6.4 Special Diets

There are times when physicians order special diets for their clients for different reasons, such as disease, weight control, or physical or neurological changes that put clients at risk of choking. But just like any meal planning, the client’s preferences, culture, religion, allergies, and intolerances are taken into consideration.

In care facilities, when a client does not have any dietary restrictions, their diet would be called either a regular or general diet. However, there are many types of special diets that you may see in your practice. For example, there are restricted diets, such as the diabetic diet, sodium-controlled diet, or a gluten-free diet. There are also diets that have modified texture due to illness, disease, or neurological and physical disabilities. A clear-liquid diet would be for acute illness or for post-operative patients, or the mechanical soft diet may be used for gastro-intestinal disorder, or moving from a liquid diet. Whatever diet is ordered for the client, it is chosen based on a thorough assessment of the client’s history, health status, and ability to swallow, and it will be outlined in their care plan.

Considerations

  1. If the client has facial weakness, arm/hand weakness, or paralysis, assist with eating from the client’s strong side and place eating utensils on their stronger side.
  2. If the client has a swallowing problem, allow longer periods between bites for adequate chewing and swallowing. Encourage the client to tuck their chin down and bend their body forward while swallowing. This encourages the food to move down the esophagus.
  3. Limit the amount of conversation while the client is chewing and/or swallowing.
  4. Ensure that food is cut into bite-sized pieces and that food is the appropriate consistency (e.g., pureed), according to the client’s prescribed diet.

Types of Modified Texture Diets

 

Figure 6.4.1 Texture-Modified Diets (Infographic courtesy IDDSI, 2022). CC BY SA 4.0

Table 6.4.1: Liquid Consistencies

 
LEVEL TYPE DESCRIPTION/ CHARACTERISTICS
0 Thin drinks
  • Flow like water
  • Can flow through a straw
1 Slightly Thick drinks
  • Are thicker than water
  • Can flow through a straw
2 ‘Sippable’ drinks
  • Pour quickly from a spoon, but slower than thin drinks and slightly thick drinks
  • Need some effort to drink this thickness using a standard straw
3 Moderately thick drinks
  • Can be drunk from a cup or taken with a spoon
  • Have a smooth texture with no lumps, fibers or seeds
  • Need some effort to drink them through a wide diameter straw
(Source: IDDSI, 2019) CC BY SA 4.0

Adaptive eating devices are modified utensils, dishes, and cups to make it easier for people with different types of physical difficulties to eat — clients who may be weak or have difficulty grasping utensils. These devices can enhance mealtime and client independence, as well. While there are many such devices on the market, they can easily be made by simply building up the hand of eating utensils with gauze and tape.

 

Figure 6.4.2 Adaptive Utensils (Image courtesy of A. Morice.) CC0 Public Domain 
Clients with visual impairments may need to be instructed about the position of food on their plate. An easy way to do this is to use the clock method. Instruct clients about position of their food using the face of a clock as a guide. For example, “The peas are at 2:00, the meatloaf is at 6:00 and the rice is at 9:00.”

Special Diets – Enteral Nutrition

Some clients, because of illness, injury, or surgery, have extreme difficulty chewing or swallowing and as a result have additional dietary considerations. For such clients, it is unsafe to eat or drink by mouth, therefore a physician will order all foods, fluids, and medications to be given through a tube. Only licensed healthcare workers can administer the foods, fluids, and medications through the tube, but as an HCA you will care for clients who have had these procedures, so it is important for you to understand.

Enteral nutrition is provided to people who cannot chew or swallow foods or fluids past their esophagus into their stomachs. Enteral nutrition is a liquid nutritional formula delivered into the gastro-intestinal tract through a Gavage tube. The need for enteral nutrition may occur due to trauma or cancers to the face, mouth, esophagus, or neck. Also, people with advanced dementia who no longer know how to eat may have a gavage tube. Many people refer to these types of tubes as “G-tubes,” and there are many types of G-tubes depending on where they are surgically placed (Sorrentino, et al., 2019).

Table 6.4.2: Types of Enteral Nutritional Feeding Tubes

Nasogastric (NG) tube:

Inserted through the nose into the stomach

  

Figure 6.4.3 Nasogastric (NG) Tube (Image courtesy of Cancer Research UK/Wikimedia Commons) CC BY-SA 4.0
Naso-intestinal (NG) tube:

Inserted through the nose into the small intestine

  

Figure 6.4.4 Naso-Intestinal NG Tube (Image courtesy of Cancer Research UK/Wikimedia Commons) CC BY-SA 4.0
Gastrostomy (G-tube) tube:

Inserted directly into the stomach through surgical opening. Types of tubes include the J-tube and the PEG-tube as noted below.

  

Figure 6.4.5 Gastronomy (G-Tube) (Image courtesy of Cancer Research UK/Wikimedia Commons) CC BY-SA 4.0
Jejunostomy (J-tube) tube or Gastro-jejunostomy (GJ) tube:

Placed in surgical opening in middle of small intestine (jejunum). Access is both stomach and jejunum. Typically, the tube is placed in a G-tube stoma with a narrower long tube into the small intestine. Used with clients at high risk of aspiration.
Figure 6.4.6 J-Tube or Gastro-Jejunostomy (GJ) (Image courtesy of Cancer Research UK/Wikimedia Commons) CC BY-SA 4.0
Percutaneous endoscopic gastrostomy (PEG) tube:

Using an endoscope to see into the stomach, the physician will make a puncture wound (stomy) in the skin and into the stomach. A short tube is inserted into the stomach through the puncture wound and the tube sits flush against the skin.

 

  

Figure 6.4.7 PEG Tube (Image courtesy of Cancer Research UK/Wikimedia Commons) CC BY-SA 4.0

(Source: Sorrentino, et al., 2019)

How often a client may receive enteral nutrition depends on how the physician or dietician orders them, as well as the type of tube in place. There could be scheduled feedings given four times per day or these could be continuous over the day. Naso-intestinal and jejunostomy tube feedings are always continuous.

What is the HCA Role in Enteral Nutrition?

As the HCA care for someone with an enteral feeding tube your role mostly be observation, unless the task has been delegated to you by a licensed healthcare worker at your agency. Clients with enteral feeding tubes are at risk for aspiration. These tubes can move from the stomach or intestine and into the esophagus or airway because clients move, or they or their caregivers may accidentally pull on the tube. Also, with such tubes regurgitation may occur due to delayed stomach emptying and over-feeding. To prevent regurgitation and aspiration, have the client in a semi-Fowler’s or sitting position during feeding and for at least one hour after eating to promote digestion. Also, avoid putting the client in a left-lying side position as this prevents stomach emptying.

Observations and Comfort Measures

As the HCA caring for clients with enteral feeding tubes, it is essential you use your skills to make observations and provide comfort because aspiration is not the only risk with this type of feeding. Delayed stomach emptying, diarrhea, and constipation can also occur, so observe and report any of the following immediately to your supervisor:

  • Coughing or gurgling voice
  • Nausea, vomiting
  • Diarrhea
  • Discomfort during the tube feeding
  • Stomach distention (enlarged or swollen)
  • Elevated temperature and/or pulse rate
  • Redness, swelling, drainage, odour, pain at ostomy site

Because most people with enteral feeding tubes do not take anything by mouth (NPO), mouth care is extremely important. Dry mouth and lips and sore throat can cause discomfort; therefore, good oral hygiene will be required. Brush teeth, moisturize lips and mouth, and if allowed, offer ice chips or hard candy to suck on. If the tube is placed into the nose, the tubes can put pressure on the nose and it becomes irritated and red. Try to reposition the tube slightly away from the nostril; tape or tube holders can be used to help with this and be sure to clean the nose at least every  four hours. To prevent the tube from being pulled out of place, pin or secure the tubing to the client’s gown with a rubber band and safety pin or secure-strip with enough slack to allow movement.

Measuring Intake

To maintain adequate health, individuals need to take in a certain amount of fluid per day. Depending on a client’s condition, they may either be encouraged to drink fluids or limit their fluid intake. Fluid that is taken in is called intake. Fluids are usually measured using milliliters (ml). One cup of liquid is 8 ounces or 250 ml.

The amount of food that is eaten can also be measured. This can be done by weighing the food prior to serving and subtracting the amount left to get the total food intake.  Food intake can also be measured by determining the total percentage eaten. If all the meal is consumed, the intake is 100%. If none of the meal is consumed, the intake is 0%. A quarter of the meal consumed would be 25% and half the meal consumed would be 50% (McLain, et al., 2018; Sorrentino, et al., 2019). The facility policy will specify the unit of measurement to be used.

  • ⇒ Explain to the client the importance of recording their intake. Throughout your shift, monitor or ask the client what and how much they have had to eat or drink.
  • ⇒ During food preparation, measure the amount of food or liquid that is served. Use standard measuring cups and spoons to properly measure intake. Record this in the appropriate place.
  • ⇒ Once the client has finished eating or drinking, subtract the amount they have consumed from the amount you served. Record this number as their input. Input for fluid should be recorded as millitres (ml).
  • ⇒ Record the weight or percentage of food consumed in the appropriate place.
  • ⇒ Document all food and drink intake. The agency may provide a specific intake and output (I & O) sheet. Healthcare staff including HCAs should report any observations or changes in condition or behavior.

Learning Activity

Complete this Meal Assistance Virtual Game Simulation Activity by Hughes, Kenmir, & Romaniuk ( n.d.).

 

English Version

When you have completed this, answer the reflective questions and complete the “Test Your Knowledge” quiz found at the end of this activity.

Summary:

There are many factors that affect individuals’ eating and nutrition. Factors such as culture, religion, age, illness, and disability to name a few. It is important to understand your clients’ preferences and needs by getting to know them and following the care plan. It is also important to know who is at risk of choking, and how the HCA can prevent such situations. Following the care plan is especially important when assisting a client to eat and knowing how to record and report the intake of foods and fluids.

Chapter 6 Attributions and References

Unit 6.2 Image Attributions

Unit 6.4 Image Attributions

Videos

References

4yourCNA [username]. (2016, August 4). Feed a resident in a chair CNA Skill NEW! (Video). YouTube. https://www.youtube.com/watch?v=uA5V-ivcEes

Girdi-Papp, M. (2022). Comparative Oral+ENT Biology. Comparative Oral+ENT Biology : Marcos Gridi-Papp : Free Download, Borrow, and Streaming : Internet Archive . Chpt 20 pg 438–450. This book is licensed under a CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/) licence. 

Hughes, M., Kenmir, A., Romaniuk, D., & Vander Meeren, P. (n.d.). Meal assistance virtual gaming simulation – Simple book publishing. ECampus Ontario. https://ecampusontario.pressbooks.pub/mavgs/

International Dysphagia Diet Standardisation Initiative (IDDSI). (2019, July). Complete IDDSI Framework
Detailed definitions 2.0 | 2019 [IPDF]. https://iddsi.org/IDDSI/media/images/Complete_IDDSI_Framework_Final_31July2019.pdf. This work is used under a CC BY SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0/legalcode) license. Derivative works extending beyond language translation are NOT PERMITTED.

International Dysphagia Diet Standardisation Initiative (IDDSI). (2022, September). Textured Modified diets [Infographic/PDF]. UK IDDSI Reference Group (UKIRG). https://iddsi.org/IDDSI/media/images/CountrySpecific/UnitedKingdom/Texture-Modified-Diets-(UK-IDDSI-Festival).png. This work is used under a CC BY SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0/legalcode) license. [Developed with Four Seasons Health Care.] Derivative works extending beyond language translation are NOT PERMITTED.

McLain, K., O’Hara-Leslie, E., & Wade, A. (n.d.). Foundations for assisting in home care. Milne Publishing/SUNY Geneseo. https://milnepublishing.geneseo.edu/home-health-aide/ This book is licensed under a CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/) licence.

Nestlé Health Science Canada. (2011, May 11). Understanding Dysphagia (Video). YouTube. https://www.youtube.com/watch?v=jK1o3LSQmB0

Nurse Jar. (2019, April 13). PEARSON VUE/CREDENTIA 2022 – FEEDS CLIENT WHO CANNOT FEED SELF (Video). YouTube. https://www.youtube.com/watch?v=faw_mOmoDxk

Sorrentino, S., Remmert, L., & Wilks, M. (2019). Mosby’s Canadian textbook for the support worker (4th ed.). Elsevier Canada.

Biomedizinische NMR Forschungs GmbH. (2011, September 16). Real-time magnetic resonance imaging at a resolution of 20 ms [GIF]. Wikimedia Commons. https://commons.wikimedia.org/wiki/File:Real-time_MRI_-_Swallowing_(Pineapple_Juice).ogv

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Personal Care Skills for Health Care Assistants Copyright © 2023 by Tracy Christianson and Kimberly Morris, Thompson Rivers University. is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, except where otherwise noted.

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