1. Feeding Adult Patients
M.J. Bailey

2. 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

3. Factors Influencing Dietary Patterns
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
Anorexia refers to lack of appetite in this case.
M.J. Bailey

4. Factors Influencing Dietary Patterns
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

5. Factors Influencing Dietary Patterns
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

6. Factors Influencing Dietary Patterns
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

7. Factors Influencing Dietary Patterns
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

8. Factors Influencing Dietary Patterns
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

9. Factors Influencing Dietary Patterns
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

10. 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

11. 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

12. 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

13. 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

14. Types of Diets Sodium Restricted Low Cholesterol
Low levels of sodium = NO SALT
CHF, Renal failure, cirrhosis, hypertension
Low Cholesterol
Cholesterol intake 300mg/day
Fat intake –35%
Eliminate/reduce fatty foods
M.J. Bailey

15. Types of Diets Diabetic Exchange list of foods
Imp. For Type I and Type II
M.J. Bailey

16. 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

17. 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

18. Suspect Dysphagia when client
Coughs/ gags during eating
Exhibits multiple swallowing
c/o food getting stuck in throat
Poor lip & tongue control
M.J. Bailey

19. Feeding the patient with dysphagia
Safety – choking/ aspiration
Symptoms 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

20. Procedure for Feeding Bedpan/washroom first Wash hands Prepare room
mid-to-high fowlers
Dentures
Bib/napkin
Prepare tray/food
M.J. Bailey

21. Procedure for Feeding Relaxed pace Small bites/spoonfuls
Rocking motion of utensil on tongue
Maintain sitting min. pc.
M.J. Bailey

22. 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

23. 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 term
Gastrostomy= long term, surgically inserted directly into the stomach(gastrostomy) or small intestine (jejunostomy)
M.J. Bailey

24. Nasogastric tube
Through nose into stomach (infants through the mouth, nostrils too small)
Only with a physician’s order
Ensure correct tube placement
Purpose
Nutrition for clients with impaired swallowing, unconscious, or inability to ingest food
M.J. Bailey

25. Nasogastric tube Small bore tube for tube feeding
Large 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

26. Tube Feedings Additional water post: Feedings Medications
Prescribed times
Liquid/ dissolved
No enteric coated or time released capsules
Do not mix meds with formula. Give meds. prior to formula
M.J. Bailey

27. Tube feeding schedule Continuous Cyclic Bolus Over 24 hrs
Prescribed period ( ie:16hrs)
Bolus
Prescribed volume over min. 4-6 X/day.
Physician orders frequency, amount, & type of feeding
M.J. Bailey

28. Problems with tube feeding
Dry mouth
Sore mouth
Thirst
Feeling deprived
M.J. Bailey

29. Do’s and don’ts re tube feeding
Do not hurry/force feeding
Abdominal distention & discomfort
Clean not sterile technique
room temp.
Warm= bacterial growth
Cold= gastric cramping & discomfort, liquid is not warmed by the mouth and esophagus
M.J. Bailey

30. Do’s and don’ts re tube feeding
Formula can hang for 8hrs. ( check directions)
Change tubing q24hrs. Or according to policy
Check tube position q8hrs. And ac feeds/meds
Clamp b/t feedings
30-60 ml water before and after feedings, meds, residual checks
M.J. Bailey

31. Procedure for checking tube placement
X-ray- best and most accurate
Air insertion and listen with stethoscope
Aspirate 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

32. Aspirate pH Stomach is acidic 1-4 Intestine is 7 or greater
Pleural secretions 6
Wait 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

33. Position for tube feeding
Fowlers before and after
Prevents aspiration
Regulate the flow of the feeding mls/min
Gravity/ feeding pump
Flush tube well post feeding
Clamp tube post flushing
Intake/output
Avoid introducing air into tubing
M.J. Bailey

34. 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
mls
M.J. Bailey

35. Fluid Loss Fluids are lost Total daily loss = 2100 –2900mls Skin Lungs
Feces
Urine output = majority
Total daily loss = 2100 –2900mls
M.J. Bailey

36. 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

37. Regulation of Body Fluids
Those at risk for dehydration include:
Infants
Elderly
Neurologically impaired
Psychologically impaired
Must be conscious and alert
M.J. Bailey

38. Fluid Output
Kidneys
Lungs
Skin
GI tract
M.J. Bailey

39. 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

40. 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

41. Sensible Losses Measurable Fluid 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

42. Intake and Output Measurement
Many illnesses cause changes in the body’s ability to maintain balance.
Require accurate measure In & Out
Institution policies
Physician orders
RN initiates
Data for assessment
Monitor patient’s condition
M.J. Bailey

43. Indications for intake and output
Special medications ( diuretics)
Post-op patients
I/V therapy
Indwelling catheters
Feeding tubes
Low oral intake
Intake =output in 48-72hr. period
M.J. Bailey

44. 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

45. Daily Weights Deficient or Excess Same time each day Same scale
Same clothing
Fluid 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

46. 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 fluids
Irrigating fluids that are not returned
M.J. Bailey

47. Output items Urine Diarrhea Profuse diaphoresis Vomit
Drainage from suction devices
Wound drainage
Bleeding
M.J. Bailey

48. Measurement Wear gloves Urine 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

49. 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

50. Fluids and Electrolyte Balance
H2O – the indispensable nutrient
60% total adult body weight
70-80% total infant body weight
Body Fluids
H2O and dissolved substances
H2O major constituent of the body
H2O = Solvent in which substances are dissolved or suspended
M.J. Bailey

51. Fluids and Electrolyte Balance
Solutes = substances dissolved in a solution
Electrolytes: Na, K, Cl
Minerals
Glucose
Urea
Bilirubin
M.J. Bailey

52. Functions of the Fluid System
Transportation of Nutrients to cells
Removing wastes from cells
Homeostasis- maintaining a stable physical & chemical environment in the body
M.J. Bailey

53. 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

54. 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 > intracellular
Body fluids & electrolytes shift from compartment to compartment to maintain Homeostasis
M.J. Bailey

55. 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

56. 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

57. 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

58. Fluids and Electrolyte Balance
Minerals
Ingested
Catalysts in nerve response, muscle contraction, regulating electrolyte balance
Cells
Basic units of all living tissue
RBC’s, WBC’s
Within body fluids
M.J. Bailey

59. 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 cation
Na+ most abundant in extraellular fluid
Where Na+ goes H2O follows
Na+ retained K+ excreted
M.J. Bailey

60. 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

61. 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

62. 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

63. 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

64. 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
M.J. Bailey