Nutrition and Hydration

Objectives:
After you take this class, you will be able to:

1. Discuss the reasons why some patients and residents do not get enough nutrition and hydration.


2. Detail ways that you can insure an adequate diet and enough hydration for your patients and residents.

HOW NUTRITION AND FLUID NEEDS CHANGE WITH AGE

Food and nutritional needs change as a person gets older and older. The need for a lot of calories decreases when a person gets older. These needs were highest when the person was an infant, a teen, and when they were pregnant or breast-feeding their baby.

Old patients and residents need the least calories of all age groups. They do not burn calories and food as quickly as they did when they were younger and more active. This doesn't mean, however, that the elderly do not need a good diet. Older patients do need a good diet just like the other age groups. They need the same amount of vitamins, minerals and protein that they needed when they were younger. They need even more vitamins, minerals and protein when they are sick or have a pressure ulcer. They also need fiber to prevent constipation. Breads, cereals, fruits and vegetables have fiber.

The older age group is at risk for a poor diet for many reasons. Although some older people may gain weight from eating too much, most older people are at risk for losing weight. They may lose weight without wanting to. This loss of weight can cause them to be weak and ill.

A good diet must have all four food groups. The four food groups are:

• Dairy. Cheese, milk and yogurt are dairy foods
  
  
• Meat. Chicken, steak, fish, beans, pork and veal products are members of the meat group.
  
  
• Fruits and vegetables. Apples, pears, lettuce, tomatoes, orange juice and potatoes are some of the foods that people can eat to get their daily fruits and vegetables.
  
  
• Grains. Bread and cereal belong to the grains food group.
  
  

The appetite and the digestive process also slow down as the human body ages. Old adults do not feel as hungry as they did when they were young. Also, when they eat meals they feel full and they may not want to eat another meal for a long time. They may even skip a meal. Old adults often do better with small snacks during the day rather than large meals three times a day.

Old adults may also lose their sense of taste and smell. Half of the taste buds are lost by the age of 60. Sweet and salty taste is lost first. Sour taste lasts the longest. Men lose their taste more often and sooner than women. These losses make many elderly people less interested in food than they were in the past. They do not enjoy the food as much because they do not taste it and they may not be able to smell the apple pie baking in the oven. Many older people will over salt their food to taste it.

Human beings are also more apt to eat when they see something that looks good to eat. Older adults, who lose their eyesight, are not able to see the food. They may be not interested in eating when they cannot see what they are eating. They will also have trouble feeding themselves if they have poor vision. If the patient or resident has eyeglasses, they should be worn during their meals.

In terms of fluid needs (hydration), a patient or resident may not be able to swallow fluids. They may not even feel thirst when they should under normal conditions. We must, therefore, offer fluids very often to older people. Nursing assistants should ask their patients and residents if they want a drink of water every time they speak to them unless they are not allowed to drink.

Some other old people may not be able to safely drink liquids unless they are thick. They may choke with water, juice and other thin fluids like tea or coffee. Nursing assistants are often asked by nurses to give the patient water and fluids that are made as thick as honey. These thick fluids help provide fluids to patients who have trouble swallowing.

Aging people may also not be able to use a spoon or a fork. They may be too confused to know how to feed themselves. Their lack of ability to eat or drink often makes it necessary to go to an assisted living facility or a nursing home so that they can be helped with eating, a basic ADL. It is the nursing assistant that most often provides the necessary food and fluids to these patients and residents

Other things that can decrease the amount and kinds of food and fluids that an elderly person will eat are:

• Money. An old person will not get a good diet if they do not have the money to pay for it.
  
  
• Physical health. If a person is not able to drive or walk to the store, if they are not able to make and cook good meals, if they are not able to use a fork or a spoon, they will need the help of others to get a good diet and enough fluids. Also, people that are sick and ill may not eat as much as they should.
  
  
• Mental ability. If a person is confused they may not be able to buy, cook and eat meals. Again, the help of others is needed so that they get a good diet. People will also eat less if they are lonely, sad, depressed or in pain.
  
  
• Medications. Some medications decrease the appetite.
  
  
• Activity level. If a person is active they will want to eat more than if they get no exercise.
  
  
• Teeth. If a person has no teeth, poor dentures or is not given their dentures before a meal, they will probably not get a good diet.
  
  
• The ability to swallow. It is dangerous when a person chokes on food or fluids. It can cause death. Unless they get a tube feeding or special care, like thick fluids, these people will not get enough food and fluid.
  
  
• The environment. Dining rooms that are noisy, not clean and attractive, poorly lit, and filled with bad odors, like urine do NOT help people eat and enjoy their meal. People will also eat less when the nursing assistant or other health care worker hurries and rushes them to eat quickly.
  
  
• The food itself. People will not eat a good diet when they are forced to eat foods they do NOT like. They will also not eat food that looks, tastes or smells bad. Patients and residents must have food choices. The meals must be attractive and pretty to look at. They must also taste good.
  
  
• Access to food and fluids. A person can not eat or drink if they can not reach their food or fluid. Nursing assistants and other health workers must give meals and fluids to their patients who can not reach it on their own.
  
  

NUTRITION PROBLEMS

Older people at home and in a hospital or nursing home are at risk for poor nutrition. They will lose weight and have malnutrition if they do NOT get a good diet. They will also be dehydrated if they do not get enough fluids. They will get weak, less able to fight off an infection or illness. When people have malnutrition and dehydration, they are:

• confused
  
• irritable
  
• sleepy
  
• nervous and anxious
  
• dizzy
  
• at risk for infection
  
• at risk for pressure ulcers
  

They may also have dry skin. The human body needs a good diet and fluids in order to work properly. If the diet is poor, the body will not work the way it should. If a person eats too much they will get fat and obese. It is also important to make sure that a person is not getting obese. These people may have to decrease the amount and kinds of food they eat and they may also have to exercise in order to burn off extra calories and fat.

HYDRATION PROBLEMS

The human body is made mostly of water. Water makes up about 2/3 of the body's weight. Water is needed to control the temperature of the body, to keep all body cells alive and to keep the blood flowing. This water is given to the body in some foods and by drinking fluids, such as tea, water, juice and coffee. As a person gets older, the amount of water that is found in the body gets smaller.

People will become dehydrated when they drink or consume less fluid than the body needs to perform its functions. When a person is dehydrated, the whole body is affected. Older patients and residents may not get enough fluid for a number of reasons. They may:

• not feel thirst and want to drink fluids. Older people do not feel thirsty like young people do.
  
  
• not be able to reach fluids. Nursing assistants must provide fluids to patients and residents who cannot reach their cup without help.
  
  
• not be able to swallow fluids. Many older patients and residents have a swallowing problem that makes them choke when they drink fluids. Nursing assistants are often asked to thicken fluids to a honey thickness for these people. These thick fluids allow many people with a swallowing problem to get their needed fluids without choking.
  
  
• choose to not drink fluids when they are incontinent of urine. They think that not drinking fluids will keep them dry. Nursing assistants and other health care workers should provide these residents with their necessary fluids during the day so they may not be incontinent during the night hours.
  
  
• be sick or ill. People that are ill and have a fever or are sweating a lot, vomiting or have diarrhea will often lose more body fluid than they take in.
  
  
• be taking medications that take water from the body. Some medications, like diuretics or water pills take water from the body. This may lead to a lack of necessary fluid in the body.
  
  

A doctor may limit fluids for a person with a heart or kidney disease. If fluids are not limited for a heart or kidney disease, the patient or resident should consume at least 1,500 cc of fluid each day. It is better if they can get 2,000 cc a day.

If a person is not taking in enough fluid, they may have:

• eyes that appear sunken
  
• dry skin
  
• skin that is loose
  
• dry mouth and dry tongue
  
• confusion
  
• a fever
  
• nausea
  
• vomiting
  
• a lack of interest
  
• weakness
  
• a lack of appetite
  
• constipation
  
• low blood pressure
  
• a weak and fast pulse rate
  
• dark urine
  
• less than normal urinary output
  
• dizziness when going from a lying to standing position
  
• weight loss
  

THINGS YOU CAN DO TO PREVENT NUTRITION AND HYDRATION PROBLEMS

Some of the things that nursing assistants can do to help the patient or resident get a good diet and enough fluids are:

• helping them to be as independent as they can be
  
  
• feeding them when needed
  
  
• proper positioning for safe eating and drinking
  
  
• helping them with their meals, their plate, spoon and fork if they need help. Many older adults need help cutting their food.
  
  
• using special plates, spill proof cups, straws and utensils if needed
  
  
• making fluids and healthy snacks available. Many older people prefer small meals more often during the day instead of 3 big meals
  
  
• making honey thick fluids for those with a swallowing problem
  
• providing good mouth and tooth care
  
  
• giving dentures to those that need them
  
  
• giving patients and residents their eye glasses and hearing aid so they can see their food and so they can talk with others, including the nursing assistant
  
  
• using spices, low sodium salt and other flavorings to increase the taste of the food
  
  
• telling the person what foods they are eating so that those with poor eye sight and taste can think about the foods, its taste and smell
  
  
• making meal times happy and nice. Soft music that a resident or patient chooses can help.
  
  
• helping residents socialize and talk with others
  
  
• letting patients and residents chose their foods
  
  
• giving any ordered vitamins and supplements, like Ensure
  
  
• monitoring, reporting and documenting how much food or fluid is taken. You must also look at the patient or resident to see if they are having a problem chewing or swallowing.
  
  
• using finger foods when preferred. Carrot and celery sticks, apple slices and bananas are some good finger foods.
  
  
• giving the person enough time to eat. Allow the person to chew and swallow every bite of food before giving them another
  
  
• serving foods at the right temperature. Hot foods and liquids, like coffee or tea, should NOT be too hot to cause a burn if spilled. They should be warm enough to safely eat. Cold foods should be cold and NOT at room temperature.
  
  
• weighing patients and residents very carefully. Accurate weights are one way to find out if a person is losing weight because they are not eating enough food. It is also a good way to find out if a person is eating too much. Weights should be done at the same time of the day and with the same amount of clothing each time they are weighed. They should be wearing light slippers, NOT boots or heavy shoes. Patients and residents are usually weighed before breakfast in their night clothing, pajamas or night gown. Foley urinary drainage bags must be empty when the person is weighed. An accurate weight can not be done if 8 hours of urine is added to the patient's actual weight.
  
  
• keeping residents and patients in a sitting position for at least 30 minutes after eating. This prevents choking on food.
  
  
• be skilled in dealing with choking. Know the Heimlich maneuver and CPR.
  
  
  

Other health care workers also play a role in nutrition and hydration.

Nurses. Nurses, doctors and some other members of the healthcare team assess patients for their risk of malnutrition when they are admitted and during the course of their stay in the hospital or nursing home.

Dietitian. The dietitian assesses the patient's nutrition status. They plan nutritional care with the doctor and other members of the health care team.

Laboratory workers. These health care team members may process blood and urine samples to make sure that the patient or resident is well nourished.

Activity coordinators. Activity coordinators often plan events like a cook out, a special meal or an afternoon tea time to promote healthy eating, hydration and socialization.

Occupational therapists. Occupational therapists work with patients and residents so they can be independent with their activities of daily living (ADLs), including eating. They often find special plates, cups, forks, etc. so person that has a disability can still feed themselves.

Speech therapists. Speech therapists assess patients with a swallowing problem. They recommend ways that patients with a swallowing problem can eat and drink safely.


Summary

Like most other care, nursing assistants and others who care for the old adult must make sure that their patients and residents get a good diet and enough fluids. We must meet these needs every day and each time we talk with or have contact with a patient or resident. Older adults have special nutrition and hydration needs. If you would like to learn more about feeding a patient or resident, take the course "Feeding Residents and Patients"

References

Berman, Audrey, Shirlee Snyder, Barbara Kozier and Glenora Erb. (2010). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice. 8th Edition. Pearson Prentice Hall.

Eliopoulos, Charlotte. (1995). Manual of Gerontologic Nursing. St. Louis: Mosby –Year Book Inc.

Lantz, John. (1996). Major Issues in Gerontological Nursing. South Easton, MA: Western Schools.

Nettina, Sandra M. (2009). The Lippincott Manual of Nursing Practice. 7th Ed. Lippincott, Williams and Wilkins.

University of Iowa Gerontological Nursing Interventions Research Center. (1998). Hydration Management. University of Iowa.

Wold, Gloria Hoffmann. (2008). Basic Geriatric Nursing. Elsevier Mosby.

Zembrzuski, Cora. (2000). Nutrition and hydration. Best Practices in Nursing Care to Older Adults. New York: The Hartford Institute for Geriatric Nursing. Sept.; 2 (2).

Copyright © 2010 Alene Burke