4.3: Nutrition, Hydration, and Elimination

Therapeutic and Modified Diets

Good nutrition is essential for tissue healing, energy, and preventing illness. As people age, their nutritional needs change, and medical conditions often require special diets. The physician orders the diet, the dietician plans it, and the LNA ensures the resident receives and consumes the correct meals.

Common Therapeutic Diets:

• Regular/General Diet: No dietary restrictions.
• NPO (Nothing by Mouth): The resident cannot eat or drink anything, not even water or ice chips. Often ordered before surgery or medical tests.
• Clear Liquid Diet: Includes liquids you can see through, such as broth, gelatin (Jell-O), clear juices (apple), and water. Usually temporary.
• Full Liquid Diet: Includes clear liquids plus dairy products like milk, yogurt, and ice cream.
• Mechanical Soft Diet: Food is chopped, blended, or ground to make it easier to chew and swallow. Used for residents with missing teeth or jaw issues.
• Pureed Diet: Food is blended into a smooth, thick paste (like baby food). Does not require chewing.
• Low Sodium (NAS - No Added Salt): Restricts salt intake. Used for residents with heart disease, hypertension, or kidney disease. LNAs must remove salt shakers from the tray.
• Diabetic / NCS (No Concentrated Sweets): Balances carbohydrates, proteins, and fats to control blood sugar. Meals must be eaten at specific times, and LNAs must ensure the resident eats all the food on the tray.

Dysphagia and Aspiration Precautions

Dysphagia is difficulty swallowing. It is common after a stroke or with neurological conditions like Parkinson's or Alzheimer's. The greatest risk of dysphagia is aspiration — the accidental breathing of food, fluid, vomit, or other objects into the lungs. Aspiration can cause severe pneumonia and death.

To prevent aspiration, residents with dysphagia may be ordered thickened liquids. Regular thin liquids (like water or coffee) flow too quickly down the throat and can enter the airway. Thickeners slow the flow. There are three standard consistencies:

1. Nectar Thick: Thicker than water; similar to fruit nectar or maple syrup. Can be consumed from a cup.
2. Honey Thick: Pours very slowly, like honey. Usually consumed with a spoon.
3. Pudding Thick: Semi-solid, holds its shape. Must be consumed with a spoon.

Aspiration Precautions During Feeding:

• Position the resident fully upright (Fowler's position, 75-90 degrees) during meals.
• Keep the resident upright for at least 30 minutes after eating.
• Feed slowly, offering small bites.
• Alternate solid bites with sips of liquid.
• Check the mouth for "pocketing" (storing food inside the cheeks) after feeding.
• Never force-feed or feed a sleeping resident.

Intake and Output (I&O)

Fluid balance is the equilibrium between fluid taken in and fluid lost. The physician may order I&O monitoring for residents with heart or kidney disease, or those at risk of dehydration. LNAs measure and record all fluids a resident consumes and excretes.

Calculating Intake: Intake includes all liquids consumed by mouth (water, coffee, juice, milk) and foods that turn to liquid at room temperature (ice cream, gelatin, popsicles). Fluid is measured in milliliters (mL) or cubic centimeters (cc), which are equivalent (1 mL = 1 cc).

The Conversion Rule: 1 ounce (oz) = 30 milliliters (mL). If a resident drinks a 4-ounce glass of juice, the intake is: 4 x 30 = 120 mL.

Calculating Output: Output includes urine, vomit (emesis), liquid stool, and drainage from wounds or tubes. Output is collected in bedpans, urinals, commode hats, or catheter bags, then poured into a graduated cylinder for accurate measurement at eye level.

Dehydration and Fluid Overload

Dehydration occurs when fluid output exceeds intake. Elderly residents are at high risk because their sense of thirst diminishes with age. Signs of dehydration: Dark, strong-smelling urine, dry mouth, cracked lips, sunken eyes, poor skin turgor (skin stays tented when gently pinched), dark circles under eyes, and sudden confusion or lethargy.

Fluid Overload occurs when the body cannot eliminate fluid fast enough (often due to heart failure or kidney disease). Signs of fluid overload: Edema (swelling in the feet, ankles, hands, or face), sudden weight gain, shortness of breath, and tight, shiny skin. Residents with fluid overload may be placed on a fluid restriction.

Bowel and Bladder Elimination

Elimination is a private and dignified process, but one that requires careful observation.

Bowel Elimination: Normal stool is brown, soft, and formed. Abnormalities to report include liquid stool (diarrhea), hard/dry stool, or stool containing blood (which may appear bright red or dark and tarry).

• Constipation: Difficulty passing hard, dry stool.
• Fecal Impaction: A severe form of constipation where a hard mass of stool becomes wedged in the rectum. A key sign is liquid stool seeping around the mass, which might look like diarrhea but is actually impaction leakage.
• Ostomy: A surgical opening (stoma) from the bowel to the abdomen. Feces drains into a pouch. LNAs assist with emptying the pouch and keeping the skin around the stoma clean and dry.

Urinary Elimination: Normal urine is pale yellow (straw-colored), clear, and has a faint odor.

• Urinary Tract Infections (UTIs): Highly common in the elderly. Signs include frequent urging, pain or burning upon urination (dysuria), cloudy urine, strong/foul odor, and fever. In elderly residents, a sudden onset of confusion or altered mental status is often the first visible sign of a UTI.
• Incontinence: The inability to control bladder or bowels. It is not a normal part of aging, though common. Care involves frequent changing, thorough perineal care, and barrier creams to prevent skin breakdown.
• Catheters: Indwelling Foley catheters remain in the bladder and drain continuously into a bag. The drainage bag must always be kept below the level of the bladder to prevent gravity from pushing contaminated urine back up, which causes infection. Secure the tubing to the resident's inner thigh so it does not pull.