1. Nutritional needs of the chronically ill Nutritional needs of the chronically ill Jana Hermanova 3 rd Faculty of Medicine Charles University, Prague

2. What does it involve? Nutritional intake Eating habits Altered nutrition Nutritional assessment Nutritional care planning Healthy foods Special diets Artificial feeding Nutrition and the end-of-life care

3. Factors affecting nutrition Eating habits and food preferences are the major factors Eating habits are influenced by: developmental stage gender ethnicity and culture beliefs about food personal preferences

4. factors influencing food intake (continued) religious practices lifestyle medications and therapy health alcohol consumption advertising psychologic factors

5. Altered nutrition Malnutrition  undernutrition (BMI < 19)– insufficient nutrient intake  overnutrition – (BMI > 26) – overweight, obese, morbidly obese, (obese people can suffer from undernourishment!)

6. BMI Weight in kilograms BMI =________________ (Height in meters) 2 60 kilograms ___________ = 26.6 1.5 x 1.5

7. Guide for BMI evaluation < 16 malnourished 16–19 underweight 20-25 normal 26-30overweight 31-40 moderately to severely obese > 40morbidly obese B. Kozier, 2004

8. Undernutrition Causes inadequate food intake improper digestion and absorption of food – (conditions?) Related symptoms weight loss weakness decreased functions delayed wound healing prone to infection impaired pulmonary functions

9. Causes of inability to eat Hemiparesis Impaired fine motor skills Vision impairment Anorexia Swallowing problems Lack of energy Lethargy Environmental factors

10. Overnutrition Increases the stress on body organs Predisposes to chronic problems (e.g. hypertension, diabetes mellitus) May present complications in providing care

11. Let’s talk multidisciplinary! Nurses Doctors Nutritional therapists Physiotherapists Asses – plan – intervene – evaluate! Who is missing? Ergotherapists/OT Social workers Psychologists Pharmacists

12. Nutritional assessment nurse, physician, dietitian (nutritionist) components: general appearance nutritional screening nursing history physical examination calculating percentage of weight loss dietary history laboratory data anthropometric measurement

13. MinimalNutritionalAssessment

14. Monitoring

15. Care planning Goals  Maintain optimal status  Promote healthy practices  Prevent complications of malnutrition  Decrease weight  Regain weight

16. Interventions Reinforce teaching of the dietitian/nutritionist Create an atmosphere that encourages eating Assist with eating Monitor the client’s appetite and intake Administer enteral and parenteral feeding Consult with the physician and dietitian

17. “We were only feeding the patients…” “giving a cup of coffee or water can be a spiritual work”

18. Special diets Consistency modifications  Clear liquid – water, tea, broth, clear juices, popsicles, coffee  Full liquid – ice cream, yogurt, cream soups, butter, peanut butter, scrambled eggs  Soft diet – chopped shredded meat, mashed potatoes, canned fruit, pasta

19. Czech dietary system Special diets 0-S tea (clear liquids) 1-S liquid, high calorie 4-S strict low fat 9-S diabetic light Basic diets 0 – liquid 1 - soft 2 – light 3 - regular 4 – low fat 5 – low residue 6 – low protein 8 – low calorie 9 – diabetic 10 – low salt, light 11 – high calorie

20. Feeding accessories - cups

21. Utensils for feeding people with weak grip and other problems

22. Plate guards

23. When patients cannot eat Mrs. E, 37, has had her first cycle of treatment for AML. She has not tolerated her treatment very well, has been vomiting a lot, had diarrhea and has developed painful stomatitis… Mr. H, 59, has suffered from a degenerative muscle disease. He has come to the point that it is very difficult for him to swallow anything…

24. Enteral feeding NG nasogastric tube NE nasoenteral tube PEG – percutaneous endoscopic gastrostomy PEJ – percutaneous endoscopic jejunostomy Intermittent Continuous Cyclic By gravity By syringe – bolus By enteral feeding pump Aspiration precautions

26. PEG tube and pump

27. PEG tube

28. Parenteral feeding Central line (CVC) Peripheral line – limited to a short time and low osmolarity solutions 10 - 20% G (D5W) TPN (all-in-one) Fat emulsion Continuous feeding Cyclic feeding Risks of TPN ◦ Infection ◦ Occlusion of the catheter ◦ Intestinal disuse

29. When patients don’t want to eat Mrs. A, 96, on admission to nursing home states: “I am not going to eat and I do not want you to feed me or use any other means of providing nutrition” Mrs. B, 78, with deteriorating dementia. Few weeks ago she was interested in finger- foods but recently has been refusing meals and has become combative during feeding attempts

30. End-of-life care – ethical considerations Artificial nutrition – yes or no? What about fluids? Does hunger and thirst hurt? When to withdraw? Who decides?

31. Thank you for attention Thank you for attention