CNA Chapter 8: Nutrition and Hydration

define nutrition

how body uses food to maintain health

define nutrient

a necessary substance that provides energy, promotes growth and health, and helps regulate metabolism

what are 6 basic nutrients

•Water

•Carbohydrates

•Protein

•Fats

•Vitamins

•Minerals

what are important facts about water?

•Most essential nutrient for life

•Water aids in 

•Digestion

•Absorption of food

•Elimination of wastes

•Maintaining normal body temperature

what are important facts about carbohydrates?

•Provide energy and extra protein

•Provide fiber

•Complex carbohydrates include bread, cereal, potatoes, rice, pasta, vegetables, and fruits

•Simple carbohydrates include sugars, sweets, syrups, and jellies

what are important facts about protein?

•Essential for tissue growth and repair

•Provides a supply of energy

•Protein includes seafood, poultry, meat, eggs, milk, cheese, nuts, nut butters, peas, dried beans or legumes, and vegetarian meat substitutes.

what are important facts about fats?

•Help the body store energy

•Add flavor to food

•Important for absorption of certain vitamins

•Monounsaturated and polyunsaturated are healthier fat. Saturated and trans fats can increase cholesterol and the risk of some diseases.

•Some fats come from animal sources, such as butter, beef and dairy products. Some fats come from plant sources such as olives and nuts.

what are important facts about vitamins?

•Vitamins are essential to body functions.

•Fat-soluble vitamins are A, D, E, and K.

•Water-soluble vitamins are B and C.

what are important facts about minerals?

•Minerals form and maintain body functions.

•Include zinc, iron, sodium, potassium, calcium, magnesium, and phosphorus

what are some facts about vitamins and minerals?

Vitamin A	dark green and yellow vegetables, such as broccoli and turnips	assists with skin and eye development; keeps the skin healthy; helps the eyes adjust to dim light; helps the linings of the respiratory and digestive tracts resist infection
Vitamin C	fruits such as oranges, strawberries, grapefruit, and cantaloupe; vegetables such as broccoli, cabbage, brussels sprouts, and green peppers	assists with healing wounds and building bones and teeth; holds cells together; strengthens the walls of blood vessels; and helps the body absorb iron
Vitamin B2 or riboflavin	milk, milk products, lean meat, green leafy vegetables, eggs, breads, and cereals	helps cells use oxygen, which allows them to release energy from food; important for protein and carbohydrate metabolism; needed for growth, healthy eyes, skin, and mucous membrane

Vitamin B3 or niacin	lean meat, poultry, fish, peanuts and peanut butter, whole grain breads and cereals, peas, beans, and eggs	important for protein, carbohydrate, and fat metabolism; important for appetite; important for the functioning of the skin, tongue, nervous system, and digestive system; helps cells use oxygen for energy
Vitamin D	milk, butter, liver, and fish liver oils; also obtained by exposing the body to direct sunlight, which interacts with the cholesterol in the skin	responsible for the body’s absorption of the minerals calcium and phosphorus and contributes to the formation of healthy bones; especially important to growing children and women who are pregnant or breastfeeding
Vitamin E	cereals, nuts, vegetable oils, wheat germ, vegetables, fish, and fruits	helps cells use oxygen, which allows them to release energy from food; important for protein and carbohydrate metabolism; needed for growth, healthy eyes, skin, and mucous membrane
Thiamin	lean pork, dried beans, peas, whole grain and enriched breads and cereals, and certain types of nuts	helps the body obtain energy from foods

Iron	egg yolks, green leafy vegetables, breads, cereals, and organ meats	necessary for red blood cells to carry oxygen; helps in the formation of enzymes
Sodium	almost all foods and table salt	important for maintaining fluid balance (helps the body retain water)
Calcium	milk and milk products, such as cheese, ice cream, and yogurt; green leafy vegetables, such as collards, kale, mustard, dandelion, and turnip greens; and canned fish with soft bones, such as salmon	important for the formation of teeth and bones, the clotting of blood, muscle contraction, and heart and nerve function
Potassium	fruits and vegetables, cereals, coffee, and meats	essential for nerve and heart function and muscle contraction
Phosphorus	milk, milk products, meat, fish, poultry, nuts, and eggs	needed for the formation of bones and teeth and for nerve and heart function; impor- tant for the body’s utilization of proteins,  fats, and carbohydrates

what should NAs know about vegetables and fruits?

•Half a person’s plate should consist of fruits and vegetables.

•Dark green, red, and orange vegetables have the best nutritional content.

•Vegetables are low in fat and calories and have no cholesterol.

•Vegetables provide fiber and vitamins.

•Fruits are low in fat, sodium, and calories and have no cholesterol.

•Fruits provide vitamins and fiber.

what should NAs know about grains?

•At least half of all grains consumed should be whole grains.

•Whole grains contain the bran and germ, as well as the endosperm. Refined grains retain only the endosperm.

•Grains are found in cereal, bread, rice, and pasta.

what should NAs know about proteins?

•Meat, poultry, seafood, and eggs are animal sources of proteins. Beans, peas, soy products, nuts, and seeds are plant sources of proteins.

•Eat seafood twice a week instead of meat.

•Choose lean meat and poultry. Include eggs and egg whites on a regular basis.

•Eat plant-based protein foods often.

•Some nuts and seeds (flax, walnuts) are excellent sources of essential fatty acids.

what should NAs remember about dairy?

•Provides protein, vitamins, and minerals

•Includes all of the foods made from milk that retain their calcium content, such as yogurt and cheese

•Most dairy group choices should be fat-free or low-fat (1%).

•Choose fat-free or low-fat milk or yogurt more often than cheese.

•Soy products enriched with calcium are an alternative to dairy foods.

what should NAs remember for making healthy food choices?

•Balance calories.

•Enjoy your food, but eat less.

•Avoid oversized portions.

•Eat these foods more often: vegetables, fruits, whole grains, and fat-free or 1% milk and low-fat dairy products.

•Eat these foods less often: foods high in solid fats, added sugars, and salt. These foods include fatty meats, like bacon and hot dogs, cheese, fried foods, ice cream, and cookies.

•Compare sodium content in foods. Select canned foods that are labeled sodium-free, very low sodium, low-sodium, or reduced sodium.

•Drink water instead of sugary drinks.

how can NA provide person-centered care regarding the resident’s nutrition?

•Knowing and following residents’ food preferences

•Asking questions

•Paying attention

define special, modified, or therapeutic diets?

diets for people who have certain illnesses, conditions or food allergies

define puree

to blend or grind food into a thick paste of baby food consistency

what are the special diets that may be found in LTC communities?

•Low-sodium diet

•Fluid-restricted diet

•Low-protein diet

•Lowfat diet

•Modified calorie diet

•Diabetic diet

•Vegetarian diet

•Vegan diet

•Pescatarian diet

•Liquid diet

•Soft and mechanical soft diet

•Pureed diet 

what should NA know about supplements?

•Usually added to diet to encourage weight gain or intake of proteins, vitamins, or minerals

•May come in powdered or liquid form

•NAs should follow facility policy about mixing supplements; they may not be allowed to do so

•NAs can help by patiently encouraging residents to drink their supplements

•A resident has the right to refuse a supplement; refusal should be reported to the nurse

define NPO

abbreviation meaning nothing by mouth, medical order that means a person should not have anything to eat or drink

define dehydration

a serious condition that results from inadequate fluid in body

why is fluid intake important?

•Helps prevent constipation and incontinence

•Dilutes wastes and flushes out urinary system

•May help prevent confusion 

what guidelines can help prevent dehydration?

•Report warning signs immediately.

•Encourage residents to drink every time you see them.

•Offer fresh water and fluids often.

•Offer other forms of liquids if permitted (e.g., ice chips, frozen flavored ice sticks, gelatin).

•Offer sips of liquids between bites of food.

•Make sure the pitcher and cup are close by and are light enough for resident to lift.

•Offer assistance.

•Record fluid intake & output. 

what are the signs and symptoms of dehydration to observe and report?

•Drinking fewer than six 8-ounce glasses of liquid per day

•Drinking little or no fluids at meals

•Needing help drinking from a cup

•Having trouble swallowing liquids

•Having frequent vomiting, diarrhea, or fever

•Being easily confused or tired

•Resident has any of the following:

•Dry mouth

•Cracked lips

•Sunken eyes

•Dark urine

•Strong-smelling urine

•Weight loss

•Fatigue

•Dizziness

•Complaints of abdominal pain

•Reports of being very thirsty

what are steps to serving fresh water?

1.Identify yourself by name. Identify the resident by name. 

2.Wash your hands.

3.Put on gloves.

4.If the resident wants ice, scoop the ice into the water pitcher without touching the ice scoop to the pitcher. Add fresh water. Do not touch the pitcher to the spout or faucet.

5.Use and store ice scoop properly. Do not allow ice to touch your gloved hand and fall back into container. Place scoop in the proper receptacle after each use.

6.Take pitcher to resident.

7.Pour water into the resident's cup. Offer the resident a drink of water. Leave pitcher and cup at the bedside.

8.Make sure that pitcher and cup are light enough for resident to lift. Leave a straw if the resident desires it and does not have swallowing problems.

9.Place call light within resident’s reach.

10.Remove and discard gloves.

11.Wash your hands.

define fluid overload?

a condition that occurs when body cannot handle the amount of fluid consumed

define edema

swelling caused by excess fluid in body tissues

what are signs and symptoms of fluid overload?

•Swelling of extremities

•Weight gain

•Decreased urine

•Shortness of breath

•Increased heart rate

•Anxiety

•Tight, smooth, or shiny skin

what guidelines should NA know for preventing unintended weight loss?

•Report observations and warning signs to the nurse.

•Food should look, taste, and smell good.

•Encourage residents to eat; talk positively about food.

•Honor food likes/dislikes.

•Offer different kinds of foods and beverages.

•Help residents who have trouble self-feeding.

•Season foods to residents’ preferences.

•Allow plenty of time to finish eating.

•Tell nurse if residents have trouble with utensils.

•Record meal/snack intake.

•Give oral care before and after meals.

•Position residents upright for feeding.

•If resident has a loss of appetite or seems sad, ask about it.

•Weigh residents as instructed and repot and document changes.

what should NAs observe for and report regarding a resident’s appetite?

•Resident needs help eating or drinking

•Resident eats less than 75% of food

•Resident has mouth pain

•Resident’s dentures do not fit

•Resident has difficulty chewing or swallowing

•Resident coughs or chokes while eating

•Resident is sad, has crying spells, or withdraws

•Resident is confused, wanders, or paces

what are NA guidelines for promoting appetites?

•Assist with grooming/hygiene tasks before dining as needed.

•Give oral care before eating if requested.

•Offer a trip to the bathroom or help with elimination needs before eating.

•Help residents wash their hands before eating.

•Encourage use of dentures, eyeglasses, and hearing aids.

•Check the environment. Address odors. Keep noise level low. Do not shout or bang plates or cups. 

•Seat residents next to friends.

•Properly position residents for eating, which is normally in the upright position.

•Serve food promptly to maintain the correct temperature.

•Plates should look appetizing.

•Give the resident proper eating tools, including assistive utensils if needed.

•Be cheerful, positive, and helpful.

•Honor resident’s legal rights regarding food including requests for different or additional food.

when assisting residents with eating NAs should remember what?

•Residents will need different levels of help.

•Some residents will only need help with setting up but can feed themselves.

•Some residents will need to be fed. Be sensitive and give privacy.

•Encourage residents to do what they can.

what are guidelines for assisting a resident with eating?

•Assist with elimination needs before meals.

•Wash your hands.

•Identify residents before serving meals.

•Sit at resident’s eye level.

•Allow time for prayer if the resident wishes.

•Be supportive and encouraging. Do not treat the resident like a child.

•Do not touch food to test its temperature. Use a hand over the dish instead.

•Cut foods and pour liquids as needed.

•Identify foods and fluids that are in front of resident. Call pureed food by the correct name.

•Ask the resident what he wants to eat first. Allow resident to make the choice.

•Do not mix foods unless resident prefers it.

•Do not rush the meal.

•Be social and friendly. Converse if the resident wishes to do so.

•Give the resident full attention.

•Alternate food and drink, cold and hot, and bland and sweets.

•Honor requests for different food.

what are steps for feeding a resident?

1.Identify yourself by name. Identify the resident by name. 

2.Wash your hands.

3.Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.

4.Provide for the resident's privacy with a curtain, screen or door.

5.Look at the diet card or menu. Ask resident to state her name. If the resident is unable to state her name check identification another way such as looking at a photo ID or an armband. Verify that resident has received the right tray. 

6.Raise the head of the bed. Make sure resident is in an upright sitting position (at a 90-degree angle).

7.Adjust bed height to where you will be able to sit at resident’s eye level. Lock bed wheels.

8.Place the tray where it can be easily seen by the resident, such as on the overbed table.

9.Help the resident to clean her hands if she cannot do it herself.

10.Help resident to put on clothing protector if desired.

11.Sit in a chair facing the resident at the resident's eye level. Sit on the stronger side if the resident has one-sided weakness.

12.Tell the resident what foods and beverage are on the tray. Offer a drink of beverage. Ask resident what she would like to eat first.

13.Check the temperature of the food. Using utensils, offer the food in bite-sized pieces. Tell the resident the content of each bite of food offered. Alternate types of food, allowing for resident’s preferences. Do not feed all of one type before offering another type. Make sure resident’s mouth is empty before next bite or sip. Report any swallowing problems to the nurse immediately.

14.Offer sips of beverage to the resident throughout the meal. If you are holding the cup, touch it to the resident’s lips before you tip it. Give small, frequent sips.

15.Talk with the resident during the meal. Do not rush the resident. 

16.Wipe food from resident’s mouth and hands as needed during the meal. Wipe again at the end of the meal. 

17.Remove the clothing protector if used. Place it and used washcloths or wipes in the proper containers

18.Remove the food tray. Check for eyeglasses, dentures, or any personal items before removing tray. Place tray in proper area.

19.Make the resident comfortable. Keep the resident in the upright position for at least 30 minutes. Make sure the bed is free from crumbs. 

20.Return the bed to its lowest position. Remove privacy measures.

21.Place the call light within the resident’s reach.

22.Wash your hands.

23.Report any changes in resident to the nurse.

24.Document the procedure using facility guidelines.

define dysphagia

difficulty swallowing

what can cause dysphagia?

•Stroke

•Head/neck cancer

•Multiple sclerosis

•Parkinson’s disease

•Alzheimer’s disease

what are signs and symptoms of swallowing problems and must be reported to nurse?

•Coughing during or after meals

•Choking during meals

•Dribbling saliva, food, or fluid from the mouth

•Having food residue inside the mouth or cheeks during and after meals

•Gurgling during or after meals or losing voice

•Eating slowly

•Avoiding eating

•Spitting out pieces of food

•Swallowing several times per mouthful

•Clearing the throat frequently during and after meals

•Watering eyes when eating or drinking

•Food or fluid coming up into the nose

•Making a visible effort to swallow

•Breathing rapidly while eating or drinking

•Difficulty chewing food

•Difficulty swallowing medications

what facts should know about thickened liquids?

•Thickening improves the ability to control fluid in the mouth and throat.

•A doctor orders the necessary thickness after evaluation by a speech-language pathologist.

•Some beverages arrive already thickened.

•NAs cannot offer residents who must have thickened liquids regular liquids, including water.

what are three thickened consistencies?

•Nectar thick - the thickness of pear nectar or tomato juice

•Honey thick - the thickness of honey; usually consumed with a spoon

•Pudding thick - the thickness of pudding; must be consumed with a spoon

what are IDDSI descriptions for thickened liquids?

•Level 0/Thin: Flows like water and can be drunk from a cup or sucked through a straw.

•Level 1/Slightly Thick: Thicker than water and requires slightly more effort to drink; it flows through a straw.

•Level 2/Mildly Thick: Flows off a spoon and can be sipped, but it is slower than thin drinks; a mild effort is needed to drink this through a standard straw.

•Level 3/Moderately Thick: Can be drunk from a cup, though some effort is required to suck through a standard straw.

•Level 4/Extremely Thick: Cannot be drunk from a cup or sucked through a straw; is usually eaten with a spoon.

what are IDDSI descriptions for texture-modified foods?

•Level 3/Liquidised: Food has a smooth texture and does not retain its shape on a plate; it cannot be eaten with a fork but can be eaten with a spoon.

•Level 4/Pureed: Food does not have lumps and is usually eaten with a spoon; it does not require chewing.

•Level 5/Minced and moist: Food is soft, with small visible lumps, and does retain its shape on a plate; it can be eaten with a fork or spoon.

•Level 6/Soft and bite-sized: Food is soft and chewing is required; food can be eaten with a fork, spoon, or chopsticks.

•Level 7/Easy to chew: Normal foods that are soft and tender, and any method may be used to eat them.

•Level 7/Regular: Normal foods that may be naturally soft or hard and crunchy, and any method may be used to eat them.

what are some ways to prevent aspiration?

•Position in a straight, upright position (90-degree angle) for eating or drinking.

•Offer small pieces of food or small spoonfuls of pureed food.

•Feed the resident slowly.

•Place food in the unaffected side of the mouth.

•Make sure mouth is empty before offering the next bite of food or sip of drink.

•Have residents  remain upright for at least 30 minutes after eating and drinking.

define parenteral nutrition (PN)

the intravenous infusion of nutrients administered directly into bloodstream, bypassing digestive system

define nasogastric tube?

a feeding tube that is inserted into nose and goes to the stomach

define percutaneous endoscopic gastrostomy (PEG) tube

a feeding tube placed in stomach through the abdominal wall

define gastrostomy

a surgically created opening into the stomach in order to insert a tube

what are guidelines for tube feedings?

•Wash hands before assisting with tube feedings.

•Make sure tubing is not coiled or kinked.

•Be aware of NPO orders.

•Report if the tube comes out.

•Doctor prescribes feedings. They will be in liquid form and served at room temperature.

•Head of the bed should always remain elevated at 30 degrees, but during feedings the head of the bed should be elevated at least 45 degrees. Resident should stay upright after eating as long as ordered (at least 30 minutes).

•Give careful skin care.

what should NA observe for and report regarding tube feedings?

•Redness/drainage around opening

•Skin sores or bruises

•Cyanotic skin

•Resident complaints of pain or nausea

•Choking or coughing

•Vomiting

•Diarrhea

•Swollen abdomen

•Fever

•Tube falls out

•Problems with equipment

•Sound of feeding pump alarm

•Change of resident’s inclined position

what should NA know for assisting residents with special needs?

•Use assistive devices as ordered.

•Use physical cues like placing your hand over his.

•Use short, clear verbal cues (e.g., “Pick up your spoon” and “Put some carrots on your spoon”). Wait until one task is finished before giving the next cue.

•For visually impaired residents, use imaginary clock face to explain position of food on plate.

•For residents who have had CVA, place food in unaffected or stronger side of mouth. Make sure food is swallowed.

•If resident has blind spots, place food in field of vision.

•If resident has tremors, use physical cues and place food and drinks close to resident.

Place residents with poor balance in dining room chair with armrests. If resident leans, ask her to keep elbows on the table

•If resident has poor neck control, neck brace may be used to stabilize head. If resident is in a geri-chair, a wedge cushion behind the head and shoulders may be used.

•If resident bites utensils, ask him to open his mouth. Wait until jaw relaxes to remove utensil.

•If resident pockets food in cheeks, remind him to chew and swallow. Touch cheek. Ask him to use his tongue to get the food.

•If resident holds food in mouth, ask her to chew and swallow. Gently press down on tongue when removing spoon from the mouth to help trigger swallowing. Make sure resident has swallowed before offering more food.