Special Populations
What could you do to help a patient with missing teeth to clear the food from their mouth?
Small bites
Liquid wash
Food placement
What is a liquid wash?
1) Same thing as alternating liquids/solids!
2) Take a sip of liquids after every 1-2 bites of food.
How high should someone be sitting upright in bed during meals?
1) Upright at 90 degrees!!
Sit the bed up as high as it will go- rearrange the pillow so that their head is completely straight (not forward OR back). Pull the patient up in bed if needed.
How do you know that a patient has actually swallowed their food?
Watch their THROAT (not their mouth). The Adam's apple will move completely up and down. If you haven't seen it, they have not swallowed yet.
What is pocketing?
Holding food/liquid in mouth or cheeks.
How do you clean dentures/how often?
Take dentures out of the patient's mouth, soak with cleaning tablets overnight in container, rinse/scrub dentures with toothbrush in the morning before breakfast to remove any residual food.
They should be removed and cleaned every night.
You have a patient that eats very quickly if left by themselves during meals. What should you do?
1) Provide supervision and cues during meals to help them slow down!
2) Ask SLP if they should be in RNA dining program!
3) Ask SLP if patient should be on softer food to prevent choking.
Why would a patient need to use a double/repeat swallow?
1) To help clear food from their mouth OR their throat (you may not be able to see the residue).
This can be hard for some patients to do independently- make sure you watch for the second swallow before they take another bite!!
Why would a patient need to stay upright at 90 degrees for 30 minutes after meals?
1) If they have leftover food or liquids in their throat after they swallow.
2) If they have acid reflux/GERD- the food/liquid can come back up into their throat after meals and they can aspirate if laying down!
What are signs of aspiration?
1) Coughing- during OR after meals.
2) Throat clearing
3) Wet vocal quality
4) Increased discomfort or difficulty breathing during meals.
Which is thicker? Honey thick or nectar thick liquids?
Honey thick liquids
How do you use denture adhesive?? Where does the adhesive go??
Small strip on the edges, a small strip in the center, and a strip across the top palate portion of the dentures.
Place denture adhesive immediately prior to placing in patient's mouth. Instruct patient or assist patient to push into place and hold for a few seconds.
Your patient does not seem to be eating during their recent meals. What can you do in order to see if there is any way to help increase their intake?
1) Join them for a meal and see IF they are able to self feed and how well. Do they get tired too quickly to feed themselves the whole meal?
2) Is the food consistency too hard for them? If they appear not to tolerate the food texture, report to RN/SLP to request swallow evaluation.
3) Would they benefit from getting up in a chair or going to the dining room for meals?
Should a patient use a chin tuck before, during, or after they swallow?
They should use a chin tuck before/during the swallow!
Take a bite/sip, chin down THEN swallow!
How would you instruct a patient to turn their head to L or R during meals?
1) Turn your head left or right BEFORE you swallow!
2) Place the food/liquid in mouth, turn your head then swallow. It’s okay to keep their head turned during feeding.
Why can some patients not use a straw?
1) Muscle weakness in mouth.
2) The liquid moves more quickly into the throat and larger amount. This can make some patients aspirate.
Your patient is on thickened liquids. Can they have ice cream or Jello?
NO!
Ice cream and Jello melt into a thin liquid when they enter your mouth.
They ARE allowed magic cup ice cream!
Your patient’s dentures seem loose (moving around a lot in their mouth). What should you do?
1) See if denture adhesive helps! Place around edges of top/bottom dentures before placing in mouth.
2) If that doesn’t work- talk to SLP about evaluating patient for modified diet consistency.
You have a patient who is legally blind. What could you do to help them during meals?
1) Tell them what is in their plate!
2) Position them appropriately in front of their tray/utensils.
3) Help them cut up their food.
What are the standard swallow precautions we should use with all patients?
1) Upright at 90 degrees during meals.
2) Small, slow bites and sips.
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Why would a patient need food placed on just one side of their mouth? (Place on L or R side of mouth only)?
1) Muscle weakness on one side of their mouth (maybe due to stroke or head injury).
How many packets of thickener for 4 ounces of liquid (one juice from the fridge)?
1 packet every 4 oz of liquid (each juice is 4 oz).
A patient that you do not know well asks for a cup of water. What should you do?
1) Immediately check the room for pink swallow guidelines.
2) If not posted in room, ask the nurse to check patient's diet order.
3) Give appropriate water consistency to patient (thin, nectar or honey).
How often should oral care be done with patients?
At a minimum, morning and night (before breakfast meal, after dinner meal or before bedtime).
You have a patient who had a stroke and can’t move their left arm. What can you do to help them during their meals?
1) Position food/utensils appropriately in front of them.
2) Help them cut up their food if on a regular diet.
Why are medicine cups sometimes better for patients than a regular size cup?
1) Prevents the patient from taking large amounts at one time.
2) May be easier for them to self feed!
Why would a patient need to be upright in a chair during meals?
1) Unable to position fully upright in bed.
2) Being in a chair ensures they are completely upright during meals.
3) Upright in chair can help with their alertness and help with self feeding.
How do you check to make sure your patient is receiving the right diet texture consistency?
1) Ask the nurse to check patient’s orders.
2) Check swallow guidelines
3) Check meal ticket.
Which is considered a mixed consistency? Water or chicken noodle soup?
Chicken noodle soup or cereal with milk is considered a mixed consistency. There is both solid and liquid in one bite!
What supplies are needed to complete oral care with a patient?
1) Toothbrush
2) Mouthwash
3) Towel
4) Basin
5) Cup of water to rinse their mouth
6) Chapstick or mouth moisturizer if available
Your patient is NPO and cannot manage their secretions. What is the best way to complete oral care?
This patient will need oral care with use of an oral suction machine.
Prompt: How will you initiate oral suction machine?
Answer: Request RN to obtain order for suction machine and set it up.
What does 1:1 supervision during meals mean?
1:1 supervision means that the patient needs someone to be with them for their whole meal. This could be due to inability to pick up items without assistance, difficulty setting up utensil, need for consistent reminders to use their swallow strategies.
If it is recommended that the patient be up in a chair for meals, is it okay to just keep them in bed and sit the bed upright?
Upright in chair is a different recommendation than upright in bed. This could be recommended for a variety of reasons. It should be implemented during each meal that it is recommended. If the patient refuses, let RN and SLP know.
If a patient is on nectar thick liquids, is it okay to give them honey thick liquids as a substitute if unable to find a pre-thickened nectar thick beverage?
NO!!! Although honey thick is thicker than nectar thick, there may be safety concerns with providing a thicker liquid than recommended. It is important to follow the exact diet consistency recommendations.
What color is used to indicate that it is a HONEY thick liquid? (hint: premixed juices and thickener packets have 2 different colors based on the thickness level of the liquid).
YELLOW!!!
Bonus: What color is used for nectar thick liquid?
Pink!!
How do you determine if your patient may need help with completing oral care?
1) Can they independently use all of the oral care supplies?
2) Can they reach all of their teeth to brush them?
3) Can they open the mouthwash and independently swish/spit?