GI and Nutrition Flashcards
3 Phases of Swallowing
- Oral
- Pharyngeal (throat, epiglottis)
- Esophageal (through bolus to stomach)
Dysphagia
impairment in any stage of the swallowing process
often caused by neurological disease such as stroke
Altered nutritional intake affects
- poorer healing
- higher risk of dehydration and constipation
- higher risk of pressure ulcer
Possible symptoms of dysphagia and aspiration
- coughing during meals
- hoarse voice following meals
- drooling
- upper respiratory infection
- pneumonia
Symptoms of aspiration pneumonia
- fever
- crackles (fine or hoarse)
- lower lobe sounds in the lower back
- consolidation in the lungs (dullness during percussion)
- chest asymmetry
Safety during feeding
- positioning, 90 degrees
- flex neck for ‘chin-down’
- avoid rushing
- alternate solid & liquid boluses
- place food in stronger side of mouth
- alter food viscosity
- minimize use of sedatives and hypnotics
- minimize distraction
- adaptive equipment
- oral hygiene
Does NPO patient need oral care?
Yes, saliva can aspirate into lungs and cause pneumonia
Safety AFTER eating
- remain upright, 90 degrees
- check for pocketing of food
- note and document intake
- note food preference
- note foods that client has difficulty with
- oral hygiene
Therapeutic or Mechanically altered diets
- regular
- soft diet
- pureed/minced diet
- full liquid, clear liquid
- low sodium
- no sodium
- high protein
- heart health diet (no salt, fruits and veggies)
What are diet habits affected by?
SES
food security
personal practice
Thickened fluids
Nectar-like (peach juice)
- slightly thicker than water
Honey-like
Pudding-like
Enteral Nutrition
Nutrients provided through the GI tract distal to the oral cavity via a tube, catheter or stoma
- also called gavage or enteral tube feeding
Indications for enteral nutrition
Unable to ingest food but can still digest and absorb nutrients
- severe swallowing deficit
- altered LOC
Enteral Access Tubes - Nasal or oral insertion
a. Nasogastric tube
- Levin or Salem sump
b. Nasogastric or nasointestinal tube
- small bore feeding tube
- Keofeed or Dobbhoff
c. Orogastric or orintestinal
- small bore feeding tube
- Keofeed or Dobbhoff
Enteral Access Tubes - Surgical insertion
a. gastrostomy (g-tube)
b. jejunostomy (j-tube)
surgically implanted in the OR
Enteral Access Tubes - Endoscopic insertion
a. PEG (percutaneous endoscopic gastrostomy)
b. PEJ (percutaneous endoscopic jejunostomy)
put in endoscopically, interventional radiology
Insertion of NG tube
From tip of the nose to ear lobe to top of xiphoid process
- if not inserted enough, risk of aspiration
- not sterile
- drinking water can assist the process
- flushing to prevent blockage
Verifying Tube Placement
should be assess when first inserted and before initiating any food, water or meds
Radiographic assessment (gold standard)
pH testing of gastric aspirate
(pH lower than 5 = gastric, pH higher than 5 ~ intestinal or respiratory)
Capnography - detect expired CO2 (attach device to end of tube to detect CO2)
Note respiratory distress (not reliable)
NG tube care
- avoid laying flat, at least 30 degrees
- hold feed when bathing or dressing change
- tape to anchor tube
- skin integrity
- flush (before and after med admin)
- use liquid form if available
- capsule meds are usually long acting and could clog up the tube
Administering Enteral Feeding
a. Continuous
b. Intermittent
- syringe, careful not to use a small syringe to give too much force
c. Bolus
- needs to be worked up
- community or home setting
Complications of Enteral Feeding
a. aspiration
b. delayed gastric emptying
c. diarrhea
d. constipation
e. occlusion of tube
Feeding (gavage)
Installation of liquid nutritional supplements or feedings into the stomach for clients unable to ingest food orally
Decompression
Removal of secretions and gaseous substances from the GI tract to prevent or relieve abdominal distension
- Salem sump, Levin
- tube drains by gravity or suction
Lavage
Irrigation of the stomach in cases of active bleeding, poisoning or gastric dilation
Compression (rare)
put pressure on the GI tract to stop bleeding (esophageal varices)
Stay Connected
a global design standard for tubing connectors to reduce incidence of medical device tubing misconnections
- ensure IV tubes can’t be connected to gastric tubes
Parenteral Nutrition
Nutrient through vascular access (central venous catheter CVC or central venous access device CVAD)
- not through peripheral lines at
- highly sterile procedure
IV infusion of highly concentrated solutions
Indications for Parenteral Nutrition
- non-functional GI tract
- extended bowel resting
- preoperative TPN (total parenteral nutrition)
Complications of Parenteral Nutrition
- infection
- air embolism
- catheter occlusion
- sepsis
- electrolyte imbalance
- hyper or hypoglycemia
- pneumothorax (air leak causing collapsed lung)
- refeeding syndrome (not absorbing well, in and out of cell space)
Assessment of Elimination Patterns
a. nursing history
b. physical exam
c. lab tests
- stool for culture & sensitivity
- stool for ova and parasite
- stool for guaiac - if blood in stool (Fecal Occult Blood Test)
d. fecal characteristics (soft, formed, hard, brown)
Diagnostic Exams
Direct visualization
- endoscopy
Indirect visualization
- barium swallow or enema
- xray
- ultrasound imaging
Constipation
Decrease in frequency of BM accompanied by difficult passage of dry hard stool
Symptoms: cramping, bloating, gas accumulation, pain
Causes: narcotics, dehydration, immobility
Fecal Impaction
Collection of hardened feces in the rectum
Symptoms: inability to pass stool despite urge to defecate, oozing of diarrheal stool, loss of appetite, abdo distention with cramping, rectal pain
Diarrhea
Increase in number of stools and the passage of liquid, unformed feces
Causes: medications, new tube feeding
Complications of diarrhea
C difficile
- distinct odour
- certain antibiotics lead to disruption of normal flora, creating colonization by c. difficile, release of toxins that damage mucosa and cause inflammation
Nursing care for diarrhea
especially if new onset and was on antibiotics
- rehydrate and correct electrolyte imbalance
- administer antidiarrheal meds
- take additional precautions (isolation, PPE)
- obtain stool sample if indicated
Fecal incontinence
Inability to control the passage of feces and gas from the anus
- implications for social isolation
- beware of skin breakdown
Flatulence
Accumulation of flatus (gas) in the lumen of the intestines causing bowel wall to stretch and distend
- can cause belching (burping)
Symptoms: abdominal fullness, pain and cramping
Hemorrhoids
Dilated, engorged veins in the lining of the rectum (may be internal or external)
Promoting Defecation
- privacy
- positioning
- nutrition (high fiber and liquid intake)
- regular exercise
- bowel retraining
Suppositories
glycerin
- soften stools to help it pass more easily
Enemas
Instillation of a solution into the rectum and sigmoid colon which promotes peristalsis
Volume instilled breaks up the fecal mass, stretches rectal wall and initiates defecation reflex
Types of enema
a. cleansing enema
Tap water (hypotonic - can cause excess fluid absorption)
NS (isotonic - safest)
Hypertonic (fleet enema, contains phosphate)
Soapsuds (castile soap)
b. oil retention
lubricates rectum and colon and soften feces
c. carminative enema
provide relief from gaseous distension
d. medicated enema
Administering an enema
- sims position
- place waterproof pad under buttocks, bed pan
- insert rectal tube
adult: 7.5-10 cm
child: 5-7.5 cm
infant: 2.5-3.75 cm - instill solution slowly
adult: 750-100 ml
adolescent: 500-750 ml
school aged: 300-500 ml
toddler: 250-350 ml
infant: 50-250 ml
Digital removal of stool
- last resort
- removal of fecal impaction
- vitals before and after procedure
- observe for bradycardia (monitor for 1 hour)
- can cause irritation to mucosa, bleeding, perforation of bowel wall and stimulation of vagus nerve
Bowel diversions
creation of an artificial opening (stoma) through the abdominal wall
- ileostomy: surgical opening in the ileum
- colostomy: surgical opening in the colon
location determines consistency of stool
