1. Nutrition and Fluid Balance
Chapter 14

2. Weight loss in elderly
Malnutrition, unhealthy weight loss, and dehydration are serious problems among the elderly.
Depression, less sensitivity to taste, decreased gastrointestinal function, low physical activity, and slowing of metabolism contribute to weight loss in elderly.
Food should look attractive, be warm, soft, be one of their favorite, and have pleasant taste in order to improve appetite in elderly.

3. Nutritionist
Sometimes older people have their preference for food and stick to certain foods, like ice cream. We should try to accommodate their choice without compromising nutritional value of food.
It is a challenging task, that’s why most of facilities have a specialist – nutritionist for at least part time.

4. Nutritionist
Monitors weight loss on patients and recommends supplemental nutrition to patients with unstable weight.
Analyzes how much food patients eat and what their preferences and makes recommendations for their menu.
Nutritionist specialty requires Bachelor or Master Degree in Nutrition.

5. Food monitoring Patients with weight loss require food monitoring.
Nursing Assistant responsibility is to record how much and what food patients ate every meal. Then this data goes to the nutritionist.
Monitoring is done in percentage for solid food and ml for fluids
Bread – 50%
Turkey – 20 %
Vegetables – 80%
Starch (mash potatoes) – 100%
Desert 50%
Milk 240 ml
Milk shake 120 ml
Juice 100 ml

6. I=O Intake and output = I&O
Intake – the amount of liquids patient consumed in a given time (shift or 24 hours)
Intake and output should be equal in a given time
Output – the amount of liquids patient lost in a given time (urine, vomiting, diarrhea)
I=O
From the previous slide – what should be counted toward Intake?

7. Fluid balance
Fluid balance occurs when person consumes and eliminates equal amount of fluid
Count of intake and output can be ordered by physician for monitoring certain conditions as CHF – congestive heart failure, and ARF – acute renal failure

8. Urine output less than 240 ml in 8 hours (one shift)
Dangerous signs
Urine output less than 240 ml in 8 hours (one shift)
This is a sign of acute renal failure! Report immediately to the nurse and chart!

9. Signs of fluid misbalance
Dehydration is a condition when there is not enough fluid in the body:
Signs: dry mouth and throat, thirst, dark urine, low blood pressure.
Causes of dehydration:
Difficulty swallowing, not drinking enough fluids during meals, nursing assistant not offering fluids to resident every time they see resident
Fluid overload – too much fluid in the body,
Happens to patients with CHF, CRF, liver cirrhosis, etc
Signs: weight gain more then 1 pound a day, swelling of ankles, feet, hands, increased abdominal grid, dyspnea (difficulty breathing), SOB – fast, shallow breathing
This patients require close monitoring of their I&O and weight, to gave accurate data to MD to adjust treatment

10. Fluid restriction
Can be prescribed by MD to relieve fluid overload in patient
Know the amount of fluids allowed to the patient during a day. It can be as little as 500ml, up to 2000ml per doctor’s order
Monitor I&O closely, count intake during the day not to exceed the daily allowed amount
Diuretics (medications increasing urinary output) can be prescribed by MD to the remove excess of fluid from the body
Urinary output in these patients is much higher then intake, sometimes – 3000 ml a day

11. Liquids count
1 oz = 30 ml

12. Liquids count
Average size cup:
8 oz = 240 ml

13. Liquids count
Small cup
4 oz = 120 ml

14. Liquids count
Big cup, or coffee mug
12 oz = 360 ml

15. Activity Get a medicine 30 ml cup, spoon, and a mug from our kitchen
Using spoon define how many spoons of water fit into the 30 ml cup. Define what a volume of the spoon is.
Using 30 ml cup define how much ml is in your chosen mug
Keep your medicine cup, mug filled with water, and a spoon for the next activity.

16. Exercise – I&Os of a patient
Patient’s intake for the day:
Breakfast – average size mug of coffee
Lunch – 120 ml of milk, 1 cup of milk
Dinner – 120 ml of juice, 12 oz of tea
Output: 1200 ml of urine through the day
Questions: Are I&Os of this patient balanced?

17. Dehydration
Remember that most residents in the nursing home unable to drink without help or even realize that they are thirsty. You can notice their dry mouth and lips and low blood pressure. That would be a sign of dehydration.
Most of residents unfortunately have liquids only during their meals, so even in case they refuse most of their food, try to gently encourage them to finish their liquids.

18. Dehydration Some facilities have Hydration Cards in the hall.
Offer fluids to residents often.

19. Dysphasia and aspiration
If patient has dysphasia (difficulty swallowing), thickening of liquids could be prescribed by speech therapist (specialist in swallowing) to ease swallowing
Liquids are the hardest thing to swallow for patient with dysphasia.
Choking, coughing, and watering eyes during meals are first signs of dysphasia. It is Nursing Assistant responsibility to report it to the nurse or speech therapist
Thickening liquids will be ordered for dysphasia
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20. Nectar thick liquids
Nectar thick liquids are thick as a pulp juice, such as mango or tomato juice

21. Honey thick liquids
Honey-thickened liquids are defined as liquids that coat the spoon. They are pourable, but not runny.
They thick as honey

22. Spoon thick liquids
Stays in spoon when it turn upside down

23. NPO NPO means nothing by mouth
Can be ordered prior to certain procedures and exams
The note NPO will be placed on the door for staff not to give food to the patient
Fasting – is a practice during which food is voluntarily given up for a period of time

24. Homework
Chapter 14 Nutrition WB, test and 10 abbreviations # due on Friday Dec 9
$12 for BLS card
Bring your stethoscope, if you have one, and a watch for tomorrow and for the rest of the week as we will need it for a disaster drill.
Bring canned and dry food for the food drive – points per leadership paper.

25. Six basic nutrients
1. Water – the most essential nutrient for life, solvent for everything. People can’t survive without water for more than 7 days, vs 40 days without food
2. Fats - source of prolonged energy
3. Carbohydrates – fast source of energy, slows down with fiber
4. Proteins – help the body to grow new tissue, essential for immune system.
5. Vitamins – enable chemical reactions in the body
6.Minerals – essential for bones Ca – calcium, fluid balance - Na sodium, Cl chloride, neurons conductivity - K potassium, thyroid function – I iodine

26. USDA My Plate
USDA – United States Department of Agriculture developed the icon My Plate for visualization of healthy eating habits for general public

27. My plate
Is developed in 2011 to provide a general guidelines to people to avoid extremes in their diets.
Principles:
1. Half of your daily menu should be vegetables and fruits
2. Eat more plant based proteins
3. Eat seafood twice per week
4. Consume fat free or low-fat milk (1%)
5. Follow your calorie recommended intake.

28. What is your calorie recommended intake?
Activity: open this site, find out your
BMI
Calorie recommended intake
Protein intake
How many calories are in an apple, a slice of pizza, a hamburger
Recommended weight: Calculator.net
calculator.html?ctype=standard&cage=53&csex=f&ch eightfeet=5&cheightinch=4&cheightmeter=180&print it=0&x=57&y=8

29. Various Diets - NIH site
dlineplus/diets.html
Clear liquid
Full Liquid
Bland, mechanical soft, pureed
Cardiac
Diabetic
Renal
Hepatic
Gluten free
High fiber
Low fiber
Vegetarian
Vegan
Vegan raw
Mediterranean
Calorie count
Low carb
Atkins
South beach

30. How to read Nutrition Facts Label
mers/NFLPM/ucm htm
Activity: How much protein do I need?
htm
ein.html
What are the types of protein? Write it in your notebook.
ein.html#Types of protein

31. Milk: to drink or not to drink? This is a question…
10 min

32. How drinking the diet soda can make you to gain weight?
9 min

33. Feeding the patient Serving meal trays: Serve patients table by table
Check the meal card with the patient’s bracelet to avoid serving wrong food to the wrong patient
Prepare food – open milk cartoons, butter cups, cut the meat in pieces
Do only what resident can’t do for themselves – encourage independence

34. Each patient is unique in their eating habits
Observe and the patient to find out the best approach to their feeding
Follow the aspiration precautions:
Be sure patient swallowed the previous bite before offering another one – observe “Adam Apple” moving

35. Feeding the blind patient
Use the imaginary clock to explain the position of what is in front of them.

36. Test of content 1. Decode a diet order: A. Regular, Regular, Thin
B. NAS, Regular, Nectar
C. Regular, Mechanical soft, Honey
D. Regular, Pureed, Spoon thick
1. Which 8 hours shift I&O you should report immediately?
A. I: 1200 O: 1300
B. I: 1500 O: 2300
C. I: 1100 O:210

37. Test of content What is constipation? What is diarrhea?
What is fluid restriction?