The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following?
A. Giving the client thin liquids.
B. Thickening liquids to the consistency of oatmeal.
C. Placing food on the unaffected side of the mouth.
D. Allowing plenty of time for chewing and swallowing.
Correct Answer: A. Giving the client thin liquids.
Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. Review individual pathology and ability to swallow, noting extent of the paralysis: clarity of speech, tongue involvement, ability to protect airway, episodes of coughing, presence of adventitious breath sounds. Weigh periodically as indicated. Nutritional interventions and choices of feeding route are determined by these factors.
Option B: Liquids are thickened to avoid aspiration. Food consistency is determined by individual deficit. For example: Patients with decreased range of tongue motion require thick liquids initially, progressing to thin liquids, whereas patients with delayed pharyngeal swallow will handle thick liquids and thicker foods better.
Option C: Food is placed on the unaffected side of the mouth. Place food of appropriate consistency on the unaffected side of the mouth. Provides sensory stimulation (including taste), which may increase salivation and trigger swallowing efforts, enhancing intake.
Option D: The client is assisted with meals as needed and is given ample time to chew and swallow. Provide a pleasant and unhurried environment free of distractions. Promotes relaxation and allows the patient to focus on the task of eating. Promote effective swallowing: Schedule activities and medications to provide a minimum of 30 min rest before eating. Promotes optimal muscle function, helps to limit fatigue.
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