CHAPTER 6

MAINTAINING FLUID BALANCE

AND MEETING NUTRITIONAL PRESENTED BY:
NEEDS
Kenneth M. Sabido, RN, MN
 ✓ Identify the various types of nutrients.
OBJECTIVES: ✓ Discuss the components of a healthy diet for older
adults.
✓ Describe age-related changes in nutrition and
fluid requirements.
✓ Examine age-related changes that affect
nutrition, digestion, and hydration.
✓ Describe methods of assessing the nutritional
status and practices of older adults.
✓ Identify the older adults who are most at risk for
problems related to nutrition and hydration.
✓ Select appropriate nursing diagnoses related to
nutritional or metabolic problems.
✓ Identify interventions that will help older persons
meet their nutrition and hydration needs.
Nutrition plays an important role
in health maintenance,
rehabilitation, and prevention
and control of disease.
 NUTRITION AND AGING
Good nutrition practices play a vital role in
CALORIC INTAKE
health maintenance and health promotion
in older adults. ✓ Calories are units of heat that are used to
measure the available energy in consumed
food.
✓ Basal metabolic rate the rate at which the
body uses calories
✓ Body mass index (BMI) is a number calculated using
a person’s weight and height that is a reliable way
to measure body fatness for most people.

Studies have shown that caloric needs in healthy individuals decrease

gradually with age, as there is a decrease in muscle and lean tissue mass and an increase in
adipose tissue.
 NUTRIENTS
General recommendations
from the U.S. Department of Agriculture
(USDA) (2011) for the general population
include:
✓ Enjoy food but eat less of it.
✓ Avoid oversized portions
✓ Increase intake of fruits, vegetables, and
whole grains
✓ Choose low-fat or fat-free dairy
products
✓ Reduce intake of sodium
✓ Drink water instead of sugary beverages
✓ Make physical activity an everyday
occurrence.
❖The plate is divided into color-
coded food groups which
include vegetables, fruits,
grains, and protein, with dairy
on the side. Regardless of the
total amount of food consumed,
the proportion of food from
each group should remain in
balance.
✓ More precise standards for
measuring the nutritional
adequacy of a diet are found
in the dietary reference
intakes (DRIs) .
CARBOHYDRATES
• Include sugars and starches that
comprise approximately half of the
standard American diet.
• Carbohydrates provide a ready source of
energy for the body and are divided into
two categories: simple and complex.
✓Simple carbohydrates are used
most readily by the body because their
bonds are easily broken.
✓Complex carbohydrates must be broken
down into simple sugars before they
can be used by the body. This
breakdown requires time and energy.
 PROTEINS
✓ Proteins are composed of amino acids,
which are essential for tissue repair and
healing.
✓ Protein needs remain constant or may
increase slightly with aging
to compensate for the loss of lean body
tissue.
✓ According to Dietary Guidelines for
Americans (2010), the DRI of protein for
adult women is 46 g/day; for adult
men, the RDA is 56 g/day.
 ❑ Fats, poultry, fish, eggs, and dairy products are
good sources of complete proteins , which
contain all of the amino acids necessary for
making and repairing tissues.
❑ Complementary proteins
consist of two or more incomplete proteins that
together provide adequate amounts
of essential amino acids.

FATS
❑ It is recommended that fats be limited to approximately 20% to 35%
of the total daily caloric intake. This recommendation does not
change with aging.
➢ When considering fat intake in the diet, it is important to watch
the type of fats ingested. The body incorporates fats into
substances called Lipoproteins, which contain cholesterol and
proteins.
➢There are three important
types of lipoproteins:
high-density
lipoprotein (HDL), low-
density lipoprotein
(LDL), and very- low-
density lipoprotein
(VLDL).
VITAMINS are organic compounds found naturally in ​foods.
They can also be produced synthetically.
MINERALS
are inorganic chemical elements that are required
in many of the body’s functions.

✓Calcium, the most abundant mineral in the body, is necessary for

bone and tooth formation, nerve impulse transmission and
conduction, muscle contraction (including cardiac function), and
blood clotting. Dietary sources of calcium are milk and
dairy products.
✓Phosphorus is needed for normal bone and tooth formation,
activation of some B vitamins, normal neuromuscular functioning,
metabolism of carbohydrates, regulation of acid-base balance,
and other physiologic processes.
• IRON- found in the center of the
heme portion of hemoglobin.
Hemoglobin in the red blood cells
transports oxygen to and removes
carbon dioxide from the cells.

✓Iron-deficiency anemia results

from inadequate intake of dietary
iron.

✓Pernicious anemia is caused by a

deficiency in intrinsic factor
secreted by the stomach.
✓Sodium is a commonly occurring mineral and
is one of the important elements in the body.
Sodium ions are involved in acid-base balance, fluid Trace elements
balance, nerve impulse transmission, and muscle
such as magnesium, copper,
contraction.
iodine,
fluorine, chromium,
✓Potassium is the major intracellular ion in the selenium, nickel, and sulfur
body. Potassium ions play an important role in acid- are
base balance, fluid and electrolyte balance, and necessary in very small
(with sodium) normal neuromuscular functioning. amounts for normal body
functioning.
✓Zinc is a trace mineral that plays a role in
protein synthesis. In adults, insufficient zinc may
result in delayed wound healing, impaired immune
function, lethargy, skin changes, diminished sense
of smell and taste, and decreased appetite.
 WATER
✓Water is essential for life.
Humans can survive
for many days without food
but not without water.

✓Water plays a role in many

aspects of normal body
functioning.
The amount of fluid taken into the body should be in balance
with the amount eliminated from the body. This is referred to
as FLUID BALANCE
 Malnutrition is defined as a
disorderof nutrition resulting from
MALNUTRITION unbalanced,insufficient, or excessive
diet or from impaired absorption,
AND THE OLDER assimilation, or use of food. The risk
for developing nutritional deficiencies
ADULT increases with aging. Older adults
who appear to be healthy may have
unhealthy nutritional practices.
FACTORS AFFECTING NUTRITION IN OLDER ADULTS
Physiologic risk factors:
❑Chronic Health Factors such as chronic obstructive pulmonary disease, chronic
heart failure, arthritis, dementia, and many others can interfere with obtaining and
preparing adequate nutritional food.
❑Alcoholism is suspected to be a risk factor in a larger percentage of older adults
than is commonly recognized.
❑Sensory changes can cause problems with safe preparation and storage of food.
❑Pain, whether it is chronic or acute, can interfere with an older person’s appetite
❑Medications can cause an unpleasant change in the taste of food; suppress
appetite; or cause nausea and vomiting.
❑Problems with chewing, swallowing, or digesting are common causes of impaired
nutrition.
❑Malabsorption
Economic risk factors
Difficulty getting
transportation to obtain food Obtaining an appropriate
Cost of food is a concern for
is a serious problem for variety and sufficient amount
many older adults
older adults, of food can be difficult for
with limited income.
particularly those who live older adults.
alone.

Social risk factors

Loneliness or Social
Depression is a common
isolation is one of the Lack of motivation to
reason for
more common risk cook is commonly an
decreased appetite in
factors for nutritional issue for older adults.
older adults.
problems in older adults.
INSTITUTIONAL FACTORS
➢ The repetitive nature of institutional meals.
➢ Problems maintaining the temperature and
appearance of food while serving many people
➢ Environmental concerns, such as the type of
background music being played, staff
conversations, or overhead announcements
➢ Problems related to being fed by others
➢ Behavior, appearance, or odors of tablemates
➢ Inability of an institution to meet the specific
cultural preferences or general likes or dislikes.
SOCIAL ❑Food is more than a means
AND of meeting nutritional needs.
Food is also used as part of
CULTURAL religious ceremonies, in
ASPECTS social interactions, and as a
OF means of cultural expression.
Throughout history, food has
NUTRITION been linked to the gods.

❑Cultural influences-
the foods we eat in our
homes from early in life
reflect our culture.
 NURSING
PROCESS FOR
RISK FOR
IMBALANCED
NUTRITION
 NURSING INTERVETION AND
IMPLEMENTATION
1. Assess the individual carefully to determine the
2. causes of a problem.
3. Schedule weekly weight checks.
4. Keep a dietary record of the amount, type,
and frequency of food intake.
5. Explain the importance of nutrition to overall health
or disease control.
6. Determine food likes and dislikes.
7. Assess the condition of the skin, hair, nails,
and mucous membranes.
8. Consult with the dietitian.
9. Institute measures to increase or decrease
nutritional intake.
The following measures can be
taken to increase the patient’s intake
Provide Provide a selection of nutritious foods.

Limit Limit excess intake of fluids during meal

Supplement Supplement food intake with nutritious snacks.

Ask Ask family members to bring the person’s favorite dishes from home.

Serve Serve meals in an attractive manner.

 Provide a social environment for meals by encouraging older adults to eat in the
Provide dining room.

Prepare food by opening cartons, buttering toast, or performing other activities that
Prepare may be difficult for the older person

Avoid Avoid hurrying the individual during meals.

Request a modification in the form of food served if the individual has difficulty
Request chewing

Provide Provide assistive devices such as plate sides, gripper spoons, and adaptive cups.
Provide Provide oral hygiene before meal

Assist Assist the individual to the toilet before meal

Provide Provide supplemental tube feedings, if ordered.

Time Time medication administration to not interfere with meals

Play Play relaxing music at mealtime.

Refer individuals for special counseling if emotional difficulties are interfering

Refer with appetite.
 The following measures
can be taken to
decrease intake:
oAssist in the selection of low-calorie food
oPlan low-calorie snacks into the daily routine
oIncrease diversional activities to decrease snacking
oEncourage increased activity levels. Inc
NURSING 10. Complete a thorough documentation of nutritional
status, including assessment, interventions, referrals,
INTERVENTION and patient response

AND The following interventions should take place in

IMPLEMENTATION the home:
➢ Assist the individual in obtaining resources
continuation.... such as Meals-on-Wheels, food stamps, a
housekeeper, or shopping services.
➢ Involve the family in shopping and meal planning.
➢ Identify senior citizen meal programs available
in the community.
➢ Use any appropriate interventions that are used
in the institutional setting.
 NURSING PROCESS FOR RISK FOR
IMBALANCED
FLUID VOLUME
Fluid balance is not an everyday problem in healthy older adults.
Common risk factors for dehydration include:
(1) a decreased thirst sensation;
(2) decreased effectiveness
of the kidney at concentrating urine;
(3) hormonal changes, including decreased aldosterone
secretion and renin activity;
(4) side effects of medications;
(5) altered level of mentation;
(6) altered levels of functional ability; and
(7) fear of incontinence
ASSESSMENT/DATA COLLECTION
• What are the vital signs (i.e., blood pressure, EXCESS FLUID
pulse, respiration, and temperature)
• What is the appearance of the skin? Is it moist? Dry?
VOLUME
• Describe the skin turgor? Is the tongue dry Excess fluid volume can result
and/or furrowed? Skin temperature? from excessive intake
or inadequate elimination of
• Does the individual complain of thirst? Weakness? fluids. A primary indica-
• Does the individual manifest any mood changes, such tion of excess fluid volume is
as restlessness or confusion? edema, which may mani-
• What is the fluid intake per nursing shift? Per day? fest as swelling of dependent
extremities and increased
• Is the person receiving fluids through non-oral routes, abdominal girth.
such as nasogastric feeding or intravenous
•
NURSING DIAGNOSES
• Deficient fluid volume
• Excess fluid volume
• Risk for deficient fluid volume
• Risk for imbalanced fluid volume
• Readiness for enhanced fluid balance
NURSING GOALS/OUTCOMES
IDENTIFICATION
The nursing goals for older individuals with or at risk
for deficient fluid volume or excess fluid volume are ​to:
(1) manifest vital signs within normal limits or
limits specified by the physician;
NURSING GOALS/OUTCOMES IDENTIFICATION
(2) evidence moist oral mucous membranes and good skin turgor
without evidence of edema;
(3) maintain a stable weight within normal limits;
(4) exhibit balanced fluid intake and output;
(5) report no problems related to thirst or weakness;
(6) exhibit blood studies (hemoglobin, hematocrit, serum electrolytes, BUN,
creatinine) within normal limits;
(7) verbalize an understanding of the recommended dietary and fluid intake;
(8) demonstrate behaviors necessary to maintain appropriate fluid intake;
(9) demonstrate a selection of appropriate foods and fluids;
(10) verbalize an understanding of prescribed medication(s), including the
frequency and
any precautions; and
(11) verbalize signs and symptoms that should be reported
NURSING INTERVENTIONS/IMPLEMENTATIONS:

• Complete a thorough assessment.

• Monitor vital signs.
• Monitor intake and output.
• Monitor laboratory values.
• Weigh the patient daily before breakfast.
• Measure changes in girth of body parts such as legs and
abdomen.
NURSING INTERVENTIONS/IMPLEMENTATIONS:

• Maintain adequate fluid intake.

• Offer smaller amounts of fluid at more frequent intervals.
• Keep preferred beverages at the bedside
• Use smaller containers such as medication cups or small juice
glasses when offering beverages
• Keep beverages easily available for individuals who are not in their
rooms (e.g., in day rooms, activity rooms, lounges, or other
common areas).
• Encourage the intake of foods with a high fluid content, such as
fruits, vegetables, soups, and cooked cereals
• Administer nasogastric, gastric, or parenteral fluids as ordered by
the physician.
 Implement the following measures to
decrease intake
[Link] keeping fluids at the bedside.
[Link] frequent oral hygiene.
[Link] lozenges or hard candy.
[Link] a schedule to distribute limited fluids throughout the day
[Link] the quantity of foods that are high in fluid content.

NURSING INTERVENTIONS continuation:

❑Administer medications as ordered by the primary care
provider.
❑Refer to the dietitian, if appropriate.
❑Provide appropriate skin care.
REFERENCES:
• Basic Geriatric Nursing by Patricia A. Williams RN MSN CCRN
• [Link]
• [Link]/fnic/pubs/[Link]
• [Link]
• ethnic-and-cultural-resources/dietary-guidelines-around-