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Assisting withNutrition and

Hydration inLong-Term Care

By Hartman Publishing Inc.

Managing Editor

Susan Alvare

Proofreader

Suzanne Wegner

Cover and Interior Designer

Kirsten Browne

Illustrators

Thaddeus Castillo/Robert Christopher

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Thaddeus Castillo

Photography

Art Clifton/Dick Ruddy/Susanita Marcos

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Gailynn Garberding/Debbie Rinker/Yvonne Gillam

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Copyright Information

© 2004 Hartman Publishing, Inc.

8529 Indian School Road, NE

Albuquerque, NM 87112

(505) 291-1274

web: www.hartmanonline.com

e-mail: [email protected]

All rights reserved. No part of this book may be reproduced, in any form or

by any means, without permission in writing from the publisher .

ISBN 1-888343-73-7

Notice to Readers

Though the guidelines and procedures contained in this text are based on

consultations with healthcare professionals, they should not be considered

absolute recommendations. The instructor and readers should follow em-

ployer, local, state, and federal guidelines concerning healthcare practices.

These guidelines change, and it is the reader's responsibility to be aware of

these changes and of the policies and procedures of her or his employer .

The publisher, author, editors, and reviewers cannot accept any responsibil-

ity for errors or omissions or for any consequences from application of the

information in this book and make no warranty, expressed or implied, with

respect to the contents of the book. The publisher does not warrant or

guarantee any of the products described herein nor perform any analysis in

connection with any of the product information contained herein.

Gender Usage

This textbook utilizes the pronouns he, his, she, and hers interchangeably

to denote healthcare team members and clients.

Acknowledgments

A special thanks for our insightful and always available reviewers:

Jean P. Stanhagen, RN, BSNBethel Park, PA

Jeanne Miles, RNHaven, KS

Sharon L. Hopper, RN, SDCCNA InstructorOneida, NY

Kathy J. Archer, BS, RNNursing Assistant Program SpecialistThe Community College of Baltimore CountyBaltimore, MD

Margaret PearsonCEO/Program DirectorP&A NursingPhiladelphia, PA

Anne SnyderCOO/Educational DirectorP&A NursingPhiladelphia, PA

Mattie Scott, RNGalesburg, IL

1The Dining Assistant 11. Explain the need for dining

assistants . . . . . . . . . . . . . . . . . . . . .1

2. Describe the role of the diningassistant . . . . . . . . . . . . . . . . . . . . . .2

3. Explain why promoting independenceis important . . . . . . . . . . . . . . . . . . .4

4. Identify the residents you will beassisting . . . . . . . . . . . . . . . . . . . . . .4

2Residents’ Rights 61. Explain Residents’ Rights . . . . . . . . .6

2. List examples of behavior supportingand promoting Residents’ Rights . .7

3. Define the terms “abuse” and“neglect” and list signs of abuse andneglect . . . . . . . . . . . . . . . . . . . . . . . .8

4. Discuss the ombudsman’s role . . .10

5. Explain HIPAA and list ways toprotect residents’ confidentiality . .10

6. Explain The Patient Self-Determination Act (PSDA) . . . . . .13

3Communication andInterpersonal Skills 151. Define “communication” . . . . . . .15

Table of Contents

2. Explain verbal and nonverbalcommunication . . . . . . . . . . . . . . .15

3. Identify barriers to communication . . . . . . . . . . . . . . .16

4. List ways to make communicationaccurate and complete . . . . . . . . . .18

5. Explain how to develop effectiveinterpersonal relationships . . . . . .19

6. List guidelines for communicating with residents with special needs . . . . . . . . . . . . .21

7. Describe appropriate responses toresident behavior . . . . . . . . . . . . . .25

8. Explain how communication affectsnutritional status . . . . . . . . . . . . . .27

9. Identify signs and symptoms ofswallowing problems and explainhow to communicate concerns . . .28

4Infection Control 311. Define terms related to infection

control and explain the chain ofinfection . . . . . . . . . . . . . . . . . . . . .31

2. Explain why the elderly are at a higherrisk for infection . . . . . . . . . . . . . . .33

3. Identify when to wash hands . . . . .33

4. Identify when to wear gloves . . . . .35

5. Define “bloodborne pathogens” andexplain OSHA’s BloodbornePathogen Standard . . . . . . . . . . . . .36

6. Explain Standard Precautions andTransmission-Based Precautions .36

7. Explain signs, symptoms, and causesof foodborne illness . . . . . . . . . . . .38

8. Identify why the elderly are at higherrisk for foodborne illness . . . . . . . .38

9. Describe ways to prevent the spreadof infection . . . . . . . . . . . . . . . . . . .38

5Proper Nutrition andHydration 421. Describe the importance of good

nutrition . . . . . . . . . . . . . . . . . . . . .42

2. Identify nutritional problems of theelderly or ill . . . . . . . . . . . . . . . . . . .42

3. List the six basic nutrients andexplain the USDA Food GuidePyramid . . . . . . . . . . . . . . . . . . . . . .43

4. Explain the role of the dietarydepartment . . . . . . . . . . . . . . . . . . .45

5. Describe factors that influence foodpreferences . . . . . . . . . . . . . . . . . . .46

6. Describe how to prevent dehydrationand identify symptoms that must bereported . . . . . . . . . . . . . . . . . . . . .46

7. List ways to identify and preventunintended weight loss . . . . . . . . .47

8. Explain special diets . . . . . . . . . . . .48

9. Explain thickened liquids and identify three basic thickenedconsistencies . . . . . . . . . . . . . . . . .51

6Feeding Techniques 541. Explain the swallowing process . . .54

2. Describe how to make diningenjoyable for residents . . . . . . . . . .54

3. Explain how to serve meal trays . . .55

4. Demonstrate how to assist a residentwith eating and drinking . . . . . . . .57

5. Demonstrate how to feed residentswho have special needs . . . . . . . . .59

7Safety and Emergency Care 641. Describe how the dining assistant

can promote safety . . . . . . . . . . . . .64

2. Explain the dining assistant’s role inemergencies . . . . . . . . . . . . . . . . . .65

3. Demonstrate knowledge of first aidprocedures . . . . . . . . . . . . . . . . . . .65

8Assisting Residents withDementia 751. Define “dementia” and recognize its

causes . . . . . . . . . . . . . . . . . . . . . . .75

2. Describe Alzheimer’s disease andidentify its stages . . . . . . . . . . . . . .75

3. List strategies for bettercommunication with Alzheimer’sresidents . . . . . . . . . . . . . . . . . . . . .77

4. List common difficult behaviorsrelated to Alzheimer’s disease . . . .78

5. List and describe interventions forproblems with eating . . . . . . . . . . .80

6. Describe creative therapies forresidents with Alzheimer’s disease . . . . . . . . . . . . . . . . . . . . . .81

9Observing and ReportingChanges in Residents 851. Explain why changes are

important to report . . . . . . . . . . . .85

2. Describe how to report factualobservations . . . . . . . . . . . . . . . . . .85

3. Recognize changes that areinconsistent with normal behavior . . . . . . . . . . . . . . . . . . . . .86

4. Identify important observations that should be reported immediately . . . . . . . . . . . . . . . . . .87

5. Understand the importance of observing and reporting aresident’s diet . . . . . . . . . . . . . . . . .87

6. Explain fluid intake and output (I&O) . . . . . . . . . . . . . . . . . . . . . . . .87

Putting on gloves

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Fig. 1-1. A long-term care facility is the resi-dent’s home. You must treat residents’rooms with respect.

homes for conditions that require carefor a few weeks or longer. Some ofthese persons recover and return totheir homes.

Most conditions seen in nursing homesare chronic. This means they last along time, even over a lifetime. Chronicconditions include physical disabilities,heart disease, stroke, and dementia.(You will learn more about these disor-ders and diseases later.)

1. Explain the need for diningassistants

2. Describe the role of the diningassistant

3. Explain why promotingindependence is important

4. Identify the residents you will beassisting

1. Explain the need for diningassistants

Long-term care (LTC) is the term usedto describe care for persons who require24-hour care and assistance for long-term conditions. Other terms used forlong-term care facilities include nursinghome, nursing facility, skilled nursingfacility, or extended care facility. Duringthe time people live in this type offacility, it becomes their home. The peo -ple who live in LTC facilities are calledresidents (Fig. 1-1).

The people who live in LTC facilitiesmay be disabled and/or elderly. Theymay come from their homes, hospitalsor other facilities. Some people willhave a terminal illness, which meansthe person is expected to die with theillness. Other people come to nursing

1. Explain the need for dining assistants

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Residents in long-term care today re-quire much more assistance than theydid in the past. Often there are notenough qualified staff available to feedor assist the many residents who needhelp. The National Policy & ResourceCenter on Nutrition & Aging estimatesthat between 35% and 50% of the olderresidents in long-term care facilities aremalnourished. Malnourished means aperson is not getting proper nutrition; itis a serious condition.

Different factors contribute to residentmalnourishment in LTC. One of thebiggest problems, which was men-tioned briefly above, is that nursinghomes are often short-staffed. Staffmembers have many residents to assist.When there are not enough staf f mem-bers, residents may feel rushed at meal-time and, as a result, do not eat enough.Mealtime is also a social occasion formany residents. When residents do notget personalized attention from over-worked staff, they may feel lonely,bored, or depressed. This also af fectsthe intake of food and drink.

Due to staffing shortages and becausemany more residents need assistancewith eating and drinking, the federalgovernment created a new regulation in2003. This regulation allows states tohire and train “paid feeding assistants”to work in LTC facilities. This positionwas developed to help residents withtheir eating and drinking needs and toreduce problems of unintended weightloss and dehydration. Dehydration oc-curs when a person does not haveenough fluid in the body, also a seriouscondition in LTC.

By following the federal requirements,states can approve training programs

for dining assistants. Dining assistantsmust complete the state-approved train-ing program successfully.

2. Describe the role of the diningassistant

Dining assistants help residents withtheir eating and drinking needs.Residents will have different problemsand needs. Some residents only needencouragement or a little assistance.Other residents need total assistancewith eating and drinking (Fig. 1-2).

Fig. 1-2. Assisting residents with hydrationwill be one of your duties.

Dining assistants will perform thesetasks: setting up meals, giving physicaland verbal cues to help direct residents,and assisting residents with eating anddrinking as necessary. Some states mayonly allow a dining assistant to help res-idents with eating by using a spoon.Residents may use a fork when feedingthemselves. Dining assistants are not al-lowed to give medications. Nurses areresponsible for giving medications.

Another very important duty of a diningassistant is socializing with residentsduring mealtime. The chance to interactwith you and other residents is mean -ingful to the residents you assist. Theylook forward to it and it may be the bestpart of their day. Keep a positive atti-

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112. Describe the role of the dining assistant

tude. Be caring, concerned, empathetic,and understanding. Empathy meansbeing able to enter into the feelings ofothers. Address residents by the namethey prefer. Speak politely and cheer-fully to residents, even if you are not ina good mood. Listen to residents whenthey talk. A good attitude and cheerfulcommunication positively impact howmuch residents eat and drink (Fig. 1-3).

Fig. 1-3. Being polite and cheerful is some -thing that will be expected of you.

Because residents have different needsand problems, people with differentkinds of education and experience willhelp care for them. This group of peo-ple is known as the care team. Diningassistants are an important part of thecare team. Other members may include:

• Registered Nurse (RN)

• Licensed Practical Nurse (LPN)

• Physician (MD or DO)

• Occupational Therapist (OT)

• Speech Therapist (ST)

• Physical Therapist (PT)

• Registered Dietitian (RDT)

• Medical Social Worker (MSW)

• Nursing Assistant (NA or CNA)

As a dining assistant, you will be work-ing under the supervision of a regis-tered nurse (RN) or a licensed practicalnurse (LPN). An RN is a licensed pro-fessional who has completed two tofour years of education. An LPN is a li-censed professional who has completedone to two years of education. Bothmust pass licensing exams that testtheir knowledge before being licensed.

The nursing assistant (NA) or certif iednursing assistant (CNA) performs dele-gated or assigned nursing tasks, such astaking someone’s temperature. A nurs-ing assistant also provides personalcare, such as bathing residents and as -sisting with toileting. NAs must com-plete a minimum of 75 hours oftraining. In many states, their trainingexceeds 100 hours. Dining assistantshelp supplement a nursing assistant’sduties.

Nursing assistants have been trained inpositioning residents, caring for theirfragile skin, and transferring themsafely. Your training does not includethese skills. You are only allowed to per-form those tasks identified in yourstate-approved training program.However, you should be aware of yourresidents’ position before assistingthem with eating and drinking. If repo-sitioning is needed, notify a nursing as-sistant or a nurse. You will learn moreabout correct positioning in chapter 6.

Dining assistants may have different ti-tles. Feeding assistant, feeding aide, andnutritional assistant are some examples.This book will use the term “dining assistant.”

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3. Explain why promotingindependence is important

Another important part of your job willbe promoting independence.Independence often means not havingto rely on others for money, daily rou-tine care, such as eating and drinking,or participation in social activities.People tend to take these activities forgranted until they can no longer dothem for themselves.

A loss of independence can cause:

• a negative self-image

• anger toward caregivers, others, andself

• feelings of helplessness, sadness,and hopelessness

• feelings of being useless

• increased dependence

• depression (Fig. 1-4)

Fig. 1-4. Not promoting independence canlead to many problems. Be patient and en -couraging.

To prevent these problems, encourageresidents to do as much as possible forthemselves. Even if it seems easier foryou to do things for your residents,allow them to accomplish a task inde-pendently. For example, if a resident isable to pick up and use a spoon, sheshould. Encourage their abilities to

complete tasks, regardless of how longit takes or how poorly they are able todo it. Be patient while they do thesetasks.

Allowing residents to make choices isanother way to promote independence.Residents can choose where to sit whilethey eat as well as what they eat and inwhat order. Respect a resident’s right tomake choices.

4. Identify the residents you will beassisting

A resident’s diagnosis, or medical con-dition, will differ from one setting toanother. The stages of illnesses or dis-eases affect how sick people are andhow much assistance they will need.Residents who require assistance witheating and drinking may have any ofthe following conditions or diseases:

• visual or hearing impairments

• dementia, including Alzheimer’sdisease

• stroke

• Parkinson’s disease

• physical impairments of the armsand hands

• malnutrition

• dehydration

• depression

For more information on these disor-ders, see chapters 3, 5, 6, and 8.

An RN or LPN will decide which resi-dents you are able to assist. Federal reg-ulations prohibit you from assistingresidents who have more complicatedproblems, such as lung aspirations, dif-ficulty swallowing, or those residents onfeeding tubes or using IV feedings.

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11Chapter Review

Aspiration is inhaling food or drinkinto the lungs. If you feel that a residentneeds assistance from someone whohas more experience, notify the chargenurse (Fig. 1-5).

Fig. 1-5. RNs and LPNs will decide who youcan assist. You will not assist residents whohave complicated problems.

The federal government closely regu-lates long-term care. It may seem to youthat you are being under-used. How-ever, by law, there are many things youare not allowed to do, including:

• moving or transferring residents

• positioning residents

• helping residents with toileting

• dressing residents

• giving mouth care

Only people who have had specializedtraining, such as RNs, LPNs, and NAs,are allowed to perform these tasks.

Chapter Review

1. Which of the following contributesto the need for dining assistants?a. Nursing homes are often

short-staffed.b. Residents need more personal-

ized attention during mealtime.c. Residents are often malnour-

ished and dehydrated. d. All of the above

2. All of the following statementsabout a dining assistant’s role aretrue EXCEPT:a. Dining assistants socialize with

residents.b. Dining assistants can give med-

ication to residents.c. Dining assistants assist residents

with eating and drinking.d. Dining assistants are part of the

care team.

3. Why should dining assistants en-courage residents’ independence?a. It helps prevent increased de-

pendence and depression.b. It promotes feelings of

helplessness.c. It lowers self-esteem.d. None of the above

4. Which of the following residents aredining assistants NOT allowed to assist?a. Residents who have Alzheimer’s

diseaseb. Residents who are depressedc. Residents who are dehydratedd. Residents who have difficulty

swallowing

5. What member of the care teammakes the decision about what typesof residents dining assistants will beassisting?a. Nursing assistantsb. Dietary departmentc. RNs or LPNsd. Dining assistants