Feeding a Helpless Patient

Subject: Fundamentals of Nursing

Overview

Feeding a Helpless Patient

It is assisting a dependent patient to take food and fluids. A patient who cannot feed him/herself needs to be fed. A person may need to be fed or have help during mealtimes if he has certain health problems. Oral feeding is the preferred and most effective method of feeding patients. If the family members are present, they can be asked to feed the patient. If there is no family member, the nurse should feed the patient.

Purposes

  • To assist the patient to meet his nutritional needs.
  • To promote the patient's wellbeing.

Guidelines

  • Create a pleasant environment. Arrange food tray in an attractive manner.
  • Place the dish within his/her sight so that he/she can see the food.
  • Give water in between if the patient prefers.
  • Be relaxed while feeding the patient and do not make the patient feel that you are in hurry.
  • Do not talk much with the patient while feeding as it will interfere in his eating. Make few short conversations in between telling him/her about the food she is giving to him/her.
  • Make the mealtime enjoyable. Ask him if he would like to listen to his favorite music.
  • Arrange for a family member or friend to visit with him during his meal.
  • Give him 5 to 6 small meals during the day instead of 3 big meals.
  • Offer him healthy snacks, such as fruit or cheese, if he gets hungry between meals.
  • The patient should be undisturbed by treatments, dressing, visitors, doctors rounds, unpleasant sounds and odour during meal time.
  • The room should be well ventilated, quiet and comfortable.
  • Encourage the patient to eat by himself if possible and the extent possible.

Equipment

  • Tray containing prepared diet,
  • Face towel or napkin,
  • Feeding cup with water,
  • Kidney tray,
  • Spoon,
  • Back rest and cardiac table or other appropriate table,
  • Water.

Procedures

  • Get ready for mealtime.
  • Explain the procedure to the patient and assess how he can participate.
  • Ask the person if he needs to use the bathroom.
  • Place the patient in a comfortable position; help him sit upright as much as possible. If allowed, help him into a chair or raise the head of the bed. Put the pillows behind his back for comfort and support.
  • If not able to assume the sitting position, head should be elevated and supported back rest or pillow. If the patient has to remain in lying position, put him/her in left lateral position.
  • Assist the patient to wash his hand and face.
  • Place a towel over chest and around the neck.
  • Make sure that therapeutic restrictions are considered.
  • Wash your hand after the articles are arranged in bed side.
  • Place the items needed for feeding within easy reach:
    • Over-bed table
    • Meal tray
    • Towels
    • Straws
    • Feeding devices, such as special spoons or a syringe.
  • Feed the person
    • Sit or stand at the patient's bed side.
    • Consider the patient's preferences while feeding and encourage his participation to the extent possible.
    • Tell him what food is on the plate. Describe how it is prepared if he has vision problems.
    • Ask the person which food he wants to eat first.
    • Put a small amount of food on the tip of the spoon.
    • Feed the patient in small-spoonful waiting for him to chew and swallow one mouthful before next. If he tends to choke, add a little water or other liquid on the spoon. This will help him swallow the food.
    • Allow the person to eat at his own pace. Give him time to chew his food completely.
    • Encourage the patient to take all the food served to him, but don't force. Forcing food causes vomiting.
    • When the patient has eaten food and feels satisfied, stop feeding and give him a glass of water if he prefers.
  • After feeding the patient remove the plate, offer water to ringe mouth and spit into kidney basin.
  • Dry the lips and face with a towel.
  • Make the patient comfortable.
  • Take care of the equipment and keep them in their respective place.
  • Wash hands and dry them.
  • Record the type of diet, time of feeding, amount take and tolerance.

Nasogastric Feeding/Gastric Gavage

Definition

Tube feeding is a process of giving liquid nutrients or medications through a tube into the stomach when the oral intake is inadequate or impossible. It is an administration of food directly into the stomach using a tube passed into the stomach through the nose (nasogastric) or mouth (orogastric). Breast milk, formula, or liquid food is given through the tube directly into the stomach.

Purposes

  • To provide nourishment to the patient who can't eat through the mouth e.g. surgery in oral cavity, unconsciousness or comatose state.
  • To administer medication.
  • To give large amount of fluids for therapeutic purpose.

Principles

  • Ensuring the patient's safety is an essential role of the nurse.
  • Use aseptic technique when preparing and delivering tube feeding practice right patient, right formula, right tube by matching formula and rate to feeding order.
  •  Have a patient sit upright or elevated the head of the bed a minimum of 30 degree unless medically contraindicated.
  • Do not add food coloring or dye to ET tube. Use of dye has been linked to hypertension, metabolic acidosis, and death. (Matheny et al,2007)
  • Administer oral hygiene frequently, every 2-4 hour to prevent drying of tissues and to relieve thrust.
  • Keep the nares clean, especially around the tube, where secretions tend to accumulate.

Indications

  • Unconscious/semi-conscious patients.
  • After certain surgeries of mouth and throat.
  • Patient unable to swallow.
  • Premature babies.
  • Recurrent episodes of aspiration.
  • The patient who requires high metabolic needs. For example - burns, cancer, etc.
  • Poor oral intake patients.
  • Obstruction of esophagus.

Articles

  • Measuring Jug
  • Large syringe (30-60ml)
  • Stethoscope
  • Kidney tray
  • Towel and mackintosh
  • Water in a container
  • Feeding Formulae
  • Artery forceps for clamp
  • Gauze pieces

Procedure

S.N. Nursing Action Rationale
1 Identify the patient. Helps in determining the right patient.
2

Verify physician's order for type, amount of feed and frequency. Assess for food allergies, bowel sounds and laboratory values.

Check amount, concentration, type and frequency of feeding.

Check for time of last feed.

 Proper assessment will provide baseline information and prevent from risk of error and complication.
3 Explain procedure to the patient. Feeding time will take around 10-20 minutes to complete. Reduces anxiety and promotes client's participation.
4 Close the door/curtain and switch off the fan. Maintains privacy. Prevents spread of dust and microorganisms.
5 Wash hands. Prevents from infection.
6 Arrange articles in bed side. Arranging articles aids for smooth functioning.
7

Prepare feeding container and formula:

Check expiration date on formula and integrity of container.

Sure that formula is at room temperature. Place container with feed in warm water if it is cold.

Ensures formula is suitable for fed.

Warms the fluid to be fed.
8 Keep the patient to fowler's position at least in 35-45 degree. Fowler's position enhances gravitational flow of feed through tube.
9 Spread towel and mackintosh over patient's chest. Protects client and bed linen from soiling.
10 Wear gloves. Protects from infection.
11 Attach syringe to nasogastric tube, after clamping the tube. Ensures readiness to feed.
12

Check the correct placement by: aspirating stomach contents.

If there is doubt about tube placement, inform physician and obtain an order for x-ray or if  any doubt inform to seniors.

Gently aspirate the gastric contents from the previous feed and check the volume if the volume is in large amount (> 50ml), inform the doctor.

Confirms tube placement.

Prevents abdominal distention.
13 If residual contents are within normal limit and placement of the tube has been confirmed, return gastric contents to stomach through syringe using gravity to regulate flow. Returning contents to stomach prevents fluid and electrolyte imbalance.
14 If tube placement is conformed in stomach, pinch the feeding tube and attach barrel of feeding syringe to tube. Pinching of feeding tube prevents air from entering the stomach and causing distention.
15 Fill syringe barrel with water and allow fluid to flow in by gravity, by raising barrel above level of the patient's bed. Water clears the tube and the rate of flow is regulated by raising and lowering the syringe.
16 Pour food into the syringe barrel and allow in to flow by gravity. Keep on pouring feed formula to barrel when it is three quarters empty. Pinch tube whenever necessary to stop, when pouring. Pinching the tube prevents air from entering.
17

When using a feeding bag:

Hang the bag on IV pole and adjust to about 12 inch above the stomach.

Clamp the tube, pour the formula into feeding bag and allow solution to run through tubing. Attach feeding setup to feeding tube, open clamp and regulate drip according to physicians order, or allow feeding to run in over 30 minutes.

Rate of flow is regulated by level of gravity.
18 After feeding, flush the tube with at least 30 ml of plain water. Prevents clogging of feeding tube.
19 After the tube is cleared, clamp it or close the end of the feeding tube. Prevents leakage.
20 Keep the head of the bed elevated for 30-60 minutes after feeding. Prevents aspiration.
21 Wash and dry the equipment and keep in proper place ready for next feeds. Prevents from growth of organisms.
22 Removes gloves. Wash hands.  
23 Record the date, time, amount of feed, nature and the reaction of the patient's intake and output chart. Documents exact procedure. It helps to communicate procedure among staff.
24

Monitor for breath sounds, bowel sounds and gastric distension.

Helps to monitor effect of gastrointestinal system and therapeutic effect of feeding.
25

Instruct the patient to notify if he experiences sensation of fullness, nausea or vomiting.

 May indicate intolerance of feeding.

Complication of Tube Feeding

  • Tube displacement, aspiration.
  • Cramping/distension.
  • Vomiting and diarrhoea.
  • Hypertonic dehydration, glucose intolerance, renal failure, cardiac failure, etc.

Gastrostomy/Jejunostomy Feeding

Definition

It is administration of food in its fluid form through a gastrostomy or jejunostomy tube which is placed through a surgical opening into the stomach or jejunun.

Purpose

  • To maintain nutritional status of a patient whose upper gastrointestinal tract is bypassed.

Indications

  • Tumours or operations on the upper gastro-intestinal tract.
  • Cancer of the oesophagus.
  • Stricture of the oesophagus caused by poisoning in case of fistula.

Articles

  • Disposable gavage bag and tubing,
  • Syringe 50 ml and 20 ml,
  • Towel,
  • Stethoscope,
  • IV stand,
  • Feed,
  • Gauze pieces if necessary,
  • Water,
  • Mackintosh,
  • Administration set.
Procedure
S.N. Nursing Action Rationale
1 Identify the patient. Ensures right patient.
2 Check written order for feeding amount, type and frequency. Reduces errors in the feeding process.
3 Explain procedure to the patient and relatives. Proper explanation enables the patient to be informed and educes anxiety.
4 Close the door/curtain and switch off the fan. Maintains privacy. Prevents spread of dust and microorganisms.
5 Wash hands. Prevents from infection.
6 Arrange articles in bed side.

Arranging articles aids for smooth functioning.
7 Prepare warm feeding before administrating the tube feeding. Ensures formula is suitable for fed.
8 Assess gastrostomy site for skin breakdown, irritation or drainage. Infection, pressure from gastrostomy tube or drainage of gastric secretions can cause skin breakdown.
9 Auscultate for bowel sound before feeding. Consult a physician if bowel sounds are absent. Bowel sounds indicate presence of peristalsis and ability of gastrointestinal tract to digest nutrients.
10

Prepare a bag and tubing to administer feed.

Connect tubing and bag.

Fill bag and tubing with feed.

 Administering of feed through tubing prevents excess air entering gastrointestinal tract.
11 Place the patient in fowler's position or elevate head of bed to 30 degrees. Elevating client's head helps to prevent chance of aspiration.
12

Check placement of gastric tube.

Aspirate gastric secretion and check gastric residual contents.

Auscultate over left upper quadrant with stethoscope and inject 10-20 ml of air into the tube using a syringe.

 Presence of gastric contents indicates that end of tube is in stomach.
13

Initiate feeding.

Bolus or intermittent feeding

  • Pinch proximal end of the  gastrostomy tube.
  • Attach a syringe to the end of the tube and elevate to 18 inches above the patient's abdomen.
  • Fill the syringe with formula. Allow the syringe to empty gradually and refill it until prescribed amount has been delivered to the patient.
  • If a gavage bag is used, attach the bag to the end of the feeding tube and raise the bag 18 inches above the patient's abdomen. Fill the bag with prescribed amount of feed; allow the bag to empty gradually over 30 minutes.

Continuous drip method

  • Hang the gavage bag to an IV pole.
  • Connect the end of the bag to the proximal end of the gastrostomy tube.
  • Connect the infusion pump and set rate.
  • When tube feedings are not being administered, clamp the proximal end of the feeding tube.

Prevents air from entering the client's stomach.

Gradual emptying of tube feeding by gravity from a syringe or gavage bag reduces the risk of diarrhea induce by bolus tube feedings.

Continuous feeding method is designed to deliver a prescribed hourly feeding. This method reduces the risk of diarrhea.
14 Administer water via the feeding tube as ordered with or between feedings. Provides the patient with source of water which helps to maintain fluid and electrolyte balance.
15 Rinse the bag and tubing with warm water after all bolus feedings are given. Prevents growth of microorganisms.
16 Change the gastrostomy exist site dressing as needed. Inspect exit site every shift. Clean the ostomy site daily with warm water and mild soap. A small gauze dressing may be applied to exit site. Leakage of gastric drainage may cause irritation and excoriation of skin around feeding tube.
17 Clean the equipment with soap and water and return to the proper place. Reduces transmission of microorganisms.
18 Wash hands.  
19 Make the patient comfortable. Ensures the client's comfort.
20 Evaluate the patient's tolerance of tube feeding. Tolerance of tube feeding is evaluated by checking the amount of aspirate every hours.
21 Weigh the patient daily. Weight gain is an indicator of nutritional status.
22 Monitor blood glucose every 6 hours if hospital policy requires it. Alerts for client's intolerance of glucose.
23 Record in intake-output chart, date, time, amount, patency of tube and type of feed. Documents client's status of feeding.
24 Report to on coming nursing staff, type of feeding, status of gastrostomy tube, patient's tolerance and adverse effects. Allows other personal to plan for next feeding.

Special Considerations

  • In case of aspiration of feed, suction patient, notify physician and obtain chest X-ray film. Risk of aspiration may be lessened if the head of the bed is elevated to 30 to 45 degrees note during feeding and for 1 hour after feeding.
  • In case of diarrhea, decrease feeding, review medication and notify the physician.
  • In case of nausea and vomiting, notify the physician and withhold feeding.
  • If bowel sounds are absent, notify the physician before initiating feeding.
  • Gastrostomy tube is appropriate for a long-term use.
  • Intermittent feeding is preferred in infants because of possible perforation of stomach and no irritation to mucous membrane.
  • Tube feeding should be gradually advanced to prevent diarrhea and gastric intolerance of formula,
Things to remember

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