1. Chapter 24
Nutrition and Fluids

2. Dietary Practices
The person’s diet affects physical and mental well-being.
A poor diet and poor eating habits:
Increase the risk for infection
Increase the risk of acute and chronic diseases
Cause chronic illnesses to become worse
Cause healing problems
Affect physical and mental function, increasing the risk for accidents and injuries
Culture, finances, and personal choice affect dietary practices.
Eating and drinking provide pleasure. A friendly, social setting for meals is important.
Dietary practices include selecting, preparing, and serving food.
Review Box 24-1 on p. 428 in the Textbook.
Review the Caring About Culture: Mealtime Practices Box on p. 426 in the Textbook.

3. Basic Nutrition
Nutrition is the processes involved in the ingestion, digestion, absorption, and use of foods and fluids by the body.
Good nutrition is needed for growth, healing, and body functions.
A well-balanced diet and correct calorie intake are needed.
Foods and fluids contain nutrients.
Nutrients are grouped into fats, proteins, carbohydrates, vitamins, minerals, and water.
A nutrient is a substance that is ingested, digested, absorbed, and used by the body.
Fats, proteins, and carbohydrates give the body fuel for energy.
The amount of energy provided by a nutrient is measured in calories. A calorie is the fuel or energy value of food.

4. Basic Nutrition (cont’d)
The Dietary Guidelines for Americans, 2010 is for persons 2 years of age and older.
The Dietary Guidelines help people:
Attain and maintain a healthy weight.
Reduce the risk of chronic disease.
Promote overall health.
The Guidelines focus on:
Consuming fewer calories
Making informed food choices
Being physically active
The Guidelines are also for persons at risk for chronic disease.
Certain diseases are linked to poor diet and the lack of physical activity. They include cardiovascular disease, hypertension (high blood pressure), diabetes, obesity, osteoporosis, and some cancers.
Review Appendix C on p. 839 in the Textbook.

5. Basic Nutrition (cont’d)
The MyPlate symbol encourages healthy eating from 5 food groups.
MyPlate, issued by the United States Department of Agriculture (USDA), helps you make wise food choices by:
Balancing calories
Increasing certain foods
Reducing certain foods
The USDA recommends that adults do at least one of the following:
2 hours and 30 minutes each week of moderate physical activity
1 hour and 15 minutes each week of vigorous physical activity
Balancing calories is done by eating less and avoiding over-sized portions.
Make half of your plate fruits and vegetable, and half of your grains whole grains. Drink fat-free or low-fat (1%) milk.
Choose low-sodium foods and drink water instead of sugary drinks.
The amount needed from each food group depends on age, sex, and physical activity.
Physical activity at least 3 days a week is best. Each activity should be for at least 10 minutes at a time. Adults should also do strengthening activities at least 2 days a week. Push-ups, sit-ups, and weight-lifting are examples.
See the Focus on Children and Older Persons: MyPlate Box on p. 429 in the Textbook.
Review Box 24-1 on p. 429 in the Textbook.

6. Basic Nutrition (cont’d)
Nutrients
Protein is the most important nutrient.
It is needed for tissue growth and repair.
Carbohydrates provide energy and fiber for bowel elimination.
Fats provide energy.
They provide and help the body use certain vitamins.
Vitamins are needed for certain body functions.
Minerals are used for many body processes.
Water is needed for all body processes.
No food or food group has every essential nutrient. A well-balanced diet ensures an adequate intake of essential nutrients.
Unneeded dietary fat is stored as body fat (adipose tissue).
Table 24-2 on p. 431 in the Textbook lists the sources and major functions of common vitamins.
Table 24-3 on p. 432 in the Textbook lists the major functions and sources of common minerals.

7. Basic Nutrition (cont’d)
Food labels
Food labels are used to make informed food choices for a healthy diet.
Food labels contain information about:
Serving size and the number of servings in each package
Calories and calories from fat
Nutrients
How a serving fits into the daily diet is called the Daily Value (DV).
The DV is a percent based on calories daily.
The percent DV helps you decide if a food is high or low in a nutrient.
According to the FDA, a 5% DV is low and a DV of 20% or more is high.

8. MEETING NUTRITIONAL NEEDS
A team approach is needed to meet a person’s nutritional needs.
The nutritional care plan involves the person’s:
Likes and dislikes
Lifelong habits
The person, nursing team, doctor, dietitian, speech–language pathologist, and occupational therapist are involved, in addition to the family if necessary.
Review the Focus on Long-Term Care and Home Care: Meeting Nutritional Needs Box on p. 000 in the Textbook.
Review the Focus on Children and Older Persons: Factors Affecting Eating and Nutrition Box on p. 434 in the Textbook.

9. Special Diets Doctors may order special diets:
For a nutritional deficiency or a disease
For weight control (gain or loss)
To eliminate or decrease certain substances in the diet
The health team considers the need for dietary changes, personal choices, religion, culture, and eating problems.
Regular diet, general diet, and house diet mean no dietary limits or restrictions.
Review Table 24-4 on pp in the Textbook.
The health team also considers food allergies and sensitivities.
The nurse and dietitian teach the person and family about the diet.
Persons with diseases of the heart, kidneys, gallbladder, liver, stomach, or intestines often need special diets. Allergies, excess weight, and other disorders also require special diets.

10. Special Diets (cont’d)
The sodium-controlled diet
Sodium causes the body to retain water.
The heart has to work harder. The extra workload can cause serious problems or death.
Sodium control decreases the amount of sodium in the body.
The doctor orders the amount of sodium allowed.
Sodium-controlled diets involve:
Omitting high-sodium foods
Not adding salt to food at the table
Limiting the amount of salt used in cooking
Diet planning
The average amount of sodium in the daily diet is 3000 to 5000 mg. The body needs no more than 2300 mg a day. Healthy people excrete excess sodium in the urine.
The USDA recommends that sodium intake be reduced to 1500 mg daily for persons aged 51 and older, African Americans of any age (including children), and persons who have hypertension, diabetes, or chronic kidney disease (including children).
Review the contents of Box 24-3 on p. 438 in the Textbook.

11. Special Diets (cont’d)
Diabetes meal plan
A meal plan for health eating is developed.
Consistency is key.
The meal plan involves:
The person’s food preferences
Calories needed
Eating meals and snacks at regular times
You need to:
Serve meals and snacks on time.
Always check what was eaten.
Report what the person did and did not eat.
Report changes in the person’s eating habits.
Diabetes is a chronic illness in which the body cannot produce or use insulin properly. Without enough insulin, sugar builds up in the bloodstream. It is not used by cells for energy.
Diabetes is usually treated with insulin or other drugs, diet, and exercise.
The meal plan may involve limiting the amount of food or changing how it is prepared.
The same amount of carbohydrates, protein, and fat is eaten each day.
If all food was not eaten, a between-meal snack is needed. The nurse tells you what to provide. The amount of insulin given also depends on daily food intake.

12. Special Diets (cont’d)
The dysphagia diet
Dysphagia means difficulty swallowing.
Food thickness is changed to meet the person’s needs.
Doctor, speech-language pathologist, occupational therapist, dietitian, and nurse choose food thickness.
When feeding the person with dysphagia, you must:
Know the signs and symptoms of dysphagia.
Feed the person according to the care plan.
Follow aspiration precautions and the care plan.
Report changes in how the person eats.
Observe for signs and symptoms of aspiration: choking, coughing, or difficulty breathing during or after meals, and abnormal breathing or respiratory sounds.
Report these observations at once.
A slow swallow means that the person has difficulty getting enough food and fluids for good nutrition and fluid balance.
An unsafe swallow means that food enters the airway (aspiration).
Aspiration is breathing fluid, food, vomitus, or an object into the lungs.
Review the contents of Box 24-5 on p. 439 in the Textbook.
Review the contents of Box 24-6 on p. 439 in the Textbook.

13. Focus on Quality of Care
A new male patient has been admitted to the medical wing of Perry Memorial Hospital. What factors does the health team need to consider when planning for the person’s nutritional needs?
Age
Finances, culture & religion
May influence how he selects, prepares & eats food
Illness, medications, anxiety, pain & disability may affect his appetite
Personal food preferences
Current illness may affect the amount & type of food he needs to promote recovery/healing
The health team needs to consider the person’s age; how his finances, culture, and religion influence how he selects, prepares, and eats food; how illness, drugs, anxiety, pain, and disability may affect his appetite; and what his personal food likes and dislikes are. The person’s illness also may affect his appetite and food preferences. His illness will affect the amounts and types of food he needs to promote recovery.

14. Fluid Balance Death can result from too much or too little water.
Fluid balance is needed for health.
The amount of fluid taken in (intake) and the amount of fluid lost (output) must be equal.
If fluid intake exceeds fluid output, body tissues swell with water. This is called edema.
If fluid output exceeds intake, dehydration occurs.
Water is ingested through fluids and foods.
Water is lost through urine, feces, vomit, the skin (perspiration), and the lungs (exhalation).
Edema is common in people with heart and kidney diseases.
Dehydration is a decrease in the amount of water in body tissues. Review Box 24-7 on p. 439 in the Textbook for a list of common causes of dehydration.

15. Fluid Balance (cont’d)
Normal fluid requirements
An adult needs 1500 mL (milliliters) of water daily to survive.
About 2000 to 2500 mL are needed for normal fluid balance.
The water requirement increases with:
Hot weather
Exercise
Fever and illness
Excess fluid losses
Review the Focus on Children and Older Persons: Normal Fluid Requirements Box on p. 440 in the Textbook.

16. Fluid Balance (cont’d)
Common special fluid orders are:
Encourage fluids: the person drinks an increased amount of fluids.
Restrict fluids: fluids are limited to a certain amount.
Nothing by mouth (NPO): the person cannot eat or drink anything.
Thickened liquids: all fluids are thickened, including water.
The doctor may order the amount of fluid a person can have during a 24-hour period in order to maintain fluid balance. This order is found in the care plan and in the Kardex.
NPO is ordered before and after surgery, before some laboratory tests and diagnostic procedures, and to treat certain illnesses. An NPO sign is posted above the bed.

17. Fluid Balance (cont’d)
Intake and output (I&O) records
The doctor or nurse may order (I&O) measurements.
I&O records are kept:
To evaluate fluid balance and kidney function
To help in planning medical treatment
When the person has special fluid orders
The following fluids are measured and recorded:
All fluids taken by mouth
Foods that melt at room temperature
IV fluids and tube feedings
Output includes urine, vomitus, diarrhea, and wound drainage.

18. Fluid Balance (cont’d)
Measuring intake and output
Intake and output are measured in milliliters (mL).
A measuring container for fluid is called a graduate.
The measuring device is held at eye level to read the amount.
An I&O record is kept at the bedside.
Amounts are totaled at the end of the shift.
The purpose of measuring I&O and how to help are explained to the person.
The urinal, commode, bedpan, or specimen pan is used for voiding.
1 ounce equals 30 mL; 1 pint is about 500 mL; 1 quart is about 1000 mL.
You also need to know the serving size of bowls, dishes, cups, pitchers, glasses, and other containers. This information may be on the I&O record.
The graduate is marked in ounces and milliliters and is used to measure left-over fluids, urine, vomitus, and drainage from suction.
Plastic urinals and kidney basins also have amounts marked.
Some persons measure and record their intake. Family members may help.
Remind the person not to void in the toilet and not to put toilet tissue into the receptacle.
Review the Delegation Guidelines: Intake and Output Box on p. 442 in the Textbook.
Review the Promoting Safety and Comfort: Intake and Output Box on p. 442 in the Textbook.

19. Meeting Food and Fluid Needs
The following can affect appetite and ability to eat:
Weakness, illness, and confusion
Unpleasant odors, sights, and sounds
An uncomfortable position
The need for oral hygiene
The need to eliminate
Pain
Review the Focus on Communication: Meeting Food and Fluid Needs Box on p. 443 in the Textbook.

20. Meeting Food and Fluid Needs (cont’d)
Preparing for meals
To promote comfort when preparing patients and residents for meals:
Assist with elimination needs.
Provide oral hygiene.
Make sure needed dentures are in place.
Make sure eyeglasses and hearing aids are in place (if worn).
Make sure incontinent persons are clean and dry.
Position the person in a comfortable position.
Assist the person with hand washing.
Review the Delegation Guidelines: Preparing for Meals Box on p. 443 in the Textbook.
Review the Promoting Safety and Comfort: Preparing for Meals Box on p. 443 in the Textbook.

21. Meeting Food and Fluid Needs (cont’d)
Serving meals
You serve meals after preparing patients and residents for meals.
Some agencies have “room service” meal programs.
Serve meals in the assigned order.
If food is not served within 15 minutes, re-check food temperatures.
Food is served in containers that keep foods at the correct temperature.
Prompt serving keeps food at the correct temperature.
Agencies with “room service” meal programs provide full menus in the person’s room. When ready to eat, the person calls the dietary department to place an order. Food is served a short while later. This program allows the person to eat when hungry.
Review the Focus on Long-Term Care and Home Care: Serving Meals Box on p. 444 in the Textbook.
Review the Delegation Guidelines: Serving Meals Box on p. 445 in the Textbook.
Review the Promoting Safety and Comfort: Serving Meals Box on p. 445 in the Textbook.
Review the Teamwork and Time Management: Serving Meals Box on p. 445 in the Textbook.

22. Meeting Food and Fluid Needs (cont’d)
When feeding the person:
Serve food and fluids in the order the person prefers.
Offer fluids during the meal.
Use teaspoons to feed the person.
Let the person do as much as possible.
Always tell the visually impaired person what is on the tray.
When feeding visually impaired persons, describe what you are offering.
For persons who feed themselves, describe foods and fluids and their places on the tray.
Use the numbers on a clock for the location of foods.
Persons with weakness, paralysis, casts, confusion, and other limits are fed.
Fluids help the person chew and swallow.
Persons who need to be fed are often angry, humiliated, and embarrassed. Some are depressed, resentful, or refuse to eat.

23. Meeting Food and Fluid Needs (cont’d)
Allow time and privacy for prayer.
Engage the person in pleasant conversation.
Allow time for chewing and swallowing.
Sit facing the person.
You can see how well the person is eating.
You can also see if the person has problems swallowing.
Review the Focus on Children and Older Persons: Feeding the Person Box on p. 447 in the Textbook.
Review the Delegation Guidelines: Feeding the Person Box on p. 447 in the Textbook.
Review the Promoting Safety and Comfort: Feeding the Person Box on p. 447 in the Textbook.

24. Meeting Food and Fluid Needs (cont’d)
Between-meal nourishments
Snacks are served upon arrival on the nursing unit.
Follow the same considerations and procedures as for serving meals and feeding persons.
Calorie counts
On a flow sheet, note what the person ate and how much.
A nurse or dietitian converts the portions into calories.
Providing drinking water
Patients and residents need fresh drinking water each shift and whenever the pitcher is empty.
Follow the agency’s procedure for providing fresh drinking water.
Many special diets involve between-meal snacks. Provide needed utensils, a straw, and a napkin.
The nurse tells you which persons need calorie counts.
Review the Focus on Communications: Providing Drinking Water Box on p. 449 in the Textbook.
Review the Delegation Guidelines: Providing Drinking Water Box on p. 449 in the Textbook.
Review the Promoting Safety and Comfort: Providing Drinking Water Box on p. 449 in the Textbook.

25. Foodborne Illnesses
A foodborne illness (food poisoning) is caused by pathogens in food and fluids.
Report signs and symptoms to the nurse at once.
Food is not sterile.
Pathogens are present when food is purchased.
Foods can become contaminated from other foods.
Food handlers with poor hygiene can contaminate the food.
Pathogens grow rapidly between 40 F and 140 F.
This range is called the danger zone by the USDA.
Review the signs and symptoms listed in Box 24-8 on p. 450 in the Textbook.
You must keep food out of the “danger zone.” Keep cold food cold and hot food hot.

26. Foodborne Illnesses (cont’d)
To keep food safe, the USDA recommends these 4 safety tips.
Clean.
Wash hands, utensils, and counter tops often.
Separate.
Avoid cross-contamination.
Cook.
Cook food to a safe internal temperature.
Re-heat cooked food to 165 F.
Chill.
Refrigerate or freeze food within 2 hours.
If the air is 90 F or above, chill food within 1 hour.
Do not let raw meat, poultry, or their juices touch other foods that will not be cooked.
Use a food thermometer to check the internal temperature.
Review the Focus on Long-Term Care and Home Care: Foodborne Illnesses Box on p. 451 in the Textbook.