels comfortable.
• Sit at the patient's eye level and make eye contact to create a more relaxed atmosphere.
• Be relaxed while feeding the patient.
• Provide appropriate drinks.
• Engage the individual in pleasant conversation to ease tension.
• After feeding the patient, remove the plate, offer water to rinse mouth and split in to kidney tray.
• Clean and dry mouth and face after eating.
• Make the patient comfortable.
• Take care of equipment and keep them in their respective place.
• Record the type of diet, time of feeding, amount taken.
• Report if any abnormality is detected.