Nursing interventions

Problem: Reduced nutritional status.

Goal: Patients will consume sufficient nutrients for their daily needs.

The nutritional needs of each individual vary according to their age, sex, activity and the severity of any illness. Patients who have been assessed as having a reduced nutritional status, or who fall into a high-risk category, should have their nutritional intake very carefully monitored. All patients require sufficient nutrients to support their basal metabolic rate, level of activity and metabolic response to trauma. Patients with heavily exuding wounds, such as fistulae or leg ulcers, may lose large amounts of protein without it being realised.

The dietitian will be able to help in assessing individual needs, so that very specific goals can be set. The goal set at the beginning of this section is of necessity broad, but needs to be more clearly defined for each individual. If a patient is being cared for at home, the carer must also be involved. Many patients will eat better at home, where they can eat what they want, when they want to.

The elderly may have special problems or needs. Penfold and Crowther (1989) have provided helpful guidelines for assisting the elderly to maintain a good diet. One problem may be developing disability. The occupational therapist can give guidance on adapting cooking equipment. Another problem may be lack of education as to what constitutes a 'good' diet. An even simpler problem may be poorly fitting dentures. A new set of teeth may be all that is needed to allow an elderly person to maintain an adequate nutritional status.

For many people, the short period of starvation during surgery followed by a rapid return to an adequate diet will not be harmful and the body will quickly adapt. However, nurses need to be aware of the amount of food their patients actually eat. These days the plated meal system is widely used in hospitals and there is little monitoring of the amount that patients eat. When assisting a patient to plan appropriate menus, it is helpful to bear in mind the sources of the nutrients particularly required for wound healing (see Table 2.5).

Table 2.5 Sources of nutrients required for wound healing.

Nutrient

RDA*

Food source

Protein

42-84g

Meat, fish, eggs, cheese, pulses, wholegrain cereals.

Carbohydrates

1600-3350 kcals

Wholemeal bread, wholegrain cereals, potatoes, (refined carbohydrates are seen as 'empty' calories).

Vitamins A B12 C D K

750 ng 3mg 30 mg 10 ng

Carrots, spinach, broccoli, apricots, melon. Meat (especially liver), dairy products, fish. Fruit and vegetables (but easily lost in cooking). Oily fish, margarine, cod liver oil. Vegetables, cereals.

Minerals Iron Copper Manganese Zinc

10-12 mg 12-15mg

Meat (especially offal), eggs, dried fruit. Shellfish, liver, meat, bread. Tea, nuts, spices, whole cereals. Oyster meat, whole cereals, cheese.

"Recommended Daily Allowance. These are the requirements in health; may need to be increased (see text).

"Recommended Daily Allowance. These are the requirements in health; may need to be increased (see text).

Some critically ill patients will not have an adequate intake without artificial feeding. This may take the form of a supplement or total nutrition. It can be either by enteral or parenteral feeding. Enteral feeding is the more desirable way of providing nutrition, but if the gastrointestinal tract is not functioning, then total parenteral nutrition is necessary. Zainal (1995) discussed the issues concerning the feeding of critically ill patients and stressed the importance of starting feeds early.

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