1. OBJECTIVES AT THE COMPLETION OF THIS UNIT YOU WILL BE ABLE TO: 1) DESCRIBE NURSING INTERVENTIONS FOR PATIENTS WITH SPECIAL DIETARY NEEDS (IMPAIRED SWALLOWING, SPECIAL DIETS, SELF-CARE DEFICITS, & NPO STATUS Fundamentals of Nursing Feeding & Meal Preparation Instructor: R. Hanock

2. Nutrition & Meal Preparation Objectives continued 2) Identify and discuss nursing interventions that correct or prevent imbalanced nutrition Reading Assignment Burton fundamentals textbook: pages: 497-501, 526-527 (skill 24-1)

3. Syllabus: Nutrition & Meal Preparation I. Assisting patients with meals II. Nutrition and health relationships III. Diet consistency modification IV. Impaired swallowing

4. Nutrition & Meal Preparation: Assisting with Meals Recommendation: one staff member for every three patients requiring feeding assistance; supervised by licensed personnel. Allow up to 30 minutes to complete a meal; prolonging or hurrying meal time both have negative impacts on appetite. Depending on client conditions, clients should eat in chair, preferably in a dining room. If client must remain in bed, put the HOB in the highest position tolerated

5. Nutrition & Meal Preparation: Assisting with Meals Assist only when necessary; encourage independence Attempt to make meal time a social event: encourage family members to be present. Assess for rituals before meals: prayers, blessings of food Provide music during mealtime while being sensitive to client preferences.

6. Nutrition & Meal Preparation: Assisting with Meals Offer food choices and control over how foods are prepared; encourage friends and family to bring in favorite foods Offer pain control at least 20 minutes before the meal Avoid intake of large amounts of fluids  full feeling Provide a friendly, clean, and odor free environment

7. Nutrition & Meal Preparation: Assisting with Meals Protect patient’s privacy and from embarrassment (How would you feel about wearing a bib?) Proper fitting dentures Provide opportunity for hand washing, toileting, and oral hygiene prior to meals. Most often a patient can feed himself after cartons are opened, meats are cut, & other preparations are made.

8. Nutrition & Meal Preparation: Assisting with Meals When Feeding: Only feed those who can not feed themselves; do not feed them because they are too slow. Always provide adequate time to chew and swallow (aspiration precautions) Ask which foods they would like next Have casual conversations

9. Nutrition & Meal Preparation: Assisting with Meals Assisting Patients with Dementia Assess individual feeding abilities and present situation Minimize distractions Remove secondary food items from site (i.e.: desserts, concentrated sweets, sodas) until priority food items are consumed. Remove unnecessary utensils and items that should not be eaten Cue verbally and use pantomime

10. Nutrition & Meal Preparation: Assisting with Meals Visually Impaired Name the items on the tray; include details Identify the locations of items on the plate based on the face of a clock. Other items on the tray are to the right, left, or above the plate Ask what they would like you to prepare and open.

11. Nutrition & Meal Preparation: Assisting with Meals After The Meal Wash hands, face, oral care; restroom Record the amounts of fluid and foods taken Document feeding behaviors Nutritional status assessments: involve multidisciplinary approach and time interval comparisons

12. Nutrition & Meal Preparation: Assisting with Meals Nutritional Needs Assessment Ability to chew and swallow Food tolerances, allergies, and preferences Cultural and religious practices Diet modifications related to medical conditions

13. Nutrition & Meal Preparation: Assisting with Meals Kosher Diet

14. Nutrition and Health Relationships Nutritional Deficiencies Poor, elderly, less educated are prone to nutritional problems because they make poor food choices Disease, illness, and delays in achieving growth and development milestones Attention deficits, behavioral & psychiatric disorders School meal programs have been overhauled

15. Nutrition and Health Relationships Decreased income is often a barrier, but nutritious food is available on a limited income. EDUCATION

16. Nutrition and Health Relationships Decreased nutritional intake  physical problems such as poor wound healing and decreased ability to combat physical stress (illness) Nursing interventions  improved nutritional intake and appetite Anxiety, pain, & fatigue  anorexia Gastric distention and bloating is relived by offering smaller and more frequent meals

17. Nutrition and Health Relationships Gastroesophageal Reflux : Certain foods cause GI irritation and reflux: fatty foods, chocolate, alcohol, fruit juices, acidy foods, smoking, & some medications Keep HOB up 45 degrees or more for at least 90 minutes before laying down Avoid eating and drinking for 90 minutes before bedtime Avoid bending over

18. Nutrition and Health Relationships Glucose Intolerance Increased intake of sugars (sweets)  initial glucose level elevation  hypoglycemia Increased production of insulin Avoid concentrated sweet and refined sugars Complex carbohydrates are better tolerated Smaller and more frequent meals may be better tolerated

19. Nutrition and Health Relationships Decreased Intestinal Peristalsis Prevent constipation and promote bowel regularity and optimal function Fiber: 5 servings of fruits and vegetables is recommended Prunes and apples are an effective remedy High fiber diet also prevents GI diseases such as diverticulosis and diverticulitis

20. Nutrition and Health Relationships Foods High in Fiber

21. Diet Consistency Modification Please complete the “Diet Consistency Modification Guided Reading Assignment”

22. Impaired Swallowing: Causes Dysphagia: difficulty swallowing Neurological disorders: CVA, cerebral palsy, cranial nerve disorders, altered mental status Mechanical obstructions: inflammation, over- growth or oropharynx structures, tumors

23. Impaired Swallowing : Assessment You note that your new client coughs and gags easily as a family member assists her while eating. How do you intervene?

24. Impaired Swallowing: Assessment Dysphagia  Risk for Aspiration

25. Impaired Swallowing: Assessment Assessment of cough and gag reflex Reflexes may be absent, weak, or over-active  report immediately Swallowing evaluations, speech therapy http://www.youtube.com/watch?v=_e4Lciu RyCA http://www.youtube.com/watch?v=_e4Lciu RyCA Bedside Swallow Screen - YouTube

26. Impaired Swallowing: Nursing Interventions Aspiration precautions Observe LOC, cough & gag reflex, & swallowing ability Position patient upright when eating or drinking (ideally 90 degrees) Suction set up at bed side Feed in small amounts

27. Impaired Swallowing: Nursing Interventions Aspiration precautions continued Avoid thin liquids, use thickening agents Cut food into small pieces and modify consistency as needed Keep HOB elevated or patient upright for one hour after eating or drinking

28. Impaired Swallowing: Nursing Interventions Avoid the use of straws Avoid thin liquids, use thickening agents Forward flex the head while swallowing (chin tuck) Place food toward the back of the mouth and on the unaffected side Assess for pocketing of food Routine body weights

29. Review and Practice Activities Video Activity: “Feeding the Patient” Using Thick-it activity Work book questions: p. 204-205 (11,13,16,20,24,25,26,27) Review and practice skill 24-1 (p. 526-7) Role Playing: Feeding a client with hemiplegia (CVA) Feeding a blind patient