1. Chapter 16 Nutrition and Hydration

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

3. 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.

4. 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.

5. 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.

6. 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.

7. 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)

8. 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.

9. 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

10. 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.

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

12. 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

13. 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

14. 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.

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

16. 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.

17. 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.

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

19. 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 

20. 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.

21. 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.

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

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

24. 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

25. 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%.

26. Source
Eliopoulos, C. (2005).  Gerontological Nursing, (6th ed.).  Philadelphia: Lippincott, Williams & Wilkins (ISBN ).