How we ensure client mealtimes are safe and enjoyable?
Overview
We have processes in place to support a client in their mealtime experiences. Unfortunately, due to a medical condition, medication side effects, or palliation, some clients lose interest in food and begin to lose weight, possibly due to swallowing difficulties. There are many reasons why clients experience swallowing difficulties - dysphagia.
A doctor will diagnose dysphagia and, with the client's consent, refer them to a speech pathologist for a dysphagia assessment and review. Each client is involved in developing their individual and unique mealtime management plan. Mealtime Management Plans are document(s) created to ensure the client's mealtimes are safe and effective. They are developed and reviewed by a speech pathologist following a dysphagia assessment process.
The speech pathologist collaborates with other allied professionals, such as a dietitian, who ensures enough nutrition and hydration in the modified meals or enteral food, and an occupational therapist for positioning techniques. Language pathologists are involved as an extension to the quality of life for a person with dysphagia, prescribing exercises to maintain language and swallowing skills. Dysphagia Our Role
HWH staff and support workers must closely follow a client's mealtime management plan and make mealtimes a pleasant experience.
It is beyond the support workers' scope of practice to alter a client's MMP.
All changes to a client's swallowing capacity must be reported to the CCM or HWH 24/7 at 1800 717 590 for further review, assessment, and modifications to the MMP.
What is in the mealtime management plan?
any food allergies and intolerances and what symptoms the client experiences when exposed, and what emergency action to take
the client's individual needs and preferences (such as for food, fluids, preparation techniques and feeding equipment)
information about the person that the support workers can refer to, ensuring a safe and comfortable meal experience for the person
specific actions for a person to eat and drink safely, such as improved seating and positioning during meals
specific information about the person’s modified diet, including a list and images of modified food textures to make the food easier to chew and swallow
specific mealtime assistance techniques, including any reminders about a safe rate of eating, or a safe amount of food in each mouthful
how to respond to coughing or choking, and make sure risks are monitored while a person is eating or drinking
it identifies how risks, incidents, and emergencies will be managed to ensure the client’s well-being and safety, including by setting out any required actions and plans for escalation.
how to use feeding equipment for people who have severe dysphagia, including assistive technology, such as spoons, plates, cups and straws; and tube feeding equipment for those with severe or profound difficulty swallowing who require tube feeding
Before supporting the client with their meal:
Ensure you have completed the Dysphagia Management courses in Talent LMS, 5.03.1 and 5.03.2
Check the mealtime management plan.
Check the person. Is it safe to proceed? Are they alert? Return later if they are asleep or drowsy.
Greet the person and explain what you are preparing to do.
Encourage the person to assist with meal preparation if possible.
Do not mix pureed food types together. Keep them separated on the plate for tasting.
1. Client positioning The mealtime management plan will state the:
Position the person should be in when eating orally or via enteral feeding tubes; correct positioning of the body when eating supports safe swallowing
An optimal safe eating position means the person is sitting upright at a 90֯ angle with the feet flat on the floor
The head is best positioned in a way that is not tilted up or down, or sideways
The person’s physical abilities will direct the best position for them
Check the mealtime plan for positioning information
2. Appropriate equipment Use an appropriate chair:
Use a chair with a back
The chair back supports the trunk to keep the person upright
Cushions, footstools or headrests may help
Use a chair of the correct height
The person should have both feet comfortably resting on the floor and their knees at 90 degrees to the floor.
If the person’s feet don’t reach the floor, use a footrest to bring their knees to 90 degrees.
The person should sit with their hips as far back in the chair as possible and still have a small space between the back of their knees and the front of the seat.
Wheelchairs, if used, must support good positioning for meals
Customised chairs and ‘Tilt in space’ chairs, which might be prescribed for specific posture or pressure management purposes, might need special consideration for safe swallowing
3. What position should the support worker be in during meal times?
Follow the mealtime management plan instructions, unless otherwise stated, and sit at eye level opposite the person.
Your interaction with the person can contribute to a safe and enjoyable mealtime experience.
4. The benefits of sitting with the person during mealtimes
You can see when the person is ready for their next mouthful
You can see if the person is eating and drinking safely
The environment becomes more natural and relaxing
There’s less strain on your body
It’s easier for you to encourage slower eating
It’s easier for the person to communicate with you
You can give the prompts and support the person needs
You can model ‘safe eating’ and link this to the person’s Quality of Life goals
Food textures
Food and fluid may be modified at the instruction of a speech pathologist based on swallow assessment results. Changing the texture of food and the thickness of fluids can assist the person in swallowing safely and minimise the risk of aspiration. However, textured diets and thickened fluids are prescribed by a speech pathologist, not a nurse or support worker. Ensure you notice any changes in the client's swallowing skills immediately for a review of the MMP by a speech pathologist.
IDDSI Framework
145 KB
View full-sizeDownload “From May 1 2019, Australia has been following the International Dysphagia Diet Standardisation (IDDSI) framework. This is a change from the Australian Food Texture Scale previously utilised.”
Rules related to preparing and giving thickened fluids:
All drinks the person receives should be thickened
Some fluids continue to thicken if left standing for a long time and are no longer suitable for the person
Check the consistency of a drink every time it is served
Discard thickened fluids within 24 hour
A spoonful refers to a level spoon, not a heaped spoon
Avoid lumps. If the thickened fluid is always lumpy, seek advice from the supervisor or speech-language pathologist
Some thickened fluids will need to stand for a specific time before they will reach the recommended thickness
Note: on thickened fluids
Some foods melt in the mouth to become liquids, for example, ice cream, ice, jelly, thick-shakes and smoothies. These foods are not safe for people who need thickened fluids. Avoid these food textures for the relevant food level, or if possible, modify that food type to be the correct thickened level once melted.
What are enteral plans?
Enteral plans are separate plans used to state the requirements for tube feeding. A dietician assesses the client and prepares enteral plans. They provide information about feed types, how the feed is administered etc. and other important information about the person and their feeding tube.
What does the dietician do?
The dietician will determine what feed is needed based on nutritional requirements.
Determines the time of feeds
Determines the delivery method—gravity feed/bolus/pump infusion
Meets client’s specific nutritional requirements with the correct formula
Minimises complications
Dietician tasks:
Determines the food formula is balanced and includes:
Assesses possible food intolerances or allergies and refers the person to an immunologist
Type of formula, some milk-based, some lactose-free
A closed system reduces bacterial contamination. Enteral feeding equipment is specific for each client—never share.
Use a no-touch technique when preparing the formula. Check the formula for the right type, expiratory date and damage to the container.
Establishes the environment for feeding:
Includes positioning
Sensory aids in place
Incorporate the use of specialised equipment
Reduce distractions
Prevent sensory overload if relevant to behaviours of concern
Eating and drinking are necessary; however, it is also a social activity
The environment should be conducive to eating, and maximise the person's independence and preferences
Establishes eating speed:
Be aware of first-aid interventions for choking
Do not rush the person
Eating is a sensory experience
Ensure the person has finished a mouthful before offering another.
Watch for the swallow reflex
Some people will eat very fast for many reasons
Assesses why the person is eating quickly:
For example, the person might:
Have difficulty coordinating or slowing arm movements
Put another mouthful in their mouth before swallowing the first one
Be worried that someone else might eat their food
Rush to get to another preferred activity
Be generally stressed, tense or anxious
Feel rushed or hurried by support people
Have a compulsive eating disorder
Be taking a medication that is having an impact on their eating
Strategies to help the person to slow down must be designed for that person. The person’s strengths and functional abilities, learning style, communication skills and sensory preferences are considered, and several strategies are tried to learn what is effective for the person. Ask the person, their support network, speech-language pathologist and occupational pathologist. Speech-language pathologists and occupational pathologists can work together to understand why the person eats quickly and help the person to slow down.
Medications and dysphagia
Some medications increase the risk of choking and aspiration:
Antipsychotics can affect the swallow response
Benzodiazepines can increase drowsiness
Anticonvulsants can affect alertness
Some people will require medications at mealtimes:
The person may have dysphagia, and their medications must be crushed, however
Not all medications can be crushed; follow the client's medication plan
Remember your scope of practice regarding assisting clients with medications.
Oral Care
Oral care is important for health reasons; poor oral care causes infections
Poor oral hygiene leads to tooth decay and gum disease
Dental procedures may evolve to tooth removal and, therefore, a change of ability to chew food safely and effectively
Follow the client's care instructions and support plan
Emergency procedures:
Know the person as much as possible within professional boundaries
Know what the hazards are for the person you support when they eat and drink
Know the signs and symptoms of the associated risks
Know what to do in an emergency.
Know the person’s action plan/do they have one? Look for risks; incidents; signs, etc.
What is choking?
Choking is when the airway is completely or partially blocked by an object (can be food)
Partially blocked airway: breathing and speaking are still possible
Completely blocked airway: no airflow at all. The person cannot breathe or speak. This will lead to cardiac arrest and death if not rectified - this is an emergency
Signs of choking may include:
Clutching the throat
Coughing, wheezing and gagging
Difficulty in breathing, speaking or swallowing
Making a whistling sound or no sound at all
Blue lips, face, earlobes, fingernails
Signs of a completely blocked airway include:
The person is trying to breathe
There are no breathing sounds, and no air escaping from the nose or mouth
Signs of a partly blocked airway include:
Breathing is difficult
Breathing may be noisy
You can feel some air escaping from the mouth
What to do if someone seems to be choking -emergency action plan:
If you know current first aid for choking, use it.
If the person is seriously distressed or their airway stays blocked, dial 000 and give first aid until medical aid arrives.
OR If you don’t know current first aid for choking, dial 000. The person who answers will step you through current first aid, and send medical aid if appropriate.
When the threat or risk is controlled, contact HWH's 24-hour number, 1800 717 590 and report the incident.
Your duties under the NDIS Practice Standards regarding choking:
Provide support and services safely and competently with care and skill.
Promptly take steps to raise and act on concerns about matters that might impact the quality and safety of support provided to people with disability.
Source: (NDIS Quality and Safeguards Commission: Practice Alert Dysphagia, safe swallowing, and mealtime management, November 2020)
Scope of Practice and Reporting
Stick to the plan
Report your concerns
Changes are only made by the speech pathologist, dietician and other health professionals.
Unnecessary changes to the plan can result in harm that may include aspiration, choking, fluid overload, organ failure and death.
Know about and implement policies, procedures and emergency action plans
Know and avoid hazards, risks and adverse events associated with not following the mealtime plan
