Nutritional care

plan

It is the substance, procedure , and setting involved in ensuring the proper intake & assimilation of nutrients , especially for hospitalized patient.

Objectives • To present the components of the nutrition

care plan• To discuss the different approaches in

determining the contents of the nutrition care plan

Components of nutrition care plan

Nutritional assessmentNutritional requirement

Micro &Macro micronutrients Fluid requirement

Access: oral, parenteral, or combinationsNutrient formulationNutrient deliveryMonitoring strategies

Nutritional Assessment

Methods Used Are:

Anthropometric Assessment Biochemical Assessment Clinical Assessment Dietary Assessment

NUTRITIONAL REQUIREMENT

Food pyramid:

Food pyramid: Education tool that shows the dietary

guidelines in easily understood graphic format.

Balanced diet : Contains the various food groups of food

stuff in the correct proportions.

Recommended dietary allowances/intakes: The intake of nutrient derived from diet

which keeps nearly all people in good health.

Group particulars

Body wt EnergyKcal/kg

Protein g/kg

Fat g/day

CalciumMg/day

Iron Mg/day

Infants 0-6 months

5.4 108 2 500

6-12 months

8.6 98 1.65 500

Children 1-3yrs 12 102 1.8 25 400 12

4-6 19 89 1.6 25 400 18

7-9 27 73 1.5 25 400 26

Adolescence (boys)

10-12yrs 35.4 62 1.5 22 600 34

girls 10-12yrs 31.5 62 1.8 22 600 19

Boys 13-15yrs 47.8 50 1.5 22 600 41

Girls 13-15yrs 46.7 44 1.4 22 600 28

Boys 16-18yrs 57.1 46 1.4 22 500 50

Girls 16-18yrs 49.9 41 1.2 22 500 30

To avoid iron deficiency a woman should consume iron rich food.

Iron rich food: roasted bengal gram , rice flakes , cow pea , sirukeerai , mullakeerai , araikerai , manathakkali , sundakai , watermelon ,raisins(dry grapes) , savalai (fish) , beef , liver sheep

Group particulars

Body wt EnergyKcal/kg

Protein g/kg

Fat g/day

CalciumMg/day

Iron Mg/day

Pregnant woman

50 +300 +15 30 1000 38

Lactating 0-6 Month

50 +550 +25 45 1000 30

6-12 month

50 +400 +18 45 1000 30

PARTICULARS ENERGY

Obese 25kcal/kg body weight

Normal weight 30 kcal/kg body weight

Underweight 35kcal/kg body weight

Preterm baby 60-150kcal/kg/dayPrt – 3.4g/kg

PEM 150-200kcal/kg body weightPrt-5g/kg

Diabetes mellitus IBW*0.9/25-35kcal

Acute renal failure 25-30kcal/kg , Prt -0.6-0.8g/kg

Chronic real failure 35-50kcal/kg , Prt-0.5g/kg

Hemodialysis 35kcal/kg , Prt-1-1.2g/kg

Peritoneal dialysis 35kcal/kg , Prt-1.2-1.5g/kg

Micronutrients Electrolytes and Minerals (Na,K,Mg,):

Na & k -essential to maintain osmotic balance and keep the cells in proper shape

Mg- required for cellular metabolismTrace elements : Needed in very minute quantity

for proper growth , development and physiology of the organism

I- required for the normal function of thyroid gland

Zn- co-factor for a no of enzymes Cu-play an important role in iron

absorption

Cr - lead to impaired glucose tolerance Mn - participate in lipid & CHO metabolism Mo -essential constituent of xanthine and

aldehyde oxidases and involved in uric acid metabolism

Vitamins: water and fat soluble: Essential for normal growth and nutrition &

required in small quantityVitamin A - necessary for clear vision in dim lightVitamin D - required for bone growth and calcium

metabolismVitamin E -preventing the oxidation of vit-A & β

carotene in intestine

Vitamin B complex;Thiamine - proper utilization of CHO in the bodyRiboflavin - essential for several oxidation process

inside the cell and concerned with energy and protein metabolism.

Nicotinic acid - component of coenzyme in oxidative reactions and concerned with metabolism of CHO,fat,and proteins.

Pyridoxine - metabolism of amino acid and conversion of tryptophan to nicotinic acid

Folic acid - required for the multiplication and maturation of red calls

Vitamin B12- required for proper functioning of the CNS & metabolism of folic acid.

Vitamin-C -required for iron absorption

FLUID REQUIREMENT Water need for the function of:

Cell life, Chemical and metabolic reactions Regulate body temperature Transport of nutrients, Elimination of waste

Formulas Used:

For 0 - 10 kg:   weight (kg) x 100 mL/kg/day For 10-20 kg:  1000 mL + [weight (kg) x 50 ml/kg/day]

For > 20 kg:  1500 mL + [weight (kg) x 20 ml/kg/day]

Infusion rate = total fluid volume per day ÷ 24 hours

Fluid Requirement for renal patient: Urine output + 500ml.

Access Oral Enteral nutrition

Nasogastric tube PEG / Gastrostomy Jejunostomy

PEG-J ( Jejunostomy feeding passed through the PEG)

Surgical jejunostomy Parenteral nutrition

Peripheral Central

Oral feeding:⍟ Clear fluid diet (eg.barley water,dhal water,clear

stained fruit juice, tea/coffee (without milk),coconut water.)

⍟ Full fluid diet ( porridge ,dhal soup , dhal payasam , strained juices , cooked& pureed fruits ,milk , milk shakes , lassi , tea , coffee , strained soups , ice cream)

⍟ Soft diet (maida,all dhals ,juices, vegetables (cooked) , milk & milk product, egg(not fried),minced non veg, kheer , puddings.

⍟ Regular diet ( normal diet)

ENTERAL NUTRITION/TUBE FEEDING During acute initial phase of illness exogenous energy 20-25 Kcal/Kg/day

During recovery phase -30-40 Kcal/Kg/day

Protein intake should be 1.2-1.5 g/Kg/day never exceeding 1.8 g/Kg/day

Except extreme losses: burns, digestive losses

Type of tube feeding:

Blended ( blended regular food,) Elemental(low residue diet , lactose free,

ready to absorb) Non elemental( low residue with fiber,

may contain lactose) Specific nutrient modular( supply single

nutrients , good for diet manipulation Disease specific formular ( those have

problem in metabolism or oral esophagus.

Total parental nutritionFor children;

Child Calories Amino acidg/kg

Lipids g/kg

New born 110-125 kcal /kg

2-5 1-3

Older child 100-110 kcal/kg

1.5-3 1-3

Adult Dextrose Amino acid Lipids Total

100ml/hr 25g 4g 110g

2400ml/hr 600g gives 2040 kcal

96g gives 384

550( 500ml)

2974

Nutrient FormulationRegular or special dietOral supplementsEnteral nutrition:

⍟ Standard formulation, Modular formulations⍟ Special (elemental or semi-elemental)

Parenteral nutrition:⍟ Individual (amino acids, fat, dextrose) or 3

in 1 combinations Formulations for peripheral or central route

Nutrient DeliveryOral (as in regular intake or as oral supplement) Gastric feeding:

Bolus (either manual or with a gravity tube) ––for adequate gastric capacity and function

Intermittent or continuous using pumps ––for volume restricted or gastric dysfunction

Small intestine feeding: Intermittent or continuous using gravity drip,

but with smaller volumes (30smaller 30-80 ml/hour)

Monitoring Strategies • Fluid balance• Complete Blood Count Total Lymphocyte Count mild depletion-1500-1800 moderate -900-1500 severe -less than 900• Serum albumin (value as initial assessment tool,

but not as protein build up; frequent determination for issues only, pressure not nutritional)