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Liquids In-Service Learning Objectives and Discussion Points

Following the in-service, participants will be able to:
• Explain the safety implications related to providing the proper liquid consistency to
hospitalized patients with a thickened liquid order- risk of aspiration, pneumonia.
• Distinguish between the different thickened liquid orders of nectar, honey, and pudding
• Properly thicken liquid to desired consistency, following reference chart and proper
measuring and mixing techniques.

Necessary materials to collect prior to in-service:
• Tray ticket that contains a thickened liquid order on it. See “sample tray ticket” below
for more details.
• 4 juices, 4 medium cups, 4 spoons, thickener, dry measuring spoons: Prepare each
consistency of juice- thin, nectar, honey, and pudding- for staff to compare. Follow the
thickener reference chart and preferably utilize the same flavor of juice.
• Ensure Enlive (any flavor), 2 medium cups, thickener, 1 spoon, dry measuring spoon
• Small plastic cup utilized to measure out 4 ounces, pen to mark 4-ounce line

Sample Tray Ticket
Find an old tray ticket with a thickened liquid on it, or develop and print a sample.
• Point out the multiple areas on ticket that signify a thickened liquid order. Explain the
orders staff may encounter and all of the places on the ticket to pay attention to.
Importance/Safety Implications
• Thickened liquid orders are put into place by a speech language pathologist whom has
evaluated the patient and is concerned for their safety as they swallow a liquid.
• There are many reasons that a patient may require some extra precautions when
swallowing, such as following a stroke, cancer of the neck or throat, nerve damage, etc.
This causes them to have less control over the muscles the body uses not only to initiate
swallowing, but to prevent liquids from traveling down the throat prematurely. One of
the easiest ways to understand what can occur in these patients is to think about when
you have swallowed something and had it “go down the wrong pipe.” This wrong pipe is
called the trachea, which leads to our lungs. The correct pipe is our esophagus, the path
towards our stomach. When we breathe something into our airway (trachea to lungs),
this is called aspiration. Aspiration pneumonia is an infection of the lungs caused by
food and drink not traveling where it should. This can lead to very negative
complications for patients.
• So, how do we prevent aspiration and other related problems? The speech language
pathologist does a swallowing assessment to determine the patient’s functioning and
subsequent needs. Depending on muscle function and other factors, thickened liquids
are ordered as nectar, honey, or pudding thick. The purpose of these modified
consistencies is that a thicker consistency will provide the patient with an easier time of
swallowing the liquid all together and prevent any uncontrolled swallowing or leakage.

Nectar, Honey, and Pudding Consistencies

• Line up your four cups of juice, scrambling the order so that they are not lined up
according to progressing thickness. Place a spoon in each cup. Quiz the staff as to which
consistency is which by lifting the spoon and having them note how the liquid falls.
Facilitate discussion regarding the different consistencies: what are some descriptors for
each, how would they typically be consumed (straw, cup, or spoon), how does each
• Nectar
o Easily pourable, consumed from a straw or a cup
o Comes off spoon in droplets
• Honey
o Slightly less pourable, consumed from a cup or a spoon
o Comes off spoon in a more solid stream
o Picture pouring honey
• Pudding
o Not pourable, holds shape, consumed from a spoon

Thin Liquids

• Examples of thin liquids include water, coffee, milk, soda, and anything that melts to a
thin consistency, such as ice cream, sherbet, shakes, etc.


Prepare thickened liquid in front of staff to demonstrate proper measuring and mixing

• Determine desired liquid consistency. Follow the thickener reference chart and show
staff how to read the chart (discuss any differences as the chart has been updated).
• Measure out the needed amount of thickener (example: nectar-thick chocolate Ensure
Enlive = 1 tablespoon plus 1 teaspoon plus ½ teaspoon).
o Demonstrate finding and utilizing the proper dry measuring spoons. Make sure
the top is leveled off to administer the correct amount. It is important to utilize
the designated measuring spoon and not to use the 1 teaspoon measure when ½
a teaspoon is needed- it is difficult to eyeball what that half would actually be.
o According to the product label, it is best to slowly incorporate the required
amount of thickener while briskly stirring the liquid for at least 15 seconds, until
thickener is dissolved. This works quite well for the majority of liquids.
§ A technique for 8-ounce Ensure Enlive is to pour 1/2 to 2/3 of the liquid
out of the bottle into a cup. Incorporate the proper amount of thickener
required to reach the desired consistency, and then pour the liquid back
into the bottle to shake. Shake for 15 seconds and pour into a new
serving cup.
o Note that the liquid will thicken slightly within five minutes of preparation.

Education Regarding 4-Ounce Mark on Small Plastic Cup

There are discrepancies between the staff as to where the 4-ounce point is on the small plastic
cups. It is indeed the mid-point between the two lines that are furthest apart at the top of the
cup. Remind staff that if they ever forget this, they can go to the tray line fridges and look at the
4-ounce milks that have been measured out.

Time for Questions

Optional Materials

Utilize supplementary materials and graphics during in-service and/or on bulletin board.