Chapter 14 – Nutrition Intervention and Diet-Drug Interactions

Chapter Outline Instructor Resources

I. Implementing Nutrition Care• Nurses can identify nutritional problems• Nursing care plans can include nursing diagnoses that suggest need for nutrition

interventionA. Care Planning

1. Assessment of nutrition2. Diagnosis of nutrition-related problems3. Identifying expected outcomes4. Implementing interventions

B. Approaches to Nutrition Care1. Long-Term Nutrition Intervention

a. Determine readiness for changeb. Emphasize what to eat, rather than what not to eatc. Suggest only 1-2 changes at a time

2. Nutrition Education - Should be tailored to:a. Person’s ageb. Level of literacyc. Cultural backgroundd. Learning style

3. Follow-Up Carea. Compare relevant outcome measures with initial assessmentb. Assess if care plan needs revision or updating

II. Dietary ModificationsA. Introduction

1. Regular diet2. Altered consistency or texture3. Altered nutrient content4. Including or eliminating foods

B. Energy Intakes in Hospital Patients1. RMR2. Stress factors3. Activity level4. Assessment of RMR using indirect calorimetry5. Energy requirement may be significantly higher than normal in critical-care

patients6. Bedridden and inactive patients have decreased overall energy needs

C. Modified Diets1. Mechanically Altered Diets - Dysphagia

a. Pureedb. Softc. Ground/minced

2. Blenderized Liquid Diet - Oral, facial surgeries, chewing problems3. Clear Liquid Diet

a. First foodsb. Little residue

4. Fat-Restricted Diet - Fat malabsorption problems5. Low-Fiber Diet

a. Acute intestinal disordersb. Before surgery

6. Low-Sodium Dieta. Prevent or correct fluid retentionb. Treatment of hypertension, CHF, kidney disease, & liver disease

7. High-kCalorie, High-Protein Dieta. Eating poorlyb. High nutrient requirements; > 35% of kcal from fatsc. Small, frequent meals & commercial liquid supplements

D. Variations in the Diet Order1. Physician prescribes the diet order2. Consults with dietitian & nurse3. Order must be precise4. Diet Progression - Diet progression as patient adapts to foods5. Nothing by Mouth (NPO)6. Alternative Feeding Routes

a. Tube feedings1. Gastric or intestinal2. Preferred over IV3. Need functioning GI tract

b. Parenteral nutrition1. Malnourished2. Non-functioning GI tract

III. FoodserviceA. Introduction

1. Complex system2. Use diet manual

B. Food Selection1. Selective menus2. Room-service, cook to order system

C. Food Safety - HACCP1. Food handling2. Cooking3. Food storage4. Cleaning/disinfecting5. Staff sanitation

D. Improving Food Intake1. Pleasant and calm environment2. Identify patient’s favorite foods3. Arrange food & utensils attractively4. Help patient wash up before the meal5. How to Help Hospital Patients Improve Their Food Intakes

IV. Diet-Drug InteractionsA. Introduction

1. Medications can:a. Alter food intakeb. Increase appetite & weight gain c. Alter absorption, metabolism, & excretion of nutrients d. Become toxic when they interact with food

2. Nutrients can: Alter absorption, metabolism, & excretion of medications3. Some interactions can be toxic

B. Drug Effects on Food Intake1. Suppress appetite2. Dry the mouth3. Alter taste sensations

4. Cause inflammation & lesions in the mouth5. Induce nausea & vomiting6. Sedate the patient7. Unintentional weight gain

C. Drug Effects on Nutrient Absorption1. Drug-Nutrient Binding

a. Bile acid bindersb. Some antibiotics

2. Altered Stomach Acidity - Affects vitamin B12, folate, & iron3. Direct Inhibition - Interferes with intestinal absorption or transport to mucosal

cells D. Dietary Effects on Drug Absorption

1. Stomach-Emptying Ratea. Meals delay absorptionb. Empty stomach enhances absorption

2. Stomach Aciditya. Some drugs need an acidic environmentb. Others may need enteric coating

3. Interactions with Dietary Components - Some foods can bind to drugs and decrease absorptiona. Phytates b. Calcium and some antibiotics

E. Drug Effects on Nutrient Metabolism1. Drugs & nutrients share similar enzyme systems in small intestine & liver2. Some drugs may enhance or inhibit the activities of these enzymes

F. Dietary Effects on Drug Metabolism1. Grapefruit juice - Increases blood concentrations of some drugs2. Vitamin K-rich foods - Can weaken the effect of blood thinners3. Herbs that enhance blood thinners: St. John’s wort, ginkgo, garlic, ginseng, dong

quai, danshen, others G. Drug Effects on Nutrient Excretion

1. Some medications may:a. Alter mineral reabsorption in the kidneysb. Cause an increase or decrease in urinary losses

2. Problems with: a. Multiple drugs with same effectb. Impaired kidney functionc. Long-term use of medications

H. Dietary Effects on Drug Excretion1. Inadequate excretion of medications can cause toxicity2. Excessive losses of medications can reduce the therapeutic effect3. Urine acidity can affect drug excretion

I. Drug-Nutrient Interactions and Toxicity1. Example:

a. Tyramine in foodsb. MAO inhibitorsc. Interactions can be fatal

2. Serious side effects are increasingly being recognized

V. Nutrition in Practice - Complementary and Alternative Therapies• Complementary therapies are used with conventional medicine• Alternative therapies are used instead of conventional medicine and have not been

scientifically validatedA. How popular is CAM in the U.S.?

1. Nearly 40% of adults in U.S. use some form

2. Most prevalent among people with chronic, debilitating illness3. 1998 - National Center for Complementary and Alternative Medicine established

B. Why should mainstream health professionals learn more about CAM? - In order to better communicate with patients regarding their care

C. What kinds of practices are considered CAM therapies? - Any and all therapies that are not normally part of conventional medicine

D. In what ways do alternative medical systems differ from conventional medicine? - Alternative medical systems:1. Naturopathic2. Homeopathic3. Traditional Chinese medicine

E. What is the theory underlying mind-body interventions? - They attempt to improve a person’s sense of psychological or spiritual well-being.1. Biofeedback2. Meditation3. Art & music therapy4. Prayer 5. Guided imagery6. Faith healing

F. What are some examples of biologically based therapies?1. Dietary supplements2. Herb and plant extracts3. Special foods

G. How effective are herbal remedies in the treatment of disease? - Benefits of their use are uncertain.

H. How safe are the herbal products that are available in the marketplace?1. Many have toxic effects2. Most common are diarrhea, nausea & vomiting3. Chaparral, kava, & comfrey - Liver damage4. Yohimbe - Hypertension, arrrhythmias, high blood pressure, & seizures5. Some herbal supplements are contaminated

I. Is there any risk that herbs may interact with medications like other dietary substances do? - Yes; they can intensify or interfere with effects of other herbs or medications.

J. Aside from herbal products, have other types of dietary supplements been found to be effective therapies? - Efficacy and safety of dietary supplements are uncertain.1. Hormones2. Glucosamine-chondroitin supplements

K. Is there any evidence supporting the use of various foods or supplements to cleanse or detoxify the body? - No

L. Which alternative practices involve physical manipulation, and how do they work?1. Includes:

a. Physical touchb. Forceful movement of body partsc. Application of pressure

2. Chiropractic - Adjustment of the spine to restore healing3. Massage - Manipulation of muscle & connective tissue

M. What are the alleged effects of “energy” therapies?1. Biofield therapies2. Bioelectrical or bioelectromagnetic therapies3. Acupuncture4. Qi gong5. Therapeutic touch

N. Do conventional health practitioners consider CAM treatments to be safe & effective? - Generally CAM treatments are excluded from mainstream medical practice.

O. Are any potential dangers associated with the use of CAM? - Yes:1. Toxicity2. Permanent disability or death3. May delay use of reliable treatment

P. What should health care professionals do if they think their patients are using CAM? - Patients should be told about potential interactions between conventional treatments and CAM therapies.