Nutrition, Hydration, and Elimination

Assisting With Nutrition and Feeding

Proper nutrition prevents malnutrition, skin breakdown, and weakness, while safe feeding prevents aspiration — food or fluid entering the airway/lungs, which can cause choking or aspiration pneumonia. This topic falls under Physical Care Skills (~35%) and appears often on the Massachusetts D&S/Headmaster written knowledge test.

Core feeding safety rules:

• Position upright: raise the head of the bed to at least 90° (fully upright) or seat the resident in a chair. Keep them upright 30–60 minutes after the meal.
• Verify the right diet (the right resident, the right ordered consistency) before serving.
• Feed small bites, alternate solids and liquids, and make sure each bite is swallowed before the next.
• Sit at eye level, do not rush, and never feed a drowsy or poorly responsive resident.

Dysphagia and Modified Diets

Dysphagia means difficulty swallowing. Warning signs to report immediately: coughing or throat-clearing while eating, a wet or gurgly voice after swallowing, drooling, or pocketing food in the cheek.

The care plan may order thickened liquids to slow flow and reduce aspiration risk:

Serve the exact ordered consistency — giving thin liquids to a resident on thickened liquids can cause aspiration and is a serious error. A mechanical soft or pureed diet may also be ordered.

Hydration and Intake & Output

Dehydration is a major risk for elders. Encourage fluids, offer preferred drinks, and keep water within reach unless restricted. Report signs of dehydration: dry mouth, dark concentrated urine, sunken eyes, confusion, or low output.

Intake and Output (I&O) tracks all fluid in versus all fluid out, recorded in milliliters (mL). The conversion you must know: 1 ounce = 30 mL.

Worked example: A resident drinks 8 oz of orange juice and 4 oz of coffee at breakfast.

• 8 oz × 30 = 240 mL
• 4 oz × 30 = 120 mL
• Total intake = 360 mL

Intake counts liquids, foods liquid at room temperature (gelatin, ice cream, broth, popsicles), IV fluids, and tube feedings. Output includes urine, emesis (vomit), liquid stool, and drainage. Empty and measure catheter bags; report urine output under 30 mL/hour as a possible problem.

Elimination and Toileting

Normal elimination supports comfort and dignity. CNAs assist with the bedpan, urinal, commode, and toileting, and observe and report on what they see.

Report these abnormalities to the nurse:

• Urine: cloudy, bloody (hematuria), dark, strong/foul odor, painful or burning urination — possible urinary tract infection (UTI).
• Stool: black/tarry (melena), bloody, very hard (constipation/impaction), or watery/loose (diarrhea).
• Any sudden change from the resident's normal pattern, or no bowel movement in 3 days.

Promote independence: provide privacy, give enough time, position upright when possible, and offer the toilet on a schedule (toileting/bladder training) to reduce incontinence and falls.

Catheter and Specimen Care

For a resident with an indwelling (Foley) urinary catheter:

• Clean the catheter and meatus from the meatus outward (away from the body) to prevent introducing bacteria.
• Keep the drainage bag below the level of the bladder at all times, and keep tubing free of kinks.
• Never disconnect the closed system; secure the catheter to the leg to prevent pulling.

A clean-catch (midstream) specimen requires cleansing the perineum, having the resident start to void, then catching urine mid-stream in a sterile container without touching the inside. A routine (random) specimen does not need the midstream technique. Always label specimens correctly and follow facility transport rules.

Special Diets and Why They Are Ordered

The nurse and dietitian set the diet; the CNA serves the right diet to the right resident. Knowing why a diet is ordered helps you spot mistakes before they reach the resident.

If a meal tray does not match the ordered diet, do not serve it — verify with the nurse first. Honor cultural, religious, and personal food preferences whenever the diet allows.

Recognizing Fluid Imbalance

Both too little and too much fluid are dangerous, and the CNA's observations trigger early intervention.

• Dehydration: dry mouth/lips, dark concentrated urine, low output, sunken eyes, weakness, new confusion, weight loss.
• Fluid overload (edema): swelling of ankles/feet, rapid weight gain, puffy face, shortness of breath.

For constipation, encourage fluids, fiber, and activity within the care plan, and report no bowel movement in 3 days or signs of impaction (hard stool, abdominal distension, small liquid leakage around a blockage).

Common Exam Traps

• Choking: if the resident can still cough forcefully, encourage coughing and do not interfere; if they cannot speak, cough, or breathe, begin abdominal thrusts (Heimlich) and call for help.
• Feeding a reclined or drowsy resident — never do this; reposition upright first.
• Charting estimated intake — always convert and record actual amounts in mL.
• Raising the catheter bag above the bladder, allowing backflow and infection.