Flashcards
therapeutic diets
Flashcards do conjunto (55)
- 1what is a therapeutic dietit is essentially a diet required by an individual caused by a clinical condition; such as special textured food (stroke), low phosphorus and potassium food in kidney disease, and enteral feeding for people who are unable to take food by mouth
- 2what is the aim of a therapeutic dietto provide the individual with their nutritional needs while modifying the diet for their clinical needs
- 3what factors influence dietary requirementsthe clinical condition, age, gender, BMI, activity level, current nutritional status, current evidence
- 4dysphagia (can occur from stroke)difficulty swallowing (one or more of the processes of swallowing are impaired)
-> difficulty swallowing food, saliva, medications, drinks
CONSEQUENCES: -> aspiration and pneumonia, choking, malnutrition, dehydration, reduced meds, reduced QOL - 5managing dysphagia (usually a speech path)• Fluid and food modification
• Postural modification (manipulation of head or body posture)
• Manoeuvres (manipulation of an isolated aspect of swallowing)
• Management of behavioural and environmental factors
• Feeding assistance and interventions + supervision (limb, sight, aids etc)
• Oral hygiene
• Meal size considerations - 6FOOD TEXTURES 1-41 – texture = “normal” / not modified
2 – texture A = soft
3 – texture B= minced and moist
4 – texture C = smooth pureed - 7examples of texture A soft foods and some things to avoid• casseroles, small pieces TENDER meat, soft vegetables, stewed fruits
• (NO charred or chewy meat, fibrous vegetables, hard cheeses or fried eggs) - 8some examples of texture B minced and moist food and some things to avoid• minced tender meats, casseroles, very soft egg, mashed soft fruit, very well cooked vegetables that can be mashed.
• particle size 0.5cm
• soft and moist, forms balls easily, can be easily mashed with a fork
• NO hard pieces - 9some examples of Texture C smooth pureed food• Lump free, smooth, should hold shape, any pureed food
• Pureed NOT minced - 10liquid textures1 – unmodified
2 – level 150 = mildly thick
3 – level 400 = moderately thick
4 – level 900 = extremely thick - 11liquid texture; level 150thicker than fruit nectar, fluid freely flows of spoon but leaves a coating
- 12liquid texture; level 400similar to room temp honey/shake, pours slowly, dollops off spoon
can be drunk from a cup (slow movement of fluid), difficult to use a straw, spoon easier - 13liquid texture; levels 900thick like mousse, does not flow, holds shape on spoon, will not flow through fork prongs
while thick, a spoon should NOT be able to stand upright in it unsupported – this would be too thick - 14metabolic stress - phases and nutritional requirementsebb phase (commence feeding at a slow rate earl and avoid overfeeding, excess glucose can precipitate muscle loss)
flow phase (protein the most important factor - 1.2-2g/kg, no good evidence for limiting glucose in this phase)
anabolic phase (back to 'normal') - 15enteral feedingNutrition is provided directly to the GI (either the stomach or further down the GI); the person is unable to eat in the usual way or unable to meet their nutritional requirements, being at nutritional risk;
examples:
dysphagia, unconscious or semi conscious, GI disorders et - 16when is enteral feeding contraindicated?Contraindicated if there is absence of a functioning gut or GIT surgery requiring complete bowel rest.
- 17types of enteral feedingnasogastric
nasoduodenal
nasojejunal
PEG
PEJ - 18nasogastric feedingShort term, fully functioning gut, radiologically verified, replace 4-6 weeks
- 19nasoduodenalShort term, delayed gastric emptying, reflux, obstruction, x-ray checked, replace 4-6 weeks
- 20nasojejunalShort term, delayed gastric emptying, reflux, aspiration risk, strictures, obstructions, N&V, unconscious supine patients (lying flat on back), x-ray checked, replace 4-6 weeks
- 21PEG (percutaneous endoscopic gastronomy)Long term feeding >6weeks, fully functioning gut
- 22PEJ (percutaneous endoscopic jejustronamy)Long term feeding >6 weeks, bypass stomach and duodenum
- 23Choosing between naso/PEG?• Duration of feed (naso short term PEG long term)
• Clinical condition
• Risk of aspiration (direct to jejunum)
o In PEG fistulous tract is created to connect tube - 24enteral feeding regimes:Continuous vs intermittent vs bolus
- 25enteral feeding regime: ContinuousOver 20-24 hours
Often used when enteral feeding commences
Gravity/pump
SMALL QUANTITIES improve tolerability
Rapid transit time
**Better BGL control
Limits mobility, expensive equipment
Can be modified for medication - 26enteral feeding regime: Intermittent4-16 hours
larger rate/quantity required to meet needs (not as well tolerated)
transitional from enteral to oral after continuous
feed during day to reduce risk of aspiration
allows mobility - 27enteral feeding regime: bolusspecific quantities at specific times, usually replicating ‘meal times’, supplement oral intake
gravity/syringe
may be long term / may be in transition to oral feeding
tolerability? (depends on where it is being directly fed to)
increased risk of reflux/aspiration, diarrhoea - 28Types of ‘food’ used in enteric feedingPolymeric vs semi / elemental vs modified
- 29polymeric nutrition in enteral feedingintact micronutrients – requires normal digestion and absorption
energy content 1-2 kcal/ml
variable nutrient profile - 30semi elemental / elemental nutrition in enteral feedingmacronutrients partially or completely hydrolysed
for impaired digestion and absorption
1-1.5 kcal/ml - 31modified nutrition in enteral feedingincreased arginine (may help wound healing)
- 32adverse events in enteral feedingBlocked tubes
N&V
Diarrhoea
Constipation
DDIs - 33managing blocked tubes in enteral feedingPrevent: Flush tubes with 30-40ml water every 4-6 hrs and/or before and after intermittent feeds
Fix: warm water flush via syringe
Can use pancreatic enzymes (but $$$) - 34managing N&V in enteral feedingChange rate of feeding (too fast, too cold), delayed gastric emptying, address opioids etc
- 35managing diarrhoea in enteral feedingFeed too rapid, fibre content, malabsorption, liquid meds with sorbitol, laxatives
- 36managing constipation in enteral feedingInadequate fibre, inadequate fluid, low mobility, analgesics, spinal cord injury
- 37managing DDIs in enteral feeding:specifically mentioned:
Phenytoin (enteral feeds may reduce efficacy - TDM)
Warfarin (enteral feeds may reduce efficacy, ? bind to feed? monitor INR) - 38what is refeeding syndromeSevere electrolyte and fluid shifts with metabolic complications.
Occurs in malnourished patients who are fed after a period of starvation
During starvation body uses less glucose and uses fat instead
Influx of carbohydrate causes rapid fall in PHOSPHATE, magnesium and potassium and increase extracellular fluid (ECF ?) volume
Life threatening complications (cardiac, neurological, haematological, neuromuscular, pulmonary) - 39Risk factors for refeeding syndrome>5 days very little – no food
BMI <20
5% weight loss in 3-6 months
hx of drug use
use of insulin, chemo, antacids, diuretics
risk increases as BMI reduces and days of little to no food increases - 40Metabolic changes in starvationdecreased basal metabolic rate
loss of lean body mass
atrophy of muscles and organs (liver, GI, renal, cardiac etc)
impaired organ function
retention of sodium and water
decreased glycogen stores
decreased insulin production
increased glucagon secretion - 41metabolic changes in feeding after starvationincreased insulin release
o increased uptake of glucose, K+ and phosphate into cells
carb metabolism (increased use of thiamine)
protein synthesis
o tissue growth
o increase in cell uptake/demand nutrients
o increased demand for water
reactivation of Na/K+ pump – movement of K+ into cells, movement of Na and fluid out
magnesium taken up into cells and utilised by Na/K+ pump
increased excretion of magnesium in urine
reduced excretion of sodium and water
excess glucose
o hyperglycaemia, lipid abnormalities - 42what happens when we go from starvation to eating?The switch from endogenous fuel to exogenous fuel; delivery of glucose causes an increase in insulin levels. Meanwhile, glucose, phosphate, magnesium and potassium are taken into cells rapidly (this is due to sudden reactivation of Na/K+ pump and high levels of circulating insulin) – as these nutrients are being taken into cells, serum levels drop. The body responds by retaining fluid, and the extracellular space expands (oedema and cardiac failure). The reduced serum levels of phosphate, potassium, magnesium and glucose causes the complications.
- 43problems associated with decreased phosphateConfusion, lethargy, weakness, acute ventilatory failure, arrhythmia, CHF, rhabdomyolysis, myoglobin related kidney damage, seizure, coma, red cell & leukocyte dysfunction
- 44problems associated with decreased potassiumWeakness, hypoventilation, polyuria, polydipsia, constipation, ileus, arrhythmia, cardiac arrest
(ileus = lack of movement somewhere in the intestines that leads to a buildup and potential blockage of food material) - 45problems associated with decreased magnesiumConfusion, diarrhoea, constipation, weakness, muscle cramps, anorexia, irregular arrhythmia, refractory decrease in potassium and phosphate
- 46how to minimise refeeding risksNo eating/minimal eating >5 days provide no more than 50% energy needs, or even less depending on length of time/BMI, and monitor for arrhythmia
Vitamin supplementation before and during first 10 days of feeding
Supplement calcium, potassium, phosphate and magnesium unless serum levels are high
Daily measurement of electrolytes week one, every other day ongoing
Monitor fluid balance - 47Total parenteral nutrition (TPN)Complete macro and micro nutrition
Requirements estimated by IBW
Commenced slowly, fed over 24hrs - 48Kidney failure and dietary modifications: intervention based on...Stage of kidney disease
Biochemical parameters (K, P)
Fluid status
Nutritional assessment
Other comorbidities (eg HT, DM, hyperlipidaemia)
Food preferences, lifestyle - 49Interventions for up to Stage 3 CKD> improving nutritional status influences disease progression
Protein requirements: 0.8-1.0mg/kg (less protein not evidenced to improve disease)
Potassium: reduce if blood levels are elevated
Phosphate: not restricted
Sodium: <100mmol/day
Energy: as ‘standard’
Fluid: as ‘standard’ unless restricted
Alcohol: as ‘standard’ - 50Interventions for Stage 4 CKD> there has been a reduction in clearance of toxic compounds (urea) and phosphorus and potassium
> impaired mineral homeostasis can develop bone disorder
> uremia – due to accumulation of the products of protein metabolism as kidneys cannot clear them –leads to N&V, anorexia, confusion, lethargy, coma
may need to reduce dietary phosphorus and potassium
consume high value protein (complete amino acids) - 51Interventions for Stage 5 CKD> dialysis (haemodialysis / peritoneal dialysis)
> nutritional requirements based on type of dialysis
> optimise health status - 52HaemodialysisPatients dialysed on average 3/week
Aim for BMI 23-26kg/m2
Energy 125-146kJ/kg < 60yrs,
Energy 125 kJ/kg > 60yrs
Protein 1.2-1.4 g/kg with > 50% HBV
Na if restricted 80-110 mmol/day
K if restricted ( serum K > 6.00mmol/L) 1mmol/kg/day
P if serum levels > 1.78mmol/L 800-1000mg/day +/- phosphate binders
Fluid 500ml + previous day output
Vitamin supplementation - 53Peritoneal dialysisPatients dialyse daily
Aim for BMI 23-26kg/m 2
Energy 146kJ/kg < 60yrs,
Protein 1.2-1.5 g/kg with > 50% HBV (some protein lost via dialysate)
Na if restricted 80-110 mmol/day
K usually not restricted. If restricted (serum K > 6.00mmol/L) 1 mmol/kg/day
P if serum levels > 1.78mmol/L 800-1000mg/day +/- phosphate binders
Fluid amounts individualised
? Constipation- common may require laxative plus gradual increase in Fibre - 54high phosphorus foods to avoidProcessed foods eg sausages, meat pies Cola based drinks
Wholemeal, multigrain, rye breads/ rolls High fibre cereals eg all bran
Vegemite Peanut butter , Nutella etc - 55High potassium foods to avoidDried fruit
Fruit and vegetable juices
Apricots, Cherries, Avocado, Banana,
Grapes , Kiwi, Mango,
Nectarine, Peacharine, Tamarillo
Coconut- all forms
Artichokes ,Brussels sprouts , Chinese cabbage, red cabbage, spinach
Homemade or canned vegetable soups
Pumpkin Parsnips, swedes, turnips
Potato chips, French fries, wedges and crisps, Sundried tomatoes, Tomato paste and puree
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- Descrição
- Nutrition FlashCards sobre therapeutic diets, criado por Amelia Claire em 05-11-2018.
- Criado por
- Amelia Claire
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