Exam 7 Enteral and PEG tube Flashcards
Capsule
Open and dissolve in 15-30 mL warm water
When should residuals be checked?
Prior to beginning a new feeding and before each feeding, or follow policy
Nasoenteric (NE)
Small and more comfortable for client
Less likely to become dislodged and cause aspiration
More likely to become occluded
Only liquid meds- no crushed or powdered meds
Better for longer term therapy
Must be x-ray verified on initial insertion
What lab values should be monitored?
BUN
Electrolytes
Glucose
Enteral feelings
Bolus (one)
Continuous
Intermittent
Reflux
A backward flow of food or fluid from the stomach into the esophagus.
Gastric
Stomach
Care of PEG tube site (percutaneous endoscopic gastrostomy)
- Cleanse with soap and water
- Assess skin around tube site (infection or excoriation)
- Rotate tube 360 degrees each day and ck for in-and-out play of 1/4 inch
- May use small precut gauze at exit site if drainage is present
- Usually clean, dry, and no gauze left around site
- As always, follow policy
Should non sterile or sterile gloves be worn during procedure?
Non-sterile gloves
A 70 year old female has been in a long term facility for 11 years. She has a dx of senile dementia, hypothyroidism, and type 2 diabetes. She is currently getting Jevity per PEG tube feedings to equal 1400 calories per 24 hrs. The chart shows her height as 66 inches and weight of 140. She has had no history of decubitus ulcers and she can move without assistance but with difficulty. Rate the following nursing consideration in order of importance and give a rationale.
A. Observe for s/s of aspiration
B. Turn and position every 2hr
C. Observe for s/s of fluid overload
D. Observe and record LOC every shift
C. Rationale - age and amt of fluid intact. Fluid overload can be critical
B. rationale - age and general condition. Even though client can move, doesn’t mean they will turn q 2 hr
D. Rationale - change in LOC with dementia could mean worsening of condition. LOC could be a cue to observe for other problems
A. Rationale - observe for s/s of aspiration (with PEG chance for aspirations is low)
How often should an irrigation set be changed?
Every 24 hrs
Nasogastric Tube
“Levine” tube
What things should be documented?
Procedure
Tolerance
Use of equipment
What is the Residual?
Feeding left over from the previous feeding that remains in the stomach
Intermittent feeding
- Pinch tube
- Attach prepared administration set
- Adjust flow via clamp to ordered rate
- Allow to empty over 30-60 min
- Don’t exceed 150-250mL at a time
- Usually 6-8 feedings/ day
- Flush with 30mL water
- Clamp or plug tube
- Rinse equipment
How often should continuous system bags be changed?
Every 24 hrs
Purpose of enteral feedings
- PCM- protein caloric malnutrition
- –if pt has a bed sore, protein plays an important role in the healing process - Anorexia - psychological and physiological
- Neurological conditions
- Burns (calories and protein)
- Chemotherapy
- Coma
**in elderly, the need for protein is often increased and enteral feeding can supply this in those with increased need for tissue repair (wounds, pressure sore, etc.)
Nasoenteric (NE)
Weighted or small feeding tube
Types of Formulas
Basic- Jevity and Ensure. For clients who have no specific needs or nutritional problems such as diabetes. The standard basic formula provides a calorie per ML
High protein formulas for clients with burns and malnutrition
Diabetic formulas such as Glucerna
High fiber formulas for clients who have chronic constipation and long term enteral feedings.
Checking for tube placement
X-ray is best and must be used for (NE) tubes when first inserted
Aspirate gastric contents and ck pH
Gastric pH 1-4
Lungs- pH >6
Gastric contents are brownish, tan, or greenish in color
Lung contents- clear, mucous, might be slightly blood tinged
Who orders when to check residuals and the amount required to hold a feeding?
The physician
Probiotic
beneficial bacteria that can be found in various foods
When you consume probiotics, you add these healthy bacteria to your intestinal tract.
Gelatin capsule
Aspirate with syringe or dissolve in warm water
Bolus feeding/open system and syringe
- Pinch tube- to keep air from getting into stomach
- Connect syringe
- Fill syringe with feeding
- Elevate 18 inches above stomach or insertion site
- Allow feeding to flow slowly (gravity)
- Can refill syringe until ordered feeding is complete
- Flush with 30mL water
- Clamp or plug tubing
- Keep HOB elevated for one hour
- Rinse syringe
- always ck electrolytes, BUN, glucose
- notify physician if pt starts having diarrhea after being on tube for 5-7 days
Potential complications
- Pulmonary aspirations- leads to pneumonia caused by not checking tube placement
- Constipation/ diarrhea
- Tube occlusion- flushing tube
- Tube displacement
- Abd. Cramping, N/V
- Delayed gastric emptying
- Electrolyte imbalance
- Fluid overload- ck for fluid overloading the first 24 hrs
- -ankle edema, aspiration, discomfort, increased respirations
What are symptoms of overfeeding or intolerance?
Fullness
Cramping
N/V
Diarrhea
Tablets
Crush pill- dissolve powder in 15-30mL warm water
Administering enteral feeding through gastric and enteric tubes
- Gather equipment
- Procedure
A. assess bowel sounds
*hypoactive bowel sounds may cause problems with tube
*contact physician with any abnormal abnormal bowel sounds
B. verify physicians order for formula, rate, and frequency
C. Wash hands
D. Prepare feeding
*room temp- do to take out of fridge and hang immediately bc it will cause cramping
E. Shake formula if required
F. Always ck expiration date - Elevate head of bed to 30-40 degrees
How often should weight and I&O be measured?
Daily
Administering meds through feeding tube
- Elevate HOB high Fowlers 70-80
- Ck placement / residual
- Insert syringe (50-60 mL)
- Flush with 20-30mL water
- Pour med into syringe
- Flush with 10mL of water between meds
- Follow the last med with 20-30mL water
- Have client maintain sitting position for 30min
Lumen
The central space within a tube shaped body part or organ, such as a blood vessel or the intestines
Prebiotic
non-digestible foods that make their way through our digestive system and help good bacteria grow and flourish.
help feed and keep beneficial bacteria healthy.
PEG complications
- Infection (most common- most infections are not life threatening and involve insertion site area. Keeping the area clean is the best preventive measure. If occurs, local and/or oral antibiotics)
* **serious complications occur in <1% patients - Perforation
- Hemorrhage (range from minor to serious)
- Leakage into the peritoneal cavity (very serious)
Enteric
Intestines
Administering medications through tubes
- Prepare med:
A. Assure med can be crushed!!!
B. Cannot administered sublingual, enteric-coated, or sustained release meds via feeding tubes
(obtain liquid for small feed (NE) tube)
C. Do not mix meds and feedings!!!
Nasogastric (NG)
Large and easily flushed
Becomes occluded less easily
Better for administering non liquid meds
Easier to insert by less skilled personnel
Easier to ck residuals
More comfortable for client
More likely to become misplaced after insertion
Best for very short term
Versatile- can be used for more than feedings
Percutaneous
medical procedure where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using an “open” approach where inner organs or tissue are exposed
Gravity and Pump
Gravity is less accurate
Pump reduces the chance of aspiration, diarrhea, and reflux
Provides a steady flow rate, and decreases chance of blockage
Gravity must be monitored more closely and flushed more frequently
Gravity method should not be used for specialized formulas such as high protein formula for burn victims, etc.
Gravity should not be used for continuous feedings. Intermittent only
What is the purpose of checking residuals?
Checking residuals or holding feedings if the residual is large ( usually 150mL or above) reduces aspiration and fluid overload.
Observe for ________ and S/S of ______
Edema
CHF
Gastric tube care
PEG (percutaneous endoscopic gastrostomy)
Purpose of checking?
If the residual is 150ml or above hold feeding. This reduces aspiration and fluid overload.
Note: the physician will order when to check residuals and the amount required to hold a feeling.
Capsules
Open and dissolve in 15-30 ml warm water
Gelatin capsules
Aspirated with a syringe or dissolve in warm water.
Document
Chart procedure, tolerance, and equipment used.
Care of PEG tube site (percutaneous endoscopic gastrostomy)
Cleanse with soap / water
Assess skin around tube site (infection or excoriation)
Rotate tube 360 degrees each day and check for in-and-out play of 1/4 inch.
May use small precut gauze at exit site if drainage is present
Usually clean, dry and NO gauze left around site.
As always, follow policy.
Types of tubes
PEG (Percutaneous Endoscopic Gastrostomy)
Nasogastric (NG) and referred to often as Levine tube.
Nasoenteric (NE) weighted or small feeding tube.
Observe for
Edema and s/s of CHF
Potential Complications
Pulmonary Aspiration #1 Diarrhea/constipation Tube occlusion Tube displacement Abd. Cramping, N/V Delayed gastric emptying Electrolyte imbalance Fluid overload
Pros and cons of nasogastric tube
Large and easily flushed. Better for administering non liquid meds. Doesn’t occlude easily.
Easier to insert by less skilled personnel.
Easier to check residual.
More comfortable for client.
Best for short term use.
Versatile - can be used for more than feedings.
Con - More likely to become misplaced after insertion.
Administering medication through tubes
Prepare medications:
Assure the meds can be crushed
Do Not mix medications and feedings!
Administering medications through feeding tube
Elevate the head of bed (high Fowler’s 70-80)
Check placement / residual
Insert syringe (use 50-60ml syringe)
Flush with 20-30 ml of water
Pour medication into syringe
Flush with 10ml of water between meds
Follow the last med with 20-30 ml of water
Have client maintain sitting position 1hr.
Monitor lab values
BUN, glucose, electrolytes
Purpose of Enteral feeding
In elderly the need for protein is often increased and enteral feeding can supply this in those with increased need for tissue repair.
( wounds, pressure sores, etc.)
Administering Enteral Feeding through Gastric and Enteric Tubes
Gather equipment
Non-sterile gloves And other PPE as needed Stethoscope Disposable pad or towel Feeding formula 60 ml syringe Asepto Alcohol pads pH paper Water for irrigation
Reflux
A return or backward flow
Points to remember! (Administering Meds)
Liquid meds only through a small feeding tube.
When disconnected or unplugged, tube should always be pinched off from air.
Why? To keep air out of the stomach.
When administering meds through a continuous feeding turn Pump Off, or On Hold, while administering meds.
Always check placement before administering meds through a tube.
Flush with 30 ml water before and after med. 10 ml between each med. Each med SHOULD be given separately.
Gravity vs pump
Gravity is less accurate.
Must be monitored more closely and flushed more frequently.
Gravity method should not be used for specialized formulas such as high protein formulas for burn victims.
Gravity should not be used for continuous feedings. Intermittent only.
Percutaneous
Effected through the skin; describes the application of a medicated ointment by friction, or the removal or infection of a fluid by needle.
PEG Complications
Infection (Most common-most infections are not life threatening and involve insertion site area. Keeping the area clean is the best preventive measure. If occurs, local and/or oral antibiotics).
When to check residuals
Prior to beginning a new feeding and before each feeding, or follow policy.
Tablets
Crush pill
Dissolve powder in 15-30ml warm water.
Probiotic
Having favorable or health-promoting effect on living cells and tissues.
(Lactobacillus acidophilus present in the gastrointestinal tract is probiotic because its presence inhibits the growth of harmful bacteria such as Salmonella and Listeria.
Prebiotic
A nutrient that stimulates the growth or health of bacteria living in the large intestine.
(Prebiotics are typically neither absorbed nor digested by the mammalian gastrointestinal tract.
Their effects on human health occur indirectly, through their promotion of commensal organisms in the colon.)
Checking for tube placement
X-ray is best and must be used for NE tube when first inserted.
Aspirated gastric contents and check pH.
Intermittent feeding
Pinch tube Attach prepared administration set Adjust flow via clamp to ordered rate Allow to empty over 30-60 minutes Don't exceed 150-250 ml at a time Usually 6-8 feelings/day Flush with 30 ml water Clamp or plug tube Rinse equipment
Lumen
The space within an artery, vein, intestine, or tube.
Pros and cons of nasoenteric tube.
Small and more comfortable for patient.
Less likely to become dislodged and cause aspiration.
Better for long term therapy.
Cons
More likely to become occluded.
Only liquid meds - no crushed or powdered meds.
Must be x-ray verified on initial insertion.
Serious complications
Occur in less than 1% of patients.
Perforation
Hemorrhage can range from minor to serious)
Leakage into the peritoneal cavity (VERY SERIOUS)
Note if your patient complains of abdominal pain and starts looking bloated and may have a fever. Start to suspect leakage
Pt. will become septic very quickly if leakage is occurring. This applies mostly to patients with new peg, but can occur to existing peg patient.
Daily
Weight, intake and output
High fiber formulas
For clients who have chronic constipation and long term enteral feedings.
Gastric pH and contents
pH = 1 - 4
Contents are brownish, tan or greenish in color.
Gastric
Pertaining to the stomach
Basic formulas
Like Jevity and Ensure
Are for clients who have no specific needs or nutritional problems such as diabetes.
The standard basic formula provides about a calorie per mL.
Pump
Pump reduces the chance of aspiration, diarrhea and reflux.
Provides a steady flow rate and decreases chance of blockage.
Purpose of Enteral feeding
PCM - protein calorie malnutrition Anorexia Neurological conditions Burns (calories & protein) Chemotherapy Coma
Check for symptoms
Of overfeeding
Intolerance
(Fullness, cramping, N/V, diarrhea)
Prepare feeding
Needs to be at or about room temperature. Not cold, if cold can cause abdominal cramping.
Shake formula (if required)
Check expiration date.
Elevate head of bed at least 30 - 40 degrees.
Bolus feeding / Open System and Syringe
Pinch tube Connect syringe Fill syringe with feeding Elevate 18 inches (above stomach or insertion site) Allow feeding to flow slowly (gravity) Can refill syringe until ordered feeding complete Flush with 30 ml of water Clamp or plug tube Keep HOB elevated 1 hr Rinse syringe
Procedure
Verify physician’s order for formula, rate and frequency
Assess bowel sounds
Wash hands
Put on gloves.
Lung pH and contents
pH > 6
Contents clear, mucous, might be slightly blood tinged.
Enteric
Pertaining to the small intestines
High protein formulas
For clients with burns and malnutrition.
CANNOT ADMINISTER via FEEDING TUBE
(Obtain liquid for small feed(NE) Tube.
Sublingual, enteric-coated or sustained release medications
Diabetic formulas
Glucerna
Continuous system bags
Change every 24 hours
Irrigate set every 24 hours.
Residuals
Is the feeding left over from previous feeding that remains in stomach.
