Course

As integral members of the healthcare team, nursing assistants need to have a basic knowledge of nutrition and hydration in order to provide acceptable care to their patients. Nutrition is defined as the the manner in which the foods that a person consumes affects the body. Likewise, a nutrient is a compound in food that is essential to life and good health, providing individuals "with energy, the building blocks for repair and growth and substances necessary to regulate chemical processes" (Australian Government Department of Health, 2013).

There are six essential nutrients: water, protein, fats, carbohydrates, vitamins and minerals. The human body needs these six essential nutrients in predetermined quantities to remain in good health. Out of all the nutrients, water is the most essential because humans can live an average of only three days without it before dying. Every body cell must be bathed in water to stay alive; in addition, water is active in many chemical reactions and carries other nutrients, regulates temperature, and helps eliminate wastes (LinksNorth, n.d.).  

Protein is needed by the body for growth, ongoing maintenance and repair of cells, tissues and organs. The muscles and immune system are comprised of proteins. Animal sources of proteins include meats such as beef, chicken, pork and lamb, as well as dairy products like milk and eggs. Plant-based protein sources include foods such as nuts, beans, peanut butter and soy milk. Also, bread, pasta and rice are considered plant-based sources of protein. 

Fats, also called lipids, are needed by the body to maintain optimal health. Dietary fats make certain fat-soluble "vitamins available for use in the body, they cushion vital organs, they comprise part of all body cells, and they help maintain body temperature" (LinksNorth, n.d.). Fats also tend to minimize feelings of hunger when consumed since meals that contain plenty of dietary fat promote fullness and remain in the stomach longer than other energy sources.

Carbohydrates, known as 'carbs' for short, are required by the body as a main source of energy. Carbohydrates are broken down during the process of digestion and go into the bloodstream as glucose. Blood glucose is better known as blood sugar. The human brain needs a constant supply of blood glucose to stay healthy. If an individual's blood glucose level remains too low for too long, permanent brain damage can happen. Therefore, carbohydrate is an essential nutrient. 

Vitamins are a group of organic "substances that are needed for normal cell function, growth, and development" (MedlinePlus, 2020). There are 13 essential vitamins that the human body cannot produce on its own, each with very specific functions in the body. For instance, vitamin K is needed for the blood clotting process, and vitamin C is important for wound healing, immunity, body tissues, skin health, proper iron absorption, and healthy teeth and gums.

Minerals are a group of inorganic substances that assist the human body with growth, development and maintenance of good health. A multitude of different minerals exist. Examples of well-known minerals include calcium and iron. Calcium is crucial to multiple bodily processes such as blood clotting, muscle contraction, heart function and bone formation. Iron is necessary for helping the red blood cells and the muscles of the body to properly store, carry and utilize oxygen.

A number of factors affect the quality and quantity of nutritional and hydration status in elderly patients. These factors include certain medications, depression, oral health, immobility, neurological diseases, cultural background, socioeconomic status and decreased thirst. Nursing assistants need to know how these factors contribute to the nutritional state of their advanced-age patients in order to provide the best care possible.  

Several common medications can affect the nutritional and hydration status of elderly patients. Certain blood pressure-lowering medications and antidepressant drugs can cause weight gain. Excessive weight gain leads to obesity, "a complex disease involving an excessive amount of body fat" (Mayo Clinic, 2020). Other medications, called diuretics, are commonly referred to as 'water pills' because they cause individuals to urinate more often than usual. Elderly patients who take these water pills are at greater risk for dehydration if they do not replenish the water they lose through urination.

Depression is the most prevalent mental health disorder in aged patients. Also, depression has a strong impact on patients' nutritional states due to the remarkable influences it has on appetite. Changes to appetite and weight "are common but variable diagnostic markers in major depressive disorder: some depressed individuals manifest increased appetite, while others lose their appetite" (Simmons, 2016). Thus, depressed patients with increased appetite often gain weight, while those that lose their appetites are at risk for malnutrition. In addition, some drugs that treat depression cause weight gain.   

The health of the oral cavity, also called the mouth, has a noteworthy affect on nutritional status. Patients with loose teeth and/or poor dental health might only be able to consume a limited range of foods. Likewise, patients that have no teeth or badly-fitting dentures will probably struggle to consume healthier options such as lean meats and fresh vegetables. In summary, patients with poor dentition may gravitate toward highly processed foods since these tend to be easier to chew.

Neurological diseases have an influence on nutrition. Weight loss happens frequently in patients with Alzheimer's disease; it may take place throughout the course of the disease, "but becomes more common as the disease progresses" (Cleveland Clinic, 2019). Essential tremor is neurological disease characterized by rhythmic shaking. Patients with tremor often lose weight and must maintain a high calorie intake "to avoid excessive weight loss" (National Tremor Foundation, n.d.).

The influences of cultural background on nutritional status are significant. The culture and/or subculture in which a patient was raised can have a robust impact on his or her food preferences. For instance, many individuals from the Southeastern United States regularly eat southern cuisine, which consists of meals that are deep-fried, starchy and fatty. The nutritional status of a patient is reflective of his or her dietary history and current food practices; additionally, "lifelong eating habits are also developed out of tradition, ethnicity and religion, all of which collectively can be called culture" (Touhy, 2016).

Socioeconomic status affects the nutritional and hydration status of patients to an enormous extent. A notable relationship exists between poor nutritional status "and socioeconomic deprivation" (Touhy, 2016). More specifically, patients who live in poverty might not always have enough money to purchase sufficient quantities of food. Elderly patients with lower incomes might be forced to choose between "needs such as food, heat, telephone bills, medications and healthcare visits; also, some older people eat only once per day in an attempt to make their income last through the month" (Touhy, 2016).

Decreased thirst has a tremendous impact on the hydration status of elderly patients. In other words, advanced-age patients do not always feel thirsty even when their bodies may desperately need fluids. As persons age, the natural sense of thirst diminishes. Even when their bodies need to be replenished with fluids, they might not realize it, and as a result, "many older adults do not drink enough liquids"  (Cleveland Clinic, 2018). Thus, the nursing assistant must remind their elderly patients to regularly consume fluids to avoid dehydration, the serious condition in which the body does not have enough fluids.

A number of chronic health problems are associated with nutritional and hydration challenges for the patients who are afflicted. Nursing assistants should be knowledgeable regarding these health problems in order to provide support to their patients during the delivery of care. The health issues that pose potential dietary problems for patients include heart failure, diabetes mellitus, chronic obstructive pulmonary disease, dysphagia and essential tremor. 

Heart failure is a common disease in elderly patients; moreover, it poses a number of nutritional challenges. Adequate nutrition is especially crucial for patients with heart failure "as the risk for developing electrolyte imbalance and vitamin and micronutrient deficiencies increases with the use of diuretics" (Abshire et al, 2015). Diuretics, also called 'water pills,' cause the patient to urinate more often so they do not retain fluid and experience swelling. 

Diabetes mellitus, a metabolic disorder that results in elevated blood glucose levels, is yet another affliction that presents nutritional challenges. Dietary interventions to address diabetes are necessary "but may also affect customary eating patterns and require lifestyle changes" (Touhy, 2016). Diabetic patients might have trouble adapting to the dietary changes that are required to manage their chronic disease, so non-adherence to the prescribed meal plans is common.

Chronic obstructive pulmonary disease, an affliction that causes enormous difficulty with breathing due to blocked airflow, causes nutritional hurdles that must be overcome. Many patients with chronic obstructive pulmonary disease are underweight and/or malnourished due to burning excess calories and expending more energy. Malnutrition in these patients is notably prevalent, and their clinical appearance "often belies the fact that they are significantly malnourished" (Zolty, 2007). 

Dysphagia is the medical term that means difficulty swallowing. Dysphagia can certainly pose nutritional and safety challenges for patients. Many survivors of strokes are afflicted with dysphagia. Numerous patients with late-stage Alzheimer's dementia also develop dysphagia. To reduce the risk of aspiration (inhalation of food and fluids into the lungs), a patient with dysphagia might either be prescribed a pureed diet or made NPO (nil per os) status, which is latin for 'Nothing By Mouth.'

Essential tremor is a neurological health condition that results in involuntary rhythmic shaking that might cause difficulties with eating. Many patients afflicted with essential tremor "find that they lose weight and have to try hard to maintain a high intake of calories so as to avoid excessive weight loss" (National Tremor Foundation, n.d.). Patients with tremor might require help from nursing assistants during meal service due to excessive shaking that interferes with feeding abilities. 

Many patients receive artificial forms of nutrition at healthcare facilities such as hospitals and nursing homes. Artificial nutrition and hydration are medically prescribed treatments that enable patients "to receive nutrition (food) and hydration (fluids) when they are no longer able to take them by mouth" (National Hospice and Palliative Care Organization [NHPCO], 2015). Nursing assistants must be familiar with the different forms of artificial nutrition in order to safely provide care for the patients who receive it.

In general, physicians can decide to provide artificial nutrition and hydration either "through intravenous (IV) administration or by putting a tube in the stomach" (NHPCO, 2015). A feeding tube, also called a gastrostomy tube, is a flexible tube a surgeon inserts through the patient's abdominal wall into the stomach when long-term difficulties with food and fluid consumption persist. Be mindful that administration of nutrition and fluids through IVs and/or feeding tubes is not within the scope of practice for nursing assistants. 

Some patients with feeding tubes must strictly have nothing by mouth. The abbreviation representing nothing by mouth is NPO, which stands for nil per os. If a patient is NPO status, he or she must have nothing by mouth since the risk of aspirating food and fluids is extremely high. All of the patient's nutrition, fluids and medications are administered through the feeding tube. In a hospital or skilled nursing facility setting, licensed nurses are the healthcare workers that typically administer nutrition and water via the feeding tube. 

Not all patients with feeding tubes are NPO status. Some patients routinely receive mechanically altered diets by mouth, but have feeding tubes in case they eat insufficient amounts of food. In essence, the feeding tube is there to maintain a patient's nutritional status. If these patients ever require a tube feeding while lying down, the nursing assistant must ensure the head of bed is elevated greater than 30 degrees to reduce the risk of aspiration. This is called the Fowler's position. 

Any patient with a feeding tube must be in the Fowler's position whenever artificial nutrition is actively being administered. If the nursing assistant must perform a procedure that requires placing the patient into a flat position, he or she must notify the nurse first. Normally, the nurse will stop the continuous tube feeding of artificial nutrition while the patient is lying in a flat position. Continuous tube feedings are administered by way of a pre-programmed pump.

After all care is completed, the nursing assistant should make the patient's nurse aware so the continuous feeding tube pump can be restarted. Nursing assistants are not permitted to start and stop feeding tube pumps. Management of the feeding tube pump is the responsibility of the licensed nurse in charge of the patient's care. The nursing assistant must remember to place the bedridden patient into the Fowler's position whenever a continuous tube feeding is running.

Nursing assistants might end up providing care for patients that have been prescribed some type of liquid diet. Therefore, knowing the differences between the different liquid diets will be immensely helpful. In most inpatient healthcare settings there are two types of liquid diets: the clear liquid diet and the full liquid diet. In the vast majority of instances these liquid diets will be prescribed on a temporary basis until the patient can safely progress to the safe consumption of solid foods.

The clear liquid diet is comprised of clear fluids "that are easily digested and leave no undigested residue in the digestive tract" (Mayo Clinic, 2017). Liquids that can be seen through are generally included in the clear liquid diet, as well as those that will liquefy or melt inside the body. Examples of clear liquids include water, tea, broth, apple juice, gelatin, ice chips, coffee, white grape juice, lemon lime soda and cranberry juice. Certain condiments such as honey and sugar are also acceptable.

The clear liquid diet is almost always prescribed on a very short-term basis because it is nutritionally inadequate. This type of liquid diet "is often used before tests, procedures or surgeries that require no food in the stomach or intestines, such as before colonoscopy" (Mayo Clinic, 2017). Even though the clear liquid diet lacks sufficient quantities of the six essential nutrients, it does provide the patient with adequate hydration and is normally enough to prevent dehydration. 

The full liquid diet includes all the fluids that appear on the clear liquid diet. In addition, it includes liquids that cannot be seen through. A full liquid diet consists of "fluids and foods that are normally liquid and foods that turn to liquid when they are at room temperature, like ice cream" (MedlinePlus, 2018). Examples of full liquids include milkshakes, ice cream, frozen yogurt, gelatin, cream soups, coffee with cream, orange juice, butter, margarine, pudding and maple syrup.

Most patients are prescribed a full liquid either immediately before or after a medical procedure or surgery to avoid strain on the digestive system. On occasion the full liquid diet is a step or upward progression from the clear liquid diet to a regular diet (MedlinePlus, 2018). The nursing assistant must keep in mind that patients are not allowed to consume solid foods whenever they have been prescribed any kind of liquid diet because it could result in problems with their upcoming medical procedure.

A therapeutic diet is a meal plan that controls intake of specific foods or nutrients as part of treatment for a particular disease (Insight Medical Publishing, 2020). Examples of therapeutic diets include diabetic diets, low sodium diets and cardiac diets since these meal plans are useful in treating diabetes, hypertension and heart disease. Nursing assistants should be familiar with common therapeutic diets that are served in hospitals and skilled nursing facilities. This is because nursing assistants check meal trays to ensure patients receive the correct foods per the prescribed diets listed on meal tickets that accompany all trays.

The diabetic diet is normally served to patients with diabetes mellitus whenever they are admitted into hospitals, nursing homes and assisted living facilities. The diabetic diet is one of the most common therapeutic diets; it involves limiting high-sugar foods to help blood sugar levels (Insight Medical Publishing, 2020). If a diabetic patient is admitted to a nursing home, the diet might be liberalized or simplified to a reduced concentrated sweets diet, which is essentially a regular diet that substantially reduces the amount of sugar and simple carbohydrates in each meal and snack to control blood glucose levels.

The low sodium diet is typically prescribed to patients with hypertension, which is the medical term for high blood pressure. For patients afflicted with hypertension, sodium aggravates their health condition and often causes their blood pressure readings to go up. Many patients with heart conditions also receive a low sodium diet. Most dietary sodium comes from salt that is either in processed foods or added to meals through table salts. The low sodium diet contains fresh fruits, fresh vegetables and fresh meats since these foods are have naturally low sodium. On the other hand, canned and preserved foods are very high in sodium. 

The cardiac diet, also called a heart-healthy diet, is a meal plan that minimizes foods that contain large amounts of saturated fats, cholesterol and sodium since all of these ingredients can worsen many heart conditions. Healthy foods such as fresh fruits, vegetables and lean cuts of chicken and fish are encouraged. The cardiac diet incorporates "whole grain products, beans, fruits & vegetables to maximize fiber intake" (New York Presbyterian Hospital, 2008). The cardiac diet is routinely prescribed to patients with heart problems such as heart failure, angina pectoris and coronary heart disease to help treat their health issues.   

While most patients can eat regular-consistency foods, some clients might have dental issues or swallowing problems that require all meals to be altered to a softened or pureed consistency. These patients consume mechanically altered diets. The two most common types of mechanically altered diets in healthcare settings are the mechanical soft diet and the puréed diet. These diets are routinely prescribed to patients with conditions such as dysphagia (difficulty swallowing) or mouth sores. Other patients are edentulous, which means they have no teeth.

A mechanical soft diet, also called a dental diet, contains foods that require less chewing than in a regular diet; "chopped, ground, and puréed foods are included, as well as foods that break apart easily without a knife" (Memorial Sloan Kettering Cancer Cencer, 2015). A puréed diet consists of foods that require no chewing, such as oatmeal and applesauce. Foods like chicken or cooked carrots may be blended with fluids added to make them into puréed consistencies. Fluids such as broth, milk, juice, or water may be added to each food to ensure it is the correct consistency for a puréed diet. 

Patients who require assistance with feeding must be kept safe during mealtimes by the nursing assistant. Safe meal service assistance involves performing meticulous hand hygiene, serving the correct thickness of liquids, adhering to aspiration precautions and properly feeding patients that have had strokes, also known as cerebrovascular accidents. Upholding principles of safety during meal service is one of a nursing assistant's most important responsibilities. 

The majority of patients consume thin liquids such as bottled water, coffee and soda. However, thin liquids are difficult to swallow and can be easily aspirated by patients with known swallowing problems. Patients who have trouble swallowing thin liquids resort to thickened liquids to prevent choking and stop fluids from entering the lungs. Thickened liquids are prescribed for these patients since they are easier to swallow. Nursing assistants can add agents to liquids to thicken them. The three consistencies of thickened liquids are (UPMC HealthBeat, 2016): 

• Nectar-thick liquids: easily poured fluids that are the thickness of apricot nectar, tomato juice or cream soups.
• Honey-thick liquids: slightly thicker fluids that are less pourable, drizzle from a cup or bowl, and cannot be consumed using a straw.
• Pudding-thick liquids: fluids that cannot be poured, hold their own shape and usually require a spoon to eat; also called spoon-thick liquids.

Some patients are placed on aspiration precautions because they are, for some reason, unable to protect their airways well enough to prevent inhalation of contents into the lungs. Aspiration precautions are the proactive steps healthcare workers and families take to ensure patients do not aspirate. Aspiration precautions entail keeping the bed in a Fowler's position at all times, which means elevating the head of the bed 30 to 45 degrees. Good mouth care should be performed every four hours and as needed to reduce the risk of aspiration pneumonia.

Many patients who have had strokes may sometimes exhibit issues such as weak swallowing muscles, facial drooping, or weakness on one side of the mouth. Nursing assistants must never feed these patients in a reclined position. Place these patients in the high Fowler's position before, during and 30 minutes after feedings to minimize aspiration risk. The high Fowler's position involves raising the head of the bed 75 to 90 degrees. Patients with weakness on one side of the mouth should be fed by placing all food in the strong side of the mouth so they will not pocket or hold food on the weak side.

Abshire, M., Xu, J., Baptiste, D., Almansa, J.R., Xu, J., Cummings, A., Andrews, M.J., Himmelfarb, C.D. (2015). Nutritional interventions in heart failure: A systematic review of the literature. Journal of Cardiac Failure, 21(12), 989-999.

Australian Government Department of Health. (2013). Nutrients. Retrieved April 30, 2020 from https://www1.health.gov.au/internet/publications/publishing.nsf/Content/canteen-mgr-tr1~nutrients

Cleveland Clinic. (2018). Drink Up: Dehydration is an Often Overlooked Health Risk for Seniors. Retrieved May 2, 2020 from https://health.clevelandclinic.org/drink-up-dehydration-is-an-often-overlooked-health-risk-for-seniors/

Cleveland Clinic. (2019). Weight Loss in Alzheimer's Disease. Retrieved May 2, 2020 from https://my.clevelandclinic.org/health/articles/21145-weight-loss-in-persons-with-alzheimers-disease

Insight Medical Publishing. (2020). Therapeutic diet. Retrieved May 3, 2020 from https://www.imedpub.com/scholarly/therapeutic-diet-journals-articles-ppts-list.php

LinksNorth. (n.d.). Nutrients. Retrieved April 30, 2020 from https://www.linksnorth.com/nutrition/nutrients.html

Mayo Clinic. (2017). Clear Liquid Diet. Retrieved May 3, 2020 from https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/clear-liquid-diet/art-20048505

Mayo Clinic. (2020). Obesity. Retrieved May 1, 2020 from https://www.mayoclinic.org/diseases-conditions/obesity/symptoms-causes/syc-20375742

MedLine Plus. (2018). Full Liquid Diet. Retrieved May 3, 2020 from https://medlineplus.gov/ency/patientinstructions/000206.htm

MedLine Plus. (2020). Vitamins. Retrieved April 30, 2020 from https://medlineplus.gov/ency/article/002399.htm

Memorial Sloan Kettering Cancer Center. (2015). Eating Guide for Pureed & Mechanical Soft Diets. Retrieved May 3, 2020 from https://www.mskcc.org/sites/default/files/node/20288/document/b-137_mech_diet_2015-3.pdf

National Hospice and Palliative Care Organization. (2015). Artificial Nutrition and Hydration at the End of Life. Retrieved May 2, 2020 from https://www.nhpco.org/wp-content/uploads/2019/04/ArtificialNutritionAndHydration.pdf

National Tremor Foundation. (n.d.). Diet & nutrition. Retrieved May 2, 2020 from https://tremor.org.uk/diet-and-nutrition.html

New Your Presbyterian Hospital. (2008). Cardiac Diet. Retrieved May 3, 2020 from https://mynyp.org/pdf/511-cardiac-diet-5-04.pdf

Simmons, W.K., Burrows, K., Avery, J.A., Kerr, K.L., Bodurka, J., Savage, C.R., & Drevets, W.C. (2016). Depression-related increases and decreases in appetite reveal dissociable patterns of abberrant activity of reward and interoceptive neurocircuitry. American Journal of Psychiatry, 173(4), 418-428.

Touhy, T.A. (2016). Nutrition and Hydration. NurseKey. Retrieved April 29, 2020 from https://nursekey.com/9-nutrition-and-hydration/

UPMC HealthBeat. (2016). How to Thicken Liquids: Nectar-Thick. Retrieved May 3, 2020 from https://share.upmc.com/2016/03/how-to-thicken-liquids/

Zolty, P. (2007). Nutrition in COPD Patients. RT Magazine. Retrieved May 2, 2020 from https://www.rtmagazine.com/disorders-diseases/chronic-pulmonary-disorders/copd/nutrition-in-copd-patients/