Week 5: Nutrition Alternative Diets and Dysphagia

Define nutrition

The science of optimal cellular metabolism and its impact on health and disease

Malnutrition

A condition caused by excess or deficient food energy or nutrient intake

Calories

A unit of energy

Body Mass Index

Ratio of patient's body weight to height

Carbohydrates

Compounds composed of carbon, hydrogen, and oxygen and a major source of energy.

Waist Circumference

An indicator of health risk where the waist is measured

Nitrogen Balance

The amount of nitrogen consumed equals the amount of nitrogen excreted over a specific period of time

What must nurses be aware of to contribute accurately to the completion of nutrition assessments?

Nurses must be aware of nutrients in whole foods

List the components assessed in a nutritional assessment

-Food and fluid intake

-Diet restrictions

-Appetite and or weight changes

-Current medical conditions

-Chief concerns

-Medications

-Medical history

-Family history

-Social history

-Physical assessment and anthropometrics (Height, weight, BMI)

-Biomedical analysis and medical tests (serum protein levels, nitrogen balance)

-Direct observation

List the tools used to assess or screen for nutrition

-24 hour dietary recall (They might not given the accurate information, and doesn't account well for portion sizes)

-Food intake records (E.g. Every 3 days, 7 days etc.)

-Food frequency questionnaires (How many times is a particular food eaten and in what quantity)

-Mini Nutritional Assessment (MNA)

-Mini Nutritional Assessment -Short Form (MNA SF)

-Malnutrition Universal Screening Tool

List the types of direct nutritional observation

-Noticing changes in diet and consumption before weight loss occurs

-Observing the way a patient eats and assessing if they require assistance with feeding

-Observing patient satisfaction with meals

List the types of nutritional implementation strategies

-Inform the care team of your findings and concerns, physician, dietitian, etc.

-Discuss with the care team the possibility of changing diet, texture change, small frequent meals, nutrient dense, higher protein, supplemental formulas etc.

-Monitor and encourage food and fluid intake

-Monitor weight

-Physical assessments (i.e. oral cavity)

-Referral to a denturist

-Education to explain to the patient and the family on what's going on

What is clear fluid diet?

A diet consisting of clear, low fiber fluids that are easily digested (i.e. tea, broth)

What is full fluid diet?

A low fiber diet consisting of pureed fruit, soups and fluids that are easily digested. (i.e. ice cream, milk)

What is pureed diet?

Foods that are finely blended and used for patients who are not able to chew or swallow solid foods

What is minced diet?

A diet used for patients who are unable to chew or swallow solid foods

What is a regular diet?

A regular healthy diet consisting of:

- No more than 35% of the total calories come from fat (≤35 % Kcal of fat)

- No more than 7g of saturated fat (≤ 7g)

-14 g fiber/1000 kcal

-Medium diet of 1600-1800 kcal

What is a thickened(er) fluid diet?

A diet that uses thickener to thicken fluids for better control of drinking to reduce aspiration

What is an easy to chew diet?

A diet consisting of soft textured foods (no hard foods) used for patients with chewing difficulties, limited dentition or to facilitate independent eating

MOA of Ensure and Boost supplements

-Adult supplements that are vitamin riched

-Does not replace meals

-Can be prescribed

Define dysphagia

The difficulty swallowing in terms of impaired oral, pharyngeal, and or esophageal phases of swallowing

How is dysphagia caused?

Caused when there is a problem with swallowing that impacts the ability to protect one's airway

Dysphagia is common in _________

Many health conditions (E.g. Stroke)

List the complications of dysphagia

-Aspiration can be silent*

-Respiratory infections

-Dehydration

-Undernutrition/Malnutrition

-Decreased quality of life

-Death

List the signs and symptoms of dysphagia in an adult

-Coughing and or choking when eating or drinking

-Drooling or poor management of oral secretions (Not able to swallow well)

-Pocketing of food in cheeks

-Facial weakness

-Gurgly, hoarse voice, or lots of throat clearing

-Multiple swallows for each bolus

-Decline in respiratory status

-Prolonged mealtimes

-Weight loss or malnutrition

-Recurring chest colds

-Pain with swallowing

-Increasing avoidance of multiple foods/liquids

What does pocketing food suggest?

The patient has difficulty swallowing

List the signs and symptoms of dysphagia in infants and children

-Back arching

-Breathing difficulties

-Decreased responsiveness during feeding

-Difficulty chewing food that are texturally age appropriate

-Loss of liquid/food when eating

-Vomiting

-Choking

-Crying or grimacing at mealtimes

What strategies are used to help manage dysphagia?

-Swallow assessment by a trained member of the interprofessional team; SLP, Dietitian, OT, Physician

-Follow the prescribed modified diet closely

-Use correct feeding technique and positioning

-Provide good oral hygiene care (Prevents bacterial buildup)

-Monitoring nutrition and hydration (intake)

-Always monitoring and reporting any signs and symptoms of concern

What is the appearance of a pureed diet?

-Consistency of pudding or mousse

-Soft, moist, smooth, without any lumps

-No visible particles

-No water separation

-Thick enough to spoon a minimum of 7.5ml a teaspoon

What is the appearance of a minced diet?

-Foods are minced, grated, or finely mashed to a size less than ¼ inch

-The food is moist and cohesive with no water separation

-Requires little chewing

What is the appearance of a dysphagia soft diet?

-Soft, moist, fork tender, and mashable

-Some foods need to be diced to a small size.

What can be done if a patient is unable to manage thin fluids?

Thickening fluids to help to improve control and reduces the risk of aspiration

What is the consistency of a mildly thickened fluid?

Nectar

What is the consistency of a moderately thickened fluid?

Honey

What is the consistency of an extremely thickened fluid?

Pudding

When is oral hygiene ideally performed?

Ideally done 4 times per day, but if only done once it should always be before bed

What patients are at risk for oral health issues?

-NPO → may have a GI tube

-Dehydrated

-Malnourished

-Medical treatments and medications (chemo, radiation)

-Medical problems (E.g. Infection, diabetes, ulcers, lesions)

-Trauma or surgery in the area

-Unconscious or unable

True or False: Some medications can cause dry mouth?

True

1 multiple choice option

Why is oral care essential for patients with dentures?

To prevent plaque and debris buildup and to avoid irritated gums

What is the maintenance care for dentures?

-Always stored in warm water in a denture cup with an effervescent cleaning tablet (per patient's request) to avoid warping

-Always use a denture brush and cleansing solutions when cleaning

Can dentures be worn all day?

Dentures must be removed at night to give gums a rest and prevent bacterial buildup

How should dentures be handled?

Handled with care as dentures could break or become damaged

How do you remove the upper and lower portions of a denture?

Removing a upper denture: Grasp the upper plate at the front teeth with your thumb and index finger wrapped in gauze and pull downwards

Removing a lower denture: Lift the denture from the jaw and rotate downward to one side

How do you wash dentures at the sink?

1. Place a washcloth of the bottom of the sink and fill the sink with an inch (2.5 cm) of warm water

2. Hold the denture close to the water

3. Apply the cleaning agent to the toothbrush and brush all surfaces of the denture using a denture brush and cleansing solutions

What happens to the denture if the water is too hot or too cold?

Too cold: Dentures can crack

Too hot: Dentures can warp and will no longer fit properly in the patient's mouth

What should be done prior to inserting dentures back into the patients mouth after cleansing?

-Have the patient rinse with mouthwash to clean the oral cavity

-If the denture is dry, moisten it before insertion

-If the patient uses adhesive, apply it to the under surface of each denture before insertion

What problems can ill fitting dentures cause?

Gum irritation and can become a choking hazard

How should the head of the bed be positioned when feeding a patient?

Feed up right at a 90° angle with the head tilted slightly forward not back

How can you assess swallowing prior to meals?

Have the patient tuck their chin at a 45°angle then ask them to swallow twice or several times as you assess their ability to swallow

How long should patients be seated up right after meals?

At least 30-60 minutes

Notes taken from the assisting with meals video (6:13)

-Perform hand hygiene and confirm providers meal orders

-Make sure the patient is free of nausea, can pass gas, and has a gag reflex (use a tongue depressor to assess)

-Check teeth condition and make sure the dentures fit properly

-Check for bowel sounds in all 4 quadrants

-If the patient cannot sit up place the head of the bed in a high folders position (60-90°) or turn the patient on their side with the head of the bed at a 45-90°

-Ask the patient what order they would like to eat the meal and ask what seasonings they like

-Cut the food into bite sized pieces

-If the patient is visually impaired us clock faces to describe the direction of specific items on the plate (E.g. Fish at 6 o'clock)

-Assist the patient with hand hygiene before and after they eat