Feeding Adult Patients M J Bailey Nutrition Nutrition

Feeding Adult Patients M. J. Bailey

Nutrition ¬ Nutrition is an important treatment in any illness. ¬ Type 2: non-insulin –dependent diabetes. Mellitus (NDDM). v Mild hypertension. Proper intake of food is essential for optimal health during illness & healing of wounds. The body needs nutrients at these times. M. J. Bailey

Factors Influencing Dietary Patterns 1. Health status Ø A good appetite is a sign of health Ø Anorexia is usually a sign of disease or side effect of drugs Ø Nutritional support is an essential part of recovery from medical treatment M. J. Bailey

Factors Influencing Dietary Patterns 2. Culture and religion. Ø Culture, ethnic, and religious patterns and restrictions re food must be considered. Ø Special foods and diets given when appropriate. Ø Older clients more apt to cling to ethnic food habits, esp. During illness. M. J. Bailey

Factors Influencing Dietary Patterns 3. Socioeconomic status. Ø Food expenses fluctuate, spending depends on $$ available. Ø Whether someone is around to prepare the food determines the amount of convenience foods used. M. J. Bailey

Factors Influencing Dietary Patterns 4. Personal preference Ø Individual likes and dislikes provide the strongest influence on diet Ø Foods associated with pleasant memories become favorite foods/ foods with unpleasant memories are avoided Ø Luxury foods = status Ø Individual preferences used to plan therapeutic diet M. J. Bailey

Factors Influencing Dietary Patterns 5. Psychological factors. Ø Individual motivations to eat balanced meals and individual perceptions about diet. Ø Food has strong symbolic value. § § Milk=helplessness. Meat=strength. M. J. Bailey

Factors Influencing Dietary Patterns 6. Alcohol and drugs Ø Excess use contributes to nutritional deficiencies Ø Excess alcohol affects GI organs Ø Drugs that appetite intake of essential nutrients Ø Drugs can deplete nutrient stores and absorption in the intestines M. J. Bailey

Factors Influencing Dietary Patterns 7. Misinformation and food fads Ø Food myths can be the result of cultural background, popular interest in natural foods, peer pressure, or desire to control diet choices Ø Fads may involve erroneous beliefs certain foods are esp. Healthy Ø Yogurt better than milk Ø Oysters sexual potency Ø Don’t be condescending when giving nutritional guidance M. J. Bailey

Factors Influencing Dietary Patterns ¬Physical Problems – Teeth – Loss of neuromuscular control – Poor state of health ¬Psychological Problems – High point of day – Very degrading M. J. Bailey

Types of Diets ¬ Regular- (full/house/DAT) – Allows client selection ¬ Clear Liquid- clear, bland ie: broth, gelatin, apple juice (little residue, easily absorbed) ¬ Full Liquid –foods that liquify at room or body temperature. Easily digested & absorbed. – Milk+ creamed, strained soups – Pre & post-op patients – Those who can’t chew or tolerate solids M. J. Bailey

Types of Diets ¬Pureed- easily swallowed foods, no chewing ¬Mechanical or Dental Soft- foods don’t need chewing, avoid tough meats & fruits with tough skins • Chewing problems • Lack of teeth • Sore gums M. J. Bailey

Types of Diets ¬Soft- low in fiber, easily digested easy to chew and simply cooked. No fatty, rich or fried foods (Low Fiber Diet) ¬High Fiber- Sufficient amt. of indigestible carbohydrates to : – relieve constipation – GI motility – stool weight M. J. Bailey

Types of Diets ¬Sodium Restricted – Low levels of sodium = NO SALT – CHF, Renal failure, cirrhosis, hypertension ¬Low Cholesterol – Cholesterol intake 300 mg/day – Fat intake 30– 35% – Eliminate/reduce fatty foods M. J. Bailey

Types of Diets ¬Diabetic – Exchange list of foods – Imp. For Type I and Type II M. J. Bailey

¬Adults usually eat independently but may need to be fed in the presence of physical or cognitive limitations. – Neurological – Neuromuscular – Orthopedic problems ¬Loss of control & independence can lead to psychological problems and depression. M. J. Bailey

Terms re Feeding ¬Dysphagia- difficulty swallowing – Most common cause of aspiration in adults during feeding ¬Aspiration- the inhalation of foreign substance into the lungs – stroke M. J. Bailey

Suspect Dysphagia when client ¬Coughs/ gags during eating ¬Exhibits multiple attempts @ swallowing ¬c/o food getting stuck in throat ¬Poor lip & tongue control M. J. Bailey

Feeding the patient with dysphagia ¬Safety – choking/ aspiration ¬Symptoms of dysphagia – Coughing, choking, drooling, spilling food ( pocketing) – Provide food that stimulates swallowing – Don’t feed too quickly – Thickened foods easier to swallow M. J. Bailey

Procedure for Feeding ¬Bedpan/washroom first ¬Wash hands ¬Prepare room ¬mid-to-high fowlers ¬Dentures ¬Bib/napkin ¬Prepare tray/food M. J. Bailey

Procedure for Feeding ¬Relaxed pace ¬Small bites/spoonfuls ¬Rocking motion of utensil on tongue ¬Maintain sitting 15 -30 min. pc. M. J. Bailey

Indications for Enteral Feeding ¬ Clients unable to eat – ie: comatose with functional GI system – Ventilated patients – Post-op oral, head or neck surgery ¬ Clients who will not eat – Older adults – Confused clients ¬ Unable to maintain adequate oral nutrition – Cancer, sepsis, infection, trauma, head injury M. J. Bailey

Intubation ¬ Placemnt of a tube into the stomach or intestine through the mouth, nasopharynx, (Nasogastric/Levine), or through an artificial opening made in the abdominal wall of the stomach (gastrostomy) or small intestine (jejunostomy) ¬ Nasogastric= short term ¬ Gastrostomy= long term, surgically inserted directly into the stomach(gastrostomy) or small intestine (jejunostomy) M. J. Bailey

Nasogastric tube ¬Through nose into stomach (infants through the mouth, nostrils too small) ¬Only with a physician’s order ¬Ensure correct tube placement ¬Purpose – Nutrition for clients with impaired swallowing, unconscious, or inability to ingest food M. J. Bailey

Nasogastric tube ¬ Small bore tube for tube feeding ¬ Large bore tube for stomach decompression and irrigation Formulas for tube feedings commercially prepared , provide complete nutritional balance and some do not require any digestion Imp. If necessary to rest the bowel ie: Crohn’s Disease M. J. Bailey

Tube Feedings ¬ Additional water post: – Feedings – Medications – Prescribed times ¬ Medications – Liquid/ dissolved – No enteric coated or time released capsules – Do not mix meds with formula. Give meds. prior to formula M. J. Bailey

Tube feeding schedule ¬Continuous – Over 24 hrs ¬Cyclic – Prescribed period ( ie: 16 hrs) ¬Bolus – Prescribed volume over 30 -60 min. 4 -6 X/day. – Physician orders frequency, amount, & type of feeding M. J. Bailey

Problems with tube feeding ¬Dry mouth ¬Sore mouth ¬Thirst ¬Feeling deprived M. J. Bailey

Do’s and don’ts re tube feeding ¬Do not hurry/force feeding – Abdominal distention & discomfort ¬Clean not sterile technique ¬Formula @ room temp. – Warm= bacterial growth – Cold= gastric cramping & discomfort, liquid is not warmed by the mouth and esophagus M. J. Bailey

Do’s and don’ts re tube feeding ¬ Formula can hang for 8 hrs. ( check directions) ¬ Change tubing q 24 hrs. Or according to policy ¬ Check tube position q 8 hrs. And ac feeds/meds ¬ Clamp b/t feedings ¬ 30 -60 ml water before and after feedings, meds, residual checks M. J. Bailey

Procedure for checking tube placement ¬X-ray- best and most accurate ¬Air insertion and listen with stethoscope ¬Aspirate gastric contents – Determines tube placement and checks for digestion of previous feeding ( should be less than 50 mls ) Note -any gastric contents should be returned to the stomach so the chemical balance is not disturbed. – Check p. H of aspirate with p. H paper M. J. Bailey

Aspirate p. H ¬Stomach is acidic 1 -4 ¬Intestine is 7 or greater ¬Pleural secretions 6 ¬Wait at least 1 hr after feedings to check Feeding is not given if no bowel sounds are heard, abdomen is distended, too much residual, or tube dislodged M. J. Bailey

Position for tube feeding ¬ Fowlers before and after – Prevents aspiration ¬ Regulate the flow of the feeding 6 mls/min ¬ Gravity/ feeding pump ¬ Flush tube well post feeding ¬ Clamp tube post flushing ¬ Intake/output Avoid introducing air into tubing M. J. Bailey

Fluid Intake and Output ¬ 3 main sources of fluids and electrolytes – Fluids ingested in liquids – Food that is eaten – H 2 O as a byproduct of oxidation of foods and body substances Total daily intake approximately 2100 -2900 mls M. J. Bailey

Fluid Loss ¬Fluids are lost – Skin – Lungs – Feces – Urine output = majority ¬Total daily loss = 2100 – 2900 mls M. J. Bailey

Regulation of Body Fluids ¬Fluid Intake primarily regulated by: – Thirst mechanism in hypothalamus ¬The thirst mechanism is affected by: – plasma osmolality – plasma volume – Dry mucus membranes – Other factors M. J. Bailey

Regulation of Body Fluids ¬Those at risk for dehydration include: – Infants – Elderly – Neurologically impaired – Psychologically impaired ¬Must be conscious and alert M. J. Bailey

Fluid Output ¬Kidneys ¬Lungs ¬Skin ¬GI tract M. J. Bailey

Kidneys ¬Major regulators fluid balance – blood flow to kidneys urinary output – Amount of urine produced influenced by ADH & aldosterone (stimulated by changes in blood volume) – Urine output = 1. 5 L/day in adults or 60 mls/hr – Where Na goes H 2 O follows M. J. Bailey

Insensible Losses ¬ Immeasurable – Evaporation through the skin • Affected by humidity – Lungs • Respiratory rate and depth – Fever • Loss through skin & lungs ¬ Infants lose more H 2 O from their skin than adults M. J. Bailey

Sensible Losses ¬ Measurable ¬ Fluid losses from – – Urination Defecation Wounds Vomiting ¬ Normally GI losses 100 mls/day ¬ In cases of severe diarrhea , losses may exceed 5, 000 ml/day M. J. Bailey

Intake and Output Measurement ¬ Many illnesses cause changes in the body’s ability to maintain balance. ¬ Require accurate measure In & Out ¬ Institution policies ¬ Physician orders ¬ RN initiates ¬ Data for assessment ¬ Monitor patient’s condition M. J. Bailey

Indications for intake and output ¬Special medications ( diuretics) ¬Post-op patients ¬I/V therapy ¬Indwelling catheters ¬Feeding tubes ¬Low oral intake ¬Intake =output in 48 -72 hr. period M. J. Bailey

Indications for intake and output ¬Risk for Fluid Volume Deficit – Intake < output ¬Risk for Fluid Volume Excess – Intake > output Urine output < 30 mls/hr x 2 consecutive hrs. indicates renal disease or dehydration M. J. Bailey

Daily Weights ¬Deficient or Excess ¬Same time each day ¬Same scale ¬Same clothing Fluid retention can be detected early b/c 510 lbs of fluid is retained before edema appears. 5 lbs fluid= approx. 2. 5 L fluid volume M. J. Bailey

Intake Items include ¬Items that are liquid at room temperature – H 2 O, milk, juice, beverages, ice cream, jello, liquid part of soup ¬Tube feedings ( not pureed foods, considered solids) ¬I/V fluids ¬Irrigating fluids that are not returned M. J. Bailey

Output items ¬Urine ¬Diarrhea ¬Profuse diaphoresis ¬Vomit ¬Drainage from suction devices ¬Wound drainage ¬Bleeding M. J. Bailey

Measurement ¬Wear gloves ¬Urine output – Mexican hat for females – Urinal for males – Mls. or cc’s – Infants, weigh diaper, subtract wt. of dry diaper from wt. of wet diaper. Count # of wet diapers. Be cautious of weight of stool. M. J. Bailey

Measurement ¬Patient participation – Instructions – Explanation – Equipment – Recording • Bedside record- individual items • Permanent record- totals for time frame designated by institutional policy. Kept on chart. M. J. Bailey

Fluids and Electrolyte Balance ¬H 2 O – the indispensable nutrient ¬ 60% total adult body weight ¬ 70 -80% total infant body weight ¬Body Fluids – H 2 O and dissolved substances • H 2 O major constituent of the body • H 2 O = Solvent in which substances are dissolved or suspended M. J. Bailey

Fluids and Electrolyte Balance ¬Solutes = substances dissolved in a solution – Electrolytes: Na, K, Cl – Minerals – Glucose – Urea – Bilirubin M. J. Bailey

Functions of the Fluid System ¬Transportation of Nutrients to cells ¬Removing wastes from cells ¬Homeostasis- maintaining a stable physical & chemical environment in the body M. J. Bailey

Body Fluid Distribution ¬ 2 Basic Compartments – Intracellular- inside the cells, must be balanced with extracellular – Extracellular- outside the cells, further divided into • Interstitial fluid in the spaces b/t cells • Intravascular or plasma- liquid portion of blood, watery, colorless fluid portion in which blood cells are suspended ¬ Hint: Inter= between ¬ Intra= within/ inside M. J. Bailey

Fluids and Electrolyte Balance ¬Many solutes in the intracellular fluid compartment are the same as those located in the extracellular fluid space. However the proportion of the substances is different ¬ie: K > intracellular ¬Body fluids & electrolytes shift from compartment to maintain Homeostasis M. J. Bailey

Fluids and Electrolyte Balance ¬ Homeostasis maintained by: – Diffusion- solutes from areas to concentrations across semipermeable membrane until = • Remember in diffusion solutes move – Osmosis- passive movement of fluid from areas with more fluid and fewer solutes to areas with less fluid and more solutes across a membrane • Remember in osmosis fluid moves – Active transport • ATP( adenosine triphosphate) pushes against concentration gradient • Solutes from concentration to concentration M. J. Bailey

Fluids and Electrolyte Balance – Filtration-removing particles from a solution by allowing the liquid portion to pass through a membrane ( ex. Nephron of the kidney) ¬All body fluids contain similar substances although concentration may vary: – Electrolytes – Minerals – Cells M. J. Bailey

Fluids and Electrolyte Balance ¬ Electrolytes – – – Substances which dissolve in solution Split into charged ions Conduct an electrical current + charged = cations( Na+, K+, Ca+) - charged = anions ( Cl-) Vital for body functioning • Neuromuscular • Acid/base balance M. J. Bailey

Fluids and Electrolyte Balance ¬Minerals – Ingested – Catalysts in nerve response, muscle contraction, regulating electrolyte balance ¬Cells – Basic units of all living tissue – RBC’s, WBC’s – Within body fluids M. J. Bailey

Fluids and Electrolyte Balance ¬Body fluids are not stagnant – fluids and electrolytes shift from compartment to facilitate body processes such as acid/ base balance. ¬K+ most abundant intracellular cation ¬Na+ most abundant in extraellular fluid ¬Where Na+ goes H 2 O follows ¬Na+ retained K+ excreted M. J. Bailey

Variables Affecting Fluid and Electrolyte Balance ¬ Age – Infants • have more H 2 O • Greater risk for loss • Kidneys immature – not able to concentrate urine – Elderly • Less body H 2 O • Decreased renal function- not able to concentrate urine ¬ Body size – Fat does not contain H 2 O – body H 2 O in females b/c more fat deposits in breasts and hips , obese have. M. J. body H 2 O Bailey

Fluids and Electrolyte Balance ¬ Environmental Temperature – – temperature and Cl- ions. sweating fluid loss = loss of Na+ ¬ Life style – Inadequate diet • • body breaks down glycogen and fat stores. Next destroys protein stores Decrease in serum protein (hypoalbuminemia) Decrease osmotic pressure and fluid shifts from circulating blood to interstitial spaces. – Stress- fluid volume – Exercise- insensible H 2 O losses M. J. Bailey

Fluids and Electrolyte Balance ¬Fluid Disturbances – Fluid Volume Deficit -H 2 O and electrolytes are lost. • At Risk – – Decreased oral intake Vomiting Diarrhea Gastric suction • The very young and very old quickly affected by these losses. M. J. Bailey

Fluids and Electrolyte Balance ¬Fluid Volume Excess – H 2 O and Na+ are retained = Hypervolemia with unchanged levels of electrolytes – At Risk • Renal failure • CHF M. J. Bailey

Fluids and Electrolyte Balance ¬Healthy bodies maintain a very precise fluid, electrolyte and acid-base balance. ¬Factors that can disturb balance – Insufficient intake – GI and Kidney function disturbances – Excessive perspiration or evaporation – Volume losses M. J. Bailey