116. Study Notes: Assisting Clients With Eating Safely and Compassionately

The Big Picture

Eating can become harder when a client is weak, ill, uncomfortable, in pain, or having trouble chewing or swallowing. Small things, such as an uncomfortable position or needing mouth care, can also affect a person’s appetite and ability to eat.

Your support should help the client eat as safely and independently as possible. Pay close attention while helping, respect the client’s choices and pace, and follow the care plan.

Some clients need direct help with eating. When this happens, provide the physical help with kindness and support. A client should never feel rushed, embarrassed, or forced to eat.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

Prepare the Client Before the Meal

A client’s appetite and ability to eat can be affected by many things. These include weakness, illness, odours, unpleasant equipment, an uncomfortable position, pain, needing oral hygiene, or needing to eliminate.

You can help prepare the client by:

• assisting with oral hygiene, elimination, and handwashing
• changing soiled clothing and providing clean linens for clients who are incontinent
• making sure dentures, eyeglasses, and hearing aids are in place
• making sure eyeglasses are clean and hearing aids are turned on
• helping the client get to the dining room
• helping the client sit comfortably for eating
• helping with a transfer from bed to chair or a sitting position in bed when needed

Preparing clients before meal trays arrive also helps food reach them at the proper temperature.

When a Client Needs to Be Fed

Weakness, paralysis, casts, and other physical limits can prevent some clients from feeding themselves.

A client who needs to be fed may be at risk for swallowing difficulties or aspiration. Aspiration means fluid or an object enters the lungs. Pay close attention to the client throughout the meal.

Needing help with eating can also be difficult emotionally. Be kind and supportive while providing assistance.

Help Make Meals Enjoyable

Illness and other factors can reduce a client’s interest in food. Small changes can make mealtimes more pleasant.

Always check the individual care plan because some suggestions will not fit clients who have special diets.

Ways to support an enjoyable meal include:

• Help the client make menu choices.
• In home care, involve the client in meal decisions when you prepare meals.
• Make the eating area attractive. At home, let the client choose table linens and utensils.
• Serve hot meals immediately instead of allowing them to become lukewarm.
• Serve moderate portions.
• Ask how much food the client wants and place that amount on the plate.
• Encourage social mealtimes when appropriate.
• In long-term care ⓘ, encourage clients to dine with others.
• In home care, stay with the client while doing a quiet task if this helps reduce loneliness.

Eating Challenges

Aging, illness, and disabilities can create eating challenges. These challenges can include problems with chewing or swallowing, weakness, and vision impairment.

Chewing Difficulties

Clients with chewing difficulties receive foods that provide soft bulk. Foods may be puréed ⓘ using a food processor or blender.

CCA action: Follow the care plan.

To support a client who has trouble chewing:

• offer plenty of fluids
• offer small mouthfuls
• give the client enough time to chew

Swallowing Difficulty, Dysphagia

Dysphagia means difficulty swallowing.

A client can have swallowing problems for different reasons. Some medications, including chemotherapy, can decrease saliva production and cause dry mouth. Paralysis can affect throat muscles and make swallowing difficult.

A swallowing assessment is completed by a speech pathologist, occupational therapist, physiotherapist, registered dietitian, or nurse who has received training in the assessment tool.

Warning Signs of Swallowing Difficulty

Watch for:

• frequent throat clearing
• a gurgling-sounding voice
• delayed swallowing or reluctance to swallow
• hiding food in the cheeks, called pocketing
• holding food in the mouth
• needing several swallows for one bite
• trouble controlling food and saliva in the mouth
• a wet cough while eating
• choking on food while eating

Thickened Liquids

Clients who have difficulty swallowing thin liquids often must drink thickened liquids.

Three common consistencies are:

Thickened Liquid	Consistency
Nectar-thickened	Easily pourable, similar to thicker cream soup or a milkshake
Honey-thickened	Similar to honey and pours very slowly
Pudding-thickened	Holds its shape when scooped, is usually eaten with a spoon, and resembles pudding

A client who requires thickeners should not receive anything that melts, such as ice cream or ice cubes.

Clients with dysphagia often do not get enough fluids. Offer fluids frequently throughout the day, every 2 hours or as directed by the care plan.

Intake means the amount of fluids taken into the body.

Thickened liquids count as part of the client’s fluid intake.

Food and Positioning for Swallowing Difficulties

Clients who have difficulty swallowing receive thick, soft, moist foods.

The care plan may direct you to:

• help the client sit upright while leaning slightly forward
• ask the client to lower the chin while swallowing
• offer plenty of fluids
• allow enough time to chew and swallow before offering more food
• ask the client to remain sitting for at least 30 minutes after the meal

When helping a client with swallowing challenges, a general recommendation is one-third of a teaspoon at a time. Feeding such a small amount requires many spoonfuls and can tire the client.

Follow the care plan for the amount to feed at one time.

Choking and Aspiration

Clients with swallowing difficulties are at risk for choking and aspiration.

If a client cannot talk or cough, the client may be choking.

First: Call for help immediately.

If help is unavailable, follow the emergency measures for choking that you learned in your first-aid and CPR ⓘ course.

Weakness and Eating

Some clients become too weak to chew and swallow well. Eating poorly can lead to even more weakness and less energy for eating.

Never force a client to eat.

If the client cannot eat, tell your supervisor.

To encourage eating, the client’s plan may include:

• frequent, small, high-calorie meals
• nutritious drinks
• liquid dietary supplements
• soft foods that require less chewing

Also:

• allow the client to rest before and after meals
• use appropriate feeding utensils
• check with your supervisor and the care plan about the correct utensils
• provide a straw if allowed so the client does not need to lift the glass
• check the care plan and your supervisor before using a straw
• provide lightweight cups, glasses, and utensils that are easy to handle

Vision Impairment

Clients with vision impairment are often keenly aware of food aromas and often identify the foods being served. Most of these clients eat independently with some guidance.

To assist:

• identify where foods and fluids are located on the tray or table
• use clock numbers to describe their location
• place the same type of food at the same clock position for consistency
• describe the food when offering it to the client

Serving Meals in Different Care Settings

Most hospital clients eat meals in their rooms. Long-term care clients are encouraged to eat in the dining room.

In most provinces and territories in Canada, clients in long-term care facilities must eat in the dining room unless they are ill so staff can ensure that each client safely consumes food and fluids. Clients who are too ill to move about eat in their rooms.

If a long-term care client wishes to eat in their room, a team conference must be scheduled to discuss the safety issues and risks of eating alone, especially if the client has dysphagia. The conference must involve the client, family, and staff. A staff member must stay with the client to supervise the meal.

CCA action: Follow your facility’s policies.

Meals served in bedrooms arrive on trays designed to keep hot and cold foods at the proper temperature. Prepare the client before the tray arrives and serve the meal promptly.

Home care clients usually eat in a dining room or kitchen. A weak or ill client may eat in bed or in a chair in the bedroom.

Between-Meal Nourishments

Some special diets include food or drinks between meals.

Examples include:

• crackers
• milk or juice
• a milkshake
• cake or wafers
• a sandwich
• gelatin
• custard

Provide nourishments according to the care plan.

Prepackaged liquid nutritional products such as Ensure and Boost are supplements. They are not intended to replace meals for an extended period because they do not provide adequate nutritional balance.

In home care, you may need to prepare the nourishment. In facilities, nourishments are supplied to the unit.

Provide the client with needed eating utensils, a straw, and a napkin. Follow the procedures for serving meals and feeding clients.

Calorie Counts

A calorie is a unit used to measure the energy produced as the body burns food.

Some clients require a record of their calorie intake. A flow sheet ⓘ is used for this purpose.

Record:

• what the client ate
• how much the client ate

For example, if a client eats all of one food, half of another, and leaves other foods untouched, the record should show those amounts.

The care plan identifies clients who require calorie counts.

Long-Term Care Dining Programs

Long-term care facilities may use different dining programs.

Social Dining

Clients eat in the dining room. A table may include four to six residents ⓘ, and food is served in a restaurant-style setting.

Depending on facility, agency, provincial, or territorial policy, clients usually sit in the same place for each meal and are not moved except under special circumstances. Relationships formed with tablemates are respected by maintaining the client’s place.

Follow the dining room seating plan in your facility.

Family Dining

Food is placed in bowls and on platters. Clients serve themselves as they would at home.

Assistive Dining

Some facilities use circular or horseshoe-shaped tables for clients who need help eating. In this arrangement, the support worker sits in the centre and is able to feed as many as four clients.

In Ontario, regulations limit a support worker to assisting and feeding a maximum of two clients at one time. For this reason, circular or horseshoe-shaped tables are no longer used in Ontario.

Follow the policy of your agency, facility, province, or territory for feeding clients.

Serving a Meal From a Food Tray

This procedure supports dignity, independence, individualized care, preferences, privacy, and safety.

Before the Meal

1. Identify the client according to employer policy.
2. Perform hand hygiene.
3. Prepare the client for the meal. Explain as needed and assist with handwashing.
4. Provide privacy if the care plan indicates it or the client requests it.
5. Check that the tray contains everything needed, including special utensils when required.

Privacy supports dignity, although many clients benefit from social interaction during meals.

During and After the Meal

6. Help the client sit up. This helps reduce choking risk.
7. Place the tray on the overbed table or another table.
8. Remove dish lids. Open cartons or boxes, cut meat, and butter bread when indicated in the care plan.
9. Place the napkin, clothing protector if needed, and utensils within reach.
10. Note the amount and types of food eaten. Measure and record food or fluid intake when ordered.
11. Check the client’s mouth for food that has been pocketed and remove it. Wear gloves. Pocketing can lead to choking and indicates difficulty swallowing. Record and report it.
12. Remove the tray.
13. Assist with handwashing and offer oral hygiene. Wear gloves for this step.
14. Clean spills and change soiled linen.
15. Help the client return to bed if indicated.

After the Procedure

16. Provide for safety and comfort.
17. Place the call bell ⓘ within reach.
18. Follow the care plan for bed rail use.
19. Perform hand hygiene.

The call bell and bed rail steps may not apply in community settings.

Report and record your actions, observations, and basic assessments according to employer policy. Include the amount and kind of food eaten.

Monitoring food intake gives the health care team information about the client’s eating. Documentation is also completed for legal reasons and to keep the team informed.

Compassionate Care While Feeding a Client

A client who cannot feed themselves may feel embarrassed, humiliated, angry, depressed, or resentful. Some clients may refuse to eat.

Your approach should protect the person’s dignity while supporting safe eating.

Dignity

Be gentle, patient, encouraging, and attentive to comfort.

Sit facing the client. Sitting shows that you have time for the person, while standing can make the client feel rushed.

Sit at a slight angle in case the client coughs or expels food.

Clean spills and dribbles tactfully. Speak respectfully.

Tell the client what food you are giving with each spoonful. This is especially important when food has been ground or puréed.

Do not mix foods together. Keeping foods separate lets the client taste each food on its own.

Independence

Encourage the client to take part in some part of the meal.

Let the client set the pace. A client may use gestures or nods to show preferences.

Individualized Care

Client-centred eating assistance should fit the person’s:

• food choices
• physical strengths and limitations while eating
• cognitive strengths and limitations while eating
• personality
• care plan

Pace the meal according to the client’s ability to swallow to avoid choking.

Preferences

Give the client time and privacy to pray before eating if requested.

Describe the foods on the tray. Ask which foods and drinks the client wants first.

Ask questions and paraphrase ⓘ to make sure you understand the client’s feelings and wishes.

Use pleasant conversation during the meal.

Privacy

Some clients do not want other people to watch them being fed.

Be sensitive to the client’s feelings and provide privacy if the client wants it.

Safety

Follow the care plan.

Use spoons instead of forks when feeding because spoons are less likely to cause injury.

The spoon should be only one-third full. Some clients need even smaller portions.

Sit where you can immediately see signs of choking or problems with eating, chewing, or swallowing.

Give the client enough time to chew and swallow.

Offer fluids during the meal because fluids help with chewing and swallowing. One guideline is to offer a drink after two spoonfuls of solid food, sometimes remembered as “bite, bite, and sip.”

Some clients may fall asleep while eating, which can create a swallowing risk. Try to wake the client by gently stroking the cheek and saying the client’s name.

Must not: If the client does not wake up, do not try to feed the client.

Report your observations and record the situation appropriately.

Assisting a Client With Eating

This procedure also supports dignity, independence, individualized care, preferences, privacy, and safety.

Before Feeding

1. Identify the client according to employer policy.
2. Explain the procedure to the client.
3. Perform hand hygiene.
4. Prepare the client for mealtime and assist with handwashing.
5. Provide privacy only if the client requests it.
6. Help the client sit comfortably. Position the client at a level that does not create an injury risk for you. Proper positioning helps prevent possible back injury to you and the client.
7. Place the tray on the overbed table or another table.

While Feeding

8. Place a clothing protector across the client’s chest and under the chin.
9. Prepare the food for eating. Small pieces help reduce choking risk.
10. Tell the client which foods are on the tray so the client can express preferences.
11. Serve foods in the order the client prefers. Alternate solid and liquid foods. Use a teaspoon for safety. Give enough food for the client to sense the amount in the mouth. Allow enough time to chew. Never rush the client.
12. Use straws only if the care plan allows them and the client cannot drink from a glass or cup. Use one straw for each liquid. Use a short straw for a weak client. Some clients with dysphagia do not use straws. Give thickened liquids with a spoon instead when directed. Follow the care plan.
13. Talk with the client. Treat mealtime as a relaxed social time.
14. Encourage the client to eat.
15. Wipe the client’s mouth with a napkin when a spill occurs to protect dignity.
16. Note how much the client ate and which foods were eaten.
17. Measure and record intake if ordered.
18. Remove the tray.
19. Assist with oral hygiene if it is in the care plan, and assist with handwashing. Wear gloves for this step.

After Feeding

20. Provide for safety and comfort.
21. Place the call bell within reach.
22. Follow the care plan for bed rail use.
23. Remove privacy measures.
24. Perform hand hygiene.

The call bell and bed rail steps may not apply in community settings.

What to Report and Record

Report and record your actions, observations, and basic assessments according to employer policy.

Include:

• the amount of food eaten
• the kind of food eaten
• complaints of nausea
• complaints of dysphagia
• signs of aspiration

Food intake observations help guide the client’s next 24 hours of care.

Recording and reporting are also required for legal reasons and to keep the rest of the health care team informed.