Pcc cna-2011 unit 10, cna

Nutrition and FluidsUnit 10

Measuring intake and outputFeeding a Person

Nutrition and Hydration Issues

Healthy food choices are important for Healthy food choices are important for every cell in the body throughout life.every cell in the body throughout life.

Poor food choices and poor diet directly Poor food choices and poor diet directly relate to at least four of the 10 leading relate to at least four of the 10 leading causes for death in the US:causes for death in the US: Heart diseaseHeart disease Cancer Cancer Poor diet is implicated Poor diet is implicated

in in StrokeStroke other disease conditionsother disease conditions DiabetesDiabetes

Nutrition and Hydration Issues continued…

The resident may experience nutrition-The resident may experience nutrition-related situations such as unintended related situations such as unintended weight loss, malnutrition, and weight loss, malnutrition, and dehydrationdehydration

These situations contribute to poor These situations contribute to poor wound healing, lowered resistance to wound healing, lowered resistance to infections and other health problems as infections and other health problems as well as diminished quality of life.well as diminished quality of life.

Structure and Function of the Digestive System

Mouth, teeth and tongue (oral cavity)Mouth, teeth and tongue (oral cavity) Food is chewed and mixed with salivaFood is chewed and mixed with saliva Chewing/swallowing function may be Chewing/swallowing function may be

affected by changes in dentition and affected by changes in dentition and muscle control.muscle control. Worn or missing teeth, poorly fitted denturesWorn or missing teeth, poorly fitted dentures A stroke or other neurological condition may A stroke or other neurological condition may

result in loss of muscle control over part of the result in loss of muscle control over part of the mouth and throat.mouth and throat.

Structure and Function-Mouth

Gag reflex may be diminished by Gag reflex may be diminished by disease.disease.

Decrease in saliva production and Decrease in saliva production and thicker saliva may affect the residents thicker saliva may affect the residents ability to swallow food.ability to swallow food.

Taste buds on the tongue decrease in Taste buds on the tongue decrease in number and sensitivity. number and sensitivity.

The sense of smell also may diminish.The sense of smell also may diminish.

Structure and Function-Mouth

Thirst sensation declines with age.Thirst sensation declines with age. Individuals may not recognize that they Individuals may not recognize that they

are thirsty, that the body needs more are thirsty, that the body needs more liquid.liquid.

Function-Esophagus

Esophagus-carries food from the throat Esophagus-carries food from the throat to the stomach.to the stomach.

Function-Stomach

Functions-Functions- Mixes food with gastric juice to begin Mixes food with gastric juice to begin

chemical breakdown.chemical breakdown. Empties food material gradually into Empties food material gradually into

intestine.intestine.Changes due to agingChanges due to aging

Decreased stomach motility may result in Decreased stomach motility may result in feeling of indigestion and flatulence.feeling of indigestion and flatulence.Irritation/inflammation of the stomach Irritation/inflammation of the stomach lining is more likely..lining is more likely..

Function-Small Intestine

Contents mixed and moved by peristalsis, a Contents mixed and moved by peristalsis, a rhythmic, wavelike contraction of the rhythmic, wavelike contraction of the digestive system’s muscle walls.digestive system’s muscle walls.

Most of digestion and absorption of usable Most of digestion and absorption of usable material or nutrients occurs in the small material or nutrients occurs in the small intestine.intestine.

Changes due to agingChanges due to aging Decreased digestion of some materials because Decreased digestion of some materials because

of decrease in digestive enzymes.of decrease in digestive enzymes. Decreased absorption of some nutrients.Decreased absorption of some nutrients.

Function-Large Intestine

Re-absorption of water Re-absorption of water Stores material that the body cannot Stores material that the body cannot

use until it is expelled from the rectum use until it is expelled from the rectum through the anus.through the anus.

Changes due to agingChanges due to aging Decreased peristalsis(decreased motility) Decreased peristalsis(decreased motility)

leads to constipation and flatulence.leads to constipation and flatulence.

Additional factors affecting nutritional/hydration status

Decreased activity lessens caloric Decreased activity lessens caloric need, and also decreases appetiteneed, and also decreases appetite

Diminished hand and arm strength or Diminished hand and arm strength or control from neurological conditionscontrol from neurological conditions

Medications may affect: *how food Medications may affect: *how food tastes, *the resident’s appetite, as well tastes, *the resident’s appetite, as well as *absorption and utilization of food as *absorption and utilization of food nutrients.nutrients.

Resident may tire easily due to chronic Resident may tire easily due to chronic disease.disease.

Additional Factors affecting nutritional/hydration status

Depression may reduce interest in food Depression may reduce interest in food and eating.and eating.

Dementia may lessen interest in food Dementia may lessen interest in food and decrease attention span to remain and decrease attention span to remain seated for meal.seated for meal.

Lack of consideration by staff for Lack of consideration by staff for resident’s food and eating preferences.resident’s food and eating preferences. Individuals have developed preferences Individuals have developed preferences

and habits over a lifetime.and habits over a lifetime.

CNA’s role related to resident nutrition and fluids

Respect resident rights, including respecting Respect resident rights, including respecting and accommodating resident’s individual and accommodating resident’s individual preferences and habits.preferences and habits. Religious beliefs and cultural practices Religious beliefs and cultural practices

may influence preferences.may influence preferences. Residents family may be able to supply Residents family may be able to supply

helpful information about preferences and helpful information about preferences and habits.habits.

Report information about residents Report information about residents preferences so that it can become part of preferences so that it can become part of care plan.care plan.


Incorporate restorative measures as Incorporate restorative measures as part of assisting the resident with part of assisting the resident with nutrition and fluids.nutrition and fluids. Goal is for resident to be as independent Goal is for resident to be as independent

as possible.as possible. Assist the resident only with what he/she Assist the resident only with what he/she

cannot do for himself/herself.cannot do for himself/herself.


Work as a team member with other staff to Work as a team member with other staff to provide resident nutritionprovide resident nutrition.. Facility’s food service director plans meals to Facility’s food service director plans meals to

meet resident’s nutritional needs.meet resident’s nutritional needs. Facility’s philosophy of care influences food Facility’s philosophy of care influences food

preparation and presentation.preparation and presentation. Meals may be prepared in a central kitchen and Meals may be prepared in a central kitchen and

delivered to the unit on trays or food may be delivered to the unit on trays or food may be prepared in the resident’s household and served prepared in the resident’s household and served family-style on traditional dishes.family-style on traditional dishes.

Meals may be served on a regular schedule or Meals may be served on a regular schedule or prepared on the unit when the resident requests.prepared on the unit when the resident requests.


The nutrition assistant has limited The nutrition assistant has limited responsibilities in assisting the resident responsibilities in assisting the resident with eating.with eating. Nurse assigns appropriate residents for Nurse assigns appropriate residents for

the nutrition assistant (individuals with no the nutrition assistant (individuals with no complicated feeding problems), gives complicated feeding problems), gives pertinent information about the resident pertinent information about the resident and explains how to assist the resident.and explains how to assist the resident.

Nutrition assistant can provide only the Nutrition assistant can provide only the direct care of assisting the resident to eat.direct care of assisting the resident to eat.


In addition, the nutrition assistant may push the In addition, the nutrition assistant may push the resident’s w/c, but cannot perform other tasks that are resident’s w/c, but cannot perform other tasks that are considered direct care, such as dressing, grooming, considered direct care, such as dressing, grooming, bathing, transferring, positioning or assisting the bathing, transferring, positioning or assisting the resident to walk.resident to walk.

Nutrition assistant may perform tasks related to Nutrition assistant may perform tasks related to housekeeping and dietary services , if properly housekeeping and dietary services , if properly trained.trained.

Nutrition assistant reports observations and problems Nutrition assistant reports observations and problems to nurse.to nurse.

CNA reports and records observations and problems CNA reports and records observations and problems to nurse.to nurse.

Guidelines that promote nutrition and safe eating

Prepare residentPrepare resident Residents eat better when dining with others, when Residents eat better when dining with others, when

social interaction with other residents and staff is social interaction with other residents and staff is possible. Most residents will eat in a dining room.possible. Most residents will eat in a dining room.

Verbally prepare the resident for mealtime. (“Its Verbally prepare the resident for mealtime. (“Its almost time for breakfast.”)almost time for breakfast.”)

Dress and groom resident appropriately for social Dress and groom resident appropriately for social contact.contact.

Assistive devices such as hearing aids, glasses and Assistive devices such as hearing aids, glasses and dentures should be in place and functioning.dentures should be in place and functioning.


Toileting needs and comfort needs should Toileting needs and comfort needs should be checked.be checked.

Assist resident to wash handsAssist resident to wash hands Residents eat better (and more safely) Residents eat better (and more safely)

when seated in an upright position.when seated in an upright position. Head should be positioned slightly forward, Head should be positioned slightly forward,

tilted forward and downward.tilted forward and downward. Body should be in alignment.Body should be in alignment. If resident must remain in bed, elevate the If resident must remain in bed, elevate the

head of bed to the highest position, supporting head of bed to the highest position, supporting the resident’s body and head in an upright the resident’s body and head in an upright position.position.


Use gloves if CNA will touch significant Use gloves if CNA will touch significant mouth secretions while feeding.mouth secretions while feeding.

Assist resident at mealtime

Provide for positive atmosphere and Provide for positive atmosphere and social interaction.social interaction. Position resident to have eye contact with Position resident to have eye contact with

others during mealtime.others during mealtime. Talk with residents during mealtime. (Staff Talk with residents during mealtime. (Staff

conversations that do not include residents conversations that do not include residents convey disrespect)convey disrespect)

While serving food

Assure that resident receives the Assure that resident receives the correct food. Some resident have correct food. Some resident have special diets.special diets.

Ask resident if she/he needs assistance Ask resident if she/he needs assistance in preparing food for eating.in preparing food for eating. Example: CNA may add seasonings to Example: CNA may add seasonings to

food, open packages of crackers, cut meat food, open packages of crackers, cut meat or add sugar to coffee.or add sugar to coffee.

Assist resident with visual impairment to Assist resident with visual impairment to locate food and utensilslocate food and utensils

While serving food

Supplemental food or snacks may be Supplemental food or snacks may be given to resident between meals.given to resident between meals.

Do not touch any of the food with your Do not touch any of the food with your fingers.fingers.

Do not blow on the food to cool it.Do not blow on the food to cool it. Open the straw wrapper carefully being Open the straw wrapper carefully being

sure not to touch either end of the sure not to touch either end of the straw.straw.

Promote independent eating

Use adaptive equipment such as plate Use adaptive equipment such as plate guard or adapted spoon to aid the guard or adapted spoon to aid the resident in independent eating. A resident in independent eating. A capped spout cup may be used by a capped spout cup may be used by a resident who cannot control a straw or resident who cannot control a straw or open cup.open cup.

Presenting food in form that is easily Presenting food in form that is easily managed will help independent eating managed will help independent eating (for example finger food)(for example finger food)

Promote independent eating Offer feeding assistance, starting with Offer feeding assistance, starting with

the least assistance and adding the the least assistance and adding the next level as needed.next level as needed. Social interaction (talking with resident on Social interaction (talking with resident on

way to dining room)way to dining room) Nonverbal cueing (placing food in front of Nonverbal cueing (placing food in front of

resident)resident) Verbal cueing (How about some meatloaf)Verbal cueing (How about some meatloaf) Physical guidance (hand over hand Physical guidance (hand over hand

techniques guiding residents hand to hold techniques guiding residents hand to hold utensils)utensils)

Promote independent eating

Full assistanceFull assistance Continue to offer feeding assistance until Continue to offer feeding assistance until

resident ends the meal, verbally or resident ends the meal, verbally or nonverbally.nonverbally.

Assist resident if he/she is unable to feed self

CNA should sit at or below the CNA should sit at or below the resident’s eye level to promote resident’s eye level to promote interaction.interaction.

Encourage resident to chew thoroughly Encourage resident to chew thoroughly and appreciate the flavors of foods.and appreciate the flavors of foods. Convey patience.Convey patience. Give time to talk between bites of food.Give time to talk between bites of food.


Maintain separate flavors of foods. Do not stir Maintain separate flavors of foods. Do not stir all foods together.all foods together.

Identify food as it is fed to resident .”This is Identify food as it is fed to resident .”This is mashed potatoes. Now I’ll give you meatloaf”mashed potatoes. Now I’ll give you meatloaf”

Alternate liquids and solids as the resident Alternate liquids and solids as the resident prefers.prefers.

Use fork with care. Load food on tip of spoon or Use fork with care. Load food on tip of spoon or fork, presenting an amount that the resident fork, presenting an amount that the resident can easily chew and swallow.can easily chew and swallow.


Use napkin to frequently remove food particles from Use napkin to frequently remove food particles from face and clothing.face and clothing.

Observe resident carefully for effective management Observe resident carefully for effective management of food and swallowing. Report observations to nurseof food and swallowing. Report observations to nurse .. If resident shows signs of pain while chewing or swallowing, If resident shows signs of pain while chewing or swallowing,

report to nurse.report to nurse. If resident has facial or mouth weakness, observe for If resident has facial or mouth weakness, observe for

retention of food debris inside affected cheek.retention of food debris inside affected cheek. If resident begins coughing, stop assisting to eat or drink If resident begins coughing, stop assisting to eat or drink

until resident recovers.until resident recovers. If resident vomits, provide for comfort and request If resident vomits, provide for comfort and request

assistance to clean area promptly.assistance to clean area promptly.

Assisting residents who have dysphagia

DIFFICULTY SWALLOWINGDIFFICULTY SWALLOWING Special care is needed to prevent Special care is needed to prevent

aspiration (food and liquid is inhaled aspiration (food and liquid is inhaled into the lungs)into the lungs) Speech therapist may develop specific Speech therapist may develop specific

plan for assisting resident.plan for assisting resident. Assist resident to upright position with Assist resident to upright position with

head flexed slightly forward.head flexed slightly forward. Offer small amounts, giving resident time Offer small amounts, giving resident time

to swallow. Provide encouragement.to swallow. Provide encouragement.

Food thickeners

Thickeners may be used to assist the Thickeners may be used to assist the resident who has difficulty swallowing.resident who has difficulty swallowing. Thickener changes consistency but not Thickener changes consistency but not

flavor of food.flavor of food. Follow care plan for use. Follow Follow care plan for use. Follow

manufacturers directions to prepare. manufacturers directions to prepare. Common consistency levels are nectar, Common consistency levels are nectar, honey and pudding thick.honey and pudding thick.

Guidelines that promote fluid intake and good hydration

An adequate amount of water and An adequate amount of water and other liquids is necessary for proper other liquids is necessary for proper body functioning.body functioning. Approximately 48-64 ounces(1500-Approximately 48-64 ounces(1500-

2000ml) of liquid is needed daily.2000ml) of liquid is needed daily. The body obtains liquid from within fruits The body obtains liquid from within fruits

and vegetables as well as from what is and vegetables as well as from what is typically viewed as liquid.typically viewed as liquid.

Dehydration results from inadequate fluid Dehydration results from inadequate fluid intake or excessive fluid loss.intake or excessive fluid loss.

Guidelines that promote fluid intake and good hydration

Techniques to promote adequate fluid intake.Techniques to promote adequate fluid intake. Fluids easily available to resident.Fluids easily available to resident.

Water pitcher is kept in resident’s living space, at bedside Water pitcher is kept in resident’s living space, at bedside or otherwise within reach.or otherwise within reach.

Glass or cup, filled with liquid is placed within resident’s Glass or cup, filled with liquid is placed within resident’s reach at dining table.reach at dining table.

Fluids offered to residents at regular intervals. The elderly Fluids offered to residents at regular intervals. The elderly typically have decreased thirst sensation, and are less typically have decreased thirst sensation, and are less aware of need to increase fluid intake.aware of need to increase fluid intake.Offer liquids that the resident prefers.Offer liquids that the resident prefers.Snacks of juice or other fluids may be distributed between Snacks of juice or other fluids may be distributed between meals.meals.

Guidelines that promote fluid intake and good hydration Resident may be cued to remind of thirst Resident may be cued to remind of thirst

”Does your mouth feel dry? Here is ”Does your mouth feel dry? Here is something to drink.”something to drink.”

Cue or offer fluids with every resident Cue or offer fluids with every resident contact, whenever care is given.contact, whenever care is given.

Regular toileting opportunities provided for Regular toileting opportunities provided for resident who limit fluid intake because resident who limit fluid intake because he/she fears incontinence.he/she fears incontinence.

Fluid Restriction

The physician may order severely The physician may order severely restricted fluid intake as a way of restricted fluid intake as a way of managing certain medical conditions. managing certain medical conditions. The nurse will determine how to The nurse will determine how to allocate the restricted total over a 24-allocate the restricted total over a 24-hour period. The CNA must monitor all hour period. The CNA must monitor all fluid intake, both at meals and between fluid intake, both at meals and between meals to help the resident stay with in meals to help the resident stay with in the 24-hour total.the 24-hour total.

Recording food intake Identifying and recording the amount of food Identifying and recording the amount of food

intake is an important part of assisting the intake is an important part of assisting the resident to meet goals for good nutrition.resident to meet goals for good nutrition.

Following a meal or snack, the proportion of Following a meal or snack, the proportion of food eaten is usually recorded as a fraction or food eaten is usually recorded as a fraction or percentage. percentage. Example : the resident ate 50% or ½ of snack.Example : the resident ate 50% or ½ of snack.Follow facility policy for reporting food intake to nurse.Follow facility policy for reporting food intake to nurse.

Example : eating less than 75% of meal is reported Example : eating less than 75% of meal is reported to nurse.to nurse.

Weighing Why weight is measured and recordedWhy weight is measured and recorded

To monitor nutrition status-find out if resident’s To monitor nutrition status-find out if resident’s caloric intake is adequate for his/her energy needs.caloric intake is adequate for his/her energy needs.

To monitor fluid balance-body may retain fluid as To monitor fluid balance-body may retain fluid as part of a medical condition. Diuretic medication may part of a medical condition. Diuretic medication may be used to help the body eliminate excess fluid. be used to help the body eliminate excess fluid. Edema may be another sign of fluid retention.Edema may be another sign of fluid retention.

Weighing continued…

How to measure weight accuratelyHow to measure weight accurately Weigh resident at same time of day(often Weigh resident at same time of day(often

before eating morning meal) and in same before eating morning meal) and in same type of clothing.type of clothing.

Use the same scale each time. Check to Use the same scale each time. Check to see that the scale balances before see that the scale balances before weighing resident.weighing resident.

Compare weight to previous weight. Compare weight to previous weight. Report changes according to facility policy.Report changes according to facility policy.

Long-term care facility diets Meeting nutritional needs happens when Meeting nutritional needs happens when

nutritious foods are presented and the resident nutritious foods are presented and the resident eats the foods. Providing appetizing food is one eats the foods. Providing appetizing food is one of the ways that a long-term care facility meets of the ways that a long-term care facility meets the goal of providing highest quality of life for the goal of providing highest quality of life for residents. The facility may choose to use what residents. The facility may choose to use what is a “liberalized” diet menu plan rather than is a “liberalized” diet menu plan rather than traditional “therapeutic diets”traditional “therapeutic diets”

Regular Diet

Includes all foods, used for most Includes all foods, used for most residents.residents.

Calories, fat and sodium are Calories, fat and sodium are controlled(about 2000 calories, 30% of controlled(about 2000 calories, 30% of calories from fat, about 3000mg of calories from fat, about 3000mg of sodium per day)sodium per day)

Mechanical Soft Diet

For resident who has difficulty chewing For resident who has difficulty chewing or swallowing.or swallowing.

Food is easy to chew and swallow, Food is easy to chew and swallow, such as bread, cooked cereals, dry such as bread, cooked cereals, dry cereals, rice, pasta; all canned, cooked cereals, rice, pasta; all canned, cooked or frozen fruits and vegetables; all fresh or frozen fruits and vegetables; all fresh fruits and vegetables that are easy to fruits and vegetables that are easy to chew or finely chopped ; eggs, cheese, chew or finely chopped ; eggs, cheese, peanut butter, tender meats and fish.peanut butter, tender meats and fish.

Pureed Diet

For resident who has more difficulty For resident who has more difficulty chewing or swallowing.chewing or swallowing.

Foods that are soft and/or smooth in Foods that are soft and/or smooth in texture. Retaining food flavors and texture. Retaining food flavors and appealing appearance is an issue.appealing appearance is an issue.

Liquid Diet For resident in preparation for diagnostic tests For resident in preparation for diagnostic tests

or following surgery or digestive system upset. or following surgery or digestive system upset. Is not nutritionally adequate for long-term use.Is not nutritionally adequate for long-term use.

Contains foods that are liquid at body Contains foods that are liquid at body temperature.temperature.

Clear Liquid-liquids one can see throughClear Liquid-liquids one can see through Full Liquid- other liquids, including milk-based Full Liquid- other liquids, including milk-based

liquidsliquids

Low Concentrated Sweets Diet

Also called limited concentrated sweets, Also called limited concentrated sweets, consistent carbohydrate, or no concentrated consistent carbohydrate, or no concentrated sweets.sweets. For resident with diabetes. Food intake is balanced For resident with diabetes. Food intake is balanced

with insulin need.with insulin need. Regular diet with limits on foods containing a high Regular diet with limits on foods containing a high

amount of simple sugar.amount of simple sugar. Resident is encouraged to eat all of meal or snack Resident is encouraged to eat all of meal or snack

provided.provided. Notify nurse if resident is unable to eat or if Notify nurse if resident is unable to eat or if

meal/snacks are delayed or omitted.meal/snacks are delayed or omitted.

No Added Salt Diet

For resident with heart or kidney For resident with heart or kidney disease, who has trouble with fluid disease, who has trouble with fluid retention.retention.

No additional salt at the table. No additional salt at the table. Seasonings or salt substitute may be Seasonings or salt substitute may be used to enhance flavor.used to enhance flavor.

No Added Fat Diet

For resident who has difficulty digesting For resident who has difficulty digesting fat or who has elevated cholesterol.fat or who has elevated cholesterol.

Omits foods that are high in Omits foods that are high in fat/cholesterol, such as regular gravies, fat/cholesterol, such as regular gravies, bacon and butter/margarine. bacon and butter/margarine. Alternatives are used, such as low fat Alternatives are used, such as low fat salad dressings and skim milk.salad dressings and skim milk.

Calorie Controlled-Low

For resident who needs to lose weight For resident who needs to lose weight or has low energy needs.or has low energy needs.

Contains foods that are lower in Contains foods that are lower in calories, as the name explains. May calories, as the name explains. May have smaller servings.have smaller servings.

Calorie Controlled-High

For residents who needs to gain weight For residents who needs to gain weight or has high energy needs.or has high energy needs.

Contains foods that are fortified with Contains foods that are fortified with high calorie ingredients such as dry high calorie ingredients such as dry milk powder, sugar, cream and butter. milk powder, sugar, cream and butter. Snacks between meals may include Snacks between meals may include canned liquid supplements or liquid canned liquid supplements or liquid “shakes” made onsite.“shakes” made onsite.

Pcc cna-2011 unit 10, cna

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