When a patient has a stroke, something that is frequently compromised is the ability to swallow food, liquids, and even saliva safely. Therefore, if your patient is coming from the ED with a stroke diagnosis, the MD will usually place an order for them to be NPO until a swallow evaluation can be completed.
Sometimes nurses can complete a prelim evaluation, but typically speech therapy comes by to assess the patient and give specific recommendations. However if the patient is admitted at 0230, they’re going to be NPO until speech comes around … probably not until later in the morning. (They usually come in at 0800, see all their new consults and go see them in the order they came in..)
This means Mee-Maw won’t eat until then. And this also means the family is mad at you because you’re starving Mee-Maw.
A stroke is sudden and scary. Families are usually pretty shaken up. They feel helpless and that’s terrifying. They want to be able to control SOMETHING. And the easiest thing to control is food. All these doctors, nurses, therapists all are dictating everything now but darnit, Mee-Maw will have her favorite snack, darn it!
The best way to explain this is coming from the “it’s for her safety” viewpoint.
“I know you think she is dying for a honey bun right now, but it’s really important that we make sure she can swallow safely. Many times after a stroke, a person’s ability to swallow safely is impaired. We don’t want her to get pneumonia. You wind pipe and food pipe are right next to each other. So if she cannot safely swallow, it will go into her lungs. She’ll get what we call aspiration pneumonia, and choke on it. And sometimes she food and fluids can go into her lungs and she doesn’t even cough and that’s called silent aspiration. The speech therapist will do a thorough exam to make sure it’s safe and make recommendations. That’s why it is vital that she does not eat and dangerous if she does.”
The chain of events typically looks like this.. the nurse does a preliminary screening. Then speech therapy will check them out (usually the next day, depending on the time the consult was placed). They will make a recommendation of the thickness of liquids and consistency food or for further, closer evaluation (barium swallow exam, for example).. etc. If they are still not safe to swallow, the next step is a feeding tube.
The feeding tube goes through the nose and sucks to be put in. It’s pretty painful/uncomfortable for the patient and rough for the family to see, but once it’s in, it’s in.
Families always ask “how about food in their IV?” (TPN), but that’s not at all a good choice. It’s crazy expensive, you need a central line, and then all meds have to be IV. There’s also many studies out there that show how bad TPN is compared to tube feeding. Furthermore, if nothing goes down into their gut for a long time, you face some serious complications that can easily be avoided by just using tube feeding. So, for very good reason, TPN is rarely used in the case of impaired swallowing.
The typical feeding tube is a Dobhoff tube (DHT) through a nostril. Sometimes MD’s will order NG’s as well, but Dobhoff’s are smaller and more comfortable for the patient. I always have family step out when I insert them because it’s rough. Families hate them, but it’s honestly the best thing for them at that point. Once it’s inserted and placement is confirmed with an x-ray, we can begin tube feedings and administering meds through the tube.
If it is predicted that the patient will not be able to regain their swallowing ability in a few weeks, an MD will order for a PEG tube to be placed. It basically a tube straight to the stomach via a hole in the abdomen to feed through and can stay permanently, if needed. With this tube in the stomach, we can take the tube out of their nose and it’s much more comfortable, safe, and easy to keep clean.
Depending on your facility, patients either go to the OR for this or it’s done at the bedside by a GI doctor.
I hope this helped put a few pieces together of the process! In my experience, families had many questions about food and how good old Mee-Maw will get her supper.. once I saw this process in action, it all made it easier to explain it to the family!