Basic principles therapeutic nutrition. Feeding the seriously ill.
Basic principles rational nutrition
Basic principles of therapeutic nutrition
Characteristics of the main treatment tables
Organization of meals for patients in the hospital
Types of artificial nutrition, indications for its use
Possible problem patient, for example:
Decreased appetite
Lack of knowledge about prescribed diet
Make a portion requirement
Conduct a conversation with the patient and his relatives about the treatment table prescribed by the doctor
Teach the patient the principles of rational and therapeutic nutrition.
Monitor food deliveries, the sanitary condition of cabinets and refrigerators, and the shelf life of food products
Feed seriously ill patient from a spoon and a sippy cup
Insert a nasogastric tube
Provide artificial nutrition to the patient (on a phantom)
Realize nursing process in case of failure to satisfy the patient's need for adequate nutrition and fluid intake using the example of a clinical situation
Treatment tables/diet(Greek δίαιτα - lifestyle, diet) - a set of rules for eating food by a person or other living organism.
Nutrition goal - give the body such food that, after its digestion in the gastrointestinal tract, entry into the blood and tissues (absorption) and subsequent oxidation (combustion), would lead to the formation of heat and vital energy(muscular, nervous).
Medical nutrition - this is, first of all, the nutrition of a sick person, providing his physiological needs for nutrients and at the same time a method of treatment with nutrition from specially selected and prepared products, acting on the mechanisms of development of the disease - condition various systems and metabolic processes. In this regard, most diets used for a long time contain the norm of all nutrients.
The following types of nutrition for patients are distinguished:
Oral (regular) nutrition (natural)
Artificial:
Enteral (tube) nutrition - through a tube inserted into the stomach;
Through the rectum;
Parenteral - intravenous administration of nutrients, which is used when tube feeding is not possible;
Through a gastrostomy tube
One of the basic principles of therapeutic nutrition for patients in a hospital is the diet and balance food ration (amount of food products that meet a person’s daily need for nutrients and energy), i.e. maintaining a certain ratio of proteins, fats, carbohydrates, vitamins, minerals and water in the proportions necessary for the human body.
So food ration healthy person should include 80-100 g of proteins, 80-100 g of fats, 400-500 g of carbohydrates, 1700-2000 g of water (including 800-1000 g in the form drinking water contained in tea, coffee and other drinks), a certain balance of vitamins, microelements, etc. Moreover, the ratio of proteins, fats, carbohydrates and other ingredients in the patient’s diet may vary depending on the nature of the disease.
The most optimal for a healthy person is considered to be four meals a day, in which breakfast includes 25% of the total diet, second breakfast - 15%, lunch - 35%, dinner - 25%. With some diseases, the diet changes.
Medical nutrition is based on 3 basic principles: gentle, corrective and replacement.
Beneficial principle - This is mechanical, chemical and thermal sparing of the diseased organ and system. A chemically gentle diet is prescribed to patients with gastrointestinal diseases if it is necessary to reduce their secretory and motor functions. At the same time, alcohol, cocoa, coffee, strong broths, fried and smoked meat are excluded from the diet. Prescribe products that cause weak secretion - butter, cream, milk soups, vegetable purees.
Mechanical sparing- all in a ground, puree form.
Thermal sparing achieved by culinary processing products (boiled, steamed, stewed)
Chemical sparing – exclusion of spicy foods, marinades, canned foods, seasonings, limiting salt.
For example, when peptic ulcer Patients tolerate fried foods (meat, potatoes) poorly, but steamed and finely chopped meat dishes or vegetable purees are tolerated well.
Corrective principle based on a decrease or increase in the diet of one or another substance. So, in case of diabetes mellitus, a disease in which carbohydrate metabolism is sharply disrupted, limiting carbohydrates is very important. On the contrary, with some diseases of the liver and heart, the amount of carbohydrates increases.
Fat intake is limited in case of diseases of the liver, pancreas and obesity and, conversely, an increase in fat is indicated in case of debilitating infectious diseases, tuberculosis.
For some diseases, it becomes necessary to fast for 1-2 days. These are the so-called fasting days. During this period, the patient either completely starves, or is given only fruit, milk or cottage cheese. This food unloading has good effect for obesity, gout, asthma. Table salt is limited in case of heart and kidney diseases accompanied by edema, with arterial hypertension. In these cases, fluid is also limited. On the contrary, in case of poisoning or dehydration, fluid administration is increased.
The replacement principle aims to introduce with food substances in which the body is deficient, as is done with vitamin deficiency, protein deficiency (nephrotic syndrome).
In Russia, the Research Institute of Medical Nutrition has developed schemes dietary tables, which are accepted in all medical institutions our country.
Therapeutic diets
Diet 1. PUD and DU, chronic gastritis with increased secretory function. Characteristics - mechanical, chemical, thermal sparing of the gastrointestinal tract, restriction table salt, substances that linger in the stomach for a long time (meat, fats). Allowed are white crackers, white stale bread, milk, cream, soft-boiled eggs, butter, slimy soups, jelly, vegetable and fruit juices, fresh cottage cheese, sour cream).
Diet 2. Chronic gastritis with reduced secretory function. Characteristics - juiced and secretion-stimulating components are allowed, such as broths, pureed borscht, meat, fish, but steamed, not in pieces.
Diet 3. Dyskinesia of the colon with constipation. Characteristics - increased amount of plant fiber (brown bread, cabbage, apples, beets, pumpkin) and liquid. Avoid products that cause rotting and fermentation in the intestines ( a large number of meat, simple carbohydrates).
Diet 4. Enteritis with diarrhea, severe dyspeptic symptoms. "Hungry", "intestinal" diet. Characteristics - limitation of fats and simple carbohydrates (promote steatorrhea and fermentation), hot and spicy substances.
Diet 5. Chronic hepatitis, liver cirrhosis. 5P - pancreatitis. Characteristics - strong stimulants of the stomach, pancreas, fats, meat are excluded. "The liver loves warm and sweet things." Increasing the diet of vegetables and fruits helps relieve the liver.
Diet 6. Gout and uric acid diathesis (accumulation uric acid in the body), erythremia. Characteristics - exclude foods rich in purine bases (meat, legumes, chocolate, cheese, spinach, coffee), introduce alkalizing foods (vegetables, fruits, berries, milk). Drink plenty of fluids liquid helps flush out uric acid.
Diet 7. Kidney diseases (glomerulonephritis, pyelonephritis, amyloidosis). Characteristic - significant restriction of protein and salt, in some cases - liquid.
Diet 8. Obesity. Characteristics - a significant reduction in total calories due to simple carbohydrates and fats. Introduction of fasting days (kefir, cottage cheese, apple). Avoid seasonings that increase appetite and somewhat limit the amount of fluid (often increased blood pressure).
Diet 9. Diabetes mellitus with normal and low body weight (for obesity - diet 8). Characteristics - simple carbohydrates are significantly limited (replaced with sweeteners), and fats to a lesser extent.
Diet 10. Cardiovascular diseases. Characteristics - limiting the intake of table salt and liquid, fats, fried meat, and other foods containing a lot of cholesterol (butter, lard, sour cream, eggs). Increase the amount of plant fiber and bran.
Diet 11. Pulmonary tuberculosis. Characteristics - increased calorie content due to additional nutrition (milk, eggs, sour cream, meat). Increased amount of vitamins (vegetables, fruits, greens).
Diet 12. Diseases nervous system and mental illness. Characteristics - limitation of stimulants (coffee, tea, alcoholic drinks, hot seasonings, spices, saltiness, marinades). Introduction of medicinal teas (with mint, lemon balm, hop cones).
Diet 13. Acute infectious diseases. Characteristics - increased amount of protein, fluid and vitamins (taking into account sweating and elevated temperature).
Diet 14. Phosphaturia with alkaline urine reaction and the formation of phosphorus-calcium stones. Characteristics - exclude alkalizing products (milk, cottage cheese, cheese), increase fluid consumption in order to wash out phosphates.
Diet 15. There are no indications for prescribing a therapeutic diet and the normal state of the digestive organs. Physiological norm proteins, fats, carbohydrates, liquids, vitamins, minerals and dietary fiber.
Diet 0, "jaw" The first days after surgery on the stomach and intestines, disturbances of consciousness (stroke, traumatic brain injury). Characteristics - liquid or jelly-like food (tea with sugar, rosehip infusion, lemon juice and other fruits, jelly, jelly, fruit drinks, weak broth, rice water).
In order to prevent violations of diet and regimen, it is necessary for a nurse to monitor the transfer of food to relatives of patients.
Standard Diets
Order of the Ministry of Health of the Russian Federation No. 330-2003. “On measures to improve clinical nutrition in medical and preventive institutions of the Russian Federation.”
It was proposed to switch to a new system of treatment tables/diet - a system of standard diets. New system diets basically contain the M.I. number system. Pevsner and includes 5 options for standard tables/diets.
1. The main version of the standard diet
Destination purpose: normalization of the secretory activity of the gastrointestinal tract, intestinal motility, liver and gall bladder function, creation of conditions for normalizing the body's metabolism and rapid elimination of toxic metabolic products (toxins), unloading of cardio-vascular system, normalization of cholesterol and interstitial metabolism, increasing the body's resistance and reactivity.
This diet replaces 1, 2, 3, 5, 6, 7, 9, 10, 13, 14, 15 number diets.
Characteristic. A diet with a physiological content of proteins, fats and carbohydrates, enriched with vitamins and minerals, plant fiber. When prescribing a diet for patients with diabetes, exclude (refined carbohydrates).
Diet exceptions: hot seasonings, smoked meats, cream-based confectionery, fatty meats and fish, spinach, sorrel, garlic, legumes, strong broths, okroshka.
Cooking method: boiled, baked and steamed. Diet: 4-6 times a day, fractional.
2. Diet option with mechanical and chemical sparing
Destination purpose: moderate mechanical, chemical and thermal sparing helps eliminate inflammatory process, normalization functional state organs gastrointestinal tract, reducing reflex excitability.
This diet replaces: 1, 4, 5 number diets.
Characteristic. A diet with a physiological content of proteins, fats and carbohydrates, enriched with vitamins, minerals, with moderate limitation of chemical and mechanical irritants of the mucous membrane of the receptor apparatus of the gastrointestinal tract.
Diet exceptions: spicy snacks, seasonings, spices, fresh bread, fatty meats and fish, cream, sour cream, legumes, crumbly porridge, strong broths.
Cooking method: boiled, baked, steamed, pureed and ungrated.
Diet: 5-6 times a day, fractional.
3. Diet option with increased amounts of protein (high protein)
Destination purpose: stimulation of protein synthesis in the organ; moderate chemical sparing of the gastrointestinal tract and kidneys; increasing the immunological activity of the body, activating hematopoietic processes, stimulating healing and reducing inflammation.
This diet replaces 4, 5, 7, 9, 10, 11 number diets.
Characteristic: a diet with a high amount of protein, a normal amount of fat, complex carbohydrates and a limitation of easily digestible carbohydrates. Limiting chemical and mechanical irritants of the stomach and biliary tract.
Diet exceptions: fatty meat and dairy products, smoked and salty fish, legumes, cream-based confectionery, spices, carbonated drinks.
Cooking method: boiled, baked, stewed, steamed.
Diet: 4-6 times a day, fractional.
4. Diet option with a reduced amount of protein (low protein)
Destination purpose: maximum sparing of kidney function, increased diuresis and improved removal of nitrogenous wastes and under-oxidized metabolic products from the body, creation of favorable conditions for blood circulation.
This diet replaces 7 number diet.
Characteristic: protein limit - 20-60 g per day.
Food without salt, enriched with vitamins, minerals, liquids no more than 1 liter. Milk is added only to dishes.
Diet exceptions: offal, fish, sausage, sausages, alcohol, salty snacks, seasonings, legumes, cocoa, chocolate.
Cooking method: boiled, steamed, not pureed, not crushed.
Diet: 4-6 times a day, fractional
5. Reduced calorie diet option (low calorie diet)
Destination purpose: prevention and elimination of excess accumulation of adipose tissue in the body, normalization of protein, water, vitamin, fat and cholesterol metabolism, restoration of metabolism, improvement of blood circulation, reduction of body weight.
This diet replaces: 8, 9, 10 number diets.
Characteristic: moderate restriction of energy value mainly due to fats and carbohydrates, exclusion of simple sugars, limitation of animal fats, table salt (3-5 g per day). The diet contains vegetable fats, alimentary fiber, fluid limit 800-1,500 ml.
Diet exceptions: offal, fish, sausage, smoked meats, mayonnaise, White bread, cream, sour cream, pasta. products, pickled and salted vegetables, raisins, finishing figs, grapes.
Cooking method: boiled, steamed.
Diet: 4-6 times a day, fractional.
This is the introduction of nutrients into the human body using probes, fistulas, and also intravenously.
Indications for the use of artificial nutrition:
Difficulty swallowing (burn of the oral mucosa, esophagus),
Narrowing or obstruction of the esophagus,
Pyloric stenosis (with peptic ulcer, tumor),
The period after surgery on the esophagus and gastrointestinal tract,
Uncontrollable vomiting
Big fluid loss,
Psychoses with food refusal.
Power through gastric tube infrequently found in therapeutic departments. The manipulation is performed by a doctor or well-trained paramedic. There is a danger of food getting into Airways with the development of aspiration pneumonia. Milk, cream, raw eggs, strong broths, glucose solutions, cocoa and coffee with cream, fruit juices.
Powered through postoperative fistula stomach or the intestines will have to face in surgical clinic. The set of products is the same. Additionally, it is allowed to introduce crushed food products diluted with liquid: finely pureed meat, fish, bread, crackers.
The third way of eating is use of nutritional enemas. It is used for swallowing disorders, esophageal obstruction, and when the patient is unconscious.
A nutritional enema is given half an hour to an hour after the cleansing enema. Water is absorbed from the rectum saline, 5% glucose solution, 3-4% alcohol solution. More often, drip administration of these solutions is used. At the same time, the intestinal wall does not stretch, intra-abdominal pressure does not increase, and peristalsis does not increase. With prolonged use of nutritional enemas, irritation of the rectal mucosa may occur, which is manifested by the urge to defecate or diarrhea.
Parenteral nutrition used in cases where the oral route of administration of nutrients is either impossible or functionally untenable. Parenteral nutrition began to be used especially widely in connection with the development of gastrointestinal surgery (after surgery, patients are excluded from oral nutrition for an average of 5 days).
The need for parenteral nutrition arises in cancer patients when severe injuries, extensive burns, uncontrollable vomiting (poisoning, acute gastritis), ulcerative or malignant pyloric stenosis, acute pancreatitis.
Artificial nutrition is performed when normal oral nutrition is difficult or impossible (certain diseases of the oral cavity, esophagus, stomach). Artificial nutrition is carried out using a tube inserted into the stomach through the nose or mouth. (Fig. 18, B) Can be administered parenterally without digestive tract(intravenous drip). Through the tube, you can administer sweet tea, fruit juice, still mineral water, broths, etc. in an amount of 600-800 ml/day. Procedure artificial feeding The nurse performs it as follows: prepare a sterile thin gastric tube, a syringe (with a capacity of 20 ml or a Janet syringe) or a funnel, and 3-4 glasses of food. If there are no contraindications, the procedure is performed with the patient sitting. If the patient cannot be seated or is unconscious, the probe is inserted in the supine position. A probe lubricated with glycerin or petroleum jelly is inserted 15-17 cm through the lower nasal passage into the nasopharynx, the patient’s head is slightly tilted forward, and forefinger hands in the mouth and, squeezing them, insert the probe into back wall pharynx, move it into the stomach. After making sure that the probe is in the stomach, put a funnel or syringe on the free end of the probe and pour in liquid food warmed to body temperature (20-30 ml each) in small portions. For artificial feeding through a tube, use milk, cream, raw eggs, dissolved butter, mucous and mashed vegetable soup, broths, juices, cocoa and coffee with cream, jelly, glucose solutions. The total one-time food volume is 0.5-1 l. After feeding, the funnel or syringe is removed, and the probe is left, fixed on the patient’s head.
The need for special restrictions and/or additions to the diet depends on the diagnosis. Used in the form oral administration, tube or parenteral nutrition. When fed orally, the consistency of food varies from liquid to puree or from soft to hard; with tube feeding and the introduction of parenteral formulations, their concentration and osmolality must be certain. Enteral nutrition is prescribed when oral administration of food is not possible or the gastrointestinal tract cannot absorb food components. Similar situations occur with anorexia, neurological disorders (dysphagia, cerebrovascular disorders), malignant neoplasms. With the enteral method, nasogastric, nasoduodenal, jejunostomal and gastrostomal tubes are used, installed using endoscopic techniques. The use of plastic or polyurethane probes of small diameter is justified due to the low incidence of complications such as nasopharyngitis, rhinitis, otitis media and stricture formation. There are various nutritional mixtures for tube feeding used in clinics, but fundamentally they can be divided into two categories.
Rice. 18. A – Feeding a seriously ill patient.
B – Feeding a seriously ill patient through a gastrostomal tube.
Lightweight nutritional mixtures. They consist of di- and tripeptides and (or) amino acids, glucose oligosaccharides and vegetable fats or medium chain triglycerides. The residue is minimal and requires little stress on the digestive processes for absorption. Such mixtures are used in patients with short bowel syndrome, partial intestinal obstruction, pancreatic insufficiency, UC (nonspecific ulcerative colitis), radiation enteritis and intestinal fistulas.
Completely liquid nutritional formulas - contain a complex set of nutrients and are used in most patients with a functioning gastrointestinal tract. Bolus feeding begins with the introduction of 50-100 ml of an isotonic or slightly hypotonic solution of the nutrient mixture into the tube every 3 hours. This volume can be increased by gradually adding 50 ml for each feeding, subject to normal patient tolerance, until the established daily feeding volume is achieved. The remainder in the stomach should not exceed 100 ml 2 hours after feeding. If the volume increases, the next feeding should be delayed and the remaining amount in the stomach should be measured after 1 hour. Continuous gastric infusion begins with the introduction of a nutrient mixture diluted by half at a rate of 25-50 ml/hour. As tolerated by the patient, the infusion rate and concentration of the nutritional mixture are increased to meet the necessary energy needs. The head of the bed of patients should be raised during feeding.
Complications with enteral feeding.
1. Diarrhea.
2. Gastric distension or gastric retention.
3. Aspiration.
4. Electrolyte imbalance (hyponatremia, hyperosmolarity).
5. Overload.
6. Warfarin resistance.
7. Sinusitis.
8. Esophagitis.
One-component nutritional solutions of proteins, carbohydrates and fats can be combined to create mixtures designed to solve specific problems, for example, high-energy, low protein and sodium for malnourished patients with cirrhosis, ascites and encephalopathy.
Parenteral nutrition. In cases where the patient cannot eat normally or his condition worsens, it is necessary to use partial or complete parenteral nutrition. Indications for total parenteral nutrition (TPN): 1) patients with malnutrition who are unable to eat or digest food normally; 2) patients with regional enteritis, when it is necessary to relieve the intestines; 3) patients with satisfactory nutritional status who require 10-14 days of abstinence from oral food intake; 4) patients with a prolonged coma when feeding through a tube is impossible; 5) to provide nutritional support to patients with increased catabolism caused by sepsis; 6) patients receiving chemotherapy that interferes with the natural way of eating; 7) for prophylactic purposes in patients with severe malnutrition before upcoming surgery.
In principle, PPP should provide an intake of 140-170 kJ (30-40 kcal) per 1 kg of body weight, while the amount of fluid administered should be 0.3 ml/kJ (1.2 ml/kcal) per day. To this amount should be added volumes equivalent to losses due to diarrhea, through the stoma, during suctioning through a nasogastric tube and drainage of the fistula.
In patients with oliguria, the basal amount of fluid infused should be 750-1000 ml, to which is added a volume equivalent to urine output and other losses. In the presence of edema, sodium administration is limited to 20-40 mmol/day. A positive nitrogen balance is usually achieved by introducing 0.5-1.0 g of amino acids per 1 kg of body weight per day along with the infusion of non-protein energy components. The maximum protein-saving effect of carbohydrates and fats occurs on a diet of 230-250 kJ (55-60 kcal) per 1 kg per day of ideal body weight. To provide sufficient non-protein caloric nutrition, carbohydrates and fats are introduced along with amino acids using a Y-shaped tee. A mixture in which lipids provide half of the energy needs is close in composition to a normal diet, does not cause either hyperinsulinism or hyperglycemia, and eliminates the need for additional insulin administration. Complications, associated with catheter insertion include: pneumothorax, thrombophlebitis, catheter embolism, hyperglycemia (with infusion hypertonic solution glucose). With prolonged parenteral nutrition, disseminated candidiasis may develop. Hypokalemia, hypomagnesemia and hypophosphatemia may lead to confusion, seizures and coma. If the sodium acetate content in the nutritional mixture is inadequate, hyperchloremic acidosis may develop. Hypoglycemia can occur with sudden cessation of TPN; its genesis is secondary and is caused by a relative excess of endogenous insulin. The infusion rate is gradually reduced over 12 hours, or replacement with a 10% dextrose solution is administered over several hours.
Depending on the method of eating, the following forms of nutrition for patients are distinguished.
active nutrition– the patient eats independently. During active nutrition, the patient sits down at the table if his condition allows.
passive nutrition– the patient eats with the help of a nurse. (feeds the seriously ill nurse with the help of junior medical staff.)
artificial nutrition– feeding the patient with special nutritional mixtures through the mouth or tube (gastric or intestinal) or intravenously drip administration drugs.
Passive nutrition
When patients cannot eat actively, they are prescribed passive nutrition. under strict bed rest, the weakened and seriously ill, and, if necessary, elderly and senile patients, are assisted in feeding by a nurse. during passive feeding, you should lift the patient's head with the pillow with one hand, and with the other, bring a sippy cup with liquid food or a spoon with food to his mouth. The patient should be fed in small portions, always leaving the patient time to chew and swallow; You should drink it using a sippy cup or from a glass using a special straw. Depending on the nature of the disease, the ratio of proteins, fats, and carbohydrates may change. It is mandatory to drink 1.5-2 liters of water per day. Regularity of meals with a three-hour break is important. The patient's body needs a varied and nutritious diet. all restrictions (diet) must be reasonable and justified.
Artificial nutrition
Artificial nutrition refers to the introduction of food (nutrients) into the patient’s body enterally (Greek entera - intestines), i.e. through the gastrointestinal tract, and parenterally (Greek para - near, entera - intestines) - bypassing the gastrointestinal tract. main indications for artificial nutrition.
Damage to the tongue, pharynx, larynx, esophagus: swelling, traumatic injury, wound, tumor, burns, scar changes, etc.
Swallowing disorder: after appropriate surgery, in case of brain damage - cerebrovascular accident, botulism, traumatic brain injury, etc.
Diseases of the stomach with its obstruction.
Coma. mental illness(refusal of food).
Terminal stage cachexia.
Procedure to complete:
1. Check the premises
2. Treat the patient’s hands (wash or wipe with a damp, warm towel)
3. Place a clean napkin on the patient’s neck and chest
4. Place dishes with warm food on the bedside table (table)
5. Give the patient a comfortable position (sitting or half-sitting).
6. Choose a position that is comfortable for both the patient and the nurse (for example, if the patient has a fracture or acute disorder cerebral circulation).
7. Feed small portions of food, be sure to leave the patient time to chew and swallow.
8. Give the patient something to drink using a sippy cup or from a glass using a special straw.
9. Remove the dishes, napkin (apron), help the patient rinse his mouth, wash (wipe) his hands.
10. Place the patient in the starting position. Tube feeding of patients
Enteral nutrition is a type of nutritional therapy used when it is impossible to adequately provide the body’s energy and plastic needs in a natural way. wherein nutrients administered orally either through a gastric tube or through an intraintestinal tube.
Main indications:
Neoplasms, especially in the head, neck and stomach;
Central nervous system disorders
Radiation and chemotherapy;
Gastrointestinal diseases;
Diseases of the liver and biliary tract;
Meals before and after postoperative periods
Trauma, burns, acute poisoning;
Infectious diseases- botulism, tetanus, etc.;
Mental disorders- anorexia nervosa, severe depression
II. Individual supplementary nutrition
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Name of chambers (departments) |
Surnames of patients |
Food |
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Ward 203 |
Zverev I.I. |
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Head of department ________________ Diet sister _________________
Senior nurse ___________________ Verified
Reception senior nurse
departments __________________
Medical statistician _______________
(for consolidated portion maker)
Types of artificial nutrition.
When normal feeding of the patient naturally (through the mouth) is impossible or difficult (certain diseases of the oral cavity, esophagus, stomach) - food is introduced into the stomach or intestines (rarely) artificially.
Artificial nutrition can be done:
Using a tube inserted through the mouth or nose, or through a gastrostomy tube.
Administer nutrient solutions using an enema (after a cleansing enema).
Administer nutrient solutions parenterally (intravenously).
REMEMBER!
With artificial nutrition, the daily calorie content of food is about 2000 calories, the ratio of proteins - fats - carbohydrates is 1: 1: 4.
The patient receives water in the form of water-salt solutions on average 2 liters per day.
Vitamins are added to food mixtures or administered parenterally.
Indications for the use of artificial nutrition:
Difficulty swallowing.
Narrowing or obstruction of the esophagus.
Pyloric stenosis.
Postoperative period (after surgery on the esophagus and gastrointestinal tract).
Uncontrollable vomiting.
Large fluid losses.
Unconscious state.
Psychosis with refusal to eat.
Basic nutrient mixtures and solutions.
Nutritional formula recipes:
Liquid nutritional mixture: 200 – 250 ml water + 250 g milk powder + 200 g crackers + 4 – 6 g salt.
Spasokukotsky's mixture: 400 ml of warm milk + 2 raw eggs + 50 g of sugar + 40 ml of alcohol + a little salt.
Water-salt solutions:
The concentration of salts in them is the same as in human blood plasma.
The simplest solution of water-salt 0.85% isotonic sodium chloride
Ringer-Locke solution: NaCl – 9 g + KC – 0.2 g + CaCl – 0.2 g + HCO 3 – 0.2 g + glucose – 1 g + water – 1000 ml.
Planning the necessary care for the patient when problems related to feeding arise.
Conduct an initial assessment of the patient's response to feeding (including artificial feeding).
Provide psychological support to the patient using methods of explanation, persuasion, and conversation, so that the patient can maintain his dignity.
Help the patient cope with his feelings, give him the opportunity to express his feelings and emotions about feeding.
Ensure that there is informed consent for feeding the patient.
Organize feeding, prepare everything necessary.
Provide assistance during meals.
Strive to maintain a comfortable and safe feeding environment.
Organize training for the patient and his relatives, if necessary, provide information about the rules of nutrition and feeding.
Assess the patient's response to feeding.
Monitor the patient after feeding.
Feeding the patient through a gastric tube inserted into the mouth or nose (nasogastric).
Lungs are used as artificial feeding tubes thin tubes:
a) plastic
b) rubber
c) silicone
Their diameter is 3 – 5 – 8 mm, length 100 – 115 cm, at the blind end there are two lateral oval holes, and at a distance of 45, 55, 65 cm from the blind end there are marks that serve as a guide for determining the length of probe insertion.
Feeding the patient through a nasogastric tube using a funnel.
Equipment:
nutrient mixture (t 38 0 – 40 0 C)
boiled water 100 ml
thin rubber probe with a diameter of 0.5 - 0.8 cm
towel
napkins
clean gloves
Tell the patient what he will be fed (after agreement with the doctor).
Warn him 15 minutes in advance. about the upcoming meal.
Ventilate the room.
Help the patient assume a high Fowler's position.
Wash your hands, put on gloves.
Treat the probe with Vaseline.
Insert a nasogastric tube through the lower nasal passage to a depth of 15–18 cm.
Using a gloved finger of your left hand, determine the position of the probe in the nasopharynx and press it against the back wall of the pharynx so that it does not fall into the trachea.
Tilt the patient's head slightly forward and right hand move the probe up to middle third esophagus.
ATTENTION! If air does not come out of the probe during exhalation and the patient’s voice is preserved, then the probe is in the esophagus.
Connect the free end of the probe to the funnel.
Slowly fill the funnel, located obliquely at the level of the patient’s stomach, with a nutritional mixture (tea, fruit drink, raw eggs, still mineral water, broth, cream, etc.).
Slowly raise the funnel 1 m above the level of the patient's stomach, keeping it straight.
As soon as the nutrient mixture reaches the mouth of the funnel, lower the funnel to the level of the patient’s stomach and clamp the probe.
Repeat the procedure using the entire prepared amount of the nutrient mixture.
Pour 50 – 100 ml into the funnel boiled water to wash the probe.
Disconnect the funnel from the probe and close its distal end with a plug.
Attach the probe to the patient's clothing with a safety pin.
Help the patient find a comfortable position.
Wash the hands.
Feeding the patient through a nasogastric tube using a Janet syringe.
Equipment:
Janet syringe with a capacity of 300 ml
syringe 50 ml
phonendoscope
nutrient mixture (t 38 0 – 40 0 C)
warm boiled water 100 ml
Place the patient in the Fowler's position.
Ventilate the room.
Heat the nutrient mixture in a water bath to 38 0 – 40 0 C.
Wash your hands (you can wear gloves).
Insert a nasogastric tube (if it is not already inserted).
Draw the nutrient mixture (prescribed amount) into the Janet syringe.
Place a clamp on the distal end of the probe.
Connect the syringe to the probe, raising it 50 cm above the patient’s torso so that the piston handle is directed upward.
Remove the clamp from the distal end of the probe and provide a gradual flow of the nutritional mixture. If it is difficult to pass the mixture, use the syringe plunger, moving it down.
REMEMBER! 300 ml of nutritional mixture should be administered within 10 minutes!
After emptying the syringe, clamp the probe with a clamp (to prevent food from leaking out).
Above the tray, disconnect the syringe from the probe.
Attach a 50 ml Janet syringe with boiled water to the probe.
Remove the clamp and wash the probe under pressure.
Disconnect the syringe and close the distal end of the probe with a plug.
Attach the probe to the patient's clothing with a safety pin.
Help the patient find a comfortable position.
Wash your hands (remove gloves).
Make a record of the feeding.
Feeding the patient using a tube inserted into the stomach through a gastrostomy tube.
Prescribed for obstruction of the esophagus and stenosis (narrowing) of the pylorus. In these cases, a funnel is attached to the free end of the probe, through which initially small portions (50 ml) 6 times a day heated liquid food is introduced into the stomach. Gradually the volume of food introduced is increased up to 250 – 500 ml, and the number of feedings reduced to 4 times.
Sometimes the patient is allowed to chew the food on his own, then it is diluted in a glass with liquid, and the diluted form is poured into a funnel. With this feeding option, reflex stimulation of gastric secretion is maintained. Feeding through a gastrostomy tube is used both in hospital and at home. In the latter case, you need to teach relatives the technique of feeding and rinsing the tube.
Feeding through a gastrostomy tube.
Equipment:
funnel (Zhanet syringe)
food container
boiled water 100 ml
Wipe down the bedside table.
Tell the patient what he will be fed.
Ventilate the room.
Wash your hands (it is better if the patient sees this), you can put on gloves.
Place the cooked food on the bedside table.
Assist the patient into the Fowler's position.
Unfasten the probe from clothing. Remove the clamp (plug) from the probe. Attach the funnel to the probe.
ATTENTION! It is advisable to start feeding with tea (water) to free the tube from mucus and food accumulated between feedings.
Pour the prepared food into the funnel in small portions.
Rinse the probe with warm boiled water through a Janet syringe (50 ml) or directly through a funnel.
Disconnect the funnel, close the probe with a plug (clamp it with a clamp).
Make sure the patient feels comfortable.
Wash the hands.
Useful practical advice.
After use, rinse the probe in a rinsing container with one of disinfectant solutions, then soak in another container with a disinfectant solution for at least 60 minutes, then rinse the probe with running water and boil in distilled water for 30 minutes from the moment it boils. To prevent sterile probes from drying out and cracking, they are stored in a 1% solution boric acid, but before use, rinse again with water.
After feeding the patient through a tube inserted through the nose or gastrostomy tube, the patient should be left in a reclining position for at least 30 minutes.
When washing a patient who has a probe inserted through the nose, use only a towel (mitten) moistened with warm water. Do not use cotton wool or gauze pads for this purpose.
For the patient’s convenience, the outer end of the nasogastric tube can be secured (tied) on his head so that it does not interfere with him (the tube can not be removed during the entire period of artificial feeding, about 2 - 3 weeks).
You can check the correct position of the nasogastric tube in the stomach:
Place a clamp on the distal end of the probe above the tray (to prevent the contents of the stomach from leaking out);
remove the plug from the probe;
draw 30 - 40 ml of air into the syringe;
attach the syringe to the distal end of the probe;
remove the clamp;
put on a phonendoscope and place its membrane on the stomach area;
Inject air from a syringe through the probe and listen for sounds in the stomach (if there are no sounds, you need to tighten and move the probe).
Parenteral nutrition.
Prescribed to patients with obstruction of the digestive tract, when normal nutrition is impossible (tumor), as well as after operations on the esophagus, stomach, intestines, etc., as well as in exhaustion, weakened patients in preparation for surgery. For this purpose, preparations containing products of protein hydrolysis are used - amino acids (hydrolysine, casein protein hydrolyzate, fibronosol), as well as artificial mixtures of amino acids (new Alvezin, levamine, polyamine, etc.); fat emulsions (lipofundin, intralipid); 10% glucose solution. In addition, up to 1 liter of electrolyte solutions, B vitamins, and ascorbic acid are administered.
Parenteral nutrition products administered intravenously by drip. Before administration, they are heated in a water bath to body temperature (37–38 0 C). It is necessary to strictly observe the rate of administration of drugs: hydrolysine, casein protein hydrolysate, fibronosol, polyamine in the first 30 minutes. administered at a rate of 10–20 drops per minute, and then, if well tolerated, the rate of administration is increased to 40–60.
Polyamine in the first 30 min. administered at a rate of 10–20 drops per minute, and then 25–35 drops per minute. Faster administration is impractical, since excess amino acids are not absorbed and are excreted in the urine.
With faster administration of protein preparations, the patient may experience sensations of heat, facial flushing, and difficulty breathing.
LipofundinS(10% solution) is administered in the first 10 - 15 minutes at a rate of 15 - 20 drops per minute, and then gradually (over 30 minutes) the rate of administration is increased to 60 drops per minute. Administration of 500 ml of the drug should last approximately 3–5 hours.
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Methodological recommendations for self-training of cadets and students in the discipline “Physical Training” Krasnodar
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In therapeutic nutrition for many diseases, especially gastric diseases, fractional nutrition in small portions is used. In response to minor irritation, a diseased stomach secretes more digestive juices than in response to heavy load. Sometimes, for example, during fever, it becomes necessary to introduce food not at the usual time, but when the patient feels better and is able to eat, even at night. In this case, meals are carried out in fractions, mainly with liquid and semi-liquid food that does not contain coarse plant fiber, so as to spend as little energy as possible on digestion and not disturb his rest. Ready-made food, prepared no more than 1 hour before shipment, is delivered to distribution and buffets in thermoses, pre-washed well with boiling water, as well as containers with tight-fitting lids. Sauces, fats, prepared foods, bread and semi-finished products are transported in special containers. The terms and conditions of storage and sale of prepared food must be strictly observed.
20. Types of nutrition. Artificial nutrition
Artificial nutrition refers to the introduction of food into the patient’s body.
enterally
Main indications for artificial nutrition.
Damage to the tongue, pharynx, larynx, esophagus: swelling, traumatic injury, wound, tumor, burns, scar changes, etc.
Swallowing disorder: after appropriate surgery, in case of brain damage -
disruption of cerebral circulation, botulism, traumatic brain injury, etc.
Diseases of the stomach with its obstruction.
Coma.
Mental illness (food refusal).
Terminal stage of cachexia.
Enteral nutrition– a type of intravital therapy used when it is impossible to adequately provide the energy and plastic needs of the body in a natural way. In this case, nutrients are administered orally either through a gastric tube or through an intraintestinal tube.
Parenteral nutrition(feeding) is carried out by intravenous drip
administration of drugs. The administration technique is similar to intravenous administration of drugs.
Depending on the method of eating, the following forms of nutrition for patients are distinguished.
Active nutrition - the patient eats independently.
Passive nutrition - the patient eats with the help of a nurse. (Cha-
The sick are fed by a nurse with the help of junior medical staff.)
Artificial nutrition – feeding the patient with special nutritional mixtures
through the mouth or tube (gastric or intestinal) or by intravenous drip
drugs.
21.Feeding the patient through a gastrostomy tube.
If a patient has an obstruction of the esophagus (tumors, scars, wounds), then, to save his life, a gastrostomy tube is placed on his stomach, through which the patient is fed. necessary:
prepare dishes with warm liquid and semi-liquid food;
seat the patient;
remove the napkin covering the inlet hole from the rubber tube and the clamp from the tube;
insert a glass funnel into the hole in the tube, lift it up, tilt it slightly to prevent the possibility of food leaking out of the stomach;
pour the nutritional composition or food chewed by the patient into the funnel;
after the food mixture leaves the funnel, pour tea or rosehip infusion into it to rinse the tube and prevent rotting of food debris in it;
remove the funnel and place it in a special container with a disinfectant solution;
Place a sterile napkin and a clamp on the end of the rubber tube, which should be secured with a loop of bandage so that the tube does not come out of the stoma. Any crushed substances can be poured through the funnel nutrients, diluted with liquid. You can add finely pureed meat, deboned fish, milk, bread, crackers. Patients can chew food themselves, collect it in a mug and give it to the sister for subsequent insertion through a gastrostomy tube. In this case, the food chewed by the patient should be diluted with the required amount of liquid.
