DIABETES

Diabetes is a common chronic health condition, found in almost 10% of hospitalized persons (Russell and colleagues, 2005). Tight blood glucose management in an ICU hospital setting has been associated with significant reduction in kidney damage, reduced need for mechanical ventilation, and earlier discharge, thereby lowering hospital costs (Van den Berghe and colleagues, 2006).

Managing blood glucose levels can be challenging in a hospital setting. Issues of a hypermetabolic state with reduced appetite and other factors can cause blood glucose levels to be erratic. Hypoglycemia that may occur has been found to be primarily an issue of excess insulin administration in relation to reduced carbohydrate intake (Hess-Fischl, 2004). Hypoglycemia needs to be avoided for optimal health outcomes.

Available technology also can play an adverse role in attempts to aggressively manage blood glucose. Capillary blood glucose level as measured by finger stick has been found to be inaccurate in critically ill ICU patients and does not meet criteria of the Clinical and Laboratory Standards Institute (CLSI). The actual cause of this is not known. It may be the technique used by staff in performing finger-stick blood glucose measurements. It is advised that finger-stick measurements should be used with great caution in protocols of tight glycemic control (Critchell and colleagues, 2007).

There is limited evidence on what constitutes the optimal diet for hospitalized persons with diabetes (Swift and Boucher, 2006). There is no one diet that works for everyone with diabetes, and because it is now recognized that sugar and starch have identical effects on blood glucose levels, the avoidance of sugar is not necessary. Increasingly hospitals are providing consistent carbohydrate in the meal-planning system that accounts for the total carbohydrate content of the meals. For the person who is not taking insulin, the goal is to test postprandial glucose levels to verify carbohydrate tolerance and adjust intake or diabetes medications as needed. To utilize carbohydrate counting (see Chapter 8), the physician or provider must know how to prescribe insulin based on an insulin to carbohydrate ratio (see Chapter 8), and insulin needs must then be coordinated with actual carbohydrate intake of the hospitalized individual.

For the hospitalized individual with diabetes who will be going home, education on diabetes is important. All nursing staff should know how to reinforce diabetes education as provided by the registered dietitian and/or diabetes educator. A performance-based approach that staff nurses can use is C-O-U-N-T C-A-R-B-S: A 10-Step Guide to Teaching Carbohydrate Counting. It has been shown that nurses who reinforce practical guidelines for persons with diabetes produce better behavioral outcomes than the didactic strategies commonly used in hospitals at present (Buethe, 2008).

SURGERY

Persons undergoing surgery should optimally have good nutritional status. Those with malnutrition undergoing surgery have increased risk of postoperative complications, especially impaired wound healing. Albumin level less than 3.5 mg/dL has been associated with postoperative complications and longer hospital stays such as found with cancer surgery (Lohsiriwat and colleagues, 2008). Normal levels of albumin, reflective of good protein status, good nutritional intake of vitamins and minerals, especially vitamin C and zinc, optimal hydration status, and good blood glucose management are all important for good wound healing, whether from surgery or other causes.

A relatively frequent problem after surgery is neuropsychiatric problems. Vitamin B₁₂ deficiency has been found to be one cause of cognitive changes following general anesthesia (El Otmani and colleagues, 2007).

BURNS

The exudate of burns results in fluid loss and significant losses of protein. Albumin and prealbumin levels need to be followed to ensure adequate protein intake. Persons with burns average a need of about 5000 kcal/day during the acute phase of the burn injury. Other nutrients affected by the fluid loss at burn sites include zinc and copper, both of which are necessary for healing. Even at intakes three times the Dietary Reference Intake (DRI), the mean plasma concentrations of zinc and copper have been found to remain low (Voruganti and colleagues, 2005). Fluid intake also needs to be increased during the healing of burns to compensate for insensible fluid losses. Enteral feeding with L-arginine supplementation with early stage of burn helps to decrease adverse levels of nitric oxide production (Yan and colleagues, 2007). Glutamine may be of additional value. In addition to the need for zinc and copper, supplements of vitamins A and C are advised to promote skin healing of burn areas (Grau Carmona, Rincon Ferrari, and Garcia Labajo, 2005).

TRAUMATIC BRAIN INJURY

There is some evidence of a nutritional component in neurologic damage associated with brain injury. Excess zinc has been implicated in the neuronal damage and death that follow traumatic brain injury (TBI) (Levenson, 2005). Vitamin B₃ has shown some therapeutic potential for the treatment of TBI, with improved working memory found in an animal study (Hoane, Akstulewicz, and Toppen, 2003). Hyponatremia is a frequently observed electrolyte abnormality in persons with central nervous system disease. A high rate of hyponatremia after TBI has been observed. Correction may result with increased intake of salt, but in severe cases hydrocortisone treatment is needed (Moro and colleagues, 2007).

HIV AND AIDS

Great strides have been made to limit human immunodeficiency virus (HIV) from progressing to AIDS-related complex (ARC) or the final acquired immunodeficiency syndrome (AIDS). Although the immune system is still functioning in the early infection stage of being HIV positive, maintaining optimal nutritional status will help prevent destruction of the immune system. It is now being found that once a person has AIDS it can regress back to HIV-positive status when antiviral medications are regularly taken, meaning the immune response can regain functioning. Preserving lean body mass through avoidance of weight loss is critical to maintaining a healthy immune system.

Once AIDS has developed, a hypermetabolic state ensues, promoting muscle wasting similar to other hypermetabolic conditions. In advanced HIV-1 infection lower albumin and inflammation are both found with lower serum selenium levels. It was found as serum albumin increases, serum selenium increases as well (Drain and colleagues, 2006). This helps demonstrate the importance of good protein status. Adequate kcalories are needed to maintain positive nutritional status. However, kcalorie needs may be as high as 3500 kcal or more per day because of a fever from an opportunistic infection. A variety of factors interfere with meeting this goal.

Thrush causes a diminished desire to eat because of discomfort in the oral cavity. Medications for treatment of AIDS also may cause nausea. Abdominal discomfort and diarrhea associated with malabsorption of food nutrients compound the lack of desire to eat while increasing the need for additional nutrients. Medical nutrition therapy in this scenario may involve altering the diet to include high-kcalorie cold beverages to prevent weight loss. The cold temperature would be soothing to the mouth. Many liquid supplements are lactose-free, and with the addition of banana flakes or commercial sources of the soluble fiber pectin, may help diarrhea to subside. If antibiotics are used, a trial of yogurt or buttermilk or commercial probiotics for a few days may help control diarrhea.

FLUID NEEDS IN CRITICAL CARE

Assessed fluid need for an adult are generally 30 mL/kg body weight (BW). Increased needs beyond this are required for correction of dehydration and for conditions in which there is excess fluid loss (generally 35 mL/kgBW). This may occur with diarrhea or from open wounds, especially for burn victims. A reduced amount of fluid may be needed for heart failure (25 mL/kgBW) or end-stage renal disease (500 to 1000 mL plus urine output). Laboratory values can assist in the determination of fluid goals. Severe hyponatremia (less than 130 mg/dL) may warrant a fluid restriction. The BUN to creatinine ratio is an indicator, with a high ratio greater than 25 mg/dL suggestive of mild dehydration and greater than 35 mg/dL indicating severe dehydration. This may be due to aggressive diuretic treatment and not simply inadequate fluid intake.

Fluid and electrolyte disorders such as diabetes insipidus, salt-wasting syndrome, and syndrome of inappropriate antidiuretic hormone (SIADH) can alter fluid goals. Such conditions have been found within 3 days after surgery for brain tumors. In one review, diabetes insipidus was found to be the most frequent electrolyte disorder after surgery for central nervous system tumors. The salt-wasting syndrome and SIADH requires close monitoring of plasma sodium and fluid intake because of the risk of hyponatremia (Segura Matute and colleagues, 2007).

Risk of dehydration occurs with inadequate oral fluid intake of less than 75% intake per assessed needs; high risk can be considered with less than 50% fluid needs being met. Generally a minimum of 1500 mL daily or 6 cups is advised. Monitoring of clinical signs and symptoms of dehydration when a person is at risk of dehydration is an important role of nursing. Symptoms such as sunken eyes, reduced skin turgor, increased body temperature, low blood pressure, and constipation are important to monitor, along with charting of interventions to increase fluid intake.

HOW IS THE OLDER ADULT’S NUTRITIONAL STATUS ASSESSED?

Factors such as bone loss and a shortening of the spinal column during later years indicate the need for current height measurement rather than relying on reported measurements from younger years. Height is frequently difficult to determine because of kyphosis (hunched shoulders), although knee height can be used to estimate true height (or arm span measurement (see Figure 1-8, C).

Protein requirement for an older person is now recognized to be greater than for a younger adult. This is due to inefficient utilization and production of proteins. A protein level of at least 1 g/kgBW is advised for an older adult. More is needed for high-needs conditions such as wound management or to correct a low albumin level. Protein needs are further determined based on tolerance such as with reduced tolerance in hepatic and renal disease, with decreased tolerance evidenced by increased levels of creatinine or ammonia.

MINIMUM DATA SET FORMS

Used in long-term care settings, minimum data set (MDS) forms were designed to help promote a total health care team approach to ensure health during long-term care. These forms help to organize critical health information useful in resident care meetings and to reassess intervention strategies in achieving health goals. The areas that need to be addressed in care planning, as identified through the MDS, include issues such as need for a therapeutic diet, weight loss, fluid intake, need for altered consistency of foods and fluids, and skin breakdown.

WEIGHT MONITORING

Monitoring weight to prevent unintended weight loss or excess weight gain is vital. Significant weight loss or gain is a change in weight equal to or greater than 5% in 30 days, 7.5% in 90 days, or 10% weight in 180 days. Chronic weight loss over this time period, even if not of a significant amount, also can indicate a goal of increased kcalorie provision needs. A significant weight loss during a 6-month period has been found to be associated with a nearly twofold increase in mortality (Yamashita and colleagues, 2002).

To promote adequate oral intake of a long-term care resident requires adequate supervision and encouragement to eat. The optimal average amount of staff time required to provide the interventions for the goal of good oral intake was found to be 42 minutes per person per meal and 13 minutes per person per between-meal snack. In contrast, usual care was found to be on average 5 minutes of assistance per person per meal and less than 1 minute per person per snack (Simmons and colleagues 2008).

Residents with dementia-related disorders are more prone to weight loss and malnutrition. Close to 70% in one study were at risk of malnutrition. Food service factors, including timing of meals; difficulty manipulating dishes, lids, and food packages; and therapeutic diets, were all significantly associated with risk of malnutrition (Carrier, West, and Ouellet, 2006).

BOWEL MANAGEMENT

When a person is dehydrated, immobilized, receiving narcotic analgesics for pain, or has altered gastrointestinal function, constipation can lead to bowel obstruction. Bowel movements are needed at least 2 to 3 times weekly to prevent bowel obstruction. Increased fluids and fiber are preferred over laxative use, but the latter also may be required to maintain normal bowel function. A cake made with oat fiber was found to be well accepted and beneficial. Laxatives were able to be reduced by about 60% in the fiber group (Sturtzel and Elmadfa, 2008). Prune juice and prunes (dried prunes) are helpful in bowel management. This is believed to be due to the naturally high content of sorbitol but may also be due to phenolic compounds (Stacewicz-Sapuntzakis and colleagues, 2001).

PRESSURE AND OTHER SKIN ULCERS

Skin breakdown contributes to mortality and morbidity. Long-term care facilities are under strict regulatory control to reduce rates of pressure ulcer occurrence. Hospitals increasingly are being held accountable. To promote this accountability the Centers for Medicare and Medicaid Services (CMS) will no longer reimburse care for skin breakdown that develops while under care of the facility. Multidisciplinary wound care teams that conduct rounds at the bedside are highly recommended to both prevent skin breakdown and efficiently promote healing as needed.

Development of pressure ulcers in the hospital has been estimated to affect 10% of admissions, with elderly patients at the highest risk (Harris and Fraser, 2004). Even children can have skin breakdown. The prevalence of skin breakdown in acutely ill hospitalized children approaches one in four, although the majority of such occurrences are stage I (Suddaby, Barnett, and Facteau, 2005). Home care nurses also may have to manage pressure ulcers.

More than half of the nursing home population is incontinent of urine or feces, which is a risk factor for skin breakdown. Close monitoring and cleansing with a pH-balanced cleanser and moisture barrier can help maintain skin integrity among persons with incontinence (Zimmaro and colleagues, 2006).

Malnutrition is a risk factor for skin breakdown. One study of older persons found intake of less than or equal to 75% of meals was related to risk along with iron deficiency anemia, inflammation, and low levels of albumin, retinol, selenium, and zinc (Raffoul and colleagues, 2006). Nutritional deficiencies of a variety of vitamins and minerals may go undetected. For this reason, a multivitamin supplement is often recommended for prevention of skin breakdown, especially when there is poor nutritional intake.

The total number of risk factors for skin breakdown is usually given a score to determine level of risk. Braden and Norton Scales are examples of scoring systems for determining risk for pressure ulcers (see Appendix 15 on the Evolve website for a sample skin score sheet). Protocols are used to guide preventive strategies such as turning and positioning every 2 hours or more and nutritional guidelines. Some of the risk factors include the following:

Pressure sores are categorized by severity from stage I to stage IV with two new additional categories:

Two new categories of skin breakdown have been described by the National Pressure Ulcer Advisory Panel:

Other common types of chronic skin ulcers include ischemic ulcers, venous ulcers, and neuropathic ulcers. Pressure relief should be provided for both pressure ulcers and neuropathic ulcers. Ischemic ulcers require revascularization. Individuals with venous ulcers need adequate edema control to promote healing (Takahashi, Kiemele, and Jones, 2004). Pressure and venous ulcers are common in the elderly population.

For wound healing a supplement of 500 mg of vitamin C and 220 mg of zinc sulfate (50 mg of elemental zinc) has been standard protocol, especially for more-severe skin breakdown (stage III or IV). However, excess intake of zinc was found to delay the rate of wound healing (Lim, Levy, and Bray, 2004). It also is known to reduce copper levels and can cause a severe form of anemia due to low copper levels. Many enzymes required for protein synthesis of new skin are dependent on copper as well as zinc. Consequently, large doses of zinc are being used less often or for short periods of time.

The upper limit of safety for zinc is 40 mg/day (see the back of the book). The DRI for zinc for persons greater than 70 years of age is 8 mg for women and 11 mg for men. It may be better protocol to use 110 mg zinc sulfate (25 mg elemental zinc). Clinical studies also have shown the beneficial effects of trace elements such as boron and manganese in wound healing (Chebassier and colleagues, 2004).

With regard to macronutrient needs for healing, an increased amount of protein is advised. The guidelines are a range of 1.2 to 2.0 g of protein per kilogram of body weight depending on the severity. Along with standard protocol, the amino acid arginine appears to be of importance in healing stage III and IV pressure ulcers (Frias Soriano and colleagues, 2004). However, there is concern that L-arginine could be detrimental in an inflammatory state (Stechmiller and colleagues, 2005), and it is advised in large doses only in critically ill persons under carefully monitored study conditions (Wilmore, 2004). In a small study, supplementary arginine (9 g), vitamin C (500 mg), and zinc (30 mg) was found to significantly improved the rate of pressure ulcer healing (Desneves and colleagues, 2005).

A higher kcalorie intake of 30 to 35 kcal/kgBW is generally needed for healing. However, in elders with pressure ulcers no increase in energy expenditure was found, and a range of 25 to 30 kcal/kgBW/day is suggested (Dambach, and colleagues 2005). For the malnourished elder, an increased number of kcalories will be needed to promote a gain of body weight, important for wound healing.

A study conducted in Turkey found honey dressings to be effective and practical. The use of honey dressings was four times more effective in promoting healing of stage II and III pressure ulcers compared with a commercial dressing (Yapucu Güne and Eer, 2007). This approach is not advised for an institutional setting in the United States, but may have implication in a situation where a commercial dressing is not readily available. However, a commercial honey-based dressing is now available.

DYSPHAGIA

Dysphagia (difficulty swallowing) affects millions of persons and is particularly common in the long-term care setting. As reviewed in Chapter 4, the act of swallowing seems simple but in fact is extremely complex with multiple muscles needing to be coordinated. Good neuromuscular control is essential for safe swallowing to prevent choking and aspiration pneumonia. A person with decreased cognition may need to be reminded to chew and swallow.

Elderly persons with dysphagia need food that requires little or no chewing, is easy to swallow, and is still appealing to eat, both visually and in terms of taste. The production of a sufficient amount of saliva is indispensable for good chewing. The addition of lemon to meals has been shown to invoke saliva production. Adding fluid to foods can significantly reduce the amount of chewing and total muscular work. Adding fluid to breakfast cake type of foods is particularly beneficial for persons with low saliva production (van der Bilt and colleagues, 2007). Buttering the food can reduce the amount of chewing needed before swallowing. This is especially helpful for dry foods such as cake and toast (Engelen, Fontijn-Tekamp, and van der Bilt, 2005).

Thickened liquids are often required, or at least may be advised, with dysphagia. This is because gravity is less able to allow the liquids to flow down the esophageal area, helping to avoid aspiration pneumonia. The various thicknesses include the following, from thinnest to thickest: nectar thick, honey thick, and pudding thick. The speech-language pathologist (SLP) helps to assess swallowing ability and advise on needed alteration of consistency or other strategies to reduce risk of choking and aspiration pneumonia.

Commercial thickeners come in two main forms. One is based on the gum type of fibers, the other is a form of starch. All thickeners have been found to suppress the flavors of beverages and give slight off-flavors (bitter, sour, metallic, or astringent). Starch-based thickeners impart a starchy flavor and grainy texture, whereas gum-based thickeners give added slickness to the beverages. Some beverages do not lend themselves well for thickening, causing lumps to form. Individual decisions must be made about which characteristics are more negative (e.g., slick versus grainy texture) for specific patients (Matta and colleagues, 2006).

Although there are commercially available prethickened liquids, there are a number of issues yet to be resolved. One impact on thickness is the amount of time it takes to consume a thickened liquid. Time and temperature have bearing on how well the thickened liquid maintains its consistency for the starch-based thickeners. The gel-based thickeners maintain their thickness regardless of time or temperature, although their use may be challenging to meet adequate thickness criteria. Simply Thick, the gum-based thickener, typically produced samples that were the least viscous, but they maintained a more consistent level of thickness over time (Garcia and colleagues, 2008).

Commercially prepared beverages can be thinned by accidental addition of saliva to the beverage as it is being consumed. This is more likely to be a problem if the person drinks slowly and uses a starch-based thickener or commercial product based on a starch base. The gel-based thickeners consist of soluble fiber that is not digestible by salivary enzymes.

Commercial nectar- and honey-consistency beverages were found to be significantly more viscous at various temperatures compared with their individually thickened counterparts. Commercially thickened beverages at nectar and honey consistencies were almost always more viscous, typically more like syrup consistency, than the National Dysphagia Diet Task Force–defined standards (Adeleye and Rachal, 2007). See Table 4-1 regarding considerations for food texture modification.

CARE PLANS

All disciplines working in a long-term care setting need to develop care plans. This is the means by which all members of the health care team communicate with one another. Care plans are developed within 14 days initially upon admission and are reviewed at least quarterly and annually through care plan meetings that include the resident, registered nurse (RN), RD, social work, activities, and others as appropriate such as the occupational therapist (OT) and physical therapist (PT). Nutritional assessments identify the nutritional areas of risk, and a nutritional care plan is developed using measureable objectives and goals with specific care communicated with all nursing staff. The CNAs need to know their daily role with pertinent nutritional goals such as may be written on CNA resident care cards (Figure 15-2).