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Patients 10 daily needs Observation Nutrition overview Swallowing evaluation and feeding Week 2, day 6, September 8, 2009 Lesa McArdle, RN Ukiah Adult School, LVN Program Today’s objectives Ten Daily Needs List the ten daily needs of all patients. Discuss the "ways & means" that these needs might be met with a variety of patients. Observation Define observation as it relates to the nursing profession. Discuss skills/tools necessary for observation. Evaluate the use of observation in defining the patients' needs and setting criteria to meet these needs. Recognize the relationship of communication and observation. Diets for Varying Needs Perform a basic nutritional assessment. Describe special diets used in the treatment of patients and the purpose of each diet. Describe basic food groups and general nutrition for adults and children. Swallowing Evaluation and Feeding Guidelines Assess the patients' swallowing ability and know what precautions are necessary for feeding, as well as appropriate foods to be eaten. Demonstrate appropriate feeding techniques for the disabled patient. List resources available to patient and family for assistance. Ten Daily Needs 10. Diversional & rehabilitative activities 9. Adjustments, physical & mental 8. Emotional & spiritual support 1. Personal care & hygiene 2. Sleep & rest 10 Daily Needs of the Patient 7. Medical treatment & care 6. Environment 3. Nutrition & fluids 4. Elimination 5. Body alignment & activity Observation in nursing Two essential parts of communication are listening and observing Observing for both verbal and nonverbal communication Non-verbal communication Body position Facial expression/gestures Moaning/crying Laughing /smiling Observation What do you need to look and listen for? Patients cultural background Perception of the illness Use of direct eye contact Body language, relaxed or tense Quality of the patients voice, loud, soft, hurried Use of gestures Emotional tone Does the verbal message match the non-verbal Gastrointestinal System Digestion and absorption Regulators of GI activity Digestive process Mechanisms of absorption Factors affecting digestion Psychological state Bacterial action Food processing Energy Energy is the capacity to do work Energy expenditure Measurement of metabolic rate BMR Energy measurements and calculations Carbohydrates Definition and composition Classification and food sources Dietary fiber Recommended dietary allowance Lipids Transport and storage Metabolism Recommended dietary allowance Food sources Proteins Definition and composition Amino acids Metabolism Deficiency Evaluation of protein quality Vitamins Fat-Soluble Vitamin A Vitamin D Vitamin E Vitamin K Water-Soluble Thiamine Riboflavin Niacin Vitamin B6 Folate Vitamin B12 Vitamin C Panthothenic acid Biotin Water Largest component of body and body tissues Provides form and structure to cells Essential to digestion, absorption, and excretion of metabolic and indigestible wastes Intake is controlled by thirst There is no way to store water Age-Related Changes Energy Renal Sensory Musculoskeletal Gastrointestinal Immunocompetence Metabolic Psychosocial Cardiovascular Guidelines for Dietary Planning Food Guide Pyramid Recommended Daily Allowance Food labeling National Guidelines for Diet Planning Dietary history information Principles of Nutrition Nutrition in Nursing Nutritional status: the state of balance between nutrient supply (intake) and demand (requirement) imbalance between intake and requirement can result in overnutrition or undernutrition Nurse’s Role and the Nursing Process Nurse’s role in facilitating nutritional care Communicate with the registered dietitian (RD) Serve as a liaison between the physician and the RD Identify clients who may benefit from programs such as Meals on Wheels Request a referral to a speech therapist Confer with the discharge planner, social services worker, and physical or occupational therapist Nutritional screening Nutritional screen: a quick look at a few variables to judge a client’s relative risk for nutritional problems Can be custom designed for a particular population (e.g., pregnant women) or for a specific disorder (e.g., cardiac disease) Nutritional assessment Nutritional assessment: an in-depth analysis of a person’s nutritional status In the clinical setting, nutritional assessments focus on moderate- to high-risk patients with suspected or confirmed protein-energy malnutrition Nutritional history Through a routine history and physical, nurses can identify who may be at nutritional risk Chronic or acute changes in health can impact nutritional status by altering intake, digestion, metabolism, or excretion of nutrients Nutritional risk A client may be at nutritional risk because of what he/she does or does not eat Ask open-ended, non-leading questions to ascertain usual intake Neither BMI nor “ideal” body weight may reliably assess health risk related to weight if muscle mass is large or edema is present Physical S&S and medications Significant weight loss increases the risk of poor nutrition even if the weight loss was intentional Medications and nutritional supplements should be evaluated for their potential impact on nutrient intake, absorption, utilization, or excretion Physical signs and symptoms of malnutrition are nonspecific, subjective, and develop slowly--suggestive but not diagnostic Physical S&S of malnutrition: Hair is dull, brittle, dry, or falls out easily Swollen glands of neck and cheeks Dry, rough, or spotty skin Poor or delayed wound healing or sores Thin appearance with lack of subcutaneous fat Muscle wasting Edema of lower extremities Weakened hand grasp Depressed mood Abnormal heart rate/rhythm, BP Enlarged liver or spleen Loss of balance, coordination Nursing diagnoses related to nutrition Nursing diagnoses relate directly to nutrition when the client’s intake of nutrients is too much or too little for body requirements Many other nursing diagnoses relate indirectly to nutrition because nutrition contributes to the problem or solution Nursing diagnoses with nutritional relevance Altered nutrition: more than body requirements Altered nutrition: less than body requirements Altered nutrition: risk for more than body requirements Constipation Diarrhea Fluid volume excess Fluid volume deficit Nursing diagnoses with nutritional relevance (cont’d) Risk for aspiration Altered oral mucous membrane Altered dentition Impaired skin integrity Noncompliance Impaired swallowing Knowledge deficit Pain Nausea Nutrition priorities A nutrition priority for all clients is to obtain adequate calories and nutrients based on individual needs Sometimes it is necessary to prioritize nutrient needs Help the client to formulate nutrition goals that are measurable, attainable, and specific Short-term nutrition goals attain or maintain adequate weight and nutritional status avoid nutrition-related symptoms and complications of illness (as appropriate) Long-term nutrition goals to promote healthy eating to avoid chronic diet-related diseases such as heart disease, hypertension, obesity, and type 2 diabetes How to promote adequate intake Reassure clients who are apprehensive about eating Encourage a big breakfast if appetite deteriorates throughout the day Advocate discontinuation of intravenous therapy as soon as feasible Replace meals withheld for diagnostic tests Promote congregate dining if appropriate Question diet orders that appear inappropriate How to promote adequate intake (cont’d) Display a positive attitude when serving food or discussing nutrition Order snacks and nutritional supplements Request assistance with feeding or meal setup Get patient out of bed to eat if possible Encourage good oral hygiene Solicit information on food preferences How to facilitate client/family teaching Listen to client’s concerns and ideas Encourage family involvement if appropriate Reinforce importance of obtaining adequate nutrition Help client to select appropriate foods Counsel client about drug-nutrient interactions Avoid using term “diet” Emphasize things “to do” instead of things “not to do” Keep message simple Review written handouts with client Advise client to avoid any foods not tolerated Diet: a four letter word The term diet inspires negative feelings in most people Replace it with eating pattern, eating style, or foods you normally eat to avoid negative connotations ** Nutrition recommendations for clients Keep in mind that intake recommendations are not always appropriate for all persons clients’ needs change what is recommended in theory may not work for an individual clients may revert to comfort foods during periods of illness or stress Nutrition counseling Counseling = teaching + brainstorming Help client understand and implement intake recommendations Nurses can reinforce nutrition counseling done by the dietitian and initiate counseling for clients with low or mild risk Nutrition counseling (cont’d) Use preprinted lists of “do’s and don’ts” only if absolutely necessary such as in the case of celiac disease For most people, actual food choices should be considered in view of how much and how often they are eaten rather than as foods that “must” or “must not” be consumed How to stay on top of client’s nutrition Observe intake whenever possible to judge adequacy Document appetite and take action when client does not eat Order supplements if intake is low or needs are high Request a nutritional consult Assess tolerance (i.e., absence of side effects) Monitor progress (e.g., weight gain) How to stay on top of client’s nutrition (cont’d) Monitor progression of clients on restrictive diets: NPO clear liquid diet receiving enteral or parenteral nutrition Monitor client’s grasp of information and motivation to change Case Study #1 Mary Jansen is a 56-year-old black female in relatively good health. She is 5’5” tall and weighs 174 pounds. She tells you, “Ever since I went through menopause, I’ve gained weight and just can’t seem to take it off, no matter what I try… and I’ve tried all of the diets – Weight Watchers, Atkins, South Beach – you name it, I’ve tried it. I know if I can I lose some weight, I’ll have more energy and feel better, but nothing seems to work. I guess it’s just a part of normal aging.” Case Study #2 Annabelle K. is a 15-year-old high school student. She comes to the medical clinical for a school-related physical examination. When she walks into the examination room, you note that she has a very thin appearance. She tells you, “I’ve been on a diet. Now I can become a model like I’ve always dreamed. What do you think? I’m going to be the next big super model!” When you ask her about her daily food intake, she tells you, “I don’t eat a lot. I need to keep my weight down so I can model. I usually have a diet soda in the morning – that’s my morning caffeine – then an apple or small salad – no dressing -- for lunch, then whatever my Mom makes for dinner – but only half a portion.” When you ask her about her normal daily activities, she tells you, “I go to my classes in the morning, then I have modeling lessons in the afternoon. I do my homework at night or watch TV or practice modeling.” During your examination, you note that her hair and skin are dry and that she has slight edema of her ankles. She has weak muscle strength and a weak hand grasp. Therapeutic & Modified Diets Therapeutic Diets Modified consistency and texture Restricted fluid intake Clear liquid Sodium restricted Full liquid Pureed Mechanical or dental soft No added salt to very strict Fat modified Low fat Fat controlled Soft Diabetic (ADA) High-Fiber Potassium modified Diet as tolerated Lactose intolerant Feeding the patient Use the clock… Causes of Dysphagia Myogenic – muscular Aging Dermatomyositis Muscular dystrophy Connective tissue disorder of unknown cause Syndrome effecting muscle strength Myasthenia gravis Autoimmune disorder causing muscle fatigue Causes of Dysphagia Neurogenic – nerve Lou Gehrigs disease Amyotrophic lateral sclerosis – nerve damage Cerebral palsy Diabetic neuropathy Guillan-Barre Syndrome Multiple sclerosis Parkinsons Stroke Causes of Dysphagia Obstruction Anterior mediastinal mass Benign peptic stricture Cadidiasis Cervical spondylosis Esophogeal webs Head or neck cancer Trauma or surgical resection Zenker’s diverticulum Signs of dysphagia Assessing for Dysphagia / Difficulty swallowing Cough after swallowing May be weak or delayed Slow tongue movements Slow speech, weak or uncoordinated Pocketing of food Dysphagia can lead to aspiration Fluid or food in the lung Feeding the dysphagic patient Use a penlight and tongue blade to gently inspect mouth for pockets of food. Elevate head of the bed so hips are at 90-degree angle and head is flexed slightly forward (or use same position in chair). Observe client consume various consistencies of food and fluids. Add thickener to thin liquids to create consistency of honey. Place 1/2 to 1 tsp of food on unaffected side of mouth. Place hand on throat to gently palpate swallowing as it occurs. Feeding the dysphagic patient (cont’d) Provide verbal coaching while feeding. Observe for coughing, gagging, choking; suction as needed. Maintain upright position for 15 to 30 minutes after feeding. Provide mouth care after meals. Advance diet to thin liquids then to thicker foods, as tolerated.
