Note from the National Guideline Clearinghouse (NGC): In this update of the guideline, the process previously used to develop the geriatric nursing protocols has been enhanced.
Levels of evidence (I – VI) are defined at the end of the "Major Recommendations" field.
Parameters of Assessment
- Assessment of older adult and caregivers
- Rituals used before meals (e.g., hand washing and toilet use), dressing for dinner.
- Blessings of food or grace, if appropriate.
- Religious rites or prohibitions observed in preparation of food or before meal begins, (e.g., Muslim, Jewish, Seventh Day Adventist. Consult with Pastoral counselor, if available).
- Cultural or special cues: family history, especially rituals surrounding meals.
- Preferences as to end-of-life decisions regarding withdrawal or administration of food and fluid in the face of incapacity, or request of designated health-proxy. Ethicist or social worker may facilitate process.
- Assessment instruments:
- The Edinburgh Feeding Evaluation in Dementia Scale (EdFED-Q) for persons with moderate to late-stage dementia (Watson, 1996 [Level III]). See Try this in resources section at www.ConsultGeriRN.org.
- Katz Index of Activities of Daily Living (ADL) for functional status (Katz et al., 1970 [Level III]). See Try this in resources section at www.ConsultGeriRN.org.
- Food diary/Meal Portion Method (Berrut et al., 2002 [Level III]).
Nursing Interventions
- Environment
- Dining or patient room: encourage older adult to eat in dining room to increase intake (Bates-Jensen et al., 2004 [Level IV]), personalize dining room, no treatments or other activities occurring during meals, no distractions.
- Tableware: use of standard dinnerware (e.g., china, glasses, cup and saucer, flatware, tablecloth, napkin) versus disposable tableware and bibs.
- Furniture: older adult seated in stable arm chair; table-appropriate height versus eating in wheelchair or in bed (Rappl & Jones, 2000 [Level V]).
- Noise level: environmental noise from music, caregivers, and television is minimal (McDaniel et al., 2001 [Level III]); personal conversation between patient and caregiver is encouraged.
- Music: pleasant, preferred by patient (Hick-Moore, 2005 [Level III]; Watson & Green, 2006 [Level I]).
- Light: adequate and nonglare-producing versus dark, shadowy, or glaring (McDaniel et al., 2001 [Level III]).
- Contrasting background/foreground: use contrasting background and foreground colors with minimal design to aid persons with decreased vision (Ellexson, 2004 [Level IV]).
- Odor: food prepared in area adjacent to or in dining area to stimulate appetite (Amella, 2004 [Level V]).
- Adaptive equipment: available, appropriate, and clean; caregivers and/or older adult knowledgeable in use; occupational therapist assists in evaluation
- Caregiver/Staffing
- Provide an adequate number of well-trained staff (Chang & Lin, 2005 [Level IV]; Crogan et al., 2001 [Level IV]).
- Deliver an individualized approach to meals (Gibbs-Ward & Keller, 2005 [Level IV]; Sydner & Fjellstrom, 2005 [Level IV]) including choice of food, tempo of assistance.
- Position of caregiver relative to elder: eye contact; seating so caregiver faces elder patient in same plane (Amella, 2004 [Level V]).
- Cueing: caregiver cues elder whenever possible with words or gestures (Simmons & Schnelle, 2006 [Level IV]).
- Self-feeding: encouragement to self-feed with multiple methods versus assisted feeding to minimize time (Simmons & Schnelle, 2006 [Level IV]).
- Mealtime rounds: interdisciplinary team to examine multifaceted process of meal service, environment, and individual preferences (Keller et al., 2006 [Level IV]).
Follow-Up Monitoring
- Providers' competency to monitor eating and feeding behaviors.
- Documentation of eating and feeding behaviors.
- Documentation of care strategies and follow-up of alterations in nutritional status and eating and feeding behaviors.
- Documentation of staffing and staff education; availability of supportive interdisciplinary team.
Definitions:
Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)
Level II: Single experimental study (randomized controlled trials [RCTs])
Level III: Quasi-experimental studies
Level IV: Non-experimental studies
Level V: Care report/program evaluation/narrative literature reviews
Level VI: Opinions of respected authorities/Consensus panels
Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3rd ed). New York: Springer Publishing Company.
