5-9. RESPONSIBILITIES OF THE PRACTICAL NURSE IN RELATION TO DIET THERAPY

a. The practical nurse should be familiar with the diet prescription and its therapeutic purpose. Although individual trays are carefully checked before leaving the Nutrition Care Division, mistakes can happen. Examine each tray with the patient's specific diet in mind. You should be able to recognize each type of diet.

b. You should relate the diet to body function and the condition being treated. For example, a low fat diet is usually the first step in treating patients with elevated blood lipids (hyperlipidemia). Hyperlipidemia may be caused by improper diet or it may have a secondary cause, such as hypothyroidism or renal failure. Untreated hyperlipidemia can lead to coronary heart disease.

c. Be able to explain the general principles of the diet to the patient, and obtain the patient's cooperation.

(1) For example, teach a diabetic patient the relationship between his insulin and the amount of food consumed.

(2) Observe the patient's reaction to the diet. If the patient understands the relationship between his condition and his diet, and is shown that he can continue to enjoy most of his favorite foods, he is more likely to remain on the diet.

d. Help plan for the patient's continued care.

(1) Most patients are hospitalized only during the acute and early convalescent phases of their illness so it may be necessary to continue a special diet at home.

(2) Chronic conditions, such as diabetes or hypertension, require permanent dietary alterations.

(3) Be aware of the patient's home situation and the problems that the diet may cause. The patient and his family will have to adjust their meal plans.

(4) Request a consultation for the patient with the dietitian early in the hospitalization to allow for instructions and follow-up care.

5-10. REASONS FOR THERAPEUTIC DIETS

Nutritional support is fundamental, whether the patient has an acute illness or faces chronic disease and its treatment. Frequently, it is the primary therapy in itself. The registered dietitian, along with the physician, carries the major responsibility for the patient's nutritional care. The nurse, and other primary care practitioners provide essential support. Valid nutritional care must be planned on identified personal needs and goals of the individual patient. We should not lose sight of the reasons for therapeutic diets.

a. To Maintain or Improve Nutritional Status. The stereotypical all-American family with two parents and two children eating three balanced meals each day with a ban on snacks is no longer a common reality. Widespread societal changes include an increase in the number of women in the work force and families who rely on food items and cooking methods that save time, space, and labor. The "snack" is clearly a significant component of foods consumed. A therapeutic diet may be planned to promote foods that contribute to nutritional adequacy.

b. To Improve Nutritional Deficiencies. Dietary surveys have shown that approximately one third of the US population lives on diets with less than the optimal amounts of various nutrients. Such nutritionally deficient persons are limited in physical work capacity, immune system function, and mental activity. They lack the nutritional reserves to meet any added physiologic or metabolic demands from injury or illness, or to sustain fetal development during pregnancy.

c. To Maintain, Increase, or Decrease Body Weight. Despite the growing interest in physical fitness, one out of every four Americans is on a weight reduction diet. Only 5 percent of these dieters manage to maintain their weight at the new lower level after such a diet. The basic cause is an underlying energy imbalance: more energy intake as food than energy output as basal metabolic needs and physical activity. Being underweight is a less common problem in the US. It is usually associated with poor living conditions or long-term disease. Resistance to infection is lowered and strength is reduced. Other causes for a person being underweight are self-imposed eating disorders, malabsorption resulting from a diseased gastrointestinal tract, hyperthyroidism, and increased physical activity without a corresponding increase in food intake.

d. To Alleviate Stress to Certain Organs or to the Whole Body.

(1) When loss of teeth or dental problems make chewing difficult, a dental soft diet may be used. All foods are soft-cooked, meats are ground and sometimes mixed with gravy or sauces.

(2) Peptic ulcer is the general term given to an eroded mucosal lesion in the central portion of the gastrointestinal tract. Little is understood about its underlying causes. The prime objective in medical management is to provide psychologic rest and support tissue healing. Three factors form the basis of care: drug therapy, rest, and diet. The bland diets used in the past for treatment of peptic ulcer have proved to be ineffective. Positive individual needs and a flexible program of a regular diet, including good food sources of dietary fiber, milk, and other protein foods prevail today.

(3) General functional disorders of the intestine may be caused by irritation of the mucous membrane. Symptoms vary between constipation and diarrhea. Dietary measures are designed to provide optimal nutrition and regulate bowel motility. There should be additional amounts of fruits, vegetables, and whole grains. The fiber content may need to be decreased during periods of diarrhea or excessive flatulence.

(4) Organic diseases of the intestine fall into three general groups: anatomic changes, malabsorption syndromes, and inflammatory bowel disease with infectious mucosal changes.

(a) Diverticulosis is an example of anatomic changes. Current studies and clinical practice have demonstrated that diverticular disease is better managed with a high-fiber diet than with restricted amounts of fiber used in former practices.

(b) Celiac disease is an example of malabsorption syndrome. Since the discovery that the gliadin fraction in gluten (a protein found mainly in wheat) is the causative factor, a low-gluten, gliadin-free diet has resulted in marked remission of symptoms.

(c) Inflammatory bowel disease is a term applied to both ulcerative colitis and Crohn's disease. These two diseases have similar clinical and pathologic features. They are particularly prevalent in industrialized areas of the world, suggesting that the environment plays a significant role. The two goals of a therapeutic diet are to support the tissue-healing process and prevent nutritional deficiency. The diet must supply about 100 grams of protein per day through elemental formulas or protein supplements with food as tolerated.

e. To Eliminate Food Substances to Which the Patient may be Allergic. There are three basic approaches to the diagnosis and treatment of food allergies: clinical assessment, laboratory tests, and dietary manipulation. Diet therapy is individualized.

f. To Adjust Diet Composition. A therapeutic diet may be ordered to aid digestion, metabolism, or excretion of certain nutrients or substances.