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Nutrition and Oral Hydration

by Diana Shenefield, PhD
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    00:01 Our topic for this lecture is nutrition and oral hydration. My name is Diana Shenefield.

    00:06 So, what are we going to talk about here? Well, that’s pretty easy. We’re talking about food and drink that we know, as nurses that it’s more than food or drink, that it’s about nutrition and what it can do for our patient, and hydration, and what happens when our patient is overhydrated or underhydrated. So it’s a little bit more than food or drink.

    00:26 So we’re going to delve into it. Our learning outcome is we need to understand the importance and the clinical significance of fluid intake. And you know as a nurse that it is important that we watch fluid intake that there’s a fine balance that our body has for what’s too much and what’s too little, and why our body needs fluid, why our body needs water, what it does to ourselves. And again, all that is understanding the body, understanding at the cellular level that a lot of our patients don’t understand.

    00:56 But we need to make sure that they know so that they understand when we talk to them about making sure they get enough to drink, what we’re talking about and not just drinking.

    01:06 The ability to manage the patient who has an altered nutritional status. Unfortunately, all of our patients don’t come with great nutritional backgrounds. We have diabetics.

    01:16 We have people that are malnourished for one reason or another. And so, we know we can’t just ignore that because that affects their healing process. It can affect their disease process. And understanding the role that vitamins and minerals play, and how there’s a balance again, of those, to keep our body in the state that we would want it to be in. And then perform a patient continuous intermittent or bolus feedings through a tube, whether it’d be an NG tube or a G-tube. We have a lot of patients, a lot of pediatric patients especially.

    01:52 They get fed through a tube. And so understanding how nutrition plays a role in that, and what kind of complications that we’re watching for when we artificially feed our patients that way. So our practice question is a nurse is assessing a patient who is admitted to the hospital with withdrawal from alcohol. And we know patients that are alcoholics have a lot of nutritional problems. So why is that? What is it about the person that is an alcoholic that makes their nutritional status so much worse? The nurse anticipates that excessive alcohol intake will directly contribute to health problems because, so again, thinking back to your pathophysiology, what is it that’s causing the problem? Is it A, lengthens passage time of the stool through the intestine tract? Is it B, it decreases the absorption of many important nutrients? Or C accelerates the absorption of medications? Or D interferes with the absorption of glucose? Again, thinking back to your patient, if you haven’t taken care of a patient that’s an alcoholic, you want to go back and look at the signs and symptoms, but look at the long-term effects that alcohol has. And the answer to this question is B. It decreases the absorption of many of the nutrients. So, you have your alcoholic patient. We know that a lot of alcohol has sugar and those kinds of things in it.

    03:13 But a lot of time, people that are alcoholics don’t eat right. And so besides not getting the nutrients through the food, what they do eat is not absorbed because of the alcohol.

    03:24 So, what do we need to remember? We need to remember that patients have to have the ability to eat. And if you think back to your very first nursing class when you talk about dentures, how important teeth are to eating. If somebody doesn’t have teeth or their dentures don’t fit right, it affects their ability to eat. Maybe they’ve had a stroke and they can’t swallow. Maybe they have an oesophageal cancer. Again, what is going on that keeps the person from being able to eat? What are the food and medication interactions? We know there's a lot of interactions between certain foods and certain medications that we need to be aware of. So when we send our patients home on these medications, we can tell them what foods to avoid. One of the more common ones is grapefruit juice. Grapefruit juice interacts with a lot of medications and either makes the medication more potent or less potent. So again, would you have to know all of that? But you need to know where to look it up in your drug books, and then you need to be able to teach your patient about those interactions. How about understanding dietary restrictions? Is it because of cultural that they have the restriction or is it because of a medical problem? And understanding that so that I can watch what my patient is eating or drinking, but again so that I can explain to them why there's the restrictions.

    04:44 Monitoring hydration status, watching for dehydration, watching for overhydration, providing the nutrients, watching my bolus feedings, watching my continuous tube feedings, and what does that mean? What’s the difference and what are the different complications between a continuous and a bolus? And then looking at the side effects, looking at the side effects of tube feeding. We lose a lot of our oral stimulation when we give a patient tube feeding. So again, to some patients, that’s not going to be a big deal. But if you have a patient that this maybe is going to be long-term, a lot of our pediatric patients have G-tubes, and they’ll lose that sensation of eating.

    05:22 And what does that mean? And does it affect their swallowing? Does it affect their speech? So again, looking at not just the act of putting formula in, but what is it doing to the patient and what kind of other signs and symptoms do you need to be watching as a nurse. And then evaluating disease process and how is it affecting the nutritional state or how is the nutritional state affecting the disease process. So things to keep in mind. You got to review your functions of your digestive system. Review carbohydrates, proteins, and fats. Go back and look at what are the carbohydrates, what are the fats, what are the proteins, what's the calories with each one of those, and what is their purpose in our body, what do they do. Review the different diets. You think about in the hospital, all the diets we have our people on. What is a clear liquid diet? What’s a full liquid, a mechanical soft, a pureed, a cardiac diet? What are those diets and what is included in those diets? How about the different dietary restrictions? Low sodium, high fiber, low fiber, 1800 ADA diets. There’s a whole multitude of different dietary restrictions. And so in the hospital, we make it easy for our patient. We bring them a tray, and they eat what’s on it.

    06:42 But when they go home, do they understand what low sodium is? A lot of our patients think that they know that it just means not adding salt, but we know as nurses that a lot of our processed foods are high in sodium. So bringing that to the attention of our patients and helping them to understand how to read labels so that they can follow their dietary restrictions. What about looking at signs and symptoms of hydration and overhydration? And we’re going to talk a little bit about that and how it relates to our patient and the disease processes that they have. What about looking at labs that relate to nutrition? Things like glucose, triglycerides, cholesterol, BUN, liver functions.

    07:23 Being able to put all of those together so if I see a problem with one of those, is it because of nutrients? Is it because of lack in nutrients and to be able to put those two together? And then review the proper procedure for giving a tube feeding. Again, some of you maybe haven’t done a tube feeding for a while, maybe only did it once in nursing school, so you want to go back and review putting the NG down, how to check for residual.

    07:48 So make sure that you’re looking at that procedure so that you can understand the steps and make sure that you have that down right. So, what are the functions of the digestive system? Think back to anatomy and physiology. Remember what each part of the digestive system does. So, why do you have to know that? If your patient has a problem with one of the organs of the system, it throws the whole system out of lack. And so to understand what happens before, what happens after, if say there’s something wrong with the stomach, how was that going to affect my patient? Maybe they can chew, maybe they can swallow, maybe their intestines are working just fine. But you had to keep part of the stomach and what is the purpose of the stomach? What does it do? So being able to understand that so I can understand what’s happening with my patient.

    08:37 And then going to your nutrition class, here we go, all the vitamins and minerals.

    08:43 There are so many, but we know there are some main ones. And it’s important that you have an understanding of the main foods that go under each one. So when a patient says to you, "You know what, I’m on Coumadin and the doctor told me I can’t have any vitamin K.

    08:57 What has vitamin K?" And all of the sudden, you’re thinking, “I don’t know.” You need to have some of those foods in mind that you can tell your patient to give examples.

    09:06 So B vitamins. You know, where are B vitamins? Meats, whole-grains, green leafy vegetables.

    09:12 I always tell patients, unless they’re on Coumadin, green leafy vegetables pretty much covers everything. But again, being specific and helping patients find foods that they have available to them that they can eat. Vitamin C, we always think of the citric fruits.

    09:27 But wonder if you have a patient that has stomatitis, has mouth sores and can’t take in citrus foods, what are they going to do? How about broccoli or cabbage? Again, being able to tell your patient what other alternatives are besides the well-known alternatives.

    09:43 Vitamin A, we know vitamin A is very important for healing. It’s also important for our vision, and helping people to understand, what has vitamin A. Well, you’ll see number one on the list is liver. Not a lot of people eat liver. So, what are you going to tell your patient? That they have to eat liver? What else can they eat? Whole milk, again, whole milk is wonderful, but wonder if you have a patient that can’t be on whole milk.

    10:05 What else can you give them? Don’t forget about your resource of the dietician. A lot of times, people are so restricted on their diet, that as a nurse, there’s no way I can think of all the foods out there. That’s when you use your resources and your consults of your dietician who can come up and maybe make a meal plan for the patient, providing the nutrition that they need but also what foods the patient has available.

    10:30 You can read through the rest, Vitamin D, vitamin E, vitamin K. Again, remembering that not everybody has access to fresh fruits and vegetable. Not everybody has access to milk. So again, knowing what your patient has access to and then devising a diet that fits their nutrition and their restrictions. What about minerals, calcium? What all has calcium? Most people know that you can drink milk to get calcium. But again, wonder if you are lactose intolerant. Is there other options? What about potassium. Most people know that bananas have potassium. Wonder if you don’t like bananas. What other options can you offer your patient? Sodium, we tell patients all the time to lower your sodium.

    11:14 But do your patients understand it? Having bacon, every morning is high in sodium.

    11:20 That ham is high in sodium. They may think that things that have sodium are only things that they actually put salt on. Wonder if they really like the taste of salt? Do they know that there are salt alternatives out there that are less in sodium? So again, helping them to understand and not just saying, “Don’t eat salt,” because we know if we tell people and we deprive them of things that they like without giving them alternatives, the motivation to follow our diets isn’t going to work very well.

    11:48 We know that with ourselves. So again, give them alternatives. Talk to them about what is possible for them. Tube feedings. Think about your tube feedings.

    11:59 They can be NG tube feedings, OG tube feedings like in the nurseries, or G-tube feedings.

    12:05 And some of our patients will do NG feedings for short-term, maybe they’ve got something going on with their gut or they just can’t eat for a while. OG feedings, we think of them a lot in the nursery just to get the patient build up enough that they can take a bottle. G-tube feedings, usually, are more long-term. So think about your feedings and how you’re placing those tubes, whether they have to go to surgery or whether the nurse places them. And then think about the kind of formulas that you’re putting in. There are many, many different kinds of formulas, and they all depend on the nutrition that the patient needs. It’s not just, just grab this one.

    12:43 They’re looking at calories. They’re looking at vitamins and minerals. So be familiar with the kind of formulas that are out there. So again, why would somebody need a tube feeding? Maybe they just can’t chew. Maybe they’ve had major facial trauma and they can’t put anything in their mouth for a while. Maybe they’ve had surgery. Maybe they have burns to where they can’t get enough nutrients that their body needs to heal. Again, is it short-term or long-term? So make sure you’re reviewing that in your fundamentals book.

    13:14 So, tube feeding, what do I need to know? Again, what is in the tube feeding? It looks like milk. Does it have milk in it? Is your patient lactose intolerant? Is it a soy-based formula? Again, understanding that so that I can make sure that it’s right for my patient.

    13:31 What type of feeding? Is it a continuous feeding that we put on a pump? Do they just get fed at night? Do they get fed 24 hours a day? Or is it a bolus feeding where I just stand there and dump it in? And then what kind of effects does that have on the patient? We know that a patient that’s not used to bolus feedings, that’s very uncomfortable.

    13:49 It fills their stomach very fast and they can have a dumping syndrome.

    13:53 So again, some patients can tolerate it if it has been a chronic long-term way of feeding.

    13:59 But if my patient just got that tube, it may not. And so if I don’t understand that, I may be causing my patient a lot more discomfort. And if I cause diarrhea or vomiting, they’re not going to get the nutrients anyway. Looking at the procedure for feeding them and checking residual, do you remember how to check residual? Do you remember what the purpose is? And what about patient positioning? We know we can’t have a patient lying down to give them a feeding.

    14:25 It always surprises me when I walk in and people are feeding and they’re lying down.

    14:29 And I say, “When you ate supper last night, were you lying down?” No.

    14:33 So think about your patient. Think about digestion and how the body works. And how is it going to make them more comfortable. Well, most of all, thinking about aspiration. We don’t want our patients to aspirate. And so sitting upright is going to eliminate that, or at least if they do decide to vomit or choke, you can get it out, keeping suction available.

    14:53 So, all of those things that you’re thinking about to keep your patients safe. Again, that’s what NCLEX is thinking about. Those are the kind of questions that you’re going to receive that are going to look at, “Do you understand the procedure and do you understand the complications and how to prevent those?” Fluid. We talk a lot about fluid, and I know in your med/surg classes, you’ve talked a lot about overhydration and underhydration.

    15:18 Make sure you review that. You know, what causes underhydration? Well, one of the biggest things is people not drinking. If I don’t drink enough, I’m not going to get hydrated.

    15:30 But what about excessive output, excessive vomiting, diarrhea, NG output? All of that is going to pull fluids out, and you’re going to cover more about output in the elimination section. So now, we’re just going to talk about inadequate intake. What are the risks? What people are at risk? Think about all your patients and all of the things that go on with our patients and all of the things they come with them? Why are people dehydrated? Well, maybe they just don’t have water available. We see that all the time, whether it’s not clean water. Maybe they’ve been out doing a sport for hours and there isn’t water available and they’ve really sweat a lot. Be thinking about, do they even have water available? And then think about the inability to take it. If somebody is paralyzed or if they have two broken arms or whatever the case may be, the water may be sitting there, but are they able to get it to their mouth? Are they able to drink it? And assessing your patient, maybe they’ve had a stroke and they’re right-handed and it’s the right side that is affected and they not feel as comfortable with their left hand. Is that keeping them from drinking? And then lack of thirst response.

    16:40 Some people just don’t get thirsty, and we know that there's illnesses out there that contribute to that. We know sometimes with age, we lose our ability to have thirst.

    16:50 So is that the problem? Is it that they can drink, the water is available, they just don’t have a desire to? Or, can they not communicate to you that they’re thirsty? Again, have they had a stroke? Have they had a brain injury to where they’re thirsty but they can’t communicate that they need to drink? Inability to swallow is a big problem. We don’t want aspiration, but whatever the reason. Is it that they have tonsillitis or strep throat to where their throat is sore? Maybe they’ve got a stomatitis to where they have sores in their mouth that they can’t swallow. Or maybe again, it’s a stroke or something like that, but can they actually swallow? And then, is there psychological alterations? We know that there's a lot of mental illnesses that affect the brain and affect the reasoning and drinking. So again, looking at that if everything else comes back negative. So, what are we going to do to help our patients? Well, we’re going to encourage drinking. Again, telling somebody to just go drink 64 ounces of water probably isn’t realistic, but showing them how they can drink small amounts to keep their hydration up. Daily weights, don’t forget that daily weights is the best way to monitor fluid because we can miss an I & O.

    18:04 Somebody can go to the bathroom and not tell us. They could drink a coke and not tell us, but their weight isn’t going to lie. So, daily weight is going to help us with dehydration and retention. Aspiration precautions, you’ve got to remember that, whether the patient is drinking themselves or whether you’re helping them, whether you’re giving them a bottle. You’ve got to watch for aspiration. Orientation, if you have a patient that forgets maybe that they’re thirsty, orienting them, telling them who they are, where they are, "Here is your water." You know. "Here is your straw." Making sure that they understand, and maybe it’s something that you have to remind them all the time.

    18:42 What about frequent assessments? Making sure that they’re drinking, not just sitting the bottle of water in front of them and leaving, but are they drinking? And if they’re not, why? Doing a really good assessment. Proper positioning. Again, it’s very hard to drink lying down. Make sure your patient is sitting up if it all possible. And then what are you going to do to help them? Maybe it’s the use of a straw instead of just drinking out of a cup. Maybe it’s a sippy cup. There is a lot of different things that we can do. Maybe it’s a syringe that you’re giving them a drink through. So again, watching your patients, assessing and helping them to get the fluid that they need by whichever means is going to work for them. And then again, monitoring our labs, making sure that we’re not overhydrated or dehydrated. So now, we’ve gone the other way. We’ve given our patient too much fluid or they’ve drank too much, or remember, somebody that’s taking excessive sodium is going to have a fluid excess. So, who is at risk? Well, we have patients, they have illnesses that they drink way too much water. That’s rare, but we don’t want to forget about those patients as well. What about your patients getting your tube feedings that we just talked about? If I give them too much volume, more than what their body needs, they’re going to have an excess of fluid. Too many IV fluids. Too many blood products. You know, sometimes we get on the kick that patient really needs a lot of blood and they do, but we also need to be monitoring on fluid overload. And is it too much fluid that the body can’t handle? So again, watching for that balance. And then our patients with kidney failure. Remember, our kidneys excrete. And if anything goes wrong with our kidneys, it’s going to affect how much fluid that we can excrete. So, that can cause either an overhydration or an underhydration. So, what kind of interventions? Well, one thing is as we always think of, if they have too much, give them a diuretic. Be thinking about your potassium-sparing and your potassium retention diuretics. Again, who needs to have potassium and who doesn’t, and how much of the diuretic? And don’t forget to remind your patient that when they’re taking a diuretic that they need to drink as well because the diuretic is taking the fluids out, and so they can get dehydrated really easy.

    21:02 Daily weights again, Is and Os. Sometimes we have to restrict fluid for our patients.

    21:07 A lot of our patients with CHF will have to restrict fluids for a while. And again, telling a patient that you can only drink so much causes a lot of distress. And so helping them through that and showing them the volume and helping them space that out. Again, and then helping them to understand what that volume fluid is doing to their body will help them understand more about the importance of restricting their fluid.

    21:32 Lab values again keep showing up. We need to watch our labs. We need to watch for trends because maybe, they’re in the normal range, but they’re leaning more towards overhydration and underhydration. That gives us a chance to intervene before our labs get to critical values. And then monitoring again our tube feedings. Are we watching the rate if they’re on the pump? And are we continuing to assess our patient and not just running the feeding but listening to lungs and watching abdominal distention? So in closing, nutrition is a big topic. As nurses, we know it’s a lot more than just food or drinking. We need to make sure our patients understand that, and we need to understand how it affects the disease process, how it can make it worse or how it can make it better.

    22:18 Think about all your diabetics and how nutrition plays such a huge part in wound healing. And again, on all of our patients and how wound healing is so important in how nutrition can really affect that and can increase the length of stay, which can also increase the infection risk. So be thinking about your nutrition, go back to your nutrition book and read, look at diets and the vitamins and the nutrients so that you can provide your patient with good education, and so you can pass NCLEX.


    About the Lecture

    The lecture Nutrition and Oral Hydration by Diana Shenefield, PhD is from the course Physiological Integrity. It contains the following chapters:

    • Nutrition and Oral Hydration
    • Tips To Keep in Mind
    • Foods High in Vitamins and Minerals
    • Tube Feeding
    • Fluid Volume Deficit
    • Dehydration Interventions
    • Over Hydration Interventions

    Included Quiz Questions

    1. Asparagus, carrots, shredded wheat
    2. Cucumbers, popcorn, cantaloupe
    3. Peas, strawberries, corn
    4. Tomatoes, peas, corn
    1. Popcorn
    2. Pancakes
    3. Muffins
    4. Ripe bananas
    1. Place patient in high-Fowler’s position
    2. Flush with 20 ml of air
    3. Advance tube 1 cm
    4. Plug the air vent during feeding

    Author of lecture Nutrition and Oral Hydration

     Diana Shenefield, PhD

    Diana Shenefield, PhD


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