Care Guides for Caregivers

Tube Feeding a Survivor

Post on 03/07/16

Following a stroke, the patient may not be able to swallow food. Tube feeding may therefore be necessary, with food being delivered in a liquid form through the tube.

Good and adequate nutrition is important for maintaining good health. The stroke patient may have deficits that may make eating and drinking difficult or unsafe. It is necessary that at every stage of the patient’s progress the right foods are provided in the right manner and in the right amounts.

In the early stages, patients are dependent on others to feed them. They are normally fed through a tube to meet their nutritional needs.

As the patient improves he may start eating foods of a suitable consistency e.g. very soft foods. Gradually he will learn to eat foods of normal texture again. The right type of nutrition will help prevent weight loss and dehydration, and protect against infections.

In addition, as part of a healthy lifestyle, healthy nutrition may reduce the chances of a recurrent stroke.

 

What is tube feeding?

A tube is inserted through the nose and into the stomach so that liquids may be fed to the patient (Nasogastric feeding). In patients on tube feeding for more than four to six weeks, the tube may be inserted directly into the stomach from the outside through an opening in the skin (Gastrostomy feeding).

How to feed through a tube?

There are two common methods of feeding:

  • Bolus: The patient is fed at regular intervals. Each feed, comprising 200 to 300 mls of fluid, is fed into the tube using a syringe over a short period of time (five to 10 minutes)
  • Continuous: The feed is delivered continuously from an overhead container into the tube attached to the patient. The feed drips slowly either over a shorter period of 30 minutes to three hours or over a longer period of 12 to 24 hours

The following information relates mainly to bolus feeding which is the usual method of feeding at home.

What can be fed through the Bolus method?

The liquid feed selected for the patient will be one that best meets the patient’s nutritional requirements. They are available as nutritionally complete formulae and are convenient, hygienic and easily tolerated.

It is difficult to give the patient foods which we normally eat. They usually do not provide complete nutrition when fed by the tube because of the limited amount of liquids allowed. There is also an increased risk of contamination and tube blockage.

The formula may be in either liquid or powder form.

What is required?

  • The formula: reconstituted from powder, or ready-to-feed formula •
  • The feeding tube: either nasogestric or gastrostomy which is already inserted in the patient
  • Other accessories: funnel, measuring cup, blue litmus paper, syringe and feeding tube stoppar or spigot
  • Water for flushing

Preparations for feeding

  • Clean hands, all equipment and accessories well before feeding
  • Use boiled water for mixing powdered formula
  • Follow the mixing instructions on the formula packing, Use the correct amounts of powder and water. Do not use less or more water unless instructed
  • Refrigerated formula should be kept at room temperature for ]5 to 20 minutes before feeding

Nasogastric Tube Feeding (NGT)

  • Seat the patient in a sifting position or head raised to an angle of at least 30 degrees
  • Check that the tube is in the stomach – connect the syringe nozzle to the feeding tube and withdraw some contents. Dip the blue litmus paper into the contents. If the blue litmus turns pink, it indicates that foe tube is in the stomach
  • Using the syringe, withdraw any fluid left in the stomach. If tube contents are more than 1(30 to 125 mls, return the contents to the stomach and delay feeding till the amount falls to less than 100 mls
  • Place the funnel or the syringe tip into the feeding tube and hold at the level of the patient’s head
  • Pour the prepared amount of formula into the funnel or syringe. Do not give a total of more than 200 to 250 mls per feed
  • Flush the tube with 10 to 50 mls of water, after the feed is completed. Disconnect the funnel or syringe and replace feeding tube stopper
  • Wait for 30 minutes to an hour after feeding before lying the patient flat

Maintaining good oral care and hygiene

  • Keep the mouth clean and moist to prevent infections caused by dry mouth linings•
  • Offer mouthwashes and gargles
  • Encourage breathing through the nose
  • Follow the other measures for dental care
  • Change the adhesive tape around the tube on the face daily or whenever it is soiled
  • Clean the area around the tube on the face daily
  • Clean the nostrils with a cotton-tipped applicator moistened with mild soap and water
  • Change the feeding tube once a fortnight

Percutaneous Endoscopic Gastrostomy (PEG) Feeding

  • Raise the patient to a sitting position or to an angle of at least 30 to 40 degrees. This is to reduce the chances of the stomach contents flowing up into the food pipe (reflux) and into the lungs (aspiration)
  • Make sure the tube is in place before each feeding:
    • Check that the tube is in place by measuring with a tape measure, the length of the tube from the PEG site to the end of the tube, or note the level of the external flange (by looking at the number of centimeters marked on the PEG tube)
    • Compare this with the previous or original measurement –
    • Contact the doctor immediately if there is a difference of more than 2 cm before trying to give the feeds or medications through the tube
  • Check the stomach contents if recommended
    • Withdraw the contents of the stomach gently with the syringe –
    • If the amount is more than 100-125 mls, return the contents to the stomach and delay feeding till the amount is reduced
    • If the amount is less than 100 mls, return the contents to the stomach and start to feed
  • Place the tip of the syringe into the feeding tube and hold not more than 15 to 30 cm above the abdominal level. This is to prevent feeds from going into the stomach too quickly
  • Pour the prescribed amount of the formula, not more than 200-300 mls in total, into the syringe and allow it to flow in slowly
  • Flush the tube with 30 mls of water or more if permitted after each feed. Disconnect the syringe and reclamp the tube
  • Wait for 30 minutes to an hour after feeding before lying the patient flat

Caring for the PEG tube

  • Make sure that the flange (tube guard) remains snug with the skin:
    • If the flange is too tight, pressure ulceration of the skin or stomach lining will result
    • If the flange is too loose, it may lead to the leakage of feeds or stomach contents
  • Rotate the tube 90 degrees daily to allow even pressure distribution on the skin and the stomach lining
  • Make sure you flush enough to prevent blockage of the PEG tube •
  • Flush with 15-30 mls of warm water before and after each intermittent feeding or every three to four hours during continuous feeding. Flush similarly before and after medication is given through the tube •
  • Check the dressing daily and change it whenever it is wet or soiled •
  • First, carefully clean the skin around the tube with warm water. Then, dry the skin thoroughly
  • Position two folded pieces of gauze on either side of the tube so that the sides overlap to protect the skin from gastric leakage (see figure) •
  • Secure them with low-allergic tape (e.g. Micropore tape)
  • Two weeks after the PEG tube is inserted, the dressing for the abdominal wound is not necessary as the stomach wall usually sticks well to the abdominal wall and leakage from the wound is uncommon

Caring for the PEG site

  • Check the PEG site before and after feeding for any leakage. If leakage of food or medicine around the tube is seen, immediately apply a warm moistened towel to soften any dried up fluid. Wash, rinse and dry the skin
  • Keep the skin around the stomach opening clean and dry to avoid skin irritation and infection. If the skin becomes irritated, dust it with stoma-adhesive powder (e.g. Comfeel or Stoma powder) •
  • See a doctor if the leakage persists or if the skin around the tube feels sore, looks red or puffy

PEG tube dressing

Replacement of the PEG tube

  • See your doctor every six to nine months to replace the PEG tube. If the tube gets out of shape or splits, see the doctor immediately •
  • The subsequent tubes are often replaced with balloon or button tubes without the use of an endoscope
  • If the balloon tube falls out (this may happen when the balloon bursts or deflates), do the following:
    • Reinsert the tube through the abdominal opening (PEG tract) immediately to prevent it from closing over
    • Seek medical attention as soon as possible

Follow-up

Only some patients receiving PEG feeds need to be followed up in the outpatient clinic. This depends on their medical condition, mobility and practicality. Most may be referred to alternative healthcare professionals or clinics. You will usually be informed of this at the time when you are first discharged from the hospital with the PEG tube.

In case of any queries or problems with the PEG, contact your doctor or nurse.

Additional pointers on PEG tube feeding

  • Refrigerate unused feeds immediately; use within 24 to 48 hours •
  • Make sure the total fluids fed to the patient in a day meet the requirements; some patients may not be allowed too much fluid
  • Check the patient’s weight if possible, once a week and note weight loss or weight gain
  • If the patient is diabetic, has increased blood fats or kidney problems, it is best not to make any changes in the recommended feeding plan without consulting the doctor or dietitian

Potential problems

Normally, if tube feed is well managed, there should be no complications. Sometimes however, patients may develop some of the following problems.

Constipation / diarrhoea

Bowel movements of the patients may continue as before or reduce in regularity; passing stools once in two to three days is not unusual. However, if there is a change in the consistency of the stool, i.e. very hard (constipation) or very watery (diarrhoea):

  • First make sure the above feeding instructions have been followed
  • Dilute the formula for a short time (for very hard stools)

A fibre supplement may be added to improve bowel movement. If the problem persists for more than a few days, consult your doctor.

Indigestion, vomiting and stomach cramps

Sometimes the patient may have undigested food left in the stomach, or he may feel like vomiting. In this case, try the following measures:

  • Delay the next feed
  • Lengthen the time interval between feeds
  • Dilute the formula for a short time
  • Do not feed in the presence of vomiting

If these problems are severe or persist for more than 24 hours, consult your doctor.

Mechanical problems

  • Tube blockage:

If feeds are not passing through the tube, remove the blockage by flushing with gentle force using a small amount of water.

  • Displacement of tube:

If the feeding tube slips out or is found not to be in the correct place, contact your doctor or nurse as soon as possible. Do not feed the patient.

  • Seek medical help and advice:
    • If there is weight loss or excessive weight gain
    • If there are problems with bowel movements
    • Before feeding any new types of food
    • If there are persistent signs of indigestion and vomiting
    • If blood appears in the stool
    • If bleeding occurs around the nostrils especially for patients on nasogastric tube feeding
    • If coughing or breathing difficulty develops
    • If fever develops in the presence of diarrhoea
    • If the feeding tube is displaced
    • When the patient has other medical problems

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