NSE 111 Week #9 Supporting Nutritional Intake and Oral Hygiene DM F23 (1).pptx

Reminders: • Performance Testing will take place over the next two weeks – Weeks #10 and #11 • Each lab section will be divided into two groups – one group will engage in Performance Testing in Week #10, the other will be in the Simulation Lab. • During Week #11, the groups will switch – more infor...

Reminders: • Performance Testing will take place over the next two weeks – Weeks #10 and #11 • Each lab section will be divided into two groups – one group will engage in Performance Testing in Week #10, the other will be in the Simulation Lab. • During Week #11, the groups will switch – more information will be given by your Lab Instructor • Student guidelines for performance testing are on your shell. Please use them to prepare. • Guidelines for work in the Simulation Lab is also provided. Have fun 2 NSE111 Week #9 Supporting Nutritional Intake & Oral Hygiene © NSE 111 Centennial College Teaching Team Learning Objectives At the end of this week the student will be able to: 1. Discuss factors that affect nutritional intake and status (cognitive/physical limitations). 2. Describe how to promote a client's appetite. 3. Understand the importance of various therapeutic diets 4. Distinguish dysphagia and aspiration pneumonia: signs and symptoms, risk factors, prevention. 5. Discuss safe and effective mealtime assistance techniques: clients who cannot eat independently and/or have dysphagia. 6. Describe the principles for provision of oral care Required Readings/Resources/Activities 1. Potter & Perry: Chap 39 pp.930-936; 2. Potter & Perry: Chap 43 pp.1097-1098; 1103-1111;1115-1120; 1127-1129 3. Meal Assistance Gaming Situation Open Educational Resource: Meal Assistance Virtual Gaming How did you make out with the VGS?? 4. Alzheimer’s Association: Food and Eating Food & Eating | Alzheimer's Association 5. Personal Care Assistant - OER: a) Assisting with meals: Assisting the client during mealtimes b) Assisting client with oral hygiene 6. Mosby Basic Skills Videos (available on LMS at TMU/ Centennial Library, GBC Library) a. Taking aspiration precautions. b. Performing oral hygiene for an unconscious patient Critical Thinking of a Client’s Nutritional Status When assessing nutrition, the nurse must integrate knowledge from nursing and other disciplines, previous experiences, information gathered from patients and families about food preferences, clinical observations, and dietary history. Professional standards, such as Eating Well With Canada's Food Guide (Health Canada, 2007b), provide guidelines for nurses when assessing a client’s nutritional status. Nutrition and the Nursing Process • Goal: assess and collaborate with clients regarding their nutrition • Subjective assessment provides data about • Eating patterns, • Social determinants of health, and • Personal resources • Assess personal goals, concerns and knowledge about nutrition • Collaborate to develop a client specific plan of care, including an evaluation plan (Lapum et al, 2019) Guidelines for Health Professionals • There are three specific guidelines that inform “Canada’s Dietary Guidelines for Health Professionals and Policy Makers” (Health Canada, 2019b). 1. Nutritious foods are the foundation for healthy eating 2. Processed or prepared foods and beverages that contribute to excess sodium, free sugars, or saturated fat undermine healthy eating and should not be consumed regularly 3. Food skills are needed to navigate the complex food environment and support healthy eating (Lapum et al, 2019) Importance of a Balanced Nutritional Intake A healthy diet: • Low in sodium and high in potassium • adequate in calcium and vitamin D • low in saturated fat and trans fat • rich in vegetables and fruit Vitamin & Mineral supplements Limit alcohol and caffeine intake Physical activity (Potter & Perry, 2019, p.11031107) Culture & Nutrition • Meaning for certain foods to client • Consider special patterns of food intake based on religion • Type of diet (e.g. vegan, gluten-free, etc.) • Food intolerances and availability of food preferences • Listen to Yasmin Khatau reflecting on the Canada’s Food Guide 2019 from a cultural perspective: https://ecampusontario.pressbooks.pub/foodguide/chapter/cultural-releva nce/ (Lapum et al, 2019) Religion-Based Dietary Restrictions and Guideline Islam • • • • • • Pork Judaism • Alcohol Caffeine Emulsifiers made from animal fats, especially margarines Ramadan fasting sunrise to sunset for one month Ritualized methods of animal slaughter required for meat ingestion • Pork Predatory fowl Shellfish (eat only fish with scales) Rare meats Blood (blood sausage, etc.) • Do not mix milk or dairy products with meat dishes • Must adhere to kosher food preparation methods • 24 hours of fasting on Yom Kippur, a day of atonement • No leavened bread eaten during Passover (eight days) Christian ity • • Minima l or no alcohol Holyday observ ances may restrict meat Church of Jesus Christ of LatterDay Saints SeventhDay Adventist s • Alcohol • • Tobacco • • Caffeine • • Limit meat • Hinduis m Pork • All meats Shellfish • Alcoh ol • Onion • Garlic Alcohol Vegetari an diet encoura ged (Potter & Perry, 2019, p.1111, Table 42-3) Canadian Nutrition Screening Tool (CNST), 2014 Ask the client the following questions: 1. Have you lost weight in the past 6 months without trying to lose weight? 2. Have you been eating less than usual for more than a week? Note: Two “YES” answers indicate a nutritional risk (Potter & Perry, 2019, p.1113 Table 42-4) Nutritional Assessment • Goes beyond nutritional screening and involves 5 major areas: • Anthropometry • Laboratory tests • Dietary and health history • Clinical observation and physical examination • Patient (Potter & Perry,expectations 2019, p.1113) Obtaining a Dietary History: FASTCHECK Components of a Dietary History Assessment and Questions Food Practices (e.g. type, preferences) Allergies Symptoms (e.g. indigestion, gas, heartburn) 24 hour recall Chewing & Swallowing Hunger (e.g. appetite, satiety) Elimination Patterns Chemical Substances (e.g. medication, alcohol) Potter & Perry, 2019, p.1115 Table 42-5 Diet Progression and Therapeutic Diets • Clear Liquid • Thickened Liquid • Full Liquid • Puréed • Mechanical Soft • Soft or Low Residue • High Fibre • Low Sodium • Low Cholesterol • Diabetic • Regular Potter & Perry, 2019, p. 1127, Box 42-9 Promoting Appetite • Environment that promotes comfort • Eliminate unpleasant odours • Provide oral hygiene as needed • Some medications affect: • Dietary and nutrient intake • Taste • Appetite • Assist client to select foods • Promote social time • Consider food preferences Potter & Perry, 2019, p. 11251126 Assisting Clients with Feeding Befor e feedi ng Durin g feedi ng After feedi ng • Assess risk of aspiration • Upright position • Glasses, hearing aids & dentures in place • Clothing & bedding protected • Open containers as necessary • If helping client eat, sit in line of vision & provide prompting & encouragement • Offer choice & meet requests as necessary • Encourage a social environment associated with meals • Use the clock face method for those with visual impairment • Encourage independence • Document intake • Perform oral hygiene Potter & Perry, 2019, p. 11261128 How would the nurse promote nutritional intake with the client who is visually impaired? Figure 42-08. Using the clock-face method to identify contents and location of food on a plate. Potter & Perry, 2019, p. 1128 Nutritional Intake During Acute Care How can the nurse promote a client’s appetite? Many client’s too uncomfortable or too tired to eat Medications can affect taste, absorption, metabolism & cause nausea Diagnostic tests can interrupt meals; & many tests require clients to be NPO (nil per os / noting by mouth) Nurses must frequently assess the nutritional status of clients & plan interventions to improve appetite & normal dietary intake (Potter & Perry, 2019, p. 11251128) Feeding Strategies for Patients with Dementia • Provide verbal encouragement • Sit down and make eye contact with patient • Determine favorite foods • Provide adequate time • Offer cold water pre meal to increase oral stimulation • May require a quiet environment with less distraction • May need to encourage finger foods • Use hand over hand technique • Prompt by touching utensil to lips • Use distraction / may need to feed patient at another time https://www.youtube.com/watch?v=NYzH_B7XfjY (Chang & Roberts, 2011) Dysphagia • “Difficulty when swallowing.”Potter & Perry, 2019, p. 1102 • “Dysphagia, the impairment of any part of the swallowing process, increases the risk of aspiration. Dysphagia and aspiration are associated with the development of aspiration pneumonia.”Palmer & Metheny, 2008, p. 41, AJN. • Watch the following video to help your understanding of dysphagia https://youtu.be/jK1o3LSQmB0 Dysphagia is more prevalent in what type of clients? What does having dysphagia place the client at risk for? Dysphagia Video • The warning signs of dysphagia include: • Coughing during eating • Change in voice tone or quality after swallowing • Abnormal movements of the mouth, tongue or lips • Slow, weak, imprecise, inconsistent or uncoordinated speech • Abnormal gag reflex • Delayed swallowing • Incomplete oral clearance • Pocketing of food • Regurgitation • Many clients do not show overt signs when food enters the airway (Potter & Perry, 2019, p. 1114, 11171118) • Feeding Strategies for Patients with Dysphagia: Aspiration Precautions • Elevate HOB, hips are flexed at 90 degrees & head flexed slightly forward • Observe client consume various foods • ½ - 1 tsp. of food on unaffected side • Assess for swallowing & other signs of dysphagia • Allow 2 attempts at swallowing • Verbal coaching as necessary • Thicken food / fluids as necessary • Remain upright for 30 minutes WHY? • Assess for pocketing (Potter & Perry, 2019, p. 11171118) Aspiration “Aspiration… [is] … (the misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract)…” (Palmer & Metheny, 2008, p. 45, AJN) •Those at risk for aspiration include • Decreased level of alertness • Decreased cough reflexes or gag reflex • Difficulty managing saliva • Wet, gurgling voice Aspiration Video (Potter & Perry, 2019, p. 1114, 1117-118) Aspiration Pneumonia Any of the following symptoms should alert the practitioner that the patient may have aspiration pneumonia:  Elevated respiratory rate  Fever  Cough  Chills  Pleuritic chest pain  Crackles (rales)  Delirium, increased confusion, or falls Marrie TJ. Clin Infect Dis 2000;31(4):1066-78; Palmer & Metheney, 2008 Airway Obstruction Choking – Emergency Procedures Stop feeding immediately, do not leave the client unattended, and call for help if client experiences: • Excessive coughing • Gagging / gasping for air or struggling to breathe • Client indicates something stuck in their throat • Grabbing at the throat • Turning cyanotic in the lips & face • High pitched noise while breathing • Excessive throat clearing • Face contortions, watering eyes • Gagging or vomiting Assessment for Oral Care • Risk for aspiration • Ability to grasp • Presence of common oral problems • Assess colour, hydration, texture, lesions, gums, tongue, teeth, lips & breath • Look for receding gum tissue, a coated tongue, discolored teeth Potter & Perry, 2019, p.906-908 Safety when caring for someone’s mouth the mouth has the highest and most variety of pathogens than any other orifice of the body. the spatter that can occur when brushing or cleaning someone else's mouth has the potential to enter the eyes or nasal openings of the providerwear mask & goggles or face shield being bitten by the patient would present the same situation as any needle stick injury for the HCP Assess the mouth including… See P&P 2019, p. 908, 932, skill 38-3 for more detail Colour Hydration Lips Breath Pain Infection Inflammation Lesions/fissures/ulcers Missing or loose teeth Risk for aspiration Discoloured teeth coated tongue Receding gums 29 Brushing Essentials • Cleans the teeth • Massages the gums • Removes plaque and bacteria • Relieves any discomfort • Stimulates appetite • 4 x’s / day • Replace toothbrush every 3 months • Ensure supplies labelled • Basics of Brushing Potter & Perry, 2019, p.930-931 Flossing Essentials • Removes plaque and bacteria in between the teeth • Reduces risk of gum disease • 1 x / day • Brush prior to flossing • Unwaxed floss if prone to bleeding • https://youtu.be/SRivxlG8Bmc Potter & Perry, 2019, p.930-931 Denture Care • Denture care • https://youtu.be/vc4hG_8t9nA • Assess if denture fits client • Document cracks or irregularities • Handle carefully • Standard precautions • Remove at night • Rest gums, reduce risk of infection, and prevent bacterial build up Potter & Perry, 2019, p.936 Denture Care • Kept in water when not worn • to prevent warping and facilitate easier insertion • Store in enclosed, labeled cup (not in napkin) • How to take dentures out • Removing Dentures Potter & Perry, 2019, p.936 Risk Factors for Oral Hygiene Problems • Inability to effectively perform oral hygiene • Dehydration • Presence of nasogastric or oxygen tubes • Medications • Trauma to mouth • Immunosuppression • Age related changes • The unconscious client • Clients with diabetes mellitus • Clients receiving chemotherapy, radiation, or nasogastric tube Potter & Perry (2019) Table 38-5, p 913 Oral Care for Those at Risk for Oral Hygiene Problems • For mucosal changes associated with aging & certain drugs • More frequent mouth care • Anti-infective agents • For those with dryness & inflammation of the oral mucosa • More frequent mouth care • Increase hydration • Water soluble lubricant to lips Potter & Perry, 2019, p.931-933 Oral Care for Those at Risk for Oral Hygiene Problems For those with stomatitis/xerostomia • Gentle brushing & flossing/soft bristle toothbrush • Increase frequency of oral hygiene • Increase hydration if permissible • Apply water soluble lubricant to lips • Avoid alcohol & commercial mouthwash • Stop smoking • Normal saline rinses Potter & Perry, 2019, p.931-933 Caring for a client living with dementia…  Optional: RNAO Videos http://www.youtube.com/results?search_query=registered+nurses+associati on+of+ontario+oral+care+for+xersotomia%2C+dysphagia+and+mucositis : Oral Care for Xerostomia, Dysphagia and Mucositis; view parts 1 – 6; Oral Care for Residents with Dementia: view parts 1- 6  Assess resident abilities  Assess functional difficulties  Assess mouth  If resistance, may have to leave and return  Massage TMJ point to relax muscles  Distraction  2 person approach  Hand-over hand technique  2 toothbrush approach Oral Hygiene for the Unconscious Client • Susceptible to drying of mucous-thickened saliva • Unable to handle salivary secretions that accumulate in the mouth • Essentials of Oral Hygiene • Never use fingers to hold mouth open • Assess for gag reflex • Place client in sims position • Rationale? Potter & Perry, 2019, p.934-935 Special Needs: Unconscious Client Discussion: Should the toothette below be used? Oral Hygiene for the Unconscious Client Essentials of Oral Hygiene • Clean mouth using brush or toothette q2h • Check policy for using chlorhexidine • Client may require suctioning while rinsing • Remember to speak to client during procedure Potter & Perry, 2019, p.934-935 Performing Mouth Care for the Unconscious Client or Debilitated Patient Skill 38-4 in P&P ( 2019) pp. 934-935  Unconscious/Debilitated person cannot swallow salivary secretions from mouth therefore requires extra care Increased risk of aspiration pneumonia (gram negative bacteria) Risk for dry inflamed oral mucosa Protect airway (absent gag reflex) Position for oral care: Sims’ Head turned well toward the side towards nurse Bedside suction necessary-requires extra knoweldge to use Insert padded tongue blade back molars when client is relaxed Toothbrush at 45 degree angle Use chlorhexidine solution (check policy) Monitor respirations Moisten lips Why are older Adults at Risk for Poor Oral Hygiene? P&P, 2019, p. 911 and 931 Box 38-11: Focus On Older Persons See Edentulous  Diseased or decayed existing teeth  Periodontal membrane weakens> infection>systemic infection  Chronic illnesses> risk for periodontal disease  Dentures or partial plates may not fit properly (gum changes), causing pain>affect digestive processes, the enjoyment of food, and nutritional status  Weaker jaw muscles and shrinkage of the bony structure of the mouth>chewing fatigue  Age-related decline in saliva secretion and use of many medications>Xerostomia (dry mouth)>poor nutritional status> increased risk and severity of dental problems  Poor nutritional status  Possible hand grasp and strength affected  Don’t seek dental care due to belief that tooth loss is natural  Unable to access care: financial limitations, low income, and lack of transportation also contribute to inadequate dental care of some older adults 42 Let’s talk about the VGS… NSE111 - Meal Assistance - Fall, week 7 2020 43 • Did you like playing the game? • How did you feel after playing the game? • What went well? • Any challenges? • What might you do differently next time? 44 Lets’ consider…. • What places Greta, who has been diagnosed with dysphagia, at risk for aspiration? • What are three (3) signs and symptoms that indicate that Greta is at risk for dysphagia and aspiration • What are four (4) specific actions to implement that would create a safe environment for Greta during mealtime? • What is the purpose of examining Greta's oral cavity for pocketing? Whys is this important? • What appropriate actions did the nurse take when Greta started to cough? • What was the nurse’s response to Greta's request to lie down after her meal? What is the rationale for this response? • In order to prepare yourself for a similar situation in the clinical setting next semester, identify four (4) specific actions that you would take prior to feeding a client with dysphagia. NSE111 - Meal Assistance - Fall, week 7 2020 45 46