Chapter 16 Nutrition and Hydration

Components of the Nutritional Assessment History Physical Examination Biochemical Evaluation Cognition and Mood Anthropometric Measurement

History Review health history and medical record for evidence of diagnoses or conditions altering the purchase, preparation, ingestion, digestion, absorption, or excretion of foods. Review medications for those that can affect appetite and nutritional state. Assess patient’s description of diet, meal pattern, food preferences, and restrictions. Keep a diary of all food intake for a week.

Physical Assessment Inspect hair. Inspect skin. Test skin turgor. Note muscle tone, strength, and movement. Inspect eyes. Inspect oral cavity. Observe person drinking or eating for difficulties.

Biochemical Evaluation Obtain blood sample for screening of: Total iron binding capacity Transferrin saturation Protein; albumin Hemoglobin; hematocrit Electrolytes; vitamins Prothrombin time Obtain urine sample for screening of specific gravity.

Cognition and Mood Test cognitive function. Note alterations in mood, behavior, cognition, level of consciousness. Be alert to signs of depression. Ask about changes in mood or cognition.

Anthropometric Measurement Measure and ask about changes in height and weight. Determine triceps skinfold measurement (TSM). Measure the midarm circumference (MC) with a tape measure (using centimeters). Use this to calculate midarm muscle circumference (MMC) with formula: MMC in cm = MAC in cm – (0.314 x TSM in mm)

Factors Contributing to Reduced Need for Calories of the Elderly The older body has less body mass and a relative increase in adipose tissue. Adipose tissue metabolizes more slowly than lean tissue and does not burn calories as quickly. Basal metabolic rate declines 2% for each decade of life. The activity level for most older adults is usually lower than it was during younger years.

Harris-Benedict Equation (REE) Males 66 + [13.7 x weight (kg)] + [5 x height (cm)] – [6.8 x age] = kcal/day Females 655 + [9.7 x weight (kg)] + [1.8 x height (cm)] – [4.7 x age] = kcal/day

Recommended Diet for Elderly Should contain calories of a high quality including: Fibers <30% total calories from dietary fat. At least 1 g protein per kg body weight daily; approximately 15% daily calories from proteins.

Examples of at Risk Nutrition-related Conditions for Women Heart disease Cancer Osteoporosis

Hydration Total body fluids are reduced with age, thereby contributing to the risk for dehydration. Older adults require approximately 1500 ml fluid daily. Factors that may cause elders to consume less fluid: Reduction in thirst sensation Fear of incontinence Lack of accessible fluids

Signs of Periodontal Disease Bleeding gums, particularly when teeth are brushed Red, swollen, painful gums Pus at gumline when pressure is exerted Chronic bad breath Loosening of teeth from gumline

Nutritional Supplements Inquire about supplement use during the assessment. Increasing numbers of people are using nutritional supplements on a daily basis. Supplements can compensate for inadequate intake of nutrients. Supplements can interact with medications.

Reasons for Increased Ingestion in the Elderly Decreased stomach motility Less gastric secretion Slower gastric emptying time

Non-Pharmacologic Measures for Managing Indigestion Eat several small meals rather than three large ones. Avoid or limit fried foods. Identify and eliminate specific foods from the diet to which an intolerance exists. Sit in a high Fowler position while eating and for half an hour after meals. Ensure adequate fluid intake and activity.

Forms of Dysphagia Transfer Dysphagia Difficulty moving food from the mouth to the esophagus. Transport Dysphagia Difficulty moving food down the esophagus. Delivery Dysphagia Difficulty moving food from the esophagus into the stomach.

Causes of Dysphagia Neurological conditions, such as a stroke Most cases are due to gastroesophageal reflux disease (GERD).

Factors to Consider When Assessing Swallowing Problems Onset Types of foods that present the most problems Solids or liquids Occurrence Consistent or periodical Other symptoms and related complications Aspiration Weight loss 

Nursing Measures for Swallowing Difficulties Have the person sit upright whenever food or fluid is being consumed. Allow sufficient time for eating. Assure there is no residual food in the mouth before feeding additional food. Place small portions in the mouth. Discourage the person from talking while eating.

Nursing Measures for Swallowing Difficulties (cont.) Keep a suction machine readily available. Monitor intake, output, and weight. Tilt the head to a side and placing food on a particular part of the tongue. Correct underlying problems.

Causes of Constipation in the Elderly Slower peristalsis Inactivity Side effects of drugs A tendency toward less bulk and fluid in the diet.

Measures to Prevent Constipation Drink plenty of fluids. Eat plenty of fruits and vegetables. Exercise regularly. Allow adequate time for a bowel movement.

Factors That Increase the Risk for Malnutrition Reduced taste and smell sensations Slower peristalsis Decreased hunger contractions Reduced gastric acid secretion Less cells on intestinal surface

Clinical Signs of Malnutrition Weight loss greater than 5% in the past month or 10% in the past 6 months. Weight 10% below or 20% above ideal range. Serum albumin level lower than 3.5 g/100 mL Hemoglobin level below 12 g/Dl. Hematocrit value below 35%.

Source Eliopoulos, C. (2005).  Gerontological Nursing, (6th ed.).  Philadelphia: Lippincott, Williams & Wilkins (ISBN 0-7817-4428-8).