8.4 Nutrition, Hydration, and Intake & Output

Special Diets

The diet on the tray must match the diet order on the care plan — check the resident's name and diet before serving. Know these common therapeutic diets:

Dysphagia (difficulty swallowing) is one of the most dangerous conditions a nursing assistant (NA) manages, because food or liquid entering the airway (aspiration) can cause choking or aspiration pneumonia. Precautions: serve only the ordered consistency, sit the resident fully upright, give small bites, allow time to swallow between bites, and never use straws unless the care plan allows them (straws speed liquids into the airway). Watch for warning signs during meals: coughing, choking, a wet or gurgly voice, drooling, pocketing food in the cheeks, or very slow eating — stop feeding and report these to the nurse.

Assisting a Dependent Resident With Eating

"Assist dependent resident with eating" is on the Montana skills-test list. Correct technique:

• Sit at the resident's eye level on their unaffected or preferred side — feeding while standing over someone is rushed and impersonal.
• Position the resident upright at 45-60 degrees or higher, and keep them upright for at least 30 minutes after the meal to prevent reflux and aspiration.
• Offer foods in the order the resident prefers, alternate solids and liquids, and give small bites — about a teaspoon at a time.
• Pace to the resident: wait for each swallow before offering more. Rushing a slow eater is an aspiration risk.
• Use a napkin or clothing protector (ask permission — it protects dignity), wipe the mouth as needed, and talk with the resident; mealtime is social.
• For residents with vision loss, describe foods using the clock method ("your peas are at 3 o'clock").
• Afterward, record the percentage eaten and report poor intake.

Intake and Output (I&O)

Residents with heart failure, kidney disease, dehydration risk, or fluid restrictions are often on intake and output monitoring. The unit is the milliliter (mL): 1 ounce = 30 mL. If a resident drinks a 6-ounce glass of juice, record 180 mL.

What counts as intake: everything liquid the resident takes in — water, juice, milk, coffee, tea, soup, gelatin, ice cream and sherbet, popsicles, and ice chips (counted at half volume when melted is not practical); plus IV fluids and tube feedings, which the nurse records. "Measure and record oral fluid intake" is a Montana skills task: pour remaining liquid into a graduate (measuring container), subtract from the amount served, and record in mL.

What counts as output: urine (measured in a graduate, hat, or bedpan), vomit, diarrhea, and wound or tube drainage. Report and record color, odor, and amount. Record promptly on the I&O sheet — memory at shift's end is not accurate documentation.

Encouraging Fluids vs. Fluid Restriction

• Encourage fluids: many older adults feel less thirst and become dehydrated. Offer fresh water every time you enter the room ("Pass fresh water" is a Montana skills task), honor preferences, and aim for the care plan's goal — commonly around 1,500-2,000 mL per day unless restricted.
• Fluid restriction: residents with heart or kidney failure may be limited to an exact daily amount. Measure precisely, remove extra water pitchers, and explain the restriction — sneaking extra fluids can cause fluid overload, pulmonary edema, and death.

Signs to report: dehydration (dry mouth, cracked lips, dark urine, confusion, poor skin turgor) and fluid overload (swelling of ankles or hands, sudden weight gain, shortness of breath).

Weighing Residents

"Weigh ambulatory resident" is on the Montana skills list. Weights track fluid status and nutrition, so they must be comparable from day to day: weigh at the same time of day (usually early morning), on the same scale, in similar clothing (gown only), after voiding, with an empty bladder. Balance a standing scale to zero first; have the resident stand still, barefoot or in similar footwear. Record to the nearest fraction per facility policy. Report a sudden weight change — a gain or loss of about 2 pounds in a day or 5 pounds in a week usually reflects fluid, not fat, and can signal worsening heart failure or dehydration.

Reporting Poor Intake

Report to the nurse when a resident eats less than about 75% of a meal consistently, refuses meals, shows swallowing problems (coughing, pocketing, gurgly voice), loses weight, or has nausea and vomiting. Poor nutrition delays wound healing, weakens immunity, and worsens every chronic condition — early reporting lets the team intervene with supplements, diet changes, or a swallowing evaluation.