By Dale Mayerson and Karen Thompson

When eating issues are identified and there is timely intervention, the effects on a resident’s quality of life can be profound. When a resident is assisted with eating and is able to maintain/improve nutrient intake, overall health and well-being will benefit.

Positioning

One of the most important steps in preparing to assist a resident at meal or snack time is assuring proper positioning, making it easier for the resident to eat as independently as possible. Residents require individual strategies for positioning, but this usually includes keeping the upper body securely in an upright position, with hips, knees and ankles bent as closely to a 90 degree angle as possible. The feet should be flat on the floor or on wheel chair supports, and the head should be held straight with the chin down slightly.  There should be approximately 12 inches/30 cm from the mouth to the food. Poor positioning leads to a higher risk for choking or aspirating food or liquid into the lungs. There are many effective strategies that can improve a resident’s mealtime positioning.  Some residents who tend to slide forward or to the side in a chair may be assisted with non-skid matting or wedge cushions, or simply by placing forearms on the table to maintain an upright posture. Pillows may be tucked at one side to help maintain a safe position.  Special consideration needs to be given when positioning bedridden residents to eat.  Positioning at mealtime is important for all residents and needs to be monitored by everyone on the care team.

Regulations in the Ontario Long Term Care Homes Act support staff by mandating that no person assist more than two residents who need total assistance with eating or drinking at one time. This allows each resident adequate time for swallowing and to prepare for the next mouthful of food.    Caregiver positioning is also important.  In most instances, the caregiver needs to be seated at the same height as the resident so eye contact can be made without excessive twisting or turning. Height adjustable swivel chairs designed for assistance with eating are helpful and should be readily available in the dining rooms.  Consider using stools with back supports for the safety of the staff.

Food and fluid texture

Prescribing the optimal texture for residents that require assistance with eating is key to success. Residents may be at risk for swallowing difficulties and need to be assessed to determine the most appropriate food and fluid textures for provide adequate intake in a safe manner while still being pleasing to the resident. Chewing stimulates digestive enzymes and is a natural part of eating and digesting foods. When residents lose this ability, we need to adjust the diet accordingly. Caregivers need to ensure that residents receive the correct texture, and that any observations of coughing, choking, pocketing of food in the cheeks, or drooling are reported to the Registered Nursing staff or Dietitian.

Techniques/Considerations

Some rules for assisting residents with eating would include:

1. Do not rush
2. Wash hands before beginning to assist and perform hand hygiene between residents
3. Serve one course at a time
4. Use a metal or hard plastic teaspoon or parfait spoon for those on minced or pureed diets
5. Ensure foods are not dangerously hot by placing a small amount of food on forearm to determine if temperature is safe for resident
6. Offer small bites at a time, bring the spoon to where the resident can see it and give resident time to open his/her mouth
7. Allow time for chewing/swallowing and try to observe the swallow taking place
8. Check that resident’s chin remains slightly tucked for safest swallowing
9. Check that there is minimal amount of food residue in the mouth after swallow.

10 .Alternate liquids with solids unless the plan of care indicates otherwise

11. Do not mix foods together unless the resident requests this or the care plan allows this
12. Cue resident to open mouth if necessary
13. Encourage resident to wipe his/her mouth with a damp cloth or napkin throughout the meal. Assist as required
14. Reheat food if it becomes cold
15. If resident begins to cough or choke- stop providing food and allow time before starting again
16. Report coughing, choking, pocketing, drooling, spitting to Registered staff overseeing the dining room service
17. Record intake as soon as possible after assisting resident

When serving a large number of residents that require assistance with eating, Homes are often grateful for any help they can get to ensure everyone has assistance with their meal as needed. Excellence in practice needs to be promoted and supported by providing opportunities for training, role playing, monitoring and interdisciplinary care planning on an ongoing basis.  Well trained and well informed staff, families and volunteers have the power to improve their own satisfaction while enriching the lives of those they serve.

Dale Mayerson B Sc RD CDE, and Karen Thompson, B A Sc RD are Registered Dietitians with extensive experience in Long-term care.  They are coauthors of “Menu Planning in Long Term Care and Retirement Homes: A Comprehensive Guide” and have participated for many years on the Ontario Long Term Care Action Group, an advocacy group of Dietitians of Canada.