Specific approaches to ensuring nutrition and hydrationSwallowing problems are complex, which has been shown in Chapter 1, hence a MDT approach must include the relevant medical professional such as nurses, SALT, doctors, physiotherapist, dietitian and pharmacist all of whom play an important role in managing a patient with swallowing complications (Royal College of Speech and Language 2019). The nurse plays a chief role as part of an MDT in the assessment, treatment and management of the patient with malnutrition and dehydration caused by stroke from the time they come into A&E right through to discharge. Dehydration is an important threat for these patients and can cause a vast array of problems from having infections to mental confusion. Sufficient fluid intake can be reached by offering patients icecream, soups, pureed fruit, milky drinks and puddings such as yogurts, jelly and rice pudding. It is particularly important to monitor hydration when a patient has been placed Nil by Mouth (NBM). Adequate fluid intake for NBM patients can be achieved through simple interventions, such as Intravenous Fluid Therapy; this is to maintain their fluid intake and lessen the risk of further dehydration (Royal Pharmaceutical Society 2019).It is crucial that fluid balance is monitored and restored for all patients with dysphagia. Fluid balance charts are initiated to determine any negative or positive balances, nursing staff are accountable for documentation of fluid input and output (Shepherd, 2011). The NMC code of conduct (2018) (10.1) states that “Clear and accurate documentation must be kept which includes the use of fluid balance charts”. However, Scales (2008) identified that poor record keeping of fluid balance charts resulted in poor outcomes of acutely unwell patients. Additionally, Georgiades (2016) state that providing all nursing staff with education sessions, such as training, on fluid balance monitoring, will help improve educational and clinical gaps in providing care. An example of a Daily Input-Output chart for fluids (in accordance with the All-Wales Prescription Chart) can be seen in Appendix 3.Another important aspect of dysphagia care, particularly for NBM patients, is maintaining oral hygiene. The patient and families along with nursing staff should be made aware of the importance of strict oral care routine and the dangers of developing thrush, xerostomia and respiratory illnesses leading to serious medical implications, if not observed and monitored (Reinstein, 2019). Gil-Montoya et al (2008), emphasized that poor oral health is strongly related with malnutrition and this in turn can affect a patient’s recovery. In addition, a study carried out by Sousa et al (2014) of hospitalized patients found that patients’ oral wellbeing was not being evaluated and that hospitals had no strategies set up for routine oral practice. This is backed by Nguh (2016) who assessed that 44% to 64% of patients in hospital do not receive enough oral care, an intervention which can prevent aspiration pneumonia. Furthermore Chan (2011) suggests healthcare professionals often lack evidence-based knowledge to deliver appropriate oral care and Dickson (2012) concludes that nurses view oral care as a comfort measure making the practice a low clinical priority. Yoneyama et al (2002), who further adds, that oral care is not seen as a priority by healthcare professionals and that patients may be unwilling to ask for help when it comes to managing their oral hygiene. Additionally, some staff may be reluctant to carry out oral hygiene on a patient with a swallowing problem because of the risk of aspiration.When a patient has failed a swallow test and is incapable of safely swallowing oral food or fluids, a nasogastric tube (NGT) should be inserted within 24 hours of admission (NICE, 2008). Artificial nutritional support is given when oral intake is likely to be absent for a period and decision on route, management and content of this support are best made by the MDT (Stroud et al 2003). There are a range of enteral feeding tubes with different indications which can be used in the management of patients following a stroke. Short-term interventions include the insertion of an NGT, whilst long-term nutritional support involves the insertion of a percutaneous endoscopic gastrostomy (PEG) tube (Omorogieva, 2015). There is a risk that the NG tube may dislodge, which could be due to the patient moving during sleep, perspiration, leading to the tape becoming unstuck, coughing, vomiting and the patient pulling the NG tube; all these may result in a delayed nutritional intake. Therefore, it is important to re-check feeding tubes before feeding commences. SIGN (2010) identifies that patients who are in the early stage of recovery should have their nutritional status reviewed weekly by the MDT to establish if longer feeding is necessary. However, it should be noted that not all stroke patients meet their nutritional needs from NG feeding as the possible consequences of being fed by tube are nausea, diarrhoea, and large gastric residual (Sanghee and Youngsoon, 2014). Ongoing assessment and monitoring of a patient’s nutritional status should also include biomedical measures of low pre-albumin, impaired glucose metabolism, unintentional weight loss, swallow status, along with eating assessment and dependence (Signs, 2010). A dietician will calculate how much fluid and food the patient requires by taking the weight and other medical factors into account, by implementing a feeding regime for the nurses to adhere to. It is imperative to get the patient’s nutritional and hydration requirements back to a base line and the dietitian is an integral part of the MDT as they play a significant role in the managing of the patient’s nutritional requirements. NICE guidelines (2017) state, that regular monitoring and assessing the patient with PEG or NG is fundamental in order to make sure that the patient is getting the nutrients they require and that the current feed is the most appropriate for the patient. Before any feed can commence the nurse will need to gain an aspiration of the pH which should be 5.5 and below. However, the findings of the National Patient Safety Agency Alert (NPSA) (2016) identified errors in pH testing by nurses, unapproved NG tube placement and communication failures which resulted in NG tubes not being checked. This is a cause for concern and practice needs to improve regarding this. If there is no aspiration or there is a high pH level, then the nurse will send the patient for an x-ray to ensure that an NG tube is in position in the stomach (Earley, 2005).When nurses administer medication via NG/PEG it can present substantial challenges to patient safety. It is fundamental that nurses follow the medication guidelines and hospital protocol regarding the safe crushing and opening of tablets and capsules in order to avoid any adverse reactions (Comerford and Hallowel, 2015). Research shows that nurses often do not adhere to the guidelines for the safe administration of drugs through enteral feeding tubes which can result in medications errors, reduce the drug’s effectiveness, cause tube obstructions and an increase of drug toxicity (Comerford and Hallowel, 2015). Nazarko (2010) states that some medications such as antibiotics can be rendered useless if they are removed from the capsules, while others which are slow releasing can expose a patient to a dangerously high dose. Furthermore Nazarko (2010) states that a patient who has difficulties in swallowing medications should have a medication review so that unnecessary medication can be discontinued and any medication that should be prescribe should be in view that it is viable for the patient to take safely.When it comes to feeding patients who can still swallow unaided, Mitchell and Finlayson (2000) state that to enhance safer swallowing and improve control it is advisable to change the consistency of food to a modifiable diet which will prevent the patients from choking. Modifying the patient’s food and fluids depend on the healthcare team to achieving the correct texture through accurate instructions and adequate guidelines (Harding and Halai, 2009). However, Vuea et al (2017) add that modified foods tend to contain fewer nutrients than normal foods. This is endorsed by Swan et al (2015) who states in a recent study that modified diets exacerbate the decline in a patient’s health. Furthermore, Logemann et al (2008) concluded that two thirds of patients who were recommended a modified diet were non-compliant, the reasons being for this is the diet was not appealing and that patient’s concordance with the regimes can be poor. Foley et al (2006) reports that only 13% of patients with swallowing problems finished their food. Furthermore, Wright et al (2005) adds that patients who were placed on a modified diet consumed 40% less energy and protein compared to a patient on a normal diet. While this evidence suggests that the recommended diet is lacking in nutritional value and patients are reluctant to consume it, it is difficult to find a sufficient number of randomised control trails to support this. Therefore, more robust studies should be undertaken to further investigate the benefits of the modified diet as recommended by SALT.The International Dysphagia Diet Standardisation Initiative (IDDSI) has published International Standardisation descriptors (see Appendix 4). These address texture-modified foods and thickened liquids for patients with dysphagia. This has been endorsed by the British Dietetic Association and the Royal College of Speech and Language Therapists. They substitute previous descriptors and they should be put in place to safely protect people from the risks of choking (Quality Care Commission, 2019). The new guidelines were also put in place to allow nursing staff to know the difference in food texture and to apply the correct foods to what is stated within the patient care plan made by SALT. Alfaro-LeFevre (2014) and White (2003), cited in Royal Marsden (2015), state that it is important to reassess and evaluate the interventions regularly as this allows the nurse to make any changes to the current plan of care. This evaluation will reflect if it is appropriate to continue with the current plan of care or try something different, and it will need to involve an element of on-going assessment and re-assessment (Royal Marsden of Clinical Nursing, 2015).After nutritional assessment, those recognized as undernourished and those at danger of malnutrition should be referred to a dietitian and regarded as part of their general dietary care plan for the prescription of oral nutritional supplements (SIGN, 2010) (4.7.3). Oral supplements maybe given if a patient is not meeting their required nutritional intake, these supplements are only available on prescription following advice from the dietitian (BAPEN, 2016). The health care team must be aware that they cannot be used solely as a source of nutrition and care should be taken when given to a patient with swallowing problems as the right consistency as to be applied (BAPEN, 2016). Regular monitoring of weight is important to clarify if the patients is maintaining or losing weight and this is to be carried out on a weekly basis.There are many reasons a patient may need assistance with feeding and drinking: An inability to lift their hand to mouth, uncontrolled movements, memory problems or maintaining an upright position (Nazarko, 2010). Numerous people believe that anyone can support another to eat, however, feeding a patient is not a simple process that can be allocated to a member of staff without experience. Nurses need to be taught how to do it, what the issues are and how they might be overcome. Education should aim to ensure patients who cannot eat and drink safely, receive acceptable and appropriate support to do so (Weetch,2001). Further to this Brogden, (2004) suggest that If all staff appreciated the fundamental role nutrition plays in patient’s recovery attitudes and values of nutritional care should improve. When a patient is found to have swallowing difficulties SALT specifies to sit the patient in an upright position, 90 degree if possible as this enhances safe swallow. Corcoran (2005) advise that positioning is vital because of the physical and neurological variations that befall after stroke, such as reduced muscle tone and paralysis which can obstruct the airway and result in aspiration. The patient should continue to sit in an upright position for at least 30 min after food to prevent reflux (Mastso et al 2007). Wyatt (2013) suggest that, talking to the patient will allow clinical observations to be made that the patient is alert and understands what is being said. This is imperative because a patient may not be able to swallow properly if they are fatigued, so reassessing alertness is important. Nurses who assist a patient with feeding should place themselves in the line of patient’s vision as this will allow the nurse to guide and prompt the patient with oral intake (Nursing Times, 2003). However, assisting patients who cannot eat and drink requires time, patience and empathy and they must never be rushed (Anderson 2013). If the patients can feed themselves, it essential for the nurse to ensure that the patient dignity is maintained, and independence is promoted. A nurse should consult with an occupational therapist (OT) to put in place tableware that is altered so the patients can feed themselves these would include: plate guards, easy grip cutlery, and non-slip mats furthermore the use of a disposable apron should be offer to protect the patients clothing and keep their autonomy (Anderson, 2013). Chapelhow (2005) suggest that, when feeding the patient, healthcare staff should ensure they deliver a patient-centred approach which will consider the patient social and emotional need providing a holistic approach along with privacy and dignity considering autonomy. Malnutrition in hospital is too common during the patient’s stay, many factors influence their nutritional state. Several reports have drawn attention to the removal of patients’ food before they have had an opportunity to eat it (ACHC, 1997; Horan and Coad, 2000). A lack of assistance at mealtimes can also be a factor. However, NICE (2006), cited in British Association of UK Diabetics (2017) states that nutritional intake can be achieved if additional support is provided for those who need help.The red tray campaign was introduced to alert nurses and health care support workers that a patient needed support with eating, as well as informing catering staff to allow more time for those patients. Furthermore, Whitehead (2006) submit that the red tray campaign is very useful in stroke patients this allows for all nursing staff to be aware of stroke patients suffering with either a left or right sided deficits, an example of this is placing food or drink on the patients’ right side if a patient had a left sided weakness. Nurses have a duty of care and a legal liability to their patients. However, Age Concern (2006, cited in British Association of UK diabetics, 2017) add that the lack of support with nutritional requirements is the most frequently raised issue in the clinical setting. This is further supported by ‘Andrews Report – Trusted to care (2014)’ who reported that staff had no extra support at mealtimes.It has been shown that hydration should be managed through a fluid balance chart and clinical observations. The same is true for nutrition: food and fluid charts that are in place to determine what the patient has consumed, regarding food and fluid throughout the day. Nurses and other members of the MDT can assess regularly to make sure the patient is receiving the right level of nutrition for their needs. If the patient is not meeting their fluid and nutritional needs the appropriate action needs to be taken. This is endorsed in the “All Wales Food Record Chart and Nutritional Care Pathway” (Welsh Government 2009). However, there can be essential problems with this type of nutritional tool such as confusion over portion sizes, along with the inaccuracy of completing the food charts (Andrews and Butler, 2014). Understanding this for nutritional care means that, even if this aspect of care is delegated to a healthcare assistant, responsibility for the outcome remains with the nurse. It is essential that nurses are aware of how effective any intervention may be and ensure progress is documented. The British Dietetic Association (2006) says that neither nutritional screening nor assessment will be of any benefit unless patients can eat or are helped to eat.Chapter summaryThis Chapter has looked at the role played by the nurse, as part of the MDT, in managing nutritional and hydration interventions in patients with dysphagia. Some specific approaches included the preparation of high liquid content foods to aid hydration, the use of NGT and PEG with NBM patients and the feeding of pureed foods. In general, it was argued that it is important to maintain patient dignity with feeding, and some approaches including the use of appropriate tableware and communication with the patient were considered.