The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [267]
Signs of recurrent chest infections and pyrexia This may indicate aspiration pneumonia as a consequence of dysphagia (Leslie et al. 2003)
Patient report of swallowing problems Patients can be very accurate in self-diagnosis of dysphagia (Pauloski et al. 2002)
Patient reports food sticking Patients can be very accurate in self-diagnosis of dysphagia (Pauloski et al. 2002)
Additional time required to eat a meal Taking a long time to eat may indicate dysphagia (Leslie et al. 2003)
Avoidance of certain foods Patients will avoid food items that they find difficult to swallow (Leslie et al. 2003)
Weight loss Patients may eat less due to difficulty swallowing (Leslie et al. 2003)
Poor oral hygiene Aspiration of secretions in those with poor oral hygiene may result in aspiration pneumonia (Langmore 2001)
Postprocedural considerations
Education of patient and relevant others
It is important that volunteers, family members or visitors who wish to assist the patient with feeding are familiar with and trained in the processes listed in Procedure guideline 8.9 (NPSA 2009). This is to ensure that the family is confident and can safely and effectively assist the patient.
Documentation
It is essential that the plate is not removed before wastage has been recorded and this is relayed to the ward catering staff prior to meal service commencement. If the patient has not managed a reasonable amount of their meal, this needs to be addressed later in the afternoon or evening. It is also important to ascertain whose responsibility it is for completion of the charts to avoid confusion, that is, nurse, healthcare assistant, ward catering staff or patient, as this will vary across institutions. These charts can be used by the dietitian or healthcare professional to effectively assess the patient’s meal pattern and nutrition intake. Some patients may be able to complete the record themselves if given guidance on what is required.
Difficulties arise when the food chart data are not accurately completed or reviewed, during which time malnutrition and its consequences continue, rather than being quickly identified and addressed.
If there is strong concern about the quantity of food that has been consumed by the patient, this must also be verbally relayed to the nurse in charge, ward dietitian and possibly the clinician.
Enteral tube feeding
Definition
Enteral tube feeding refers to the delivery of a nutritionally complete feed (containing protein, fat, carbohydrate, vitamins, minerals, fluid and possibly dietary fibre) directly into the gastrointestinal tract via a tube. The tube is usually placed into the stomach, duodenum or jejunum via either the nose or direct percutaneous route (NCCAC 2006).
Related theory
Enteral feeding tubes allow direct access to the gastrointestinal tract for the purposes of feeding. A nasogastric or nasojejunal tube is placed via the nose and passed down the oesophagus with the feeding tip ending in the stomach (gastric) or small intestine (jejunum) respectively. A gastrostomy tube is placed directly into the stomach allowing infusion of nutrients into the stomach or, alternatively, such tubes may have a jejunal extension passing through the pylorus, allowing feeding into the jejunum (small intestine). A jejunostomy tube allows direct access to the jejunum for feeding. The choice of appropriate tube should be based on the method of insertion and the associated risks, length of time feeding is required, function of the gastrointestinal tract, the physical condition of the patient and body image issues relating to the visibility of the feeding tube, after discussion with the patient. The feeding regimen, care of the tube and stoma will depend on the enteral feeding tube inserted.
Evidence-based approaches
Rationale
While the majority of patients will be able to meet their nutritional requirements orally, there is a group of individuals who will require enteral tube feeding either