Nutrition, Hydration, Elimination, and Skin Integrity

Feeding is a safety skill

Nutrition assistance is not only placing food in a resident's mouth. Before meals, perform hand hygiene, verify the resident's identity, confirm the correct tray and diet order, position the resident upright at about 90 degrees (high-Fowler's), apply dentures, glasses, or hearing aids if used, and make sure adaptive equipment is available. Keep the call light within reach and protect clothing with a napkin or clothing protector per preference and policy.

Encourage independence. Open containers, cut food if allowed, cue the resident, and allow enough time. Sit at eye level when feeding, offer small bites, alternate solids and liquids as tolerated, and do not rush. Respect dislikes and cultural or religious food preferences. If a resident refuses food, report and document the percentage eaten rather than arguing or hiding the refusal. After the meal, keep the resident upright for about 30 minutes to reduce reflux and aspiration.

Common therapeutic diets the CNA should recognize include a mechanical soft or pureed diet for chewing or swallowing problems, a low-sodium diet for heart or kidney conditions, a diabetic (consistent-carbohydrate) diet, a renal diet, and NPO (nothing by mouth), which means the resident gets no food or fluids and the tray must not be served.

Hydration and swallowing (dysphagia) risks

Hydration prevents constipation, urinary infection, confusion, skin breakdown, and weakness. Offer fluids allowed by the care plan and record intake accurately. Some residents have fluid restrictions, so the CNA must not push extra fluids without checking the plan. Others require thickened liquids (nectar, honey, or pudding consistency) because thin liquids increase aspiration risk in dysphagia. Never thin a liquid because the resident dislikes it.

Swallowing problems demand immediate attention. Watch for coughing, a wet or gurgly voice, drooling, shortness of breath, food left in the cheeks, repeated throat clearing, watery eyes while eating, or refusal because swallowing hurts. Stop feeding at the first sign of aspiration risk and report to the nurse. Do not put more food in the mouth to test whether the problem continues.

Elimination and dignity

Toileting carries a high dignity burden. Answer call lights promptly, provide privacy, use safe transfer technique, and never shame a resident for incontinence. For bedpans and urinals, position the resident safely and comfortably, provide tissue and hand hygiene, and check the skin after incontinence. Record bowel movements, urine output, and unusual findings per policy.

Report dark, cloudy, bloody, foul-smelling, or very low urine output; burning or pain with urination; new incontinence; constipation; diarrhea; black tarry stool or bright red blood; vomiting; abdominal pain; or a sudden change in bowel pattern. With an indwelling catheter, keep the drainage bag below bladder level, off the floor, and free of kinks, and anchor the tubing to the leg per policy so it does not pull on the urethra. Do not disconnect tubing or raise the bag above the bladder, which can cause urine to backflow and infect the bladder.

Adequate fluid and fiber, regular toileting, and activity help prevent constipation; report no bowel movement in about three days. Normal adult urine output is roughly 1,500 mL per day, and output under about 30 mL per hour should be reported.

Skin integrity and pressure-injury staging

Pressure injuries are more likely when residents are immobile, poorly nourished, dehydrated, incontinent, or have reduced sensation. The CNA prevents them by repositioning at least every 2 hours (and shifting weight in a chair every hour), keeping skin clean and dry, smoothing sheet wrinkles, using pressure-relief devices as directed, encouraging nutrition and fluids within orders, and reporting early skin changes. Friction and shear (such as dragging a resident up in bed) also damage skin, so lift rather than drag.

The National Pressure Injury Advisory Panel (NPIAP) staging system is testable:

Common bony risk points include the heels, ankles, knees, hips, coccyx (tailbone), elbows, shoulders, ears, and the back of the head. Do not massage a reddened bony area, because massage can worsen tissue damage. Do not apply powders, creams, dressings, or heat unless directed by the nurse or care plan.

Exam filter

Choose answers that keep the resident upright for meals, follow diet orders, measure I&O, provide privacy, keep catheter drainage flowing downward below the bladder, clean incontinence promptly, reposition on schedule, and report skin changes by stage. Reject choices that force-feed, ignore choking, thin a thickened liquid, leave residents wet, massage reddened skin, or treat a pressure injury without nurse direction.