Question

Enteral Feedings Case Study:

George kroo is a 79 year old male admitted to your unit with failure to thrive. He has not been eating due to complaints of difficulty swallowing, has lost 11 lbs. in the past 3 weeks, and has been complaining of weakness, headaches, dizziness, and blurry vision quite frequently for the past week. George has a history of a stroke in 2016 and diabetes mellitus type 2. You are the nursing caring for Mr. Kroo this shift. You just see that the doctor has placed an order for Mr. Kroo to be started on 0.9% Sodium Chloride IV fluids at a rate of 125ml/hr as well as for a Dobhoff nasogastric tube to be inserted so that tube feedings can be initiated. Mr. Kroo is to remain NPO for now.

1. What member of the interdisciplinary team should be consulted for George complaints of difficulty swallowing?
2. What conditions are you concerned for based on Mr. Kroo presenting symptoms and based on his medical history
3. What are some physician orders you would anticipate for this patient based on his presenting symptoms, medical history, and current status?
4. Although Dobhoff feeding tubes cannot be inserted by nurses, unlike normal NG tubes, the procedure for insertion is still the same. What is the first step the nurse would do to prepare to insert the nasogastric tube in this patient
5. Once the Dobhoff tube (DHT) is inserted, what is the best way to confirm correct placement of the DHT?
6. While waiting for DHT placement confirmation, you notice that the patient all of a sudden becomes confused, irritable, has slurred speech and starts sweating. What is your initial intervention based on these new symptoms?
7. You check a BG level and the patient’s level is 51 mg/dL. What do you do now?

2. Placement is confirmed and tube feedings are started at a continuous rate of 30ml/hr via a kangaroo pump, with an order to increase the rate by 10 ml/hr q6h as the patient tolerates the feedings. 6 hours after starting the infusion, the nurse checks the DHT for residual and aspirates 300 ml of feeding. The patient complains of nausea and the patient’s abdomen feels firm and distended upon inspection. Bowel sounds and very hypoactive. Should the nurse still increase the rate up to 40 ml/hr as ordered? If not, what should the nurse do?

3. You see two CNAs in the patient’s room to pull the patient up in bed and turn him on his right side, per request. The patient still has continuous tube feedings infusing. The CNAs flatten the head of the bed and place the patient in reverse Trendelenburg position without first stopping the tube feedings. What is the issue with this? What could happen?

Answer 1

Dysphagia

Dysphagia, or difficulty swallowing, affects up to 15 million adults in the United States. According to past publications, 1 in 25 people will experience some form of dysphagia in their lifetime, including 22% of those age 50 and older (ASHA, 2008; Bhattacharyya, 2014). People at the greatest risk for swallowing impairments include individuals who have had strokes, those with neurological conditions (such Parkinson’s disease), survivors of head and neck cancer, and the elderly.

The word dysphagia, which comes from the Greek words dys (difficulty) and phagia (to eat), refers to the sensation of food being delayed or hindered in its passage from the mouth to the stomach. Dysphagia may be classified anatomically as either oropharyngeal or esophageal. Oropharyngeal, or transfer, dysphagia is related to the initiation of the swallow (ie, the movement of a food bolus from the hypopharynx to the esophagus). Esophageal dysphagia arises in the body of the esophagus and relates to difficulty in passing food to the stomach. Dysphagia may result either from mechanical obstruction or altered motor function along the area of food passage.

Mr Karoo is an old person, Elderly are at an increased risk for development of dysphagia due to illnesses (diabetic) that affect the swallowing mechanism.

HOW TO IMPROVE SWALLOWING PROBLEMS

Eat small meals frequently instead of three large meals daily. Moderate to severe dysphagia may require you to follow a soft or liquid diet. Avoid sticky foods, such as jam or peanut butter, and be sure to cut your foods into small pieces to make swallowing easier.

Reflex placement of NG Tubes

A thin catheter was inserted through the nostril with its tip being placed in the oropharynx. The NGT was placed through the other nostril in approximately the same position. The swallowing reflex was induced by bolus injection of 0.5–2.0 ml of distilled water through the thin catheter. At the onset of swallowing, which was identified by observation of the characteristic upward laryngeal movement, the NGT was moved forward.

Study design

For evaluating the efficiency of the new method, patients in whom a NGT had to be placed were divided into two groups. The control group comprised those patients in whom the conventional approach was successful. Patients in whom the conventional approach failed were allocated to the study group. At least four attempts and the use of known facilitating measures such as increasing the rigidity of the tube by refrigeration and tilting the patient’s head forward were required before the application of the new method was allowed.

For evaluating the tolerability of the new method, changes in heart rate, systolic arterial blood pressure and oxygen saturation in response to either method of tube placement were scored in a further group of patients needing tube feeding because of dysphagia. For this investigation, we took into account only patients for whom, because of self-extubation or tube obstruction, at least two NGT placements within 48 h were necessary, and therefore both methods could be studied in close succession. In half the patients, the conventional method was performed first, and in the other half the new method was used. The number of attempts until achievement of correct placement was scored. The presence of concomitant medication modulating blood pressure or heart rate was noted.

Confirmation of Dub hoff tube (DHT)

Chest radiography is the gold standard for confirming appropriate placement of a nasogastric tube. If the feeding tube is blindly inserted, radiographic confirmation of correct placement is recommended before administration of medication or feeding.

PROBLEMS AFTER PLACEMENT DOB HOFF TUBE

1. Low blood sugar (BG) level less than 130 mg/ml

2. Show symptoms of slurred speech, sweating, confusion & irritation

3. Here Patient Mr Karoo has 51 mg/ml of BG level, so above symptoms will occur.

How to improve distended and firm condition of Mr Karoo

1. Overfeeding can cause firm and distended stomach

2. Infusion should stop after checking their blood sugar by glucometer strip.

3. Hyperglycemia is also very common (10-30%) in patients being fed enterally. High calorie intake may unmask glucose intolerance or diabetes. Acute illness, overfeeding, in addition to inappropriately low insulin or medication supplementation can account for hyperglycemia.

The CNAs flatten the head of the bed and place the patient in reverse Trendelenburg position without first stopping the tube feedings. What is the issue with this?

It is better to stop infusion feeding first before reverse TRENDELENBURG position to prevent aspiration. If you Change the position without stop of fluid feeding stop immediately after that when you recognize that and start latter if there is no problems.