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Practical procedures

Assisting patients with eating and drinking to prevent malnutrition

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This article outlines the procedure for helping patients to eat at mealtimes. It highlights the importance of monitoring food and fluid intake and the need for accurate documentation

Citation: Anderson L (2017) Assisting patients with eating and drinking to prevent malnutrition. Nursing Times [online]; 113, 11, 23-25.

Author: Liz Anderson is nutrition nurse specialist at Buckinghamshire Healthcare Trust.

Introduction

Malnutrition costs the UK health economy £19bn a year and affects one in four people admitted to care settings (Elia, 2015). It is most prevalent in the community but nutritional status often deteriorates when patients are admitted to hospital because of acute injury or illness that can impair swallowing, appetite and gastric absorption. When patients are unwell and do not feel like eating it can be a challenge to help them meet their nutritional needs.

Patients with malnutrition will have a deficit of vitamins, protein, minerals and energy and this will have an adverse effect on the body. Complications associated with malnutrition include poor wound healing, skin breakdown, increased risk of sepsis and hospital-acquired infections, such as chest and urinary tract infections (Elia and Russell, 2009). Provision of adequate nutrition and hydration is a hallmark of good, compassionate care but remains neglected in many areas of healthcare (Leach et al, 2013).

The Hospital Food Standards Panel report (Department of Health, 2014) recommends that all NHS hospitals adhere to and be compliant with the Ten Key Characteristics of Good Nutritional Care (Council of Europe, 2003); this includes ensuring an environment that is conducive to patients being able to enjoy their meals uninterrupted. Good nutrition and hydration is part of the Care Quality Commission’s Fundamental Standards (CQC, 2015) and all care settings are expected to demonstrate how they put nutrition and hydration at the heart of patient care.

It is essential that all patients receive adequate food and drink appropriate to their needs (Nursing and Midwifery Council, 2015) and while many will be able to manage independently, some patients will need assistance.

All patients admitted to care settings should have nutritional screening performed within the first 24 hours (CQC, 2015; National Institute for Health and Care Excellence, 2006) using a validated tool such as the Malnutrition Universal Screening Tool (MUST). This is essential as it helps to ascertain whether a patient needs help and informs their nutritional plan of care.

There are a number of patients who have medical conditions that mean that they may need assistance with eating and drinking; these are summarised in Box 1.

Box 1. Medical conditions that may affect eating and drinking

Swallowing complications: may be associated with conditions such as stroke, Parkinson’s disease, motor neurone disease and multiple sclerosis

Cancer: some patients with cancer have increased energy requirements but they may feel unable to eat due to nausea, vomiting, pain or gastrointestinal obstruction. Patients prescribed chemotherapy often experience a change in taste which can affect their appetite

Surgery: people who have had surgery require extra energy to help heal wounds but they can sometimes find eating difficult due to pain and nausea

Other: people with severe learning disabilities, visual impairment or dementia, and older people who have an acute delirium, need specialist support to ensure they are adequately nourished

Preparing for mealtimes

Nurses should assist patients to make appropriate meal choices; for example, if they can only eat soft food due to poor dentition they should be made aware which foods on the menu are soft and easy to chew. Nurses should not choose food for patients without consultation; if they are unable to choose for themselves, their nurse should speak to a carer or relative to find out their likes and dislikes where possible.

As part of the assessment process, it is important to know whether patients have any special dietary needs. For example, a patient who has swallowing difficulties (dysphagia) may need a texture modified diet (National Patient Safety Agency, 2011) as giving food that is difficult to swallow may lead to choking. This information should be obtained when admitting the patient to hospital and shared with the multidisciplinary team; refer to local policies for further guidance.

Protected mealtimes

It is best practice for clinical areas to follow a protected mealtime policy. During protected mealtimes, all non-urgent clinical activity should stop and staff should take the time to help patients to eat and drink in a relaxed, and unhurried atmosphere (Council of Europe, 2003).

While this can often be challenging in practice, especially in a busy acute environment, staff should make every effort to ensure that patients are able to eat and drink their meals without unnecessary interruptions.

Many organisations encourage family and carers to come in at mealtimes to assist their relative with eating and drinking. This is good practice, particularly for patients with dementia or learning disabilities as they may be more willing to accept help from a person they know.

Equipment assessment

The use of red tableware such as red trays, jugs and beakers can help to highlight patients who need help with eating and drinking. This assessment should ideally be made at the same time as the nutritional screening and included as part of their care plan (Fig 1a). This is an ongoing process and should be reviewed regularly.

Adapted cutlery such as easy-grip handles and other equipment such as plate guards and nonslip mats can be useful for patients who have restricted use of their hands or who have had a stroke and can only manage to eat with one hand (Fig 1b). These are usually provided by an occupational therapist.

fig 1b adapted cutlery

Preparation for mealtime

Before mealtime, nurses should ensure all patients are prepared to eat their meal in a dining room or in a chair by their bed. If this is not possible they should be sat up in bed, well-supported with pillows (see checklist in Box 2). Independence should be encouraged and it is important to assess what help the patient needs, for example:

  • Unwrapping packets;
  • Removing yoghurt pot lids;
  • Cutting food into bite size pieces to promote independence.

Box 2. Preparation checklist

  • Is the bedside table clear of clutter and of the right height for your patient to eat comfortably?
  • Has the patient been given the opportunity to use the toilet and wash their hands?
  • Does the patient have dentures in and hearing/visual aids on if worn?
  • Does the patient have all necessary items within easy reach?
  • Once the meal has been delivered, is it what the patient ordered?

Assisting patients

Helping patients who cannot eat and drink independently takes time, understanding and patience. It must not be rushed and any nurse who is involved in this task should not be interrupted.

Equipment

  • Clean table or tray;
  • Gather equipment required to assist the patient to eat, such as adapted cutlery;
  • Provide a serviette to protect clothing;
  • Obtain a chair to sit beside or opposite the patient (Dougherty and Lister, 2015).

The procedure

1. Explain to the patient that you are going to help them to eat their meal.

2. Decontaminate your hands to reduce the risk of cross infection and put on an apron (Dougherty and Lister, 2015).

3. Assist the patient to sit in an upright position at a table in a dining room, in a chair by the bed or upright in bed if the patient cannot get up. This helps with swallowing and protects the airway (Dougherty and Lister, 2015). Eating in a dining room also makes the meal a social occasion.

4. If the patient use dentures ensure they are clean and offer assistance to insert them if necessary.

5. If necessary decontaminate your hands before handing food and allow the patient to wash and dry their hands before the meal.

6. Protect the patient’s clothing with a serviette to maintain dignity.

7. Sit down at the patient’s eye level. This aids effective communication but also provides reassurance the patient that you have the time to help the patient to eat (Fig 1c).

8. Do not be distracted by what is going on around you or talk to other people.

9. Tell the patient what is on the plate – this is particularly important for those who are are visually impaired or eating a puree diet as food may not be instantly recognisable.

10. Ask whether the patient wants any seasoning or sauces and has a preferred order in which they wish to eat the food.

11. Ask how the patient would like to receive the food; some may prefer a fork, others a spoon. It is important to let the patient feel in control of the mealtime.

12. Visually impaired patients should be told what you are putting on the fork or spoon before raising it to their lips. Do not overload the fork. Bring it up to the patient’s mouth to avoid the need to bend to reach the food. Allow plenty of time for the patient to chew and swallow.

13. When patients have a small appetite, suggest that they try to eat a little of each course for a balanced nutritional intake. However, these patients are at high risk of malnutrition and should be referred to a dietitian to assess their dietary intake.

14. Offer sips of fluid after every couple of mouthfuls; this can help eating.

15. When the patient has had enough of the main course, offer dessert in the same way. Make sure the spoon is the correct size, for example, using a teaspoon for a yoghurt.

16. After the meal ensure the patient is clean and comfortable and has had enough to eat and drink. Patients should be encouraged to eat but should not be pressured when they have indicated that they have had enough.

17. Offer the patient a chance to clean their teeth and dentures or if this is not possible, perform mouth care.

18. At the end of the meal ensure the patient has a drink to hand but be aware that those who need help with eating will need help with drinking too and regular fluids should be offered.

19. Remove your apron, decontaminate your hands and document the patient’s dietary intake.

fig 1c sitting with your patient at eye level helps

Documentation

Food and fluid charts are a vital way of assessing patients’ nutritional status. Dietitians and nutrition teams rely on them when working out nutritional requirements and the need for additional nutrition support. These charts are a useful tool when assessing weight loss. An example of a completed form is illustrated in Box 3.

box 3 how to complete a food fluid chart accurately

Impaired swallow

Mealtime is an ideal opportunity to assess swallowing. An urgent referral should be made to a speech and language therapist if the patient has any of the following symptoms of dysphagia:

  • Coughing/choking;
  • Wet/‘gurgly’ voice;
  • Taking a long time over a meal/falling asleep;
  • Complaining of difficulty eating or drinking;
  • Reluctance to eat certain consistencies;
  • Feeling of food getting stuck in mouth, holding food in cheeks;
  • Food/drink falling out of the mouth.

If you notice any of the above observe the patient for signs of aspiration pneumonia; this occurs when patients have swallowing problems and food inadvertently enters the respiratory tract. Symptoms of aspiration pneumonia include: breathlessness, decreased oxygen saturations tachycardia and pyrexia. If these are present, seek medical advice urgently.

Reflection

Look at your own area. Are patients prepared for meals? Do they have the help they need? Are all staff helping with meals? If not, what are they doing? Can you make five small changes that will improve the mealtime experience? Look at the food record charts – are they completed accurately? If not, can you share good practice and ensure that all staff know how important it is?

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