Patients who have dsyphagia and bradykinesia need appetizing foods that are easily chewed and swallowed. The diet should contain adequate roughage ad fruit to avoid constipation. Food should be cut into bite size pieces before it is served and it should be served on a warmed plate to preserve its appeal. Eating six small meals a day maybe less exhausting than eating three large meals a day. Ample time should be planned for eating to avoid frustration and encourage indolence. In addition, absorption of levodopa can be impaired by protein ingestion.
The aim of nutritional management is to provide a suitable nutritious diet which will prevent aspiration and help make eating a pleasant experience. Other than texture modification, crucial elements in effective nutritional management of dysphagia are appropriate food choice, food fortification and the use of dietary supplements. The key player from the multi-disciplinary team here is the dietitian, who will monitor the patient’s nutritional status and intake and advise accordingly.
If the patient’s nutritional intake is insufficient, alternative feeding may need to be considered. In fact, in severe cases of dysphagia or aphagia (complete absence of swallow), the patient may be put nothing by mouth but the swallow assessor, and have to be entirely fed via a naso-gastric or gastrostomy tube. Parenteral fluids may also be initiated to ensure adequate hydration. PEG (Percutaneous Endoscopic Gastrostomy) Feeding In this case however the patient was commenced on PEG feed.
A PEG is a feeding tube that goes into the stomach directly through the abdominal wall. It involves having an endoscopy (the insertion of a flexible tube via the mouth into the stomach) and a small cut on the skin over the abdomen. It is a simple and safe way of receiving food when there are problems with swallowing or eating. PEG stands for Percutaneous (through the skin) Endoscopic (via an endoscope) Gastrostomy (to the stomach). It is a hole specially created in the stomach to allow insertion of feeding tubes through the abdominal wall directly into the stomach.
Nursing care of this patient on PEG feeds requires checking the tube placement before feeding and before drug administration, assesses bowel sounds before feeding, if it is necessary to use tablets, be sure to crush drugs to fine powder to avoid clogging feeding tubes (not for sustained release or enteric coated or microencapsulated forms). Assess regularly for complications (for example aspirations, diarrhea, abdominal distension, hyperglycemia, constipation and fecal impaction).
Some of the common problems of patients on PEG feeds are vomiting and or aspiration which could be caused by improper placement of tube, delayed gastric emptying, and increased residual volume. A nurse is to check for proper placement of the tube before commencing feeds and every 8 hours if continuous feed. Diarrhea maybe due to feeding too fast, hypertonic formula or medications and or contamination of formula or tubing. If this occurs, decrease rate of feeding, change to continuous drip feedings, check for drugs that may cause diarrhea (e. g. antibiotics). Consult the dietician for change in formula if lactulose intolerant.
Change tubing every 24 hours, allow for 8 hours formula at a time, taking into account not to exceed the manufacturer’s guidelines. Constipation could be due to formula components. Consult the doctor for change of formula to one with more fiber content, and check the drugs that cause constipation. Dehydration is as a result of excessive diarrhea and or vomiting, if this happens decrease rate of the formula, check drugs that patient is receiving especially antibiotics. Take care to prevent bacterial contamination of formula and equipment and also check blood glucose levels frequently.