4.4 Nutrition, Hydration & Elimination

Feeding and Aspiration Precautions

Adequate nutrition, hydration, and normal elimination are essential to healing, energy, skin integrity, and comfort. New Jersey CNAs assist daily with these needs and observe for problems such as aspiration, dehydration, and infection.

Aspiration is food or fluid entering the airway instead of the stomach; it can cause choking or aspiration pneumonia, a major cause of death in long-term care. To prevent it during feeding:

• Position the resident upright at 90° (high-Fowler's) before feeding, never lying down.
• Offer small bites, allow time to chew and swallow, and alternate solids and liquids.
• Check that the mouth is empty before the next bite.
• Use thickened liquids if ordered for swallowing problems (dysphagia).
• Keep the resident upright at least 30 minutes after the meal.
• Sit at eye level, minimize distractions, do not rush, and let residents feed themselves when able to preserve independence.

Stop feeding and report immediately if the resident coughs, chokes, has a wet 'gurgly' voice, drools, or pockets food in the cheek — all signs of swallowing trouble.

Therapeutic Diets

The nurse or registered dietitian orders special diets; the CNA serves the correct tray, assists, and reports how much was eaten.

Always verify the name on the tray matches the resident and check for the right diet, since the wrong tray (for example, a regular tray to a diabetic resident) can cause harm. Report poor intake — eating less than about 70% of a meal is often flagged.

Fluid Balance and Intake & Output

A typical adult needs about 1,500-2,000 mL of fluid per day. Intake and output (I&O) tracks all fluids in (drinks, soups, ice chips, IV fluids, tube feedings) versus all fluids out (urine, emesis/vomit, diarrhea, wound or ostomy drainage), recorded in milliliters (mL). Memorize the conversion: 1 ounce (oz) = 30 mL (so an 8-oz cup = 240 mL). Measuring and recording urine output is one of the NNAAP measurement skills — you pour the urine into a graduate at eye level on a flat surface and read the volume.

Dehydration and Edema

Report early signs of dehydration: dark, concentrated, strong-smelling urine; dry mouth and cracked lips; dry skin that 'tents' (stays pinched); sunken eyes; weight loss; constipation; and new confusion. Encourage fluids and offer water frequently — unless the resident is on a fluid restriction, where intake is limited and must be tracked carefully. The opposite problem, edema (swelling from fluid retention), shows as puffy ankles, feet, or hands and sudden weight gain; report it too.

Catheter Care

An indwelling (Foley) urinary catheter drains urine continuously into a closed bag. CNA responsibilities:

• Keep the drainage bag below the level of the bladder at all times so urine cannot flow back and cause infection.
• Never let the bag touch the floor; hang it on the bed frame (not a movable side rail), and keep the tubing free of kinks and coils.
• Give catheter/perineal care daily and after bowel movements: hold the catheter at the meatus without tugging and clean at least 4 inches of the catheter, moving in ONE direction away from the meatus with a clean area of cloth each stroke.
• Empty the bag at the end of the shift, measure and record output, and report cloudy, bloody, or foul-smelling urine, leaking, or a bag that is not draining — all signs of a possible catheter-associated UTI (CAUTI).

Bowel and Bladder Training

Bladder and bowel training helps a resident regain control on a schedule and supports continence and dignity. Offer the toilet at regular times (for example, every 2 hours and after meals), provide privacy, encourage fluids and fiber, promote activity, and respond promptly to requests. Praise success and never scold or shame an accident — incontinence is never punished or ignored. Watch for and report constipation (no bowel movement for several days, hard stools, straining) and diarrhea (loose, frequent stools), which can cause dehydration and skin breakdown.

Ostomy Basics

An ostomy is a surgical opening (stoma) on the abdomen that diverts stool (colostomy/ileostomy) or urine (urostomy) into a pouch. The CNA empties the pouch, observes the stoma — it should look pink/red and moist — keeps the surrounding skin clean and dry, and reports a pale, dark, dusky, or bleeding stoma or any skin breakdown. Provide privacy, control odor, and use a matter-of-fact, non-judgmental approach to protect dignity.

Specimen Collection

Label the container before collection, wear gloves, follow medical asepsis, and transport promptly with the requisition:

• Clean-catch (midstream) urine: clean the perineal area first, have the resident start to void, then catch urine mid-stream. Never touch the inside of the container or lid.
• Routine (random) urine: collect at any voiding into a clean container.
• 24-hour urine: discard the first void, then save all urine for 24 hours, keeping it cool.
• Stool specimen: the resident must not urinate into the sample or mix it with toilet tissue; use a clean specimen 'hat' and container.

Record the time of collection on the chart and report any abnormal appearance to the nurse.