1. Chapter 19 Nutrition and Fluids All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

2. Nutrition   The person’s diet affects physical and mental well-being.   A poor diet and poor eating habits:   Increase the risk for infection   Increase the risk of acute and chronic diseases   Cause chronic illnesses to become worse   Cause healing problems   Affect physical and mental function, increasing the risk for accidents and injuries   Eating and drinking provide pleasure. 2 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

3. Dietary Factors   Many factors affect dietary practices.   Culture   Finances   Personal choice   Dietary practices also include selecting, preparing, and serving food.   The Centers for Medicare and Medicaid Services (CMS) requires that the health team assess the resident’s nutritional status. 3 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

4. Basic Nutrition   Nutrition is the processes involved in the ingestion, digestion, absorption, and use of foods and fluids by the body.   Good nutrition is needed for growth, healing, and body functions.   A well-balanced diet and correct calorie intake are needed.   Foods and fluids contain nutrients.   Nutrients are grouped into fats, proteins, carbohydrates, vitamins, minerals, and water. 4 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

5. Dietary Guidelines   The Dietary Guidelines for Americans 2010 are for persons 2 years of age and older.   They describe a healthy diet as one that: Is high in fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products Includes lean meats, poultry, fish, beans, eggs, and nuts Is low in fats, cholesterol, salt (sodium), and added sugar   The Guidelines also include recommendations for persons at risk for chronic disease.   The Guidelines promote overall health.   They focus on consuming fewer calories, making informed food choices, and being physically active. 5 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

6. MyPlate   MyPlate includes “Steps to a Healthier You.”   The kind and amounts of food to eat daily   Gradual improvement   Physical activity   Variety   Moderation   The right amount from each food group band   Food groups   Grains   Vegetables   Fruits   Dairy   Proteins   Oils 6 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

7. Essential Nutrients   Nutrients   No food or food group has every essential nutrient.   Essential nutrients are those the body must ingest for health.   Protein is the most important nutrient (besides water).   Carbohydrates provide energy and fiber for bowel elimination.   Fats provide energy, add flavor to food, and help the body use certain vitamins.   Vitamins are needed for certain body functions. Vitamins do not provide calories. The body stores vitamins A, D, E, and K. Vitamin C and the B complex vitamins are not stored. 7 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

8. Nutrition ● ●Minerals are used for many body processes.   Bone and tooth formation   Nerve and muscle function   Fluid balance   Other body processes ● ●Water is needed for all body processes.   Food labels are used to make informed food choices for a healthy diet.   Food labels contain information about:   Serving size and number of servings/package   Calories and calories from fat   Nutrients 8 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

9. Factors Affecting Eating and Nutrition   Meeting a person’s nutritional needs requires a team approach.   Culture influences dietary practices, food choices, and food preparation.   Selecting, preparing, and eating food often involve religious practices.   Finances affect the foods people buy.   Appetite relates to the desire for food. 9 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

10. Factors Affecting Eating   Personal choice   Body reactions   Illness   Chewing and swallowing   Disability   Age   With aging, changes occur in the gastro-intestinal (GI) system. 10 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

11. OBRA and CMS Dietary Requirements   Each person’s nutritional and dietary needs are met.   The person’s diet is well-balanced.   Food is appetizing.   Hot food is served hot and cold food is served cold.   Food is served promptly.   Food is prepared to meet each person’s needs. 11 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

12. Meeting Nutritional Needs   Other foods (of similar nutritional value) are offered to residents who refuse the food served.   Each person receives at least three meals a day.   A bedtime snack is offered.   The center provides needed adaptive equipment and utensils. 12 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

13. Special Diets   Doctors may order special diets:   For nutritional deficiency or a disease   For weight control   To eliminate or decrease certain substances in the diet   Regular diet, general diet, and house diet mean no dietary limits or restrictions. 13 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

14. Sodium   The sodium-controlled diet   If there is too much sodium, the body retains more water.   Sodium control decreases the amount of sodium in the body.   The doctor orders the amount of sodium allowed.   Sodium-controlled diets involve: Omitting high-sodium foods Not adding salt to food at the table Limiting the amount of salt used in cooking Diet planning 14 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

15. Diabetic Nutrition   Diabetes meal planning is for people with diabetes.   Diabetes is usually treated with insulin or other drugs, diet, and exercise.   The dietitian and person develop a meal plan that involves: The person’s food preferences Calories needed Eating meals and snacks at regular times   You need to: Serve the person’s meals and snacks on time. Always check the tray to see what was eaten. Tell the nurse what the person did and did not eat. 15 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

16. Dysphagia   The dysphagia diet   Food thickness is changed to meet the person’s needs.   The doctor, speech-language pathologist, occupational therapist, dietitian, and nurse choose the right food thickness.   When feeding a person with dysphagia, you must: Know the signs and symptoms of dysphagia. Feed the person according to the care plan and swallow guide. Follow aspiration precautions. Report changes in how the person eats. Report the following at once:   Choking, coughing, or difficulty breathing during or after meals   Abnormal breathing or respiratory sounds 16 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

17. Fluid Balance   Death can result from too much or too little water.   Fluid balance is needed for health.   The amount of fluid taken in (intake) and the amount of fluid lost (output) must be equal.   If fluid intake exceeds fluid output, body tissues swell with water (edema).   If fluid output exceeds intake, dehydration occurs. 17 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

18. Fluid Requirements and Orders   Normal fluid requirements   An adult needs 1500 mL of water daily to survive.   About 2000 to 2500 mL of fluid per day is needed for normal fluid balance.   The older person is at risk for dehydration and edema.   Some persons have special fluid orders.   Encourage fluids   Restrict fluids   Nothing by mouth (NPO)   Thickened liquids 18 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

19. Intake and Output   Intake and output (I&O) records:   Are used to evaluate fluid balance and kidney function   Help in evaluating and planning medical treatment   Are kept when the person has special fluid orders   All fluids taken by mouth are measured and recorded.   Foods that melt at room temperature are measured and recorded.   The nurse measures and records IV fluids and tube feedings.   Output includes urine, vomitus, diarrhea, and wound drainage.   An I&O record is kept at the bedside.   Amounts are totaled at the end of the shift. 19 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

20. Meeting Food and Fluid Needs   The following can affect appetite and ability to eat:   Weakness, illness, and confusion   Unpleasant odors, sights, and sounds   An uncomfortable position   The need for oral hygiene   The need to eliminate   Pain 20 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

21. Dining Programs   Dining programs meet the needs of the following residents:   Alert and oriented residents   Those who like to eat in their rooms   Those who are confused and noisy at mealtime   Persons who are incontinent or have odor problems   Persons who are too weak or ill to leave their rooms 21 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

22. Types of Dining Programs   The following dining programs are common in nursing centers:   Social dining   Family dining   Low-stimulation dining   Restaurant-style menus   Open-dining 22 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

23. Preparing Residents for Meals   Preparing for meals   Assist with elimination needs.   Provide oral hygiene.   Make sure needed dentures are in place.   Make sure needed eyeglasses and hearing aids are in place.   Make sure incontinent persons are clean and dry.   Position the person in a comfortable position.   Assist the person with hand washing. 23 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

24. Serving Meals   Serving meal trays   OBRA requires that food be at the desired temperature when the person receives it.   You serve meal trays after preparing residents for meals.   Serve trays in the order assigned by the health team.   If food is not served within 15 minutes, recheck food temperatures.   If food is not at the correct temperature, get a fresh tray.   When feeding the person:   Serve food and fluids in the order the person prefers.   Offer fluids during the meal.   Use teaspoons to feed the person. 24 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

25.   Persons who need to be fed may:   Be angry, humiliated, and embarrassed   Be depressed or resentful   Refuse to eat   Let the person do as much as possible.   Always tell the visually impaired person what is on the tray.   For persons who feed themselves: Describe foods and fluids and their place on the tray. Use the numbers on a clock for the location of food.   Allow time and privacy for prayer if the person wishes. Feeding the Person 25 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

26. Feeding the Person (Cont’d)   Meals provide social contact with others.   Engage the person in pleasant conversation.   Sit facing the person.   Persons with dementia may:   Become distracted during meals   Not be able to sit long enough for a meal   Forget how to use eating utensils   Resist your efforts to assist them with eating   Throw or spit food 26 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

27. Between Meals   Between-meal nourishments   Nourishments are served upon arrival on the nursing unit.   Provide needed utensils, a straw, and a napkin.   Follow the same considerations and procedures as for serving meal trays and feeding persons.   Providing drinking water   Residents need fresh drinking water each shift and whenever the pitcher is empty.   Calorie counts   On a flow sheet, note what the person ate and how much.   A nurse or dietitian converts the portions into calories. 27 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

28. Foodborne Illnesses   A foodborne illness (food poisoning) is caused by pathogens in food and fluids.   Report signs and symptoms of foodborne illnesses to the nurse at once.   Signs and symptoms depend on the pathogen.   Food is not sterile.   Pathogens are present when food is purchased.   Foods can become contaminated from other foods.   Food handlers with poor hygiene can contaminate the food.   Pathogens grow rapidly between 40  and 140  F (Fahrenheit). This range is called the “danger zone” by the USDA. 28 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

29. Keep Food Safe   To keep food safe, the United States Department of Agriculture (USDA) recommends four tips:   Clean. Wash hands, utensils, and counter tops often.   Separate. Avoid cross-contamination. Do not let raw meat, poultry, or their juices touch other foods that will not be cooked.   Cook. Cook food to a safe internal temperature. Use a food thermometer to check the internal temperature. When re-heating cooked food, re-heat to 165  F.   Chill. Refrigerate or freeze food within 2 hours. If the air is 90  F or above, chill food within 1 hour. 29 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

30. Quality of Life   Nutrition and fluid balance are important for quality of life.   The right to personal choice is important in meeting food and fluid needs.   Residents have the right to express their preferences.   Persons with dementia may require special measures to meet their nutritional needs.   Sometimes families and friends bring food from home.   OBRA requires that food be served correctly. 30 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.