Nutrition

Nutrition, Hydration, and the Elderly
Lesson Plan and Speaking Notes

Hydration

Making sure our patients are well hydrated can be very challenging. Most elderly patients need to be encouraged to drink enough fluids, and an elderly patient can become dehydrated very quickly.

Dehydration is a life-threatening condition, and is considered an emergency. You need to notify the charge nurse immediately if you suspect the patient is not taking in adequate fluids.

Factors that can Cause Dehydration

Inadequate fluid intake

Diarrhea

Excessive Urine Output

Vomiting / Nausea

Excessive Sweating

Presence of Infection or Fever

Frequent Use of Laxatives, Enemas, Diuretics

Swallowing Problems

Impaired Decision-Making Ability

Comprehension/Communication Problems

Body Control Problems

Hand Dexterity Problem

Signs of Dehydration
Thirst
Decreased urine output
Dark urine
Confusion
Dry skin and mucous membranes, thirst, diarrhea, lethargy, agitation, altered mental state

What are some ways we can encourage patients to consume more fluids?

Hydration Interventions

Ice pitcher filled and in reach

Assistance and reminders to drink fluids provided if needed

Patient preference of fluids honored

Alternative fluids provided

Fluids offered regularly

Monitor room temperatures

Cup holder on wheelchair

Staff to assist / cue patient to drink all fluids

Meeting the nutritional needs of the elderly is challenging.

Weight loss in the elderly correlates strongly with morbidity and mortality rates.

The desire to eat and drink decreases with age, and the elderly person gets full quickly.

The senses of taste and smell decline, as well as the ability to synthesize protein.

Exacerbating the metabolic differences of the aged are multiple conditions such as dementia, depression, polypharmacy, chronic illness, and loss of mobility

Other Factors That Affect Nutritional Needs:
Gastrointestinal problems
Increased nutritional/caloric needs related to pressure sores and wound healing
Infection
Radiation or chemotherapy
Refusal to eat
Behavior problems such as agitation

Can you name some interventions that can improve the patient's intake?

Review food preferences, favorite foods, and comfort foods

Evaluate sizes and portions of meals and snacks

Provide high calorie supplement between meals

Give supplements between meals rather than at meals to achieve maximum intake of regular food

Decrease distractions during meals

Change assistance with meals - evaluation by occupational therapy

If we suspect a swallowing or chewing problem, we can ask for an evaluation by the speech therapist.

Increase social contact during meals

Meet with family: ask to visit at mealtime and help feed patient or eat with patient

Give pain medication 2 hours before meals

How to Measure Intake

For low-weight patients or patients at risk for weight loss, intake records may be ordered.

Each food item served except for water, coffee, tea, or condiments equals one point.

Example: Breakfast: juice, cereal, milk, bread and butter, coffee (no points) equals four points. If the patient consumes all four items in the amount served, the patient consumes 100% of breakfast. If the patient consumes two of the four food items served, then 50% of the breakfast would have been consumed.

Liquid measurements:

8 oz. cup = 240 cc	6 oz. cup = 180 cc
4 oz. cup = 120 cc	1 oz. cup = 30 cc.

Notify the charge nurse when the patient's intake is inadequate.

Weighing Patients

Weight monitoring may also be ordered for low-weight patients or patients at risk for weight loss.

What are some things to remember about weighing patients?

Make sure the scale is calibrated correctly.

Weigh the patient in the same amount of clothing, in the same wheelchair.

Notify the charge nurse if there has been a weight loss since the last weight taken, or if there is a discrepancy in the weights.

Cooking

When the charge nurse does the initial patient and home care evaluation, she will determine if the patient is able to cook for herself adequately and safely, or if she needs assistance with cooking or time with occupational therapy to improve her skills.

Know the patients plan of care for meal preparation.

Assess the patient's ability and safety awareness with each meal because an elderly patient's abilities can change very quickly due to physical or cognitive limitations.

Some Goals for Assisting a Patient with Cooking

Patient will demonstrate ability to cook a light meal twice per week

Patient safety will be maintained

Patient will accept assistance with cooking

Some Interventions for Assisting a Patient with Cooking

Assist with meal planning

Hand utensils and ingredients to patient

Cut vegetables and meats

Patient to cook only under supervision - monitor safety

Encourage patient to participate in cooking, and praise accomplishments

Assist only as necessary

Provide equipment within easy reach.

Allow sufficient time for cooking

Break tasks down into manageable segments

Some patients will have a Meals on Wheels delivery every day. Make sure you know whether or not this is in the patient's care plan. Report to the charge nurse any problems with the deliveries.

Getting the Patient Ready for Mealtime

Provide appropriate hygiene prior to the meal - the better the patients feel about themselves, the more positive they will feel about eating.

Make sure eyeglasses, dentures, and hearing aids are in place.

Make sure patients are properly seated, and that tables are adjusted to accommodate wheelchairs

How do you think staff attitudes and behavior affect the patients during mealtimes?

Behavior and Attitude of the Staff during Meals

The meal should never seem rushed.

The attitude of the staff at mealtimes has a big impact on the patients' appetites. Bad feelings and negativity are contagious.

Negative comments from the staff about the food, such as "same old thing again" or "mystery meat" will certainly reduce a patient's intake, whereas remarks like "that looks so good" or "this is making me really hungry" can only have a positive impact. This is very, very important. Make a resolve to remember to say positive things about the food several times during each meal.

How can we assist patients with meals?

Patients should receive appropriate assistance with eating - know each patient's plan of care, as this can change quickly. If you think a patient needs more help than is reflected on the plan of care, let the charge nurse know.

There are different Levels of Assistance Patients May Require

Supervision

Cues

Set-up - for instance, opening condiment and milk containers, cutting meat

Limited / extensive / total / assistance of one staff

Causes of Reduced Ability to Feed Self
Impaired movement, dexterity
Dementia
Depression
Agitation
Sensory deficit
Weakness

Signs that a Patient Needs Assistance with Meals:
Unable to hold utensils
Unable to comprehend utensil use
Leaves food uneaten if not assisted
Wanders or paces

Can you name some assistive devices for meals?

Assistive Devices for Meals
Plate guard
Roller knife
Weighted utensils
Two handled cups
Altered handles on utensils
Make sure that the required assistive devices are in place as ordered.

Assisting Patient to Eat

Make sure all items are in plain view and in reach

Encourage patient to assist

Give patient as much time as possible to eat

Provide finger foods when appropriate

Assisting the Visually Impaired Patient

Describe location of food on plate using clock method

Tell patient what the food items are

Feeding a Patient

Allow patient to choose the order of foods when possible

Test food temperature

Do not mix foods together

Alternate bites of food with fluids

Allow patient ample time to chew and swallow

Monitor for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth

Can you name some of different diet consistencies prescribed for patients?

Each patient's diet must be followed as prescribed. Diet consistencies include: Mechanically altered
Ground meat
Pureed
Thickened liquids
Thin liquids

What are some things you should observe for when feeding a patient who has a risk of choking?

Protecting Patients from Aspiration and Choking

Make sure you stay informed of each patient's special dietary and safety needs. This can change at any time.

Some patients can feed themselves, but may only eat with supervision.

Moisten meats and vegetables with gravies or sauces when possible.

Give small bites and sips

Alternate liquids with solids

Instruct the patient to eat slowly, and to chew each bite thoroughly.

Monitor for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth.

For the patient eating in bed, keep head of bed elevated 45 degrees during meal and thirty minutes afterwards.

Check the patient's mouth after meals for pocketed food and debris.

If you think the patient is having chewing or swallowing difficulty with his prescribed diet, notify the charge nurse immediately. This can happen very quickly due to stroke, confusion, or weakness. The patient will be evaluated by the speech therapist or diagnostic tests may be ordered.

How can you tell if a patient is choking, and what should you do?

Call for help immediately.

Perform the Heimlich maneuver. We'll review your handout on this now.
(Review handout with class, demonstrate technique, and have several class members
demonstrate. Answer any questions on technique, and correct errors)
This is also reviewed in the CPR class, and you can ask for a refresher course at any time.