The 240 mL Afternoon: Post-Stroke Hydration and Dysphagia
Mr. Delgado, 78, is five days post-stroke with right-sided weakness and mild dysphagia. His care plan lists thickened liquids, no straws, and a 1,500 mL fluid goal per 24 hours. It is 2:00 PM and his intake sheet shows 240 mL total - two 120 mL cups of thickened coffee. His urine in the urinal is dark amber, his lips are cracked, and when you offer a cup he turns his head away and says, "I'll just spill it with this hand." He is due to be repositioned and has physical therapy at 3:00 PM.
1. Before 3:00 PM, what do you do first, and in what order? Justify the priority.
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Priority reasoning: the number that matters is 240 mL out of 1,500 mL with 10 hours left in the day - he would need roughly 175 mL per hour, which is not realistic. Add dark amber urine and cracked lips and this is a developing problem, not a preference issue.
Order of action:
- Report the intake and the dark urine to the nurse now, before the therapy session. Dehydration is a nursing judgment; the nurse decides whether a supplement, IV, or lab work is needed.
- Reposition and check skin - he has been sitting and cannot shift his own weight on the weak side.
- Offer fluids in small amounts before therapy, since therapy will tire him and he will drink less afterward.
Do not wait for the end of shift to report a cumulative deficit. A single refused cup is a preference; 240 mL at 2:00 PM is a pattern.
2. How do you encourage fluids for this resident without breaking his dysphagia precautions?
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Do:
- Sit him fully upright, head slightly forward with a chin tuck, before any swallow.
- Use a spoon or a cup sipped from the rim - not a straw, which pushes fluid back too fast and is off his plan.
- Offer small amounts often (30–60 mL at a time) rather than one large cup, and stay to watch him swallow.
- Check for pocketing in the weak cheek after each swallow and cue him to swallow again if needed.
- Offer the thickened liquids he already accepts, and ask the nurse whether ice chips or thickened juice are on his plan if he wants variety.
Don't: fill the cup to the top, rush him, let him talk and drink at the same time, or substitute unthickened water "just this once" to get the numbers up. Changing the consistency is a swallowing-order decision, not an aide decision.
Document each offer and each refusal with the amount - that record is what supports the nurse's next step.
3. What must be reported, to whom, and what should you not say when you report?
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Report to the charge nurse (and hand off to the therapy aide before the session):
- Intake: 240 mL at 2:00 PM against a 1,500 mL goal.
- Dark amber urine, no strong output recorded.
- Cracked lips, and his own statement that he will spill because of the weak arm.
- Refusal behavior and the reason he gave.
Objective language only. Say "intake 240 mL at 1400, urine dark amber, refused two offered cups, stated he would spill." Do not say "he's dehydrated" or "he's not trying" - that is a diagnosis and a judgment.
What not to do: do not wait until the end of shift, do not record fluids you did not actually see him drink, and do not tell the family he is dehydrated. Also flag the functional piece: he refuses partly because of the weak arm, so adaptive equipment or setup help may solve more than encouragement will.