Nutrition and Fluid Balance

Transcription

1 90 14 Nutrition and Fluid Balance 1. Define important words in this chapter 2. Describe common nutritional problems of the elderly and the chronically ill 3. Describe cultural factors that influence food preferences 4. Identify six basic nutrients 5. Explain the USDA s MyPlate 6. Explain the role of the dietary department 7. Explain the importance of following diet orders and identify special diets 8. Explain thickened liquids and identify three basic thickening consistencies 9. List ways to identify and prevent unintended weight loss 10. Describe how to make dining enjoyable for residents 11. Describe how to serve meal trays and assist with eating 12. Describe how to assist residents with special needs 13. Discuss dysphagia and list guidelines for preventing aspiration 14. Describe intake and output (I&O) 15. List ways to identify and prevent dehydration 16. List signs and symptoms of fluid overload and describe conditions that may require fluid restrictions Supplemental Tools transparency 14-1 myplate transparency 14-2 preventing aspiration transparency 14-3 conversion table handout 14-1 simple math chapter 14: exam Assignments textbook reading, pp workbook exercises, pp Overview of Teaching Strategies Good nutrition is important for all human beings. It is imperative that the students in this course learn the basics about good nutrition, the purpose of nutrients, and the sources of essential vitamins and minerals. The USDA s MyPlate, just released in June of 2011, is explained, and the students should have an opportunity in class to apply the food groups to their own lives as well as to examples of special types of diets that are included in this chapter. It is a good idea for the students to share their cultural or religious preferences so that others get a feel for differences they may encounter. An emphasis here on respect for all differences is important. Emphasize the importance of fluid balance, and as an experiment have the students actually drink eight glasses of water in one day and keep track of it in a log as they would for a resident. Emphasize signs of dehydration and remind students how serious dehydration and unintended weight loss are. They should be able to recognize signs and report them immediately. 1. Define important words in this chapter textbook pp workbook p. 79

2 91 Pronounce and define each of the key terms listed in the Learning Objective on pages Describe common nutritional problems of the elderly and the chronically ill textbook p. 243 workbook p. 79 Pronounce and define the following key term: Nutrition Review problems that can affect nutrition: Less saliva Side effects from medication Decrease in activity and mobility Weakened sense of smell and taste Loss of vision Dentures, tooth loss, or poor dental health Depression and lack of interaction Special diets that restrict foods Discuss conditions that make it more difficult to eat or swallow: Stroke Cancer Parkinson s disease Multiple sclerosis Alzheimer s disease 3. Describe cultural factors that influence food preferences textbook pp workbook pp Pronounce and define the following terms: Fasting Vegetarians Vegans and Discussion Discuss the following points: Know and honor residents food preferences. Report requests for diet substitutions immediately. Encourage students to discuss their own regional, cultural, or religious food preferences. 4. Identify six basic nutrients textbook pp workbook p. 80 Pronounce and define the following key terms: Nutrient Metabolism Discuss the following six basic nutrients: Water Water is the most essential nutrient for life. Water helps with digestion and absorption of food. It helps to maintain normal body temperature. Fats Good source of energy Add flavor to food Fall into four categories: saturated, trans fat, monounsaturated, and polyunsaturated Saturated and trans fats can increase cholesterol levels and the risk of some diseases, like cardiovascular disease. Monounsaturated and polyunsaturated fats can be helpful in the diet, and can decrease the risk of cardiovascular disease and type 2 diabetes. Carbohydrates Provide fuel for energy Provide fiber Protein Essential for tissue growth and repair Provides a supply of energy Vitamins Vitamins are essential to body functions.

3 92 Fat-soluble vitamins are A, D, E, and K. Water-soluble vitamins are B and C. Minerals Minerals form and maintain body functions Examples of minerals include: zinc, iron, calcium, and magnesium 5. Explain the USDA s MyPlate textbook pp workbook pp Display Transparency 14-1 myplate Referring to Figure 14-7 (p. 245 in textbook), discuss the following points about food groups and MyPlate: Vegetables and fruits Make half your plate fruits and vegetables. Dark green, red, and orange vegetables have the best nutritional content. Vegetables are low in fat, calories, and have no cholesterol. Vegetables provide fiber and vitamins. Fruits are low in fat, sodium, calories, and have no cholesterol. Fruits provide vitamins and fiber. Grains At least half of all grains consumed should be whole grains. Whole grains contain bran and germ, as well as the endosperm. Refined grains retain only the endosperm. Grains are found in cereal, bread, rice, and pasta. Proteins Meat, poultry, seafood, and eggs are animal sources of proteins. Beans, peas, soy products, nuts, and seeds are plant sources of proteins. Eat seafood twice a week in place of meat or poultry. Choose lean meat and poultry. Include eggs and egg whites on a regular basis. Eat plant-based protein foods more often. Some nuts and seeds (flax, walnuts) are excellent sources of essential fatty acids. Dairy Provide protein, vitamins, and minerals Includes all of the foods made from milk that retain their calcium content, such as yogurt and cheese Most dairy group choices should be fat-free or low-fat (1%). Choose fat-free or low-fat milk or yogurt more often than cheese. Soy products enriched with calcium are an alternative to dairy foods. Review additional tips for making healthy food choices include the following: Balance calories. Enjoy your food, but eat less. Avoid oversized portions. Foods to eat more often are vegetables, fruits, whole grains, and fat-free or 1% milk and low-fat dairy products. Foods to eat less often are foods high in solid fats, added sugars, and salt. These foods include fatty meats, like bacon and hot dogs, cheese, fried foods, ice cream, and cookies. Compare sodium in foods. Select canned foods that are labeled sodium free, very low sodium, low sodium, or reduced sodium. Drink water instead of sugary drinks. 6. Explain the role of the dietary department textbook p. 248 workbook pp Pronounce and define the following key term: Diet cards Discuss that the dietary department has a responsibility to meet residents different nutritional needs and to take into account likes and dislikes. Responsibilities also include making sure residents can manage the food they re eating and that it looks

4 93 appealing. Infection prevention measures must be strictly followed. 7. Explain the importance of following diet orders and identify special diets textbook pp workbook pp Pronounce and define the following key terms: Special diet Puree Lactose intolerance Diuretics Intake Input Glucose Describe the differences in the following special diets: Liquid diets Soft diet and mechanical soft diet Pureed diet Bland diet Lactose-free diet High-residue or high-fiber diet Low-residue or low-fiber diet Modified calorie diets Low-sodium diet High-protein diet Low-protein diet Low-fat/low-cholesterol diet High-potassium diet Fluid-restricted diets Diabetic diet Gluten-free diet Vegetarian diets (lacto-ovo, lacto, ovo, vegan) Point out that residents who are NPO should not be offered drinks (even water) or snacks. Discussion Encourage students to share their own diets with the class. Some may be Jewish and can tell others what they eat and special restrictions. Some may be vegetarians and can discuss what types of food they eat. Others may be diabetics and will be familiar with the exchange lists. Group Exercise Ask each student to choose a special diet from the above list and give a one-minute report to the rest of the class, including an example of a one day/ three meals menu plan. The food choices should be made based on the foods allowed and the foods the student prefers. The other students could ask the presenter questions about certain foods and whether they are allowed on that special diet. For example: Can you eat salt on your special diet? Can you eat chips on your special diet? What do you eat in restaurants? 8. Explain thickened liquids and identify three basic thickening consistencies textbook p. 252 workbook p. 83 Discuss thickened liquids: Thickening improves the ability to control fluid in the mouth and throat. A doctor orders the necessary thickness. Some beverages arrive already thickened. NAs cannot offer regular liquids, including water, to residents who must have thickened liquids. Define the three basic thickened consistencies: Nectar thick Honey thick Pudding thick 9. List ways to identify and prevent unintended weight loss textbook pp workbook p. 83 Pronounce and define the following key term: Apathy

5 94 Emphasize that NAs must report any weight loss, no matter how small. Discuss the problem of unintended weight loss. Review the signs and symptoms of unintended weight loss to report, including: Needing help eating or drinking Eating less than 70% of meals/snacks Having mouth pain Having dentures that do not fit properly Having difficulty chewing or swallowing Coughing or choking while eating Being sad or withdrawing from others Being confused, wandering, or pacing Review the signs of malnourishment: Feeling of coldness throughout body Weight loss Abdominal distention Abdominal pain Constipation Edema Cracks or splits at the corners of the mouth Inflammation of the mucous membranes of the mouth Dry or peeling skin Brittle, easily-cracked nails Rapidly thinning hair that breaks off easily; hair that changes or loses color Frequent infections Muscle weakness Fainting Fatigue Withdrawal or apathy Anxiety and irritability Problems with sleeping Low body temperature Slow pulse Low blood pressure Discuss the following guidelines for preventing unintended weight loss: Report warning signs immediately. Report any decrease in appetite. Talk about eating and food being served in a positive way. Check to make sure proper diet is being served. Respond promptly to complaints about food. Season foods to residents preferences. Use adaptive equipment as needed. Record meal/snack intake. Ask for dietician, OT, or SLP consultation, if necessary. 10. Describe how to make dining enjoyable for residents textbook pp workbook pp Point out that meals are not only a time for getting nourishment but also a time for socialization as well. The NAs must understand how integral they are to residents getting proper nutrition. Review the following guidelines for dining: Follow a routine. Assist with grooming. Encourage use of dentures, glasses, and hearing aids. Give oral care before eating. Assist with handwashing. Offer a trip to the bathroom before eating. Seat residents next to friends. Properly position residents for eating, normally in the upright position. Place residents in appropriate chairs. Serve food at correct temperature. Provide proper eating tools. Cut food when necessary before bringing it to the table. Allow enough time for eating. Keep noise level low. Do not shout or bang plates or cups. Be cheerful, positive, and helpful. Honor requests regarding food. Give additional food when requested.

6 Describe how to serve meal trays and assist with eating textbook pp workbook p. 84 Review the guidelines for serving trays: Wash hands first. Check the diet card for special diet orders, and identify each resident before serving a meal tray. Serve all residents at one table before serving another table. Maintain proper temperature of food. Prepare food, only doing what residents cannot do for themselves. Open milk or juice cartons. Put in straw if resident uses one. Butter roll, bread, and vegetables as resident likes. Offer to season all food as resident likes, including pureed food. Remind students about the following when serving meal trays to residents in isolation: Follow Isolation Precautions, along with Standard Precautions. Apply PPE as needed. Do not share food with anyone. Discuss the following points about assisting residents with eating: Residents will need different levels of help. Prepare residents who require the least assistance first. Some residents will need to be fed. Be sensitive and give privacy. Encourage residents to do what they can. Pay attention to person you re helping. Do not talk to other staff. Make appropriate conversation. Say positive things about the food. Offer a clothing protector but respect the resident s right to refuse to wear it. Do not judge food choices. Follow infection prevention precautions. Sit at resident s eye level and give him full attention. Identify food and fluids in front of resident, including pureed foods. Ask resident which food he wants first. Do not mix foods. Put hand over food to test temperature. Do not blow on it or touch it. Alternate between food and drink. Honor requests for different food. Respect a resident s right to refuse to eat. Demonstration Demonstrate the procedure: Feeding a resident who cannot feed self. Include all of the numbered steps in your demonstration. Have the students return the demonstration. Procedure checklists are located at the end of the Student Workbook. Group Activity Give everyone one very small jar or portion of baby food (preferably a meat flavor) and a plastic spoon. Then simply ask them to taste it. Many will refuse and this is an excellent learning point (after all, our elderly residents don t think pureed food looks appetizing, either). Participants who do taste will probably describe to the class how unpleasant the food tastes. Whatever happens, you ve made your point. If the group is very open or small, or you know the participants personally or are comfortable with this idea, you can even have a volunteer restrained in her chair and have another volunteer feed her. This learning point goes deeper and opens discussion regarding the emotional side of being fed a pureed diet (or other type of diet) by another person. Feelings of being demeaned, helpless, etc., can be explored in discussion. Example: Does being fed this way make you want to continue eating? 12. Describe how to assist residents with special needs textbook pp workbook pp Review the guidelines for dining techniques:

7 96 Use assistive devices, when necessary. Use physical and verbal cues. Always put food into the stronger side of the mouth. Read menus to visually-impaired residents. Allow time with eating and use the face of an imaginary clock to explain the position of food. and Discussion Review the special problems that NAs may see and discuss the tips on how to deal with them found on pages of the textbook: Resident eats too quickly Resident bites down on utensils Resident cannot or will not chew Resident will not stop chewing Resident holds food in his mouth Resident pockets food in his cheek Resident has poor lip closure Resident has no teeth Resident has dentures that do not fit properly Resident has change in vision that causes problems seeing food clearly Resident has protruding tongue or tongue thrust Resident will not open his mouth Resident falls asleep while eating Resident chokes when drinking Resident is susceptible to choking Resident forgets to eat Resident drools excessively Resident has poor sitting balance Resident tends to lean on one side Resident tends to fall forward Resident has poor neck control Ask students if they can think of any other ways to help with these problems. 13. Discuss dysphagia and list guidelines for preventing aspiration textbook pp workbook p. 86 Review signs and symptoms of dysphagia that must be reported to the nurse: Slow eating Avoidance of eating Spitting out pieces of food Difficulty chewing food Difficulty swallowing small bites of food or pills Several swallows needed per mouthful Dribbling saliva, food, or fluid from the mouth Food residue inside the mouth or cheeks during and after meals Vomiting while eating or drinking Frequent throat clearing Food or fluid coming up into the nose Coughing during or after meals Choking during meals Gurgling sound in voice during or after meals, or loss of voice Problems breathing while eating or drinking Visible effort to swallow Watering eyes when eating or drinking Display Transparency 14-2 preventing aspiration Review the guidelines for preventing aspiration: Position in a straight, upright position at a 90-degree angle. Feed resident slowly. Avoid distractions. Offer small pieces of food or small spoons of pureed food. Offer food and then a liquid. Place food in the non-paralyzed side of the mouth. Make sure food is actually swallowed before next bite of food or sip of drink. Have residents stay in upright position for at least 30 minutes after eating and drinking. Provide mouth care after eating. Observe residents closely. Report signs of aspiration immediately.

8 Describe intake and output (I&O) textbook pp workbook p. 86 Pronounce and define the following key terms: Output Fluid balance Graduate Show students a sample intake and output (I&O) form, if one is available. Display Transparency 14-3 conversion table If in a facility, discuss the facility s particular methods of documenting units of measure. Optional Activity Distribute Handout 14-1 simple math If students need a review of mathematics, distribute this handout for them to take home and study. They can also reference the mathematics review at the end of the textbook on pages 498 and 499. Demonstration Demonstrate the procedure: Measuring and recording intake and output. Include all of the numbered steps in your demonstration. Have the students return the demonstration. Procedure checklists are located at the end of the Student Workbook. 15. List ways to identify and prevent dehydration textbook pp workbook pp Pronounce and define the following key term: Force fluids Remind students that drinking at least 64 ounces (eight 8-ounce glasses) of water or other fluids per day can help prevent constipation, urinary incontinence, and dehydration. Review the signs and symptoms of dehydration to report, including: Drinking less than six 8 oz. glasses of liquid per day Drinking little or no fluids at meals Needing help drinking from cup Having trouble swallowing liquids Having frequent vomiting, diarrhea, or fever Being easily confused or tired Severe thirst Dry mouth Decrease in urinary output Also report if the resident has any of these signs or symptoms: Severe thirst Dry mouth and mucous membranes Cracked lips Dry, warm, wrinkled, or clammy skin Sunken eyes Flushed face Decrease in urinary output Dark urine Strong-smelling urine Constipation or weight loss Weakness, dizziness, lightheadedness, or confusion Headache Irritability Rapid or weakened pulse Irregular heartbeat Low blood pressure Discuss the following guidelines for preventing dehydration: Report warning signs immediately. Encourage residents to drink every time you see them. Offer fluids that residents prefer. Make sure pitcher and cup are close by and are light enough for resident to lift.

9 98 Offer assistance. Offer other forms of liquids. Record fluid I&O. Follow posted schedules for fluids. Discuss approaching residents positively with, Would you like water or juice? rather than, Do you want anything to drink? Caregivers should make an effort to find out what resident s favorite beverages are and offer at least three times a day, in addition to meals. Emphasize that prevention of dehydration is ongoing! Point out the POURR acronym in the textbook on page 267 as a way of encouraging fluids. 16. List signs and symptoms of fluid overload and describe conditions that may require fluid restrictions textbook p. 267 workbook p. 87 Pronounce and define the following key terms: Fluid overload Restrict fluids Review the signs and symptoms of fluid overload, including: Weight gain Fatigue Difficulty breathing or shortness of breath Swelling of extremities Coughing Decreased urine Increased heart rate Tight, smooth, or shiny skin Swollen abdomen Chapter Review Exam distribute chapter 14: exam (appendix c, pp ) Allow students enough time to finish the test. See Appendix D for answers to the chapter exams. Answers to Chapter Review in Textbook 1. Answers include: less saliva; side effects from medication; decrease in activity and mobility; weakened sense of smell and taste; loss of vision; dentures, tooth loss, or poor dental health; depression and lack of interaction; special diets that restrict foods 2. Answers include: cultural and ethnic background; family traditions; country or the area of the country that a person is from; religious reasons 3. Water, fats, carbohydrates, protein, vitamins, minerals. Water is the most essential nutrient for life. 4. Vegetables and fruits 5. Beans, peas, soy products, nuts, and seeds are plant sources of proteins. 6. Most dairy group choices should be fat-free or low-fat (1%). 7. Resident s name and information about special diets, allergies, likes and dislikes, as well as any other dietary instructions 8. Serving a resident the wrong food can cause serious problems, such as allergic reactions and possibly death. 9. The mechanical soft diet does not limit spices, fat, and fiber. 10. Low Na or NAS 11. A clear liquid diet consists of fluids that you can see through, such as clear soups and juices. A full liquid diet includes clear liquids with the addition of cream soups, milk, and ice cream. 12. It is necessary to maintain blood sugar. 13. Nothing by mouth 14. Nectar thick is similar to a fruit nectar or other thicker juices, such as tomato juice. A resident can drink this from a cup with or without a straw. Honey thick is similar to the thickness

10 99 of honey. It will pour very slowly, and spoons are usually used to consume these types of liquids. Pudding thick is semi-solid, much like the consistency of pudding. A spoon will stand up straight when put into this thickened liquid. Spoons are used to consume these liquids. 15. Thickened liquids move down the throat more slowly, reducing coughing and limiting the risk for choking. 16. Answers include: needing help eating or drinking; eating less than 70% of meals/ snacks; having mouth pain; having dentures that do not fit properly; having difficulty chewing or swallowing; coughing or choking while eating; being sad or withdrawing from others; being confused; or wandering or pacing 17. Upright at 90 degrees 18. Answers may vary but could include: Assist with grooming. Seat residents by their friends. Help with toileting. Cut food before bringing it to the table. Give proper eating tools. Do not rush residents. Keep noise level low. Make conversation. Honor requests regarding food. 19. Answers may vary, but could include: This promotes dignity, independence and self-care. Promoting independence with eating positively affects self-esteem. 20. Answers will vary. 21. Respect the resident s refusal. 22. Put her hand over the food to sense the heat. 23. Stronger side 24. By using the face of an imaginary clock 25. Answers include: If the resident bites down on utensils, ask the resident to open his mouth. Wait until the jaw relaxes to pull the utensil out of the mouth. Offer finger foods instead. Use smaller utensils. If the resident cannot or will not chew, ask him to chew. Lightly press on the edge of the lips or on the chin to stimulate chewing. You can also show him how to chew by doing it yourself. Serve softer foods. If the resident pockets food in his cheek, ask him to chew and swallow the food. Touch the side of the cheek and ask him to use his tongue to get the food. Using your fingers on the cheek near the lower jaw, gently push food toward teeth. Avoid offering food such as rice that can stick inside the mouth or on dentures. Give sips of fluids often. Check the mouth for food often before offering more. If the resident has poor sitting balance, seat him in a regular dining room chair with armrests, rather than a wheelchair. Position him upright at a 90-degree angle. Knees should be flexed and feet and arms should be fully supported. Push chair under the table and place his forearms on the table. If the resident has poor neck control, a soft neck brace may be used to stabilize the head. For a resident in a geriatric chair, a wedge cushion behind the head and shoulders may be used. 26. Answers include: eating very slowly; avoidance of eating; spitting out pieces of food; difficulty chewing food; difficulty swallowing small bites of food or pills; swallowing several times when eating a single bite; dribbling saliva; food or fluid from the mouth; keeping food inside the mouth or cheeks during and after meals; vomiting while eating or drinking; frequent throat clearing; food or fluid coming up into or out of the nose; coughing during or after meals; choking during meals or while drinking; gurgling sound in voice during or after meals; problems breathing when eating or drinking; visible effort to swallow; or watering eyes when eating or drinking 27. Answers include: Position in a straight, upright position at a 90-degree angle. Feed resident slowly. Avoid distractions. Offer small pieces of food or small spoons of pureed food. Offer food and then a liquid. Place food in the non-paralyzed side of the mouth. Make sure mouth is empty before next bite of food or sip of drink. Have residents stay in upright position for at least 30 minutes after eating and drinking. Provide mouth care after eating. Observe residents closely. Report signs of aspiration immediately. 28. Output includes urine, feces, vomitus, perspiration, moisture in the air that a person exhales, suction material and wound drainage. 29. Fluid balance is consuming and eliminating equal amounts of fluid.

11 ounces 32. Answers include: drinking less than six 8-oz glasses of liquid per day; drinking little or no fluids at meals; needing help drinking from cup; having trouble swallowing liquids; having frequent vomiting, diarrhea, or fever; being easily confused or tired; being thirsty; having a dry mouth; having a decrease in urinary output; severe thirst; dry mouth and mucous membranes; cracked lips; dry, warm, wrinkled, or clammy skin; sunken eyes; flushed face; decrease in urinary output; dark urine; strong-smelling urine; constipation or weight loss; weakness, dizziness, lightheadedness, or confusion; headache; irritability; rapid or weakened pulse; irregular heartbeat; or low blood pressure 33. Answers include: Report warning signs immediately. Encourage residents to drink every time you see them. Offer fluids that residents prefer. Make sure pitcher and cup are close by and are light enough for resident to lift. Offer assistance. Offer other forms of liquids. Record fluid I&O. Follow posted schedules for fluids. 34. Answers include: weight gain; fatigue; difficulty breathing or shortness of breath; swelling of extremities; coughing; decreased urine; increased heart rate; tight, smooth, or shiny skin, swollen abdomen 35. A restrict fluids (RF) order means the person is allowed to drink, but must limit the daily amount to a level set by the doctor.