Student ______________________________________________________ Instructor ____________________________________________________

Date _________________________ Date _________________________

PERFORMANCE CHECKLIST SKILL 30-2 ASSISTING AN ADULT PATIENT WITH ORAL NUTRITION

S
ASSESSMENT

NP

Comments

1. Assessed that GI tract is functioning and types of diet patient can tolerate. 2. Reviewed prescribed diet. 3. Assessed patients ability to swallow and gag reflex. 4. Assessed oral cavity and proper fit and availability of dentures. 5. Assessed patients energy level and appetite. 6. Assessed patients cognitive and sensory status, motor skills, and ability to feed self. 7. Determined patients food preferences and tolerance.
NURSING DIAGNOSIS

1. Developed appropriate nursing diagnoses based on assessment data.

PLANNING

1. Identified expected outcomes. 2. Collaborated with dietitian on meal plans. 3. Prepared patients room. 4. Prepared patient for mealprovided mouth care, dentures, positioning, and sensory aids.
IMPLEMENTATION

1. Prepared Patients Tray a. Performed hand hygiene. b. Assessed tray for completeness and correct diet. c. Prepared tray to meet patients needs. d. Determined how well patient was eating independently. 2. Assisted Patient Who Could Not Eat Independently a. Established comfortable position from which to offer assistance.

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published.

S b. Asked in what order the patient would like the food, and cut food into bite-size pieces. c. Identified food by location on the plate. d. Fed patient small amounts at a time and assessed ability to chew and swallow. (1) Older adult: Fed small amounts, observed ability to chew and swallow. Observed for fatigue. Allowed rest periods. (2) Neurologically impaired patient: Fed small amounts, assessed ability to chew and properly swallow. Provided small amounts of thickened fluids as requested. (3) Oncology patient: Assessed for presence of nausea, and premedicated as ordered. Asked about food aversions. e. Monitored fluid intake throughout meal, not all liquid at the beginning of meal. f. Conversed with patient during meal. Provided patient education as appropriate. g. Assisted patient with oral and hand hygiene. h. Assisted patient to resting position, with head properly elevated. i. Returned patients tray and washed hands.
EVALUATION

NP

Comments

1. Observed patients ability to swallow. 2. Monitored patients weight if ordered. 3. Assessed patients tolerance to diet. 4. Monitored patients fluid and food intake. 5. Assessed patients ability to assist with feeding. 6. Identified unexpected outcomes.
RECORDING AND REPORTING

1. Documented tolerance of diet, amount eaten, and intake and output. 2. Documented calorie count, nutritional supplements taken, I&O, weight and elimination pattern. 3. Report nutritional alterations to nurse in charge and/or physician.

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published.