Nursing Practice

Review
Nutrition

Keywords: Nutrition/Nil by mouth/

Fasting/Surgical care
This

article has been double-blind

peer reviewed

Nurses need to understand why patients must be nil by mouth, be familiar with best
practice and be able to educate patients in the procedure and the reasons for it

Nil by mouth: best practice

and patient education
In this article...
 hy patients should be nil by mouth before and after surgery
W
Best practice and how to educate patients
How to relieve patients discomfort when they are nil by mouth
Author Catherine Liddle is senior lecturer
at Birmingham City University.
Abstract Liddle C (2014) Nil by mouth:
best practice and patient education.
Nursing Times; 110: 26, 12-14.
Some patients need to stop eating and
drinking, to be nil by mouth, at certain
points in their care pathway for their own
safety; their care will vary, depending on
individual needs. Nurses need adequate
knowledge of NBM guidelines to know
how to implement them and be able to
educate patients. This article explains how
to care for patients who are NBM during
pre- or post-operative periods.

Alamy

atients are restricted from eating

and drinking, commonly known
as being nil by mouth (NBM), as
a result of a variety of conditions
and at different times in their treatment
pathway, particularly during surgery.
Conditions include non-functional
bowel, acute abdomen, dysphagia, unconsciousness or reduced level of consciousness, and nausea or vomiting. The nursing
care will vary for each, depending on the
length of time the patient will be NBM and
their individual circumstances. This
article looks at caring for patients who are
NBM before or after an operation.
When a patient fasts in hospital for a
long time, problems may occur, typically:
Dehydration;
Malnutrition and electrolyte imbalance;
Hypoglycaemia;
Nausea and vomiting.
Older people, children, pregnant
women and patients who are critically ill
are particularly vulnerable (Chand and
Dabbas, 2007). When patients become
dehydrated, they display physiological

signs including hypotension, tachycardia,

oliguria, confusion and a decreased level of
consciousness. This, together with the psychosocial factors of fasting being unable
to eat or drink like other patients can
make being NBM an unpleasant experience.

Preparing patients

The multidisciplinary team should have a

good knowledge and understanding of
fasting guidelines so patients are given
accurate information, relevant information is documented and local guidelines
are followed (Lorch, 2007; Royal College of
Nursing, 2005).
Before admission, patients need to be
fully informed about fasting pre- and postoperatively to:
Ensure adherence;
Reduce the risk of surgery being
delayed/cancelled;
Aid a smooth and rapid recovery.
Patients with a learning disability or
cognitive impairment will need extra support to ensure they understand the importance and safety aspects of fasting. Patients
who are prepared are less prone to experiencing anxiety and more likely to have a
reduced stress response to surgery (Varadhan et al, 2010).

5 key
points

Patients who are

to be nil by
mouth need to be
physically and
psychologically
prepared for the
period of fasting
All staff should
have a good
understanding of
current fasting
guidelines
Communication between
staff and patients is
essential
A nil-by-mouth
plan of care
and associated
assessments
should be
implemented,
documented and
updated
Patient privacy,
dignity,
comfort and safety
must be maintained
at all times

2
3

4
5

Pre-operative fasting

For decades, patients have fasted from

midnight or even longer for a morning theatre list and from 6am if on the afternoon
list (Brady et al, 2010). This practice has
become ritualistic in clinical areas. The
RCN (2005) published guidelines to change
out-of-date and varied practice in the UK.
Evidence-based pre-operative fasting is a
medical and legal requirement to maintain
patient safety. Unless it is for emergency

12 Nursing Times 25.06.14 / Vol 110 No 26 / www.nursingtimes.net

Intravenous fluids may be required when

patients exceed fasting times

Ensure patients are at the

centre of your thinking
Tracy Mannix

surgery, patients should not be given an

anaesthetic without a period of being
NBM; this reduces the risk of pulmonary
aspiration if gastric contents are regurgitated. The gag, swallow and cough reflexes
usually protect the airway from aspiration
of food or fluids but, when patients are
anaesthetised, these are suppressed to
varying degrees (Brady et al, 2010).
Brady et als (2010) review of randomised
controlled trials suggested that patients
who drank clear fluids up to a few hours
before surgery were at no greater risk of
aspiration than in those who fasted from
midnight; those who fasted for the shorter
period also had a lower gastric volume.
The RCNs (2005) guideline states that
prolonged fasting can increase the risk of
aspiration of stomach contents, leading to
respiratory problems and possibly death.
Obesity, pregnancy, peptic ulcer, gastric
reflux, stress and pain place patients at a
higher risk of aspirating (Brady, 2010; RCN,
2005). A surgeon or anaesthetist may
request a longer fasting time for these
patients (RCN, 2005).
Jones and Swarts (2013) Guidelines for the
Provision of Anaesthetic Services recommends
patients with diabetes are fasted for the
minimum amount of time, as fasting, surgical stress and inactivity can all have a negative effect on blood-sugar control, and
are placed at the top of the operating list.
A safety alert (National Patient Safety
Agency, 2011) reported the risk of harm to
patients who are kept unintentionally NBM
for prolonged periods. This was prompted
by the case of a patient kept NBM for 10
days awaiting a procedure. The alert
underlines the fact that vulnerability,
dehydration, malnutrition or complications from omitted or delayed medication
are intensified when a patient is exposed to
long periods of being NBM. It concludes by
recommending that organisations:
Assess for alternative methods of
hydration, nutrition and medication;
Document a NBM care plan;
Communicate the patients NBM status
to all relevant staff.
Patients should be reviewed individually by nursing and medical staff to ensure
their NBM time is kept to a minimum.
Nurses are pivotal in ensuring communication is maintained between theatre and
ward staff and the patient.
The RCN (2005) published recommendations for pre-operative fasting for
healthy adults (Box 1). These advise that
sweets are classed as food and chewing
gum should be avoided on the day of surgery; however, Poulton (2012) states there
is evidence that gum chewing promotes

p28

Box 1. Nil by mouth:

guidance
Patients can take the following before
being anaesthetised:
Adult
Water up to two hours before
Food up to six hours before
Child
Water and clear fluids up to two
hours before
Breast milk up to four hours before
Formula/cows milk or solids up to six
hours before
Source: Royal College of Nursing (2005)

gastrointestinal motility and physiologic

gastric emptying.
When surgery is delayed, the guidelines
recommend the surgical team consider
allowing adults some water to prevent
dehydration and relieve thirst; they do not,
however, stipulate how much water can be
drunk. Staff should consider giving children a drink of water or another clear fluid;
if the delay is to be longer than two hours,
one should definitely be given (RCN, 2005).
Roberts (2013) literature search revealed
that, despite best-practice guidelines, preoperative fasting times remain excessive.
He recommended more detailed patient
literature, including the implications of
extending fasting times and the possibility
of associated nausea and headaches.
Lorch (2007) undertook an action
research study to improve the patient experience and implement the RCNs (2005)
guidelines. The outcome improved patient
and staff knowledge, improved patient
comfort and safety, ensured uniformity of
practice,
improved
communication
between patients and staff, and avoided
the omission of prescribed medication.
Pre-operative medication
Prescribed regular oral medication and premedication, unless contraindicated and
excepting oral hypoglycaemic medicines,
should be administered pre-operatively to
avoid surgery being cancelled, for example
due to hypertension (Lorch, 2007; RCN,
2005). Adults can have up to 30ml of water
and children up to 0.5ml/kg (up to 30ml) to
take the medication (RCN, 2005).
Risk assessment
Pre-operatively, a malnutrition risk assessment should be performed, which should

consider how long the patient will be

fasting before, during and after surgery.
National Institute of Health and Care
Excellence (2006) guidance recommends
using a validated screening tool (such as
the Malnutrition Universal Screening
Tool). Screening should include:
Assessment of body mass index;
Unintentional weight loss;
Time of unintentional reduced
nutritional intake or future impaired
nutrient intake.
This is important to prevent surgery
being cancelled due to malnutrition and
related post-operative complications.
Patients who have post-operative
nausea, vomiting or a non-functioning gut
due to gastrointestinal surgery can remain
NBM for longer; in some cases, nutritional
support may be required.
NICE (2006) guidance provides flowcharts on when to consider oral, enteral
and parenteral nutritional support preoperatively. A few surgical patients will
have artificial feeding pre-operatively
those with severe weight loss, very low
body mass index or a risk of post-operative
complications (Braga et al, 2009). Parenteral nutrition will be considered for
patients who are malnourished and have
an inadequate or unsafe enteral intake or
a non-functional inaccessible or perforated gastrointestinal tract (NICE, 2006).

Post-operative care

Fasting
Patients with a short fasting time are less
likely to experience post-operative nausea
and vomiting and are more likely to have a
quicker and more comfortable post-operative recovery and experience (Chand and
Dabbas, 2007).
RCN (2005) guidelines state that as long
as there are no contraindications, patients
can be offered and encouraged to drink
fluids post-operatively. They say it may be
better for children to try breast milk or
clear fluids first. This does not apply to
patients who have had gastrointestinal or
major abdominal surgery.
Enhanced recovery programme
The NHS Institute for Innovation and
Improvements enhanced recovery programme, launched in 2008, has been used
in many specialties. It aims to minimise
the bodys stress response to anaesthesia
and surgery, reducing post-operative
recovery time so patients can be discharged
earlier (Foss and Bernard, 2012; Slater, 2010).
Key aspects are managing fluid balance
and fasting times, and ensuring patients do
not become malnourished or dehydrated.

www.nursingtimes.net / Vol 110 No 26 / Nursing Times 25.06.14 13

Nursing Practice
Review
Patients are given a clear,carbohydraterich drink before midnight and a second
drink 2-3 hours before surgery to reduce
their discomfort from fasting and preoperative thirst and hunger (Brady et al,
2010). The evidence suggests that carbohydrate drinks pre-operatively result in a
shorter stay in hospital due to a quicker
return of bowel function, a reduced loss of
body mass and a decrease in post-operative
nausea and vomiting (Jones et al, 2011).
Fluids and diet are often reintroduced
on the day of surgery to promote gut
motility and reduce the risk of the patient
developing an ileus (when peristalsis stops
and the bowel ceases to function) (Varadhan et al, 2010).
Intravenous therapy
Nurses need to know when patients exceed
their fasting time and discuss introducing
intravenous fluids with doctors. BAPEN
(2011) offers recommendations on pre-,
intra- and post-operative fluid management in adult surgical patients. Mechanical bowel preparation is avoided where
possible but, if it is necessary, it is common
for an electrolyte imbalance and dehydration to occur; this should be corrected with
IV fluid and closely monitored (BAPEN,
2011; National Confidential Enquiry into
Patient Outcome and Death, 2011).
Nursing care should include maintenance of an accurate fluid balance chart;
cannula care should include the use of a
phlebitis scale to prompt action.
Fluid balance
Patients receiving additional fluid or
nutritional support should have their fluid
balance recorded on a fluid balance chart
so it can be assessed. This should include:
Urine output (minimum of 0.5ml/kg/hr);
Any other output;
All IV fluids;
Parenteral nutrition/feeds.
Oral hygiene
Fasting can cause oral discomfort (Box 2)
and be an infection risk. Oral care is sometimes neglected by nurses and not considered a priority (RCN, 2012; Bisset and Preshaw, 2011).
Some patients will have experienced
oral problems before surgery due to treatment or an existing problem, for example:
Xerostomia (dry mouth) is common in
older people and patients who have had
chemotherapy, causing soreness and an
unpleasant taste;
Fear of surgery raises anxiety levels,
which can contribute to a decreased,
thicker flow of saliva due to activity of

Box 2. Oral effects

of being nil by mouth
Dry mouth, throat and tongue
Difficulty in speaking
Saliva that feels thick and stringy
Bad breath
Teeth that feel coated and unclean
Dry, cracked lips

the sympathetic nervous system.

In dehydrated patients, saliva secretion
stops to conserve water (Jenkins et al, 2010).
Post-operatively, patients may remain
NBM for several hours or longer and be
prone to xerostomia due to dehydration,
oxygen therapy and side-effects of the
anaesthetic. They will need frequent oral
care (Bisset and Preshaw, 2011).
Mouthwash should be available for
patients; they may prefer to use their own
but those that contain alcohol can have a
drying effect on the mouth. Chlorhexidine
mouthwashes can reduce the level of plaque
and bacteria but should not be used more
than twice a day because of their alcohol
content. Dingwall (2010) suggests using
0.9% saline as this does not affect the pH of
saliva and is flavourless. Lemon and glycerine swabs are discouraged the lemons
acidity damages tooth enamel and glycerine
draws fluid away from the tissues, reducing
saliva production. Glycerol or petroleum
jelly can be applied to the lips but can feel
sticky; patients own lip balm or a watersoluble gel can be used (Dingwall, 2010).
Patients who wear dentures may prefer
to keep them in for as long as possible,
sometimes until induction of the anaesthesia; however, a dry mouth can make
wearing them uncomfortable.
Pressure ulcers
Nurses need to use a validated assessment
tool to assess pressure ulcer risk before and
after surgery, and as the patients condition changes. Nutrition is important in
preventing pressure ulcers (NICE, 2014)
and forms part of the risk assessment.
Nurses must consider other factors that
could increase the risk, such as:
Length of operation;
Hypotension and low core temperature
during surgery;
Possible post-operative reduced
mobility.
Patients must not fast for longer than
necessary and, if they are at risk of developing pressure ulcers, pressure-redistributing mattresses should be used and
patients position varied.

14 Nursing Times 25.06.14 / Vol 110 No 26 / www.nursingtimes.net

Conclusion

Educational and clinical institutions must

work together to educate all healthcare
workers so patients have the best possible
care when they are NBM. Surgeons, nurses,
theatre staff, students and housekeeping
staff need to follow the most recent guidelines. Patients must be educated and kept
informed about their NBM status. The
RCN (2005) guidelines inform practice;
local policies should reflect them. NT
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