Question on swallowing precautions

[Glycerine82, LPN]

I've been wondering this for a few weeks now, and I think I'll get some good feedback here.

If a patient has swallowing difficulty so severe that he/she has to be on pudding thick liquid with a 1:1 assist and only allowed to be fed by speech or RN staff, wouldn't that qualify him/her to be NPO with a feeding tube placed? Perhaps the patient refused the feeding tube?

I've seen patient in the past who were NPO, on tube-feeds and allowed to eat for pleasure under the supervision of speech.

What do you guys think?

Im a student, don't have a whole lot of experience with this stuff, but enough that it strikes me kind of odd......

[MendedHeart]

Is this patient older and/or DNR or palliative? I would think it may be many factors Influencing this. Patients wishes, nutritional status, etc. If the patient is eating and recieving adequate nutrition even though it is dysphagic diet and requires feeding, it wouldnt be necessary to place a PEG or Duo tube and definitely not because its more convenient for staff

[Glycerine82, LPN]

The patient isn't palliative or DNR. they do have a chronic neurological condition as well as a TBI.

It isn't inconvenient for staff, but it is inconvenient for the patient. If a Nurse isn't nearby to offer a drink of water the pt can't have one, as the CNAs aren't allowed to assist because swallowing is so severe. There is only one speech therapist and they go home at 5.

Im thinking maybe the family doesn't want the feeding tube, but I was just wondering if there were other reasons that I am missing

Seems like I see feeding tubes in patients for swallowing problems much less severe than this.

I've never seen anyone on pudding think in 6 years.

[MendedHeart]

Im curious about the setting and if the severe swallowing problem was new onset. I guess if the patient was not having a hard time with the pudding(nectar thick?) Thick then it is least invasive as long as nutrition is ok.

[jadelpn, LPN, EMT-B]

I think it is a matter of risk/benefit. I would take the direction of speech therapy. Is there some sort of feeding plan in place? Deep suctioning?

Is this a new thing for this patient? Or has the patient always had these issues, and the family has dealt with it for a long time? Regardless, it is up to the MD and the speech therapist to have conversation about the risks, and why a feeding tube would/would not be a bad thing. Even TPN is a viable option, I would think. But again, you could suggest it, ask about it, but it is a decision that the family needs to make with input from other disciplines.

Good mouth care, swabs, etc. can moisten a mouth. Some families just need to come to grips with the fact that this patient will probably not recover to the level that they would like to have happen. That it is ok and there's other options than PO feeding. So on that premise, I would most definetely have regular patient care conferences, will all disciplines, to talk about progression of care.

If the patient is new to your facility, and was being cared for at home prior, that is a difficult thing for family to process. Or even if they have realized that for whatever reason they can not care for this patient at home. So your job as a nurse is to be sure that they have as much information that they need to be ok with whatever personal decision that they come to. And employ the MD, social work, the speech therapist...

[MendedHeart]

TPN is short term...should not be used for more than a week or two

[leslie :-D]

The patient isn't palliative or DNR. they do have a chronic neurological condition as well as a TBI.

It isn't inconvenient for staff, but it is inconvenient for the patient. If a Nurse isn't nearby to offer a drink of water the pt can't have one, as the CNAs aren't allowed to assist because swallowing is so severe. There is only one speech therapist and they go home at 5.

Im thinking maybe the family doesn't want the feeding tube, but I was just wondering if there were other reasons that I am missing

Seems like I see feeding tubes in patients for swallowing problems much less severe than this.

I've never seen anyone on pudding think in 6 years.

the bottom line is food is still considered a pleasure of life....

and is always preferable to a fdg tube.

the pt still gets to satisfy this most basic need by tasting and swallowing her food.

you don't get any of those sensations with a fdg tube.

speech needs to stay involved, to ensure pt is tolerating these fdgs and isn't microaspirating.

fdg tubes should always be a very last resort, and not used as a means of convenience.

leslie

[loriangel14, RN]

Feeding tubes are not for the "convenience " of staff. Putting a feeding tube in when it is not necessary would be wrong in my eyes. Eating is still a pleasure of life. Putting a tube in just because feeding is time consuming is not patient centred care.

[Glycerine82, LPN]

Feeding tubes are not for the "convenience " of staff. Putting a feeding tube in when it is not necessary would be wrong in my eyes. Eating is still a pleasure of life. Putting a tube in just because feeding is time consuming is not patient centred care.

Certainly not for staff convenience.....I am the CNA not the nurse so I don't have to do anything for the pt since im not allowed. I feel terribly for him because he can't get a drink of water unless I flag down the super busy nurse during her med pass......

I am sure they will re-evaluate once he becomes dehydrated. I have seen many patients on tube feedings who were allowed to eat for pleasure under the supervision of speech. As it stands now he only eats when speech is able to sit with him, which I have seen happen 1.5 hours after breakfast time.

[Glycerine82, LPN]

I think it is a matter of risk/benefit. I would take the direction of speech therapy. Is there some sort of feeding plan in place? Deep suctioning?

Is this a new thing for this patient? Or has the patient always had these issues, and the family has dealt with it for a long time? Regardless, it is up to the MD and the speech therapist to have conversation about the risks, and why a feeding tube would/would not be a bad thing. Even TPN is a viable option, I would think. But again, you could suggest it, ask about it, but it is a decision that the family needs to make with input from other disciplines.

Good mouth care, swabs, etc. can moisten a mouth. Some families just need to come to grips with the fact that this patient will probably not recover to the level that they would like to have happen. That it is ok and there's other options than PO feeding. So on that premise, I would most definetely have regular patient care conferences, will all disciplines, to talk about progression of care.

If the patient is new to your facility, and was being cared for at home prior, that is a difficult thing for family to process. Or even if they have realized that for whatever reason they can not care for this patient at home. So your job as a nurse is to be sure that they have as much information that they need to be ok with whatever personal decision that they come to. And employ the MD, social work, the speech therapist...

The swallowing problems are new onset, after a TBI the pt suffered. I give him good mouth care and he is able to brush his teeth but the poor guy cant get a drink of water or anything else unless there is an RN around to watch him drink it.

I think they are still processing the severity of his decline and Perhaps they will come around or perhaps his swallowing will improve.

I just feel like if his swallowing is so severe that CNAs/Family aren't allowed to assist him he should be on a tube feed with pleasure food under speech's supervision, but I still have a lot to learn, I know.

[leslie :-D]

I am sure they will re-evaluate once he becomes dehydrated. I have seen many patients on tube feedings who were allowed to eat for pleasure under the supervision of speech. As it stands now he only eats when speech is able to sit with him, which I have seen happen 1.5 hours after breakfast time.

i can assure you there are many pts on fdg tubes who are not eligible to eat foods by mouth...

unless one's intent was to cause serious harm or death.

also, fdg tubes do not prevent thirst, and so, a fdg tube would not address that particular problem with your pt.

continue on giving good mouth care, that is helpful.

and there is a reason that only skilled personnel can feed this pt...as it is too easy in causing a pt to aspirate.

i appreciate your compassion, but i do believe you will understand so much more when you advance in your studies.

good luck to you.

leslie

[carolinapooh, BSN, RN]

Not only are they still evaluating the best approach for treatment, but they are also evaluating the possibility (and I'm no rehab RN, just oncology - but we see everything - and I work at a military hospital where the Center for the Intrepid is located, so we hear about all sorts of stuff) of his own rehabilitation: can he relearn how to swallow?

The brain can, in some cases, 'rewire' itself - this is how some aphasic stroke victims end up able to speak to some extent. It depends on the degree of damage, how motivated the patient is, the age of the patient, baseline before TBI, where the brain was damaged, etc. It's how double LE amputees learn to walk (it's the root of so-called 'muscle memory' - it's not your muscles doing the remembering! :) ), right handed people who lost their right arm to the Taliban learn how to write with their left hand, and so on.

And it's not just the joy of food. It could very well be a step towards some semblance of independence, or a way to help preserve the pt's self esteem, or maybe they're just letting her try to see how she does.

If it's a new injury, this process has just begun. I'm glad to know you find it disheartening (gosh, that sounds weird), and that you want to advocate for your patient, but it's part of a process.