CNA CH 8 - Food & Fluids

Before the meal

Facility staff should sanitize and dry the tables. Ensure the dining area is a pleasant, enjoyable atmosphere by eliminating odors and controlling lighting. Ensure table heights are appropriate for the residents to comfortably reach the food. (Ideally, wheelchair arms should fit underneath the table.) Ensure the resident is comfortable and clean. This requires communicating with the nurse aides and nurses to ensure the resident has been toileted, has had their face and hands washed, and has good oral hygiene. Be sure the resident has dentures in, glasses on and clean, and hearing aides in, as appropriate. Provide clothing protectors as needed. Ensure the resident is positioned appropriately (ask facility staff to reposition the resident if needed).

Swallowing difficulty signs

Taking a long time to begin to swallow Coughing or throat clearing while eating or drinking or very soon thereafter Needing to swallow 3-4 times for each bite of food Pocketing food in cheeks (i.e. stroke) Wet sounding voice during or after eating Food or liquid falling from the mouth Drooling Watering eyes after eating Extra effort in chewing or swallowing Rocking the tongue back and forth (front to back)

Texture-modified

* Dentures or teeth in poor condition * Difficulty chewing * Dentures may be poor fitting due to shrinkage of supporting bone, and mouth sores may develop. * They may not salivate as much, which causes a dry mouth and makes it hard to chew. Food texture may be chopped or blended to different levels. Diet orders may be for mechanical soft, pureed, dysphagia diets or other similar terminology. Liquids may be modified to a thicker consistency than a usual cup of water.

Ensure Adequate Fluid Intake

* Give special attention to confused - place cup/straw in mouth or frequent offerings of sips. * Offer variety of liquids & note their preferences * adaptive devices from specialist (i.e special cups).

Hot foods

150 degrees or warmer

1 oz

30 cc

Cold foods

40 degrees or colder

1 cup

8 oz = 240 cc

Water

Carries nutrients & wastes to & from cells, essential for normal body functions. 2 qts (8 cups)/day. 50-60% of body weight. Foods (juicy fruits & vegetables) contain water. Even dry foods (i.e. bread) supply some water.

CVA

Cerebral Vascular Accident (stroke)

Infections

Definitions How Infections are Spread Infection: A condition caused by the growth of pathogens or germs in the body Infection control: The method used in health care facilities to prevent the spread of pathogens or germs Infections are commonly spread by: • direct contact such as touching the source of infection; • indirect contact such as touching contaminated objects; • airborne routes such as inhaling small pathogens floating in the air; or • droplet spread such as contacting drops of secretions placed in the air when someone sneezes, coughs, or talks.

Different diets

Diet type (i.e. special focus), Texture (reg. cut up, pureed), Fluid thickness (nectar, honey, pudding)

Dehydration signs

Elderly show signs quicker than younger. Signs: dry lips & mouth, difficulty swallowing, loss of appetite, white coating on tongue. Dry, itchy, cracking skin. Decrease urine, darker in color. Fatigue, weakness, confused. Weak & fast pulse.

Nutriton approaches

Examples: • Enhanced foods, such as super cereal • Supplement drinks, such as shakes and Ensure • Between meal snacks and supplements • Protein powder added to food and drinks

Reporting intake

Fluids: 1 oz = 30 cc. Food: 0% (refused) 25%, (poor - 25% of entree or 50% of one item) 50% (Fair), 75% (Good), 100%. Nurse will record IV and tube feedings.

hyperglycemia

High blood glucose. Not enough insulin or ineffective insulin. High levels of sugar in the urine, Frequent urination, Increased thirst. Headache, fatigue,hot skin. Usually don't start having symptoms until glucose reaches 200+. If untreated, Ketoacidosis (diabetic coma) may develop when your body doesn't have enough insulin - dry mouth, SOB, N&V. Monitor glucose levels.

hypoglycemia

Low blood glucose < 70. Insulin reaction or shock. Shaky, sweating, nervous, confusion, rapid pulse and breathing, anger, hunger. Consume 15-20 grams of glucose or simple carbohydrates (2 glucose tabs, 1 oz sugar or honey, 4 oz juice, 8 oz milk, candy) followed by protein. If left untreated, hypoglycemia may lead to a seizure or unconsciousness (coma). If your blood sugar at bedtime is low - less than 126 mg/dl, a snack can help prevent a nighttime dip. Sugar + protein such as a glass of milk and 3 graham crackers.

Diet

MD orders diet, in care plan. May be to assist in treatment of disease. Most residents have general, regular diet

Soft diet

Mechanical (cooked) or Pureed. difficulty swallowing, chewing or digesting. Stroke. finely chopped or blended

Food

Most elderly use less energy/calories but need same vitamins, minerals, protein as younger. Need more nutrition when sick, wound or pressure ulcer to get better and heal. Good nutrition positive effects on physical and mental health. For some elderly, protein-rich foods (meat or poultry), may be hard to chew or to digest.

Therapeutic Diets

Relationship between nutrition and disease. MD may order special diet. One or more ingredients are lowered or increased, or food texture modified. Depends on: • disease or potential disease • chewing or swallowing problems or potential For frail older adults, overall health goals may not warrant use of therapeutic diet cuz possible negative effect on quality of life. Resident may find it unpalatable or unacceptable and refuse. Poor intake results in weight loss and undernutrition spiraling into negative health. Trend in some LTC to eliminate or reduce restrictions

Chinese

Rice and noodles common, food used to treat disease

Nutrition - elderly vs young adults

Same needs. quantity varies, harder to meet for elderly

Edema

Too much fluid in tissues. Signs: swelling (feet ankles may be first), congestion/wheezing, quick weight gain, decreased urine

TPN

Total Parenteral Nutrition - IV tube fluid nutrient pack added to water

Bland diet

avoid spicy, stomach problems

Infant feeding

breast milk or formula (timing varies), control swallowing 3-4 mo, add semi-solid foods 4-6 mo (infant cereal then strained veggies and fruits). Finger foods (bananas, crackers) sat 8 mo, bite-sized cooked foods at 10 mo, select adult foods at 1 year. Formulas can start spoiling in 2 hrs at room temp, 2 days in fridge.

Minerals

build & repair body tissue (bone and teeth)

Proteins

build or repair body tissue. healing wounds

Nutrition - teeth

dentures, broken or missing teeth

Diabetic diet

diabetes or reduced calorie for weight loss. Sugar not allowed, carbs - exchanges.

Dysphagia

difficulty swallowing. Position upright (prevents choking and aspiration), help control chewing and swallowing. Dysphagia is the term used for any change in the normal process of swallowing. Dysphagia is not a disease. Dysphagia is difficulty swallowing, which can occur at any time from the time food enters the mouth to when it reaches the stomach. Some residents may not be able to swallow at all, while others have problems with solids, liquids, saliva, or any combination of these items.

Full liquid diet

digestive disorders, difficulty chewing, recovering from illness. sherbet, ice-cream, milk, eggnog, yogurt, strained veggies or cereal. liquids at room temp

fluid balance

encourage, find out what they like (temp, ice, flavor), slip in water after brush teeth, etc. keep fresh water within resident's reach, correct position, use aids to assist them, offer bedpan frequently. Observe for wheezing,swelling, cloudy, pink or particles in urine. Hot temp or fever - increase water. Report emesis. Speech therapist may determine thickener: nectar, honey, pudding (add water)

Nutrition - physical factors

fatigue and alertness levels, disease, meds (constipation)

Weight loss

frequent problem. may be due to infection or disease (i.e. cancer). Other contributors : • Increased need for assistance with eating • Disability • Ill-fitting dentures • T eeth in need of repair • Depression • Changes in body composition • Confusion or memory loss • Increased nutritional needs • Frequent use of medication or multiple medications • Immobility • Lack of socialization The primary goal of feeding assistants is to help prevent weight loss in residents.

Mexican

fresh natural food preferred, beans, corn tortillas & rice common. Disease is hot or cold (not temp - effect on body) - food used to complement

Low sodium diet

heart, blood vessel or kidney disease. no salt on tray

Low fat/cholesterol diet

heart, liver or gallbladder disease, no fried, saturated, trans fat.

Carbs

heat and energy

Fats

heat and energy, fatty acids for growth

Aspiration

inhaling food or liquids into lungs (via trachea) instead of stomach (via esophagus). Most serious health risk from dysphagia (swallowing problems). Residents who aspirate may develop pneumonia, have difficulty breathing, or choke.

Low or no added salt

limit sodium to prevent build up of fluid, to promote a loss of excess body water, or both. Diet orders may state low sodium, 4-gram sodium, 2-gram sodium, or no added salt NAS (no salt packet on tray)

Dehydration

loss of body water. may experience thirst, followed by fatigue, weakness, delirium, and ultimately death. Thirst decreases as we age.

Calorie or carb controlled

manage diabetes (causes problems w/processing carbs, fat and protein) or induce weight loss. Diet order may specify "1500-calorie diet" or "no concentrated sweets NCS (regular diet w/modified desserts - no sugar packets.

Nutrition - stroke

may "pocket" food in cheek on weak side. Teach to "clear" mouth, no straws (will come out too fast), offer water

Hindu

most are vegetarians. Right hand for eating and left hand for personal hygiene

NAS

no added salt

Mormon

no alcohol, coffee, tea

NCS

no concentrated sweets

Buddhist

no meat

Jewish

no pork or shellfish, food prep regulations

Muslim

no pork, some shellfish, alcohol

CNA Eating

observe resident eating in their room, may feed two people at once in DR, report any conflicts in DR, guest trays for family, avoid use of bibs unless resident wants, adaptive needs, check diet card, assist them "set them up" (i.e. cut their food, open carton, butters bread), encourage self-feeding, use clock description for visually impure, ask them if they want food reheated. offer liquids every 2-3 bites. Hot food 150 degrees.

Low calorie diet

overweight. Protein 20%, fat 25-35%, carb 45-65%. Resident energy, nutritional state and weight considered

Thirst

physical sensation signals body needs more fluid to perform functions. However, body fluids may already be depleted in elderly cuz many have decreased sensation of thirst and don't drink adequate fluid. Many drink smaller amounts throughout day. Some don't drink adequate fluids for fear of incontinence, inability to request fluids, or med side effect. Offer fluids throughout day.

Proper fluid balance

proper blood flow, protect cells - keeps skin eyes, mouth and throat moist. Regulates body functions - temp, digestion secretions out of lungs, urine diluted, stool soft, prevents dehydration or edema

High Calorie, High Protein Diets

provide extra energy (or calories) and extra protein to improve nutritional status, promote weight gain, aid in healing wounds or response to medical treatment. Nutritional beverages or snacks may be provided.

MyPlate

recommends balance food and activity

Vitamins

regulate body functioning

Burping infant

removes air swallowed when eating. Every 2-3 oz. patting or rubbing back of infant while being held upright against shoulder. At least until 2-3 mo.

Clear liquid diet

replaces fluid lost thru vomiting or diarrhea or GI test prep. Mostly carbs or water. Jello turns to liquid at room temp. May need to thicken if resident has dysphagia. Short-term. Broth, jello, clear soda, juice or popsicles

Low fat

restrict types and/or amount of fats. Diet order may state low fat or low cholesterol, or both

Avoid foods

saturated fat, trans fat, cholesterol, salt, added sugar

Pressure ulcers

skin w/reddened area or open sore as result of pressure. usually develop over a bony area. Nutrition is risk factor. Nutritional supplement (milkshake or cookies) usually have added protein to aid healing of pressure ulcers.

Essential Nutrients

supply heat and energy, build or repair tissue, regulate body functions

Nutrition - sensory loss

taste, smell, vision, hearing. Give pain meds before eating so they feel like eating

Gastrostomy feeding

tube in abdomen to stomach

Nasogastric feeding

tube in nose to stomach, short-term, machine pumps liquid

Needs Alternative Nutrition

unconscious, cancer in digestive track, ulcerative colitis, unable to keep food in stomach, can't swallow without choking. CNA care - provide frequent mouth care, do not adjust equipment, elevate bed 30 degrees or per CP. Check skin at site of tubing. Nutrient/IV bag must be higher than site of tube. Watch for swelling or pain.

Intravenous fluids

vein usually in arm, only given for fluid replacement - may include vitamins and minerals. Also used to give some meds

Emesis

vomit

Dehydration - increase risk

• Fever • High protein diet • Infection • Constipation • Confusion • Diarrhea • Medications • Decreased appetite • Draining wounds • Excessive sweating

Interfere with Adequate Nutrition and Fluid Intake

• Inability to feed oneself • Poor oral health • Dementia • Medications • Depression • Medical condition • Loss of senses (smell, taste, sight)