Feeding dependent clients and clients with potential swallowing difficulties

Due to physical impairment, swallowing difficulties or generalized weakness some clients may be unable to feed themselves without assistance. In addition, some clients with severe dementia can also require assistance as they may not recognize food or cutlery or remember how to feed themselves. Having to be fed can threaten the client’s dignity; therefore the health care professional should try to minimize any negative aspects that may contribute to these feelings. Therefore in addition to the guidelines outlined above, the procedure outlined below may also need to be considered. The aim of feeding dependent clients is to ensure that they receive the optimum amount of food and fluid whilst maintaining their dignity and safety.

Procedure	Rationale
Wash hands following correct procedure and put on appropriate coloured apron, and also assist the client to wash their hands	Infection control
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
If clients are unable to get out of bed ensure they are sat upright if condition allows; pillows should be arranged so that they can lean forward	As above
Put adjustable chairs into the upright position for meals and drinks and do not put back to recline position for at least 15 minutes afterwards	To prevent reflux of gastric contents
Ensure that the client can close their lips	A lip-seal needs to be maintained to trigger a swallow
Sit down at the same level to feed the client	Demonstrates a relaxed approach and that you can spend time with the client
Protect the client’s clothing with a napkin	Maintains dignity
Ask the client in what order they would like the food	Client’s likes/dislikes are met
Talk to the client but avoid asking questions during mealtimes	To avoid distracting the client during mealtimes
Allow time for the client to chew and swallow the food and drink before offering the next mouthful	To prevent client from feeling hurried as this could result in discouraging the client from eating
Adjust the amount of food and drink offered to suit client – a teaspoon per mouthful is plenty, and is best placed in the stronger side of the mouth	As above. Lessens risk of aspiration and choking
Allow two swallows per mouthful	Ensures mouth is empty
After every few mouthfuls ask the client to cough and to do so again at the end of the meal	To check and clear the airway
When giving a drink, tip the cup gently or use a feeder cup	Ensures flow of fluid is controlled and regulated. Lessens risk of aspiration and choking
With a napkin remove any dribbles of food or drink from the client’s chin	To maintain client’s dignity
During feeding listen to the client’s voice by asking them to say ‘Ah’ after every few mouthfuls and if the client’s voice sounds ‘wet’ or ‘gurgly’ stop feeding and call for qualified assistance	A wet or gurgly-sounding voice is a sign of aspiration into the respiratory tract
After the meal is completed check the mouth for retained food and remove it with a swab or toothbrush	To prevent aspiration and choking on retained food particles
Observe for any signs of choking, for example coughing or poor colour, and stop feeding immediately if this is suspected (refer to section below on choking)	To minimize harm

Further points

When feeding dependent clients and clients with potential swallowing problems consider the following:

• If a hot drink is delivered too early, put a lid on it and check it again later.

• A straw may be used to assist a client to drink. However, some clients may not be able to use a straw if their orbicularis oris muscle (the muscle around the mouth) is weak, as in some stroke patients, because it makes their suction power lower; straws with valves or a feeder cup may help.

• Some clients who cannot communicate their needs may go red in the face after meals, which may indicate that they need to defecate as a result of the gastrocolic reflex (putting food in at the top causes the system to shunt into action).

• All clients with problems swallowing must be referred to a speech and

language therapist.

• The easiest consistency to eat is a smooth texture. Soft solids such as ice cream, yoghurt, custard and mashed potato are acceptable. Normal solids and thickened liquids are more difficult. These include thick milkshakes, yoghurt drinks and thickened soups.

• Note: It is important that the dietician in consultation with the speech and language therapist prescribes the appropriate diet after assessing the client, and you should therefore seek their guidance on the use of thickening powders etc. before you use them.

• Food types to be avoided by the client with eating or swallowing difficulties are those which are stringy, crumbly, tough, or of mixed textures (solids and fluids) or such things as chips, peas and sweetcorn.