Paramby, T. & Leslie, P. (2014, November). Does it prevent aspiration? For guidelines regarding our scope of practice, Paramby and Leslie point to The American Speech Language Hearing Association (2002 ): Knowledge and Skills Needed by SLP Providing Services To Individuals With Swallowing and/or Feeding Disorders. Part of preventing aspiration, in addition to considering alternative means of feeding, is to perform aggressive NPO oral care so that the patient will have saliva without bacteria growing — so to lessen the risk of aspiration pneumonia or other further medical complications. Research demonstrates that G tube feedings are NOT helpful in patients who are terminally ill with end-stage cancer, COPD, and dementia. Smith, I. et al. An imbalanced nutrition: less than body requirements is one of the updated nursing diagnoses which means that … If a patient has a medical condition necessitating diet therapy, the assistance of a dietitian may be required (Crist, 1992). It represents an opinion or dogma of an expert society to balance optimizing patient status, minimizing patient distress, and maximizing patient safety. This would depend of course on the patient’s goals of care. Therefore, you really need to double check with MD. Does it result in prolongation of life? In patients who were npo, aspiration occurred in 8 of 82,546 patients (0.97 events per 10,000), while in patients who were not npo, aspiration occurred in 2 of 25,401 (0.79 events per 10,000) patients.11 To gain perspective, with an incidence of aspiration close to 1 in 10,000, this low risk is equivalent to the lifetime odds of drowning in a bath-tub (1 in 8,078).12 This study concluded that npo status for liquids and solids are not independent predictors of aspiration and that other factors, such has ASA Physical Status and age had higher correlation to major adverse outcomes.11, A study by Andersson et al. If you get a bedside swallow evaluation on a patient whose orders are currently NPO, you should check with the MD/NP/PA who placed the order to make sure she/he is okay with you testing a few items. Reddened, irritated oropharyngeal cavity (stomatitis) 5. February 4, 2020 Mitchell, S. L., Kiely, D., & Lipsitz, L. (1998). Hypokalemia disease Definition of Hypokalemia Disease: Hypokalemia (Low Potassium) refers to low concentration of potassium level in blood. Veldee, M. S., & Peth, L. D. (1992). ADBA. Save my name, email, and website in this browser for the next time I comment. Gastric distention 2. The American Journal Of Medicine, 119(6), 527.e511-527.e516. As speech-language pathologists, we play a very important role in the assessment and treatment medically fragile patients with swallowing difficulties. Oral Health welcomes this original article. Wright, L., Cotter, D., Hickson, M., & Frost, G. (2005). Insufficient chewing 13. NURSING DIAGNOSIS . She owns Speak Well Solutions, LLC, a thriving practice started in 2005 that now has four employees. What is your first recommendation? Evaluate client's physiological status in relation to weight control. Let us be judicious in our recommendations, considering all aspects of the patient’s condition, as well as familial concerns. Conclusion. Clostridium difficile in the intensive care unit: epidemiology, costs, and colonization pressure. (2007). Hughes, J., & Baldwin, C. (2006). British journal of anaesthesia 114, 77-82, doi:10.1093/bja/aeu338 (2015). Cameron is from Niagara-On-the-Lake and along with his wife, Erin Goertzen, a 1st year pediatric dental resident also at the University of Toronto, hope to practice together following their studies. (2002). Asha, N.J., Tompkins, D., & Wilcox, M.H. She currently serves on the Adult Services Committee for the Maryland Speech-Language and Hearing Association, as well as on the Website, Communications and Public Relations Committee for The Dysphagia Research Society. Dobson, G. et al. American Speech-Language-Hearing Association. SwallowStudy.com. She is also a member of the Dysphagia Research Society and is an MBSimP registered clinician. Pre-operative fasting standards have been developed by anesthesia societies with almost all following a variant of the “2-4-6-8 rule”. Teasell, R., & Foley, N. (2005). Food falls from mouth 6. Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. (1998). European journal of anaesthesiology 35, 337-342, doi:10.1097/eja.0000000000000760 (2018). What, you recommend? … I will be thinking very carefully the next time I make a recommendation that may include an “alternate method of nutrition.”. Some patients are recommended to take medications, while others with a critical condition, need to undergo surgery or invasive procedure like angioplasty. Generally, nursing interventions during the acute stages following a stroke aim at preventing secondary brain injury (intracranial hypertension), maintaining the airways (due to paralysis of the pharynx muscles), providing general body support (vital signs, fluid and electrolyte balance), and anticipating the occurrence of complications (atelectasis and pneumonia). It does not result in prolongation of life, and quality of life is subjective. Does artificial enternal nutrition prolong the survival of institutionalized elders with chewing and swallowing problems? Tube feedings can be beneficial in the acute phases of illness for brief periods of time when the patient may not be able to safely take enough nutrition and hydration by mouth. JPEN. Choking prior to swallowing 3. By accepting this notice and continuing to browse our website you confirm you accept our Terms of Use & Privacy Policy. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Excursion of muscles or decreased strength involved in mastication 3. Your small donations support this Labor of love. Practical guidance for evidence-based ICU family conferences. Paediatric anaesthesia 25, 770-777, doi:10.1111/pan.12667 (2015). I like to always let the nurse know that I will evaluate the patient’s swallowing before I start the exam, and the nurse can let us know if there is any other contraindications to trying po. Conversely, a person with an acute stroke may be at high risk for aspiration pneumonia and the prevention of negative sequela from aspiration may be paramount. Follow her on Twitter @yjohnsonmccoy, and connect with her on LinkedIN or visit her website at. We as clinicians can not determine what the patient’s quality of life will be. The scientific basis for fasting standards are largely reliant on theories of anatomy and physiology and rooted in consensus of expert opinions with limited evidence to support improved clinical outcomes. What should you recommend? What are the risks associated with tube feedings? Marks, M., & Arkes, H. (2008). Nursing Care Plan Nursing Diagnosis. Required fields are marked *. Likely, the pt is NPO due to aspiration risks, awaiting SLP recs for upgrading the diet. The state in which an individual who is not NPO experiences or is at risk of experiencing vascular, interstitial or intracellular dehydration. Facebook. Coughing prior to swallowing 4. this information will usually be found immediately below the title of a nursing diagnosis. Thank you for the valuable article, (2002). Another example, if the patient’s aspiration issues were due to small bowel obstruction and vomiting, the patient may require NGtube on “low-wall suction.” You will see an NGtube in the patient’s nose and liquids coming out on suction. Lawrence, S.J., Puzniak, L.A., Shadel, B.N., Gillespie, K.N., Kollef, M.H., Mundy, L.M. Fatigue 3. This is an extreme example, but an immediately visibly obvious one. Do not attempt any course of action when you are alone and without direct access to the appropriate health care professional and emergency medical care. NURSING CARE PLAN 1. Clinical indicators for instrumental assessment of dysphagia. Patient and surrogate disagreement in end-of-life decisions: can surrogates accurately predict patients’ preferences? Therefore, npo rules for liquids should account for equivalent calories rather then liquid type or volume. Generally, nursing interventions during the acute stages following a stroke aim at preventing secondary brain injury (intracranial hypertension), maintaining the airways (due to paralysis of the pharynx muscles), providing general body support (vital signs, fluid and electrolyte balance), and anticipating the occurrence of complications (atelectasis and pneumonia). Clostridium difficile in the intensive care unit: epidemiology, costs, and colonization pressure. Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. Mitchell, S. L., Kiely, D., & Lipsitz, L. (1998). There are different classifications of nursing interventions that can involve care of the entire patient. Journal of parenteral and enteral nutrition 40, 1158-1165, doi:10.1177/0148607114567713 (2016). Food pushed out of mouth 7. Gagging prior to swallowing 8. Bliss, D.Z., Johnson, S., Savik, K., Clabots, C.R., Willard, K. & Gerding, D.N. For example I have intervention: encourage pt to be involved in ADL's and to walk halls every day. Carey, T. S., Hanson, L., Garrett, J. M., Lewis, C., Phifer, N., Cox, C. E., & Jackman, A. Guidelines to the Practice of Anesthesia–Revised Edition 2018. Pooling of bolus in lateral sulci 16. What exactly is our role in this area of our practice? Gastric emptying for liquids of different compositions in children. She is also a member of the Dysphagia Research Society and is an MBSimP registered clinician. Maintain NPO status during acute phase of illness Provide clear liquid diet for a few days once inflammation is under control Parnteral nutrition – in severe cases may be given to inhibit stimulation of pancreatic enzymes and to decrease metabolic stress We know that the sole purpose of tube feeding is to offer nutrition and hydration. A key factor that should guide decisions about nutrition and hydration at the end of life is patient choice. examined retrospectively 10,015 pediatric patients at Uppsala University Hospital, Sweden, between 2008 and 2013 who were allowed unlimited clear fluids up until surgery.5 The study’s objective was to determine the incidence of pulmonary aspiration associated with general anesthesia in elective procedures. & Matava, C. Canadian Pediatric Anesthesia Society statement on clear fluid fasting for elective pediatric anesthesia. The key factor in gastric emptying may be the caloric content. It has been reported that patients on average fast from liquids for seven hours before surgery despite instruction to maintain fluid intake following current guidelines until two hours prior.7 A recent study published in the European Journal of Anaesthesiology in 2018 by McCracken and Montgomery examined post-operative nausea and vomiting of approximately 10,487 patients, of whom 4,697 had no restrictions on pre-operative intake of clear fluids prior to surgery at Torbay Hospital Day Surgery Unit in the United Kingdom.8 The incidence of nausea within 24 hours post-operatively was reduced from 270/5192 (5.2%) to 179/4724 (3.8%) in patients that could drink up until surgery.8 Likewise, patients with unrestrictive fluid intake were more likely to categorise their surgical experience as ‘very good’. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Here is Yvette McCoy’s summary of a session by Dr. Towino Paramby of the University of Central Arkansas and Dr. Paula Leslie of the University of Pittsburg. (2006). The Lancet, 365(9461), 764-772. Audrey, (1998). It is part of the protocol for pre-printed insulin orders. Then – you really can’t do any po trials!! Some hospitals may have the information displayed in digital format, or use pre-made templates. The patient will: Not develop a fluid volume deficit . 1. She is on no laxatives and stool softeners. The quality‐of‐life scores improved after 4 weeks of intervention with the community case conferences. There are many things to learn, so much Veldee, M. S., & Peth, L. D. (1992). Lee, J., Tse, S., Tsze, S., & Kwok, T. (2004). Required fields are marked *. Yvette McCoy, MS, CCC-SLP, BCS-S is a speech-language pathologist with over 22 years experience, specializing in adult-neurological rehabilitation with a special interest in dysphagia and stroke rehabilitation. Risk for falls r/t impaired physical mobility 4. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. by Cameron Goertzen, BMSc, MSc, DDS, MSc (Candidate Dental Anesthesia); Joonyoung Ji, DMD, MSc, DIP. Acceptability and outcomes of the Percutaneous Endoscopic Gastrostomy (PEG) tube placement: Patients’ and care givers’ perspectives. The most appropriate clients for the nursing intervention of Weight Management are adults with no major health problems who require diet therapy. Dr. Leslie notes: “We (SLP’s) need to have knowledge of the appropriate tube feedings available, but nowhere does it say that we should be the ones making the decision.” Our role is to talk about the increased risk of aspiration, to educate staff/patients/families, and to assist the medical team in guiding informed decision-making. VITAS Healthcare always works with patients and families to develop individualized care plans that support the patient’s wishes and values, and those plans include a discussion about the role of artificial nutrition and hydration. She obtained a Bachelor of Science Degree in Speech Pathology from Northeast Missouri State University in 1990. There are also additional considerations of the underlining medical diagnoses. Protein Malnutrition is adversely associated with swallowing recovery in tube-fed older people (letter). Clinical indicators for instrumental assessment of dysphagia. Each individual’s medical situation is unique. Do not treat a patient based on this care plan. They found the incidence of pulmonary aspiration to be 3 in 10,000 in pediatric patients with unrestricted fluid intake prior to surgery.5 In the 3 cases of aspiration, the patients did not require post-operative ventilatory support or intensive care and symptoms diminished the day following surgery, without sequelae, after treatment with antibiotics.5. Absent or decreased gag reflex 2. Nursing Times subscribers have free access to a range of learning units, including one on Preventing Dehydration. Okabe and colleagues examined whether caloric content rather then composition determined gastric emptying.10 Comparing equal volumes of non-human milk and pulp-free orange juice diluted with either gum syrup or water to match the number of calories, this study found that there were no significant differences in liquid gastric emptying time after drinking equal number of calories. I want sessions that will challenge my current way of thinking about what I do in treatment. The Standard of Practice for sedation/anesthesia as created by the Royal College of Dental Surgeons of Ontario (RCDSO) adopted its preoperative fasting standards from the ASA. (2006). She is a Board Certified Specialist in Swallowing and Swallowing Disorders. Retrieved October 4, 2010, from http://www.asha.org/policy/PP2004-00191.htm. Knowledge deficit regarding patient’s condition, prognosis, treatment and discharge needs r/t lack of information Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): A multi-centre randomized controlled trial. When a patient has a stroke, something that is frequently compromised is the ability to swallow food, liquids, and even saliva safely. British journal of anaesthesia 119, 948-955, doi:10.1093/bja/aex340 (2017). Anis, M., Abid, S., Jafri, W., Abbas, Z., Shah, H., Hamid, S., et al. Free pre-operative clear fluids before day-surgery? investigated whether milk or other non-clear fluids require fasting of six hours as recommended in current guidelines.9 In this prospective cross-sectional study, 8- to 14-year-olds fasted overnight and were randomized to drink equal volumes (296 mL) of either apple juice, 2% milk, or Ensure Clear (high-protein clear-fluid). She obtained a Bachelor of Science Degree in Speech Pathology from Northeast Missouri State University in 1990. 2. Their research demonstrated that clear liquids were cleared more completely at 90 minutes post-ingestion. Anesthesiology 126, 376-393, doi:10.1097/aln.0000000000001452 (2017). Crystalloid intravenous fluids an isotonic solutions such as normal saline solution or lactated Ringer’s solution 100–500 mL/hr of IV, depending on volume state of the patient, is used to replaces fluids and electrolytes lost through fever and vomiting; replacement continues until urine output is 1 cc/kg of body weight and electrolytes are replaced Feel free to keep asking questions. (2002). Journal of Clinical Microbiology, 44(8), 2785-2791. Journal of Human Nutrition and Diet, 18(3), 213-219. Indwelling foley’s catheter to monitor urine output and most of the magnesium excrete by urine. While charting and documenting is a nurse’s life, it is all the more crucial when dealing … Marks, M., & Arkes, H. (2008). Imbalanced Nutrition: Less Than Body Requirements Nursing Diagnosis and Nursing Care Plan Imbalanced Nutrition: Less Than Body Requirements . Patient and surrogate disagreement in end-of-life decisions: can surrogates accurately predict patients’ preferences? Your email address will not be published. … Until standards evolve, this is a medicolegal requirement. Bliss, D.Z., Johnson, S., Savik, K., Clabots, C.R., Willard, K. & Gerding, D.N. Ann Intern Med., 129(12), 1012-1019. Paramby and Leslie point to the following as the most common: Other risk factors: increased need for restraints and sedation, as well as an increased risk for C-difficile infection. 2. Twitter. In Ontario, dental anesthesia is a recognized specialty. She is certified by the American Speech-Language-Hearing Association, and a four time ACE Awardee. We know that the sole purpose of tube feeding is to offer nutrition and hydration. Jaw Joint and Muscle Strain/Sprain Treatment Technique. This is a simple, nurse initiated test that should really be performed on any patient that is not NPO. It is important that you consult directly with your physician before beginning any treatment, any therapeutic technique, or any exercise. Don’t give her anything now!”. Studies have shown that tube feedings do not prevent aspiration, and in some cases may cause increased aspiration. There was limited evidence of non‐pharmacological nursing interventions improving the quality of life of patients with idiopathic pulmonary fibrosis. (2006). Cardiac pain 3. Lashonda Decker March 12, 2019 No Comments dental care Npo patients teeth. Chest, 134(4), 835-843. Drooling 5. Comparative analysis of prevalence, risk factors, and molecular epidemiology of antibiotic-associated diarrhea due to Clostridium difficile, Clostridium perfringens, and Staphylococcus aureus. Dr. Leslie encourages clinicians to give options based on the findings, with one option being: “recommend consideration of supplemental nutrition.” We should give facts based on OUR scope of practice. Edema 2. She currently serves on the Adult Services Committee for the Maryland Speech-Language and Hearing Association, as well as on the Website, Communications and Public Relations Committee for The Dysphagia Research Society. Good nutrition, and proper wound care is next. Your email address will not be published. Arch Intern Med, 161, 594-599. Your email address will not be published. 1. Med Decis Making, 28(4), 524-531. Bowel obstruction 2. Does artificial enternal nutrition prolong the survival of institutionalized elders with chewing and swallowing problems? Ultimately if the patient has been NPO for a day or more, check the mouth thoroughly before giving anything. Save my name, email, and website in this browser for the next time I comment. Expectations and Outcomes of Gastric Feeding Tubes. Anis, M., Abid, S., Jafri, W., Abbas, Z., Shah, H., Hamid, S., et al. Do not treat a patient based on this care plan. Lee, J., Tse, S., Tsze, S., & Kwok, T. (2004). Postoperative 4. : Challenging the dogma. The FOOD Trial Collaboration. Thank you! Thanks for question. They concluded that differentiation between clear and non-clear liquids in current guidelines is not supported by their results.9 This suggests that current fasting guidelines are too rigid for non-human milk and that four hours, instead of six hours, may be more appropriate. Preferred Practice Patterns for the Profession of Speech-Language Pathology. Acquisition of Clostridium difficile and Clostridium difficile-associated diarrhea in hospitalized patients receiving tube feeding. Acceptability and outcomes of the Percutaneous Endoscopic Gastrostomy (PEG) tube placement: Patients’ and care givers’ perspectives. European journal of anaesthesiology 35, 334-336, doi:10.1097/eja.0000000000000805 (2018). What else does tube feeding have to offer? The potential for poor oral hygiene is high. Du et al. Checking the patient’s ability to swallow gives the nurse so much information about how to proceed with the plan of care. Results from the FOOD trial. (now Truman State University) In 1991 she earned a Master of Science in Speech Pathology from Southern Illinois University at Edwardsville. Beach, M. L., Cohen, D. M., Gallagher, S. M. & Cravero, J. P. Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room: A Report of the Pediatric Sedation Research Consortium. Carey, T. S., Hanson, L., Garrett, J. M., Lewis, C., Phifer, N., Cox, C. E., & Jackman, A. Here are some factors that may be related to nursing diagnosis Nausea: Treatment-related: 1. All rights reserved. Inefficient nippling 11. This website and all its content is for informational purposes only and should not be used as a substitute for consultation with an appropriate health care professional (e.g., a Speech-Language Pathologist who specializes in Swallowing and Swallowing Disorders). That is a question that requires an answer with many caveats. Food Choices For Optimal Post-Operative Healing: What Advice Can We Provide a Patient? A Glass of Milk After Eating Sugary Cereals May Prevent Cavities, Dual anesthetics preferred by most U.S. dentist anesthesiologists, The American Academy of Pediatric Dentistry Issues the First-Ever Evidence-Based Guideline for Using Silver Diamine Fluoride to Treat Cavities, Weekly Wisdom: Why Bleaching is the Best Option, Peri-Operative Epistaxis During Dentistry: A Case Report, Intraosseous Access to the Circulation: A Valuable Tool in Medical Emergencies, Mystery Solved: Acid Reflux and the Oral Cavity, ‘Mask Mouth’ is a Seriously Stinky Side Effect of Wearing Masks, Mouth Breathing: Physical, Mental and Emotional Consequences, Paying it Forward: 8 Ideas that Helped Me Lose 50 lbs in 6 Months, Dangerous TikTok Trends Worrying Dentists. Careful monitoring and skilled nursing interventions can help correct potassium level and prevent associated complications. Lawrence, S.J., Puzniak, L.A., Shadel, B.N., Gillespie, K.N., Kollef, M.H., Mundy, L.M. In a survey (Carey, et al, 2006), 90% of families expected that G tube feeding would correlate with the following positive results: However, after tracking the patients at 3 and 6-month intervals, the study showed very different real outcomes with G tube feedings: Dr. Leslie suggests: “Do not write NPO”, as this can often lead the physician to recommend tube feedings (i.e., via an NG tube or a G tube) without careful discussion with the patient/family. Retrieved September 29, 2012, from http://www.asha.org/policy/GL2000-00047/, American Speech-Language-Hearing Association. Of the 10,487 patients in the study, there were no adverse events of pulmonary aspiration of gastric contents. Anesthesiology 124, 80-88, doi:10.1097/aln.0000000000000933 (2016). Desired outcomes: Patient will report a decrease in pain from 8 to 0 on the pain scale by discharge. She is certified by the American Speech-Language-Hearing Association, and a four time ACE Awardee. Within that framework, clinicians should ensure that patients receive enough clear fluids until two hours prior to surgery with sedation/anesthesia for the best balance between providing positive outcomes and minimizing risks. Yvette McCoy, MS, CCC-SLP, BCS-S is a speech-language pathologist with over 22 years experience, specializing in adult-neurological rehabilitation with a special interest in dysphagia and stroke rehabilitation. Can protein-calorie malnutrition cause dysphagia? Nursing Diagnosis. 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. NPO, or nil per os, is also known as ‘nothing by mouth’, and is a medical instruction meaning to withhold fluids and food. Beach and colleagues examined aspiration and pulmonary adverse events in a prospective database of 139,142 pediatric patients who received procedural sedation/anesthesia across 40 general and children’s hospitals in the United States between September 2007 and November 2011.11 Of the 139,142 pediatric patients, npo status was known for 107,947 patients, and 25,401 patients violated npo as defined as no solid foods for at least eight hours, no non-clear fluids for at least six hours, but having clear fluids within two hours prior to surgery. This is up to the MD. References Associated With This ASHA Session: American Speech-Language-Hearing Association. For example: That fever they have, is not going to … For example, a person with head and neck cancer with chronic dysphagia from late-radiation induced dysphagia may tolerate some aspiration and want to stay on a least restrictive diet. JAGS, 52(9), 1588-1589. (2004). Stroke is the third leading cause of death and an important cause of hospital admission and long-term disability in all industrialized populations. Abnormal oral phase of swallow study 2. Refer as appropriate. Nursing Interventions MAINTAINING FEEDING EQUIPMENT AND NUTRITIONAL BALANCE The temperature and volume of the feeding, the flow rate, and the total fluid intake are important factors to be considered when tube feedings are administered. Meier, D., Ahronheim, J., Morris, J., Baskin-Lyons, S., & Morrison, R. (2001). If … European journal of anaesthesiology 28, 556-569, doi:10.1097/EJA.0b013e3283495ba1 (2011). Curtis, J. R., & White, D. B. Oral Care Protocol for NPO Patients. However, prolonged fasting may cause dehydration, post-operative nausea and vomiting and contribute to a poor patient experience.6 Clinicians must follow the RCDSO standard, or face consequences from their regulatory body. Dysphagia, 7(2), 86-101. Copyright © 2020 Swallow Study. Your email address will not be published. Read Also: Imbalanced Nutrition: Less Than Body Requirements Nursing Diagnosis & Care Plan Assessment Cues: Subjective data: “ I have loss of appetite […] Premature entry of bolus 1… Karen Perceptual impairment Mechanical: 1. (2008). Follow her on Twitter @yjohnsonmccoy, and connect with her on LinkedIN or visit her website at www.speakwellsolutions.com. 1135: Tube Feeding & the SLP’s Scope of Practice. Knowledge and skills needed by speech-language pathologists providing services to individuals with swallowing and/or feeding disorders. Seminar presented at the annual convention of American Speech-Language-Hearing Association, Orlando, FL. Maybe start with ice chip trials if the patient is managing secretions well and alert. You have just received an order to “evaluate and treat for dysphagia.” You complete the evaluation and determine the patient is not safe to eat or drink by mouth. Maybe the nurse will say, “Oh no, that patient was really agitated and just got medicated with Ativan. Results from the FOOD trial. Acquisition of Clostridium difficile and Clostridium difficile-associated diarrhea in hospitalized patients receiving tube feeding. Jooyoung Ji practices in Ottawa, Ontario. Does it improve quality of life? Meier, D., Ahronheim, J., Morris, J., Baskin-Lyons, S., & Morrison, R. (2001). Imbalanced nutrition: less than body requirements is defined by Nanda as an intake of nutrients insufficient to meet metabolic needs. Maybe the patient can only have trials of clear liquids if it is a GI issue. Can the speech therapist perform trial feedings for a pt. Pre-anesthesia fasting standards apply to any procedure where sedative medications reduce the protective airway reflex that under normal conditions prevent aspiration. These are the questions that we should be asking ourselves as clinicians. Okabe, T., Terashima, H. & Sakamoto, A. Determinants of liquid gastric emptying: comparisons between milk and isocalorically adjusted clear fluids. The risk of bias for these two studies was high. All patients admitted to care settings should have nutritional screening performed within the first 24 hours (CQC, 2015; National Institute for Health and Care Excellence, 2006) using a validated tool such as the Malnutrition Universal Screening Tool (MUST). I often find myself sifting through the convention planner at ASHA trying to juggle which sessions I want to attend. Our clinical decisions have a significant impact on the patient’s health and quality of life. MEASURABLE EXPECTED PATIENT OUTCOME. Team approach: Turning the patient every 2 hours like clockwork, and getting the pressure off the wound is step 1. Risk for fluid volume deficit . Medications like analgesics, HIV treatment, aspirin, opioids, radiotherapy, or chemotherapyagents 3. I know some interventions but the problem is my pt. Infections 8. If any problem is detected in the coronary circulation, the physician will discuss to the patient the plan of care or interventions. Cameron has a diverse background in research and has published articles in the fields of breast cancer and oral cancer. Eating is associated with good health in our society and taking that away is mistakenly often seen as “starving the person to death.” As the body is trying to shut down, a natural loss of appetite occurs, as well as decreased sensation. It covers the different causes of dehydration and the physical and emotional harm dehydration can cause. If the patient does not have pre-printed orders, call a physician right away for an order. Normal level of potassium in blood is 3.5-5.2mmol/L. Incomplete lip closure 10. Rosen, D., Gamble, J. Cancer 4. Raeder, J., Kranke, P. & Smith, I. Teasell, R., & Foley, N. (2005). The American Society of Anesthesiologists (ASA) recommends patients to fast from fatty food or meats eight (8) hours prior to surgery, non-human milk or light meal for six (6) hours prior, breast milk for four (4) hours prior, and clear liquids including water, pulp-free juice, and tea or coffee without milk for two (2) hours prior to the anesthetic.1 In Canada, the Canadian Anesthesiologists’ Society’s guidelines are very similar to the ASA guidelines, however, the Canadian Pediatric Anesthesia Society fasting guidelines now encourages children to have clear liquids up to one hour prior to surgery.2,3 The European Society of Anaesthesiology (ESA) pre-operative fasting guideline prohibits solid foods for six hours prior to elective surgery and encourages patients to drink clear fluids up to two hours for adults and one hour for children.4 The concern is that the standards may be too rigid and contribute to patient harm or poor anesthetic outcomes. (2007). The Lancet Neurology, 4(5), 267-267. Risk for aspiration r/t weakness of the swallowing muscles and decreased swallowing reflex. LinkedIn. Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. Current nil per os (npo) standards promote pre-operative fasting as an approach to reduce the volume and acidity of a patient’s stomach contents to reduce the risks of regurgitation and subsequent pulmonary aspiration. Pinterest. Providing Therapeutic Nursing Interventions Interventions are action plans put in place to fix a problem or health condition. Ethical Issues in Dementia Care: Making difficult decisions. By Guest Blogger: Yvette McCoy, MS, CCC-SLP, BCS-S, Edited by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com, The American Speech-Language and Hearing Association’s (ASHA) 2014 convention inspired us. Canadian journal of anaesthesia = Journal canadien d’anesthesie 65, 76-104, doi:10.1007/s12630-017-0995-9 (2018). Current nil per os (npo) standards promote pre-operative fasting as an approach to reduce the volume and acidity of a patient’s stomach contents to reduce the risks of regurgitation and subsequent pulmonary aspiration. Tumor Document. Inability to clear oral cavity 9. reddit. Retrieved October 4, 2010, from. Practical guidance for evidence-based ICU family conferences. Journal of Gerontology: Medicial Sciences, 53A, M207-M213. Knowledge and skills needed by speech-language pathologists providing services to individuals with swallowing and/or feeding disorders. As speech-language pathologists, we play a very important role in the assessment and treatment medically fragile patients with swallowing difficulties. (now Truman State University) In 1991 she earned a Master of Science in Speech Pathology from Southern Illinois University at Edwardsville. Therefore, McCracken and Montgomery suggest that unrestricted consumption of clear fluids before anesthesia may help reduce the rate of postoperative nausea and vomiting.8. Care Plans are often developed in different formats. Tube feedings can interfere with the body’s natural process of “shutting down”. Cameron Goertzen is a current University of Toronto dental anesthesia resident and a University of Toronto DDS graduate. We use cookies to make your website experience better. What is your first recommendation? McCracken, G. C. & Montgomery, J. Postoperative nausea and vomiting after unrestricted clear fluids before day surgery: A retrospective analysis. with NPO status? Potentially, the patient is NPO due to GI issues. If the patient has dysphagia, put the patient on NPO and notify physician. The FOOD Trial Collaboration. How many times have we as clinicians recommended that a patient be NPO? (2006). She owns Speak Well Solutions, LLC, a thriving practice started in 2005 that now has four employees. (Note: tube feeding is used to refer to alternative nutrition given via a tube. They also discovered that ingestion of beverages that do not exceed 220 kcal in calories will be adequately cleared in less than two hours.10 Therefore, liquid gastric emptying may depend primarily upon total caloric content rather type of liquid whether it be non-clear fluids such as milk or clear fluids such as apple juice. This unit explains the biological functions of water and its importance to health. Running head: Teaching plan for NPO patient Teaching plan for NPO patient Dona Hubbard Hampton University NUR-327-01-F07 Georgiana Bougher and Brenda Rhea November 3, 2007 Teaching plan 2 The purpose of a teaching plan is to educate a patient about treatment, medications, diet, or any procedure that pertains to their care. This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions. Paramby, T. & Leslie, P. (2014, November). Additionally, a person can still get aspiration pneumonia from tube feeding – which may only elevate the risk for aspiration pneumonia is some patients – especially in bedridden patients who are dependent for oral care. Hello, (2002). Council, N. S. Odds of dying due to injury, United States, 2017 (2017). Asha, N.J., Tompkins, D., & Wilcox, M.H. NURSING INTERVENTION . Of the patients examined, there were zero deaths, 10 aspirations, and 75 major complications, defined as cardiac arrests or any other reason requiring hospital admission. Protein Malnutrition is adversely associated with swallowing recovery in tube-fed older people (letter). When the tube is placed into the stomach through the skin it is called PEG tube feeding or G tube feeding.) ASA. Tracheostomytube 6. npo; determination of the patient's problem(s) ... many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. When I saw Dr. Towino Paramby and Dr. Paula Leslie’s session on feeding tubes and the role of the SLP , I was immediately intrigued. (2006). High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding. However, at 3 to 3.5 hours after ingestion, both clear-fluids and milk were essentially completely cleared. Gastrointestinal diseases 6. Rationale: Patient at high risk for aspiration should be kept NPO until swallowing study has been completed. DATA . Curtis, J. R., & White, D. B. Nursing Diagnostic Label . If the patient not safe for any oral feeding and he had silent aspiration with positive history of aspiration pneumonia, could I recommend tube feeding in this case? Canadian journal of anaesthesia = Journal canadien d’anesthesie 66, 991-992, doi:10.1007/s12630-019-01382-z (2019). Facial paralysis (cranial nervesVII, IX, X, XII) 4. Example of Nursing Care plan for Imbalanced nutrition: less than body requirements Nursing Diagnosis: Imbalanced nutrition: less than body requirements related to vomiting and loss of appetite as manifested by low protein level (47g/L). Stomach upset due to alcohol, drugs, blood, or iron 5. She had a colon resection. Inefficient suck 12. & Frykholm, P. Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite. Retrieved September 29, 2012, from, American Speech-Language-Hearing Association. If the patient is NPO, unconscious or unable to take fluids, give the patient 50ml 50% dextrose solution IV push over 1-3minutes. The global inciden… Lambert, E. & Carey, S. Practice Guideline Recommendations on Perioperative Fasting: A Systematic Review. Recent research into pre-operative fasting suggests that prolonged fluid fasting can lead to undesirable outcomes such anxiety, dehydration and post-operative nausea and vomiting.5 Likewise, prolonged fasting has resulted in cases of hypoglycemia and hypovolemia, more frequently seen in children.2,5 To improve our understanding of pre-operative fluid management, research has been undertaken to understand if the current fasting standards are actually beneficial for protecting patients from detrimental clinical outcomes.6, Post-operatively, nausea and vomiting are a common complaint of patients who have received sedation/anesthesia, which has been attributed to patient dehydration due to prolonged pre-operative fluid fasting. Acute pain related to distention and rigidity as evidenced by patient rates pain at 8/10 on pain scale and states abdominal cramping and tenderness in abdomen. Dr. Leslie suggests: “Do not write NPO”, as this can often lead the physician to recommend tube feedings (i.e., via an NG tube or a G tube) without careful discussion with the patient/family. Infect Control Hosp Epidemiol, 28(2),123-130. During his free time, Cameron enjoys playing hockey, cooking/baking, and hiking. High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding. Here are some factors that may be related to Impaired Swallowing: Neuromuscular: 1. For guidelines regarding our scope of practice, Paramby and Leslie point to. Deficient Knowledge: The state in which an individual or group experiences a deficiency in cognitive knowledge or psychomotor skills concerning the condition or treatment plan. See also the blog on palliative care: http://www.swallowstudy.com/?p=623. Comparative analysis of prevalence, risk factors, and molecular epidemiology of antibiotic-associated diarrhea due to Clostridium difficile, Clostridium perfringens, and Staphylococcus aureus. BMC Gastroenterology, 6(37). London: Jessica Kingsley Publishers. Risk for impaired skin integrity r/t immobility 3. Wright, L., Cotter, D., Hickson, M., & Frost, G. (2005). Preferred Practice Patterns for the Profession of Speech-Language Pathology. Piecemeal deglutition 15. Clean mouth. The schedule of tube feedings, in-cluding the correct quantity and frequency, is maintained. Is Your Tongue Causing Your Health Problems? (2008). The order may indicate this. Hope others will add to this discussion too. Your blog really inspires me a lot. Cough 5. Retrieved September 29, 2012, from, American Speech-Language-Hearing Association. The belief that withholding food and hydration causes suffering is NOT supported by research. A care plan by a practitioner caring for a patient with impaired swallowing should help to implement measures to improve swallowing ability and help the patient to achieve these outcomes: Display ability to swallow safely as shown by the absence of choking, coughing or aspiration (drawing breath) when drinking or eating. Expectations and Outcomes of Gastric Feeding Tubes. We can advise as consultants. is NPO. Limited awareness 4. The placement of a tube is often driven by family concerns, and not by an fully informed decision-making process. Our job is to support the medical team as consultants, using facts to support “why” we are making specific recommendations. How Family Members and Caregivers Can Help. It may be called NG tube feeding if the tube is placed through the nose. Another very important role is to educate the patient/family by teaching the mechanics of protecting the airway and discussing the risks versus benefits versus outcomes. Can protein-calorie malnutrition cause dysphagia? read more about The SLP’s Role in Palliative Care, http://www.asha.org/policy/PP2004-00191.htm. (2005). Du, T. et al. (Note: In a survey (Carey, et al, 2006), 90% of families, No change at all in activities of daily living (expectation of better quality of life), No change in percentage of patients admitted to nursing homes (expectation of better quality of life), 30% had a 6-month mortality rate (expectation of longer life), No change in decubitus ulcers (expectation of better health). information on it. So i cant say increase her fiber intake or anything like that. Andersson, H., Zaren, B. Retrieved September 29, 2012, from http://www.asha.org/policy/KS2002-00079/, American Speech-Language-Hearing Association. Less than 3.5mmol/L is considered low potassium (Hypokalemia). (2006). (2004). On the other hand, angioplasty or also known as a percutaneous coronary intervention is a procedure where … (2005). Nasal reflux 14. Tube feeding Biophysical: 1. Increased ICP 7. You have just received an order to “evaluate and treat for dysphagia.” You complete the evaluation and determine the patient is not safe to eat or drink by mouth. She is a Board Certified Specialist in Swallowing and Swallowing Disorders. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): A multi-centre randomized controlled trial. Sorry if this is vague but do you have any ideas for constipation.