A major nursing challenge in the care of the elderly is ensuring that they ingest all required nutrients while reducing the caloric intake to an age-related essential level. Nurses should participate in or actually perform an appropriate nutritional assessment on each older person under their care.1 Nutrition history2 and functional and cognitive abilities, as well as anthropometric measures (height, weight, triceps skin fold, and mid-arm circumference) must be determined.
Baseline laboratory data should be current.3 If not, new values must be collected, including total serum proteins (measures visceral protein stores), serum albumin (most widely used biochemical indicator of protein status), serum cholesterol (if value is allowed to go below 160 mg/dL, death may ensue), serum creatinine (indicator of lean body mass), serum transferrin (indicative of protein stores), and a complete blood count (especially hemoglobin, hematocrit, and lymphocyte count, which are necessary for nutrient transport and an adequately functioning immune system).
RISK FACTORS FOR MALNUTRITION
Risk factors for malnutrition must be identified in the health-care plan, which should list specific interventions to prevent damage to the older person because of these risks. The elderly who are at risk are those who are bedridden, have contractures, and who are generally immobile, especially those elderly with strokes, Parkinson's disease, dementias, or debilitating diseases impairing their swallowing abilities and preventing them from feeding themselves.4 Elderly with no teeth, few teeth in poor repair, or who have ill-fitting dentures will have difficulty eating. Elderly with impaired sensory and motor function may have their selffeeding inhibited or they may need to be fed by someone. Appetite can decrease for the elderly who are experiencing pain or depression. Draining wounds, infection, and dehydration all place the elderly at very high risk for malnutrition. Certain drug regimens can decrease the appetite. Environments that smell foul, are noisy, and are stressful affect the desire to eat.
Nurses must determine the older person's physical and cognitive abilities to consume a meal. They must determine how long it takes the person to eat a meal, and if the person needs to be fed by someone. Please do not call these elderly who need to be fed "feeders." That pejorative term has no place in humanistic care of the elderly. These elderly are people who need assistance with meals.
WAYS TO IMPROVE NUTRITIONAL INTAKE
Because mealtimes can take considerable staff time, a cadre of volunteers may be needed to help out at these hours. For example, some businesses encourage community service work by releasing their employees at mealtimes to feed patients in private homes, long-term care facilities, and hospitals.
Nurses must determine and make every effort to honor the meal patterns of the individual, not only likes and dislikes, but also meal schedules and lifestyle food beliefs, preparation, and service.
Drug regimens must be designed so that scheduling takes into account the times of meal service. For example, if a drug (eg, astemizole [Hismanal]) is to be given on an empty stomach, it should be given at bedtime at least 4 to 5 hours after a meal is ingested, so the stomach remains empty. Diclofenac sodium (Voltaren) should be given toward the end of a meal. Nurses must know the interactions of foods with every drug they give, which means drug schedules must accommodate mealtimes. No longer can nurses blindly give medications at "routine" times.
Nurses must look for the reasons why older persons are not eating. Always look for the obvious first. Usually these obvious reasons can be quickly eliminated. For example, the older person may be eating food served in activities too close to mealtime or brought in by family and visitors. Talks with visitors and inservice training for staff can be effective in dealing with the problem.
Medications are the next obvious reason. Sometimes, simply changing the drug schedule or discontinuing drugs that are no longer therapeutic can improve food intake.
The food itself may be another obvious reason the elderly do not eat. Food that is of poor quality, served unattractively, and allowed to get cold inhibits the appetite.
Sometimes older persons may be too restless to sit down at a table and go through the social amenities and physiologic steps required to eat a meal. These elderly can quickly become undernourished from high energy expenditure and lack of adequate food intake to meet their increased energy needs. Nurses may need to be creative in arranging finger foods and bite-sized morsels for these elderly who can easily manage these foods in their rocking and pacing activities.
Nurses must determine just what the elderly are actually eating. Stating that the person ate "good," "fair," and "poor" are subjective, ambiguous terms that cannot be objectively measured. Nurses must record exactly what the "at risk" older person is actually eating; eg, one-quarter cup green beans, 1 oz ground meat, onequarter cup mashed potatoes; 3 oz skimmed milk. The actual nutrients the person is ingesting are what is crucial to know, not just the degree of appetite. Altered intake of even one essential nutrient can derange homeostatic mechanisms in the body, causing illness and even death.
Nurses must learn to call physicians in a timely manner, rather than waiting until the person's weight has dropped precariously or the person is in severe protein energy malnutrition. Not only must the physician be notified in 2 days (or less) of failed efforts to get the older person to eat, but nurses must also insist that prompt medical intervention be instituted to find and treat the reason for the loss of appetite or inability to feed. Infections, dehydration, and drug toxicities can be quickly discovered and treated, thus preventing the older person from experiencing the horrors of severe dehydration, skin breakdown, sepsis, and drug-related cardiac arrests. Never ignore poor appetites or poor food/fluid intakes.
Malnutrition and "wasting away" syndromes do not just happen and are not a foregone conclusion. The reasons why these deleterious nutritional problems are occurring must be identified and the proper interventions must occur to try to reverse the causes.5 Never attribute weight loss or "wasting away" simply to old age.
This brief article can only begin to address tube feeding. Nurses must know exactly what kind of tube is being used, as well as the correct terminology for describing the placement of the tube (an enteral tube is not a gastric tube). Nurses should never substitute one tube for another without a proper medical order and a concrete understanding of the needs and status of the patient, the choice of the tube used, the pros and cons of such use, and the rationale for making a change. Nurses should be well aware of the hazards and complications of tube feeding. They should know that a complication like aspiration constitutes a medical emergency, and that the physician must be mobilized to action no matter what the time of day or night.
MONITORING NUTRITIONAL STATUS
One of the simplest ways to monitor nutritional status in the elderly is by their weight. There is rarely a good excuse for not weighing the elderly; lack of equipment is not a good excuse. Standing, chair, or bed scales can be used for weighing. In addition to the admission weight, the "at risk" elderly should be weighed weekly. In this way, status change can be picked up early and interventions put into place. Edema can present false weight-gain values. The older person can actually be losing weight, even though the scales show a weight gain.
Helping the elderly take in sufficient fluid on a daily basis is another challenge to nursing care. An intake of at least 1 500 mL per day of water is recommended.6 Water can be ingested in the form of clear liquids, soups, gelatin, ices, and other fluids. If fluid taken in this manner does not add up to 1 500 mL, then the amount of water still needed can be measured into a pitcher. By bedtime, all of the measured fluid should be gone.
Care must be taken that older persons actually do drink the needed fluids. The use of 4-oz glasses may be more acceptable that 8- or 1 2-oz glasses. Allow older persons to drink at their own pace. This means the nurse must frequently help older persons drink their scheduled fluids.
One of the best ways to determine adequate fluid intake is by output. The older person should be voiding about 1500 mL urine daily. Recognize that fluid loss can occur through respiration, perspiration, emesis, diarrhea, and draining wounds.
The elderly at risk for fluid deficit must be identified etiological Iy and assessed for present and potential problems related to the water deficit Nursing interventions for water deficit should be very specific. Strict intake and output data should be collected. Astute nursing clinical decisions must be made regarding the older person's risk for or presence of dehydration.
As fluid intake decreases, so does the output. Older persons may become agitated, disoriented, and combative. If the dehydration is allowed to progress, they will become lethargic, anorexic, have adverse drug interactions, and begin to have various system alterations and failures, such as constipation, skin breakdowns, pneumonia, cardiac arrhythmias, infections, etc. If dehydration persists, death can ensue.
Again, nurses must know how to read laboratory values for data that point to impending or present dehydration. Elevations in the blood urea nitrogen (BUN), creatinine, and sodium (eg, BUN 95 mg/dL, creatinine 4.0, sodium 600 mg/dL) all point to dehydration and the damage it is doing to the kidneys and heart (Table).
TABLE LABORATORY VALUES IN NUTRITIONAL ASSESSMENT*
The one lesson that must be learned from this very brief discussion is that nurses, along with every other health team member, must make sustained, conscientious efforts to ensure that older persons under their care have every opportunity to receive the necessary foods and fluids to sustain life comfortably and to prevent the devastating consequences of nutritional and fluid derangement.
Nurses have a crucial role in ensuring adequate food and fluid intake in the elderly. Nurses can improve the nutritional intake of their elderly patients by obtaining proper nutritional assessments, addressing risk factors for malnutrition and fluid deficit, providing enough staff and volunteers to help feed impaired patients, honoring each older person's meal pattern, scheduling drug regimens that do not interfere with food and fluid intake, not scheduling food-related activities and visits too near mealtime, serving food that is palatable and attractively served, ensuring adequate fluid intake, and being creative in finding ways to keep the restless, wandering patient well-nourished and hydrated.
Monitoring food and fluid intake requires precise recording of what foods and fluids the older person is ingesting, keeping accurate intake and output records, determining periodic weights, informing the physician of patients' weight loss in a timely manner, and instituting corrective measures at once.
- 1. Henderson C. Nutrition and malnutrition in the elderly nursing home patient. Clin Geriatr Med. 1988;4:527-543.
- 2. Yen P. Eat right to avoid pressure ulcers.
- Geriatr Nurs. 1991; 11:255.
- 3. Collinsworth R, Boyle K. Nutritional assessment of the elderly. Journal of Gerontological Nursing. 1989; 15(12): 17-21.
- 4. Rudman D, Feller A. Protein-calorie undernutrition in the nursing home. J Am Geriatr Soc. 1989;37:173-183.
- 5. Verdery R. "Wasting away" of the old: Can it - and should it - be treated? Geriatrics. 1990;45:26-31.
- 6. Chemoff R. Aging and nutrition. Focus on Geriatric Care and Rehabilitation. 1990; 4(2): 1-9.
TABLE LABORATORY VALUES IN NUTRITIONAL ASSESSMENT*