3.5 Feeding and Nutrition

Why Feeding Is Tested So Heavily

Death certificates for nursing home residents frequently list aspiration pneumonia as a primary or contributing cause of death. Most aspiration is preventable with correct positioning, diet consistency, pacing, and supervision — all of which are CNA responsibilities. North Carolina survey teams observe at least one full meal during inspections, and the NNAAP commonly includes a feeding station.

Diet Types

Thickened Liquid Consistencies

• Nectar-thick — flows like cold heavy syrup; drinkable from a cup
• Honey-thick — slow pour, drinkable from a cup with effort, often spoon-fed
• Pudding-thick — does not pour; must be spoon-fed

Never pour an unthickened liquid for a resident on thickened liquids. Match the order exactly — "nectar" is not the same as "honey."

Positioning for Meals

• High Fowler's (80–90°) in the bed, or upright in a chair, is required for all oral intake.
• Feet should be flat on the floor or on a footrest.
• The head should be in a neutral or slightly forward (chin-tuck) position — never tilted back, which opens the airway.
• After the meal, keep the resident upright for at least 30 minutes to allow gravity to keep food in the stomach.

Safe Feeding Technique

1. Identify the resident (check name band per facility policy) and confirm the diet on the tray matches the order.
2. Wash hands, offer the resident a chance to wash hands, and provide oral care if needed.
3. Position the resident upright; place the napkin or clothing protector.
4. Sit down at eye level with the resident — standing rushes the meal and feels disrespectful.
5. Describe what is on the tray. Ask about preferences and order of eating.
6. Offer small bites (less than one teaspoon).
7. Allow the resident to chew and swallow completely before offering the next bite. Check that the mouth is empty.
8. Alternate solids and liquids to clear the mouth.
9. Engage in pleasant conversation — but do not ask questions that require talking with food in the mouth.
10. Allow at least 20–30 minutes for the meal.

Dysphagia and Aspiration Prevention

Dysphagia is difficulty swallowing. Signs include coughing or choking when eating or drinking, wet/gurgly voice after swallowing, pocketing food in the cheek, slow or effortful chewing, drooling, weight loss, and recurrent pneumonia.

Aspiration-Prevention Precautions

• Chin-tuck position during swallows (head slightly forward, not back).
• Small bites, one at a time.
• Thickened liquids as ordered.
• No straws for most dysphagia residents — they speed liquid into the airway.
• Stay with the resident the entire meal.
• Stop feeding at the first sign of distress — coughing, wet voice, pocketing — and notify the nurse.
• Keep the resident upright at least 30 minutes post-meal.

Intake Estimation and Recording

Intake is recorded as a percentage of the meal eaten and as fluid volume in mL:

• 0% — Did not eat
• 25% — Ate one quarter
• 50% — Ate half
• 75% — Ate three quarters
• 100% — Ate all

Report sudden drops (e.g., from 75% to 25% over consecutive meals), refusal to eat for an entire shift, or new chewing/swallowing difficulty. Fluid intake includes water, juice, milk, broth, gelatin (counted at 50% of volume because it liquefies), ice chips (counted at 50% of volume), and IV intake when applicable.

Religious and Cultural Diets

Food is identity. Respect resident and family preferences exactly as ordered.

• Kosher (Jewish) — No pork or shellfish; meat and dairy not served together or with the same utensils; separate dishware in strictly observant homes.
• Halal (Muslim) — No pork or alcohol; meat must be slaughtered following halal practices.
• Hindu — Many do not eat beef; some are vegetarian or vegan.
• Buddhist — Many are vegetarian.
• Seventh-day Adventist — Often vegetarian; avoid pork and shellfish.
• Vegetarian — No meat (sometimes no fish); usually allows eggs and dairy.
• Vegan — No animal products at all (no meat, fish, eggs, dairy, honey).

Cultural preferences (rice as a staple, traditional spices, mealtime timing) also affect intake. If a resident is not eating, ask whether the food is unfamiliar — and tell the nurse and dietary department. A culturally appropriate substitute often restores intake faster than any medication.

Reporting

Report: coughing or choking during meals, wet voice, refusal of meals, weight loss, change in chewing/swallowing, complaints about taste or texture, and any food allergy reaction (rash, swelling, breathing trouble — call the nurse immediately).