09.05 Specialty Diets (Nutrition)

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Hi, guys. Today, we will be discussing specialty diets, also known as diet orders. The diet can be used as a form of management for some diseases. Because of this, hospitals have a number of specialty diets that can be prescribed for a patient while they are in the hospital. "Human beings do not eat nutrients. They eat food." I think this is super important to keep in mind as we work with patients to help them make good food choices within their diet.

What to know about diet orders ... We are going to go over a bunch of diet orders today, and this is what you need to know about each one. First, what is it? Second, when is it used? Third, what you can eat. For each diet order, I will give you the definition, the indication, and a food list.
Here we go. The first, and possibly most common or most important, is the order NPO, which is nothing by mouth or [foreign language] in Latin. Indications include surgery, swallowing problems, also known as dysphagia, and gastrointestinal patients, for example, pancreatitis. NPO refers to food, liquid, and medication. It's very important to understand the reason for NPO since it can mean different things. Let's look at a couple examples.

Example one, a patient has had a barium swallow evaluation and has been found to be aspirating food and liquid, which means parts of their meals are actually going into their lungs instead of their esophagus. The patient is then placed on NPO, and they are not allowed liquid, food, or medications by mouth. In this case, NPO is really only talking about what goes past the swallow reflex. The next day, the patient may be placed on two feeds and fed directly into the stomach while still being NPO.

Another example is a patient that has surgery scheduled on their hip in the morning. The night before surgery, the diet order will say, "NPO after midnight." What this means is that the patient's stomach needs to be empty for surgery. In this case, something like two feeds would need to be put on hold, as well. PO medications would need to be held, unless specified by the doctor. In some cases, when a patient is NPO, they can have ice chips or certain medications, but in general, assume they can't, unless specified by the doctor in the diet order. For example, NPO, ice chips okay, et cetera.

Our second diet order is clear liquids. This is commonly used as an intermediary between a patient that is NPO and a full liquid or regular diet. It's also used for patients with GI issues, GI surgeries, and patients that are unable to tolerate PO or oral intake, for example, a patient that is vomiting and can't keep food down. After a patient is tolerating clear liquids, they may be progressed to a full liquid diet and monitored for tolerance. Full liquid is an all liquid diet, but now, foods don't have to be transparent. The biggest thing here is the full liquid diet allows for dairy, which has protein and fat. The clear liquid diet is almost exclusively carbohydrate.

Our next diet order can go by different names. I've seen it called the soft diet, the low fiber, the low residue, or a combination of those. It's generally thought of as a diet low in fiber, which reduces the amount of residue that would go from the small intestines into the large intestines. It is good for patients with chewing problems, as well, and it's often used for gastrointestinal patients.

High fiber diets can be used to help with bowel regularity. Certain types of fiber can help add bulk to the stool for diarrhea, and fiber can help with regularity for patients that are constipated.

The next two diet orders are for patients with dysphagia or swallowing problems. Of all the diets I have seen, these tend to change the most from hospital to hospital. If you want to be very well-versed in the dysphagia diets in your hospital, make sure that you get to know your speech therapists. They will evaluate patients and recommend a diet based on what the patient is able to chew and swallow.

The pureed diet requires blending or mashing and then passing the food through a sieve to remove any enlarged pieces. It has to be completely uniform.

The mechanical soft diet often comes in two forms. One is ground, which requires grinding food to small size, and the second is chopped, which is slightly bigger pieces, food chopped to uniform shape and size. Grind, use as a food processor. Chop, cut with a knife. Typically, mechanical soft diets avoid raw fruits and vegetables, hard crusty breads, nuts, and seeds. Meats are ground, chopped, or gravies are added, or more tender cuts are used, et cetera.

Carbohydrate consistent, this is the diet order used for patients that are having issues with blood sugar. There are typically a few levels, low, medium, high, which should be prescribed based on the size of the patient. They are based on a calorie range, and then a specific amount of carbohydrate is allotted for each meal. For example, a medium level might allow 45 grams for breakfast, maybe 60 grams for lunch, 60 grams for dinner, and then there are usually a couple 15 to 30 gram snacks allowed throughout the day, as well. This consistency of carbohydrate helps with blood sugar maintenance for a variety of patients. This diet is one of the most commonly used in the hospital, so I think it is worth taking a minute to review the foods that are high in carbohydrates, as you will need to feel comfortable with this information.

Foods that are high, anything that is sweet has had extra sugar added to it, for example, desserts, candy, et cetera, all fruit, all dairy, except cheese, all bread-type foods, this includes tortillas, pancakes, biscuits, beans, sorry, beans, starchy vegetables, which most are actually low carb or non-starchy vegetables, but there are a few that are the starchy ones, and I'll list them here, potatoes, corn, peas, and then squash, winter squash, specifically, so pumpkin, butternut, acorn. Those are foods that are high in carbohydrate.

Now I'll list a couple of foods that are low. It's important to know your low carb foods. If your patient is hungry, but has already met their carb amount for that meal, you can recommend some of these. Meat, vegetables, almost everything except for those high carb ones, cheese, eggs, nuts, seeds are all great low carb options.

High protein diets are used commonly for patients that require more protein for healing. It is also used for dialysis patients. The process of dialysis unintentionally filters out some protein during the process that needs to be replaced. Meat and dairy are the highest sources of protein in the diet, but beans, nuts, and seeds are also good sources.

Now the renal diet. Typically, I see this diet with normal amounts of protein, not high or low, because different renal patients need different amounts of protein. What is restricted is sodium, potassium, and phosphorus. I've listed, for reference, some of the highest foods in potassium and phosphorus, and then sodium is its own diet order, so I'll cover those foods below.

The low sodium diet is also one of the most common diet orders in the hospital. It's prescribed often and is a part of the renal diet, as mentioned, and the cardiac diet, as well. Restriction can range from 500 milligrams up to 4,000 milligrams. I see probably a 2 gram or 2,000 milligram as the most common. You'll likely need to know some basic sodium sources. Most foods naturally contain very little sodium. Meats, dairy, and vegetables naturally contain some, but not in large quantities. So the more processed the food is, the more salt that has been added. It's used as a preservative. Typically, we recommend finding lower sodium options for things like canned food, sauces, dressings, pickled foods, lunch meats, salty snack foods, and pre-made or boxed meals.

The cardiac diet is, both low in fat and sodium, as mentioned, and limiting sodium can help improve blood pressure. Limiting fat can help improve blood cholesterol. A low fat diet might be ordered for a patient that has high cholesterol, but another common use is pancreatitis. The pancreas makes digestive enzymes and fat stimulates the pancreas. After a pancreatitis patient has tried and tolerating an NPO diet and then the clear liquid diet, they will often progress to a low fat.

A lot of heart patients are on a medication called Coumadin. That helps to thin the blood. When patients start this medication, their blood is tested to make sure that PT and INR, which check for clotting, are within therapeutic limits. The dose is adjusted until the lab values are at that desired level. Well, unfortunately, vitamin K counteracts the effects of Coumadin, as it plays a role in blood clotting. You'll see this diet and the medication a lot. The important thing is that a patient keeps their intake consistent, similar number of servings of vitamin K day-to-day. Here are some of the top vitamin K sources, the dark green leafy vegetables, anything in the cabbage group, for example, broccoli, Brussels sprouts, cauliflower.

Here are just a couple other dietary things to consider. If a patient has a food allergy, hospitals will accommodate to make sure meals don't have eggs, or dairy, or gluten, et cetera. Celiac disease falls into this category. It is an allergy to the protein in meat. A lot of diet preferences can be accommodated by hospital food service. They are not usually prescribed, just requested by the patient, things like Kosher, vegan, et cetera.

Lastly, let's talk about liquid. Fluid restrictions may be ordered for patients that are having fluid retention, typically with heart failure or renal patients. I've seen a one liter and a two liter fluid restriction most commonly. I really want to emphasize the importance here of counting every milliliter that the patient consumes. You will usually have them drink one glass at a time and let you know how much they've had. This may also be in conjunction with monitoring the Os, or the patient's urine output.

Thickened liquids ... Thickened liquids are used for patients with dysphagia, which is a swallowing disorder. Some patients get liquid in their lungs when they drink, and thickening the liquids can stop this from happening. The two consistencies are nectar thick and honey thick. The consistency is actually what they sound like, if you can picture nectar and honey. Some liquids naturally will have the right consistency for the order, where other liquids will need to have a commercial thickener added to make sure it's right for the patient. Patients that are on a pureed and thickened liquid diet may need their pureed food to be drained or thickened, as some pureed foods have water that separates out and could be aspirated.
The diet order is a very important piece of the overall treatment of a patient. It is an order, just like a medication, and in some cases, the diet can change the effectiveness of other treatments. For example, vitamin K and medication Coumadin. Patients ultimately control what they eat. Even if on a specific diet order, we often see family members bringing food in. If you can provide some insight for them as to why they can't drink thin liquids, for example, then they will be more likely to continue when we aren't there.

Lastly, your hospital will likely have a set of handouts for your facility. Make sure you know where they are and review the most common ones, vitamin K, cardiac, consistent carbohydrate. Each facility is a little different, but if you take a spare moment to look at those, you can reinforce what the patient will be taught.
You are on an amazing path of helping care for the world. Go out and be your best self today, and as always, happy nursing.
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