1.4 Nutrition Support & Hydration
Key Takeaways
- Enteral nutrition delivers formula into a functioning GI tract through a feeding tube; parenteral nutrition delivers nutrients intravenously when the gut cannot be used
- The guiding principle is "if the gut works, use it" — enteral feeding is preferred over parenteral when the GI tract is functional
- Tube feedings require monitoring of formula type, rate, water flushes, and aspiration precautions such as keeping the head of bed elevated
- Signs of dehydration include dark urine, dry mouth, decreased intake, confusion, and sudden weakness; older adults are especially vulnerable
- CMS significant weight loss thresholds are 5% in 30 days, 7.5% in 90 days, and 10% in 180 days
When a resident cannot meet needs by mouth, the care team turns to nutrition support. The CDM must understand the two routes, support safe tube-feeding operations, and watch for the hydration and weight problems that dominate long-term-care nutrition.
Enteral vs. Parenteral Nutrition
This is the single most confused pair in the domain, so fix it permanently.
| Enteral Nutrition | Parenteral Nutrition | |
|---|---|---|
| Route | Feeding tube into the GI tract | Intravenous (IV) into the bloodstream |
| Requires | A working gut | Used when the gut cannot be used |
| Examples | NG tube, PEG/G-tube | TPN (total parenteral nutrition) |
| Preference | Preferred route | Last resort |
The memory hook is "if the gut works, use it." Enteral feeding keeps the digestive tract active, costs less, and carries fewer infection risks than parenteral, so it is preferred whenever the GI tract is functional. Enteral = enters the gut; parenteral = bypasses the gut.
Tube-Feeding Basics
For enteral feeding, the team monitors:
- Formula type and concentration ordered by the provider
- Rate and method (continuous pump, intermittent, or bolus)
- Water flushes to maintain hydration and keep the tube patent
- Aspiration precautions — keep the head of bed elevated (about 30-45 degrees) during and after feeding
The CDM helps ensure the correct formula reaches the right resident and that supplies and storage meet food-safety standards.
Dehydration: Signs and Strategies
Older adults have a blunted thirst response, making dehydration the most common fluid problem in long-term care. Watch for:
- Dark, concentrated urine and decreased output
- Dry mouth, dry skin, poor skin turgor
- Confusion, weakness, or sudden functional decline
- Decreased fluid intake at meals
Hydration strategies include offering fluids frequently, providing preferred beverages, hydration carts and pass rounds, fluids with medications, and high-water foods. Dehydration raises the risk of urinary tract infections, falls, and confusion.
Unintended Weight Loss Thresholds
Unintended weight loss is a major clinical red flag and a focus of regulatory surveys. CMS defines significant weight loss by these thresholds:
| Time period | Significant loss |
|---|---|
| 30 days (1 month) | 5% |
| 90 days (3 months) | 7.5% |
| 180 days (6 months) | 10% |
Reaching any threshold should trigger nutrition intervention. In practice, the facility should not wait for a deadline — a noticeable downward trend warrants prompt assessment, provider notification, and a documented plan.
A resident has a fully functioning GI tract but can no longer eat enough by mouth after a stroke. Which form of nutrition support is preferred?
A long-term-care resident weighed 200 lb and now weighs 185 lb one month later. Does this meet the CMS threshold for significant weight loss?
Which finding is MOST consistent with dehydration in an older resident, and why are older adults especially at risk?