Assisting clients in selecting appropriate meals / fluids in nursing
To be able to assist clients in the selection of an appropriate diet it is important that health carer professionals understand the key components of a nutritious diet and are aware of factors affecting nutritional demands in the healthy individual. In addition, health promotion is a statutory requirement of the registered nurse so knowledge of what constitutes a healthy diet and fluid intake for the client is crucial. An in-depth discussion of what the constituents of a healthy balanced diet are is beyond the scope of this chapter and will require further reading, but an outline of the required nutrients and their role within the body.
In addition to knowing about the various nutrients it is important to know what foods make up a balanced diet. This can be summarized by the percentages given below
• Starchy foods: 33%
• Fruit and vegetables: 33%
• Milk and dairy products: 14%
• Meat and alternatives (e.g. tofu, pulses): 12%
• Oils, fats, fatty foods, sugars, sugary foods (and alcohol, if taken): 8%
Factors that influence a healthy individual’s nutritional needs
• Age: Children have higher metabolic rates than adults, and so require more energy and also need to eat the correct amount and type of food to support growth. In adulthood, as age increases, energy requirements decrease due to the lower metabolic rate of older people compared with younger adults.
• Sex: Men require more energy, hence calories, because they have a higher metabolic rate than women due to their relatively greater muscle mass.
• Amount of physical activity: As energy is used as fuel, the higher the level of activity the more energy is used up and more calories are required.
• Height and build: The bigger the size of the body, the larger the amount of nutrients required to maintain cells.
• Pregnancy: The rapid growth of the foetus, during the second and third trimesters of pregnancy, changes nutritional needs although the exact changes vary from woman to woman. In particular, the demand for energy, protein and vitamins A, B, C and D are higher. However, ‘eating for two’ is not necessary as decreased maternal energy towards the end of pregnancy often compensates for the increased energy requirements of the foetus. In addition, the average British diet usually contains sufficient protein to meet the increased demands.
• Lactation: Women who are breast-feeding require more energy and therefore increased calorific intake (up to 500 calories a day) as well as increased vitamin A, C and D and calcium intake.
These healthy eating recommendations need to be considered, along with client choice, when assisting an individual to choose a healthy meal. It is good practice to spend time with the client to establish their likes and dislikes. If you are with the client you can direct their choice towards the correct food to choose. For example, if a client is underweight or has a wound or pressure sore, you can encourage them to choose highprotein/high-calorie options to help facilitate weight gain and provide them with sufficient amounts of protein, which is required for effective wound healing.
If a person’s appetite is very poor or due to illness they have increased nutritional demands as a result of higher metabolic rate, food intake may be insufficient to meet nutritional needs. In these instances a wide range of supplements can be used. Supplements are used to increase the nutritional value of oral intake, with some providing only calories whilst others, in addition to calories, containing proteins, vitamins and minerals. Some can be added to the client’s normal diet (for example powdered glucose polymers such as Polycal and Maxijul) and others are drinks that the client has between meals (for example Fresubin, Fortisip and Enlive). A dietician will prescribe the most appropriate supplements for the client following a nutritional assessment.
The client’s cultural and religious beliefs also need to be considered when assisting the client to choose their meals. All hospitals are now required to provide special diets such as halal meals for Muslim clients as well as cater for vegetarians and vegans (see Table 5.2). However, it must be recognized that the choice available for these clients can be restricted.
Selection of appropriate fluids
As well as the client’s food intake the health care professional needs to ensure that sufficient fluid is consumed on a daily basis. The normal requirement for an adult is three litres of fluid every 24 hours. Our role is to ensure that clients drink a sufficient amount of fluids to prevent dehydration. Encouraging patients to drink (or ‘push fluids’ as it is often known) is usually left to junior or inexperienced staff. It is therefore essential to have sound knowledge of the client’s needs and to work very closely with them in order to encourage them to drink. They should be checked frequently, that is, at least every two hours, ensuring that they are offered the most acceptable beverages or alternatives (for example ice lollies) and that what the client has consumed is accurately documented.
An important point to remember is that some patients may have restrictions placed on the amount of fluid they are allowed to drink each day. For example, some clients with renal failure can be restricted to as little as 600 ml per day. Clients suffering from heart failure may also have restrictions on the amount of fluid they are able to receive. In contrast, clients may need extra fluid if they are losing excess fluid due to, for example, a raised temperature (pyrexia). It is therefore important to be aware of the client’s individual hydration needs in order to educate and assist clients to select the appropriate amount and type of fluid. In addition, the older person, children, people with learning difficulties and some clients with mental health problems can easily become dehydrated if they are not encouraged to drink sufficient amounts of water.
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