Nursing Diagnosis: Feeding Self-care deficit Application of NANDA, NOC, NIC

Nursing Diagnosis: Feeding Self-care deficit
Linda S. Williams

NANDA Definition: Impaired ability to perform or complete feeding activities

Defining Characteristics: Inability to swallow food; inability to prepare food for ingestion; inability to handle utensils; inability to chew food; inability to use assistive device; inability to get food onto utensils; inability to open containers; inability to ingest food safely; inability to manipulate food in mouth; inability to bring food from a receptacle to the mouth; inability to complete a meal; inability to ingest food in a socially acceptable manner; inability to pick up cup or glass; inability to ingest sufficient food

Related Factors: Weakness or tiredness; severe anxiety; neuromuscular impairment; pain; perceptual or cognitive impairment; discomfort; environmental barriers; decreased or lack of motivation; musculoskeletal impairment

NOTE: See suggested Functional Level Classification in the care plan Impaired physical Mobility.

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Self-Care: Activities of Daily Living (ADLs)

·         Self-Care: Eating

Client Outcomes

·         Feeds self

·         States satisfaction with ability to use adaptive devices for feeding

·         Provides assistance with feeding when necessary (caregiver)

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Feeding

·         Self-Care Assistance: Feeding

Nursing Interventions and Rationales

·         Observe for cause of inability to feed self independently (see Related Factors). Self-care requires multisystem competence. Restorative program planning is specific to problems that interfere with self-care (Phaneuf, 1996).

·         Assess client's ability to feed self. Test gag reflex bilaterally, and note specific deficits. Functional assessment provides ADLs task analysis data for matching client's ability to feed self with caregiver's level of assistance (Van Ort, Phillips, 1995).

·         Ask client for input on methods to facilitate eating and feeding (e.g., cultural foods, other food and fluid preferences) and provide four entrée choices, including ethnic choice. When clients are given a choice, their food intake increases (Kayser-Jones, 1997).

·         Request referral for occupational and physical therapy; request a dietician. Collaboration and correlation of activities with interdisciplinary team members increases the client's mastery of self-care tasks.

·         Ensure that client has dentures, hearing aids, and glasses in place. Adaptive devices increase opportunity for self-care.

·         Use any necessary adaptive feeding equipment (e.g., rocker knives, plate guards, suction mats, built-up handles on utensils, scoop dishes, large-handled cups). Adaptive devices increase independence.

·         Seat client at table using name card and place mat with meal in visual range next to role model who can eat, if applicable. Familiar feeding patterns and cues increase self-feeding (Van Ort, Phillips, 1995).

·         Help client into sitting position; ensure that client's head is flexed slightly forward and shoulders are supported while eating and for 1 hour after a meal. Gravity assists with swallowing, and aspiration is decreased when sitting upright.

·         Prepare meal items before client begins eating. Preparing items for the client conserves energy for hand-to-mouth activities.

·         Provide small portions of favorite foods, one entrée at a time, at proper serving temperature. Food intake is increased when meal appeals to client and is simplified (Kayser-Jones, Schell, 1997).

·         Provide consistency in caregiver and meal activities. Assigning caregivers to clients rather than dining areas allows caregiver to learn client's needs and promotes a positive attitude between caregiver and client (Kennedy-Holzapfel et al, 1996).

·         Caregiver should sit beside client (on client's unaffected side) at eye level. Sitting at eye level with client increases eye contact and promotes a relaxed atmosphere that increases consumed food (Kennedy-Holzapfel et al, 1996).

·         Caregiver should sit at a half circle table if interacting with a group of clients and should remain with clients until meal is completed. Environmental strategies that reduce interruptions and distractions increase food intake (Van Ort, Phillips, 1995).

·         Encourage participation; guide client's hand through task if needed; provide cues and pantomime desired behaviors. Experiencing the normal process of a task through guided practice facilitates optimal relearning (Tappen, 1994).

·         Allow client to participate in feeding as able; provide verbal prompting; provide praise for all feeding attempts; increase tasks as able. The client should be an active participant in feeding instead of a passive recipient of food (Osburn, Marshall, 1993).

·         Plan activities to prevent fatigue before meals. Energy conservation increases activity tolerance and promotes self-care.

·         Provide medication for pain before meals if needed. Pain relief promotes participation in self-care.

·         Provide client with a pleasant social meal environment. Keep the environment free of toileting devices and odors, avoid painful procedures before meals, remove lids from tray, and provide clean utensils for separate courses. Attention to the aesthetics of feeding increases food intake (Kayser-Jones, Schell, 1997).

·         Do not mix different foods together when assisting client with eating. Mixing foods together decreases client dignity and reduces appeal of food, decreasing food intake (Kayser-Jones, Schell, 1997).

·         Play slow-tempo, quiet music during meals. Agitated behaviors may communicate anxiety from a noisy, overwhelming environment; quiet music can mask this, resulting in relaxed and smiling clients (Denney, 1997).

·         Encourage client to keep food on the unaffected side of mouth with a rocking motion to deposit the food. Keeping food away from the affected side of the mouth prevents pocketing of food (Donahue, 1990).

·         Be prepared to intervene if choking occurs; have suction equipment readily available and know the Heimlich maneuver. Dysphagia increases the risk of choking (Donahue, 1990).

·         Provide oral hygiene after eating and check for pocketing of food. Aspiration can occur from food left in the mouth.

Geriatric

·         Allow client with dentures adequate time to chew. Chewing with dentures takes four times longer to reach a certain level of mastication than chewing with natural teeth.

·         Choose soft foods rather than liquids, or use dietary thickeners. Choking occurs more easily with clear liquids than with solid or soft foods.

·         Assess for intolerance to food texture and, if found, reverse food texture pattern as tolerated, progressing finally to texture stage of thick liquids. Dementia clients lose ability to tolerate texture-pattern reverses from regular to soft to mechanical soft to mechanical soft with chopped meat to puree to thick liquids, and pocketing of food is seen, along with statements of choking and spitting of food (Boylston et al, 1995).

·         Provide finger foods for clients with Alzheimer's disease and place in hands as needed to cue. Finger foods attract patient attention and increase involvement in meal. They are easier to handle than utensils and, as a result, weight is maintained (Slotesz, Dayton, 1995). Finger foods can be nutritious and can allow independence and the choice of what and when to eat (Kennedy-Holzapfel et al, 1996).

Home Care Interventions

·         Based on functional assessment and rehabilitation capacity, refer for home health aide services to assist with feeding. Support by home health aides preserves the energy of the client and provides respite for caregivers.

·         Cue cognitively impaired client when feeding. Cognitively impaired clients can participate successfully in many activities with cueing. Participation in self-care can enhance the self-esteem of cognitively impaired clients.

·         Respect the preference of terminally ill clients to refuse nutrition or assistance with eating. Refer to care plans for Imbalanced Nutrition: less than body requirements and Impaired Swallowing.

·         If terminally ill client requests nutrition, take special care to provide foods and assistive devices that protect the client from aspiration, minimize energy requirements, and meet the client's taste preferences. Terminally ill clients have altered taste and other sensations, which impacts their willingness to eat or to invest time or energy in eating.

Client/Family Teaching

·         Teach client how to use adaptive devices. Adaptive devices increase independence.

·         Teach client with hemianopsia to turn head so that the plate is in the line of vision. Compensation for hemianopsia is done by turning head to place items in line of vision (Needham, 1993).

·         Teach visually impaired client to locate foods according to numbers on a clock.

·         Teach caregiver-feeding techniques that prevent choking (e.g., sitting beside client on the unaffected side, feeding client slowly, checking food temperature, providing fluid between bites, establishing a method to communicate readiness for next bite, limiting conversation while chewing).