What is in this woman's mouth?

  1. I work LTC and we have a resident who is a GT feeder and completely NPO (we have two GT residents who have managed to rehab back to oral feedings but have a bolus if the don't eat much). This resident suffered a massive stroke, doesn't move much, can follow you with her eyes, moans off and on throughout the day and is a mouth breather. She is on continuous feeding with a pump that runs 20 hours a day. There is little to no residual when checked.

    We started noticing she would moan and it would sound like she was gargling. Got an order to suction PRN and when we did we would get this thick, beige stuff comming out the back of her throat. Suspecting it was maybe the lemon flaverd swabs leaving a film we only clean her mouth with a toothbrush and water. Thing is she still gets thick, beige mucously stuff in her mouth. It usually comes out in a big chunk when suctioned.

    Any ideas on what is causing it? Or what we can do to avoid it?
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  2. 16 Comments

  3. by   weetziebat
    No real ideas, just questions. Is the head of the bed kept elevated? Could it possibly be the formula is not going down into her stomach? Are lungs clear? How are her sinuses? Would she be better off with several feeding rather than 20 hours/day? Never experienced that situation, but those are my first thoughts. Hope you get to the root of the problem and she gets it taken care of. Sounds like she has enough problems already, no?
  4. by   canoehead
    Does she have GERD?


    On another note I read the title for this thread and immediately thought, "Well I'M not looking in THERE!" I'm willing to bet there were at least a half dozen other ER nurses that thought the exact same thing.
  5. by   Undecided7
    It sounds like she may have GERD and the formula (which is usually beige) mixes with the mucous building up in her esophogus. Just out of curiousity, you can add blue food coloring to the formula. If she starts coughing up blue chunks of mucous, you know the problem!
  6. by   ray2512
    As a hospice nurse I see this happen all the time. The main problem is the probably the volume of fluids the client is getting. You said its running 20hrs a day but you did not say how much they are getting. Also how much of a bolus are they getting with each medication? A client in this shape can only metabolize about 1600 ml of fluids of all kinds daily. Otherwise they start refluxing and aspirating on the fluids. You can check the GT for back flow. If the GT could back flow much of the time to much is going into the stomach and they cant handle all that.
  7. by   Katnip
    Quote from canoehead
    Does she have GERD?


    On another note I read the title for this thread and immediately thought, "Well I'M not looking in THERE!" I'm willing to bet there were at least a half dozen other ER nurses that thought the exact same thing.
    LOL I almost didn't look, too. I worked ER until last month. Old habits die hard.

    I think the hospice nurse came up with the best answer. I've never seen this either.
  8. by   marymack57
    Someone else sorta hit it on the head...all our GT patients get a GERD medication to control reflux. My problem is getting people to understand that just because they don't eat, doesn't mean they don't need EXTRA oral care.
  9. by   Agnus
    Quote from marymack57
    Someone else sorta hit it on the head...all our GT patients get a GERD medication to control reflux. My problem is getting people to understand that just because they don't eat, doesn't mean they don't need EXTRA oral care.
    YES oral care is more important when a patient is NPO. Try explaining the rationale. Sometimes that helps. Then there are those who just don't like doing oral care. Yet if it is done Q2 like it should be it ceases to be the yukkie job that it otherwise turns out to be.

    Sometimes you just have to take the bully by the horns and do it yourself. I know I know time is often the issue for the RN but. I find If I do good oral care at the start of shift (to make up for what was not done on previous shifts) then the 2 hour care takes less than a minute. I can and do find time for that.

    Again there are those who think if they do it once they don't have to keep doing it and then it gets out of hand again.

    This is where we end up with oral infections that can lead to sepsis. Mouth care is just too important for these folks.
  10. by   meownsmile
    Even with precautions, true there may be some occasional GERD involved, however my thought is that it may be mucus from the sinuses/nose. Post nasal drip left to dry with mouth breathing can become very thick and sticky quickly and if mouth care isnt consistent and the patient is boardering mild dehydration it would get dried and stuck near the back of the throat. If tissues in the throat/nose are irritated from dryness there could be some slight oozing of blood from capillaries causing the tinge that appears like it could be tube feeding being regurged. Just a thought but another avenue to explore.
  11. by   suebird3
    first thing i thought was "aspiration". i just had a resident get sent out for the saaame problem. rezzie was able to walk/eat this time last year, butd/t declining condition, on feedings. still has "back up" even with prevacid.

    i agree w/ the blue food colouring. and keep the hob up 30 degrees. that is standard protocol in our facility. just to be curious, what is the water flush you give this patient?

    suebird :d
  12. by   not now
    Quote from ray2512
    As a hospice nurse I see this happen all the time. The main problem is the probably the volume of fluids the client is getting. You said its running 20hrs a day but you did not say how much they are getting. Also how much of a bolus are they getting with each medication? A client in this shape can only metabolize about 1600 ml of fluids of all kinds daily. Otherwise they start refluxing and aspirating on the fluids. You can check the GT for back flow. If the GT could back flow much of the time to much is going into the stomach and they cant handle all that.
    The pump runs at 85 ml/hour so that's....1700 ml a day. It's turned off between midnight and 2AM. Then again between 10AM and noon. I know it's random but all GT's on a pump follow this routine.

    We (well, I have no idea what the other nurses are doing but I do this) give meds with as little water as possible. My other two GT residents on pumps get 200 every six or eight hours along with juice to go with Promod. She has no order to flush or an order for Promod.

    How do I check a GT for back flow? I'm a brand new nurse and this is all new to me.
  13. by   suebird3
    i should clarify that statement.....the rezzie has been prone to near-aspiration, and that is the "back flow" i speak of. really a sad situation over all.

    suebird :d
  14. by   LauraF, RN
    We had a woman in our LTC that got something similar. But it would cake her tongue and her cheeks. And she always had mucous, though her chest x-rays were always clear. She was pretty much non-responsive but had a really good gag reflex. We found that really good oral care improved this situation. I assigned a CNA that I could trust not to forget to do it each time she was in there, I did it when I was in there, and it got better. I hope you get it figured out.

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