Nursing Skill: Assisting patients to feed and drink
My chosen skill is to assist the patients to feed and drink. I have chosen this skill because I believe that it is a very important task, research and my personal experience has showed me that it is common in the hospital setting for patients to need assistance at meal times. It is undeniable that patient malnutrition needs to be taken seriously and nurses should have the appropriate knowledge and training to understand all the issues surrounding assisting patients to eat. Furthermore, nutritional support needs to be discussed and arranged between members of the multidisciplinary team to identify the problems and to adapt to the circumstances of each patient. Holland et al (1993: 169) claims “Being fed by others can be quite threatening and demoralising” and to support the patient the nurses need to understand and apply the Holistic approach to health in taking into account the individual physical, emotional, social and spiritual well-being.
This essay will explain the importance in using nursing models when assessing patient’s nutritional condition and assessment tools that help to identify the patient’s individual needs and also guide the nurses in assisting the patient. I will also explore the importance of communication skills when assisting patients to feed. As good communication skills are so imperative when assisting patients to eat I will explore patient’s personal limitations, environmental and cultural issues giving some solutions to overcome these barriers. I will also describe some biological factors such as ingestion, digestion, absorption and will point out ways to improve patient nutritional requirements using artificial feeding and food supplements.
In addition, I will demonstrate the impact of psychological factors involved in feeding the patient taking into consideration the Lazarus and Folkman (1984) “Transactional model” to understand and support the patient. I will also link the importance of sociological factors and health using Parson’s sick role and the sociological importance given to food. Moreover, I will explore the importance of understanding and respecting other cultures to overcome barriers when feeding the patient and will give some examples of how other cultures perceive food. Finally, I will identify the professional, legal and ethical issues related with assisting the patient to eat and drink being aware of codes of practice and personal accountability. I will also speak about “protected meal times” policy that was implemented to focus on the patient’s individual needs.
Newton (1991) believes that nursing models provide the foundation to nursing practice but also using the same nursing model can guarantee validity and “continuity” to patient individualised care. The Roper, Logan and Tierney model has five dimensions “biological”, “psychological”, “socio-cultural”, “politico-economical” and “environmental” there are also 12 “activities of living”, some of which are essential such as “eating and drinking” and others which enhance the quality of life such as “working and playing” (Roper et al, 1996). Applying the Roper model will enable the nurse to make an individual assessment for the patient using a Holistic approach to health by taking into account the individual physical, emotional, social spiritual well-being and also should identify abilities, beliefs and preferences of the patient ( Holland et all, 2003).
To assess and identify the patient nutritional condition; to implement an individualised daily dietary requirement, to be able to recognise if the patient needs assistance, to document patient oral intake and revise if needed is the “responsibility” of the nurse (Lindsay, 1998). Nutritional assessment tools are recommendations that support the nurse and the patient in making conscious decisions in relation to their individual health needs (NICE, 2006). The initial assessment should be able to identify individual needs of the patient in relation to the activity of eating and drinking such as, physical problems (e.g., swallowing), cultural, religious, psychological (e.g. motivation), nutritional status, personal preferences and their accessibility to food and drink (Holland et all, 2003).
Lindsay (1998) claims that nursing skills are the key to an accurate nutritional assessment and this can be achieved using verbal or non verbal communication skills such as, questioning the patient or their carers, to observe patient body language, to monitor patients vital signs and the use of appropriate “nutrition assessment tools”. To validate the assessment it is important that all members of the multidisciplinary team are involved such as the “dietician”, “nutritionist”, “speech and language therapists”, “occupational therapists” and “physiotherapists” (Essence of care, 2003). To be able to apply the appropriate “nursing interventions” the assessment process should be reviewed as many times as is required by any alteration in the patient health (Holland et all, 2003).
Sheldon et al (2006) argues that to achieve effective communication it is important to learn about the patient, create a relationship of understanding and trust that can be facilitated by the time that patient and nurses spend together. Benchmarks were created to improve the provision of care in meeting patients individual needs, for example, when assisting a patient to eat and drink it is important to guarantee the daily diet requirements; to monitor and to document; to ensure patient dignity, to respect and be aware of the patient’s preferences, choices, beliefs (Essence of care, 2001). Communication is a vital tool in health care settings because it assists the nurse to meet the patient’s physical and emotional requirements (Sheldon et al, 2006).
Robinson et al (2006) suggests that the “aging process”, “life experiences” and personal limitations of the older patients can make communication difficult and to overcome these barriers it is necessary to spend additional time, being interested, attentive and showing empathy to the patient. Nurses need to allow time with the patients to support them in choosing the menu, respecting the patient’s choices but also being attentive with the patient’s individual health needs. To ensure effective communication with patients with special needs D’Wynter (2006) claims “We attain success in our relationships, our education, and our occupations through the ability to adapt our language and communication style to the unique requirements of every situation”.
Patients who suffer from sensory disabilities will require specific communication techniques when assisting them to eat, for example patients with visual disabilities will rely on ways of communication like olfactory, tactile communication can be very important but it depends on how comfortable or not people feel with touch. Ways to overcome these barriers are to use language to describe and explain the food, assist people to handle cutlery, to smell, and also to check aid equipment. Lieu et all (2007) says that some people with hearing disabilities are able to lip-read, others can use sign language to communicate and ways to assist the patient in this case can be by speaking in normal and clear speech, making sure that the face is visible and learning to sign or to ask for help from interpreters.
New environments can be barriers to communication too, because they can be heavily influenced by emotional barriers like fear and feeling apprehensive with new situations. Ways to reduce these problems when assisting patients to eat could be by reducing noise, checking seating arrangements and trying to familiarise the patient with the new environment. The patient’s carer needs to be involved in all processes because they are the persons who are in more direct contact with the patient and can give important clues. Cultural and ethnic influences need to be taken into account when feeding the patient; therefore it is important to use communication skills to overcome these cultural barriers to have some understanding about cultural differences.
Food and water are the main supply of fuel that the body requires to survive (Roper et al, 1996). Holland et al (2003) explains food “ingestion” , “digestion” and “absorption” saying that “ingestion” starts when food enter into the body via the mouth, the lips have the function of holding the food inside the mouth to be chewed and broken into small pieces by teeth then swallowed before passing through the oesophagus towards the stomach; “digestion” happens in the stomach continuing the breakdown of food helped by the “gastric juices” until a semi liquid texture can pass slowly into the duodenum to be broken down completely, for example proteins broken into amino acids, these nutrients are prepared to be “absorbed” and delivered to other parts of the body using the “bloodstream”.
For the patients that cannot swallow and have “poor oral intake”, “artificial” feeding can be given by “enteral tube feeding” respecting the patient’s best interests and doses should be monitored by the dieticians (Stroud et al, 2003). When assessing the patient, Body Mass Index (BMI) should be calculated and documented “The BMI calculation determines if you are healthy for your height” (The United Bristol Healthcare) and considers a healthy weight to be 18.5 – 25. To improve patient nutritional requirements “oral dietary supplements” can be recommended to “complement” the patient daily diet , moreover patients with dysphasia (swallowing problems) can benefit from the varieties of supplements such as “rice puddings” or “soups” that have the required texture (Green, 1999). Patients with swallowing difficulties require different food consistency, some patients need thicker foods and others maybe need liquidised foods.
According to Holmes (2008) patients can decrease their food intake when they are admitted to hospital as they can perceive the ward environment as a stressful one. The way that patients perceive “food and drink” can be related to psychological issues as Holland et al (2003) points out. When assisting patients to feed it is important to observe and recognise any sign of stress or anxiety to be able to address the patient’s real concerns. Lazarus and Folkman (1984) “Transactional model” focus on the interaction between the patient and the way the patient “appraise” their surroundings. In practice, this relates to previous life experiences and the way that patients had coped before.
Manthorpe and Watson (2003:166) suggest “people who accept being fed instead of eating independently may develop a form of learned helplessness” that will delay their discharge. Therefore it is important to reduce insecurity and increase patient personal control and this can be achieved by enhancing patient self-education, giving emotional support and encouraging independency. Some reasons for cognitive impairment in hospitalized elderly patients can include dementia, delirium, trauma and stress.
Patients suffering from dementia for example, are more susceptive to degenerate while in hospital because of their challenging behaviour to new settings and also distorted eating habits, loss of desire for food, loss of capacity to identify food, lost of capacity to use cutlery and swallowing problems (Amella and Lawrence, 2007). The multidisciplinary team consisting of the nurse, the Occupational Therapist, Social Worker and a Psychiatrist will work to identify the problems and to adapt to the circumstances of each patient.
Health is dependent on “social factors”, “physical” and “economic conditions” in which people live and it is crucial to a life without illness, also the “sociology of health” studies the personal experiences when someone is ill (Giddens, 2001). By doing this it was possible to understand certain behaviour patterns people adopt when they are ill and at the same time to be aware that particular diseases influence peoples behaviour and actions. Parson’s ‘”sick role” outline patterns of behaviour that a sick individual will adopt when they are ill to minimize the impact of the illness on the social daily life, the patient has obligations and privileges when ill, the patient is not responsible for their illness, needs to seek medical advice to get well soon as possible and finally the individual is free from some responsibilities or activities (Giddens, 2001).
On the other hand, patients who choose not to comply with the treatment or who will not recover from their illness are not recognised by the “sick role” (Roper et all, 1996). Sherwood suggests that food and drink are usually perceived as a pleasant social activity and is also an indicator of “personal identity”. Xia and McCutcheon (2005) believes that during mealtimes “social interaction” between elderly patients in the ward should be encouraged because eating together could result in patients becoming more entertained with other patients company and consequently increase their food intake.
In my placement I used this approach with two patients that during mealtimes used to chat with each other usually shouting because their beds were far away, I asked them if they wanted to be near so they could talk and with their consent I put the two tables together. At the end of the meal, when taking their plates away I realised that both plates were empty and with one of the patients this was unusual.
For the nurse to establish the patient diet it is essential to find out about the patient’s culture and religious beliefs because cultural differences need to be taken into account when feeding the patients. This can be achieved by talking with the patients or their carers about their dietary requirements, cultural preferences and also having in attention special celebrations and calendar events ((Wrightington, Wigan & Leigh NHS Trust). It is very important not to make assumptions and label people because they behave differently, being sensitive and respecting different beliefs will help the health professionals in the delivery of good practice, always considering the patients individual needs.
Different cultures have different religious beliefs in relation to food therefore it is important to overcome these cultural barriers by having some understanding about cultural differences, for example, for Muslims some foods are not allowed such as, “pork, non-halal meat and chicken, shellfish and alcohol” and for Sikhs “Beef, sometimes all meats and fish, alcohol” ( Food Standard Agency, 2008). To overcome these barriers hospitals had to transform their menu choices taking into account special diet needs. Carlowe (2007) suggests that patient health will benefit and consequently decrease the hospitalization time if they are given food that meets their religious beliefs because patients will feel more confident and in control.
To deliver a better care to patients the staff should be informed about other cultures and beliefs. To achieve the necessary knowledge it is necessary to the Health Care Organizations to be responsible to provide enough education to staff as for example, the document provided by The County Durham and Darlington Acute Hospitals Trust “Respecting the Religious and Cultural Needs of Patients” that gives useful information about other religions and beliefs.
When delivering care to the patient legal and ethical procedures need to be taken into account because they are essential to good practice. The Nursing & Midwifery Council (NMC) code of professional conduct (2004) established guidelines to inform nurses about their “professional accountability and practice”. Nurses are professionally accountable for their actions and decisions involving patient care and safeguarding patient’s interests independently of their “culture, ethnicity and religious beliefs” (NMC, 2004). Prior to delivering patient care the nurses need to request for “voluntary consent” which is valid if given by a patient that fully understood all the consequences of their decisions (Department of Health, 2004).
When assisting the patient to eat and drink it is important to provide the required assistance and also meet the patient’s individual dietary needs while ensuring their dignity, the nurse can follow guidelines such as the “Essence of Care benchmarks” or implemented policies such as “protected meal times” (Healthcare Commission, 2007). Furthermore, the Royal College of Nursing (2007) published the “Principles for Nutrition and Hydration” to assist the nurses in providing daily dietary requirements to the patient focusing on the principles of “accountability”, “responsibility” and “management” always working together with a multidisciplinary team.
The introduction of “Protected meal times” policy focus on food and nutrition and were implemented to protect patients against avoidable distractions aiming to offer a better “patient-meal experience” with appropriate assistance and encouragement by the nurses (Leicestershire County and Rutland Primary Care Trust, 2007). When assisting patients to eat nurses should be attentive to patients individuals needs, such as “positioning the patient properly, washing hands or providing wipes” before mealtimes (The Healthcare Commission, 2007).
Other example of policy relating to food is the “Better Hospital Food programme” that aims to provide a better care focused on patient individual needs and choices, for example in providing “24-hour catering”, “flexi-menus” ( Department of Health, 2007). It is an ethical duty to assist patients to eat and monitor their nutritional status although if the oral intake is nil and the patient is not able to swallow, enteral tube feeding can be used to achieve patient nutritional status having in consideration patient choices and valid consent (Royal College of Nursing, 1998).
In conclusion, I had learned that when assisting patients to eat and drink it is necessary to use a Holistic approach to health in taking into account the individual physical, emotional, social and spiritual well-being. It is vital that the nurses can be able to adapt to different circumstances relating to assisting patients to eat and at the same time acknowledge a patient centred approach to deliver care. It is necessary to prevent weight loss during patient hospitalization because this is when the patient is more susceptive to feeling anxious or in distress and consequently they can loose their appetite. The patient needs to be assessed to find their medical history and to focus on why the loss of weight for example, happened in the first place.
I had also learned how important the use of a multidisciplinary team is to address the patient physical condition, for example if a patient has dysphasia a specialist in speech or a language therapist can give the best advice about sitting posture or head position that gives more comfort for the patient, the dietitian can ensure that nutritional requirements are met. I realize that to ensure correct nutritional support it is vital to ensure patients requirements such as, preferred foods and ethnic food choices are available. It is vital to check the patient’s progress against the identified goals discussed beforehand by the multidisciplinary team to evaluate if they were met or not. I also learned that food handling should strictly follow policies respecting hygiene and should be given special attention because it is important for the patient’s recovery. It is vital to ensure a clean environment, for example, a clean table, clean cutlery, to minimise smells or unpleasant noises. Staff should always wash their hands and encourage the same from the patients and their visitors.
The nursing care plan should include a plan for discharge or transfer of care, for example patients returning to nursing homes, to assist a safe and successful discharge back into the community, it is necessary to ensure the same nutritional requirements continue to be met after discharge. It is important to have good communication skills to promote patient self-care through education and involving the patient’s carer if necessary. It is also important to provide the carer’s with appropriate knowledge to meet the patient’s needs. To be able to write this assignment I had to do a lot of research. I used books from the library, the library database “OVID”, the UBHT intranet in my placement and the internet to look for articles and journals.
Word count: 3,766
References:
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