Assisting with eating and drinking

In many acute hospitals domestic or housekeeping staff now serve meals but it is still essential that nurses supervise mealtimes to ensure that clients receive adequate amounts of the correct diet, that they eat it and that an evaluation is completed if any problems arise.

Unfortunately, food and drink is sometimes left out of reach, or the client is not given any help when required, resulting in the client receiving neither. Nutritional assessment should identify those people who need assistance with feeding. Guidance in assisting adults to meet their nutritional needs is given below. Assisting with feeding the client orally will be discussed in detail later in the chapter. Clients with special feeding needs such as enteral feeding via nasogastric or gastrostomy tubes have different needs and this is beyond the scope of this text.

In relation to infants the procedure for giving a bottle feed varies from hospital to hospital. Some have feed units where formula feeds are prepared and pasteurized centrally, thus preventing the need to make up feeds in ward kitchens. If you are required to prepare a formula feed, the manufacturer’s instructions should be followed strictly, as the wrong concentration of powder to water can cause too-high sodium levels and be very dangerous to the infant. All the equipment to be used must be sterilized prior to undertaking the procedure, in keeping with local policy. Most acute hospitals have ‘ready to feed’ bottles of formula whereby a disposable teat is screwed onto the bottle and all that is required is to heat the feed to the correct temperature prior to giving. A full assessment is essential as some infants prefer the milk to be very warm and others just aired.

It is common for infants to have a small vomit when bringing up wind. This is known as a posit and is quite normal. There are various ways of helping the infant to bring up wind but placing the baby upright and rubbing or patting the back is a general recommended principle.

It is also recommended that weaning is introduced at 4 months of age and usually begins by introducing a few spoonfuls of baby rice mixed with breast milk or formula feed. Children should never be forced to eat, as this is often a cause of feeding problems such as food refusal later. It is normal for children to refuse food when they are ill or stressed. When feeding children the following foods should be avoided:

• under 3 years: nuts and nut products (can cause choking and are a potential allergen)
• under 1 year: nuts and nut products (as above); milk as a main drink (nonmodified protein and therefore difficult to digest at this age); and added salt or sugar (can cause electrolyte imbalance)
• under 6 months: nuts and nut products (as above); milk as a main drink (as above); added salt or sugar (as above); fish, wheat, eggs (potential allergens), food with lumps in (potential for choking), and fresh fruit juices, which can cause diarrhoea if given in excess.

It should be remembered that mealtimes can also be used as teaching opportunities for children and other people with learning needs. In addition people with eating disorders may have individualized feeding programmes.

Eating and drinking also have a sociable element so it can sometimes be beneficial to involve relatives and friends in assisting clients to eat and enjoy their food, though this should be considered carefully beforehand, preferably in discussion with the client, as too many distractions can result in some clients being put off their food.

Clients, if able, may also benefit from being encouraged to eat in a separate dining area if one is available. This is especially pertinent in long-term care facilities and can also act as a useful reminder to those with limited memory who simply forget to eat without the external prompt of seeing others doing it. However, it may be more appropriate with clients who have difficulty feeding themselves, or those who need to be fed, to undertake this activity in more private surroundings in
order to reduce embarrassment and distractions. What is important is that clients are involved in decisions about their food – its amount, timing and so on.

The aim of assisting clients with eating and drinking is to ensure that they receive the optimum amount of food and fluid whilst promoting independence. The following should be taken into account when preparing to assist clients:

• Consider the cleanliness of the surroundings and ensure that there are no unpleasant odours or sights.
• Remove any offensive material such as sputum pots, urinals, etc. from the client’s bed table/eating area and clear a space for the tray.
• Place a chair beside the client’s bed/chair for the nurse.
• Have to hand:
non-slip plate mat
plate guard
appropriate handled cutlery or soft spoon in the case of children. (You may need to liaise with the occupational therapist to determine appropriateness of the above.)

The procedure for assisting is given below.

Procedure	Rationale
Wash hands following correct procedure, put on appropriate coloured apron, and ensure client has also washed their hands	To prevent cross-infection
Ensure that the client is in a comfortable position, preferably upright and sitting out of bed in a comfortable chair drawn up to a table of comfortable height	Sitting the client as upright as possible allows the first third of the oesophagus to work, generating a wave of peristalsis that takes food and fluid into the stomach and also lessens the risk of food passing into the respiratory tract
Tell the client what the choices of food are and ensure that an appropriate size meal is served	Gives client food choices. Some clients with a poor appetite can be overwhelmed if served a large portion
Before mealtimes avoid procedures that may result in the client being frightened, nauseated or in pain	To avoid stimulation of the GI tract by the sympathetic nervous system, as stimulation may decrease gut motility and also dry up secretions, resulting in a dry mouth and leaving clients unable to utilize what is taken in
Ensure that the food is presented attractively	To tempt the client’s appetite
Make sure that the food is within reach of the client and that any packaged (e.g. butter, yoghurts, cartons, etc.) are opened if the client is unable to do so themselves	To ensure food is accessible to client
If the client is visually impaired make them aware of the position of the food on the plate, using the clock method to explain	To aid client to locate different foods, e.g. meat is at 12 o’clock, the vegetables are at quarter past and quarter to the hour, and the potatoes are at the half-past position
Provide a napkin	To protect the client’s clothing
Provide the correct equipment, e.g. appropriate handled cutlery, plate guard, non-slip mat, for clients who are unable to grip normal cutlery, can only use one arm or have erratic hand and arm movement	To aid clients who are unable to grip normal cutlery. To prevent food from being pushed over the side of the plate. To prevent the plate from moving around
Cut up food as necessary	To promote independence
Encourage clients to eat and drink but do not press this if they indicate they have had sufficient	Small amounts taken more frequently may be more successful
After the meal, remove tray and crockery and wipe up any spillages	Infection control and to maintain a pleasant environment
Following eating, assist client to complete oral hygiene and wash hands/face as necessary	To meet client’s hygiene needs
Put the client’s belongings and a drink of water back within easy reach	To restore the client’s environment
Wash hands and remove apron	Infection control
Complete documentation, e.g. food chart, fluid balance chart	Legal requirement to maintain documentation and safeguard client through good communications