Download Eat to your meter - Faculty Web Pages

DR. ED. BARRE
PROFESSOR OF HUMAN
NUTRITION
CAPE BRETON UNIVERSITY
1
NRSG 2201
Nutrition-some basics about
eating management in diverse
populations at different points
over the lifespan
2 November 2016
2
Topics for Today
Glucometers
Assisting to feed
Intake/Output
Special diets
as applied across the lifespan
3
Whole idea of today’s topics is to get each of the
nutrients to where (W) they are needed, when (W) they
are need, in the form (F) they are needed, and in the
quantity (Q) they are needed so as to meet the
metabolic needs of the body to support health and
recovery including meeting and to the extent possible
overcoming the metabolic challenges brought on by
pathology
4
Nutrition-across the lifespan
Glucometers
5
Glucometer
 A glucometer is an electronic device used to test the
amount of glucose in the blood.
 New models are able to read and calculate the blood
sugar within seconds.
 Some models not only display the glucose reading but
also say it.
How a Glucometer Works
 Prick side of finger to get a small about of blood.
 Place a drop of blood on the test strip. This strip interfaces with a digital
meter, enabling it to read the strip.
 Within seconds, blood sugar will be displayed in the meter window.
Blood Glucose Monitoring
What is it?
 Blood Glucose Monitoring is a way of checking the
concentration of glucose in the blood using a glucometer.
What is the purpose?
 Provides quick response to tell if the sugar is high or low
indicating a change in diet, exercise or insulin.
 Over time, it reveals individual of blood glucose changes.
Glucometers-cautions
-manufacturers directions must be followed exactly or get
inaccurate readings
-manufacturers directions include timing and the amount of blood
on the strip and correct supplies
-accuracy also depends on the quality of the meter and test stripsstrips must be compatible with meter
-patient’s ability to correctly use the meter also affects accuracy of
results
-high hct leads to falsely low results and lower hct leads to falsely
high results
-anaemia and sickle cell anaemia affect hct
9
Glucometers-cautions
•
when adding or modifying therapy- monitoring should be more
frequent than usual
• also useful when person is ill or pregnant or has manifestations
of hypoglycaemia or hyperglycaemia
10
Glucometers-cautions
-medications may affect results depending on the glucometer
-uric acid, glutathione and vitamin C are known to interfere with
results
11
Why monitor blood glucose?
 Reduces risk of developing complications with
diabetes.
 Allows diabetics to see if the insulin and other
medications they are taking are working.
 Gives diabetics an idea as to how exercise and food
affect their blood sugar.
 May prevent hypoglycemia or hyperglycemia
Glucometers-when to monitor
• Timing of monitoring depending on client’s diagnosis, general
disease control and physical state
• Type 1 diabetes with multiple daily insulin injections or insulin
pump- monitor at least 2 times per day
• T2D pts who are not using insulin should test frequently enough
to help them reach glucose goals
• Post prandial monitoring is most useful for monitoring glycaemic
control in T2D
13
Glucometers-when to monitor
• When you wake up
• Before meals
• 1 to 2 hours after meals
• Before physical activity
•
15 minutes after physical activity
• Before bed
14
Glucometers-across the
lifespan
Eat to one’s meter
•
Samples before and after a meal to watch
one’s or another’s blood glucose response
to a meal and hence make better food
choices
15
Glucometers-across the
lifespan
Blood Glucose meters for children, and especially for newborns, must have very
important characteristics - minimum volume and rapid results. This is due to the fact
that children usually suffer from insulin-dependent type of diabetes; having a poorly
developed compensatory abilities of the body, they quickly go into a coma, and fast
results can sometimes be vital. Pain upon puncture children's finger should be
minimal
Food and children. What and how much your child eats will affect your child's blood
sugar level. Food can pose a particular challenge for parents of very young children
with type 1 diabetes. That's because young children are notorious for not finishing
what's on their plate, and that's a problem if you've given the child an insulin
injection to cover more food than he or she ate.
If you know this will be an issue, let the child's doctor know so that he or she can
work with you to come up with an insulin regimen that works for the child’s family.
16
Glucometers-across the
lifespan
Children- type 1 diabetes
Children require more frequent glucose monitoring than adults and have different
targets due to erratic oral intake and activity
Results (in part) contribute to decisions about daily insulin dosage in children- best
dose of insulin achieves best control for a child while avoiding hypoglycaemia
Insulin dose may change due to child’s pre-meal blood glucose level- designed to
reach the post-meal glucose target (extra insulin is called the correction factor)
17
School Students-Any Time, Any Place
Monitoring
For students who can self-check:
•
•
•
•
•
•
Improved blood glucose control
Safer for student
Student gains independence
Less stigma
Less time out of class
Assists decision making in response to result
1-800-DIABETES
18
www.diabetes.org
School students-When to Check?
School protocol specifies for an individual
student
Regularly scheduled checks:
•
Routine monitoring before meals and snacks
•
Before, during and/or after physical activity
1-800-DIABETES
19
www.diabetes.org
School students-When to Check?
Per school protocol, extra checks may be
necessary:
• Hypoglycemia or hyperglycemia symptoms
• Change in diabetes management
• Periods of stress or illness
• Prior to academic tests
• Early or delayed release from school
• CGM alarms
1-800-DIABETES
20
www.diabetes.org
Glucometers-across the
lifespan
Blood Glucose meters for the elderly –
• many old people suffer from type 2 diabetes.
• Receiving glucose-lowering drugs require regular monitoring of
blood sugar level easy and affordable way.
• Therefore, the device must be simple in operation, have a robust
design and large display. Low cost will be another advantage
glucometer for the elderly.
21
Glucometers-across the
lifespan
Food and elderly
• The imposition of dietary restrictions on elderly patients with
diabetes in long-term care facilities is not warranted. Residents with
diabetes should be served a regular menu, with consistency in the
amount and timing of carbohydrate.
• There is no evidence to support prescribing diets such as “no
concentrated sweets” or “no sugar added.”
• In the institutionalized elderly, undernutrition is likely and caution
should be exercised when prescribing weight loss diets.
22
Glucometers-across the lifespan
Food and elderly . Older residents with diabetes in
nursing homes tend to be underweight rather than
overweight. Low body weight has been associated with
greater morbidity and mortality in this population.
• Experience has shown that residents eat better when
they are given less restrictive diets.
• Specialized diabetic diets do not appear to be superior
to standard diets in such settings .
23
Glucometers-across the lifespan
Food and elderly
• Meal plans such as no concentrated sweets, no sugar
added, low sugar, and liberal diabetic diet also are no
longer appropriate.
• These diets do not reflect current diabetes nutrition
recommendations and unnecessarily restrict sucrose.
(These types of diets are more likely in long-term care
facilities than acute care.)
24
Glucometers-across the lifespan
Food and elderly
• Making medication changes to control glucose rather
than implementing food restrictions can reduce the
risk of iatrogenic malnutrition (Iatrogenic
malnutrition-malnutrition due to medical
treatment or procedure)
• The specific nutrition interventions recommended will
depend on a variety of factors, including age, life
expectancy, comorbidities, and patient preferences
25
Glucometers-across the
lifespan
• regardless of age, can use glucometers to
confirm hypoglycaemia extent or
hyperglycaemia extent
• decisions regarding carbohydrate intake
and medications-record readings regularly
along with other details related to diet,
activity and stress
26
Your Blood Sugar:
Symptoms of Hypoglycemia
• Shaking
• Fast
heartbeat
• Sweating
• Dizziness
• Anxiety
•
•
•
•
•
Hunger
Impaired vision
Weakness/fatigue
Headache
Irritability
Your Blood Sugar:
Hypoglycemia or Low Blood Sugar
• Causes
– Too little food
– Too much insulin or diabetes medicine
– Extra activity or exercise
• Onset
– Sudden
• May progress to unconsciousness,
confusion, or insulin shock
Your Blood Sugar:
Treatment of Hypoglycemia
4 Steps to treating your blood sugar:
Quick sugar, 10 to 15 grams carbohydrate
Recheck blood glucose in 15 to 20 minutes and
repeat treatment if necessary
3. If your glucose is normal, eat a protein meal or snack
4. If you have symptoms, but BG is over 70, have snack
1.
2.
*Treat all sugars under 70 mg/dl (with or without symptoms)
*If you have symptoms, but no meter, treat and try to be
prepared and have meter with you the next time.
Hypoglycemia or Low Sugar:
Step 1- 10 to 15 Grams of Carbs
Pick One of these
5 to 8 Life
Savers®
1/4 to 1/3 cup
raisins
4 oz. orange juice
8 oz. milk
2 to 3
Glucose
Tablets
½ can of
regular soda
3 to 5 peppermint candies
Hypoglycemia or Low Sugar:
Step 2- Recheck Blood Sugar
Hypoglycemia or Low Sugar:
Step 3- Eat a protein snack
Pick One
½ meat sandwich
peanut butter
sandwich or
crackers
crackers & cheese
Hypoglycemia or Low Sugar:
Foods to avoid for lows
Potato
Chips
Doughnuts
Chocolate
Pizza
Cookies
Nuts
Ice Cream
Cake
Physical Activity: Before You
Begin an Exercise Program...
• Consult your doctor
• Adjust insulin and
carbohydrate, if necessary
• Check your blood sugar before
and after exercising
• Carry fast-acting sugar
• Wear ID
• Use stomach area for shots
Fast acting sugar: 15/15 rule...
• If in hypoglycaemia take 15
grams of carbohydrate and
check blood glucose 15
minutes later
• e.g. ½ cup regular soda or juice
• tablespoon honey
• 4-6 pieces of hard candy
• 15 jelly beans
Hyperglycaemia- symptoms...
• It stands to reason that by
reducing your sugar levels after
meals, this will help to reduce
hyperglycaemia symptoms
Hyperglycaemia- symptoms...
Glucose Control Benefits
 Keeping blood glucose levels as close to normal as possible:
 Few or even no complications
 Normal life span
 Short term benefits of glucose control




Feel better
Stay healthy
Have more energy
Reduce risk of hyperglycemia and hypoglycemia
 Long term benefits of glucose control
 Lower chances of having eye, heart and kidney disease and nerve damage
 Enjoy a better quality of life
Eat to your meter
Take the following steps:
•Test your blood glucose before a meal and record the
result
•Have your meal and record what you ate
•Test your blood glucose levels 2 hours after having
started your meal and record the result
•Test your blood glucose levels 4 hours after having
started your meal and record the result
Also note down any other factor that could affect one’s
blood glucose, this could include any activity carried out
earlier in the day or after eating or any periods of stress
or illness.
39
Eat to your meter
Making sense of the results
• The aims of eating to your meter is in identifying the foods or
meals that lead to a larger rise in your blood sugar levels after
eating and the foods and meals that lead to a smaller rise after
eating.
• This helps you to tailor your diet towards the foods that help you
to meet the guideline blood glucose targets.
• If a meal causes a large rise in blood glucose levels at the 2 hour
mark, you may wish or need to either remove this meal from your
regular diet or look to reduce the size of the portion one had of it.
40
Eat to your meter
Making sense of the results
• Note that it is the rise in your sugar levels you are looking for. To
find the rise, take your result 2 hours after eating and subtract
from this your before meal reading.
• Similarly, it is also worth looking at difference between the result 4
hours after eating and your before meal reading when deciding
whether a meal is suitable for you.
41
An example of eating to your meter
It helps to run through an example to see how eating to your meter can be applied
In the example below, we look at two meals in which we take readings before the meal (A), 2
hour after eating (B) and 4 hours after eating (C).
Before
meal result
(A)
2 hours
after eating
(B)
2 hour
rise
(B-A)
4 hours after
eating
(C)
4 hour
rise
(C-A)
2 egg sandwiches (white bread)
5.0
11.0
6.0
7.0
2.0
Pork chop and swede mash
7.0
11.0
4.0
8.0
1.0
Meal
To assess the best meal for blood glucose levels, we need to look at the columns
marked ‘2 hour rise’ and ‘4 hour rise’.
In this example, the pork chops and swede mash show the best results as it produces a
smaller rise at both the 2 hour and 4 hour mark.
So, in this example, we may want to consider either having egg sandwiches less
regularly in our diet or to test again to see if having egg sandwiches with whole grain
bread produces better blood sugar readings.
Note this is just an example and you may find that you have different results to those
above. The best way to see how your own body responds is to try it out for yourself.
42
Prepare for surprises
• Be prepared to get some surprising results. It’s not
uncommon for people with diabetes to get results that
don’t match their expectations.
• Take porridge as an example, some people find their
sugar levels respond very well to porridge whereas
other members find it can lead to too sharp a rise in
blood glucose levels. Whilst porridge is widely regarded
as being a healthy breakfast, it’s well worth testing to
see whether your body copes well with it.
• Note also, when testing foods or meals, it’s often worth
re-testing foods at least to build up a fair picture of how
it affects your sugar levels as irregular results can
sometimes occur for different reasons.
43
Benefits of eating to your meter
There are a number of benefits to support eating to your meter:
• Allows you to tailor your diet your own individual needs
• We’re all individuals and how different foods affect different
people can vary substantially.
• Eating to your meter helps you to test how much different foods
and meals affect your own sugar levels.
• Effective at reducing high blood glucose levels after meals
• As after meal periods can account for around a third of the day,
improving your after meal blood glucose results can have a
significant effect on lowering your HbA1c.
• Reduce unpleasant symptoms of high and low sugar levels
44
Benefits of eating to your meter
Build confidence in your control
As you begin to build a greater understanding of how
different foods affect your blood glucose levels and your
sugar levels start to improve as a result, this will not only
help you feel better but build your confidence in your
diabetes control.
45
Disadvantages of eating to your meter
• Testing blood glucose levels is an essential part of eating to your
meter so you will need to get used to taking blood tests.
• Blood glucose testing is not always pain free but it has become
easier as technology has improved and most people get used to
and comfortable with testing once the first few tests have been
done.
• In addition, cost can be an issue. If you get blood glucose test strips
supplied this may not be an issue. If your doctor is not happy to
prescribe test strips or only happy to prescribe limited amounts,
you may need to personally buy some of your test strips.
46
Nutrition-across the lifespan
Glucometers-not only for selffeeding but also if assisting to
feed
47
Nutrition-across the lifespan
Assisting to feed
48
Feeding a Patient –0verarching themes

Nurses need to refine their feeding skills to assist patients in
maintaining:
Nutritional Status
Independence
Dignity







Altered activity level
Decreased mobility
Illness
Physical impairments that limit self-feeding such as
hemiplegia, fractured arm, burns, cancer, surgery,
or generalized weakness.
The presence of intravenous catheters or tubing’s,
dressings, and bandages
Some elderly patients may require feeding
assistance because of the physical alterations
associated with aging (young persons too can have
physical alterations due to accident or congenital).
Neurologically or orthopedically impaired patient
who may be unable to manipulate feeding utensils.

Culture

Religion

Personal preference

Mental cognition. When individuals are depressed,
lonely, apathetic, fearful, grieving, or feeling
hopeless, nutritional intake usually decreases.

Being fed by another person may have psychological
implications. The increased need for feeding
assistance may lead to depression, because patients
feel they are a burden to either the staff or their
family.

Remove any unpleasant sights

Remove any obnoxious odors

Clear the over-bed table

Provide good lighting

Set up chair for the nurse







Assist patient to urinate or defecate prior
to the mealtime
Provide oral hygiene
Provide with dentures or eyeglasses
Place in comfortable position
Apply any special devices
Provide with clothing protectors
Assemble needed supplies to facilitate
feeding.






Wash hands before handling food and
serving trays
Identify the diet tray for particular patient
Assess tray for completeness and correct
diet
Prepare tray to meet patient’s needs
Check temperature of food
Place tray at height and position so it is
easy for the patient to access.
Sit in chair next to patient
 Allow patient to eat in order and speed of
choice, and the amount requested
**Do NOT Hurry patient
 Cut food in bite size pieces






Feed patient, putting one type of food on
utensil at a time
Provide fluids as requested
Use time to develop rapport with patient
At end of meal
◦ Wash hands
◦ Provide mouth care
◦ Assist to comfortable position
Document




If patient is at risk for aspiration, check the
gag reflex first.
Check temperature—do not burn patient
Do not feed patient who is asleep,
unresponsive, choking, unable to swallow,
unable to elevate head 450, or whose head
is tilted backwards or downwards.
Feed patients with swallowing difficulties
semi-solid foods that will not choke the
patient.

If a patient questions anything on tray, check
the doctor’s order for possible changes that
the dietary department did not know about.

If the patient should get choked, turn to the
side, sweep any food out of the mouth. If no
food is present, may need to perform the
Heimlich maneuver.

https://moodle.gprc.ab.ca/videos/nursing_
videos/mosby_4th_edition/Basic/skill/F001
.html
Assisted feeding

Dysphagia management- see special diets

Can also include enteral feeding by tube, or
parenteral feeding (peripheral parental nutrition,
and total parenteral nutrition)

Keep track of input/output regardless of how patient
is receiving nutrients
Helping to feed a child with autism
Seven Ways to Help a Picky Eater with Autism
#1 Rule Out Medical Problems
If your child is clamping her lips shut when offered a certain food, it may be that she knows
it will make her stomach hurt. Gastrointestinal distress is common among children with
autism, many of whom can’t easily describe their distress. Your child’s doctor can help you
figure out if this is the case and how to deal with it.
#2 Stay Calm
Many children need to taste a food more than a dozen times before they’re willing to eat it
without a fuss. Children with autism-related sensitivities can take longer. Be patient as your
child explores and samples new foods. If your child continues to reject a food even after a
dozen-plus tries, perhaps he just doesn’t like it. Consider trying a different food. Above all,
don’t let mealtime become a family battleground. Instead, get creative.
#3 Take Steps Toward Tasting
Many individuals with autism are afraid to try new things. Help your child explore a new
food by looking at it, touching it and smelling it. When he’s ready for a taste, he can try
giving the food “a kiss” or licking it before putting a whole bite into his mouth. Sometimes,
mixing a new food with a favorite one can help.
Helping to feed a child with autism
Seven Ways to Help a Picky Eater with Autism
#4 Tune into Textures
Autism often comes with hypersensitivity to textures. So remember
that it may be how a food feels in the mouth, rather than its flavor,
that produces a food aversion. The squishiness of a fresh tomato is
a classic example. Try chopping or blending such foods to smooth
out the offending texture. That tomato, for example, can be
chopped into salsa or blended and cooked into pasta sauce.
#5 Play with New Food
That’s right. Playing with a new food is another way to build
familiarity and decrease mealtime anxiety. Together, try painting
with pasta sauce. Use veggies to make faces on pizza. Use cookie
cutters to cut sandwiches into fun shapes. While you’re playing, let
your child see you taste — and enjoy — the food.
Helping to feed a child with autism
Seven Ways to Help a Picky Eater with Autism
#6 Offer Choices and Control
Your loved one with autism may need to feel some control over
what she puts into her mouth. It’s also okay to simply not like some
foods. So try to offer a broad variety and allow choices within the
categories you care about. For example, you might decide that your
child needs to have one serving of vegetables and one of protein for
dinner. So put five types of these foods on the table and allow your
child to choose at least one vegetable and one protein. Along the
same lines, if you’re making a favorite dish such as pasta, ask your
child to add one mystery ingredient for other family members to
discover during the meal. She gets to choose: corn, broccoli or
chicken?
Helping to feed a child with autism
Seven Ways to Help a Picky Eater with Autism
#7 Be Careful with Rewards
In the long-run, it’s important to reward and reinforce your child’s
flexibility with food and willingness to try to new foods. But blatant
bribes can backfire. Your child may eat the food, but won’t learn to
enjoy it or understand why it’s important to eat a well-rounded diet
— and that’s the goal. Let dessert and treats be part of meals and
snacks, but don’t use them as carrots to get your child to eat …
carrots.
Case Example
• K.S.
– 4 year old male
– Autistic Disorder
– Preferred (Self fed): Doritos, Vanilla wafers
– Non-preferred (caregivers presented): pureed
foods, Pediasure, liquids
– Feeding involved
• 3 adults to complete
• Special highchair designed to restrain child
• Syringe for depositing liquids
– No growth concerns
Target Population
Chronic food refusal:
Volume and/or Variety
Severe problem
behavior during
meals
-Crying
-Disruptions
-Elopement
-Aggression
VS
• 380 calories
• 2 grams of saturated fat
• 10 grams of dietary fiber
• Key micronutrients:
Vitamin A
Thiamin
Riboflavin
Niacin
Vitamin B12
Vitamin C
Vitamin D
Vitamin E
Folate
Calcium
Iron
Magnesium
Zinc
• 720 calories
• 8 grams of saturated fat
• 4 grams of dietary fiber
• Key micronutrients:
Thiamin
Riboflavin
Niacin
Vitamin C
Calcium
Iron
Magnesium
•No quantities of:
Vitamin A
Vitamin B12
Vitamin D
Vitamin E
Folate
Zinc
Medical Impact
Long term medical sequelae
Hediger et al.
(2008)
Does high
consumption of fats
and snacks?
Egan, Dreyer, Odar, Beckwith, &
Garrison, 2013
Cardiovascular
disease and
cancer
Quality of Life
Disrupted family
meals & further
limitations in
social
interactions
Required to
prepare multiple
menus for each
meal
Increased
parental stress
regarding health
and
development
Reduced
opportunities to
eat at
restaurants or
social occasions
Assessment of
Feeding Concerns
General Behavioral Concepts
Treatment must involve:
Persistence
with a
Feeding
Demand
Escape Extinction
Levels• Ignoring negative statements
• Non-removal of the plate
• Non-removal of the spoon
• Physical guidance
Exposure with Response Prevention
Recognition
of
Appropriate
Behaviors
Differential
Reinforcement
Types• Praise and attention
• Access to preferred activities
• Consumption of preferred food
• Escape / break
General Behavioral Concepts
• Reasonable Demand
• Match feeding demand to child’s response during
meals
• Increase demand after stability (Must take data!!!!)
– 3 meals with no problems behaviors, double the
bite size
• Manipulation: Portion size, bite volume, food texture,
mealtime variety
Feeding an ASD child
• Increase structure and routine:
– Regular meal/snack schedule
– Meals involve a table with age appropriate seating
• Differential Attention
– Provide attention and praise for appropriate mealtime
behaviors• Accepting bites, swallowing, eating properly with a
spoon, trying a new food, or staying seated
throughout the meal
– Ignore minor behavior problems
• Whining, negative statements regarding food,
messy eating (if age appropriate)
Feeding Recommendations
1) Gradually introduce feeding demands by presenting bites
on spoon. Ignore disruptions, limit prompting
2) Use a toy or video throughout the meal
3) Record mealtime behaviours to guide introduction of new
foods or increasing the bolus
4) Empty spoon initially (rapid acceptance and no
disruptions or crying)
5) Short meal length at the beginning- 5 bites to start (each
bite is ¼ then ½ then a level teaspoon (food should be in
very small pieces, mashed, or pureed based on child’s
response
6) Increase to 10 bites and then to 20 bites per session
7) As child increases acceptance (swallows more than 80% of
bites) of a new food increase number of bite and bite size
76
Feeding Recommendations
Want to avoid frustration
77
Pediatric Feeding Disorders
INTERVENTIONS: POSITIONING
•Limited, but positive evidence that positioning interventions
improve oral intake and skill in children with cerebral palsy
•Videofluoroscopy may be helpful to determine optimal
position for feeding
•Key factors for positioning older children
• Goal – Most function with the least support/restriction
• Stable pelvis in neutral position
• Supported feet!
• Neutral or slightly flexed head
• Arms forward and free to move
6/01/20
13
DR. RACHEL STANKEY,
OTD, OTR/L
7
9
INTERVENTIONS: REFLUX
•Lack of high-quality evidence to support or refute the
efficacy of thickening feeds in infants with reflux
*
6/01/20
13
DR. RACHEL STANKEY,
OTD, OTR/L
8
0
INTERVENTIONS: SENSORY
•There is expert opinion that sensory-based
interventions are effective at improving number and
variety of accepted foods in children with sensory
processing issues
FEEDING AND MEALTIMES SHOULD
BE FUN!!
•Exploration and play with food
•Find new ways to interact with food
•Consider the sensory properties of food
•“Stretch” sensory horizons
6/01/20
13
DR. RACHEL STANKEY,
OTD, OTR/L
8
1
INTERVENTIONS:
STRUCTURE
•There is expert opinion (consistent across disciplines) that
creating structure around food and mealtimes is important when
working with children with feeding disorders
•How?
• Environment (positive place)
• Time (3 meals, 2-3 snacks, water between meals, food first,
then drinks)
• Consistent preparatory activities (warn of transitions)
6/01/20
13
DR. RACHEL STANKEY,
OTD, OTR/L
8
2
INTERVENTIONS: OTHER
STRATEGIES
•Work on mealtime relationships; “positive tilt”
•Consider the size of the bolus; aim for success!
•Try pretend play with real food
•Fun tools and toys
6/01/20
13
DR. RACHEL STANKEY,
OTD, OTR/L
8
3
Assisting to feed- Feeding the Older
Resident
Preparing the Dining Area
•
Facility staff should sanitize and dry the tables.
•
Ensure the dining area is a pleasant, enjoyable atmosphere by eliminating odors and
controlling lighting.
•
Ensure table heights are appropriate for the residents to comfortably reach the food.
(Ideally, wheelchair arms should fit underneath the table.)
Preparing the Resident for Meals
Before eating, we normally do several things to prepare for mealtimes. You should care for
residents as you would care for yourself or for your loved ones.
Before the meal:
•
Ensure the resident is comfortable and clean. This requires communicating with the
nurse aides and nurses to ensure the resident has been toileted, has had their face and hands
washed, and has good oral hygiene.
•
Be sure the resident has dentures in, glasses on and clean, and hearing aides in, as
appropriate.
•
Provide clothing protectors as needed.
•
Ensure the resident is positioned appropriately (ask facility staff to reposition the
resident if needed).
How to Serve Trays
•
Carry the tray away from your body, one tray at a time.
•
Identify the tray by the name on the tray card.
•
Verify that the tray contains the right food for the resident.
•
Identify the resident and place the tray within easy reach of him or her.
You MUST make sure the right resident gets the right tray with the right food.
Encouraging Independence
You should promote independence in eating by encouraging residents to do whatever
they can for themselves. Encourage them to hold and eat finger foods, hold and use a
napkin, and participate in feeding any way they can. Independence with eating may
have an impact on the residents' feelings of self-worth and good health. Special
feeding devices (also called adaptive devices) may be very helpful in promoting
independence. Self-feeding is frequently the last activity of daily living that residents
can do independently, and it is very difficult when they become dependent on others
for such a basic human need.
Every Resident has Unique Needs
The facility may have special instructions for individual residents available in the dining
room or on the tray card. Check for special instructions and follow them as needed.
Nurse aides and nurses may tell you some specific needs of a resident.
Residents who are mostly independent but need occasional help need to be checked
on throughout the meal to ensure all their needs are met.
Watch for those who don't eat 75% of their meal or who leave a whole food item.
Encourage residents to eat their food. Ask if the resident would like something to
replace an uneaten item, then request a substitute from the kitchen.
You should assist those who spill food; obtain extra condiments if needed; and
refill coffee cups as needed.
Basic Guidelines for Assisting Older Residents
• Feed a resident the way you would want to be fed.
• Offer assistance in an unobtrusive manner. Don't offer help when none is
needed.
• Be guided by the resident's wishes.
• Don't control the resident's food choices. Respect their individuality.
• Don't rush residents.
• Sit with residents. Don't stand above residents when assisting.
• Always use positive comments to describe the food. Example: "This is
spaghetti and meat sauce, and boy does it smell good!"
• Identify pureed foods for residents. The pureed diet is usually the same as
the regular diet, but if you are not sure what the food is, be sure to ask.
• Take time to talk to the resident and socialize with the resident. Make him or
her feel comfortable with the process.
• Offer liquids at intervals between solid foods.
• Use a straw for liquids if the resident can manage it.
• Offer liquids that meet the resident's preferences.
• Utensils and cups suitable for patient
• Stable routine and schedules
Older Residents Who Need Assistance with Eating
Residents have several levels of need. Feeding assistants will offer different types of assistance
based on the resident's needs.
There are three types of assistance:
Minimal assistance
Cueing and prompting (provided along with minimal assistance)
Total assistance (or feeding the resident)
Minimal Assistance
Older residents who need minimal assistance may be able to feed themselves, but have
difficulty with setting up their meals.
These residents may need help with the following tasks:
Putting on a clothing protector
Unwrapping or uncovering drinks, opening milk cartons, or placing straws in beverages
Uncovering food
Spreading margarine on toast or bread
Adding margarine to hot cereal
Cutting meat
Opening condiment packages
You should:
Offer to add salt and pepper, cream and sugar, syrup, jelly, and other condiments to the food
items served. (Never add any of these without first asking the resident. Some residents may be
able to do this themselves).
Offer to cut sandwiches into quarters (four).
Verbal Cueing and Prompting
This is the next level of assistance.
Residents who need verbal cueing and prompting can feed themselves but may be easily
distracted or have difficulty staying on task. They need minimal assistance as well as some
cueing or prompting.
Verbal Cues
You may say something to get the resident back on track. Cues should be very brief directions.
Avoid multiple step instructions.
Examples of verbal cues
Resident Action
Your Cue
Resident stops eating.
"Take a bite of your eggs, Mrs. Smith." or "Take another
bite."
Resident doesn't drink liquids during the
meal.
"Take a drink now."
Resident plays with food.
"Pick up your spoon, Mr. Jones."
Resident forgets to chew (has food in the
mouth).
"Chew, Mrs. Johnson." or "Chew some more."
Physical Prompts
You may use touch to get the resident back on track.
Examples of physical Prompts
Resident Action
Resident stops eating.
Your Cue
Point to the food.
Resident stops eating while holding a fork or Touch the resident's hand to draw attention to the fork
spoon.
or spoon.
Hand-over-hand Feeding Technique
Hand-over-hand feeding is a method that may serve as a prompt for the resident to complete the
task on his or her own.
Place your hand over the resident's hand and complete the task together. Be sure to sit on the
same side as the hand you are assisting. If a resident is weak but knows what to do, using the
hand-over-hand technique helps the resident maintain or improve self-feeding ability.
When the Hand- over-hand Technique is Useful
The hand-over-hand technique may be used when a resident:






forgets how to eat;
is unable to cut food;
is unable to spread margarine or jelly on toast or bread;
cannot lift utensils;
cannot pierce food with a fork; or
is too tired to feed him- or herself as the day progresses.
Total Assistance (Feeding a Resident)
This next level of assistance is provided when the resident needs to be fed.
Guidelines For Feeding a Resident:







Fill the spoon half full and offer from the tip of the spoon. Place the spoon in the middle of the
resident's tongue.
Continue at an unhurried pace.
Offer most nutritious foods first: meat, milk, starch, vegetable, etc. Offer desserts and
supplements last.
Alternate liquids and solids to make the meal more enjoyable and to ease swallowing. This also
helps to ensure the resident gets needed fluids.
Do not indicate impatience with residents who eat slowly. Allow residents ample time to eat. Try
to make mealtime relaxing and enjoyable.
Wipe the resident's face with a napkin as needed.
Be sure to offer alternatives or substitutes if the resident does not like what is offered, or if the
resident is not eating well (eats less than 75% of his or her meal).
Monitoring Mealtime






Allow all residents (regardless of the level of assistance they require) ample time to eat.
Encourage socialization.
§Remain pleasant and unhurried.
Try to avoid or control unpleasant situations.
Monitor the intake of residents during mealtime and identify problems with eating.
Notify the charge nurse of residents who are absent or who appear to have eating problems.
Removing Trays




Remove the tray after the resident has finished eating.
Ensure that meal intake is recorded by the person responsible before removing the tray (or
follow your facility's policy).
Place used trays on the cart AFTER all the clean trays have been served.
Wash your hands.
If you observe any of these problems, you must ensure that the charge nurse is aware of them.
Eating Problems
Possible Interventions
The resident chews
constantly or overchews food.
Tell the resident to stop chewing and to swallow after food has been
appropriately chewed. Encourage or offer smaller bites.
The resident eats
too fast.
Encourage the resident to set his or her spoon or fork down between bites to
slow down the eating rate. Explain the benefits of slower eating to the resident
(i.e., avoid choking, enjoy the meal by being able to taste the food, and improve
digestion by taking time to chew food thoroughly).
The resident eats
too slowly.
Provide verbal cues such as "chew," "take another bite," or "try some more."
Praise the resident for positive efforts to feed him- or herself within a reasonable
time frame.
Adaptive Devices
Sometimes, adaptive measures or tools are needed for the resident's comfort and independence.
Adaptive equipment or eating utensils are substitutes for motions lost due to a resident's
disability. The resident's disability may be from different causes such as the loss of use of a hand
or arm, weakness, vision problems, or tremors (shaking that a resident cannot control).
Knowledgeable professionals, such as an occupational therapist, should select adaptive devices
for residents. The adaptive device should be provided to the resident at every meal.
Examples of Adaptive Devices




Weighted utensils: Utensils with enlarged weighted handles that are easy to grasp
Long-handled utensils: Utensils with long handles
Plate guard: A metal or plastic ring that snaps onto the edge of the plate. The resident is able to
gather food on a spoon by pushing the spoon against the edge of the plate guard.
Nosey cup or nose cutout cup: A cup with a cutout "u" for the nose to allow the resident to
drink without bending his or her head back.
Restorative Dining
Restorative dining refers to a program that provides increased assistance for residents. The
restorative dining room may be a table, a corner of the dining room, or a separate dining room. A
trained therapist determines whether residents benefit from an individualized therapy plan.
Nutrition-across the lifespan
Intake/Output
Important in assist to feed
96
Intake output refers to fluids- usually what is meant by intake/output
However….
Intake output may also refer to food in and watching bowel movements in addition to fluid
intake/output
Intake- 24 hour recall-everything eaten and drunk (quantities over last 24 hours)
-3 dairy food diary- record usually 2 weekdays and 1 weekend day
-food frequency questionnaire-frequency of consumption of approximately 125
line items over a defined period
http://sharedresources.fredhutch.org/sites/default/files/FFQ-GNA-Sample.pdf
Output- patient versus normal 24 output for urine
-whether patient has had bowel movements
Intake vs output
Why is intake versus output
important?
Fluid balance is key to:
-blood pressure
-adequate distribution of water for its functions
-correct concentrations of molecules and atoms to
meet their functions
98
Intake vs output
So assuming appropriate bodily
hydration, intake must equal output
99
Intake vs output
-we do not drink enough to match our needs so must make
up the fluid shortfall by consuming foods with water in
them and by making water
-we make water by metabolic processes which also
contributes up the shortfalls
100
Fluid-intake
• Fluid intake
Oral fluids
Ice chips
Liquid foods
Foods that become liquid at room
temperature
 Tube feedings
 Parenteral fluids, IV medications
 Catheter, tube irrigants




Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Fluid-intake by type and numbers
• Fluid intake
 Oral fluids (1200-1500 ml in healthy person)
 Ice chips
 Liquid foods (750 ml in healthy person)
 Foods that become liquid at room temperature
 Tube feedings
 Parenteral fluids, IV medications
 Catheter, tube irrigants
 Metabolic water-made in our bodies- (200 ml
per day in healthy person)
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Fluid-Output
• Fluid output
 Urine-major route of output (1400-1500 ml
per day if healthy)
 Loss through skin (300-400 ml per day) and as
perspiration (100 ml per day if healthy)and as
water vapour via respiration (300-400 ml per
day if healthy)
 Vomitus
 Liquid feces (100 ml per day if healthy)
 Tube drainage (gastric, intestinal)
 Wound drainage including fistulas
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Regulating Body Fluids
• Fluid balance
-kidneys are major control (e.g. lose
more in sweat or in other ways and
kidney puts out less in urine)
-kidneys are major control (e.g. lose
less in sweat or in other ways and
kidney puts out more in urine)
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Measuring fluid intake and output
Most agencies have an intake and output
form
Must note type and amount of each intake
and output
Patient to be instructed not to put toilet
paper in with any output- why?
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved

https://moodle.gprc.ab.ca/videos/nursing_
videos/mosby_4th_edition/Basic/skill/F003
.html
NCLEX-RN (1)
The nurse is completing the intake
and output record for a client who
had an abdominal cholecystectomy
2 days ago. The client has had the
following intake and output
during the shift.
Intake
4 oz of orange juice 1 oz = 30 ml
½ serving of scrambled eggs
6 oz of water
½ cup (120 ml) of fruit-flavored gelatin
1 cup of chicken broth
400 cc of 0.45% sodium
chloride (half-strength saline), IV
Output
1,000 ml of urine
120 ml of drainage from the T-tube
How many milliliters should the
nurse document as the client’s intake?
Source: www.ncsbn.org
Special diets
108
Special diets
the idea is to get each of the nutrients to where (W)
they are needed, when (W) they are need, in the
form (F) they are needed, and in the quantity (Q)
they are needed so as to meet the metabolic needs
of the body to support health and recovery
including meeting and to the extent possible
overcoming the metabolic challenges brought on by
the pathology
109
Specific Nutritional Needs
Patients with:
 Allergies
 Anemia
 Cancer
 Diabetes
 Hypertension
 Heart disease
Patients with:
 Lactose
sensitivity
Patients who are:
 Pregnant
 Overweight
 Children
Specified Modified Diets
Used to treat or prevent certain conditions.
Specific modified diets include changes for:
 Texture
 Nutrient level
 Frequency
 Timing of meals
 Exclusions

Clear liquid
◦ Contains liquids that are thin and without
pulp or foods that liquefy at room
temperature.
◦ Most often used after surgery on stomach
or bowel, or with patients with diarrhea of
vomiting
◦ Examples:
 Apple juice, ginger ale. Gelatin
 Decaffeinated coffee, tea, broth
 Fruit ices, or Popsicles
◦ Temporary diet

Full liquid
◦ Addition of calories, about 1500 and
provides more nutrients than a clear liquid
diet
◦ step between clear liquid and solid diet
◦ Examples:
 Milkshakes, all juices
 Blenderized foods
 Custards and puddings
 Eggnog
 Creamed soups

Soft Diet
◦ Used as a transition to the regular diet or
for those who have difficulty eating
◦ Designed to be chewed and provide
minimal fiber.
◦ Low in fiber and devoid of brans, grains,
strong vegetables, raw fruit or vegetables
◦ Mechanical soft – food is chopped,
ground, or pureed-for those with
difficulty with chewing / poor teeth

Dysphagia diet
 Texture and consistency of diet (food and
drink) is such that the patient can swallow
easily- different textures and
consistencies based on the relative extent
of the ability to swallow
 Pureed foods can be thickened, shaped so
as to appear like normal food rather than
baby food

Dysphagia diet

Dysphagia diet

Kidney diet
◦ Used for patients with kidney disease.
◦ Protein restriction with restrictions of
fluid, sodium, potassium, phosphorus
Cystic fibrosis
https://www.cfireland.ie/pdf/
Paediatric_Nutrition_CF.pdf
Digestive enzymes and hydrolysed
proteins can be given to overcome
digestive compromise in these patients
119
Dietary Regimen-cystic fibrosis
 High calorie diet
 Recommendations: 120-150% RDA
 35-40% calories from fat
 Enzymes with every meal and snack
 Vitamins, supplements
 Tube feedings at night
Interventions That May Help Anorexia
• Serve food attractively and season it according to
individual taste.
• Schedule procedures and medications when they are
least likely to interfere with meals, if possible.
• Control pain, nausea, or depression with medications as
ordered.
• Provide small, frequent meals.
• Withhold beverages for 30 minutes before and after
meals.
• Offer liquid supplements between meals.
• Limit fat intake if fat is contributing to early satiety.
Anemia (iron deficient) Dietary
Guidelines
• Eat foods rich in iron-red meat, dark green
vegetables, cereals
• Eat foods rich in vitamin C- citrus fruits, green
vegetables-helps improve iron absorption from iron in
plants
Powerpoint Templates
Page 122
COELIAC DISEASE
Powerpoint Templates
Page 123
What is Coeliac Disease?
A disease where gluten causes an autoimmune
response which inflames the small intestine reducing
the ability to absorb nutrients
• Gluten is a protein.
• It is found in wheat, rye, oats and barley and their
products.
Powerpoint Templates
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Dietary Guidelines
(Think GUIDE)
•
•
•
•
•
Gluten-free diet should be followed.
Use gluten-free products.
Include naturally gluten-free foods.
Dieticians recommendations should be followed
Eating processed foods requires being able to
understand food labelling
Powerpoint Templates
Page 125
Avoid
•Bread
•Pasta
•Biscuits
•Cakes
•Sausages
•White sauce
•Pastry
•Soups
•Sauces etc.
Gluten free foods
(natural)
•Fruit
•Vegetables
•Meat
•Fish
•Yoghurt
•cheese
Powerpoint Templates
Gluten free food products
available
Gluten free flour
used for
making....
•Gluten free
biscuits
•Gluten free
cakes
•Gluten free
breads
Page 126
Coronary Heart Disease
Powerpoint Templates
Page 127
Dietary guidelines
• Decrease the overall fat content
• Use fish and chicken as
your source of protein
instead of red meat
which is high in saturated
fat (and cholesterol).
• Reduce salt intake
Powerpoint Templates
Page 128
• Increase fibre intake
e.g. oats, bran, fruit and
vegetables as they
reduce LDL levels
• Use mono and poly unsaturated sources
of oil (they reduce LDL levels and
reduce hardening of arteries)
Monounsaturated fats like olive oil
Polyunsaturated fats like corn oil
Powerpoint Templates
Page 129
Therapeutic Lifestyle Change (TLC) diet
•
Component
TLC Diet
•
Total fat
25-35% of total calories*
•
Saturated fat
<7% total calories
•
Polyunsaturated fat
Up to 10% of total calories
•
Monounsaturated fat
Up to 20% of total calories
•
Trans fat
•
Carbohydrate** 50-60% of total calories
•
Dietary fiber
20-30 grams per day
•
Protein
15-25% of total calories
•
Cholesterol
<200 mg/day
•
Sodium
<2,300 mg/day
•
Dietary options
•
Plant sterols/stanols Add up to 2 grams per day
•
Soluble fiber
•
Fish (fatty fish) Include in weekly eating plan
•
* allows an increase of total fat to 35% of total calories and a reduction of carbohydrate to
50% in persons with metabolic syndrome and/or at risk for type 2 diabetes.
•
** Carbohydrate should derive predominantly from foods rich in complex carbohydrates
including grains (especially whole grains) and fruits and vegetables.
Lower intake
Increase 5-10 grams per day
Type 1 Diabetes
Dietary Guidelines
1. Reduce saturated fat intake, as
a high fat intake could lead to
coronary heart disease
2. Salt intake should be low, as salt
increases the risk of high blood
pressure
3. Maintain a high fibre diet
Powerpoint Templates
Page 131
Type 2 diabetes
Dietary Guidelines
1. Body weight should be
reduced by eating fewer
calories
2. The intake of saturated fat
should be reduced
3. The intake of fruit &
vegetables, which are healthy
alternatives to sugary
snacks, should be increased
4. Salt intake should be kept
low
5. Low glycemic index(low GI)
foods should be consumed as
they release energy slowly
eg. starch
Powerpoint Templates
Page 132
Dietary Guidelines for Tackling
Obesity
1. Weight Loss – gradual weight loss is more effective
than excessive weight loss
2. Increase the intake of fruit & vegetables
3. Increase the intake of high fibre foods
4. Reduce the intake of saturated fat
5. Avoid convenience foods, which are high in salt, fat
and sugar
6. Eat a balanced diet – follow the food pyramid
7. Drink plenty of water
8. It is important to consult
doctor
PowerpointaTemplates
Page 133
Hypertension- The DASH eating plan
DASH Food Groups
DASH Daily Servings
(except as noted)
DASH Serving Sizes
Vegetables
4-5
250 mL (1 cup) raw leafy vegetables
125 mL (½ cup) cooked vegetables
170 ml (6 oz) juice
Fruit
4-5
1 medium piece of fruit
63 mL (¼ cup) dried fruit
125 mL (½ cup) fresh, frozen or canned fruit
Grains
(mainly whole grains)
7-8
1 slice bread
250 mL (1 cup) ready to eat cereal
125 mL (½ cup) cooked rice, pasta or cereal
Low Fat or No-Fat Dairy Foods
2-3
250 mL (1 cup) milk
250 ml (1 cup) yogurt
50 g (1½ oz) cheese
Lean meats, poultry and fish
2 or less
3 ounces cooked lean meats, skinless poultry,
or fish
Nuts, seeds and dry beans
4-5 per week
1/3 cup (1.5 oz.) nuts
30 mL (2 tbsp) peanut butter
2 tbsp (1/2 oz.) seeds
1/2 cup cooked dry beans or peas
Fats and Oils
2-3
5 ml (1 tsp) soft margarine
15mL (1 tbsp) low-fat mayonnaise
30 mL (2 tbsp) light salad dressing
5 ml (1 tsp) vegetable oil
Summary
Glucometers
Assisting to feed
Intake/Output
Special diets
135
Whole idea of today’s topics is to get each of the
nutrients to where (W) they are needed, when (W) they
are need, in the form (F) they are needed, and in the
quantity (Q) they are needed so as to meet the
metabolic needs of the body to support health and
recovery including meeting and to the extent possible
overcoming the metabolic challenges brought on by
pathology
136
Glucometers, assisting to feed,
tracking intake/output, and
special diets can be connected
to one another…
How?
137
Glucometers, assisting to feed,
tracking intake/output, and
special diets help accomplish
WWFQ
How?
138
Questions??
139
10 multiple choice exam
questions from me for each of
Professor Bailey’s classes
140
1) Canada’s food guide dictates serving size based on:
a)
b)
c)
d)
Age
Gender
a and b
None of the above
141
1) The best measure of central adiposity is:
a)
b)
c)
d)
Waist circumference
BMI
a and b equally
BMI and height equally
142
3) Glucometers, assist to feed, intake/output and special
diets are best directed at getting nutrients to go _____________
needed in the body so as to maintain or improve health :
a)
b)
c)
d)
Where and when
In the form
In the quantity
All of the above
143
4) Which type(s) of diet(s) is/are specifically directed at
lowering blood pressure?
a)
b)
c)
d)
DASH
TLC
Mediterranean
All of the above
144