Nutrition Care Process (ADIME) Process
A. Assessment of Nutritional Status
Responsibilities and Role of Nurses in Nutritional Care
Observing
Nurse - usually the first person who sees the patient’s eating problems
has direct communication with the patient
how well the patient’s eats his food
what kinds and amounts of food are refused
the patient’s attitude towards his food are readily determined
must have a knowledge in diet therapy (food allowed / restriction)
should immediately forward the diet prescription to the dietary department
makes sure that the patient is ready to consume the food served on the tray
Listening
Nurse - shows his/her general interest and understanding of the patient
helps the patient express his/her feelings
learned from the patient some of his/her favorite foods and dislikes
explains concerns on foods that cannot be eaten due to ethnic, cultural background and religious
beliefs
becomes aware of what concerns the patient may have about the diet he will have at home
Reporting
Nurse – documents and chart all the problems related to food intake
Nutritional History
a. Dietary Intake Data
- Dietary Computations: Desirable Body Weight
Basal Metabolic Rate
Total Energy Requirement
Food Exchange List
b. Nutrient Intake Analysis (NIA)
c. Food Diary
d. Food Frequency
e. 24 hour Recall
Physical Assessment
a. Anthropometric Measurements
b. Height and Weight
c. Body Mass Index
d. Body Composition
e. Mid-arm Circumference (MAC)
f. Fat-fold or Skin-fold Thickness
Other Sources of Data
Malnutrition Universal Screening Tool (MUST)
Subjective Global Assessment (SGA)
Mini Nutritional Assessment (MNA)
Geriatric Nutritional Risk Index (GNRI)
B. Nutrition Diagnosis and Plan of Care
Nutrition Problems and/or Needs
Planning the Diet with Cultural Competency
Resources needed in Planning and Implementing Dietary Regimen
C. Nutrition Intervention
Food and Nutrient Delivery
Food Administration
Oral Nutrition
Short-term enteral access
Long-term enteral access
Enteral Nutrition
Tube Feeding
Provide enteral nutrition for clients who cannot swallow, with esophageal obstruction,
unconscious, and cannot consume oral feeding.
Rubber – ice; Plastic- warm (Levine-single; Salem sump-double lumen)
High fowler’s, if contraindicated place right side lying position with head slightly elevated to
prevent aspiration.
Measure the distance from the tip of the nose to earlobe through the bottom of the xiphoid
process (adult)
Measure the distance from the tip of the nose to earlobe through the midway of xiphoid
process and umbilicus (children)
Use water soluble jelly as lubricant
Offer sips of water and advance tube forward, head bent forward closes the epiglottis and
trachea
Inject 10 ml of air and auscultate for gurgling sound in the epigastrium.
Aspirate for residual stomach content (ph 1-3 of yellow to green)
Immerse tip of the NGT into water and observe for bubbling.
X-ray confirms
Flush with 30-60 ml of water after feeding
If NGT is to removed, instruct client to exhale and remove tube with smooth, continuous
pull
NG TUBE
N- ever give without checking
G- ive warm(room temperature)
T- urn to right side during the feeding for the stomach to empty better
U- se gravity, never force feeding
B- e sure to aspirate
E- nd with water and chart
Types of Enteral Formulation
1. Ready to Use Formulations
2. Tube feedings – prepared from regular foods
1. Standard tube feeding - fiber free, high in cholesterol, fat and sugar
- milk based, sugar and soft cooked eggs
2. Blenderized tube feeding - soft diet allowances which can be blenderized easily
Complications:
Mechanical
nasopharyngeal irritations – ice chips
luminal obstruction – flush, replace tube
mucosal erosions – reposition tube, ice water lavage, remove tube
tube displacement – replace tube
aspiration – discontinue tube feeding
Gastrointestinal
cramping/distention – change formula, reduce infusion rate
vomiting/diarrhea – dilute formula, reduce infusion rate
constipation – promote sufficient, fluids and fibers, encourage patient activity
Metabolic
hypertonic dehydration – increase water
cardiac failure – reduce sodium content, fluid restriction
renal failure – decrease phosphate, magnesium, potassium, CHON restriction, amino acids
solution
glucose intolerance – reduce infusion rate
hepatic encephalopathy – decrease amount of CHON
Parenteral Nutrition
1. Peripheral Parenteral Nutrition (PPN) – nutrients are given via small veins, usually in the
arms
2. Total Parenteral Nutrition (TPN) – also called Central Parenteral Nutrition (CPN) or
intravenous hyperalimentation (IVH); nutrients are given centrally into the superior or
inferior vena cava or the jugular vein
TPN solutions are nutritionally complete based on the patient’s weight and
caloric/nutritional needs
TPN is indicated in clients who need extensive nutritional support over an extended period
like CA and severe malnutrition
Mixture of dextrose, amino acids, multivitamins, electrolytes and trace of minerals
The usual site is subclavian vein
During TPN catheter insertion, Trendelenburg position – to engorge the vein and facilitate
insertion of the vein and prevent air embolism
The primary purpose of TPN is to administer glucose
PIC – basilic / cephalic; PPC - subclavian
Administer TPN at room temperature
Cold temperature of solution may cause chills
Consume TPN formula for 24 hours to prevent contamination
The TPN solution is hypertonic (25-35% of dextrose)
Use infusion pump to maintain steady infusion this prevents abnormal shifting of fluids from
intracellular compartment to the extracellular compartment (cells shrink)
If infusion is delayed do not catch up – notify physician for calculation
Monitor urine and glucose level. Glycosuria is expected.
The client may need small amount of insulin as prescribed by the physician to prevent
glucose intolerance
Prevent infection on the catheter site. Infection is the most common complication of TPN.
If TPN administration is interrupted or discontinued, administer D10W to prevent
hypoglycemia
D. Monitoring Nutritional Status
Strategies to address Age-related changes affecting Nutrition
Selected Therapeutic Diets
Recording and reporting of Nutritional Status
E. Evaluation of Plan of Care
Effectiveness of the plan of care
