It’s Not the Tube Feeds! …Or Is It?
You have a patient that is unable to eat by mouth. You recommend a tube feed regimen, and move on to your next patient. The next day, you are consulted by a nurse because the patient has diarrhea. If you have worked in the clinical field, you know this can be a frustrating and all too frequent occurrence. While sometimes the easy response is to change the formula to appease the nursing staff, it might not always be the best intervention. As Registered Dietitians, Dietetic Interns, or nutrition students and RD2Bes, we are often taught “it’s not the tube feeds!” I hate to break it to you, but after working with thousands of tube fed patients, I have learned that sometimes it actually might be…
Real-life Experience
In my experience as a Clinical Dietitian and CNSC for over 10 years, I have learned that there are sometimes exceptions to the rules, and that the generic answers you find in a textbook don’t work for everyone. I want to save you time and frustration by giving you a look inside my thought process and courses of action.
When I recommend a tube feed regimen, it is typically what I feel to be the most appropriate regimen for that patient at that time. At that time being the key words – this can always change, especially in higher acuity environments, such as in the ICU.
How I Approach a Diarrhea Consult
If a nurse comes to me asking to change the tube feed because the patient has diarrhea, I usually respond with “I will take a look.” I usually look at it right away, if I’m not in the middle of something. What I don’t want to do is give a blind verbal recommendation on the spot. Even when I am familiar with a patient, I know that things can change, or that my brain could easily confuse some of the minute details with those of my other patients. If they are a proactive nurse, they might immediately go change the formula based on your verbal recommendation, before you write a note or propose an updated order. I always give myself time to review the notes and re-familiarize myself with that patient, so I don’t have to go back to the nurse that has already spiked and hung a new formula and say, “nevermind, I actually want to recommend something different.”
If I feel the current regimen is no longer the best for that patient at that time, then I will provide an updated recommendation. If it appears to still be the best or most appropriate regimen, I then move through a checklist to determine if making a formula change might improve the diarrhea.
Potential Offenders
* Check the bowel history. Did they have diarrhea or frequent BMs documented prior to starting the tube feeds? Do they have a history of inflammatory bowel disease, such as IBS or Crohns?
* Review the Medication Administration Record (MAR). Are bowel meds ordered? Any other meds that commonly have a side effect of diarrhea, such as antibiotics or sorbitol-based liquid medications?
* Are they receiving a hypertonic modular supplement in order to better meet nutritional needs?
* Does the patient have an infection, such as Clostridium Difficile (aka: C.Diff)
It seems like a no-brainer, but I can’t tell you how many times I have found that the patients had diarrhea prior to even starting the tube feeds, or have a current order for daily bowel meds. These are not the tube feeds!
If all of the above are negative, then I take a look at the formula itself.
Investigate the Formula
* Does it contain fiber? In my years of experience, I have found fiber in tube feeds to be an enigma. Some patients develop diarrhea, some constipation, and some develop relief from one or the other. Does the patient specifically need a low residue formula?
* What is the osmolarity? Some formulas are more concentrated, which may be necessary for fluid restricted patients. This results in a higher osmolarity, thus increasing the chance of hyperosmotic or secretory diarrhea – aka: intolerance.
* Is the tube feed running at a high rate, or high volume in short period of time?
In these instances, it might be the tube feeds! It could potentially be appropriate to recommend a trial of something else.
What if diarrhea doesn’t improve?
Occasionally, you could be between a rock and a hard place. Maybe you trial a different formula, and it does not result in improvement. Maybe you have answered yes to some of the issues that tube feeds can cause, but it is not appropriate to change the tube feed formula due to labs or fluid issues. This might be a good time to consider recommending alternative interventions to help provide relief – fiber modulars, medications, or even off-formulary formula orders.
Need more guidance?
Unfortunately, there is no specific algorithm to determine the cause of diarrhea, or how to fix it, because each patient is so unique. In my Nutrition Supportive courses, I give you all the tools that it took me 10+ years to develop, to help save you time and frustration. I teach you how to narrow down the most appropriate regimens and recommendations, and how to support these recommendations, so you can confidently respond to any questions. I discuss medications, modulars, and formulas that are common offenders, and explain how to create an updated plan. Most importantly, I teach you how to navigate potential complications – not if, but when they arise. As a more confident and
Want to improve your nutrition support skills to work smarter, not harder? Check out the resources and courses that I have to offer at Nutrition Supportive and find one that works best for you!
Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice or preceptorship. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, recommendations, and/or diagnosis. Always check with your director, preceptor, physician, or appropriate regulatory authority if you are unsure about any courses of action.