Decline in competence associated with eating independently
Assess patient's functional, cognitive, and perceptual level at periodic intervals. Document and report any changes. Ongoing assessment allows you to identify changing needs and adjust interventions accordingly.
Observe patient's functional, perceptual, and cognitive level every shift; document and report changes. Careful observation helps you adjust nursing actions to meet patient's needs.
Perform the prescribed treatment for the underlying condition. Monitor patient's progress and report responses. Applying therapy consistently aids patient's independence.
Weigh patient weekly and record weight. Report a change of more than 1 lb/week to ensure adequate nutrition and fluid balance.
Monitor and record breath sounds every 4 hours to check for aspiration of food. Report crackles, wheezes, or rhonchi.
Encourage patient to express feelings and concerns about feeding deficits to help patient achieve the highest functional level. Provide emotional support to help patient come to terms with self-care deficit and achieve the highest functional level.
Initiate an ordered feeding program: - Determine the types of food best handled by patient to encourage patient's feelings of independence.
- Place patient in high Fowler position to feed to aid swallowing and digestion. Support weakened extremities and wash patient's face and hands before meals.
- Provide assistive devices; instruct patient on their use to allow more independence.
- Supervise or assist at each mealfor example, cut food into small pieces. This aids chewing, swallowing, and digestion and reduces the risk of choking or aspiration.
- Feed patient slowly. Rushing causes stress, reducing digestive activity and causing intestinal spasms.
- Keep suction equipment at the bedside to remove aspirated foods, if necessary.
- Instruct patient and family members in feeding techniques and equipment. This aids understanding and encourages compliance.
- Record the percentage of food consumed to ensure adequate nutrition.
Encourage patient to carry out the aspects of feeding according to patient's abilities. This gives patient a sense of achievement and control.
Refer patient to a psychiatric liaison nurse, support group, or such community agencies as Visiting Nurse Association and Meals on Wheels. Additional resources reinforce activities planned to meet patient's needs.
Suggested NIC Interventions
Fluid Management; Nutrition Management; Nutritional Monitoring; Self-Care Assistance: Feeding; Swallowing Therapy; Aspiration Precautions; Family Involvement Promotion |