SECTION 12 Meal assistance and special diets

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► Stroke and swallowing problems ► Consequences of eating and swallowing problems ► Observing signs and symptoms of swallowing problems ► Management of swallowing problems - safe feeding and modified diets ► Assistive devices ► Positioning for meal assistance ► Oral hygiene 3

Stroke and eating A stroke can leave survivors unable to feed themselves or to swallow food or liquid safely. Eating: The effects of a stroke can interfere with moving food from the plate to the mouth in two ways such as the effects on: ► Arm and hand movement ► Cognitive abilities 4

Stroke and swallowing problems Swallowing: Swallowing requires the coordinated activity of many muscles to move food from the mouth to the stomach. Stroke can affect these muscles and their action. Weakness in facial muscles and drooling are easy to see. But other effects of stroke may be invisible to observers and unrecognized by the survivor. 5

Stroke and swallowing problems Effects of a stroke that may make meals challenging include: ► Difficulty getting the food or drink to the mouth ► Difficulty chewing and moving food in the mouth ► Loss of the normal cough reflex: This leaves the survivor unable to cough when choking. They may silently aspirate (inhale) into their lungs. 6

Stroke and swallowing problems (cont’d) ► Decreased alertness and attention. A normal level of alertness and attention to eating protects against choking. ► Swallowing problems may prevent survivors from safely taking in enough nourishment, especially during early recovery 7

Consequences of problems Dehydration: ► Not consuming enough liquids ► Can cause dry mouth, constipation, urinary tract infection, confusion, and even severe illness or death. Malnutrition: ► Not eating enough ► Can result in malnutrition, weight loss, reduced energy, skin breakdown, impaired wound healing, and lower resistance to infection. 8 8

Consequences of problems Aspiration: ► The entry of saliva, solid or liquid food, or refluxed stomach contents (stomach contents coming back up) into the airway. ► Can cause choking, airway obstruction, respiratory problems, and pneumonia. Quality of Life: ► Can make the survivor reluctant to take part in group meals. ► Increasing social isolation and decreasing quality of life. 9

Common problems ► Coughing or choking during or after meals ► Shortness of breath ► No swallow reflex ► Drooling ► Poor lip closure, loss of food from mouth ► Altered voice quality: wet or gurgling voice 10

Associated problems ► Spikes in temperature shortly after meals ► Watery eyes when eating or drinking ► Runny nose when eating or drinking ► Spitting food out ► Pocketing of food in cheeks, under tongue, side of mouth ► Slow, effortful chewing ► Difficulty swallowing pills 11

Associated problems (cont’d) ► Rapid, uncontrolled eating ► Low intake of solids or fluids ► Avoiding specific foods or fluids ► Throwing head back to swallow ► Dry mouth ► Poor oral care or hygiene ► Dental problems, such as loose or decayed teeth or poorly fitting dentures 12

Associated problems (cont’d) ► Weight loss ► History of chest infections ► Poor air intake or weak cough ► Survivor reports: o Tight throat o Food sticking in throat o Difficulty swallowing solids o Reflux or heartburn o Fullness after eating very little 13

Assessing and monitoring swallowing ability Several health care professionals play a role: ► A trained healthcare professional screens survivors for swallowing problems ► A speech-language pathologist assesses swallowing ability and recommends diet textures and strategies for safe feeding ► A registered dietitian ensures that the recommended diet texture or tube feed meets the survivor’s nutrition and hydration needs ► An occupational therapist recommends positioning strategies and adaptive equipment 14

Management approaches Best positioning: ► Trunk (upper body) upright at 60–90º ► Stabilize with pillows ► Head in midline and flexed forward 15

Positioning for meal assistance 16

Management approaches Monitor feeding rate and amount: ► Provide small, frequent meals ► Small amounts: ½ –1 teaspoon at a time (do not use a tablespoon) ► Medications: crush 1–2 pills at a time in food ► Present one food item at a time if the survivor is easily distracted 17

Management approaches Check for complete swallow ► Laryngeal elevation - that is the movement of the Adam’s apple up and down ► Encourage swallowing twice ► Encourage napkin use if drooling 18

Management approaches Teach survivor to: ► Monitor self-feeding with a mirror ► Remove pocketed food with tongue ► Be aware of drooling ► Remain upright for 30 minutes after meal ► Perform mouth care after meals ► Encourage coughing to clear the throat ► Elevate head of bed 30º to prevent reflux ► Encourage survivor to wear loosely fitting clothes and to avoid tight belts ► Ask the survivor how they feel 19

Managing swallowing problems To eat safely, stroke survivors with swallowing problems often need their food textures adapted. ► Type of swallowing problem determines the food textures a survivor can swallow safely. ► A survivor who cannot safely swallow thin fluids may be able to manage thickened fluids. ► A survivor who cannot manage adapted food textures may need to be fed through a tube. ► Tube feeding can provide the calories and nutrients needed. 20

Diet In your workbook (12.3) there are tables describing the types of diets that could be ordered for a stroke survivor, and what types of food you might choose as well as what types of food to avoid if you are caring for someone with special diet needs (12.4) 21

Assistive devices ► Rimmed plates ► A gripper pad to prevent dishes from slipping ► Cup or glass holders ► Modified utensils with built up or bent handles ► Cutting utensils for one-handed use, such as a rocker knife, cheese knife, and pizza cutter ► Modified cups with a cut-out or partial lid. 22

How you can help ► Observe stroke survivors for signs and symptoms of swallowing problems. Contact your team lead when you see the signs ► Set up the environment to minimize distractions that helps the survivor focus on chewing and swallowing ► Use safe feeding practices with all stroke survivors ► Discuss concerns with the appropriate person on your team 23

Oral hygiene A clean mouth and clean teeth are essential to comfort and good health. Gum disease is linked to heart disease, pneumonia, and stroke. Bacteria and food particles in the mouth can be especially dangerous if aspirated into the lungs. A clean mouth and teeth are important whether the survivor takes food orally or by tube. 24

Oral hygiene Oral care and assessment After meals ► Remove dentures after each meal, if the survivor wears them, as food particles can collect and cause irritation. ► Check the mouth for food debris. Once a day ► Examine the oral cavity and tongue - should be pink and moist. 25

Oral hygiene Oral care and assessment (cont’d) Report these problems: ► The mouth should not be dry with patchy white areas ► The tongue should not be white and coated 26

Upon reflection Think about a stroke survivor who had difficulty eating. What did you do that helped? 27