Advanced Nutrition Flashcards
Feeding a Pt with Dysphagia
- ensure pt is awake, alert, and ready to fully participate
- position in high fowlers (40-60 degrees)
- assess risk of aspiration
- if paralysis, place food on unaffected side
- signs of aspiration = coughing, throat clearing
- protect safety, independence, dignity, common courtesy
- assess for appropriateness to delegate feeding to UAP
- no straws
- thickened liquids?
Enteral Nutrition
aka tube feeding, goes through GI tract
administration of nutritionally balanced liquefied food or formula through tube inserted into:
- stomach
- duodenum
- jejunum
provides nutrients alone or supplement to oral or parenteral nutrition
- easy to administer
- safer, less expensive, and more physiologically efficient than parenteral
feedings can be started when bowel sounds are present, usually w/in 24 hours after surgical placement
Indications for Enteral Nutrition
anorexia orofacial fractures head/neck cancer neurologic or psychiatric conditions extensive burns critical illness chemotherapy radiation therapy
Enteral Nutrition: Delivery Options
continuous infusion or bolus by pump
bolus by gravity
bolus by syringe
Enteral Nutrition: Tubing Types
Polyurethane or silicone tube:
- radiopaque (can see on xray)
- placement in small intestine (decreased likelihood of regurgitation and aspiration when placed in intestine, passed pyloric sphincter, instead of stomach)
NG and Naso-intestinal tubes:
- clog easily
- can be dislodged by vomiting or coughing
- can be knotted/kinked in GI tract
Percutaneous Endoscopic Gastronstomy
gastrostomy tube placement via percutaneous endoscopy
w/ use of endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through a stab wound made in the abdominal wall
retention disk and bumper secure the tube
most feedings can start w/in 4 hours of insertion
Gastrostomy and Jejunostomy Tubes
may be used when a pt requires tube feeding for an extended time
*pt must have intact, unobstructed GI tract
can be placed surgically, radiologically, or endoscopically
Enteral Nutrition: Tube Position
- x-ray confirmation for new nasal or orogastric tubes
- mark exit site of tube
- check placement before feeding/drug administration or every 4 hours w/ continuous feeds (book says every 8 hours)
can check tube placement w/ aspiration of stomach contents, pH check
ideally placement should be confirmed w/ more than 1 test
*x-ray is most accurate assessment
Enteral Nutrition: Medication Administration
- use liquid form of medication if possible
- crushed meds mix in warm water
- flush before and after w/ water (10-20ml before and 30-60ml after) to prevent clogging of tube (sterile water only)
- do not crush enteric coated or sustained released meds
Enteral Nutrition: Site Care
- assess the skin around tube daily
- monitor bumper tension (too tight, can cause irritation and breakdown, can also get imbedded into skin)
- apply a dressing until site is healed
- after healed, wash with soap and water
- protective ointment or skin barrier
Enteral Nutrition: Misconnection
inadvertent connection between an enteral feeding system and a non-enteral feeding system (IV line, peritoneal dialysis catheter, tracheostomy tube cuff)
severe pt injury or death can result
Enteral Nutrition: General Nursing Considerations
daily weights bowel sounds before feedings accurate I&O initial glucose checks label w/ date and time started pump tubing changed q24h
Enteral Nutrion: Complications
- vomiting (have suction equipment at bedside)
- dehydration (more calorically dense, less water formula contained, check for high protein content)
- diarrhea (common especially early on)
- constipation
Enteral Nutrition: Gastrostomy or Jejunostomy Feedings - Complications
- residuals, assess and document every 4 hours
- skin irritation
- pulling out of tube (teach pt/family about feeding administration, tube care, and complications)
Enteral Nutrition: Gerontologic Considerations
more vulnerable to complications:
- fluid and electrolyte balances
- glucose intolerance
- decreased ability to handle large volumes
- increased risk of aspiration
Parenteral Nutrition
aka TPN, HAL
administration of nutrients directly into the bloodstream
goal = meet nutritional needs and allow growth of new body tissue
customized to meet each patient’s needs
Indications for Parenteral Nutrition
chronic severe diarrhea and vomiting complicated surgery or trauma GI obstruction GI tract anomalies and fistulae Intractable diarrhea Severe anorexia nervosa Severe malabsoprtion Short bowel syndrome
*anything that’s causing problems in the gut or where nutritional needs are not being met or not being met with enteral
Parenteral Nutrition: Composition
base solution contains dextrose and protein in the form of amino acids
prescribed electrolytes, vitamins, and trace elements are added to customize
IV fat emulsion is added to complete the nutrients
Parenteral Nutrition: Methods of Administration
central parenteral nutrition:
-used for long-term support
-through catheter whose tip lies in superior vena cava
(peripherally inserted central catheters)
peripheral parenteral nutrition (PPN):
- for short-term therapy or special conditions
- through peripherally inserted catheter or vascular access device
- protein and caloric requirements can’t be too high
- used when risk of central catheter is too great
Parenteral Nutrition: Tonicity of Nutrition
Central solutions are hypertonic
-large veins can handle high glucose content
Peripheral solutions are less hypertonic
- peripheral veins cannot handle as high glucose content
- NOT preferred route of administration
Parenteral Nutrition: Solutions
prepared by pharmacist or trained technician under strict aseptic techniques
must be refrigerated until 30 minutes before use
must be labeled w/ nutrition contents, all additives, time mixed, date and time of expiration
usually 2 RN check
Parenteral Nutrition: Complications
Refeeding Syndrome:
- fluid retention and electrolyte imbalances
- hypophosphatemia is hallmark sign
- pts predisposed by long-standing malnutrition states (ex. chronic alcohol syndrome)
Metabolic Problems:
- altered renal function from bypassing GI system and hitting kidneys hard
- essential fatty acid deficiency
- hyperglycemia, hypoglycemia
- hyperlipidemia
- liver dysfunction
Catheter-related problems:
- air embolus
- catheter-related sepsis
- dislodgement, thrombosis of vein, phlebitis
- hemorrhage, occlusion
- pneumothorax, hemothorax, hydrothorax
Parenteral Nutrition: Nursing Management
- VS: every 4-8 hours
- daily weights
- blood glucose (check initially every 4-8 hours)
- infusion pump must be used, periodically check volume infused
- monitor labs (electrolytes, BUN, CBC, liver enzymes)
- dressing changes
- watch for complications
- examine bag for signs of contamination and recheck against orders
- discontinue PN solution at end of 24hrs
- change tubing every 24hrs (filters needed on all tubing)
