Talking About Tubes
A new order for an ST eval is always exciting because you never know what to expect.
Caring for a new feeding tube can be overwhelming and confusing for patients and caregivers.
These thoughts came to mind today as I was taking a medical history from the son of my new patient. I was excited to be there. He was overwhelmed and confused.
His 88 year old mother was discharged from a skilled nursing facility two days prior to my visit. She had experienced a stroke "somewhere back there" and had a brand new feeding tube "because she failed the swallowing test."
Does this sound familiar?
He could not relate any specific information about the stroke or the feeding tube, but now, he is in charge of the daily care of a stroke victim and the daily operation of a feeding tube. That's scary!
To make matters worse, her discharge from SNF to home was poorly planned. She arrived home without any medical equipment. In fact, the son told me the feeding pump she was using had been "borrowed from the rehab place." Oh my!
I worked hard to contain myself from dropping my jaw as the son answered my questions and explained the situation. No matter the circumstances, it was obvious: she needed equipment and he needed education.
Though I'm limited in what I can do to solve an equipment problem, I felt I could provide some helpful information about feeding tubes. Here are the 7 things I told him:
What Your SLP Wants You to Know
About Feeding Tubes
About Feeding Tubes
1. You can still aspirate!
Even though the nutrition being provided by a feeding tube bypasses the problem areas (mouth, larynx, esophagus), feeding tubes are not guaranteed to prevent aspiration. Families need to know that saliva, secretions and stomach contents can be aspirated.
2. Oral care is super important
Because saliva and secretions can be aspirated, it is important to keep the mouth as clean as possible. Routine oral care helps to reduce the amount of bacteria in the mouth, thereby reducing the risk of pneumonia in the event of an aspiration.
3. The head of the bed should always be elevated to 30 degrees
Digestion is improved and reflux is reduced by simply elevating the head. Propping the head and shoulders on pillows or adjusting the head of the bed to a 30 degree angle reduces the risk of aspiration. Gravity is a wonderful thing.
4. There are continuous feedings
Feeding pumps regulate and deliver continuous feedings. These feedings occur at a certain rate and are delivered over a predetermined amount of time. The flow rate and feeding schedule are ordered by a doctor. The feeling of continuous feeding can be compared to the sensation of fullness when continuously snacking- you're never really hungry. While a pump may be necessary during acute illness, it may be impractical as you become for active.
5. There are bolus feedings
Bolus feedings involve administering a specific volume of formula at a specific time of the day. A doctor sets the feeding amount and schedule. Either a gravity drip or a large syringe is used to deliver formula, water and medications. Bolus feedings approximate the sensation of fullness you experience after consuming a complete meal. Since there are long intervals of time in between the feedings, a person may experience the sensation of being hungry. Because a large volume of liquid is quickly entering the body, some have trouble tolerating bolus feedings.
6. Speech pathologist are permitted to work around your restrictions
Feeding tubes are often inserted due to dysphagia (swallowing difficulties) and come with an NPO (nothing by mouth) restriction. When a patient is placed on NPO status, it doesn't automatically mean that he will never, ever eat or drink anything ever again. With MD authorization and as judged clinically appropriate, speech pathologists are able to introduce small amounts of food or liquid into treatment sessions for the purpose of assessing swallow function and safety. While these therapeutic trials are carefully planned and are an important part of helping you reach your treatment goals, patients should continue to follow NPO restrictions outside of treatment sessions.
7. If you cheat, we want to know
Sometimes, as patients progress, they are tempted to disregard their NPO status. They may take a few sips of water, one good slurp of coffee or a bite of birthday cake. No matter what it is that tempts them, patients are encouraged to tell their therapist if they are eating or drinking anything outside of a supervised therapy session. Reporting these cheats provides valuable information to the therapist about swallow function and safety. Depending on the circumstances and/or the outcome the patient experienced, unsupervised cheats may: reinforce the need for NPO status, explain that mysterious new pneumonia diagnosis or lead to a therapeutic progression of oral intake. No matter what a patient chooses, it is important to emphasize that honesty is the best policy.
The use of feeding tubes is increasingly common, and due to the aging of America, their rate of placement continues to rise each year. The most common primary diagnoses among patients receiving feeding tubes are dementia (25-50%), stroke (50-75%) and head and neck cancer (60-70%). As an SLP, if you work with patients in any of these populations, it is important to be prepared to provide education, answer questions and make recommendations regarding feeding tubes.
If you are a patient, family member or caregiver that is just becoming familiar with the basic operations of a feeding tube, remember your SLP can be a great source of information and support.
Don't be afraid of the answers, be afraid of not asking the questions.