Define the following term:

Define the following term:
Nutrition how the body uses food to maintain health.

1. Describe the importance of good nutrition
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.

Define the following terms:
Nutrient something found in food that provides energy, promotes growth and health, and helps regulate metabolism. Complex carbohydrates carbohydrates that are broken down by the body into simple sugars for energy; found in foods such as bread, cereal, potatoes, rice, pasta, vegetables, and fruits. Simple carbohydrates carbohydrates that are found in foods such as sugars, sweets, syrups, and jellies and have little nutritional value.

Transparency 15-1: Six Basic Nutrients
Protein Carbohydrates Fats Vitamins Minerals Water

2. List the six basic nutrients and explain the USDA’s MyPyramid
Protein Essential for tissue growth and repair Provides a supply of energy Protein includes fish, seafood, poultry, meat, eggs, milk, cheese, nuts, peas, dried beans or legumes.

Carbohydrates Provide fuel for energy, help the body use fat efficiently Provide fiber Complex carbohydrates include bread, cereal, potatoes, rice, pasta, vegetables, and fruits. Simple carbohydrates include sugars, sweets, syrups, and jellies.

Fats Help the body store energy Provide insulation Protect the organs Add flavor to food Fats include butter, margarine, salad dressings, oils, and fats in meat.

Vitamins Vitamins are essential to body functions. Fat-soluble vitamins are A, D, E, and K. Water-soluble vitamins are B and C.

Minerals Minerals form and maintain body functions. Minerals include zinc, iron, calcium, and magnesium.

Water We need about 8 glasses, or 64 ounces, per day. Water is most essential nutrient for life. Water aids in digestion, absorption of food, elimination of wastes, and maintaining normal body temperature.

Transparency 15-2: MyPyramid

Grains Found in cereal, bread, rice, and pasta Examples of complex carbohydrates include whole wheat breads, bran cereals, brown rice, and whole-wheat pastas.

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.

Fruits Provide complex carbohydrates, vitamins, and fiber Examples include oranges, grapefruit, strawberries, mango, papaya, and cantaloupe.

Milk Provides nutrients necessary for bones and teeth Provides protein, vitamins, and minerals Examples include cheese, yogurt, milk, buttermilk, cottage cheese, and evaporated milk

Meat and beans Provide protein, vitamins, and minerals Examples include fish, chicken, turkey, lean meats, and dry beans.

Oils Fats and oils are needed in very 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: The elderly 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.

Total parenteral nutrition (TPN) the intravenous infusion of nutrients administered directly into the bloodstream, bypassing the digestive tract. Nasogastric tube a feeding tube that is inserted into the nose and goes to the stomach. Percutaneous endoscopic gastrostomy (PEG) tube a tube placed through the skin directly into the stomach to assist with eating. Gastrostomy an opening in the stomach and abdomen.

3. Identify nutritional problems of the elderly or ill
Changes of aging that can affect nutrition include the following: Slower metabolism and body movement Loss of vision Weakened sense of smell and taste Less saliva Dentures, tooth loss, or poor dental health Less efficient digestion Medications

Unintended weight loss is a serious problem for the elderly. Observe and report the following: Resident needs help eating/drinking Resident eats less than 70% 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

Remember these guidelines for preventing unintended weight loss: Report observations and warning signs to the nurse. Encourage residents to eat; talk positively about food. Honor food likes/dislikes. Offer different foods/beverages. Help residents who have trouble self-feeding. 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 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 low appetite or seems sad, ask about it.

The following conditions make it more difficult to eat or swallow: Stroke/CVA Nerve and muscle damage MS Parkinson’s Alzheimer’s

Observe and report for residents receiving 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

4. Describe factors that influence food preferences
Remember the following points: Know and follow residents’ food preferences. Ask questions. Pay attention.

Think about this question: Do you have specific 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. Communicate with residents to best understand their preferences and the reasons behind them.

Define the following term:
Diet cards cards that list the resident’s name and information about special diets, allergies, likes and dislikes, and other instructions.

5. Explain the role of the dietary department
The dietary department must Meet residents’ different nutritional needs Take into account likes and dislikes Make sure residents can manage the food they’re eating and that it looks good Strictly follow infection control measures

Therapeutic (modified, or special) diets diets for people who have certain illnesses. Fluid balance taking in and eliminating equal amounts of fluid. Diuretics medications that reduce fluid volume in the body.

Exchange lists lists of similar foods that can be substituted for each other on a meal plan. Puree to chop, blend, or grind food into a thick paste of baby food consistency. Vegetarians people who do not eat meat, fish, or poultry and who may or may not eat eggs and dairy products.

6. Explain special diets Residents may be on any of the following special diets: Low-sodium diet (Low NA or NAS) Fluid-restricted diets High-potassium diets Low-protein diet Low-fat/low-cholesterol diet Modified calorie diet for weight management (Low-Cal or High-Cal)

6. Explain special diets Special diets (cont’d.): Bland diet Dietary management of diabetes Low-residue (low-fiber) diet High-residue (high-fiber) diet Liquid diet Soft and mechanical soft diet Pureed diet

6. Explain special diets Some dietary practices are based on religious, moral or other beliefs, including the following: Eating kosher foods Muslim dietary practices, including fasting Not eating meat on Fridays (some Catholics) Vegetarianism

7. Explain thickened liquids and identify three basic thickened consistencies
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.

7. Explain thickened liquids and identify three basic thickened consistencies
These are the three basic thickened consistencies: Nectar thick Honey thick Pudding thick

8. Describe how to make dining enjoyable for residents
REMEMBER: Meals are not only a time for getting nourishment but a time for socialization as well. NAs can be a great help in assisting residents to get proper nutrition.

Remember the following 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.

Guidelines for promoting appetites (cont’d.): Encourage use of dentures, glasses, and hearing aids. 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.

9. Explain how to serve meal trays and assist with eating
Remember these points about serving meal trays: Food must be served at proper temperature. NAs will need to work quickly. Serve all residents at one table before serving another table. Wash hands first. Identify residents before serving meals.

Remember the following when preparing the food: Do only what resident cannot do. Remove food and drink if on tray and set on table. Cut food into small portions if necessary. Try to cut food before bringing it to the table. Open milk or juice cartons. Put in straw if resident uses one, taking care to touch only the paper wrapper. Butter roll, bread, and vegetables as resident likes. Open condiment packets. Offer to season all food as resident likes, including pureed food.

Remember these points about assisting residents: Residents will need different levels of help. Some residents will only need help with setting up but can feed themselves. Some residents will benefit from cues—verbal and physical. Some residents will need to be fed. Be sensitive and give privacy. Encourage residents to do what they can. Positive attitudes and conversation can increase food and drink intake and vice versa. Say positive things about the food. Do not judge food preferences.

Follow these 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 a resident use a clothing protector if he or she does not wish to do so, and always use the term “clothing protector” rather than “bib.”

Feeding a resident who cannot feed self
Equipment: meal tray, clothing protector, 1-2 washcloths or wipes Wash your hands. Identify yourself by name. Identify the resident by name. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.

Feeding a resident who cannot feed self (cont’d.)
Pick up diet card and ask resident to state his or her name. Verify that resident has received the right tray. Raise the head of the bed. Make sure resident is in an upright sitting position (at a 90-degree angle). Adjust bed height to where you will be to able to sit at resident’s eye level. Lock bed wheels.

Help resident to clean hands with hand wipes if resident cannot do it on her own. Place meal tray where it can be easily seen by the resident, such as on the overbed table. Help resident to put on clothing protector, if desired.

Sit facing resident at the resident’s eye level. Sit on the stronger side if the resident has one-sided weakness. Tell the resident what foods are on tray and ask what resident would like to eat first.

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. Offer drink of beverage to resident throughout the meal.

Make sure resident’s mouth is empty before next bite or sip. Talk with resident during meal. 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.

Remove clothing protector if used. Dispose of protector in proper container. Remove food tray. Check for eyeglasses, dentures, or any personal items before removing tray. Place tray in proper area. Make resident comfortable. Make sure sheets are free from wrinkles and the bed free from crumbs.

Return bed to lowest position. Remove privacy measures. Place call light within resident’s reach. Wash your hands. Report any changes in resident to the nurse. Document procedure using facility guidelines.

10. Describe how to assist residents with special needs
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.

Remember these dining techniques helpful for 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.

Dining techniques helpful for residents with special needs (cont’d.): 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.

Dining techniques helpful for 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.

11. Define “dysphagia” and identify signs and symptoms of swallowing problems
REMEMBER: “Dysphagia” means difficulty in swallowing and may be caused by stroke, head/neck cancer, multiple sclerosis, Parkinson’s or Alzheimer’s disease.

The following are signs and symptoms of swallowing problems and must be reported to the nurse: 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

Signs and symptoms of swallowing problems (cont’d.): Slow eating 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

Signs and symptoms of swallowing problems (cont’d.) 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

Transparency 15-3: 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 at least 30 minutes after eating and drinking.

Remember these guidelines for 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 unaffected side of the mouth. Make sure mouth is empty before next bite of food or sip of drink. Have residents remain upright for about 30 minutes after eating and drinking.

Intake (input) the fluid a person consumes. Output all fluid that is eliminated from the body; includes fluid in urine, feces, vomitus, perspiration, and moisture in the air that is exhaled.

Transparency 15-4: Conversion Table
A milliliter (mL or ml) is a unit of measure equal to one cubic centimeter (cc). 1 oz. = 30 mL or 30 cc 2 oz. = 60 mL 3 oz. = 90 mL 4 oz. = 120 mL 5 oz. = 150 mL 6 oz. = 180 mL 7 oz. = 210 mL 8 oz. = 240 mL 1/4 cup = 2 oz. = 60 mL 1/2 cup = 4 oz. = 120 mL 1 cup = 8 oz. = 240 mL

12. Explain intake and output (I&O)
REMEMBER: Know and follow your facility’s procedures for documenting intake and output.

Measuring and recording intake and output
Monitoring fluid balance begins with measuring intake. Equipment: I&O sheet, graduate (measuring container), pen and paper to record your findings Wash your hands. Identify yourself by name. Identify the resident by name.

Measuring and recording intake and output (cont’d.)
Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. Provide for resident’s privacy with curtain, screen, or door. Using the graduate, measure how much fluid a resident is served. Note the amount on paper.

When resident has finished a meal or snack, measure any leftover fluids. Note this amount on paper. Subtract the leftover amount from the amount served. If you have measured in ounces, convert to milliliters (mL) by multiplying by 30.

Document amount of fluid consumed (in mL) in input column on I&O sheet. Record the time and what fluid was taken. Report anything unusual that was observed, such as the resident refusing to drink, drinking very little, feeling nauseated, etc. Wash your hands.

Measuring output is the other half of monitoring fluid balance. Equipment: I&O sheet, graduate, gloves, pen and paper Wash your hands. Put on gloves before handling bedpan/urinal. Pour the contents of the bedpan or urinal into measuring container. Do not spill or splash any of the urine.

Measure the amount of urine. Keep container level. After measuring urine, empty measuring container into toilet. Do not splash. Rinse measuring container and pour rinse water into toilet. Clean container using facility guidelines.

Rinse bedpan/urinal. Pour rinse water into toilet. Use approved disinfectant. Return bedpan/urinal and measuring container to proper storage. Remove and dispose of gloves. Wash hands before recording output.

Document the time and amount of urine in output column on sheet. For example: 3:45 p.m mL urine. To measure vomitus, pour from basin into measuring container, then discard in the toilet. If resident vomits on the bed or floor, estimate the amount. Document emesis and amount on the I&O sheet. Report any changes in resident to the nurse.

Force fluids a medical order for a person to drink more fluids. Restrict fluids a medical order that limits the amount of fluids a person takes in.

13. Identify ways to assist residents in maintaining fluid balance
Fluid intake is important for the following reasons: Helps prevent constipation and incontinence Dilutes wastes and flushes out urinary system May help prevent confusion

REMEMBER: The abbreviation “NPO” means “nothing by mouth.” Never offer any food or drink to a resident with this order—not even water.

Remember the signs and symptoms of dehydration to report, including 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

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: Make an effort to find out what resident’s favorite beverages are and offer at least three times a day, in addition to meals. Prevention of dehydration is ongoing!

Equipment: water pitcher, ice scoop, glass, straw, gloves
Serving fresh water Equipment: water pitcher, ice scoop, glass, straw, gloves Wash your hands. Identify yourself by name. Identify the resident by name. Put on gloves. Scoop ice into water pitcher. Add fresh water.

Serving fresh water (cont’d.)
Use and store ice scoop properly. Do not allow ice to touch your hand and fall back into container. Place scoop in proper receptacle after each use. Take pitcher to resident. Pour glass of water for resident. Leave pitcher and glass at the bedside.

Serving fresh water (cont’d.)
Make sure that pitcher and glass are light enough for resident to lift. Leave a straw if the resident desires. Place call light within resident’s reach. Remove gloves. Wash your hands.

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