Skill 11-1

Assisting a Patient With Eating

A variety of oral diets are available in health care settings and may be prescribed for use at home. A diet is prescribed based on the individual person's condition. Table 11-1 outlines several commonly prescribed modified consistency diets and therapeutic diets. Many patients can independently meet their nutritional needs by feeding themselves. Other patients, especially the very young and some older adult patients, such as people with arthritis of the hands, may have difficulty opening juice containers, for example. Patients with paralysis of the upper extremities or advanced dementia may be unable to feed themselves. The nurse should ensure patients receive the assistance they need to maintain sufficient oral intake to meet their nutritional needs, either by assisting the patients as needed, or delegating as appropriate.

The skill of assisting a patient with eating is frequently delegated to assistive personnel (AP). However, the nurse remains responsible for the initial and ongoing assessment of the patient for potential complications related to feeding. Before this skill can be delegated, it is paramount for the nurse to make sure that the AP has been educated to observe for any swallowing difficulties and has knowledge of aspiration precautions. Box 11-1 (on page 686) outlines special considerations and interventions for assisting patients with dementia or other alterations in cognition with eating. Box 11-2 (on page 686) discusses special considerations and interventions for assisting patients with dysphagia with eating.

Delegation Considerations

Assisting patients to eat may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). See previous discussion. The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Prepared food, based on prescribed diet
Wet wipes for hand hygiene, or access to hand gel/skin cleanser and water
Mouth care materials
Patient's dentures, eyeglasses, hearing aid, if needed
Special adaptive utensils, as needed
Napkins, protective covering, or towel
PPE, as indicated

Assessment

Before assisting the patient, confirm the type of diet that has been ordered for the patient. Also, it is important to assess for any food allergies and religious or cultural preferences. Check to make sure the patient does not have any scheduled laboratory or diagnostic studies that may impact whether they are able to eat a meal. Before beginning the feeding, assess for any barriers to eating, such as swallowing difficulties or weakness and/or fatigue. Assess the patient's abdomen. Inspect the abdomen for distention and firmness; auscultate for bowel sounds or peristalsis and palpate the abdomen for distention and tenderness. If the abdomen is distended, consider measuring the abdominal girth at the umbilicus to establish a baseline.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Impaired Self Feeding
Aspiration risk
Impaired Swallowing

Outcome Identification and Planning

The expected outcome to achieve when assisting a patient with feeding is that the patient consumes a variety of food consistent with the prescribed diet and individual circumstances to attain and maintain ideal body weight. Other outcomes include that the patient does not aspirate during or after the meal, and the patient expresses contentment related to eating, as appropriate.

Implementation

Action	Rationale
1. Check the prescribed interventions for the type of diet prescribed for the patient.	This ensures the correct diet for the patient.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Discuss the procedure with the patient and assess the patient's ability to assist in the bathing process.	Discussion and explanation promotes reassurance and facilitates patient engagement.
5. Assess level of consciousness and for physical limitations and decreased hearing or visual acuity. If the patient uses a hearing aid or wears glasses or dentures, provide, as needed. Ask if the patient has any cultural or religious preferences and food likes and dislikes, if possible.	Alertness is necessary for the patient to swallow and consume food. Using a hearing aid, glasses, and dentures for chewing facilitates the intake of food. Patient preferences should be considered in food selection as much as possible to increase the intake of food and maximize the benefit of the meal.
6. Pull the patient's bedside curtain. Assess the abdomen. Ask the patient if they have any nausea. Ask the patient if they have any difficulty swallowing. Assess the patient for nausea or pain and administer an antiemetic or analgesic, as needed.	This provides for privacy. A functioning GI tract is essential for digestion. The presence of pain or nausea will diminish appetite. If the patient is medicated, wait for the appropriate time for absorption of the medication before beginning the feeding.
7. Offer to assist the patient with any elimination needs.	This promotes comfort and may avoid interruptions for toileting during meals.
8. Provide hand hygiene and mouth care, as needed.	This may improve appetite and promote comfort.
9. Remove any bedpans or undesirable equipment and odors, if possible, from the vicinity where the meal will be eaten. Perform hand hygiene.	Unpleasant odors and equipment may decrease the patient's appetite. Hand hygiene prevents the spread of microorganisms.
10. Open the patient's bedside curtain. Assist to, or position the patient in, a high-Fowler or sitting position in the bed or chair. Position the bed in the low position if the patient remains in bed.	Proper positioning improves swallowing ability and reduces the risk of aspiration.
11. Place a napkin or a towel over the patient if desired and as necessary.	This prevents soiling of the patient's gown.
12. Check the food tray to make sure that it is the correct tray before serving. Place the tray on the overbed table so the patient can see the food, if able. Ensure that hot foods are hot and cold foods are cold. Use caution with hot beverages, allowing sufficient time for cooling, if needed. Ask the patient for their preference related to what foods are desired first. Cut food into small pieces, as needed. Observe swallowing ability throughout the meal.	This ensures that the correct tray is given to the patient. Encouraging the patient choice promotes patient dignity and respect. Close observation is necessary to assess for signs of aspiration or difficulty with meal.
13. If possible, sit facing the patient at their eye level while eating is taking place (Figure 1). If the patient is able, encourage them to hold finger foods and feed themself as much as possible. Converse with patient during the meal and make eye contact, as appropriate. If, however, the patient has dysphagia, limit questioning or conversation that would require patient response during eating. Play relaxation music if the patient desires..	Sitting at the patient's eye level and making eye contact create a more relaxed, person-centered atmosphere. In general, optimal mealtime involves social interaction and conversation. Talking during eating is contraindicated for patients with dysphagia because of increased risk for aspiration.
14. Allow enough time for the patient to chew and swallow the food adequately. The patient may need to rest for short periods during eating.	Eating requires energy, and many medical conditions can weaken patients. Rest can restore energy for eating.
15. When the meal is completed or the patient is unable to eat any more, remove the tray from the room. Note the amount and types of food consumed. Note the volume of liquid consumed.	Nutrition plays an important role in healing and overall health. If the patient is not eating enough to meet nutritional requirements, alternative methods need to be considered. Noting the amount and type of food and volume of liquids consumed allows for accurate documentation of intake.
16. Reposition the overbed table; remove the protective covering; offer hand hygiene, as needed; and offer toileting. Assist the patient to a position of comfort and relaxation.	This promotes the comfort of the patient, meets possible elimination needs, and facilitates digestion.
17. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the patient has consumed an adequate amount of nutrients consistent with the prescribed diet and individual circumstances to attain and maintain ideal body weight. In addition, the patient did not aspirate during or after the meal, and the patient has expressed contentment related to eating.

Documentation

Guidelines

Document the assessment of the abdomen. Note that the head of the bed was elevated to at least 30 to 45 degrees. Note any swallowing difficulties and the patient's response to the meal. Document the percentage of the intake from the meal. If the patient had a poor intake, document the need for further consultation with the health care team and dietitian, as needed. Record any pertinent teaching that was conducted. Record liquids consumed on intake and output record, as appropriate.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient states that they do not want to eat anything on the tray: Explore with the patient the reason why they do not want to eat anything on the tray. Assess for psychological factors that impact nutrition. Malnutrition is sometimes found with depression in the older adult population. Mutually develop a plan to address the lack of nutritional intake and consult the dietitian, as needed.
Patient states that they feel nauseated and cannot eat: Remove the tray from the patient's room. Explore with the patient the desirability of eating small amounts of foods or liquids, such as crackers or ginger ale, if the patient's diet permits. Administer antiemetic as prescribed and encourage patient to retry small amounts of food after medication has had time to take effect.

Special Considerations

Patients with arthritis of the hands may benefit from use of special utensils with modified handles that facilitate an easier grip. Contact an occupational therapist for guidance on adaptive equipment.
A visually impaired patient may benefit from use of special plate guards, utensils, double handles, and compartmentalized plates. These patients may be guided to feed themselves through use of a “clock” pattern. For example, the chicken is placed at 6 o'clock; the vegetables at 3 o'clock.
Refer to Box 11-1 for interventions and considerations related to assisting patients with alterations in cognition.
For the patient with dysphagia, suggest small bites of food such as puddings, ground meat, or cooked vegetables. Advise the patient not to talk while swallowing and to swallow twice after each bite. Refer to Box 11-2 for additional considerations for this patient population.

EVIDENCE FOR PRACTICE

Nutrition Support Strategies and Dementia

People living with dementia often lose some or all of the ability to feed themselves, which often is a source of significant challenges for caregivers. What are effective nutrition support strategies that have potential to be of assistance to these caregivers?

Related Research

Liu, W., Williams, K., Batchelor-Murphy, M., Perkhounkova, Y., & Hein, M. (2019). Eating performance in relation to intake of solid and liquid food in nursing home residents with dementia: A secondary behavioral analysis of mealtime videos. International Journal of Nursing Studies, 96, 18-26. https://doi.org/10.1016/j.ijnurstu.2018.12.010.

This study examined the association between intake and characteristics of eating performance cycles among nursing home residents with dementia. An eating performance cycle was defined for this study as the process of getting food from the plate or container, transporting it into the mouth, and chewing and swallowing it. A secondary analysis of mealtime video clips from a nursing home communication training study was conducted. The 111 video clips involved 25 residents and 29 staff in 9 nursing homes. The Cue Utilization and Engagement in Dementia Mealtime video-coding scheme was used to code the characteristics of eating performance cycles, including eating technique (resident completed, staff facilitated), type of food (solid, liquid), duration of each eating performance cycle, and intake outcome (intake, no intake). The Generalized Linear Mixed Model was used to examine the interaction effects of eating technique by type of food, eating technique by duration, and type of food by duration on intake outcome. A total of 1,122 eating performance cycles were coded from the video clips. The majority of the cycles (85.7%) resulted in intake of liquid or solid food, with the rest (14.3%) resulting in no intake. As the duration of the eating performance cycle increased, staff-facilitated cycles resulted in greater odds of intake than resident-completed cycles (odds ratio [OR] = 17.80 vs. 2.73); and cycles involving liquid food resulted in greater odds of intake than cycles involving solid food (OR = 15.42 vs. 3.15). The odds of intake were greater for resident-completed cycles than for staff-facilitated cycles regardless of the type of food being involved in the cycle (OR = 3.60 for liquid food, OR = 10.69 for solid food). The researchers concluded that interventions to improve oral intake should support resident independence in eating performance. In addition, liquid food should be provided when residents struggle with solid food and staff should provide longer and continuous facilitation at mealtimes. The researchers suggested that innovative mealtime assistance and staff training are important interventions to promote eating performance and intake.

Relevance for Nursing Practice

People with dementia are at risk for reduced nutritional intake with the potential for weight loss and malnutrition. This study suggests that health care professionals should consider interventions to support optimal nutritional intake for individuals with dementia. Nurses are involved in all aspects of nutritional care and have a responsibility to assist patients and their care givers in attaining and maintaining adequate nutritional intake. Nurses must utilize appropriate interventions to provide appropriate education and support to achieve this outcome.

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Skill 11-1

EVIDENCE FOR PRACTICE