4.3 Nutrition, Hydration, Elimination, and Skin
Key Takeaways
- Feeding assistance starts with the care plan: verify the resident and diet, position upright, provide resident hand hygiene, offer small bites, and watch for swallowing trouble.
- Missouri feeding-skill scoring expects percent food intake within 25 percentage points and total fluid intake within 60 mL of the observer's recorded amount.
- Elimination care protects dignity and skin: answer toileting requests promptly, provide privacy, clean correctly, keep catheter drainage flowing, and report changes.
- Nutrition, hydration, mobility, incontinence, and pressure relief are linked; skin problems are often the visible sign that basic care needs adjustment.
One Chain of Basic Nursing Care
Nutrition, hydration, elimination, and skin are often taught as separate topics, but they appear together in real CNA work. A resident who drinks poorly may become constipated, dizzy, confused, weak during transfers, and at higher risk for skin breakdown. A resident with diarrhea may lose fluid, soil linens, develop perineal irritation, and feel embarrassed enough to avoid the call light. Missouri tests the CNA's ability to notice those connections while still staying within scope.
The CNA does not order diets, thicken liquids, start bowel programs, diagnose dehydration, or stage wounds. The CNA follows the care plan, helps with meals and toileting, records assigned amounts, keeps skin clean and dry, protects privacy, and reports changes. These actions are basic, but they are not minor. In long-term care, they are often the first defense against decline.
Feeding and Hydration
Feeding assistance begins before the first bite. Check the resident's identity and the diet card or care-plan direction. Make sure dentures, glasses, hearing aids, and adaptive devices are available when used. Position the resident upright. Missouri's feeding skill uses at least a 45-degree upright position before feeding and leaves the head of the bed up at least 30 degrees after the meal. Provide hand hygiene for the resident before feeding, protect clothing, sit at eye level, describe the food, offer fluids frequently, and give small amounts at a reasonable pace.
| Situation | CNA action | Report promptly if you see |
|---|---|---|
| Dysphagia risk | Upright position, small bites, slow pace, diet followed exactly. | Coughing, wet voice, pocketing food, drooling, choking, or refusal after swallowing difficulty. |
| Poor appetite | Offer encouragement and choices allowed by the care plan. | Sudden drop in intake, weight loss, nausea, mouth pain, depression signs. |
| Fluid needs | Offer allowed fluids often and keep water within reach if permitted. | Dark urine, dry mouth, dizziness, confusion, very low intake, vomiting, diarrhea. |
| Adaptive dining | Set up plates, utensils, clothing protector, and safe positioning. | New inability to hold utensils, tremors, fatigue, or frustration. |
| Special diet | Follow the diet card exactly. | Wrong tray, wrong texture, missing thickener, allergy concern, or NPO conflict. |
A common exam trap is changing the care plan because the resident asks. If a resident on thickened liquids asks for plain water, the CNA should not provide it unless the care plan allows it. Offer what is permitted, explain simply, and tell the nurse about the request. Another trap is continuing to feed through coughing. Stop, keep the resident upright, and report swallowing signs to the nurse.
Missouri's feeding skill also tests recording. The candidate records solid food intake as a percentage and total fluid intake in mL. The food percentage must be within 25 percentage points of the observer's amount, and the fluid total must be within 60 mL. This is why practice should include reading cups, converting common amounts, and recording as soon as the meal ends.
Elimination Care
Elimination care includes toileting, bedpans, urinals, commodes, incontinence care, catheter care, ostomy assistance when trained and assigned, and reporting bowel or bladder changes. Privacy is essential. Close the curtain or door, keep the resident covered, answer call lights promptly, and do not shame accidents. Many falls happen when residents try to toilet without help, so toileting is also fall prevention.
Report burning, pain, blood, cloudy urine, strong odor with symptoms, inability to void, new incontinence, constipation, diarrhea, black or tarry stool, vomiting, abdominal distention, or a major change from normal pattern. For catheter drainage, keep the bag below bladder level and off the floor, avoid kinks, do not pull on tubing, and report low output, leakage, pain, or dislodgement. During perineal care for a female resident, clean from front to back or away from the urethra, using a clean area of cloth for each stroke. The point is to move organisms away from the urinary tract, not toward it.
Skin Protection
Skin care is prevention plus observation. Keep skin clean, dry, and moisturized as appropriate. Reposition residents according to the care plan, use pillows or wedges to protect bony prominences, avoid dragging residents across sheets, and smooth linens. Heels, sacrum, hips, elbows, shoulders, ankles, and ears are common pressure areas. Moisture from urine, stool, sweat, or wound drainage increases breakdown risk.
Do not ignore early redness. A red area over a bony prominence, especially if it does not fade after pressure is relieved, needs prompt reporting. Do not massage reddened skin. Massage adds friction and pressure to tissue already under stress. Also report tears, blisters, bruises, swelling, warmth, drainage, odor, pain, or a resident saying a shoe, splint, brief, or tubing is rubbing.
Scenario Traps
Scenario trap: A resident eats almost nothing at lunch, drinks 60 mL, and later needs two-person help to stand when she usually transfers with one assist. Treat those as connected changes. Report intake, weakness, dizziness if present, output concerns, and skin or toileting issues. Do not simply chart "poor appetite" and move on.
Another trap is prioritizing speed over skin. Pulling a resident up in bed without a draw sheet or help can cause shear. Leaving a brief wet because rounds are busy can damage skin and dignity. Basic nursing care is repetitive, but it is not routine to the resident whose comfort depends on it.
While feeding a resident, you notice coughing after thin liquids and a wet-sounding voice. What should the CNA do next?
A Missouri feeding skill requires recording how much the resident consumed. Which recording habit best matches the tested skill?
During incontinence care, you see a new red area over the resident's coccyx that does not fade after pressure is relieved. What is the best CNA action?