Nutrition, Hydration, and Elimination

Why Nutrition and Hydration Matter

Malnutrition, dehydration, and aspiration (food or fluid entering the airway/lungs) are among the most common preventable harms in nursing facilities. The CNA is often the person who actually feeds residents and tracks what they consume, so this content appears repeatedly on the written and skills tests.

Dysphagia means difficulty swallowing. Residents with dysphagia, dementia, or a recent stroke are at high aspiration risk and may have thickened-liquid orders (nectar, honey, or pudding consistency). Honor these orders exactly — giving thin liquids to a resident on thickened liquids can be fatal.

Safe Feeding: Position, Pace, and the Weak Side

Key feeding rules:

1. Sit the resident upright — Fowler's position (head of bed at 60-90 degrees) or in a chair — and keep them up at least 30 minutes after the meal to prevent reflux and aspiration.
2. Sit at the resident's eye level so they do not tip the head back (which opens the airway).
3. Offer small bites, alternate solids and liquids, and let the resident fully swallow before the next bite.
4. For a resident with one-sided weakness, place food on the stronger (unaffected) side of the mouth.
5. Identify the resident, check the meal ticket/diet order, and provide adaptive utensils if ordered.

Aspiration warning signs mean STOP feeding and call the nurse: coughing, choking, a gurgling or wet voice, watery eyes, drooling, or food pocketing in the cheek.

Hydration and Preventing Dehydration

Elderly residents have a reduced thirst sensation, so they need active encouragement to drink. A common guideline is offering fluids regularly and aiming for adequate daily intake unless a fluid restriction is ordered.

Signs of dehydration to report:

• Dark, concentrated, strong-smelling urine and low urine output
• Dry mouth, cracked lips, dry/tenting skin
• Sudden confusion or weakness, dizziness
• Sunken eyes, rapid pulse, low blood pressure

Conversely, fluid overload (swelling/edema, weight gain, shortness of breath) is reported in residents with heart or kidney conditions and fluid restrictions.

Practical ways the CNA encourages fluids: offer preferred drinks, keep a fresh water pitcher in reach (unless restricted), offer fluids with every contact, and provide cups the resident can lift. Daily weights and skin turgor checks help the nurse track hydration.

Feeding the Resident Who Needs Total Help

For a resident who cannot self-feed, the CNA still promotes independence by encouraging finger foods or hand-over-hand technique where possible. Describe the meal ('this is mashed potato'), tell the resident before each bite, fill the spoon one-third to one-half full, touch the spoon to the lower lip, and wait for the mouth to open. Check for pocketing (food held in the cheek) and offer fluids between bites. Allow enough time — rushing causes choking and reduces intake.

Intake and Output (I&O)

Intake and output (I&O) is the measured record of fluids in versus fluids out. It is recorded in milliliters (mL).

The essential conversion: 1 fluid ounce = 30 mL. So a 4-ounce juice = 120 mL; an 8-ounce cup = 240 mL.

• Intake counts anything liquid at body temperature: water, juice, milk, coffee, soup, gelatin, ice cream, ice chips (record about half the volume of melted ice chips).
• Output counts urine, emesis (vomit), liquid stool, and wound drainage. Measure urine in a graduated container.
• Record what the resident actually consumed, not what was served. If a resident drinks half of a 240 mL cup, record 120 mL.

Elimination: Bowel and Bladder Care

The CNA assists with toileting, bedpans, urinals, and incontinence care, and reports changes. Normal urine is pale yellow and clear; report cloudy, bloody, dark, or foul-smelling urine (possible UTI).

For bowel patterns, report diarrhea, constipation, blood in stool, or no bowel movement for 3 days. Black, tarry stool (melena) can signal upper-GI bleeding — report it.

Incontinence care protects skin: clean promptly, dry thoroughly, apply barrier cream if ordered, and never leave a resident in a wet brief (leads to skin breakdown and pressure injuries).

For a resident with an indwelling urinary catheter: keep the drainage bag below the level of the bladder (so urine does not flow back), keep tubing free of kinks, never let the bag touch the floor, and provide daily perineal/catheter care. When transporting in a wheelchair, hang the bag low on the chair frame, never in the resident's lap. Empty the bag into a graduated container, measure the output, and report cloudy or bloody drainage.

Choking: The Emergency Side of Nutrition

If a resident is choking and cannot speak, cough, or breathe, that is a complete airway obstruction — perform abdominal thrusts (the Heimlich maneuver) if trained and call for help. If the resident can still cough forcefully, encourage coughing and do not interfere. A resident who suddenly clutches the throat (the universal choking sign) during a meal needs immediate action. This is why upright positioning, small bites, and watching for swallowing before the next bite matter so much.

Common Exam Traps

• Feeding or laying a resident flat — they must be UPRIGHT and stay up 30 minutes after.
• Recording the amount served instead of the amount actually consumed.
• Forgetting 1 oz = 30 mL when calculating I&O.
• Raising a catheter bag above the bladder (causes backflow and infection).
• Giving any food or fluid — even water or ice chips — to a resident who is NPO.