Nasal feeding is a method of inserting a gastric tube into the stomach through the nasal cavity on one side and instilling liquid diet, water and medication from the tube. Most of the neurology patients are suffering from impaired consciousness, swallowing disorder and cannot eat by mouth. Nasal feeding is one of the main methods to supply patients with nutrition and heat energy, to meet the metabolic needs of the body, to maintain water-electrolyte and acid-base balance, to promote patients’ recovery and to maintain their lives. Nasal feeding is operated by hospital nurses during the patient’s hospitalization, and when the patient is discharged from the hospital, his family members can learn the operation of nasal feeding through guidance and practice. Therefore, the family guidance of nasal feeding patients is an important part of the health education of neurology patients.
I. Commonly used nasal feeding diet and amount
Commonly used nasal diet includes mixed milk and homogenized diet. It can be the homogenized milk mixture formulated by the nutrition department of the hospital, or there can be various kinds of nutritional products purchased from outside, or prepared by the family members themselves. Available foods for mixed milk include: milk, soy milk, cooked eggs, thick rice soup, broth, sucrose, vegetable oil, salt, etc. Available foods for homogenized diet include: rice, rice porridge, noodles, steamed buns, eggs, fish, shrimp, chicken, lean meat, pork liver, vegetables, oil, salt, etc.
Nasal feeding patients need a process of adaptation, the amount of nasal feeding should be small and bland at the beginning, and gradually increase later. For those who are in coma or have not eaten for a long time, the first and second days are based on fat-free rice soup, 50~100ml each time, fed once in 4 hours, if there is no special discomfort, from the third day onwards, you can eat homogenized meals. If there is no special discomfort, from the third day onwards, you can eat homogenized meals. For patients who have been eating homogenized meals for a long time, the amount of infusion including water should be 200-250 ml each time, 6-7 times a day, and the total amount is between 1500-2000 ml per day.
The general daily calorie requirement for healthy adults is 1100-1300 kcal. Nasal feeding patients should eat according to their own condition in quantitative terms. Patients with strong body and short-term nasal feeding can be controlled to eat 1000 kcal per day; elderly and frail patients, women, children and patients with long-term nasal feeding can eat less and can be controlled to 500-800 kcal; patients who can move on their own can eat more. The specific quantity should be decided according to the patient’s condition and the opinion of the medical staff and dietitian with reference to the calorie table.
Preparation requirements.
① Recipe preparation should be combined with the condition, and different formulas should be given according to different symptoms and comorbidities. High fever, respiratory tract infection, impaired consciousness, wound healing, infection, etc., all require high quality protein and calorie supplementation. Sodium, potassium, chloride and water should be decided according to the brain edema and electrolyte balance.
②The nasal nutrition solution should be fine and soft without dregs, and prepared with copper wire wick over the wick to avoid blocking the nasal feeding tube.
All utensils (measuring cups, funnels, pots, pans and bottles) must be washed and disinfected before use, and pay attention to the cleanliness of hands to prevent bacterial infection.
④After the preparation of various kinds of milk, not directly heated on the fire, the application of hot water insulation method of heating, so as not to coagulate the mixed milk into a block, mixed milk preparation, do not add the cover when hot, to be cooled and then put the cap in the refrigerator, otherwise easy to sour.
⑤ If you add acidic juice or vitamin C powder, you must add it when you are filling, so as not to precipitate the mixed milk.
Temperature of nasal diet
The temperature of nasal diet should be around 38-40 degrees, not too hot or too cold. Too hot stimulates the esophagus and gastric mucosa causing damage, while too low temperature will easily cause stomach cramps, vomiting, indigestion, diarrhea, bloating and discomfort. Fresh juice and milk should be instilled separately to prevent clotting. When taking medicine, the medicine should be crushed and dissolved before instillation.
Cautions for nasal feeding
1. Before each nasal feeding, make sure the stomach tube is in the stomach before injecting food. There are three ways to check whether the gastric tube is in the stomach: <1>Gastric tube connected to a syringe to aspirate, and gastric juice is withdrawn. <2>Inject 10 ml of air from the stomach with a syringe, place a stethoscope in the stomach, and hear the sound of air passing through water. <3>The gastric tube should be placed in the bowl of water at the beginning of the tube and no gas should escape, if a large amount of gas escapes, it indicates that it is mistakenly entered into the trachea. Special attention should be paid to the elderly because the pharynx is dull to stimulation, accidentally into the lungs can be no significant cough, or because of lung infection sputum thick, accidentally into the lungs after the sputum blocking the tube also no significant bubble overflow.
2, nasal feeding before feeding must be aspirated gastric fluid observation. Observe the nature of gastric juice, whether there is a tendency to bleed and the digestion of food, if there is blood in the gastric juice and other abnormalities should promptly notify the doctor, stop eating if necessary, and apply hemostatic drugs according to medical advice. Observe the digestion of food, if there is food retention, suspend meals or reduce the amount of meals. If gastric juice cannot be pumped, inject 10 ml of air from the stomach with a needle and place a stethoscope in the stomach to listen to the sound of air over water to determine whether the gastric tube is in the stomach. Do not discard the pumped gastric juice, but inject it into the stomach to help digestion.
3. Turn and tap the back before nasal feeding, aspirate, do oral care, and shake the head of the patient’s bed 30-35 degrees higher. After nasal feeding, try not to move the patient, do not aspirate or tap the back, and ask the patient to stay in the original lying position for 30-60 minutes before changing the position to avoid vomiting, reflux and accidental aspiration.
4.After nasal feeding, apply 20-30ml of warm water to rinse the gastric tube, and lift the tube to control the water down, and then wrap the end of the gastric tube with reflexive gauze, clamp it in a suitable position and fix it properly to avoid the tube from coming out.
5, long-term nasal feeders with ordinary rubber tube should be replaced once a week, silicone tube can be replaced once a month. Or according to different gastric tube use time requirements to be replaced on a regular basis. In order to make the patient get rest, the gastric tube should be pulled out after the last meal is fed the day before and replaced by another nostril in the next morning. The nasal cavity should be cleaned before the gastric tube is inserted. Patients should be given oral care day by day, even though they have not been fed orally. Tube placement should be performed by nurses.
6.General care
(1) Fix the gastric tube to prevent it from falling off and keep it open. Nasal feeding is the best way to maintain nutrition during the period when the patient cannot eat. Pay attention not to repeatedly intubate the tube to avoid damage to the mucous membrane in the esophagus and discomfort in the pharynx, which increases the patient’s pain. If necessary, be restrained and protected.
(2) Do a good job of oral cleaning, the patient is bedridden indwelling gastric tube nasal feeding life can not take care of themselves, the oral cavity is easy to grow and breed bacteria, so we should pay attention to keep the oral hygiene.
(3) Keep the room clean and fresh air.
(4) Psychological care: psychological care should be done before operation for patients who are conscious, to relieve their nervousness and fear, and patiently explain the purpose and method of nasal feeding to obtain cooperation.
Prevention and treatment of complications
1.Aspiration pneumonia
Improper position of the nasal feeding tube, mistakenly entering the trachea or insufficient depth, excessive retention in the stomach, regurgitation of food in the stomach through the esophagus, etc. can cause aspiration pneumonia; failure to clean up excessive secretions in the oropharynx in a timely manner is also a cause of aspiration pneumonia.
Treatment: After placing the gastric tube and before each feeding, check whether the gastric tube is in the stomach; the depth of the tube to ensure that the lateral hole in the stomach; each instillation of food or water should not be too much, generally 150-300 ml for adults, reduce the amount of discretion for children. If the amount of retention exceeds 100 ml, it is necessary to suspend feeding and reduce the amount of feeding, and give pro-gastric drugs such as morbutine. The speed of nasal feeding should not be too fast, and the position should be semi-recumbent with the head elevated 20°~30°; or left lateral position. Turning and aspiration are prohibited within 30 minutes after nasal feeding to prevent food reflux.
2.Blocking of nasal feeding tube
Blockage of nasal feeding tube can be caused by thin nasal feeding tube and too high food concentration. The method of prevention is to choose suitable nasal feeding tube, appropriate concentration of nutrition solution, and flush the tube with 20-30ml of warm water after feeding. If drugs are used, they should be finely ground, and the tube should be continuously flushed 3 to 5 times after feeding, and then flushed 3 to 5 times after feeding. Normally, the end of the gastric tube is reflexed and wrapped with sterile gauze, fixed at a position above the stomach level, which can prevent food from staying in the tube and causing blockage.
3.Local stimulation damage and adhesion
The stimulation of local mucosa by nasal feeding tube can cause mucosal ulcer and bleeding, and the adhesion of mucosa between gastric tube and esophagus can also occur after long-term gastric tube placement, increasing the chance of infection and causing pain to patients. The treatment method is to choose a nasal feeding tube with suitable thickness, soft texture and little irritation. For long-term nasal feeding, a small amount of liquid paraffin oil or peppermint oil nasal drops can be put into the nasal cavity of the tube twice a day to prevent nasopharyngeal infection and reduce the local irritation of the nasal feeding tube. In addition, in order to prevent long-term placement of adhesions, the gastric tube can be gently pulled out 4 to 5 cm daily and then inserted.
4.Nausea and vomiting
Excessive amount or speed of nasal feeding can increase the stomach volume rapidly and lead to stomach cramps, causing nausea and vomiting. Therefore, before pushing the injection should be pumped back the retained liquid in the stomach, reduce the amount of feeding, each feeding can be completed in 20-30 minutes, the feeding interval of not less than 2 hours; nasal feeding after observation for 5 minutes, if the patient does not vomit before leaving. When critically ill patients are in a state of stress, the method of continuous nasal drip can be chosen, keeping the temperature of the solution at
30 ℃ ~ 40 ℃ to reduce the stimulation of the gastrointestinal tract.
5.Diarrhea
Diarrhea is one of the most common complications of nasal feeding diet, mainly due to the large amount of liquid entering the gastrointestinal tract to stimulate gastrointestinal peristalsis, or the massive use of broad-spectrum antibiotics to make the intestinal flora imbalance. If the patient has an increased number of stools, unformed or watery stools, slow down the feeding speed, reduce the feeding amount appropriately, and give digestive drugs or antidiarrheal drugs, but do not stop nasal feeding in a hurry. Use special sterilization tools for the configuration of nasal feeding solution, and prepare it now. When diarrhea occurs, do a good job of perianal skin care to prevent complications.
6.Constipation
Many nasal feeding patients need to be bedridden for a long time, and nasal feeding substances are relatively fine, if not early care intervention, it is easy to lead to constipation. Methods such as abdominal massage can promote regular bowel movements and reduce the occurrence of abdominal distension, discomfort and increased intracranial pressure caused by constipation.
Specific practices are as follows.
① abdominal massage, three times a day, 30 minutes after three daily feedings in the direction of intestinal travel, the right ascending colon to the transverse colon, descending colon, sigmoid colon to do circular massage, in the left lower abdomen slightly hard and lasting, 15-20 minutes each time;
② every night after 1 hour of feeding with warm water foot soak, and foot massage, stimulate the plantar small intestine reflex area blood circulation, promote intestinal peristalsis, to facilitate the excretion of stool;
(③) daily early in the morning first tube feeding appropriate amount of warm boiled water (100-200 ml), the first day feeding to give vegetable soup and rice soup, the patient adapted to the thin rice, fruits, vegetables, lean meat and other substances will be broken and cooked to add sesame oil, honey and other laxative substances for tube feeding.
In addition, during the nasal feeding treatment, attention should be paid to monitoring the patient’s blood sugar and electrolyte changes, paying attention to the supplementation of vitamins and other nutrients, and reasonable dietary mix.