Nutrition and hydration are essential human needs that should be the main focus of the nurse in the care of the patient/client. If the nutritional state of the patient is inadequate or unbalanced the effect of therapeutic medical interventions can be ineffective therefore nutrition is as important as medication in the recovery from chronic diseases, wounds, infections and surgical operation. The lack of a balanced diet can lead to malnutrition which is considered to be a major risk for morbidity and mortality among the elderly (Webb and Copeman, 1996). Research done by the European Nutrition for Health Alliance (2005) found that four out of 10 older people admitted to hospital are malnourished on arrival and six out of 10 are at risk of becoming malnourished or their condition worsening. Florence Nightingale stated that, “thousands of patients are starved in the midst of plenty, from the want of attention to the ways which alone make it possible for them to eat” (Webb and Copeman 1996). It is vital for nurses to implement a patient centred care to develop trust as meeting the needs of the elderly can be challenging. Nursing and Midwifery Council (NMC) (2008) acknowledges that nurses should make the care of people their first concern treating them as individuals and respecting their dignity therefore providing food and help with eating are important elements in maintaining dignity.
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This essay is going to focus on the importance of nutrition in the care of adults mainly the elderly as care for the elderly is different in that a child’s main focus is growth and maturation while that of the elderly is maintaining a healthy physical status, building strength and avoiding excess weight. It is going to look at the definition of nutrition, some of the essential nutrients, ways of nutritional support, malnutrition, role of nurse in preventing malnutrition and barriers faced. This report is going to have different materials that back up evidence based practise and support the importance of nutrition in patient/client care.
Williams, (1999) describes nutrition as the sum of the processes involved in food nutrients, assimilating and using them to maintain body tissue and provide energy which is the foundation for life and health. There are different types of nutrients which are responsible for regulating different functions, providing energy, enable growth and maintain cell tissue. There are two categories of nutrients which are classified as macronutrients and micronutrients.
Protein is an essential nutrient needed by every human being as it is vital for the growth and repair of tissues (Quinn et al 1987). It is responsible for making hormones, enzymes and antibodies which help fight infections as well as deliver oxygen and transportation of other nutrients to the body. Nurses should encourage strict vegetarian patients to take a complementary protein to ensure they have a sufficient supply of amino acids as the lack of these can lead to protein- energy malnutrition (PEM) (Beck 1985). Evidence from a systematic review (Potter et al 1998) suggests that protein and energy supplementation improves outcomes in the elderly patients with multiple medical and surgical conditions.
Enough energy intakes is required to help in restoring and preventing loss of fat stores which provide cushioning against pressure in patients with wounds and pressure ulcers (Thomas 2001). As people age their energy and calorie intake declines because of the decline in metabolic rate, lean body mass and physical activity. The Food Standard agency (FSA) (2001) emphasises that patients with wounds and pressure ulcers should be encouraged to have a carbohydrate source with each meal. Fibre is a form of indigestible carbohydrate which increases the muscle tone in the digestive tract and lowers the risk of developing bowel cancer, constipation, piles and osteoporosis which are common in the elderly (BDA, 2003).
Fat provides a store of concentrated energy, heat, insulation and protection from injuries. Fats, especially mono and polyunsaturated fatty acids are responsible for reducing the incidences of heart diseases, brain function, regulating mood and lower depression. They are helpful in preventing cardiovascular diseases such as coronary thrombosis (COMA, 1992). High levels of saturated fat and cholesterol in the diet may increase the risk of obesity and cardiovascular diseases while reducing fat in the diet may deplete levels of serotonin in the brain causing mood changes and depression (Beck et al, 2005).
As people age they need more vitamins and minerals to support their general wellbeing. Vitamins are found in fruits and vegetables as well as dairy products, meat and fish. Vitamin B12, B6 and folate are examples of water soluble vitamins which are good at fighting heart diseases, cancers and prevent declining neurological deficiencies such as memory loss and anaemia. It is important for nurses to recommend five portions of fruit and vegetables a day and supplements for patients who cannot receive enough from their normal diet. Minerals are responsible for hormonal, enzymatic, transportation of molecules and electrolyte balance. Calcium is an example of a mineral found in the bones and teeth responsible for the function of muscles, nerves and blood clotting.
Fluid intake is a vital nutrient needed for the maintenance of healthy tissues, regulating temperature and transportation. Patients who have an imbalance in fluid are unable to efficiently oxygenate vital organs or carry waste products to be excreted. As the kidney’s function deteriorate with age this can impair the renal function in regulating salt and electrolyte balance and this can lead to dehydration (Nursing standard 2009). This can cause renal and cardiac problems especially in patients who have suffered from stroke and Alzheimer’s disease who can be insensitive to thirst (Water UK 2006). It is important for nurses to encourage frequent sips of water to vulnerable patients as some may have lost a sense of thirst from medication.
Types of nutritional supply
Food can be administered through oral feeding using modified foods; food fortification moulded foods, finger foods, snacks as well as using enteral (tube feeding inserted in the nose directly to the stomach) and parenteral feeding (intravenously using a sterile liquid) (National Institute of Health and Clinical Excellence (NICE) 2006).
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NICE (2006) defines malnutrition as, “a state in which a deficiency of nutrients such as protein, energy, vitamins and minerals causes measurable adverse effects on body composition, function and clinical outcome”. Elderly patients are at risk of malnutrition caused by hospital diet, processes and shortcomings known as iatrogenic malnutrition (Coates 1985). Some of the factors that increase the risks are poor dentures, hearing difficulties, chronic diseases, surgical treatments and other degenerative diseases. Social factors such as isolation, poverty, culture and bereavement can also contribute to the risk. This could lead to a number of deficiencies which may include reduced immunity, impaired function of the heart and lungs. This can increased the risk of admission to hospital and length of stay. NICE (2006) stated that if poor dietary intake or complete inability to eat persists for weeks the resulting malnutrition can be life threatening.
Patients are usually screened on admission using their dietary history or screening tools such as the Malnutrition Universal Screening Tool (MUST) to check if they are malnourished, at risk of malnutrition or obese (British Association of Parenteral and Enteral Nutrition (BAPEN) 2003). This screening tool consist of a five step guide based on the patient’s body mass index, weight loss, illness score, overall score and management guidelines. It is important in guiding the carers on which steps to follow which can help to develop and manage an individual care plan. There are a lot of campaigns that are on going to help reduce the number of malnutrition in hospitals such as Hungry to be heard (Age concern 2006) and Nutrition Now (Royal College of Nursing (RCN) 2007). Nutritional screening done in 2007 found that 28% of hospital patients were at risk of malnutrition, of which 22% were considered to be at high risk and 6% at medium risk (BAPEN 2008).
Role of nurses and barriers they face
The Roper, Logan and Tierney model for nursing states that the nurse has a primary role , within the multidisciplinary team, in ensuring that patients receive food, fluids and adequate nutrition whilst they are in their care and health education regarding a healthy diet (Holland et al 2008). It is important for the nurse to have relevant physiological knowledge and understanding of what makes a balanced diet and different constituent food groups (Docherty and McCallum 2009). Assisting patients to eat is regarded as a fundamental nursing skill that nurses need to develop for the health and wellbeing of patients as well as prevention of diseases. The nurse plays a big role in meeting the nutritional needs of patients by assessing them on admission, monitoring, providing help, advice and referrals. It is the role of the nurse to ensure that collaborative care with other multidisciplinary team such as dieticians, rehabilitation nurses, social workers and occupational therapists is implemented as soon as possible in cases of malnutrition, anorexia or obesity disease (Docherty and McCallum 2009).
The Caroline Walker Trust (2004) recommends that staff should be present and involved at mealtimes, respecting individual preferences, making sure that patients are sitting in an upright position to encourage normal digestion and making the environment pleasant by removing bed pans and commodes to enhance a good appetite. Nurses, in collaboration with the catering staff should respect individual cultural preferences such as providing Kosher for Jews, meat free dishes for vegans/vegetarians and recognising any food allergies and intolerances such as gluten (NMC 2008). Nurses should identify patients who need assistance using the red tray initiative as directed in the Nutrition Now campaign (Royal College of Nursing (RCN) 2007).
It is important for the nurse to imply good interpersonal communication skills with the patient as this will encourage the patient to eat. The nurse should also check that all records are well documented such as care plans; food and fluid balance charts as it is a good way of communicating with the other staff and gives a clear nutritional outcome. From the experience I had at my placement the red tray initiative was a good form of identifying patients who needed assistance. It gave me the chance to be aware that meeting nutritional requirements of older patients can be more challenging as the patient declined to be assisted in feeding (Docherty and McCallum 2009). Barriers faced by nurses lack of nursing time, lack of nutritional training, lack of communication, trust and respect within the multidisciplinary team.
In conclusion providing good nutrition is important in the prevention of malnutrition, degenerative diseases and overall well being of patients. It is vital for nurses to develop good nutritional knowledge and interpersonal skills to be able to provide holistic quality care towards the recovery of patients.
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