1. Chapter 19 Nutrition and Fluids
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2. Nutrition 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
Eating and drinking provide pleasure.
Eating and drinking often are part of social times with family and friends. A friendly social setting for meals is important. Otherwise, the person may eat poorly.
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3. Dietary Factors Many factors affect dietary practices.
Culture
Finances
Personal choice
Dietary practices also include selecting, preparing, and serving food.
The Centers for Medicare and Medicaid Services (CMS) requires that the health team assess the resident’s nutritional status.
Review Caring About Culture: Mealtime Practices on p. 315.
Assessment of nutritional status includes considering drugs that affect taste or cause dry mouth, nausea, or confusion; weight and height (see Chapter 27); appearance; food and fluid intake; and other factors that affect eating and nutrition.
Be prepared to answer questions about your observations and reports concerning residents’ food and fluid intake, meeting a person’s nutrition needs, a person’s weight and eating ability, and goals for nutrition in the person’s care plan.
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4. 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. Nutrients are grouped into fats, proteins, carbohydrates, vitamins, minerals, and water.
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.
Older persons need fewer calories than younger people. Energy and activity levels are lower.
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5. Dietary Guidelines
The Dietary Guidelines for Americans are for persons 2 years of age and older.
They describe a healthy diet as one that:
Is high in fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products
Includes lean meats, poultry, fish, beans, eggs, and nuts
Is low in fats, cholesterol, salt (sodium), and added sugar
The Guidelines also include recommendations for persons at risk for chronic disease.
The Guidelines promote overall health.
They focus on consuming fewer calories, making informed food choices, and being physically active.
The Guidelines include recommendations of what to eat and how it should be prepared and what not to eat or drink.
Review Box 19-1 on pp
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6. MyPlate MyPlate includes “Steps to a Healthier You.” Food groups
The kind and amounts of food to eat daily
Gradual improvement
Physical activity
Variety
Moderation
The right amount from each food group band
Food groups
Grains
Vegetables
Fruits
Dairy
Proteins
Oils
People can take small steps each day to improve their diet and life-style.
For health benefits, at least 30 minutes of physical activity is needed on most days of the week. It is best to do so every day.
Review Figure 19-3 on p. 318.
Foods from the five food groups are needed every day.
Review Box 19-2 on p. 318.
Review Table 19-1 on p. 318.
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7. Essential Nutrients Nutrients
No food or food group has every essential nutrient.
Essential nutrients are those the body must ingest for health.
Protein is the most important nutrient (besides water).
Carbohydrates provide energy and fiber for bowel elimination.
Fats provide energy, add flavor to food, and help the body use certain vitamins.
Vitamins are needed for certain body functions.
Vitamins do not provide calories.
The body stores vitamins A, D, E, and K.
Vitamin C and the B complex vitamins are not stored.
A well-balanced diet ensures an adequate intake of essential nutrients.
Dietary intake not needed by the body is stored as fat (adipose tissue).
Review Table 19-2 on p. 320.
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8. Nutrition Minerals are used for many body processes.
Bone and tooth formation
Nerve and muscle function
Fluid balance
Other body processes
Water is needed for all body processes.
Food labels are used to make informed food choices for a healthy diet.
Food labels contain information about:
Serving size and number of servings/package
Calories and calories from fat
Nutrients
Foods containing calcium help prevent musculoskeletal changes.
Review Table 19-3 on p. 320.
Most foods have labels (Fig on p. 321). Figure 19-5 on p. 321 shows how to use a food label.
How a serving fits into the daily diet is called the Daily Value (DV). The DV is expressed in a percent (%). The percent is based on a daily diet of 2000 calories.
The % DV helps you decide if a food is high or low in a nutrient.
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9. Factors Affecting Eating and Nutrition
Meeting a person’s nutritional needs requires a team approach.
Culture influences dietary practices, food choices, and food preparation.
Selecting, preparing, and eating food often involve religious practices.
Finances affect the foods people buy.
Appetite relates to the desire for food.
Review Caring About Culture: Food Practices on p. 321.
Selecting, preparing, and eating food often involve religious practices.
Review Box 19-3 on p. 322.
A person may follow all, some, or none of the dietary practices of his or her faith. You must respect the person’s religious practices.
Loss of appetite (anorexia) can occur. Causes include illness, drugs, anxiety, pain, and depression. Unpleasant sights, thoughts, and smells are other causes.
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10. Factors Affecting Eating
Personal choice
Body reactions
Illness
Chewing and swallowing
Disability
Age
With aging, changes occur in the gastro- intestinal (GI) system.
Body reactions involve allergic reactions, nausea, vomiting, diarrhea, indigestion, gas, or headaches.
Appetite usually decreases during illness and recovery from injuries. However, nutritional needs are increased.
Mouth, tooth, and gum problems can affect chewing (see Chapter 17). Many health problems can affect swallowing.
Impaired cognitive function may affect the person’s ability to use eating utensils, and it may affect eating, chewing, and swallowing.
Disease or injury can affect the neck, hands, wrists, and arms. Assistive devices may let the person eat independently (Fig on p. 323).
With aging, taste and smell dull. Good oral hygiene and denture care improve taste.
Follow the care plan to assist the person.
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11. OBRA and CMS Dietary Requirements
Each person’s nutritional and dietary needs are met.
The person’s diet is well-balanced.
Food is appetizing.
Hot food is served hot and cold food is served cold.
Food is served promptly.
Food is prepared to meet each person’s needs.
Food is well-seasoned.
Food has an appealing aroma and is attractive.
Food is served at the correct temperature.
The center provides assistive devices and utensils.
Food is prepared to meet each person’s needs. Some people require food cut, ground, or chopped; others may have special diets ordered by the doctor.
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12. Meeting Nutritional Needs
Other foods (of similar nutritional value) are offered to residents who refuse the food served.
Each person receives at least three meals a day.
A bedtime snack is offered.
The center provides needed adaptive equipment and utensils.
Substituted food must have a similar nutritional value to the first foods served.
Make sure the person has needed assistive devices and utensils.
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13. Special Diets Doctors may order special diets:
For nutritional deficiency or a disease
For weight control
To eliminate or decrease certain substances in the diet
Regular diet, general diet, and house diet mean no dietary limits or restrictions.
Review Table 19-4 on p. 324.
The doctor, nurses, and dietitian work together to meet the person’s nutritional needs. They consider the need for dietary changes, personal choices, religion, culture, and eating problems.
The nurse and dietitian teach the person and family about the diet.
Allergies, excess weight, and other disorders also require special diets.
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14. Sodium The sodium-controlled diet
If there is too much sodium, the body retains more water.
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 milligrams (mg). The body needs no more than 2400 mg a day.
Healthy people excrete excess sodium in the urine.
Review Box 19-4 on p. 325.
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15. Diabetic Nutrition Diabetes meal planning is for people with diabetes.
Diabetes is usually treated with insulin or other drugs, diet, and exercise.
The dietitian and person develop a meal plan that involves:
The person’s food preferences
Calories needed
Eating meals and snacks at regular times
You need to:
Serve the person’s meals and snacks on time.
Always check the tray to see what was eaten.
Tell the nurse what the person did and did not eat.
Diabetes is a chronic illness in which the body cannot produce or use insulin properly (see Chapter 36). The pancreas produces and secretes insulin. Insulin lets the body use sugar. Without enough insulin, sugar builds up in the bloodstream.
In a meal plan for healthy eating for persons with diabetes, consistency is key.
Eating at the same time every day maintains a certain blood sugar level.
If all food was not eaten, a between-meals snack is needed. It makes up for what was not eaten at the meal. The amount of insulin given also depends on daily food intake.
Report changes in the person’s eating habits.
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16. Dysphagia The dysphagia diet
Food thickness is changed to meet the person’s needs.
The doctor, speech-language pathologist, occupational therapist, dietitian, and nurse choose the right food thickness.
When feeding a person with dysphagia, you must:
Know the signs and symptoms of dysphagia.
Feed the person according to the care plan and swallow guide.
Follow aspiration precautions.
Report changes in how the person eats.
Report the following at once:
Choking, coughing, or difficulty breathing during or after meals
Abnormal breathing or respiratory sounds
Dysphagia means difficulty (dys) swallowing (phagia).
Review Box 19-5 on p. 326.
Aspiration is breathing fluid, food, vomitus, or an object into the lungs (see Chapter 20).
Review Box 19-6 on p. 326.
Review Box 19-7 on p. 328.
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17. 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 (edema).
If fluid output exceeds intake, dehydration occurs.
Water is ingested through fluids and foods and is lost through urine, feces, vomit, the skin (perspiration), and the lungs (expiration).
Dehydration is a decrease in the amount of water in body tissues. Fluid output exceeds intake.
Review Box 19-8 on p. 328.
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18. Fluid Requirements and Orders
Normal fluid requirements
An adult needs 1500 mL of water daily to survive.
About 2000 to 2500 mL of fluid per day is needed for normal fluid balance.
The older person is at risk for dehydration and edema.
Some persons have special fluid orders.
Encourage fluids
Restrict fluids
Nothing by mouth (NPO)
Thickened liquids
The water requirement increases with hot weather, exercise, fever, illness, and excess fluid losses.
The amount of body water decreases with age. Older persons also are at risk for diseases that affect fluid balance.
Older persons may have a decreased sense of thirst.
An “encourage fluids” order means the person drinks an increased amount of fluid. The order states the amount to ingest.
A “restrict fluids” order means fluids are limited to a certain amount. Fluids are offered in small amounts and in small containers.
“Nothing by mouth (NPO)” means a person is not allowed to eat or drink anything.
The term “thickened liquids” means all fluids are thickened, including water. The thickness depends on the person’s ability to swallow. Review Box 19-5 on p. 326.
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19. Intake and Output Intake and output (I&O) records:
Are used to evaluate fluid balance and kidney function
Help in evaluating and planning medical treatment
Are kept when the person has special fluid orders
All fluids taken by mouth are measured and recorded.
Foods that melt at room temperature are measured and recorded.
The nurse measures and records IV fluids and tube feedings.
Output includes urine, vomitus, diarrhea, and wound drainage.
An I&O record is kept at the bedside.
Amounts are totaled at the end of the shift.
Intake and output are measured in milliliters (mL): 1 ounce (oz) equals 30 mL; 1 pint is about 500 mL; 1 quart is about 1000 mL.
A measuring container for fluid is called a graduate. A graduate is marked in ounces and milliliters.
The information is kept on the I&O record (see Fig on p. 329).
Review Delegation Guidelines: Intake and Output on p. 328.
Review Promoting Safety and Comfort: Intake and Output on p. 329.
Review the Measuring Intake and Output procedure on p. 330.
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20. 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 Focus on Communication: Meeting Food and Fluid Needs on p. 330.
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21. Dining Programs
Dining programs meet the needs of the following residents:
Alert and oriented residents
Those who like to eat in their rooms
Those who are confused and noisy at mealtime
Persons who are incontinent or have odor problems
Persons who are too weak or ill to leave their rooms
Dining programs meet the differing needs of residents.
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22. Types of Dining Programs
The following dining programs are common in nursing centers:
Social dining
Family dining
Low-stimulation dining
Restaurant-style menus
Open-dining
With social dining, a dining room table seats four to six residents. Food is served as in a restaurant.
For family dining, food is served in bowls and on platters. Residents serve themselves as at home.
With low-stimulation dining, mealtime distractions are prevented.
Restaurant-style menus means the person selects food from a menu as in a restaurant.
With open-dining, residents can eat any time while the buffet is open.
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23. Preparing Residents for Meals
Preparing for meals
Assist with elimination needs.
Provide oral hygiene.
Make sure needed dentures are in place.
Make sure needed eyeglasses and hearing aids are in place.
Make sure incontinent persons are clean and dry.
Position the person in a comfortable position.
Assist the person with hand washing.
When residents are ready to eat, you can serve meal trays faster.
Review Delegation Guidelines: Preparing for Meals on p. 331.
Review Promoting Safety and Comfort: Preparing for Meals on p. 331.
Review the Preparing the Person for a Meal procedure on pp
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24. Serving Meals Serving meal trays When feeding the person:
OBRA requires that food be at the desired temperature when the person receives it.
You serve meal trays after preparing residents for meals.
Serve trays in the order assigned by the health team.
If food is not served within 15 minutes, recheck food temperatures.
If food is not at the correct temperature, get a fresh tray.
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.
Be sure to check the person’s identification (ID) before serving the tray.
Food is served in containers that keep foods at the correct temperature. Hot food is kept hot. Cold food is kept cold.
Serve meals in the assigned order. Residents seated at tables are served at the same time.
Review Delegation Guidelines: Feeding the Person on p. 334.
Review Promoting Safety and Comfort: Feeding the Person on p. 334.
Review the Feeding the Person procedure on p. 335.
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25. Feeding the Person Persons who need to be fed may:
Be angry, humiliated, and embarrassed
Be depressed or resentful
Refuse to eat
Let the person do as much as possible.
Always tell the visually impaired person what is on the tray.
For persons who feed themselves:
Describe foods and fluids and their place on the tray.
Use the numbers on a clock for the location of food.
Allow time and privacy for prayer if the person wishes.
You may need to feed people with weakness, paralysis, casts, confusion, and other limits.
Fluids help the person chew and swallow.
Teaspoons are less likely to cause injury than forks.
For portion size, follow the care plan.
Review Delegation Guidelines: Feeding the Person on p. 334.
Review Promoting Safety and Comfort: Feeding the Person on p. 334.
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26. Feeding the Person (Cont’d)
Meals provide social contact with others.
Engage the person in pleasant conversation.
Sit facing the person.
Persons with dementia may:
Become distracted during meals
Not be able to sit long enough for a meal
Forget how to use eating utensils
Resist your efforts to assist them with eating
Throw or spit food
Sitting is more relaxing. You can see how well the person is eating. You can also see if the person has problems swallowing.
Review Residents with Dementia: Feeding the Person on p. 334.
Review the Feeding the Person procedure on p. 335.
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27. Between Meals Between-meal nourishments Providing drinking water
Nourishments are served upon arrival on the nursing unit.
Provide needed utensils, a straw, and a napkin.
Follow the same considerations and procedures as for serving meal trays and feeding persons.
Providing drinking water
Residents need fresh drinking water each shift and whenever the pitcher is empty.
Calorie counts
On a flow sheet, note what the person ate and how much.
A nurse or dietitian converts the portions into calories.
Follow the center’s procedure for providing fresh drinking water.
If the pitcher is taken to an ice and water dispenser, fill the pitcher with ice first. Then add water to the pitcher.
Review Delegation Guidelines: Providing Drinking Water on p. 337.
Review Promoting Safety and Comfort: Providing Drinking Water on p. 337.
Review the Providing Drinking Water procedure on p. 336.
The nurse tells you which persons need calorie counts.
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28. Foodborne Illnesses
A foodborne illness (food poisoning) is caused by pathogens in food and fluids.
Report signs and symptoms of foodborne illnesses to the nurse at once.
Signs and symptoms depend on the pathogen.
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 and 140 F (Fahrenheit). This range is called the “danger zone” by the USDA.
Review Box 19-9 on p. 337 in the textbook.
You must keep food out of the “danger zone” of temperature. Keep cold food cold and hot food hot.
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29. Keep Food Safe
To keep food safe, the United States Department of Agriculture (USDA) recommends four tips: 
Clean. Wash hands, utensils, and counter tops often.
Separate. Avoid cross-contamination. Do not let raw meat, poultry, or their juices touch other foods that will not be cooked.
Cook. Cook food to a safe internal temperature. Use a food thermometer to check the internal temperature. When re-heating cooked food, re- heat 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.
Cook food to a safe internal temperature. Use a food thermometer to check the internal temperatures.
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30. Quality of Life
Nutrition and fluid balance are important for quality of life.
The right to personal choice is important in meeting food and fluid needs.
Residents have the right to express their preferences.
Persons with dementia may require special measures to meet their nutritional needs.
Sometimes families and friends bring food from home.
OBRA requires that food be served correctly.
Respect the person’s right to express personal food choices. Share this information with the nurse.
With the person’s help, the dietitian plans healthy meals that include personal choices.
Gifts of food from family and friends are common. Tell the nurse when the person receives food. The food must not interfere with the person’s diet.
Provide needed help with eating. This includes providing eating devices and utensils.
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