Transcript Feeding Adult Patients

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.
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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
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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
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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 eating
Exhibits multiple attempts @ swallowing
c/o food getting stuck in throat
Poor lip & tongue control
M.J. Bailey
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
Procedure for Feeding
Bedpan/washroom first
Wash hands
Prepare room
mid-to-high fowlers
Dentures
Bib/napkin
Prepare tray/food
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Procedure for Feeding
Relaxed pace
Small bites/spoonfuls
Rocking motion of utensil on tongue
Maintain 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
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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
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
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
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
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Problems with tube feeding
Dry mouth
Sore mouth
Thirst
Feeling deprived
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Do’s and don’ts re tube feeding
Do not hurry/force feeding
– Abdominal distention & discomfort
Clean not sterile technique
Formula @ room temp.
– Warm= bacterial growth
– Cold= gastric cramping & discomfort, liquid is
not warmed by the mouth and esophagus
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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
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
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
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Position for tube feeding
 Fowlers before and after
– Prevents aspiration
 Regulate the flow of the feeding
6mls/min
 Gravity/ feeding pump
 Flush tube well post feeding
 Clamp tube post flushing
 Intake/output
Avoid introducing air into tubing
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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
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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:
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Infants
Elderly
Neurologically impaired
Psychologically impaired
Must be conscious and alert
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Fluid Output
Kidneys
Lungs
Skin
GI 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
 Measurable
 Fluid losses from
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Urination
Defecation
Wounds
Vomiting
 Normally GI losses 100mls/day
 In cases of severe diarrhea , losses may exceed
5,000ml/day
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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
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
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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
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Daily Weights
Deficient or Excess
Same time each day
Same scale
Same clothing
Fluid retention can be detected early b/c 510lbs 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 fluids
Irrigating fluids that are not returned
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Output items
Urine
Diarrhea
Profuse diaphoresis
Vomit
Drainage from suction devices
Wound drainage
Bleeding
M.J. Bailey
Measurement
Wear gloves
Urine output
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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.
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Measurement
Patient participation
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Instructions
Explanation
Equipment
Recording
• Bedside record- individual items
• Permanent record- totals for time frame designated
by institutional policy. Kept on chart.
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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
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Fluids and Electrolyte Balance
Solutes = substances dissolved in a
solution
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Electrolytes: Na, K, Cl
Minerals
Glucose
Urea
Bilirubin
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Functions of the Fluid System
Transportation of Nutrients to cells
Removing wastes from cells
Homeostasis- maintaining a stable physical
& chemical environment in the body
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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 > intracellular
Body 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
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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 balance
Cells
– 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 cation
Na+ most abundant in extraellular fluid
Where 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 haveM.J.body
H2O
Bailey
Fluids and Electrolyte Balance
 Environmental Temperature –
–
temperature
and Cl- ions.
sweating
fluid loss = loss of Na+
 Life style
– Inadequate diet•
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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
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Fluids and Electrolyte Balance
Fluid Disturbances
– Fluid Volume Deficit -H2O and electrolytes
are lost.
• At Risk
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Decreased oral intake
Vomiting
Diarrhea
Gastric suction
• The very young and very old quickly affected by
these losses.
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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
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Insufficient intake
GI and Kidney function disturbances
Excessive perspiration or evaporation
Volume losses
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