Master feeding tips to ensure safe feeding

As the aging population in my country becomes increasingly serious, the incidence of cerebrovascular diseases is increasing year by year. Literature reports that 53.61% of stroke patients in recovery have varying degrees of dysphagia, and community stroke patients need long-term swallowing guidance [1]. Normal oral eating can bring pleasure and is also an important part of social life. However, some stroke patients cannot eat independently and need assistance in feeding. How to guide caregivers to feed correctly and ensure patient safety is of great significance to rehabilitation caregivers.

How to guide feeding? Assisted feeding is divided into three stages:

1. Before eating:

⑴ Environmental preparation: Create a clean, quiet and comfortable dining environment, stop other nursing activities, and reduce factors that distract the patient's attention.

⑵ Patient preparation: Ask the patient whether he needs to urinate or defecate, whether he needs to wear dentures, and whether he needs to take oral medication before meals.

⑶ Food preparation:

① According to the properties of food, food is generally divided into five categories, namely thin liquid, thick liquid, paste, semi-solid such as soft rice, and solid such as biscuits and nuts.

② Choose the best food viscosity for the patient and the order of eating: first, rotten food or paste → chopped food or concentrated liquid → normal food and water. Acidic or fatty foods can easily cause pneumonia, while clear water is not likely to cause pneumonia.

③ According to the degree of dysphagia, choose the form of food based on the principle of starting with the easy and then the difficult. The characteristics of easy swallowing are uniform density, appropriate viscosity, not easy to loosen, easy to deform when passing through the pharynx and esophagus, and little residue on the mucosa.

(4) Body positioning: adopt an appropriate body position according to the patient's condition. Patients who can sit up should try to eat while sitting.

① Sitting position: Sitting on a chair with a backrest, with the upper body leaning forward and both feet completely on the ground is the most ideal eating posture, which can not only maintain a stable posture, but also avoid the risk of aspiration. In addition, those who have difficulty controlling balance due to hemiplegia can choose a chair with armrests.

② Semi-sitting position: Generally, the trunk is in a supine position of at least 30°, the head is flexed forward, and the shoulder on the hemiplegic side is supported by a soft pillow. In clinical practice, the head of the bed can be raised to 45° for patients with air mattresses, and to 60° for patients without air mattresses. This position is conducive to the descent of the food bolus, thereby reducing the occurrence of aspiration. Neck flexion is a method to prevent aspiration. When lying on the back, the neck is prone to flexion, which makes the muscles of the anterior cervical spine related to swallowing tense and the larynx difficult to lift, making aspiration more likely. After confirming that swallowing can be done safely, the angle can be raised [2].

2. During eating:

⑴ Choice of position: If the patient is hemiplegic, the caregiver should sit on the healthy side of the patient, with the caregiver's line of sight parallel to the patient's line of sight, and try not to stand.

⑵ Temperature of food: The caregiver takes a small amount of food and tests the temperature of the food on the skin on the palm side of the wrist. If it is too hot, you will get burned; if it is too cold, it will cause stomach discomfort.

⑶Spoon size: Choose a spoon of appropriate size, preferably one with a capacity of about 5-10 ml. The amount of food should be 1/3 of the spoon. The spoon should be horizontal to the lips and the food should be placed in the most sensitive part of the patient's mouth, such as the back of the healthy tongue or the healthy cheek, to facilitate swallowing. This is also suitable for patients with weak facial and tongue muscles [3]. After seeing the patient swallow completely, instruct the patient to swallow empty-mouthed or alternately.

⑷ Do not talk while eating: When the patient is eating, the caregiver should try not to communicate with the patient verbally to prevent choking and aspiration.

⑸ Once choking occurs, take two steps immediately: one is to dig out the food in the oropharynx to clear the airway; the second is first aid, abdominal impact method, and Heimlich first aid method should be used immediately, including abdominal impact method for adults in standing and supine positions; if conditions permit, a simple negative pressure suction device can be prepared at the bedside.

3. After eating:

⑴ Check whether there is any residual food in the patient's mouth and remove it immediately to prevent residual food from falling off and being inhaled into the respiratory tract. Keep the patient in a semi-recumbent or sitting position for more than 30 minutes after eating and avoid frequent activities to ensure that the food completely enters the stomach and prevent food reflux [4]. During this period, it is not advisable to turn over or pat the back.

(2) Cleanliness: Oral hygiene is very important for patients with dysphagia. Cleaning the oral cavity and pharynx before and after eating can effectively prevent lung infections in patients with dysphagia [5].

Master the swallowing technique to prevent choking and add three additional actions when feeding [6]:

01 Empty swallowing and interactive swallowing

Before eating, ask the patient to do an empty swallowing movement, and after swallowing the food, ask the patient to do an empty swallowing movement again to ensure that the food is completely swallowed.

02 Lateral swallowing

During each meal, ask the patient to turn his head to the left and right while swallowing, and perform lateral swallowing 3 times per meal.

03 Nodding swallowing

After each meal, tilt your neck back and flex it forward, and swallow while flexing it forward, do this twice to clear any remaining food in the throat.

The best time for body function recovery after stroke is 3 to 6 months after onset. Therefore, paying attention to early swallowing and feeding management can promote functional recovery to the greatest extent [7]. It is worth noting that the "Chinese Guidelines for Clinical Management of Cerebrovascular Disease" recommends that all acute stroke patients should complete swallowing function screening before oral feeding and drinking to identify whether there is aspiration. Early screening for aspiration can reduce adverse health events such as pneumonia and reduce post-stroke mortality or composite endpoint events [8]. By identifying high-risk groups prone to dysphagia, swallowing-feeding management and rehabilitation care for stroke patients in the community can be more instructive, and can further reduce the occurrence of aspiration pneumonia and other complications.

References:

[1] Zhang Xiaoyan, Wang Yuanhong, Chai Jingjing, et al. Preliminary construction of community evidence-based practice program for identification and management of dysphagia in stroke patients[J]. Journal of Nursing, 2020, 35(1): 14-17.

[2] Zheng Cai'e, Li Xiuyun. Practical rehabilitation nursing[M]. Beijing: People's Medical Publishing House, 2020: 287-288.

[3] Yin Yamei. Observation on the effect of rehabilitation training on patients with dysphagia after stroke[J]. Journal of Practical Clinical Medicine, 2019, 23(12): 98-102.

[4] Gao Caiping, Zhai Hua, Pan Caihua, et al. Application analysis of swallowing and feeding management in improving dysphagia in patients with post-traumatic brain injury[J]. Chinese Journal of Practical Nursing, 2018, 34(33): 2561-2566.

5]Kyoung DK, Hyun JL, Myoung HL, et a1. Effects of neck exercises on swallowing function of patients with stroke[J]． J Phys Sci, 2015, 27(4): 1005-1008.

[6] Pei Hua, Zhang Laihua. Application of swallowing function training in elderly patients with swallowing dysfunction[J]. Shanghai Nursing, 2016, 16(1): 12-14.

[7] Zhu Meihong, Shi Meifang, Wan Lihong, et al. Study on swallowing-eating management to prevent pneumonia associated with stroke dysphagia[J]. Chinese Journal of Nursing, 2016, 51(3): 294-298.

DOI:10.3761/j.issn.0254-1769.2016.03.007.

[8] Wang Yongjun, Xu Anding, Dong Qiang, et al. Cerebrovascular Disease in China[M]. People's Medical Publishing House, 2019: 412-416.

Author: Li Hong1 Gao Caiping2

Unit 1: Beicai Community Health Service Center, Pudong New District, Shanghai

Unit 2: Shanghai Yangzhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center)

Chief Judge: Zhai Hua, Vice Chairman of the Science Popularization Working Committee of the Chinese Rehabilitation Medicine Association,

Secretary of the Party Committee of Yangzhi Rehabilitation Hospital Affiliated to Tongji University

The popular science content of this platform has been funded by the China Association for Science and Technology's Science Popularization Department's 2022 National Science Literacy Action Project "National Society Science Popularization Capacity Improvement Project-Rehabilitation Science Popularization Service Capacity Improvement Action Plan"