M.J. Bailey

Feeding Adult Patients

M.J. Bailey

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

1. 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 Patterns

2. 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 Patterns

3. 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 Patterns

4. 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 Patterns

5. 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 Patterns

6. 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 Patterns

7. 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 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 300mg/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 eatingExhibits multiple attempts @ swallowingc/o food getting stuck in throatPoor lip & tongue control

M.J. Bailey

Feeding the patient with dysphagia

Safety – choking/ aspirationSymptoms 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 firstWash handsPrepare roommid-to-high fowlersDenturesBib/napkinPrepare tray/food

M.J. Bailey

Procedure for Feeding

Relaxed paceSmall bites/spoonfulsRocking motion of utensil on tongueMaintain 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 termGastrostomy= 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 orderEnsure correct tube placementPurpose

– Nutrition for clients with impaired swallowing, unconscious, or inability to ingest food

M.J. Bailey

Nasogastric tube

Small bore tube for tube feedingLarge 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: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

Dry mouthSore mouthThirstFeeling deprived

M.J. Bailey

Do’s and don’ts re tube feeding

Do not hurry/force feeding– Abdominal distention & discomfort

Clean not sterile techniqueFormula @ 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 8hrs. ( check directions)Change tubing q24hrs. Or according to policyCheck tube position q8hrs. And ac feeds/medsClamp b/t feedings30-60 ml water before and after feedings, meds,

residual checks

M.J. Bailey

Procedure for checking tube placement

X-ray- best and most accurateAir insertion and listen with stethoscopeAspirate 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

Stomach is acidic 1-4Intestine is 7 or greaterPleural secretions 6Wait 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 6mls/min

Gravity/ feeding pumpFlush tube well post feedingClamp tube post flushing Intake/outputAvoid 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– H2O as a byproduct of oxidation of foods and

body substances

Total daily intake approximately

2100-2900mls

M.J. Bailey

Fluid Loss

Fluids are lost– Skin– Lungs– Feces– Urine output = majority

Total daily loss = 2100 –2900mls

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

KidneysLungsSkinGI 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 = 1.5L/day in adults or 60 mls/hr– Where Na goes H2O 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 H2O from their skin than adults

M.J. Bailey

Sensible Losses

MeasurableFluid 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

Many illnesses cause changes in the body’s ability to maintain balance.

Require accurate measure In & Out Institution policiesPhysician ordersRN initiatesData for assessmentMonitor patient’s condition

M.J. Bailey

Indications for intake and output

Special medications ( diuretics)Post-op patientsI/V therapyIndwelling cathetersFeeding tubesLow oral intakeIntake =output in 48-72hr. 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 ExcessSame time each daySame scale Same clothingFluid 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

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 fluidsIrrigating fluids that are not returned

M.J. Bailey

Output items

UrineDiarrheaProfuse diaphoresisVomitDrainage from suction devicesWound drainageBleeding

M.J. Bailey

Measurement

Wear glovesUrine 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

H2O – the indispensable nutrient60% total adult body weight 70-80% total infant body weightBody 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 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 cellsRemoving wastes from cellsHomeostasis- 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 > intracellularBody fluids & electrolytes shift from

compartment to 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 balanceCells

– 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 compartment to facilitate body processes such as acid/ base balance.

K+ most abundant intracellular cationNa+ most abundant in extraellular fluidWhere Na+ goes H2O follows Na+ retained K+ excreted

M.J. Bailey

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 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 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 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 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