6.2 Measurement & Documentation
Key Takeaways
- Weigh residents at the same time of day, on the same scale, in similar clothing, after voiding, for accurate trend tracking.
- Record intake and output (I&O) in millilitres; convert household measures (1 oz = 30 mL) and report large imbalances to the nurse.
- Output includes urine, emesis, liquid stool, and wound or tube drainage; intake includes all fluids and foods that are liquid at room temperature.
- Document promptly, factually, and objectively — record what you measured, never estimate from memory or chart in advance.
- Report a sudden weight gain or loss, sharply reduced intake, or low urine output to the nurse immediately.
Why Measurement Accuracy Matters
Measurements drive care decisions: a sudden weight gain can signal fluid retention from heart failure, and low urine output can signal dehydration or kidney problems. Because the nurse and physician act on the numbers the CNA records, accuracy and honesty are non-negotiable. This content sits in the Basic Nursing Care domain and recurs on the Florida written exam.
Height and Weight
To make weights comparable over time, control the variables:
| Factor | Standard Practice |
|---|---|
| Time of day | Weigh at the same time, usually before breakfast |
| Scale | Use the same scale each time |
| Clothing | Similar light clothing, no shoes |
| Bladder | After the resident voids |
| Zeroing | Balance/zero the scale before each use |
Use a chair or lift scale for residents who cannot stand safely. Measure height with the resident standing straight or, if bedbound, using an approved measuring method per facility policy.
Intake and Output (I&O)
Intake is everything the resident takes in that is liquid or liquid at room temperature: water, juice, milk, coffee, soup, gelatin, ice cream, popsicles, and IV or tube fluids the nurse records. Output is everything the body puts out: urine, emesis (vomit), liquid stool, and wound or drainage-tube output.
I&O is recorded in millilitres (mL). Memorize the common conversion:
| Household Measure | Metric Equivalent |
|---|---|
| 1 ounce (oz) | 30 mL |
| 1 cup (8 oz) | 240 mL |
| 1 pint (16 oz) | 480 mL |
To record intake, note how much of a known container the resident actually consumed (for example, half of a 240 mL cup = 120 mL). For output, measure urine in a graduate; never estimate. Report a large imbalance, very low urine output, or repeated refusals to drink to the nurse.
Documentation Standards
Florida CNAs document care that was actually given, when it was given, exactly as observed.
- Be prompt: record as soon as the task is done, not from memory hours later.
- Be objective: write what you saw, did, and measured — not opinions or conclusions ("ate 50% of lunch," not "resident was being difficult").
- Be accurate: record the real number; do not round to make it look neat.
- Never pre-chart: never document care before it is performed — this is falsification and a serious offense affecting registry standing.
- Correct errors properly: per facility policy (single line through, initial, date) — never erase or use correction fluid.
- Use only approved abbreviations and report, then document, abnormal findings.
Exam Tip
If an answer choice involves estimating, charting ahead, or recording care that did not happen, it is wrong. The correct documentation answer is always: timely, factual, objective, and accurate.
A resident drank a full 240 mL cup of juice and ate half of a 240 mL bowl of gelatin. What total fluid intake should the CNA record?
Which weighing practice gives the most accurate trend over time?