6.3 Nutrition, Hydration & Assisted Feeding

Proper nutrition and hydration are essential for maintaining skin integrity, preventing pressure ulcers, promoting healing, and sustaining body functions. Certified Nursing Assistants in Oregon play a critical role in monitoring dietary intake, recognizing signs of dehydration, and assisting residents with feeding in a manner that maintains dignity and safety.

Specialized and Modified Diets

A resident's diet is prescribed by a physician and managed by a registered dietitian. CNAs must verify the resident's diet order on their care plan before serving meals. Common modified diets include:

• Mechanical Soft Diet: This diet consists of foods that are chopped, ground, or blended to make them easier to chew. It is prescribed for residents with dental issues, missing teeth, or mild chewing difficulties, but who still have a functional swallowing reflex.
• Pureed Diet: This diet consists of foods that are blended or pressed into a smooth, thick paste with a uniform consistency (like pudding). No chewing is required. It is prescribed for residents with moderate to severe dysphagia (difficulty swallowing) or severe neurological impairment.
• Thickened Liquids: Dysphagia is a significant risk factor for aspiration (when food or liquid enters the airway instead of the stomach). Thin liquids (like water, tea, or juice) flow quickly and are difficult for residents with weak throat muscles to control, leading to coughing and choking. Thickening agents are added to liquids to slow down their flow. There are three standard levels of thickness:
  1. Nectar-thick: The liquid has the consistency of tomato juice or eggnog. It can be sipped from a cup or straw.
  2. Honey-thick: The liquid pours slowly, like honey or syrup. It is usually eaten with a spoon, though it can be sipped.
  3. Pudding-thick: The liquid holds its shape and has the consistency of pudding. It must be eaten with a spoon. CNA Safety Responsibility: A resident with an order for thickened liquids must never be given thin liquids, including ice chips (which melt into thin water), as this poses an immediate aspiration hazard.

Hydration and Dehydration

Dehydration is a serious clinical condition that occurs when fluid loss exceeds fluid intake. Elderly individuals are at high risk for dehydration because their thirst sensation naturally decreases with age, and they may have cognitive or physical barriers to obtaining fluids.

• Signs of Dehydration: The CNA must observe and report:
  • Dark, concentrated, or strong-smelling urine.
  • Low urine output (oliguria).
  • Dry mucous membranes, dry mouth, and cracked lips.
  • Sunken eyes.
  • Increased confusion, lethargy, or dizziness.
  • Poor skin turgor (when skin pinched on the back of the hand or clavicle remains "tented" instead of immediately flattening).
  • Rapid heart rate and low blood pressure.
• Promoting Hydration: The CNA should offer small amounts of preferred fluids frequently (e.g., every hour) and ensure a fresh pitcher of water is within the resident's reach.
• Intake and Output (I&O): For residents on I&O monitoring, the CNA must document all fluids consumed in milliliters (mL). One ounce of fluid is equal to 30 mL (e.g., an 8-oz cup of coffee is 240 mL).

Assisted Feeding Steps and Dignity

Feeding a resident requires patience, attention to safety, and a commitment to preserving the resident's dignity.

• Preparation: Wash the resident's hands before eating. Ensure the resident is sitting completely upright at a 90-degree angle (High-Fowler's position). This position uses gravity to facilitate swallowing and prevent aspiration.
• Maintaining Dignity:
  • Oregon TMU/Headmaster testing point: The CNA must sit at eye level with the resident while feeding them. Standing over a resident is intimidating, rushes them, and diminishes their dignity.
  • Engage the resident in pleasant conversation. Do not rush the meal.
  • Describe the food on the plate (for visually impaired residents, use the "clock face" method, e.g., "Your potatoes are at 3 o'clock").
  • Ask the resident what they would like to eat first and respect their pace.
  • Use a spoon, filling it only 1/3 to 1/2 full. Offer fluids between bites to help moisten food.
• Identifying and Managing "Pocketing": Residents who have had a stroke or have dementia may "pocket" food, which means keeping unswallowed food in the side of their mouth or cheeks (often on their weak side). Pocketing is a major choking hazard. The CNA must check the resident's mouth between bites to ensure they have swallowed completely. Gently prompt the resident to swallow, or assist with oral clearing if necessary.
• Recognizing Choking Signs: If a resident begins to choke, they may cough weakly or be unable to make any sound.
  • Signs of Complete Airway Obstruction: Inability to speak, breathe, or cough; silent gasping; clutching the neck (the universal sign of choking); and cyanosis (blue skin color around the mouth or fingernails due to lack of oxygen).
  • Emergency Action: If the resident cannot speak or cough, the CNA must immediately call for help and perform abdominal thrusts (the Heimlich maneuver) to clear the airway.
• Post-Meal Care: After the meal, the resident must remain in an upright position (at least 30-45 degrees, preferably 90 degrees) for at least 30 minutes. This prevents gastroesophageal reflux and silent aspiration of stomach contents. Perform oral care to ensure no pocketed food remains in the mouth.