274

Part II Nutrition Assessment, Consequences, and Implications

inexpensive; has few complications; and can be admin- istered at home (38).

HELPING THE CLIENT WHO CAN AND WANTS TO EAT

For clients who want to eat and who can be helped to eat better, it is important to improve their appetite and enable them to eat as normally as possible. Medications such as corticosteroids, megestrol acetate, tricyclic antidepressants, dronabinol, and anabolic ste- roids, as well as alcohol as an aperitif, can be adminis- tered to improve appetite and mood (39,40). If anorexia is due to correctable causes and the client has a predicted life expectancy of several months, the correctable causes can be treated aggres- sively if desired by the client. Likewise, treatment should be aggressive if the client’s anorexia appears to be an isolated symptom and the suspected consequence is malnutrition that could compromise both the quality and quantity of the client’s remaining days. Suggest- ions for improving oral intake of terminally ill clients through the use of food are provided in Boxes 19.4 and 19.5 (see pages 274 and 282–283). Dorner also pro- vides an excellent source of information for dietary management of troublesome symptoms associated with pain (41).

Medical Nutritional Supplements Oral medical nutritional supplements may be consid- ered for adult clients and children who want a high- energy intake in a small volume (6,27). Medical nutri- tional supplements are often appreciated because the client can drink the highly fortified liquid products with minimal effort, and the family members feel that they are providing “something special” (6).

Nutrition Support

If a client desires enteral tube feedings in addition to oral intake or as the sole source of nutrition, liquid commercial nutritional products can be administered from a small-bore flexible catheter, which in most clients is passed directly into the stomach through the abdominal wall or through the nose into the stomach or upper small intestine (42). Generally, formulas to be administered should be isotonic solutions (43). Depending on the client’s ability to tolerate the solu- tion, successful feedings can usually be started with a continuous drip at full strength if isotonic solutions are used or at half strength if hypertonic solutions are used. Begin with a rate of 30 to 50 mL/h (up to a final rate of 100 to 125 mL/h) (43), or increase the concentration (half to three-quarter to full strength) over several days, depending on client tolerance and nutrition goals. Many clients and families prefer intermittent tube

BOX 19.4 Suggestions for Improving Oral Intake

●

Provide food when client is hungry, changing mealtimes if needed. Note the client’s best meals, and make these the largest.

● ●

Provide a small serving of the client’s favorite foods on a small plate.

Gently encourage, but do not nag, the client to eat; remove uneaten food without undue comment.

● Cold foods are generally preferred to hot foods. ●

Set an attractive table and plate, using a plate garnish or table flower if enjoyed by the client. In an institutional setting, serve the client’s food on trays set with embroidered tray cloths and pretty china or stoneware rather than on traditional paper underlin- ers and dishes. Allow the client’s personal china and utensils from home to be used if feasible.

●

Make mealtimes sociable (when desired by the client) and enjoyable, vary the place of eating, and remove unnecessary medical equipment (such as bedpans) from the room.

● ●

Suggest the client rest before eating; most people feel more like eating when they are relaxed.

Encourage high-calorie foods day or night, including eggnog, milkshakes, custard, pudding, peanut butter, cream soups, cheese, fizzy drinks, pie, sherbet, and cheesecake. In an institutional setting, consider serving foods from a hot trolley instead of or in addition to allowing clients to choose their meals in advance. Consider soup and soft sandwiches for midday meals. Try to supply as much variety in food selection as possible, including regional favorites.

●

Provide lipped dishes for those clients who have arm and hand weakness; use rubber grips on ordinary cutlery for those with a weak grip.

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In an institutional setting, have a dining room available, with a homelike atmosphere, where clients or clients and their families can eat together. Allow the family to eat with the client in the client’s room if desired. Have staff available to assist clients who are unable to dine without help. Do not hurry clients to eat.

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Liberalize diets as much as possible. Rarely are diabetic or low-sodium diets essential, but if they are, consider low simple sugar foods and no regular salt packets instead of more restricted diets.

●

Consider referring the client to a speech language pathologist if there are chewing and/or swallowing difficulties present.

Source: Adapted with permission from Gallagher-Allred CR. Nutritional Care of the Terminally Ill. Rockville, MD: Aspen Publishers; 1989:221,269, with permission of Aspen Publishers.