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Chapter 12Chapter 12

Nutritional Care OrdersNutritional Care Orders

Slide 2Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

ObjectivesObjectivesObjectivesObjectives

• Interpret the dietary orders included in Interpret the dietary orders included in this chapter.this chapter.

• Explain the importance of communicating Explain the importance of communicating patient food allergies to the nutritional patient food allergies to the nutritional care department.care department.

• List the diets that provide change in the List the diets that provide change in the consistency of food.consistency of food.

• Identify two diets that may be requested Identify two diets that may be requested by patients.by patients.

• Interpret the dietary orders included in Interpret the dietary orders included in this chapter.this chapter.

• Explain the importance of communicating Explain the importance of communicating patient food allergies to the nutritional patient food allergies to the nutritional care department.care department.

• List the diets that provide change in the List the diets that provide change in the consistency of food.consistency of food.

• Identify two diets that may be requested Identify two diets that may be requested by patients.by patients.

Slide 3Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Objectives, continuedObjectives, continuedObjectives, continuedObjectives, continued

• Identify five therapeutic diets.Identify five therapeutic diets.• List four diets that may be selected List four diets that may be selected

for the patient who is on a for the patient who is on a diet as diet as toleratedtolerated..

• List three types of formula or List three types of formula or preparations used for tube feeding.preparations used for tube feeding.

• Identify five therapeutic diets.Identify five therapeutic diets.• List four diets that may be selected List four diets that may be selected

for the patient who is on a for the patient who is on a diet as diet as toleratedtolerated..

• List three types of formula or List three types of formula or preparations used for tube feeding.preparations used for tube feeding.

Slide 4Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Objectives, continuedObjectives, continuedObjectives, continuedObjectives, continued

• List three methods of administering tube List three methods of administering tube feedings.feedings.

• List three items a health unit coordinator List three items a health unit coordinator may have to order when transcribing an may have to order when transcribing an order for tube feeding.order for tube feeding.

• List three methods of administering tube List three methods of administering tube feedings.feedings.

• List three items a health unit coordinator List three items a health unit coordinator may have to order when transcribing an may have to order when transcribing an order for tube feeding.order for tube feeding.

Slide 5Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 12.1Lesson 12.1

Slide 6Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Communication with the Nutritional Care Communication with the Nutritional Care DepartmentDepartmentCommunication with the Nutritional Care Communication with the Nutritional Care DepartmentDepartment

• The HUC communicates an order for a The HUC communicates an order for a new diet or a change/modification by new diet or a change/modification by computer to the nutritional care computer to the nutritional care department.department.

• If the computer is shut down, the HUC If the computer is shut down, the HUC orders the diet from the nutritional care orders the diet from the nutritional care department by telephone or written department by telephone or written requisition and later enters the diet order requisition and later enters the diet order into the computer to maintain a record. into the computer to maintain a record.

• The patient’s food allergies and The patient’s food allergies and intolerances must be communicated to intolerances must be communicated to the nutritional care department (noted on the nutritional care department (noted on the order). the order).

• The HUC communicates an order for a The HUC communicates an order for a new diet or a change/modification by new diet or a change/modification by computer to the nutritional care computer to the nutritional care department.department.

• If the computer is shut down, the HUC If the computer is shut down, the HUC orders the diet from the nutritional care orders the diet from the nutritional care department by telephone or written department by telephone or written requisition and later enters the diet order requisition and later enters the diet order into the computer to maintain a record. into the computer to maintain a record.

• The patient’s food allergies and The patient’s food allergies and intolerances must be communicated to intolerances must be communicated to the nutritional care department (noted on the nutritional care department (noted on the order). the order).

Slide 7Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

A Nutritional Care Department RequisitionA Nutritional Care Department RequisitionA Nutritional Care Department RequisitionA Nutritional Care Department Requisition

Slide 8Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Communication with the Nutritional Care Communication with the Nutritional Care DepartmentDepartmentCommunication with the Nutritional Care Communication with the Nutritional Care DepartmentDepartment

• With EMR and CPOE, the HUC may With EMR and CPOE, the HUC may have to order equipment from CSDhave to order equipment from CSD

• The HUC may communicate with The HUC may communicate with the nutritional care department the nutritional care department when ordering a diet for a patient when ordering a diet for a patient who had been NPO for a procedure who had been NPO for a procedure or testor test

• With EMR and CPOE, the HUC may With EMR and CPOE, the HUC may have to order equipment from CSDhave to order equipment from CSD

• The HUC may communicate with The HUC may communicate with the nutritional care department the nutritional care department when ordering a diet for a patient when ordering a diet for a patient who had been NPO for a procedure who had been NPO for a procedure or testor test

Slide 9Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Standard or Regular DietsStandard or Regular DietsStandard or Regular DietsStandard or Regular Diets

• Regular: example: steak, baked potatoRegular: example: steak, baked potato• Soft: example: broiled chicken, mashed Soft: example: broiled chicken, mashed

potatoespotatoes• Mechanical soft: example: ground meats, Mechanical soft: example: ground meats,

vegetables chopped or dicedvegetables chopped or diced• Pureed: food is blended in blenderPureed: food is blended in blender• Full liquid: example: creamed soups, Full liquid: example: creamed soups,

puddingspuddings• Clear liquid: example: broth, jello, teaClear liquid: example: broth, jello, tea

• Regular: example: steak, baked potatoRegular: example: steak, baked potato• Soft: example: broiled chicken, mashed Soft: example: broiled chicken, mashed

potatoespotatoes• Mechanical soft: example: ground meats, Mechanical soft: example: ground meats,

vegetables chopped or dicedvegetables chopped or diced• Pureed: food is blended in blenderPureed: food is blended in blender• Full liquid: example: creamed soups, Full liquid: example: creamed soups,

puddingspuddings• Clear liquid: example: broth, jello, teaClear liquid: example: broth, jello, tea

Slide 10Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diet as Tolerated Diet as Tolerated Diet as Tolerated Diet as Tolerated

• When a doctor orders DAT, the HUC When a doctor orders DAT, the HUC would need to ask the nurse caring for would need to ask the nurse caring for the patient, as personnel preparing the the patient, as personnel preparing the tray have no idea what that patient could tray have no idea what that patient could toleratetolerate

• Choices would be consistency (liquid to Choices would be consistency (liquid to solid) diets solid) diets

• Nurse could not modify or restrict Nurse could not modify or restrict nutrients or caloriesnutrients or calories

• An initial consistency is often specifiedAn initial consistency is often specified

• When a doctor orders DAT, the HUC When a doctor orders DAT, the HUC would need to ask the nurse caring for would need to ask the nurse caring for the patient, as personnel preparing the the patient, as personnel preparing the tray have no idea what that patient could tray have no idea what that patient could toleratetolerate

• Choices would be consistency (liquid to Choices would be consistency (liquid to solid) diets solid) diets

• Nurse could not modify or restrict Nurse could not modify or restrict nutrients or caloriesnutrients or calories

• An initial consistency is often specifiedAn initial consistency is often specified

Slide 11Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diet as Tolerated (DAT) Diet ChoicesDiet as Tolerated (DAT) Diet ChoicesDiet as Tolerated (DAT) Diet ChoicesDiet as Tolerated (DAT) Diet Choices

• RegularRegular• SoftSoft• Mechanical softMechanical soft• BlandBland• Full liquidFull liquid• Clear liquidClear liquid

• RegularRegular• SoftSoft• Mechanical softMechanical soft• BlandBland• Full liquidFull liquid• Clear liquidClear liquid

Slide 12Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Patient Requested DietsPatient Requested DietsPatient Requested DietsPatient Requested Diets

• OvolactovegetarianOvolactovegetarian• LactovegetarianLactovegetarian• VeganVegan• FlexitarianFlexitarian• Kosher, and other religious dietary Kosher, and other religious dietary

restrictionsrestrictions

• OvolactovegetarianOvolactovegetarian• LactovegetarianLactovegetarian• VeganVegan• FlexitarianFlexitarian• Kosher, and other religious dietary Kosher, and other religious dietary

restrictionsrestrictions

Slide 13Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Therapeutic or Special Diet OrdersTherapeutic or Special Diet OrdersTherapeutic or Special Diet OrdersTherapeutic or Special Diet Orders

• Need to be ordered specifically by doctorNeed to be ordered specifically by doctor• ExamplesExamples

• Low cholesterolLow cholesterol• Modified fatModified fat• High carbohydrateHigh carbohydrate• Sodium restricted Sodium restricted • High fiberHigh fiber• Low residueLow residue• Potassium restrictedPotassium restricted

• Need to be ordered specifically by doctorNeed to be ordered specifically by doctor• ExamplesExamples

• Low cholesterolLow cholesterol• Modified fatModified fat• High carbohydrateHigh carbohydrate• Sodium restricted Sodium restricted • High fiberHigh fiber• Low residueLow residue• Potassium restrictedPotassium restricted

Slide 14Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Therapeutic or Special Diet OrdersTherapeutic or Special Diet OrdersTherapeutic or Special Diet OrdersTherapeutic or Special Diet Orders

• Need to be ordered specifically by doctorNeed to be ordered specifically by doctor

• ExamplesExamples• 1200 cal ADA1200 cal ADA• Renal dietRenal diet• Cardiac prudent dietCardiac prudent diet• Dysphagia diet (levels I, II, III, IV)Dysphagia diet (levels I, II, III, IV)• BRAT dietBRAT diet

• Need to be ordered specifically by doctorNeed to be ordered specifically by doctor

• ExamplesExamples• 1200 cal ADA1200 cal ADA• Renal dietRenal diet• Cardiac prudent dietCardiac prudent diet• Dysphagia diet (levels I, II, III, IV)Dysphagia diet (levels I, II, III, IV)• BRAT dietBRAT diet

Slide 15Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Tube Feeding OrdersTube Feeding OrdersTube Feeding OrdersTube Feeding Orders

Tube feeding order may require the HUCTube feeding order may require the HUC

to order:to order:• The formulaThe formula• An enteral feeding set with or without An enteral feeding set with or without

pumppump• Chest x-ray to check tube placement Chest x-ray to check tube placement

(would need to be a specific doctor’s (would need to be a specific doctor’s order)order)

Tube feeding order may require the HUCTube feeding order may require the HUC

to order:to order:• The formulaThe formula• An enteral feeding set with or without An enteral feeding set with or without

pumppump• Chest x-ray to check tube placement Chest x-ray to check tube placement

(would need to be a specific doctor’s (would need to be a specific doctor’s order)order)

Slide 16Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

A Nasogastric Feeding TubeA Nasogastric Feeding TubeA Nasogastric Feeding TubeA Nasogastric Feeding Tube

Courtesy of Baxter Travenol laboratories, Inc.

Slide 17Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

A Gastrostomy Feeding A Gastrostomy Feeding A Gastrostomy Feeding A Gastrostomy Feeding

Slide 18Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Administration of Tube FeedingsAdministration of Tube FeedingsAdministration of Tube FeedingsAdministration of Tube Feedings

• Bolus: infusion of a small amount of Bolus: infusion of a small amount of formula over a short timeformula over a short time

• Gravity: formula runs in by gravity by Gravity: formula runs in by gravity by attaching a bag to the nasogastric tubeattaching a bag to the nasogastric tube

• Infusion pump: drip is controlled by the Infusion pump: drip is controlled by the feeding pumpfeeding pump

• Bolus: infusion of a small amount of Bolus: infusion of a small amount of formula over a short timeformula over a short time

• Gravity: formula runs in by gravity by Gravity: formula runs in by gravity by attaching a bag to the nasogastric tubeattaching a bag to the nasogastric tube

• Infusion pump: drip is controlled by the Infusion pump: drip is controlled by the feeding pumpfeeding pump

Slide 19Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Administration of a Bolus through a Administration of a Bolus through a Syringe Syringe Administration of a Bolus through a Administration of a Bolus through a Syringe Syringe

From Potter PA, Perry AG: Fundamentals of Nursing, 6th ed, St. Louis, Mosby, 2005.

Slide 20Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

An Enteral Feeding Pump with Tubing An Enteral Feeding Pump with Tubing for Continuous Feeding for Continuous Feeding An Enteral Feeding Pump with Tubing An Enteral Feeding Pump with Tubing for Continuous Feeding for Continuous Feeding

From Potter PA, Perry AG: Fundamentals of Nursing, 6th ed, St. Louis, Mosby, 2005.

Slide 21Copyright © 2009, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Other Nutritional Care OrdersOther Nutritional Care OrdersOther Nutritional Care OrdersOther Nutritional Care Orders

• The HUC would send any diet-related orders toThe HUC would send any diet-related orders to

nutritional carenutritional care• ExamplesExamples

• All food allergiesAll food allergies• Limit or force fluidsLimit or force fluids• Calorie countCalorie count• Dietary consultDietary consult• NPONPO• Sips and chipsSips and chips

• The HUC would send any diet-related orders toThe HUC would send any diet-related orders to

nutritional carenutritional care• ExamplesExamples

• All food allergiesAll food allergies• Limit or force fluidsLimit or force fluids• Calorie countCalorie count• Dietary consultDietary consult• NPONPO• Sips and chipsSips and chips

From Potter PA, Perry AG: Fundamentals of Nursing, 6th ed, St. Louis, Mosby, 2005.