Nutrition, Hydration and Oral Health PDF

Nutrition Chapter 14 Copyright © 2020 by Elsevier, Inc. All rights reserved. Nutrition  Adequate nutrition is a key factor in maintaining the health of older adults  Adequate diet is an important factor in delaying onset and managing chronic illness associated with aging  The quality and quantity...

Nutrition Chapter 14 Copyright © 2020 by Elsevier, Inc. All rights reserved. Nutrition  Adequate nutrition is a key factor in maintaining the health of older adults  Adequate diet is an important factor in delaying onset and managing chronic illness associated with aging  The quality and quantity of diet are important factors in preventing, delaying onset, and managing chronic illnesses associated with aging  Age related changes affect GI system(box 14-1) Copyright © 2020 by Elsevier, Inc. All rights reserved. Copyright © 2020 by Elsevier, Inc. All rights reserved. Nutrition Dietary Recommendations  Fats: less than 10% of total calories, limit saturated fat and trans fatty acids  Protein: increase for older adult who tends to experience protein deficiency when ill; minimizes frailty  Fiber: 25 grams fiber recommended daily (Box 14-4)  Vitamins and minerals: consumption of five servings of fruits/vegetables provides adequate A,C,E, and potassium; changes of aging contribute to decreased absorption of B12 Copyright © 2020 by Elsevier, Inc. All rights reserved. Factors Affecting Fulfillment of Nutritional Needs  Age related changes in taste and smell  Lifelong eating habits  Socialization  Chronic diseases and conditions  Polypharmacy, Inactivity, High-fat, high-volume meals  Socioeconomic deprivation  Transportation  Side effects of medications  Oral health status Copyright © 2020 by Elsevier, Inc. All rights reserved. Nutrition Screening & Assessment (Box 14-14)  Several screening tools available  Minimum Data Set—includes risk factors and triggers for further evaluation  Interview and physical examination  Anthropometrical measurements  Weight/height considerations  Biochemical analysis/measures of visceral protein Copyright © 2020 by Elsevier, Inc. All rights reserved. Promoting Healthy Aging: Implications for Gerontological Nursing (Cont.) Interventions  Formulated around specific problems  Nurses hold a pivotal role in ensuring adequate nutrition to promote healthy aging  Collaboration with interprofessional team  Considerations: modification of environment, supervision, feeding techniques that enhance intake and preserve dignity and independence  Evaluate the outcome Copyright © 2020 by Elsevier, Inc. All rights reserved. Nutritional Problems in Institutional Setting Feeding Assistance  Estimated that 50% of all residents unable to eat independently  Inadequate staffing is associated with poor nutrition and hydration  The Centers for Medicare and Medicaid Services implemented a rule that allows feeding assistance, with 8 hours of approved training  See Box 14-15 Copyright © 2020 by Elsevier, Inc. All rights reserved. Obesity (Overnutrition)  Obesity is a global epidemic and major public health concern  It is associated with increased costs, functional impairments, disability, chronic disease, and admission to nursing home  More than a third of persons over 65 years are obese  Obesity paradox: some research found that persons who survived to 70 years had lower mortality rate if they were overweight  What are some other concerns related to obesity or overnutrition?  Identify cues, s/s, risk factors, identify/prioritize hypothesis, prioritize interventions, identify lab values Copyright © 2020 by Elsevier, Inc. All rights reserved. Malnutrition  Rising incidence in acute care, long-term care, and in the community  Institutionalized older adults at high risk for malnutrition due to chronic disease and functional impairments  Increased risk of infection, pressure ulcers, anemia, hip fractures, hypotension, impaired cognition and increased morbidity and mortality  Comprehensive screening and assessment is critical to identify older adults at risk  Identify cues, prioritize/formulate hypothesis, & interventions Copyright © 2020 by Elsevier, Inc. All rights reserved. Risk Factors for Undernutrition and Assessment Copyright © 2020 by Elsevier, Inc. All rights reserved. Dysphagia  Common problem of older adults  As many as 60% of nursing home residents demonstrate clinical evidence of dysphagia  A serious problem with negative sequelae including weight loss, malnutrition, dehydration, aspiration pneumonia, and even death.  Identify cues, s/s, risk factors, formulate/prioritize hypothesis, identify interventions, evaluate Copyright © 2020 by Elsevier, Inc. All rights reserved. Unfolding Case A  Jeb Smith is 80 years old and recently went to live in assisted living. He has lost 10 lbs recently without trying. His daughter discusses the situation with the nurse.  What are some interventions that might help?  Hint: Box 14-15 & 14-16 Copyright © 2020 by Elsevier, Inc. All rights reserved. Improving Nutritional Status in Institutionalized Settings & Acute Care  Family involvement when possible  Use of nutritionally dense supplements with medication pass  Restorative dining rooms sit with those of like interests  Consideration of ethnic food choices  Easy access to refreshment stations with juices, water, and healthy snacks  Food preferences and liberal diet as possible  Finger foods  Visually appealing pureed foods Copyright © 2020 by Elsevier, Inc. All rights reser Unfolding Case B  Jeb Smith has a history of Parkinson’s and he had pneumonia twice last year.  What other health problems are risk factors for dysphagia?  Hint: Box 14-11 Risk Factors for Dysphagia  Cerebrovascular accident (CVA, stroke)  Parkinson’s disease  Neuromuscular disorders: amyotropic lateral sclerosis (ALS), multiple sclerosis (MS), myasthenia gravis  Dementia  Head & neck cancer  Traumatic brain injury  Aspiration pneumonia  Inadequate feeding technique  Poor dentition Copyright © 2020 by Elsevier, Inc. All rights reserved. Unfolding Case C  Jeb has begun having problems swallowing meds, drools periodically, and has a wet, gurgling voice.  What other signs & symptoms would the nurse assess for that could indicate dysphagia?  Hint: Box 14-12 Signs and Symptoms of Dysphagia  Difficult, labored swallowing  Wet or gurgling voice  Excessive throat clearing  Drooling  Food or liquid leaking from  Copious oral secretions nose  Coughing, choking at meals  Prolonged eating time  Holding or pocketing of food  Discomfort during swallowing in the mouth  Difficulty chewing  Nasal voice or hoarseness  Sensation of something stuck in throat during swallowing Copyright © 2020 by Elsevier, Inc. All rights reserved. Unfolding Case D  Jeb has been diagnosed with dysphagia after a barium swallow test with the speech therapist. The CSD or speech therapist has posted interventions to help with swallowing during meal times.  What interventions does the nurse anticipate to assist with feeding?  Hint: Box 14-13 Interventions for Dysphagia Box 14.13  Provide a rest break before meals  Sit at 90 degrees during all po intake & maintain for atleast ___ hour.  Adjust rate of feeding & size of bites  Alternate solid and liquid boluses  Have the person swallow twice before the next mouthful  Stroke under the chin downward to initiate swallowing  Follow speech therapist recommendations for safe swallowing  Keep suction equipment ready  Supervise all meals  Monitor temperature, observe phlegm  Visually check the mouth for pocketing food in cheeks  Check for food under dentures Copyright © 2020 by Elsevier, Inc. All rights reserved. Unfolding Case E  Jeb’s condition has worsened and even with swallowing techniques he continues to aspirate food and fluids. He does not have an advanced directive and the family agrees to a PEG.  What are the nursing responsibilities in caring for someone with a PEG, G-tube or nasogastric tube? Identify nursing safety interventions and actions when giving medications through a PEG or other enteral feeding tube?  Hint: Think about skills class, see safety alert in ch 9 geropharmacology Safety Alert – Enteral Feeding  “Be A.W.A.R.E” enteral feeding safety campaign  Medications administration and feeding tubes  Do not add medication directly into an enteral feeding formula  Administer each medication separately  Flush tube before and after each medication is administered  Dilute solid or liquid medications as appropriate  Administer each medication using a clean oral or enteral syringe  See safety alert pg 108. Copyright © 2020 by Elsevier, Inc. All rights reserved. Question 1 What is the estimated number of institutionalized older adults who are unable to eat independently? a. 40% b. 50% c. 60% d. 70% Copyright © 2020 by Elsevier, Inc. All rights reserved. Hydration & Oral care Chapter 15 Copyright © 2020 by Elsevier, Inc. All rights reserved. Hydration Management  Water is important for thermoregulation and dilution of water-soluble medications, facilitates bowel and renal function, and maintains metabolic processes  A significant number of older adults drink less than 1 liter of fluid/day, less than the recommended amount of 1500 mL/day  Adequate fluid consumption and maintenance of fluid balance is essential to health Copyright © 2020 by Elsevier, Inc. All rights reserved. Hydration Management (Cont.)  Age-related changes affecting hydration  See Box 15-1 for changes  Other contributing factors include medications, functional impairment, and other comorbid conditions like diabetes  Identify cause of dehydration in elderly:  Identify risk factors for dehydration: (Box 15-4) Copyright © 2020 by Elsevier, Inc. All rights reserved. Dehydration  Significant issues associated with dehydration: thromboembolic complications, kidney stones, constipation, falls, medication toxicity, renal failure, seizure, electrolyte imbalance, hyperthermia, and delayed wound healing  Majority of older people develop dehydration from increase fluid losses combined with decreased fluid intake, related to decreased thirst  Risk factors for dehydration include... (Box 15-4) Copyright © 2020 by Elsevier, Inc. All rights reserved. Dehydration (Cont.) Signs and symptoms  Often atypical in the older adult  Skin turgor is not a reliable indicator in older adults  Look for dry mucous membranes in mouth and nose, furrows on the tongue, orthostasis, speech incoherence, rapid pulse, decreased urine output, extremity weakness, dry axilla, and sunken eyes. Copyright © 2020 by Elsevier, Inc. All rights reserved. Dehydration (Cont.) Laboratory tests and urine  Labs: serum sodium, serum and urine osmolarity, and specific gravity  Most cases of dehydration have an elevated blood urea nitrogen (BUN); however, there are many other causes for elevation of BUN/creatinine ratio  Observe urine color for Copyright © 2020 by Elsevier, Inc. All rights reserved. Dehydration (Cont.) Interventions  Based on comprehensive assessment, risk identification, and hydration management  Monitor closely and implementation of intake and output is essential  Oral hydration is the first treatment approach  Water is the best fluid to offer  Tips for best practices: Ongoing Management of Oral Intake in Long-Term Care (LTC) (Box 15-5) Copyright © 2020 by Elsevier, Inc. All rights reserved. Dehydration (Cont.) Rehydration  Depends on severity and type of dehydration  Intravenous  Replace 50% of loss within first 12 hours or sufficient quantity to relieve tachycardia and hypotension  Monitor for overhydration…???  Hypodermoclysis  Infusion of isotonic fluids into the subcutaneous space  Not for severe dehydration Copyright © 2020 by Elsevier, Inc. All rights reserved. Oral Health  Dental health increasingly neglected with advanced age  Poor oral health associated with dehydration, malnutrition, and other systemic diseases  Not reimbursed by Medicare  Few older adults have private dental insurance  Tips for best practice: Promoting Oral Health (Box 15-6)  Healthy People 2020: Dental Health Goals for Older Adults pg.195 Copyright © 2020 by Elsevier, Inc. All rights reserved. Common Oral problems  Xerostomia (mouth dryness) and hyposalivation  30% of older adults affected  Affects eating, swallowing, speaking  More than 400 medications cause hyposalivation  Treatment: review medications, good oral hygiene, adequate water, avoid alcohol and caffeine, over-the-counter oral saliva substitutes Copyright © 2020 by Elsevier, Inc. All rights reserved. Oral Cancers  Occur more frequently later in life  Occur more frequently in men than women  Early detection essential as 60% of cases aren’t diagnosed until Stage 4  Signs and symptoms (Box 15-9)  Risk factors (Box15-17)  Tobacco use  Alcohol use  HPV (human papillomavirus) infection  Genetic susceptibility Copyright © 2020 by Elsevier, Inc. All rights reserved. Unfolding Case F  Describe oral assessments and interventions while Jeb has a PEG tube. Promoting Healthy Aging: Implications for Gerontological Nursing  Assessment of oral health  Physical examination of oral cavity and oral health  Risk factors  Federal regulations mandate annual examination for long-term care residents  Oral health instrument: The Kayser-Jones Brief Oral Health Status Examination (BOHSE) Copyright © 2020 by Elsevier, Inc. All rights reserved. Promoting Healthy Aging: Implications for Gerontological Nursing Interventions for Oral Health  Promote oral health through teaching persons and caregivers recommended interventions, screening for oral disease, making dental referrals  Provide supervision and evaluation of oral care in hospitals and LTC facilities  Tips for best practices: Oral Care (Box 15-10) Copyright © 2020 by Elsevier, Inc. All rights reserved. Unfolding Case G  Describe nursing care of dentures for Jeb if he has them.  Hint: Box 15-11, 15-12 Copyright © 2020 by Elsevier, Inc. All rights reserved. Promoting Healthy Aging: Implications for Gerontological Nursing (Cont.) Dentures  Patient and/or caregiver education of proper cleaning techniques  Tips for best practices: Denture Care (Box 15-12)  Damaged and ill-fitting dentures are a common problem  Only 13% of persons with dentures get an annual dental examination Copyright © 2020 by Elsevier, Inc. All rights reserved. Promoting Healthy Aging: Implications for Gerontological Nursing (Cont.) Oral Hygiene in Hospitals and LTC  Lack of attention to oral hygiene contributes to poor nutrition and negative outcomes  Cleaning teeth with a toothbrush after meals lowers risk of aspiration pneumonia  Crucial in prevention ventilator-associated pneumonia  LTC residents vulnerable secondary to cognitive impairment and dependency on staff to provide good oral care Copyright © 2020 by Elsevier, Inc. All rights reserved. Promoting Healthy Aging: Implications for Gerontological Nursing (Cont.) Tube Feedings and Oral Hygiene  Tube feedings are associated with significant pathological colonization in the mouth  Provide oral care twice a day for persons with gastrostomy tubes and brush teeth after each feeding  Only toothbrushes assist in the removal of plaque; use foam swabs to clean mouth of endentulous  Safety Alert: Lemon Glycerin Swabs pg 198 Copyright © 2020 by Elsevier, Inc. All rights reserved. Question 1 Which of the following is NOT an age-related change that affects hydration? a. Thirst sensation diminishes b. Creatinine clearance declines c. Total body water decreases d. Loss of fat cells and increase in muscle mass Copyright © 2020 by Elsevier, Inc. All rights reserved. Question 2 Signs and symptoms of dehydration in an older adult include all of the following except: a. dry mucous membranes in mouth and nose. b. decreased skin turgor. c. dry axilla. d. speech incoherence. Copyright © 2020 by Elsevier, Inc. All rights reserved.