Feeding Adult Patients

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 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 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

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 causeof 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 attempts @ 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 15-30 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 • Medications • 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 • 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 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 • Formula @ 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 6mls/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 2100-2900mls M.J. Bailey

35. Fluid Loss • Fluids are lost • 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