Define the following terms:

8 Nutrition and Hydration

Nutritionhow the body uses food to maintain health.

Nutrientsomething found in food that provides energy, promotes growth and health, and helps regulate metabolism.

Define the following terms:


REMEMBER:• Bodies rely on proper nutrition to function well. • A well-balanced diet will help residents maintain muscles and skin tissues and prevent pressure sores.

1. Identify the six basic nutrients and explain MyPyramid


1.Protein

2.Carbohydrates

3.Fats

4.Vitamins

5.Minerals

6.Water

Transparency 8-1: Six Basic Nutrients


Remember this information about the six basic nutrients:

Protein• Essential for tissue growth and repair• Provides a supply of energy• Includes fish, seafood, poultry, meat, eggs, milk, cheese, nuts, peas, dried beans/legumes



Six basic nutrients (cont’d.):Carbohydrates• Provide fuel for energy• Provide fiber• Complex carbohydrates include bread, cereal, potatoes, rice, pasta, vegetables, and fruits

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



Six basic nutrients (cont’d.):Fats• Help the body store energy• Provide insulation• Protect the organs• Fats include butter, margarine, salad dressings, oils, and fats in meat



Six basic nutrients (cont’d.):Vitamins• Vitamins are essential to body functions.• Fat-soluble vitamins are A, D, E, and K.• Water-soluble vitamins are B and C.



Six basic nutrients (cont’d.):Minerals• Maintain body functions• Minerals include zinc, iron, sodium, potassium, calcium, magnesium, and phosphorus.



Six basic nutrients (cont’d.):Water• We need about eight glasses, or 64 ounces, per day.• Water is the most essential nutrient for life.• Water aids in digestion, absorption of food, elimination of wastes, and maintaining normal body temperature.



Transparency 8-2: MyPyramid


Here are some examples of the six food groups:Grains• Found in cereal, bread, rice, and pasta• Two subgroups of grains: whole grains and refined grains

• At least half of all grains consumed should be whole grains such as whole wheat breads, bran cereals, brown rice, and whole wheat pastas.



Examples of the six food groups (cont’d.):Vegetables• Provide fiber and vitamins• Subgroups are dark green vegetables, orange vegetables dry beans and peas, starchy vegetables and other vegetables.

• Examples include spinach, carrots, peas, corn and potatoes.



Examples of the six food groups (cont’d.):Fruits• Provide complex carbohydrates, vitamins and fiber• Examples include oranges, grapefruit, strawberries, mango, papayas, and cantaloupe.



Examples of the six food groups (cont’d.):Milk• Provides nutrients necessary for bones and teeth• Provides protein, vitamins, and minerals• Examples include cheese, yogurt, milk, buttermilk, cottage cheese, and evaporated milk.



Examples of the six food groups (cont’d.):Meat and beans• Provide protein, vitamins, and minerals• Examples include fish, chicken, turkey, lean meats,

and dry beans.



Examples of the six food groups (cont’d.):Oils• Fats and oils are needed in small amounts.• Foods like nuts, olives, some fish, and avocados are naturally high in oils.

• Most of the fats consumed should be polyunsaturated (PUFA) or monounsaturated (MUFA) fats.



Remember these points about elderly residents and MyPyramid:

• Elderly residents may need a modified MyPyramid that emphasizes nutrient-dense foods, fiber, and water.

• Calories may be reduced, but need for vitamins and minerals does not decrease.

• Dietary supplements may be appropriate.



Remember these points about food preferences:• Know and follow residents’ food preferences.• Ask questions.• Pay attention when residents express preferences, verbally or non-verbally.

2. Describe factors that influence food preferences


Think about this question:What are your regional, cultural, or religious food

preferences?



REMEMBER:Residents have a legal right to make choices about

their food and to refuse food, and NAs must honor residents’ beliefs and preferences.



Therapeutic dieta diet for people who have certain illnesses; also called special or modified diet.

Diet cardscards that list the resident’s name and information about special diets, allergies, likes and dislikes, and other instructions.

Pureeto chop, blend, or grind food into a thick paste of baby food consistency.



3. Explain special diets

The following are common special diets:• Low-Sodium Diet• Fluid-Restricted Diet• Low-Protein Diet• Low-Fat/Low-Cholesterol Diet• Modified Calorie Diet for Weight Management• Dietary Management of Diabetes• Liquid Diet• Soft Diet• Pureed Diet


3. Explain special diets

Think about this question:Do you now or have you ever followed a special diet?


Force fluidsa medical order for a person to drink more fluids.

Restrict fluidsa medical order for a person to limit fluids.

Dehydrationa condition that results from inadequate fluid in the body.



Fluid intake is important for several reasons:• Helps prevent constipation and incontinence• Dilutes wastes and flushes out urininary system• May help prevent confusion

Describe how to assist residents in maintaining fluid balance


Watch for these signs and symptoms of dehydration:• Drinking less than six 8 oz glasses of liquid per day

• Drinking little or no fluids at meals• Needing help drinking from cup• Having trouble swallowing liquids• Having frequent vomiting, diarrhea, or fever



Signs and symptoms of dehydration (cont’d.):• Being easily confused or tired• Resident has any of the following:

• Dry mouth• Cracked lips• Sunken eyes• Dark urine• Strong-smelling urine• Weight loss• Complaints of abdominal pain



Remember these guidelines for preventing dehydration:• Report warning signs immediately.• Encourage residents to drink every time you see them.

• Offer fresh water and fluids often.• Record fluid I&O.• 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 pitcher and cup are close by and are light enough for resident to lift.

• Offer assistance.



REMEMBER:• Approach residents positively with, “Would you like

water or juice?” rather than, “Do you want anything to drink?”

• Make an effort to find out what residents’ favorite beverages are and offer at least three times a day, in addition to meals.

• Prevention of dehydration is ongoing – you must constantly help residents to stay hydrated.


Serving fresh water

Equipment: water pitcher, ice scoop, glass, straw, gloves

1.Wash hands. Provides for infection control.

2.Identify yourself by name. Identify the resident by name. Resident has right to know identity of his or her caregiver. Addressing resident by name shows respect and establishes correct identification.

3.Put on gloves. Promotes infection control.

Serving fresh water (cont’d.)

4. Scoop ice into water pitcher. Add fresh water.

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

6. Take pitcher to resident.

7. Pour glass of water for resident. Leave pitcher and glass at the bedside. Encourages resident to maintain hydration.

Serving fresh water (cont’d.)

8. Make sure that pitcher and glass are light enough for resident to lift. Leave a straw if the resident desires. Demonstrates understanding of resident’s abilities and/or limitations. Prevents dehydration.

9. Before leaving resident, place call light within resident’s reach. Allows resident to communicate with staff as necessary.

10.Remove and discard gloves.

11.Wash your hands. Provides for infection control.


Fluid overloada condition that occurs when the body is unable to handle the amount of fluid consumed.

Edemaswelling caused by excess fluid in body tissues.



Watch for these signs and symptoms of fluid overload:• Swelling of extremities• Weight gain• Decreased urine• Shortness of breath• Increased heart rate• Tight, smooth, or shiny skin



REMEMBER:Unintended weight loss is a serious problem for the

elderly and NAs must report any weight loss, no matter how small.

5. List ways to identify and prevent unintended weight loss


Watch for these signs and symptoms of unintended weight loss:

• Needing help eating or drinking• Eating less than 70% of meals/snacks• Having mouth pain• Having dentures that do not fit properly• Having difficulty chewing or swallowing• Coughing or choking while eating• Being sad or withdrawing from others• Being confused, wandering, or pacing



Remember these guidelines for preventing unintended weight loss:• Report observations warning signs to the nurse immediately.

• Encourage residents to eat; talk positively about food.

• Honor food likes and dislikes.• Offer different kinds of foods and beverages.• Help residents who have trouble feeding themselves.• Food should look, taste, and smell good. Resident may have poor sense of taste and smell.



Guidelines for preventing unintended weight loss (cont’d.):

• Season food to residents’ preferences.• Allow plenty of time to finish eating.• Tell nurse if resident cannot use utensils.• Record meal/snack intake.• Give oral care before and after meals.• Position residents sitting upright for feeding.• Ask about loss of appetite or sadness if you observe them.



REMEMBER:• Residents often view mealtime as the highlight of their days.

• Meals are not only a time for getting nourishment but a time for socialization as well.

• NAs play an important role in assisting residents to get proper nutrition.

6. Identify ways to promote appetites at mealtime


Remember these guidelines for promoting appetites:• Check the environment. Address odors. Make sure room is a comfortable temperature. Turn off TVs. Do not shout or bang plates or cups.

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

• Assist with handwashing. • Give oral care before eating. • Offer a trip to the bathroom before eating. • Encourage use of dentures, glasses, and hearing aids.



Guidelines for promoting appetites (cont’d.):• Properly position residents for eating, which is normally in the upright position.

• Seat residents next to friends. • Serve food at correct temperature. • Plates should look appetizing. • Provide proper eating tools, including adaptive utensils if needed.

• Be cheerful, positive, and helpful. • Give additional food when requested.



Remember these points about assisting residents with eating:

• 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.

7. Demonstrate how to assist with eating


Review the guidelines for assisting a resident with eating:

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

• Sit at resident’s eye level. • Allow time for prayer if resident wishes. • Verify that it is the right resident. • 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.



Guidelines for assisting a resident with eating(cont’d.):

• Ask 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. • Make mealtime social and friendly. Converse if the resident wishes to do so.

• Give resident full attention. • Alternate food and drink and cold and hot or bland and sweets.

• Honor requests for different food.



REMEMBER:• Do not insist on using a clothing protector if a resident does not wish to use one.

• Use the term “clothing protector” rather than “bib.”


Feeding a resident who cannot feed self

Equipment: meal tray, clothing protector, 2-3 washcloths or wipes

1.Wash hands. Provides for infection control.

2.Identify yourself by name. Identify the resident by name. Resident has right to know identity of his or her caregiver. Addressing resident by name shows respect and establishes correct identification.

Feeding a resident who cannot feed self (cont’d.)

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

4. Pick up diet card. Ask resident to state his or her name. Verify that resident has received the right tray. Tray should only contain foods, fluids, and condiments permitted on the diet.


5. Raise the head of the bed. Make sure resident is in an upright sitting position (at a 90-degree angle). Promotes ease of swallowing. Prevents aspiration of food and beverage.

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

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


8. Help resident to clean hands with hand wipes if resident cannot do it on her own. Promotes good hygiene and infection control.

9. Help resident to put on clothing protector, if desired. Protects resident’s clothing from food and beverage spills.

10.Sit facing resident at resident’s eye level. Sit on the stronger side if resident has one-sided weakness.


10.(cont’d.) Promotes good communication. Lets resident know that he or she will not be rushed while eating.

11.Tell the resident what foods are on the tray. Ask what resident would like to eat first. Resident has legal right to make decisions.


12.Offer the food in bite-sized pieces, telling 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. Report any swallowing problems to the nurse immediately. Small pieces are easier to chew and lessens the risk of choking.

13.Offer sips of beverage to resident throughout the meal. Promotes ease of swallowing.


14.Make sure the resident’s mouth is empty before next bite or sip. Lessens risk of choking.

15.Talk with the resident during the meal. Makes mealtime more enjoyable.

16.Use washcloths or wipes to wipe food from resident’s mouth and hands as needed during the meal. Wipe again at the end of the meal. Maintains resident’s dignity.

17.Remove clothing protector if used. Dispose of in proper container.


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

19.Make resident comfortable. Make sure sheets are free from wrinkles and the bed free from crumbs. Wrinkles and crumbs can cause skin breakdown.

20.Return bed to lowest position. Remove privacy measures. Provides for safety.


21.Place call light within resident’s reach. Allows resident to communicate with staff as necessary.

22.Wash your hands. Provides for infection control.

23.Report any changes in resident to the nurse. Provides nurse with information to assess resident.

24.Document procedure using facility guidelines. What you write is a legal record of what you did. If you don’t document it, legally it didn’t happen.


REMEMBER:• It is important to know how much food a resident is eating.

• Tracking methods vary from facility to facility. • Know your facility’s method.



REMEMBER:• “Dysphagia” means difficulty in swallowing. • It might be caused by stroke, head/neck cancer, multiple sclerosis, Parkinson’s or Alzheimer’s disease.

8. Identify signs and symptoms of swallowing problems


Watch for these signs and symptoms of dysphagia:• Coughing during or after meals• Choking during meals• Dribbling saliva, food, or fluid from the mouth• Food residue inside the mouth or cheeks during and after meals

• Gurgling sound in voice during or after meals or loss of voice

• Slow eating



Signs and symptoms of dysphagia (cont’d.):• Avoidance of eating• Spitting out pieces of food• Several swallows needed per mouthful• Frequent throat clearing during and after meals• Watering eyes when eating or drinking• Food or fluid coming up into the nose• Visible effort to swallow• Shorter or more rapid breathing while eating or drinking

• Difficulty chewing food• Difficulty swallowing medications



Remember these points 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 therapist.

• Some beverages arrive already thickened. • NAs cannot offer residents who must have thickened liquids regular liquids, including water.



There are three different thickening consistencies for liquids:

• Nectar thick• Honey thick• Pudding thick



REMEMBER:Never offer regular liquids, including water, to residents who need thickened liquids.



Transparency 8-3: Preventing Aspiration

• Position in a straight, upright position. • Offer small pieces of food or small spoons of pureed

food. • Feed resident slowly. • Place food in the non-paralyzed side of the mouth.• Make sure mouth is empty before next bite of food or

sip of drink.• Have residents stay in upright position for 30

minutes after eating or drinking.


Total parenteral nutrition (hyperalimentation)the intravenous infusion of nutrients administered directly into the bloodstream, bypassing the digestive tract.

Nasogastric tubea feeding tube that is inserted into the nose and goes into the stomach.

Percutaneous endoscopic gastrostomy (PEG) tubea tube placed through the skin directly into the stomach to assist with eating.

Gastrostomysurgical opening into the stomach.



REMEMBER: • Your role in tube feelings is to observe for problems and changes in the resident.

• NAs do not insert or remove tubes, do the feeding, or clean the tubes.



Observe and report the following regarding tube feedings:

• Redness/drainage around opening• Skin sores or bruises• Cyanotic skin• Resident complaints of pain or nausea• Choking• Tube falls out• Problems with equipment• Feeding pump alarm sounds



REMEMBER:Residents with certain conditions or diseases, such as stroke, Parkinson’s disease, Alzheimer’s disease or other dementias, head trauma, blindness or confusion may need special assistance when eating.

9. Describe how to assist residents with special needs


Remember these guidelines for assisting residents with special needs:• 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.

• Use assistive devices as ordered.• 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.



Guidelines for assisting residents with special needs (cont’d.):

• 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. Use assistive devices as needed. If resident is in a geri-chair, a wedge cushion behind the head and shoulders may be used.



Guidelines for assisting residents with special needs (cont’d.):

• 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.



Multiple Choice. 1. To help prevent aspiration, residents should be in the ________ position when eating. (A) Upright (B) Lying down (C) Prone (D) Lateral

2. A nursing assistant’s duties regarding tube feedings include (A) Inserting tubes (B) Doing the feedings (C) Observing the feeding and reporting problems (D) Cleaning the tubes

Chapter Exam


3. Which of the following foods supplies a significant amount of calcium? (A) Cream cheese (B) Butter(C) Unfortified rice milk(D) Yogurt

4. Which statement is true of fats? (A) Saturated fats should be limited. (B) Fat provides nothing useful to the body. (C) Fat is not stored in the body when eaten in

excess. (D) Fats do not add flavor to foods.

Chapter Exam (cont’d.)


5. Grains are found in which of the following foods? (A) Bananas (B) Cheese (C) Pasta (D) Nuts

6. Which is the most essential nutrient for life? (A) Vegetables (B) Water (C) Grains (D) Protein

Chapter Exam (cont'd.)


7. Which of the following is a good source of protein? (A) Corn oil (B) An orange (C) Fish (D) Grape jelly

8. Which of the following is true about food preferences? (A) Residents are old enough that their preferences

will not change.(B) It is not important to honor residents’ food

preferences.(C) Education is never a factor in determining food

preference.(D) Religion might influence food preference.



9. Which of the following is an effective way for a nursing assistant help prevent dehydration? (A) Encourage a resident to drink every time she sees him(B) Insist that the resident drink juice (C) Withhold fluids if a resident is incontinent (D) Leave a carton of milk with the resident each time she leaves the room

10.Which of the following are signs of unintended weight loss that should be reported to the nurse? (A) Eating lean cuts of meat (B) Eating dessert before dinner(C) Avoiding fried foods and sweets (D) Coughing or choking while eating



11.Which of the following can be an effective way to prevent unintended weight loss?(A) Promoting independence by insisting residents feed themselves without help (B) Honoring food likes and dislikes (C) Telling the resident how unappetizing their meals look (D) Insisting that residents eat everything on their trays no matter what

12.Which of the following statements about mealtime is true?(A) Social interaction is an important part of mealtime. (B) Mealtime is only about getting proper nourishment. (C) Mealtime is a good time for NAs to chat with co-workers since the residents are busy eating.(D) If you think a resident’s meal looks awful you should say so.



13.At which angle should residents be positioned for eating? (A) 90 degrees (B)120 degrees (C)180 degrees (C) 30 degrees

14.If a resident refuses to wear a clothing protector, the nursing assistant should (A) Respect the resident’s refusal (B) Refuse to serve the resident until she puts it on (C) Insist that the resident wear it (D) Point out to the resident that she’s making your

work more difficult

Chapter Exam (cont’d.):


15.Residents who need some assistance with eating may benefit from: (A) The nursing assistant doing everything for the

resident (B) The nursing assistant insisting the resident eat

alone so he can learn to be independent(C) The nursing assistant using the hand-over-hand

approach (D) The nursing assistant telling his family they need

to come at mealtimes to help



16.Which of the following statements shows how a nursing assistant can promote dignity and independence during mealtime? (A) The nursing assistant should make the choice about

which food the resident should eat first. (B) The nursing assistant should talk to other staff

members while assisting residents with eating.

(C) If the resident requests a different food from what is being served, the nursing assistant should honor this request.

(D) The nursing assistant should mix a resident’s foods together without discussing it with the resident.



17.Which of the following is a symptom of dysphagia (difficulty swallowing)? (A) Eating everything on the tray at every meal (B) Sweating during meals (C) Fever during meals(D)Watering eyes during meals

18.Which of the following is a reason a resident might be placed on a special diet? (A) Because the NA thinks the resident is too heavy (B) Because the dietary department is testing out new

recipes(C) Because the resident doesn’t care for eggs (D) Because the resident has food allergies



19.What is the first food to be restricted in a low-sodium diet? (A) Milk (B) Salt (C) Red meat (D)Foods high in fat

20.Which statement best describes a pureed diet? (A) This diet is often used for people who have trouble

chewing and/or swallowing more textured foods. (B) This diet consists of only clear juices, broth,

gelatin, and popsicles. (C) This diet consists of only clear liquids, cream soups,

milk, and ice cream. (D) This diet is often used for people who are tired of

chewing.



21.What does the abbreviation “NPO” mean? (A) Nothing pureed only (B) Not prepared on-site (C) Nothing by mouth (D) Note preferences only

22.Which type of residents may have an order for thickened liquids? (A) Residents who have swallowing problems (B) Residents who refuse to drink water (C) Residents who do not eat meat (D) Residents who have certain religious beliefs



23.Why is it important to observe plates and meal trays when residents have finished eating? (A) It helps the NA decide what to feed residents

first.(B) Residents who are trying to lose weight will want

you to keep a record of how much they’ve eaten.(C) It is not important to observe what and how much a

resident eats. (D) It helps to identify a change in food preferences.



24.When assisting residents who have had a stroke, the nursing assistant should (A) Place food in the stronger side of the resident’s

mouth (B) Place food in the weaker side of the resident’s

mouth (C) Offer another bite of food before the resident has

swallowed the last bite (D) Encourage the resident to take large bites


Define the following terms:

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