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