CLIN 1130 Week 7
Nutrition, Oral Care,
Intake/Output
Monitoring & Fluid
Volume
Professor Nelson
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Nutrition
Oral Care
Agenda
Intake/Output Monitoring
Fluid Volume
2
Assessment
Physical
examination
• Oral cavity
•
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Self-care ability
Hygiene practices
Cultural factors
Assessment
Clients at risk for hygiene
problems
Special considerations
Client expectations
Examples
Nursing
Diagnosis
•Fatigue
•Ineffective health
maintenance
•Self-care deficit,
bathing and
hygiene
Goals and outcomes
Planning
Setting priorities
Continuity of care
Implementation
Health promotion
• Oral Care
•
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Oral Care
Complete
assisted oral care
• Partial assisted
oral care (e.g.
setting client up
with the required
supplies)
•
Client-Centered Care
Accommodate client’s preferences and
culture when performing hygiene
• Consider client’s normal oral routines
• Involve family members when possible
• Preserve client dignity of persons with
dementia
•
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9
Oral Hygiene
Daily oral hygiene prevents and controls
plaque-associated oral disease
• Oral hygiene promotes health, comfort,
nutrition, and verbal communication
• Ill clients may require assistance with activities
ranging from preparing supplies to brushing
teeth
• Care for dentures as frequently as natural teeth
•
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10
Care of Dentures
Procedural Guideline 18-3
Clean dentures as often as
natural teeth
• Store in an enclosed,
labeled cup when not worn
• Reinsert as soon as possible
• When inserting, ensure a
good fit
• Loose dentures cause
discomfort and make it
difficult to chew food and
speak clearly
•
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11
These clients are at risk for:
• Alterations of the oral
cavity
• Infection
• Aspiration
• For safety, two nurses
provide care
• One nurse provides oral
care, while the other
suctions oral secretions
•
Performing
Mouth Care
for the
Unconscious
or Debilitated
Client
Skill 18-3
Oral
Hygiene
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13
Special Considerations
Teaching
• Instruct family members on mouth care,
and how to prevent aspiration
• Use teach-back
• Home care
• Irrigate oral cavity with bulb syringe
• Instruct on risk of aspiration
• Encourage oral cleansing twice a day
•
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14
The
Canadian
Dental
Hygienists
Association
“The need for good oral
health continues as a
person ages, becomes
chronically ill, or moves to
long-term care”
(The Canadian Dental Hygienists Association, nd)
Findings from nursing research
“Oral hygiene care is discretionary and
often missed”
1. Nurses often convey oral hygiene care to their patients as
being optional.
2. Nurses are inclined to preserve patient autonomy in oral
hygiene care.
3. Oral hygiene care is often spontaneous and variable and
may not be informed by evidence.
4. Oral hygiene care is not embedded into bedtime care
routines.
(Coker, Ploeg, Kaasalainene, & Carter, 2017)
Findings from nursing research
• Many older adults, especially those who rely on
others for care have poor oral hygiene and high
rates of oral disease (The Canadian Hygienists
Association, nd)
• Oral disease/issues can be linked to pain,
difficulties with chewing/swallowing, heart/lung
disease, diabetes, and stroke (The Canadian
Hygienists Association, nd)
Preforming
Watch this video:
Conscious Oral
https://youtu.be/eIqBFOX5YTo
Care
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This Photo by Unknown Author is licensed under CC BY
Preforming Watch this video:
Unconscious https://youtu.be/49jF6RZy3GE
Oral Care
Nutrition
Basic component of health
Malnutrition develops as a result of decreased intake of nutrients, increased
nutrient requirements, and complications due to the disease process
What complications may occur as a result of malnutrition?
Nurses have a key role in ensuring that patients maintain optimal nutritional
status
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Slide 20
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Slide 21
Screenings are time-sensitive
Identify common risk factors for nutritional
problems
Principles for
Practice
Nutrition assessment for all patients identified at
risk by nutrition screening
Document weight and appetite loss, collaborate to
make dietary referrals
Assist in eating as needed
Follow dietary guidelines
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Slide 22
Physical examination
Performing a
Nutritional
Screening &
Physical Exam
• Nutrition-focused
• Individualized to patient
Registered dietitian
• Uses steps like the
nursing process
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Slide 23
Screening for Nutritional Risk: Assessment
Are time-sensitive
Require screening for actual and potential nutritional alterations
Determine the presence of physical limitations and psychosocial factors
May result in consultations with a registered dietitian (RD) or a speechlanguage pathologist (SLP)
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Slide 24
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Slide 25
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Slide 26
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Slide 27
PatientCentered
Care
Provide patients with nutritious food
that is familiar and congruent with
their beliefs
Collaborate with a registered dietitian
in considering a patient’s knowledge,
skills, social skills, and access and use
of food
Some individuals follow special
patterns of food intake based on
religion, cultural background, health
beliefs, or environmental concerns
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Slide 28
Canada’s Food
Guide
https://foodguide.canada.ca/en/
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Slide 29
Obese patients
Critically ill experience more
complications
EvidenceBased Practice
Nutrition support plan is recommended
within 48 hours of admission to an ICU
All hospitalized patients should be screened for
nutritional risk
Energy requirements should be based on
predictive equations
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Slide 30
Special
Considerations
Gerontological
• Those with dementia are at
high risk for difficulties and
malnutrition
• Eating difficulties are likely
to worsen during
hospitalization
• Minimize use of sedatives
and hypnotics
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Slide 31
Special
Considerations:
Home Care
• Teach about aspiration
precautions used to prevent
pneumonia
• Determine knowledge of
appropriate food choices,
strategies to increase caloric
intake, and food and liquid texture
modifications needed
• Use a multidisciplinary approach
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Slide 32
Evidence Based Practice
Geriatric protocol for improved oral intake:
• Conduct mealtime rounds to determine
amount consumed
• Limit staff breaks before or after mealtimes
• Assist with mouth care and dentures prior to
meal
• Encourage family members to visit at
mealtimes
• Ask family to bring favorite food from home
• Suggest small, frequent meals
• Provide nutritious snacks
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Slide 33
Malnutrition
Develops because of decreased intake of
nutrients, increased nutrient requirements,
and complications due to the disease
process: Undernutrition.
What complications may occur because of
malnutrition?
Nurses have a key role in ensuring that
patients maintain optimal nutritional status
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Slide 34
Safety Guidelines
1. Improper handling, preparation, and storage
practices in the home environment may result in
cases of foodborne illness.
2. Identify patients at risk for dysphagia and
collaborate with other members of the health
care team to minimize complications.
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Slide 35
Safety Guidelines
3. Ensure that the patient is receiving the correct
therapeutic diet.
4. Assess level of consciousness before feeding.
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Slide 36
•
Document assessment
results on nurses' notes, flow
sheet, and nutritional
screening form in the
electronic health record
(EHR) or chart
•
Notify health care provider of
abnormal findings. Make
referral to the RD
Recording and
Reporting
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Slide 37
Special Considerations
Teaching
•Educate patient and family caregiver about a casespecific nutritional diet
•Provide resources to promote healthy eating
•Introduce technology nutrition tools
Nutrition is one of the major determinants of
Gerontologi successful aging
cal
Food insecurity occurs when availability and ability
to acquire foods is inadequate or uncertain
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Slide 38
Special
Considerations:
Home Care
Slide 39
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• Instruct about safe handling,
preparation, and storage of
food
• Assess home environment
Assisting an
Adult Patient
with Oral
Nutrition
Slide 40
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Improve nutritional intake by assisting
with feedings or instructing caregivers
how to do so safely
Preserve patient dignity
Assisting with oral nutrition requires
time, patience, knowledge, and
understanding
Special Considerations: Teaching
Educate
• Educate patient and family caregiver
about a case-specific nutritional diet
Provide
• Provide resources to promote healthy
eating
Introduce
• Introduce technology nutrition tools
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Slide 41
Special Considerations
Gerontological
• May have diminished appetite
Home care
• Assess financial resources of patient and family
• Help patient and family identify ways to make meals in
the home pleasant and enjoyable experiences
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Slide 42
Recording and Reporting
•
Document in patient’s electronic health record (EHR) or
chart the type of diet, amount of feeding assistance
needed, tolerance of diet and amount or percentage of the
meal eaten (e.g., 25% of food consumed at breakfast) and
calorie count (if ordered)
•
If evaluating I&O, record fluid intake on appropriate form
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Slide 43
Recording and Reporting
•
If patient is receiving oral nutritional supplements
(e.g., Ensure, boost), record the amount taken
and patient’s tolerance (likes or dislikes,
supplements to fill or replace meals) to the
health care team
•
Report any swallowing difficulties, food dislikes,
refusal to eat
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Slide 44
Aspiration Precautions
Dysphagia
Aspiration
• Most common in
elderly, but can occur at
any age
• Many conditions can
cause dysphagia
• Food, water, vomitus, or
oral contents may be
aspirated
• Aspiration pneumonia
can be fatal, especially
in older adults
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Slide 45
Aspiration
Precautions
• Dysphagia evaluation
• Goal: to ensure that the patient
will be able to safely swallow
oral fluids and foods
• When assessment shows risk
for dysphagia and aspiration,
refer for a more comprehensive
examination
• Screening is minimally invasive
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Slide 46
• Dysphagia management
Aspiration
Precautions
• Dietary modification by
altering consistency of
foods and liquids
• SLP/RD central to
management
• Program individualized
based on which phase of
swallowing is affected
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Slide 47
National Dysphagia Diet (NDD) Stages
NDD1: dysphagia pureed
NDD2: dysphagia mechanically altered
NDD3: dysphagia advanced
Regular
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Slide 48
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Slide 49
Aspiration
Precautions
• Consequences of dysphagia
• Physiological consequences
may include decreased
appetite, weight loss,
dehydration, malnutrition,
and pneumonia.
• Emotional responses may
include altered body
image, embarrassment,
social isolation, and
depression.
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Slide 50
What do we
measure?
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BY-SA
•Drinks •Blood
•Liquids •Serum
•Ice
•Emesis
•Urine
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Slide 51
Monitoring
Intake &
Output
• Measuring I&O is part of the
assessment for fluid and
electrolyte balance.
• Accuracy is critical; requires
patient and family cooperation
• Monitor I&O for patients with
fever or edema or a urinary
catheter; receiving diuretic or IV
therapy; or on restricted fluids
(per employer policy or health
care provider prescription).
• Why is accuracy so critical?
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Slide 52
Monitoring Intake & Output
Parts of this task cannot be
delegated to a UCP; some
parts can be delegated.
The nurse directs the UCP to:
• The nurse is responsible for
assessing I&O totals at end
of each shift; comparing 24hour totals over several
days; monitoring and
documenting IV therapy,
wound, or chest drainage,
and tube feedings
• Measure and record all
sources of input and
output.
• Report changes in patient’s
condition such as alteration
in intake or changes in
colour, amount, or odour of
output.
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Slide 53
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Signs of Fluid Volume Overload
Rapid weight gain
Noticeable swelling
(edema) in your
arms, legs and face
Swelling in your
abdomen
Cramping,
headache, and
stomach bloating
Shortness of breath
High blood
pressure
Heart problems,
including
congestive heart
failure
Slid
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Feeling very thirsty
Dry mouth
Signs of
Fluid
Volume
Deficit
Headache
Dry skin
Urinating and sweating less than usual
Dark, concentrated urine
Feeling tired
Changes in mental status
Dizziness due to decreased blood pressure
Elevated heart rate
Slid
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Document
• Document I&O balance or
imbalance.
Communication
&
Documentation
Report
• Report to health care provider
any urine output less than 30
mL/hr or significant changes in
daily weight.
Document on
• Document on I&O forms or EHR.
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57
Intake &
output
https://youtu.be/HZTXvlRpaWI
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BY
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Slide 58
References:
1.
Perry A.G., Potter, P., Ostendorf, W., & Cobbett, S.L. (2020). Clinical Nursing
Skills & Techniques (1st Canadian edition)
2. Coker, E., Ploeg, J., Kaasalainen, S., & Carter, N. (2017). Nurses’ oral hygiene care
practices with hospitalized older adults in post acute settings. Int J Older People
Nurs, 12(1)
3. The Canadian Dental Hygienists Association. (nd). Keeping Canada’s aging
population healthy: Resources for dental hygienists. Retrieved from,
https://www.cdha.ca/cdha/The_Profession_folder/Independent_Practice_folder/
Long_Term_Care_Resources/CDHA/The_Profession/Resources/LTC_Resources.as
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