Nutrition &

Hydration
CHAPTER 5
 Introduction
Nutrition has many physiologic as well as
psychosocial connotations. Nutritional
status affects one's health and the ability to
defend the body from diseases, maintain
anatomic and physiologic integrity, think
clearly, and possess the energy and desire to
engage in social activities.
 01
Nutritional Needs of
Older Adults
A. Quantity and Quality of
Caloric Needs
The body's needs for basic nutrients are consistent
throughout life. However, the required amount of
specific nutrients may vary. One of the most
significant differences in nutrient requirements
among people of different ages involves caloric
intake.
There are several factors that influence the older
person's reduced need for calories, which are as
follows:
• The older body has less lean body mass and a considerable increase in adipose tissue.
Adipose tissue metabolizes more slowly than lean tissue and does not burn calories as
quickly.

• Basal metabolic rate declines by 2% for each decade of life after age 25, which
contributes to weight increase when the same caloric intake of younger years is
consumed.

• The activity level of most older adults is usually lower that that during their younger
years..
A. Quantity and Quality of
Caloric Needs
Each person has a unique caloric need based on
individual body size metabolism, health status, and
activity level.
However, some generalizations can be made as
follows:
• Caloric needs gradually decrease throughout adulthood as a result of age related changes,
and a reduction in calories is recommended beginning the fourth decade of life.

• Current research shows that high caloric intake combined with a sedentary lifestyle
increases the risk of cognitive impairment in late life (Frechette and Marracinni, 2014).

• Quantity and quality of caloric intake must be monitored. One valuable way to determine
resting caloric needs that considers age and basal metabolic rate among other factors is
the Harris-Benedict equation, also called the resting energy expenditure.
 Harris-Benedict Equation

Weight in kg / height Weight in pounds /

in centimeters: height in inches

Males: 66+ (13.7 x wt in Males: 66+ (6.23 x wt. in

kg) + (5 x ht in cm) - (6.76 lbs) + (12.7 x ht. in inches)
x age in years) (6.76 x age in years)

Females: 655+ (9.6 x wt. in Females: 655+ (4.35 x wt.

kg) + (1.8 x ht. in cm) - in lbs) + (4.7 x ht. in
(4.7 x age in years) inches)- (4.7 x age in years)
• In addition to monitoring quantity, it is important to monitor the quality of calories
consumed. Because caloric requirements and intake are often reduced in later life, the
ingested calories need to be of higher quality to ensure an adequate intake of other
nutrients.

• Limiting dietary fat intake to less than 30% of total calories consumed is a good practice
for older adults.

• Fiber is particularly important in the older adult's diet. Soluble fibers, found in food such
as oats and pectin, help to lower serum cholesterol; improve glucose tolerance in
diabetics; and prevent obesity, cardiovascular disease, and colorectal cancer (Dahm et al.
2010). Insoluble fibers promote good bowel activity and can be found in grains and many
vegetables and fruits.
• Carbohydrates provide important sources of energy and fiber. However, because of a
decreased ability to maintain a regular blood glucose level, older adults need a reduced
carbohydrate intake.

• A high-carbohydrate diet can stimulate an abnormally high release of insulin in older

adults. This can cause hypoglycemia, which can first present in older adults as a confused
state.

• At least, 1g. protein per kilogram of body weight is necessary to renew body protein and
protoplasm and to maintain enzyme systems.

• Older adults must eat at least five servings of fruits and vegetables daily.
• The ability to absorb calcium decreases with age, but calcium is still required in the diet
to maintain a healthy musculoskeletal systems, as well as to promote the proper
functioning of the body's blood clotting mechanism. A good intake of vitamin D and
magnesium facilitates calcium absorption.

• Limit foods high in trans- and saturated fats, salt, and added sugar.

• Whole grains and foods with high levels of vitamins and minerals per serving are
recommended for older adults.
 Nursing Diagnosis
(From NANDA-International, 2014)
Aging and Risks to Nutritional Status

Causes or Contributing Factors Nursing Diagnosis

Nutritional Deficiency related to limited ability to

Teeth have various degrees of erosion; abrasions
chew foods.
of crown and root structure; high prevalence of
tooth loss.
Acute Pain related to poor condition of teeth.

Reduction in saliva to approximately one third the Nutritional Deficiency related to less efficient
volume of earlier years. mixing of foods.

Inefficient digestion of starch due to decreased Nutritional Deficiency related to reduced

salivary ptyalin. breakdown of starches.
 Nursing Diagnosis
(From NANDA-International, 2014)
Aging and Risks to Nutritional Status

Causes or Contributing Factors Nursing Diagnosis

Atrophy of epithelial covering in oral mucosa. Violation of Integrity of the Oral Mucosa.

Increased taste threshold; approximately one third Risk of Nutritional Excess related to increased
the number of functioning taste buds per papilla of intake of salts and sweets to compensate for taste
earlier years. alterations.

Decreased thirst sensations; reduced hunger Nutritional Deficiency related to reduced ability to
contractions. sense hunger sensations.
 Nursing Diagnosis
(From NANDA-International, 2014)
Aging and Risks to Nutritional Status

Causes or Contributing Factors Nursing Diagnosis

Fluid Volume Deficit related to decreased thirst.

Weaker gag reflex; decreased esophageal
Risk of Aspirations.
peristalsis; relaxation of lower esophageal
Nutritional Deficiency related to self imposed
sphincter; reduced stomach
restrictions to avoid discomfort.

Less hydrochloric acid, pepsin, and pancreatic acid Nutritional Deficiency related to ineffective
produced. breakdown of food.

Lower fat tolerance. Acute Pain related to indigestion.

 Nursing Diagnosis
(From NANDA-International, 2014)
Aging and Risks to Nutritional Status

Causes or Contributing Factors Nursing Diagnosis

Nutritional Deficiency related to reduced appetite

Decreased colonic peristalsis; reduced sensation
and self-imposed restrictions related to
for signal defecate.
constipation.

Less efficient cholesterol stabilization and Risk of Infection related to risk of gallstone
absorption. formation

Increased fat content of pancreas; decreased Nutritional Deficiency related to problems in

pancreatic enzymes. normal digestion.

from NANDA-International (NANDA-1). (2014) Nursing Diagnoses: Definitions and classification, 2015-2017. West Sussex UK: Wiley-Blackwell.
B. Nutritional Supplements

Although not a substitute for good nutrition,

nutritional supplements can compensate for
inadequate intake of nutrients and deficiencies
resulting from diseases and medication effects.
Niacin, riboflavin, thiamine, and vitamins B6, C,
and D are most common nutrients found to be
deficient in older adults.

NUTRITIONAL SUPPLEMENTS
However, caution is needed because vitamins, minerals,
and herbs particularly in high doses can produce adverse
effects and can interact with many medications.

NUTRITIONAL SUPPLEMENTS
 The nursing assessment should include a review of the
type and amount of nutritional supplements used. Nurses
should encourage older adults to consult the use of
nutritional supplements with their doctors.
NUTRITIONAL SUPPLEMENTS
 Risks Associated With Excess Intake of Selected
Vitamins and Minerals

Vitamin / Mineral Possible Effects with High Doses

Vitamin D Calcium deposits in the kidneys and arteries

Vitamin K Blood Clots

Masking of vitamin B12 deficiency(a cause of

Folic Acid
dementia)

Renal calculi; impaired ability to absorb other

Calcium
minerals

Potassium Cardiac Arrest

C. Special Needs of Women

Heart disease, cancer, and osteoporosis are among

the nutrition-related conditions to which older
women are susceptible. Attention to dietary
requirements and reduction of diet-related risks can
reduce some of these problems.
C. Special Needs of
Women
From 64 to 74 years of age, the rate of heart
disease among women equals that of men.
The reduction of fat intake to 30% kcal or
less (70g in a 1,800-cal diet) can be
beneficial in reducing the risk of heart
disease in older women.
C. Special Needs of
Women
Alcohol consumption also has a role in
breast cancer (40g of alcohol equals 30oz of
beer or 3oz of 100-proof whiskey). Thus,
reducing alcohol intake is advisable.
C. Special Needs of
Women
Nearly all women are affected by some
degree of osteoporosis by the time they
reach their seventh decade of life. The risk
of bone loss is increased by estrogen
reduction, obesity, inactivity, smoking, and
the excessive consumption of caffeine and
alcohol.
C. Special Needs of
Women
The risk of fracture from brittle bones and
the complications that follow warrant
consideration to prevent bone loss by
controlling risks. Postmenopausal women
should have a daily calcium intake of at
least 1,000mg. Calcium from carbonate and
citrate is the most common form of calcium
supplement.
In Capsule:
Provision of Nutritional Needs
in Older Adults
 In Capsule:
Provision of Nutritional Needs in Older Adults

1 Increase Fiber 3 Skim Milk

This is rich in protein
in diet and fluids to
and calcium and low in
prevent constipation.
fats and cholesterol.

2 Vitamins & Minerals

4 Increase Protein

Provide vitamin and Increase protein in diet,

mineral supplements as but reduce calories. The
prescribed. To promote metabolic rate of the
health. elderly is slowed.
 In Capsule:
Provision of Nutritional Needs in Older Adults

1 Limit
Limit foods high in SCALES
trans- and saturated
fats, salt and added S - adness or mood change
sugar. C - holesterol, high
A - Ibumin, low

2 Nutritional Assessment L - oss or gain of weight

E - ating problems
-To assess the risk S - hopping and food
preparation problems
factors for poor
nutritional status in
older adults.
 Increase Eating Pleasure
American College of Sports Medicine (2004)

01 02 03
Add texture & Flavors Stimulating sense of Eating with a
taste friend
• Texture: e.g., cereals on yogurt • Eat hot and cold foods in the • Arrange a regular date, e.g.,
• Flavor: e.g.. garlic in meals same meal every Wednesday evening.

04 05
• Rotate bits of food from the • Have a potluck meal where
choices in your plate friends bring a dish

Preparing food Setting the table

with care attractively

• Buy and cook small quantities • Make mealtime more interesting,

• Cook meals ahead and reheat or defrost fun, and enjoyable
• Keep easy-to-fix items available • Eating adequate calories is critical so
make it a focus of each day.
 D. Hydration Needs of
Older Adults

1
Total Body Fluids
With age, intracellular fluid (ICF) is lost,
resulting in decreased total body fluids. Water
constitutes 50% or less of body weight in older
adults. Whereas, in younger adults, water
comprises approximately 60% of their body
weight.
 D. Hydration Needs of
Older Adults

2
Total Body Fluids
This reduces the margin of safety for any fluid
loss; a reduced fluid intake or increased loss that
would be only a minor problem in a younger
person could be life threatening to an older
person.
 recommended fluid intake
It is recommended that fluid intake for men over the age of 50 years of
3.7 L/day and for women of the same age group 2.7/day (equivalent to 11
to 15 glasses containing 8oz/240cc).
D. Hydration Needs of
Older Adults

3
Less Fluids

Some health conditions may require less fluid

like cardiac and kidney disorders.
Nurses should evaluate older adults for factors that
can cause them to consume less fluid, such as:

• Age-related reduction in thirst sensation.

• Fear of incontinence (physical condition and lack of toileting
opportunities).
• Lack of accessible fluids.
• Inability to obtain or drink fluids independently.
• Lack of motivation.
• Altered mood or cognition.
• Nausea, vomiting and gastrointestinal distress.
 adequacy of fluid intake
When any of these factors is/are present or there is any suspicion
regarding the adequacy of fluid intake fluid and output should be
recorded and monitored.
 D. Hydration Needs of
Older Adults

4
Fluid Restriction
Fluid restriction may pose serious problems for
older adults such as infection, constipation,
decreased bladder distensibility, fluid-electrolyte
imbalances.
 D. Hydration Needs of
Older Adults

5
Dehydration
Dehydration, a life-threatening condition to older
persons because of their already reduced amount
of body fluid, is demonstrated by dry, inelastic
skin; dry, brown tongue; sunken cheeks;
concentrated urine; blood urea value elevated
above 60mg/dL; and in some cases, confusion.
 D. Hydration Needs of
Older Adults

6
overhydration
On the other hand, older adults are also more
sensitive to over-hydration caused by decreased
cardiovascular and renal function. Over-
hydration is consideration if intravenous fluids
are needed therapeutically.
E. Promotion of Oral Health

Pain-free, intact gums and teeth will promote the

ingestion of a wider variety of food. The ability to
meet nutritional requirements in late life is
influenced by basic dental care throughout one's
lifetime.
E. Promotion of Oral Health

Poor dental care, environmental influences,

inappropriate nutrition, changes in gingival tissue
commonly contribute to severe tooth loss in older
persons.
 losing their teeth
After the third decade of life periodontal disease becomes the first cause
of tooth loss; by 70 years of age, most people lose all their teeth.
E. Promotion of Oral Health

Growing numbers of aging adults are preserving

their teeth as they grow older, however, without
attention to the prevention of periodontal disease,
they, too could face their senior years without their
natural teeth.
E. Promotion of Oral Health

Nurses are responsible in teaching methods to

prevent periodontal disease. Moreover, nurses must
ensure that older adults and their caregivers
understand the signs of this condition so that they
can seek help in a timely manner.
Signs of periodontal disease include the following:

• Bleeding gums, particularly when teeth are brushed.

• Red, swollen, painful gums.
• Pus at gum line when pressure is exerted.
• Chronic bad breath.
• Loosening of teeth from gum line.
E. Promotion of Oral Health

The use of toothbrush is more efficient than swabs

or other soft devices in improving gingival tissues
and removing soft debris from the teeth.
E. Promotion of Oral Health

Lemon-glycerine swabs dry the oral mucosa and

contribute to tooth enamel erosion.
E. Promotion of Oral Health

Mouthwashes with high alcohol content can be too

harsh for older mouths diluting a commercial
mouthwash with water (half and half is
recommended).
E. Promotion of Oral Health

Care should be taken to prevent trauma to tissues

when performing oral hygiene because they are
more sensitive, fragile, and prone to irritation in
older adults.
E. Promotion of Oral Health

Loose teeth should be extracted to prevent from

being aspirated and causing a lung abscess.
E. Promotion of Oral Health

Loose teeth should be extracted to prevent from

being aspirated and causing a lung abscess.
A lifetime of poor dental care cannot be reversed. Geriatric
dental problems need to be prevented early in a person's
life.
E. Promotion of Oral Health

Many persons do not have access to geriatric

dentistry or the financial means to avail themselves
of this care or they are unaware of available free
services provided by the government or private
groups of dentists.
E. Promotion of Oral Health

Through education, nurses can make the public

aware of the importance of good, regular dental
care and oral hygiene at all ages and inform
patients that aging alone does not necessitate loss
of teeth.
E. Promotion of Oral Health

Many older adults believe that having dentures

eliminates the need for dental care. It is the
responsibility of nurses to correct this
misconception and encourage continual dental care
for the individual with dentures.
E. Promotion of Oral Health

Lesions, infections, and other diseases can be

detected by the dentist and corrected to prevent
serious complications from developing. Changes in
tissue structures may affect the fit of the dental
appliances which then require readjustments.
E. Promotion of Oral Health

Lesions, infections, and other diseases can be

detected by the dentist and corrected to prevent
serious complications from developing. Changes in
tissue structures may affect the fit of the dental
appliances which then require readjustments.
Poorly fitting dentures need not always be replaced;
sometimes they can be lined to ensure a proper fit.
E. Promotion of Oral Health

Nurses can explain this to older adults, who may

resist correction because of concern for expenses
involved.
Most importantly, dental appliances should be used and
not kept in a pocket or dresser drawer!
E. Promotion of Oral Health

Wearing dental appliances allows proper chewing,

encouraging older people to introduce a wider
variety of foods into their diets.

On the whole, dental problems can affect every

system of the body; therefore, must be identified
and corrected promptly.
 03
Threats to Good Nutrition
 Indigestion and food intolerance are common
among older people because of decreased stomach
motility, less gastric emptying time.

INDIGESTION & FOOD TOLERANCE

 Older persons frequently attempt to self-manage
these problems by using antacids or limiting food
intake, but both strategies potentially predispose
them to other risks.

INDIGESTION & FOOD TOLERANCE

The following suggestions may be given by the
nurse to manage indigestion and food intolerance:

• a. Eating several small meals rather than three large ones.

• b. Avoiding or limiting fried foods; it is easier to digest boiled, broiled, or
baked foods.
• c. Eliminating specific foods that cause intolerance from the diet.
• d. Sitting in an upright position while eating and for 30 minutes after
meals.
• e. Ensuring adequate fluid intake and activity to promote the motility of
food through the digestive tract.
Anorexia (loss of appetite to eat) can be related to various factors such as
medication side effects, inactivity, physical illness, or age-related changes
such as decreased taste and smell sensations, reduced production of the
hormone leptin, and gastric changes that cause satiation with smaller
volumes of food intake.

ANOREXIA
 In addition, anxiety and depression could affect the appetite of older
adults. Anxiety and depression may be due to losses and stresses such as
death of loved ones, loneliness, financial worries, and living with the
effects of chronic illnesses.

ANOREXIA
 In addition, anxiety and depression could affect the appetite of older
adults. Anxiety and depression may be due to losses and stresses such as
death of loved ones, loneliness, financial worries, and living with the
effects of chronic illnesses.

ANOREXIA
The following interventions may help manage
anorexia in the older adults:
• a. Identify the cause of anorexia and resolve their cause.
• b. Serve food in pleasant and attractive manner.
• c. Place the patient in a comfortable position, usually sitting upright
• d. Provide good hygiene measures i.e., handwashing before meals, oral
position, care after meals.
The following interventions may help manage
anorexia in the older adults:
• E. promote comfort
• Relieve pain
• Adequate ventilation and humidity of the environment
• Empty the bladder
• Change wet clothes and diapers
• Remove unsightly articles such as bed pan, urinal, emesis basin, solid
linens, etc.
• ✓ Check very tight or very loose dressing.
The following interventions may help manage
anorexia in the older adults:
• f. Remember that color affect appetite to eat; include red-, yellow-,
orange-, and green-colored foods.
• g. Engage in pleasant conversation.
• h. Serve food at proper temperature, i.e., soup is served hot, salad is served
cold.
• Assist weak patient in feeding.
• j. Curtain the unit of patients who are on NPO (nothing by mouth) or very
ill; the patient may not feel comfortable eating while being watched by
another patient; the patient's appetite to eat may be affected by the sight of
a very ill patient connected to a lot of life
The causes of dysphagia may be neurologic conditions, such as stroke or
from gastroesophageal reflux disease (GERD).

DYSPHAGIA
The incidence of dysphagia increases with age and it may be
due to the ff. factors:

• a. difficulty moving food: from the mouth to the esophagus (transfer

dysphagia);
• b. down the esophagus (transport dysphagia);
• c. or from the esophagus into the stomach (delivery dysphagia).
The following are appropriate interventions for a patient with
dysphagia:

• a. Having the patient sit upright whenever food or fluid is being

consumed.
• b. Allowing sufficient time for eating;
• c. Ensuring there is no residual food in the mouth before feeding
additional food;
• d. Placing small portions in the mouth;
• e. Discouraging the person from talking while eating;
• f. Keeping a suction machine readily available;
The following are appropriate interventions for a patient with
dysphagia:

• g. Monitoring intake, output, and weight;

• h. Giving thickened liquids or mechanically soft foods;
• i. Tilting the head to the side and placing food on a particular part of the
tongue.
• j. Referring to a speech pathologist to evaluate the problem of dysphagia.
The most dangerous potential complication of dysphagia
is ASPIRATION.
 Constipation among older persons may be because of slower peristalsis,
inactivity, side effects of drugs, and a tendency toward less fiber and fluid
in the diet.

CONSTIPATION
The following are preventive measures for constipation, a frequent
problem for older adults:

• a. Include plenty of fluids, fruits, and vegetables in the diet;

• b. Regular pattern of activity and exercise to promote peristalsis;
• c. Adequate time allowance for a bowel movement.
• d. Answer immediately to the urge to have bowel movement;
• e. Laxatives should be considered only after other measures have proved
unsuccessful and, when necessary, should be used with great care.
 Factors contributing to malnutrition include decreased taste and smell
sensations, reduced mastication capability, slower peristalsis, decreased
hunger contractions, reduced gastric acid secretion, less absorption of
nutrients because of reduced intestinal blood flow, and a decrease in cells
of the intestinal absorbing surface.

MALNUTRITION
Effects of medications can contribute to
malnutrition.

MALNUTRITION
Some clinical signs of malnutrition include the following:

• a. Weight loss greater than 5% in the past month or 10% in the past 6
months.
• b. Weight 10% below or 20% above ideal range;
• c. Serum albumin level lower than 3.5g/100 mL;
• d. Hemoglobin level below 12g/ Dl
• e. Hematocrit value below 35%.
 Other problems can indicate malnutrition such as delirium, depression,
visual disturbances, dermatitis, hair loss, pallor, delayed wound healing,
lethargy, and fatigue.

MALNUTRITION