Nutrition

Every patient must have a diet order written in the chart within 8 hours of admission.

Oral Diets
Modified Consistencies
Indicated for patients with problems chewing and/or swallowing
All diets are of a regular consistency unless otherwise specified (i.e. mechanical soft or puree)
Modified consistency liquids ordered as needed per swallow evaluation recommendations
Speech Pathologists/Dysphagia Team are available for bedside swallow evaluations and modified barium swallow studies (MBSS)
Disease Specific Modifications (liberalize restrictions for patients with poor oral intake)

Coronary Artery Disease:
Sodium: 3-4gm Na
Total/saturated fat and cholesterol: order Low Fat, Low Cholesterol

Congestive Heart Failure:
Sodium: 2 gm Na restriction
Fluid: 1.5-2.0 L fluid restriction

Diabetes:
Carbohydrate controlled diet

Renal Failure:
Sodium (based on urine output, edema, and fluid status)
Potassium (based on K⁺ (with corrected acidosis) levels and renal function)
Phosphorus (only in face of calciphylaxis; if phos elevated should be on phosphorus binder)
Protein (restrict only if severely uremic/pre-dialysis)
Fluid (restriction based on urine output, edema and fluid status)

Liver Failure:
Sodium (2 gm or 3-4 gm based on severity of ascites and fluid retention)
Fluid (only if progressive ascites and/or hyponatremia)
Protein (only if encephalopathic)
Nutritional Supplements (order these for patients with poor oral intake or poor nutritional status)
Boost (general; lactose free) OR Carnation Instant Breakfast (general; milk-containing)
Nepro (Renal failure/Dialysis)
Suplena (Renal failure/Pre-dialysis)
Glucerna (Diabetic)
Can order "Snack TID" and patient can choose

Enteral Nutrition (see enteral feeding order form) "If the gut works, use it!"
Consult dietitian for assessment prior to initiation of enteral feeds and for assistance with management of feeding as needed. See Nutrition notes in Essentris for diet recommendations.
Specify route of administration (type of tube) on order form.
Available enteral formulas summarized on order form

Aspiration precautions: head of bed elevated at least 30 degrees, blue coloring added to feeds

Parenteral Nutrition (see TPN order form and UCLA Enteral/Parenteral Handbook)
Consult dietitian for nutritional assessment prior to initiating PPN/TPN.
Indications
Bowel obstruction and unable to feed distal to obstruction, bowel ischemia/necrotic bowel, true small bowel ileus, malabsorption, enteral feeding intolerance/high gastric residuals with failure of jejunal feedings, intractable vomiting
Peripheral Parenteral Nutrition (PPN)

Incomplete nutritional needs: short term use 5-7 days.
Can be administered via peripheral line, with standard concentration of D₁₀ and 3.5% AA plus Intralipid
Intralipid 20% (soybean oil based), 2 kcal/ml (available in 100 ml, 250 ml, and 500 ml)
Total Parenteral Nutrition (TPN)
Longer term use >1 week to months.
Must have central line access, standard concentration D₂₅, 4.25% AA or D₂₈ 6% AA
Intralipid 20% (soybean oil based), 2 kcal/ml (available in 100 ml, 250 ml, and 500 ml)

Approved Diet Orders For Westwood, Santa Monica, and RNPH UCLA Medical Centers
Diet Order Name	Diet Purpose/Indication
NPO, NPO except meds, NPO except sips NPO except ice chips	No food sent to patient, nothing by mouth
Clear Liquid$	Fluids, electrolytes and energy in a form that requires minimal digestion/stimulation of GI tract
Bariatric Clear Liquid	Broth and juice only in measured quantities for after bariatric surgery (WW ONLY)
Blenderized Liquid	To provide food in a liquid form for patients who are unable to chew, swallow or tolerate solid foods
Mechanical Soft	Cut up, soft, moist and easy to chew and swallow foods for chewing or swallowing problems.
Ground	To provide moist, soft and ground up foods for chewing or swallowing problems (SMH ONLY)
Low Fiber	Low fiber, esophageal soft, previously known as GI Soft.
Puree	To provide thick, smooth, homogeneous, semi-liquid textures for severely reduced swallowing ability
Kosher	To provide foods for patients observing Jewish dietary laws and the practice known as kashrut
Regular	To provide food appropriate for adults, with no restrictions
Pediatric	To provide foods appropriate for pediatric age patients
Pediatric 3 gram Sodium	To provide age appropriate foods with a 3000 mg sodium restriction.
Pediatric Renal	To provide age appropriate food for pediatric patients that are lower in potassium, sodium and phosphorous.
2 gram Sodium	To limit sodium provided to tissues to prevent accumulation of fluid in a 2000 mg Na restriction
Low Potassium	To achieve normal potassium levels in patient at risk for hyperkalemia with a 3000 mg K+ restriction
Low Bacteria	To eliminate foods that may be contaminated with bacteria for patients undergoing chemotherapy or BMT
Carbohydrate Controlled	To provide a consistent amount of carbohydrate to achieve blood glucose control
Low Fat	To provide foods lower in saturated and trans fats for patients with heart disease
No Red Meat	To limit the amount of aromatic amino acids for patients with hepatic encephalopathy
Low Lactose	To provide foods that contain minimal amounts of lactose for patients with lactose intolerance
Gluten Free	To provide adequate energy for patients unable to tolerate gluten
Low Iodine	To deplete the body of iodine for radioiodine scan
Gestational DM	Different calorie levels: 1800, 2000, 2200 and 2500 calories per day for pregnancy
Ketogenic	To induce and maintain a state of ketosis for an antiepileptic effect (WW ONLY)
Metabolic Diet	To provide moderate carbohydrate and low fat options (NPH ONLY)
No caffeine	Restricts main sources of caffeine from diet: no coffee, no black tea.
Thickened Liquids	Options: Nectar, honey or pudding thickened liquids
Fluid Restrictions	Options for Adults and Pediatrics: 1000 ml, 1200 ml, 1500 ml, 1800 ml, 2000 ml fluid restriction levels Options for Pediatrics: 500 ml, 550 ml, 600 ml, 650 ml, 700 ml, 750 ml, 800 ml, 850 ml, 900 ml, 950 ml
$No diabetic clear liquid tray: The American Dietetic Association recommends that "patients requiring a clear liquid diet should receive approximately 200 grams of carbohydrates per day in equally divided amounts, at meals and snack times. Liquids should not be sugar free. Patients require carbohydrates and calories, and sugar free liquids do not meet these needs. Diabetes medications may need to be adjusted to achieve and maintain metabolic control." Diet orders no longer accepted: advance diet as tolerated (ADAT), resume diet, ADA, Diabetic, Renal, Cardiac, CCU, 1 gm Na, Liver diet, No Salt, No Concentrated Sweets, No fat, Soft and Full Liquid.