2.3 Nutrition, Hydration & Intake/Output

2.3 Nutrition, Hydration & Intake/Output

Quick Answer: Proper nutrition and fluid balance are vital for wound healing, metabolic maintenance, and preventing organ failure. CNAs must recognize therapeutic diets, implement strict aspiration precautions for residents with dysphagia (sitting upright at 90° High Fowler's during meals and 30 minutes post-meal), and measure Intake and Output (I&O) accurately. Remember the fundamental metric conversion: 1 fl oz = 30 mL (or 30 cc). Report urine output below 30 mL/hour to the nurse immediately.

Providing adequate nutrition and hydration is a cornerstone of nursing assistant care. Long-term care residents are particularly vulnerable to protein-calorie malnutrition, severe dehydration, and life-threatening aspiration pneumonia due to age-related physiological changes, chronic diseases, cognitive decline, and swallowing difficulties.

Basic Nutritional Requirements & Therapeutic Diets

Dietary orders are prescribed by physicians and managed by registered dietitians to meet specific medical requirements.

Essential Nutrients

• Proteins: Essential for tissue growth, cell repair, and wound healing (e.g., pressure injury recovery).
• Carbohydrates: Provide primary energy for cellular function.
• Fats: Provide concentrated energy and insulation.
• Vitamins & Minerals: Regulate bodily processes (e.g., Calcium for bones, Iron for blood production).
• Water: The most critical nutrient for survival; accounts for 50%–60% of adult body weight.

Overview of Therapeutic Diets

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Dysphagia Management & Aspiration Precautions

Dysphagia is medical terminology for difficulty swallowing. Dysphagia creates a severe risk of aspiration—the entry of food, liquid, or saliva into the lungs—which can lead to aspiration pneumonia and death.

Clinical Signs of Dysphagia

• Coughing, choking, or throat-clearing during or immediately after swallowing
• A wet, gurgly voice quality after eating or drinking
• Pocketing food in the cheeks or sides of the mouth
• Watery eyes or watering at the mouth while eating
• Exceptionally slow or painful chewing and swallowing

Aspiration Precaution Protocol

1. Positioning: Sit the resident fully upright in High Fowler's position (90°) during all meal service.
2. Post-Meal Position: Maintain the resident in an upright position (at least 45° to 90°) for at least 30 minutes (preferably 60 minutes) after eating.
3. Feed Slowly: Offer small bites (1/2 teaspoon) and ensure the resident swallows completely before offering the next bite.
4. Alternate: Offer alternating bites of food and sips of liquid.
5. Check Mouth: Inspect cheeks for pocketed food at the end of the meal and perform thorough oral hygiene.

Thickened Liquid Levels

For residents with dysphagia, thin liquids (like water or coffee) slide down the throat too quickly before the airway closes. Speech-language pathologists prescribe thickened liquids:

• Nectar-thick: Thickened to the consistency of fruit nectar or thick syrup; can be drunk from a cup.
• Honey-thick: Thickened to the density of honey; pours slowly and is usually taken with a spoon.
• Pudding-thick: Thickened to a semi-solid state like pudding; holds its shape on a spoon and must be eaten with a spoon.

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Hydration Management & Dehydration Risk

The recommended daily fluid intake for adults is 2,000 mL to 2,500 mL (approximately 64 to 80 ounces) unless medically restricted.

Signs of Dehydration

• Dark, concentrated, strong-smelling urine
• Dry mouth, cracked lips, and dry mucous membranes
• Decreased skin turgor (skin remains tented when gently pinched)
• Confusion, disorientation, extreme fatigue, and dizziness
• Sunken eyes and rapid, weak pulse

Fluid Restriction Protocols

Residents with heart failure or end-stage renal disease may be placed on a fluid restriction (e.g., 1,500 mL per 24 hours). The nursing assistant must distribute fluid allowance across shifts (e.g., 800 mL Day, 500 mL Evening, 200 mL Night) and log every drop consumed.

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Intake and Output (I&O) Measurement

Intake and Output (I&O) tracks fluid balance. Fluid intake must equal fluid output over a 24-hour period to maintain homeostasis.

Metric Conversions for I&O

In U.S. healthcare, fluid volume is measured in milliliters (mL) or cubic centimeters (cc). Note that 1 mL = 1 cc.

$\mathbf{1\text{ fluid ounce (fl oz)} = 30\text{ mL (or 30 cc)}}$

Measuring Fluid Output

Fluid output includes urine, liquid emesis (vomitus), wound drainage, and diarrhea.

• Graduate Measurement: Pour urine into a calibrated measuring container (graduate). Place the graduate on a flat surface and read the liquid level at eye level.
• Catheter Bags: Empty urinary drainage bags into a graduate container prior to reading; never read fluid levels directly from the soft plastic bag markings.
• Critical Low Output: Report urine output of less than 30 mL per hour (or less than 240 mL over an 8-hour shift) to the nurse immediately.

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Clinical Scenario: Calculating 8-Hour I&O

Clinical Scenario: CNA David is recording 8-hour shift I&O for Mr. Ramirez, who is on a 1,500 mL fluid restriction. At breakfast, Mr. Ramirez drank a 4 oz glass of orange juice and a 6 oz cup of coffee. At lunch, he consumed an 8 oz bowl of broth and 4 oz of gelatin. During the shift, David emptied 350 mL of urine from his catheter bag.

Calculation:

• Breakfast Intake: (4 oz + 6 oz) = 10 oz × 30 mL/oz = 300 mL
• Lunch Intake: (8 oz + 4 oz) = 12 oz × 30 mL/oz = 360 mL
• Total Shift Intake: 300 mL + 360 mL = 660 mL
• Total Shift Output: 350 mL

CNA Action: David records 660 mL intake and 350 mL output in the electronic chart and confirms intake is within shift restriction limits.

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