Journal of Community Nursing - page 82

82 JCN
2013,Vol 27, No 4
crush tablets and add them to water.
The latter usually produces a bolus,
which is not as thick as a thin puree
— however, if the thickness is not
appropriate for the patient then they
may be more at risk of aspiration.
Thickeners are designed to reduce
the risk of aspiration by helping
the patient create a cohesive bolus
and altering the bolus’ viscosity
and texture. However, thickeners
can also negatively affect both food
palatability and the bio-availability
of medications taken at mealtimes.
Also, thickeners are often mixed
incorrectly by carers and the required
fluid viscosity may not be achieved
(Crawford et al, 2007).
It has been shown that patients
on thickened fluids rarely meet
the hydration targets necessary for
good health, while still experiencing
a high incidence of aspiration
pneumonia (Finestone et al, 2001).
Posture is important for patients
with limited motor ability. During
the feeding process poor posture can
affect the initiation of motor skills,
the breathing pattern required for
eating and drinking, the swallow
mechanism, and effective gut motility
(Morton et al, 1993). Providing
postural stability during mealtimes
can improve oral preparatory and oral
phase stability. Also, appropriate head
control and whole-body stability —
particularly in the pelvis and hips,
trunk, shoulder girdle, and legs —
can help to reduce the risk
of aspiration.
Where possible, patients should
be encouraged to be independent
when eating as this enables them
to control the speed and pace of the
meal. Importantly, by setting the
pace, the patient can create a bolus
of food and clear the oral cavity
before taking the next mouthful
(Pinnington and Hegarty, 2000).
When using utensils, hand-over-
hand prompting can also maximise
opportunities for independent
eating and drinking. This method
involves the clinician actually
‘cupping’ the patient’s cutlery-
holding hand and providing
physical guidance. Hand-over-hand
prompting can help the patient
prepare themselves as much as
possible for the subsequent swallow.
PEG feeding
Percutaneous endoscopic
gastrostomy (PEG) may be necessary
if eating and drinking difficulties
are so severe that oral feeding is not
safe or if the patient is not able to
consume adequate nutrition orally.
In these situations the guidelines
highlight the importance of oral
hygiene to prevent the build-up of
residues that can cause infection
or contribute to aspiration-related
illnesses. If a patient is receiving
food and liquids via PEG, nurses
should assess the administration of
medicines as they may be unlicensed
through this route —White and
Bradnam (2010) provide guidance on
safe PEG administration.
Care plans
In their guidelines, Wright et
al (2012) state that in order to
adequately care for patients with
swallowing difficulties, carers need
to understand the implications
of the condition, have received
training on management strategies,
and have a written management
plan. Written materials should
be used to manage swallowing
difficulties in patients with a
learning disability and these should
include care plans for eating,
drinking and swallowing and
mealtime information forms.
Management/care plans should:
Be individualised
Include advice provided by a
speech and language therapist
and a dietitian
Outline the patient’s needs
Identify plans or goals to address
those needs
Make clear the actions needed to
achieve the goals
Evaluate the management
A community nurse visiting a
patient should be aware of such plans
and is ideally placed to monitor
their implementation.
The correct administration of
medicines is key to patient safety.
An appropriate medication review
must include investigating the best
method of drug delivery, which
will improve patients’ willingness
to take their medication. When
selecting the administration method
it is necessary to consider delivery,
patient safety, and the legality
of any recommendations that
are made.
The guidelines strongly
recommend that patients with
learning disabilities who are newly
diagnosed with dysphagia should
undergo a medication review to
ensure they are only receiving
medicines that are necessary
and effective as well as being the
appropriate dosage (Wright et al,
2012). Medication reviews should
be conducted regularly and a
structured review process should
be created in order to improve care,
reduce risk, and address compliance
issues. The NO TEARS tool is
recommended (Lewis, 2004) and
summarised below:
eed and indication: does the
patient still need the treatment
and is the indication for the
medication still relevant?
pen questions: while difficult
in patients with learning
disabilities, open questions
present an opportunity to
explore compliance issues
ests and monitoring: should
any tests be conducted or
monitoring carried out?
vidence and guidelines: has
the premise for initiating,
maintaining, or stopping
treatment changed?
dverse events: has the patient
developed any new signs
or symptoms that could be
isk reduction or prevention: are
there any other risks to consider
and would current therapy affect
these risks?
‘It has been shown that
patients on thickened fluids
rarely meet the hydration
targets necessary for
good health.’
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