Principles of nutrition therapy &
the role of the nurse
Diet Therapy: NURS 2018
Objectives
At the end of this presentation students will be able
to:
 Describe the nutritional intake of persons who are
institutionalized
 Explain the basis for determining the therapeutic
nutritional requirements of individuals
 Use the concept of diet therapy in planning menus
for patients
 Identify ways of incorporating dietary management
in nursing care plans
 Describe the role of nurse in providing nutritional
care to institutionalized individuals
Factors affecting nutritional
requirement and intake
Individual differences exist which impact
nutritional requirements they include:
 Age
 Gender
 General condition
 Health disorder
 Nutritional status
 Soci-economic background

Factors affecting nutritional
requirement and intake




Emotional and cultural factors are very
important in determining food intake.
The cultural pattern of three meals will impact
dietary choice.
Animal experiments have shown that habitual
factors such as three meals per day have great
influence on dietary pattern and choices
Dietary information may affect early choices
which has implications for later life; in respect of
NCDs and excesses
Factors affecting nutritional
requirement and intake



Appetite may be adequate for selection of a
nutritionally acceptable diet under certain
circumstances
Selection of food on the basis of nutritional
principles is more reliable and is recommended
There are normal variations in food intake in
relation to




age,
sex,
environmental temperature,
and caloric expenditure
Factors affecting nutritional
requirement and intake

Age- higher caloric and micronutrient
requirement needed to support :
◦ growth and development;
◦ bone and muscle mass development

Sex- BMR is increased with higher muscle
mass
◦ higher in adults compared with older adults who
have sarcopenia;
◦ higher in males than females
Factors affecting nutritional
requirement and intake

Reports have suggested that decrease in
appetite occurs when environmental
temperature has reached a point at which
maintenance of body temperature is difficult

Caloric expenditure increases both the
requirement for more calories and usually the
appetite (thus intake)

Illness and disease- though this may decrease
appetite in some instances- the actual
micronutrient and caloric requirements may be
higher
Factors affecting nutritional
requirement and intake

Factors causing increased intake

Cystic fibrosis of the pancreas

Hyperthyroidism

Diabetes mellitus

Epinephrine-producing tumors of the adrenal medulla

Pts on ACTH, adrenal cortical steroids, androgens, estrogens, and
isoniazide.

Tumors of the hypothalamic regions of the brain
Factors affecting nutritional
requirement and intake

Factors causing reduced intake

Dietary deficiency of any essential nutrient

Acute and chronic febrile illnesses,

Debilitating illnesses such as rheumatoid arthritis and
ulcerative colitis,

Hepatic and renal diseases,

Hypothyroidism
Hospitalized people

Nutrition care in hospitals is aimed at the
role that nutrition plays in any acute process
occurring during hospitalization as well as
long-term goals.

Nutrition services include food service and
clinical nutrition

Medical nutrition therapy is the assessment
and treatment of illness or disease that
relates to nutritional care.
Hospitalized people

Malnutrition risk increases in the hospitalized client
because of factors that decrease dietary intake,
increase nutrient losses and lead to increased
metabolic needs

The provision of specialized nutrition support in the
form of enteral or parenteral nutrition should be
done after careful consideration of the indicators,
risks and benefits of treatment

Palliative nutrition care involves providing hydration
and nutrition in accordance with client centered
decisions particularly in end of life care.
Hospitalized people

Hospital patients usually spend most of their time in
bed.

Their needs for energy are therefore lower than
those of active persons of the same sex, age and
weight.

However, some may have increased nutritional
requirements. These include
◦ patients who entered hospital undernourished;
◦ those who are pregnant or lactating or have recently had
a baby;
◦ and those with diseases that require a special diet or
extra nutrients.
Hospitalized people

Nutrition care in hospitals is aimed at the
role that nutrition plays in any acute process
occurring during hospitalization as well as
long-term goals.

Nutrition services include food service and
clinical nutrition

Medical nutrition therapy is the assessment
and treatment of illness or disease that
relates to nutritional care.
Hospitalized people

Malnutrition risk increases in the hospitalized client
because of factors that decrease dietary intake,
increase nutrient losses and lead to increased
metabolic needs

The provision of specialized nutrition support in the
form of enteral or parenteral nutrition should be
done after careful consideration of the indicators,
risks and benefits of treatment

Palliative nutrition care involves providing hydration
and nutrition in accordance with client centered
decisions particularly in end of life care.
Hospitalized people

The nurse is a vital member of the
interdisciplinary health care team providing
nutrition support and care.

One of the key processes in clinical
nutrition in nutritional assessment which
includes anthropometric and clinical
measures of assessment.
Hospitalized people



Hospital patients usually spend most of their
time in bed.
Their needs for energy are therefore lower
than those of active persons of the same sex,
age and weight.
However, some may have increased nutritional
requirements. These include
◦ patients who entered hospital undernourished;
◦ those who are pregnant or lactating or have recently
had a baby;
◦ and those with diseases that require a special diet or
extra nutrients.
Hospitalized people

Nutrition care in hospitals is aimed at the
role that nutrition plays in any acute process
occurring during hospitalization as well as
long-term goals.

Nutrition services include food service and
clinical nutrition

Medical nutrition therapy is the assessment
and treatment of illness or disease that
relates to nutritional care.
Hospitalized people

Malnutrition risk increases in the hospitalized client
because of factors that decrease dietary intake,
increase nutrient losses and lead to increased
metabolic needs

The provision of specialized nutrition support in the
form of enteral or parenteral nutrition should be
done after careful consideration of the indicators,
risks and benefits of treatment

Palliative nutrition care involves providing hydration
and nutrition in accordance with client centered
decisions particularly in end of life care.
Hospitalized people

The nurse is a vital member of the
interdisciplinary health care team providing
nutrition support and care.

One of the key processes in clinical nutrition
in nutritional assessment which includes
anthropometric and clinical measures of
assessment.
Hospitalized people
Hospital patients usually spend most of their
time in bed.
 Their needs for energy are therefore lower
than those of active persons of the same sex,
age and weight.
 However, some may have increased nutritional
requirements. These include

◦ patients who entered hospital undernourished;
◦ those who are pregnant or lactating or have recently
had a baby;
◦ and those with diseases that require a special diet or
extra nutrients.
Hospitalized people

Nutrition care in hospitals is aimed at the
role that nutrition plays in any acute process
occurring during hospitalization as well as
long-term goals.

Nutrition services include food service and
clinical nutrition

Medical nutrition therapy is the assessment
and treatment of illness or disease that
relates to nutritional care.
Hospitalized people

Malnutrition risk increases in the hospitalized client
because of factors that decrease dietary intake,
increase nutrient losses and lead to increased
metabolic needs

The provision of specialized nutrition support in the
form of enteral or parenteral nutrition should be
done after careful consideration of the indicators,
risks and benefits of treatment

Palliative nutrition care involves providing
hydration and nutrition in accordance with client
centered decisions particularly in end of life care.
Hospitalized people

The nurse is a vital member of the
interdisciplinary health care team
providing nutrition support and care.

One of the key processes in clinical
nutrition is nutritional assessment which
includes anthropometric and clinical
measures of assessment.
Psychological Impact of Illness
Being ill may have severe psychological
impact on health and result in several
health care conditions suited to the
NANDA list:
 Emotional needs- caregiver role strain,
sadness, anxiety, fear
 Ability to cope:- impaired coping,
anticipatory grieving, depression, social
isolation
 Institutional setting:- powerlessness

Illness:- Impact on food behaviour

Illness and institutionalization may impact
negatively on dietary intake as they may
impair:◦ Appetite- smells, appearance of food, texture may
differ from what was consumed at home
◦ Acceptance and Rejection of foods:- pain, nausea,
drowsiness, physical disabilities (temporary and
permanent) may affect the willingness to accept or
reject food
◦ Failure to eat:- the same conditions affecting
acceptance may also affect and result in failure to
eat
Nutritional Needs of the hospitalized
patient

The nutritional status of a patient at admission has
implications for the management and outcome of the
condition. Some nutritional issues that have negative
impact on outcome and management are:◦ Undernutrition
◦ Loss of lean body mass
◦ Prolonged admission

These have negative impact
◦
◦
◦
◦
Co-morbidity
Opportunistic infections
Length of stay
Mortality
Nutritional Needs of the
hospitalized patient

Basis of determining needs
Predictive
Equation
Formulae
Harris-Benedict (males)
66.45 +13.75 * wt + 5 * ht - 6.75 * age
Harris-Benedict
(females)
655.09 + 9.56 * wt + 1.84 * ht - 4.67 * age
Mifflin-St. Jeor (males)
9.99 * wt+6.25* ht - 4 .92 * age + 5
Mifflin-St. Jeor (females)
9.99 * wt + 6.25 * ht – 4.92 * age - 161
WHO (males) [18-30
years]
15.3 * wt + 679
WHO (females) [18-30
years]
14.7 * wt + 496
Tucker & Dauffenbach, 2011
Nutritional Needs of the
hospitalized patient

Basis for determining needs
EER by gender
Formulae
Females
354- (691* age) + PA * (9.36 * wt + 726 * ht)
Males
662- (9.53 * age) + PA * (15.91 * wt + 539 * ht)
Activity
Activity Factor (PA)
Sedentary
1
Light active
1.16
Active
1.31
Very active
1.56
Disadvantages of estimating energy
requirements

Estimating energy needs just based on
weight may be erroneous as the ratio of
active lean body mass to total weight is
not constant- thus a DEXA scan or a
bioelectrical impedance may be useful.
 (Duggan and Golden, 2007)
Nutritional Needs of the hospitalized
patient
Basis for determining needs
Based on Nitrogen balance studies the normal
Nitrogen requirements range from 105mg N/kg/d to
132mg N/kg/d for nitrogen equilibrium- losses=
intake
 NB. 1g protein= 6.25mg N
 Thus 0.105gN * 6.25= 0.65g Protein/kg/d & 0.132gN
* 6.25= 0.83kg Protein/kg/d - which is two sd units
of the mean of 0.65
 Thus normal protein requirement for nitrogen
balance is 0.65 to 0.83 g/kg/d
 Protein requirements should be 10%- 15% of total
energy intake/d

 (Smith, 2007)
Nutritional Needs of the
hospitalized patient
The tools that are important in
determining the needs of hospitalized
patients include
 Nutritional assessment including –
anthropometry, biochemical tests and
clinical assessment
 Medical diagnosis:- this is often a multiplier
in energy determination
 Dietary history which provides an analysis
of usual intake

Prescribed nutritional therapy

There are several ways that the hospitalized
patient may be supported nutritional. The
method of dietary delivery is dependent on:
◦ Anorexia due to illness- weakens due to illness
or surgery; cancer; eating disorders
◦ Swallowing disorders:- presence of gag reflex;
Cerebrovascular motor neuronal, esophageal
stricture
◦ Gastric stasis, gastroparesis- post op; ICU
◦ Inability to take sufficient orally- burns, trauma,
Inflammatory bowel disease
Nutrition as part of the Nursing
Care Plan




Analysis of food- The nurse identifies, type,
amount, preparation styles, likes and dislikes
Plan and implement diet instruction:- in
collaboration with the dietician/nutritionist and
based on patient needs the nurse prepares the
patient for discharge and wellness maintenance
and in primary settings
Identify follow-up care needs- HTN, Renal, DM,
HIV/AIDS clinic along with dietary referral
Other assistance- Social Worker, Path
programmes, advise regarding gyms, recovery
groups
References

Duggan, M., & Golden, B. (2007). Deficiency
diseases. In C. Geissler & H. Powers (Eds.), Human
Nutrition (11th Ed.) (pp 517-536). Edinburgh, UK:
Elsevier Churchill Livingstone.

Smith, R. C. (2007). Nutritional support for
hospitalized patients. In J. Mann & A. S. Truswell
(Eds.), Essentials of human nutrition (pp 33-52).
New York, USA: Oxford University Press.

Tucker, S. & Dauffenbach,V. (2011). Nutrition and
diet therapy for nurses. Boston, USA: Pearson.