Our topic for this lecture is nutrition and
oral hydration. My name is Diana Shenefield.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
And then going to your nutrition class, here
we go, all the vitamins and minerals.
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.
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.
So B vitamins. You know, where are B vitamins?
Meats, whole-grains, green leafy vegetables.
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.
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.
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.
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.
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.
But do your patients understand it? Having
bacon, every morning is high in sodium.
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.
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.
They can be NG tube feedings, OG tube feedings
like in the nurseries, or G-tube feedings.
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.
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.
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.
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.
It fills their stomach very fast and they can
have a dumping syndrome.
So again, some patients can tolerate it if
it has been a chronic long-term way of feeding.
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.
It always surprises me when I walk in and
people are feeding and they’re lying down.
And I say, “When you ate supper last night,
were you lying down?” No.
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.
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.
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.
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.
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.
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.
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.
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.
Daily weights again, Is and Os. Sometimes
we have to restrict fluid for our patients.
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.
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
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.
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.