Below is the feeding schedule provided by the hospital in Thailand where my mother is currently being treated. Usually the schedule is also applied to other patients who are fitted with a nasogastric tube due to other illnesses such as stroke or neurological disorders.
The objective of this post is to give you a general idea with regards to how often, timing and volume that tube feeding need to be administered. It is important to check with the doctor on your loved one’s schedule as treatment options may differ from one healthcare provider to another.
Feeding time recommended to me by the Thai hospital:
Feeding, done via bolus or enteral feeding bag should be done 4 times a day at the following time:
- 6am
- 12pm
- 5pm
- 11pm
Please check my post on Useful Videos on Nasogastric Feeding where guidelines are provided by 2 hospitals in Singapore on the feeding.
Before each feed is administered, a syringe test need to be performed to check if there are previously undigested feed. The volume varies but generally if you could pull out 50ml or more of undigested content from the stomach, then you should not do the feeding but wait for at least an hour before testing again. This is because of there are a large volume of undigested content, if you add in more food, it may cause the person to vomit and risk having aspiration pneumonia (food and acidic content moving to the lungs resulting in infection).
Preparation of feed
In most countries, I understand milk formulas are being used. Most of these formulas are expensive to be used long term and may be out of the budget of many. In Thailand, there are various videos by hospitals in Thailand to teach how the food is prepared and the ingredients required. We were fortunate that the hospital where my mom is seeking treatment from also caters to tube feeding food (which is used for stroke and other patients on nose feeding).
Before your proceed, always check with your doctor and dietician if you can prepare based on the ingredients below.
It is important to take note that if you decide to prepare the tube feeding food yourself, preparation hygiene (ie lots of hand washing and cleanliness of the place), utensils need to be separated from the rest of the household use, airtight storage, etc need to be adhered too. The digestive system of a person on tube feeding is weak and sensitive. Any contamination may lead to food poisoning or diarrhea that may require hospitalization.
Administering medication
Medication can be given after feed or as per advice by doctors. Medication needs to be crushed and mixed with water to pour into the syringe. After the medication is given, then flush down the tube with 50ml of water. There are some medications that cannot be crushed- and usually your doctor would be mindful not to prescribe such medication.
As you are would be crushing the medication and mixing with water, you need to ensure the total volume of fluid does not exceed the volume as advised by your healthcare provided.
I wish to share with you my experience on administering tube feeding and medication:
We source our food from the hospital. Each day we would get 4 enteral bags for each meal. We also need to buy the tube that connects the enteral bag to the nose tube. If you are making the feed on your own based on the guidelines from Thai hospitals (view post with translation of the video), then you would also cook these ingredients once and split it into 4 portions and store the later meals in airtight containers or enteral bags and put in the fridge.
Before each feed, please ensure:
- you did the draw of stomach contents to make sure the previous food has been digested or if not, then do not exceed the volume as advised by your doctor or nurse
- the food is heated up (note: CANNOT heat up in pan or microwave) by soaking the air tight container/enteral bag in a container containing water of maximum 80 degrees for 20 minutes before the meal time:
Image source: From video of Siriraj (general hospital in Bangkok). The glass bottle containing the food is soaked in a pan of hot water. Do not boil the contents directly nor heat in the microwave as it would destroy the nutrients.
- ensure diapers, if soiled has been changed. This is because when you change diapers, you need to flatten the bed. But after feed, at least 30 minutes (preferable longer for those with bad digestion) you cannot have the person lie flat. That is why, unless you wish to tackle soiled bed sheets later, change soiled diapers before feed.
- if the person is immobile or dependent, it is better not to move the person to a wheelchair or go out in a car within a hour or so after feed as the person may throw up
Preparing and administering medicine
You would always need a thermal flask containing hot water and a jug of clean drinking water (covered) in the room with you. It will come in handy when you need to use it to mix the medication or use during mouth cleaning or phlegm suction. The water can be boiled once in the morning or evening and stored in the thermal flask to be used the whole day.
After connecting the feed to my mom, while waiting, I would prepare her medication. All medication in tablet form must be crushed/grinded into powder form using a medicine grinder or a small pestle. I pound the medicine separately one by one. I start with the one that has least colour, followed by one that has strong colour:
Above, I pounded the folic acid and placed on the medicine cup. Then followed by the multivitamin.
These medicine are all dissolved in warm water. Exception is Fluimucil, a medication that is used to dilute the thick mucus in my mother’s throat. The medication cannot be crushed. I place on the medicine cup with room temperate water and wait for the pill to dissolve. Do note after dissolving, it water becomes clear so it is hard to different if you have a different pill container to hold the medication. What I do is I have a separate small glass cup that looked different from the rest. I place the Fluimucil inside so that after it dissolves I could differentiate.
I take a drop of the medicine and test on the back of my hand to ensure it is not too hot or cold. But you should not add a lot of water to dilute the medication. Just little bit of water would do to ensure the total feed does not exceed the maximum volume as prescribed by your doctor. If I am not mistaken it should not exceed 400 ml in total.
After the feeding is finished, I bend the tip of the feeding tube to prevent air from going in while I removed the connecting tube from the enteral bag (you can watch the videos I have included in this post). Then I put in the glass syringe in the tip, I unbend the tube.
Then unless being told by the doctor otherwise, I would pour in the medication that has the strongest color first. Namely the multivitamin, then followed by folic acid and Fluimucil. Meaning this works opposite sequence during medicine grinding. This is because strong colour medicine like a multivitamin will stain the tube with colour and also it is very hard to grind and dissolve the multivitamin completely so when I put in the strong colour medicine, subsequently it can be washed down by the other medication so that nothing gets lodged in the tube.
Some medicine come in capsule form. You can place these medicine in a pestle and add a little warm water. It will dissolve the outer shell. You can then proceed to grind it.
Each time I let the volume almost complete leaving the syringe but do not let the syringe be empty. The last I pour in would be warm water of 50ml to rinse the tube (I would test the warm water at the back of my hand to make sure it is not too hot).
I would then carry my tray and used items to be washed in the sink. I use a separate sponge than others are using to clean the items to avoid contamination.
Important note:
The person needs to be kept at an incline of minimum 30 degrees after feeding to minimize the risk of the fluid regurgitating upwards. If it move upwards and then flow to the lungs, the acid from the stomach contents would damage the lungs, as well as infection may set in causing pneumonia. For tips on how to lift a person who have slide down the bed, please refer to this post.
I do observe my mother’s mood. Sometimes she is sleepy and inactive during feeding- I would then leave the room for a short while to wash the items.
However, at times she is active and playful, ie moving her legs around a lot and have the tendency to want to slide downwards to try to lie down flat. I have a wedge which is placed below her buttocks area but I know she would find a way to slide down by moving her body sideways. I would then climb up on her bed and seat myself at the end of the wedge and then monitor her for at least 30 minutes, making sure she does not slide down and moving her when she attempts to change position. After about 30 minutes, she would get a little sleepy and rest, then I would leave the room to wash the items. Note: I do not mind her being active and moving around. It is a blessing as it was a far cry from how she was prior to her hospitalization where she could have died had she not been fitted with a feeding tube.