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Feeding Adult Patients. Nutrition . Nutrition is an important treatment in any illness. Type 2: non-insulin –dependent diabetes. Mellitus (NDDM). Mild hypertension.

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nutrition
Nutrition
  • Nutrition is an important treatment in any illness.
  • Type 2: non-insulin –dependent diabetes.

Mellitus (NDDM).

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

M.J. Bailey

factors influencing dietary patterns1
Factors Influencing Dietary Patterns
  • Culture and religion.
    • Culture, ethnic, and religious patterns and restrictions re food must be considered.
    • Special foods and diets given when appropriate.
    • Older clients more apt to cling to ethnic food habits, esp. During illness.

M.J. Bailey

factors influencing dietary patterns2
Factors Influencing Dietary Patterns
  • Socioeconomic status.
    • Food expenses fluctuate, spending depends on $$ available.
    • Whether someone is around to prepare the food determines the amount of convenience foods used.

M.J. Bailey

factors influencing dietary patterns3
Factors Influencing Dietary Patterns
  • Personal preference
    • Individual likes and dislikes provide the strongest influence on diet
    • Foods associated with pleasant memories become favorite foods/ foods with unpleasant memories are avoided
    • Luxury foods = status
    • Individual preferences used to plan therapeutic diet

M.J. Bailey

factors influencing dietary patterns4
Factors Influencing Dietary Patterns
  • Psychological factors.
    • Individual motivations to eat balanced meals and individual perceptions about diet.
    • Food has strong symbolic value.
      • Milk=helplessness.
      • Meat=strength.

M.J. Bailey

factors influencing dietary patterns5
Factors Influencing Dietary Patterns
  • Alcohol and drugs
    • Excess use contributes to nutritional deficiencies
    • Excess alcohol affects GI organs
    • Drugs that appetite intake of essential nutrients
    • Drugs can deplete nutrient stores and absorption in the intestines

M.J. Bailey

factors influencing dietary patterns6
Factors Influencing Dietary Patterns
  • Misinformation and food fads
    • Food myths can be the result of cultural background, popular interest in natural foods, peer pressure, or desire to control diet choices
    • Fads may involve erroneous beliefs certain foods are esp. Healthy
      • Yogurt better than milk
      • Oysters sexual potency
    • Don’t be condescending when giving nutritional guidance

M.J. Bailey

factors influencing dietary patterns7
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
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 diets1
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 diets2
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 diets3
Types of Diets
  • Sodium Restricted
    • Low levels of sodium = NO SALT
    • CHF, Renal failure, cirrhosis, hypertension
  • Low Cholesterol
    • Cholesterol intake 300mg/day
    • Fat intake 30–35%
    • Eliminate/reduce fatty foods

M.J. Bailey

types of diets4
Types of Diets
  • Diabetic
    • Exchange list of foods
    • Imp. For Type I and Type II

M.J. Bailey

slide16
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
Terms re Feeding
  • Dysphagia- difficulty swallowing
    • Most common causeof aspiration in adults during feeding
  • Aspiration- the inhalation of foreign substance into the lungs
    • stroke

M.J. Bailey

suspect dysphagia when client
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
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
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 feeding1
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
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
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
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 tube1
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
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
Tube feeding schedule
  • Continuous
    • Over 24 hrs
  • Cyclic
    • Prescribed period ( ie:16hrs)
  • 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
Problems with tube feeding
  • Dry mouth
  • Sore mouth
  • Thirst
  • Feeling deprived

M.J. Bailey

do s and don ts re tube feeding
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 feeding1
Do’s and don’ts re tube feeding
  • Formula can hang for 8hrs. ( check directions)
  • Change tubing q24hrs. Or according to policy
  • Check tube position q8hrs. 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
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 50mls ) Note -any gastric contents should be returned to the stomach so the chemical balance is not disturbed.
    • Check pH of aspirate with pH paper

M.J. Bailey

aspirate ph
Aspirate pH
  • 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
Position for tube feeding
  • Fowlers before and after
    • Prevents aspiration
  • Regulate the flow of the feeding 6mls/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
Fluid Intake and Output
  • 3 main sources of fluids and electrolytes
    • Fluids ingested in liquids
    • Food that is eaten
    • H2O as a byproduct of oxidation of foods and body substances

Total daily intake approximately

2100-2900mls

M.J. Bailey

fluid loss
Fluid Loss
  • Fluids are lost
    • Skin
    • Lungs
    • Feces
    • Urine output = majority
  • Total daily loss = 2100 –2900mls

M.J. Bailey

regulation of body fluids
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 fluids1
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
Fluid Output
  • Kidneys
  • Lungs
  • Skin
  • GI tract

M.J. Bailey

kidneys
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 = 1.5L/day in adults or 60 mls/hr
    • Where Na goes H2O follows

M.J. Bailey

insensible losses
Insensible Losses
  • Immeasurable
    • Evaporation through the skin
      • Affected by humidity
    • Lungs
      • Respiratory rate and depth
    • Fever
      • Loss through skin & lungs
  • Infants lose more H2O from their skin than adults

M.J. Bailey

sensible losses
Sensible Losses
  • Measurable
  • Fluid losses from
    • Urination
    • Defecation
    • Wounds
    • Vomiting
  • Normally GI losses 100mls/day
  • In cases of severe diarrhea , losses may exceed 5,000ml/day

M.J. Bailey

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

M.J. Bailey

indications for intake and output1
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
Daily Weights
  • Deficient or Excess
  • Same time each day
  • Same scale
  • Same clothing

Fluid retention can be detected early b/c 5-10lbs of fluid is retained before edema appears.

5 lbs fluid= approx. 2.5 L fluid volume

M.J. Bailey

intake items include
Intake Items include
  • Items that are liquid at room temperature
    • H2O, 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
Output items
  • Urine
  • Diarrhea
  • Profuse diaphoresis
  • Vomit
  • Drainage from suction devices
  • Wound drainage
  • Bleeding

M.J. Bailey

measurement
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

measurement1
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
Fluids and Electrolyte Balance
  • H2O – the indispensable nutrient
  • 60% total adult body weight
  • 70-80% total infant body weight
  • Body Fluids
    • H2O and dissolved substances
      • H2O major constituent of the body
      • H2O = Solvent in which substances are dissolved or suspended

M.J. Bailey

fluids and electrolyte balance1
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
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
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 balance2
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 compartment to maintain Homeostasis

M.J. Bailey

fluids and electrolyte balance3
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 balance4
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 balance5
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 balance6
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 balance7
Fluids and Electrolyte Balance
  • Body fluids are not stagnant – fluids and electrolytes shift from compartment to compartment to facilitate body processes such as acid/ base balance.
  • K+ most abundant intracellular cation
  • Na+ most abundant in extraellular fluid
  • Where Na+ goes H2O follows
  • Na+ retained K+ excreted

M.J. Bailey

variables affecting fluid and electrolyte balance
Variables Affecting Fluid and Electrolyte Balance
  • Age
    • Infants
      • have more H2O
      • Greater risk for loss
      • Kidneys immature – not able to concentrate urine
    • Elderly
      • Less body H2O
      • Decreased renal function- not able to concentrate urine
  • Body size
    • Fat does not contain H2O
    • body H2O in females b/c more fat deposits in breasts and hips , obese have body H2O

M.J. Bailey

fluids and electrolyte balance8
Fluids and Electrolyte Balance
  • Environmental Temperature –
    • temperature sweating fluid loss = loss of Na+ and Cl- ions.
  • 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 H2O losses

M.J. Bailey

fluids and electrolyte balance9
Fluids and Electrolyte Balance
  • Fluid Disturbances
    • Fluid Volume Deficit -H2O 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 balance10
Fluids and Electrolyte Balance
  • Fluid Volume Excess
    • H2O and Na+ are retained = Hypervolemia with unchanged levels of electrolytes
    • At Risk
      • Renal failure
      • CHF

M.J. Bailey

fluids and electrolyte balance11
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