If you ever receive a stroke patient and they are NPO, this is why that call was made and how you should handle it.
Your Stroke Patient is NPO: What to Do?
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 physician will usually place an order for them to be NPO (nothing to eat or drink) until a swallow evaluation can be completed.
What happens after NPO order for stroke patient
Once that NPO order is placed, the patient cannot eat or drink. Unless we know that their ability to swallow safely has not been compromised, the risk is not worth it. The patient could get food, fluids, or saliva down into their trachea and then lungs without even realizing it
This is called silent aspiration, and anywhere from 2-25% of stroke patients can actually start to choke on food or liquid without displaying outward signs of difficulty, like coughing or gagging. According to the aforementioned article, “Mechanisms associated with silent aspiration may include central or local weakness/incoordination of the pharyngeal musculature, reduced laryngopharyngeal sensation, impaired ability to produce a reflexive cough, and low substance P or dopamine levels.”
The last thing we want is for the patient to get aspiration pneumonia, which means the food, fluid, and/or saliva has gotten into the lungs and is now causing pulmonary complications. This is a major preventable complication, which is why we place the NPO order to ensure this isn’t happening.
Sometimes nurses can complete a preliminary evaluation at the bedside, but typically speech therapy comes by to assess the patient and give specific recommendations. Speech therapist have much more in-depth training to assess for these complications, so their input is incredibly valuable.
However if the patient is admitted at 0230, they might not be able to eat or drink until speech comes around … probably not until later in the morning.
(Speech therapy is a department who works during normal business hours, usually 0800-1700. They usually come in at 0800, see all their new consults that have been ordered since the previous day, and go see them in the order they came in and based on severity.)
This means the patient likely won’t be able to eat until then. And this also means the family is might be upset at you because they may think you’re starving their loved one.
How to educate family members about NPO
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 Grandma 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 this is a very serious complication that we can avoid by waiting for speech therapy to come see her. And sometimes food and fluids can go into her lungs without showing any signs that she’s struggling, like coughing or gagging. That is something 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 doctor has ordered IV fluids, so she is getting hydration in the meantime. Rest assured, we will not let her go longer than absolutely necessary without nutrition.”
Typical chain of events
Here’s what to expect when you receive a stroke patient with an NPO order.
#1 Preliminary Screening
If your hospital has a nurse-guided policy where the bedside nurse can perform a preliminary screening, that would happen first. These enable those patients who have had a stroke, but display very few or very mild symptoms to eat and drink earlier.
However, this test is very sensitive, meaning patients easily fail. But that’s okay, because it’s by design. Any patients with even minor signs of swallowing issues need an more in-depth evaluation. And this would trigger that consult.
If your hospital doesn’t have this policy, you may automatically make ALL stroke patient NPO until speech can see them.
#2 Speech Therapy Evaluation
Then speech therapy will check them out (usually the next day, depending on the time the consult was placed). They do a pretty in-depth evaluation of the patient to ensure they can safely swallow.
This isn’t something where they can either eat normally not at all, there’s actually a lot of grey area in between. They can order a “modified diet” which can mean that the liquids need to be thicker (and there are varying levels of thickness) and food can be soft, ground, or even pureed. Eating normally is always the goal. That’s the best thing for our bodies, and far superior to tube feedings and much more superior to TPN (food given through a patient’s IV).
However, they also may recommend getting an actual scan done of the patient swallowing to check further if they aren’t able to definitively say at the bedside. A barium swallow study is an example of this. This would require ordering the study and getting the patient down to to that area of the hospital to complete it. Naturally, it takes time and this should be communicated to the patient and family as they are often chomping at the bit (no pun intended) to eat and drink as soon as possible.
#3 Feeding Tube Insertion
Sometimes, it’s pretty apparent to the physician right away or to the speech therapist that there is no way this patient can safely swallow, even with a modified diet. In this case, the next best thing is to insert a feeding tube.
There are a few options for this, but the most common and least invasive way to ensure food is safely delivered to the stomach is by inserted a tube in the patient’s nose. This is called a Dobhoff tube (DHT). It is very uncomfortable to put in, but necessary to feed the patient. Again, it’s really important to educate the family and patient about why this is necessary because it may seem like overreaction or too much… when really, the patient needs it to be able to get the food and fluids their body needs to heal.
Food through their IV (Total Parental Nutrition, or TPN)
Because putting a feeding tube in someone’s nose is pretty rough, families often ask if we can just give them food in their IV until they can swallow safely again. I definitely understand wanting that, however here is where you’ll be an awesomely educated nurse and be able to explain why this isn’t ideal.
Giving food via an IV requires inserting a central line (which carries its own risks that you want to avoid if possible). It also means nothing is going through the patient’s gastrointestinal system at all, which impairs its function and can create more complications. And, studies show that patients on TPN have longer hospital stays and more infections (source). And finally, it is incredibly expensive for both the patient and hospital.
Therefore, TPN is often viewed as a last option in terms of nutritional support, and not at all a first choice. The choice to start TPN is not made lightly, nor is is made simply for comfort or patient preference. The benefits truly must outweigh the risks to make this decision. Often (if not always), in the case of temporary impaired swallowing due to acute stroke, TPN is not indicated.
Types of feeding tubes
The typical feeding tube placed by the nurse is a Dobhoff tube (DHT) inserted through a nostril. Sometimes physicians will order a nasogastric tube, but Dobhoff’s are smaller and more comfortable for the patient.
Typically before inserting the tube, I ask family step out when I insert them because it’s rough to watch (unless the patient wants someone there to hold their hand, of course!). Families hate them, but it’s honestly the best thing for them at that point. Once it’s inserted and placement is confirmed with (often with an x-ray), we can begin tube feedings (nutrition) and administering meds and water (for hydration) through the tube.
Long Term Option – PEG Tube
If it is predicted that the patient will not be able to regain their swallowing ability in a few weeks, a physician may order for a PEG tube (percutaneous endoscopic gastrostomy) to be placed. It basically a tube that is surgically inserted into the stomach via a hole in the abdomen. It can be temporary or permanent.
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. Taking care of a PEG tube is much easier from the nursing perspective and exponentially more comfortable for patients.
Depending on your facility, patients either go to the operating room or a procedural area for this or it’s done. In some hospitals, it can also be done at the bedside by a specially trained physician.
More Resources for Stroke Patient Care
Taking care of stroke patients can get incredibly complex. Throughout my career, I’ve worked with stroke patients in acute care extensively and have created some resources to help those of you new to neuro nursing or those looking to brush up a bit.
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