Lab 4 Flashcards
what is enteral nutrition
- nutrients given via the GI tract
why is enteral nutrition used?
- when the patient cannot ingest food thru their mouth
- but they are still able to digest & absorb nutrients
what is a nasogastric or nasointestinal tube
- feeding tube inserted thru the nose into the stomach or intestine
what is an orogastric or orointestinal tube
= feeding tube inserted thru the mouth into the stomach or intestine
what is a gastrostomy
- feeding tube surgically placed thru a stoma into the stomach
what is a jejunostomy
- feed tube placed thru a stoma into the jejunum
what is a stoma
- surgically created opening
list some indications for enteral nutrition
- cancer
- critical illness or trauma
- neuro or muscular disorders
- GI disorders
- other
what types of cancer indicate enteral feeding
- head & neck
- upper GI tract
list some examples of critical illnesses or trauma that indicates enteral feeding
- resp failure with prolonged intubation or inadequate oral intake
- pts in critical care with suspected/evidence of catabolism
- trauma patients, espeically with hypermetabolic state (ex. burns)
what are some examples of neuro or muscular disorders that indicate enteral feeding(5)
- stroke
- brain neoplasm
- cerebrovascular accidents
- neuromuscular disorders (ex. parkinsons, MS)
- dementia
what are some examples of GI disorders that indicate enteral feeding (3)
- enterocutaneous fistula
- inflammatory bowel disease
- mild pancreatitis
what are some examples of other situations that indicate enteral feeding (5)
- inadequate oral intake
- continuous feedings
- anorexia nervosa
- difficulty chewing or swallowing
- severe depression
what is a large-bore (diameter) sump tubing nasogastric tube used for>
-both decompression and short-term enteral feeding
what is small bore, silastic tubing with an insertion stylet used for
- longer-term feeding
why are small bore nasogastric or nasojejunal tubes preferred over large-bore tubes?
- reduce patient discomfort & gastric erosion
- can be used over long periods
why might a large tube be used first and then switched to a small?
- might be used to start the tube feed, and if the patient tolerates it for the first 24-48 hrs, a small-bore tube is then inserted
why might the physician choose to leave both the small bore tube & the large bore sump in at the same time?
- for gastric decompression
- to prevent vomitting & aspiration
what period of time are nasoenteral tubes used for?
- less than 6 weeks
what kind of tubes are preferred for long term feeding (>4 weeks)? why?
- surgical or endoscopically placed tubes
- to reduce the discomfort of a nasal tube and provide more secure, reliable access
what is gastroparesis
- decreased or absent innervation to the stomach, causing decreased gastric emptying
pts with gastroparesis, esophageal refluc, risk of aspiration, and history of aspiration pneumonia, require…
- placement of tubes beyond the stomach into the intestine
who inserts the nasoenteral tube and can administer enteral feedings?
- the nurse can insert
- nurse & others (including family in a home setting) can administer
how can tube placement be verified? when should it be verified?
- via Xray examination
- BEFORE the pt received their first enteral feeding
what is paralytic ileus
- obstruction of the intestine due to cessation of peristalsis
- no peristalsis = prevents passage of food = blockage of the intestine
gastric ileus may prevent _____? how do we work around this?
- may prevent nasogastric feedings
- nasointestinal or jejunostomy tubes allow successful pyloric feeding of formula directly into the small intestine, jejunum, or beyond the pyloric sphincter of the stomach
what are the 3 parts of the small intestine
- duodenom (first part
- jejunum
- ileum
what is the pyloric sphincter
- band of smooth muscle around the junction where the pylorus (end of) of the stomach and the duodenom meet
enteral feedings can be administered thru a … (3)
- nasoenteric tube
- gastrostomy
- jejunostomy
tube feedings are typically started…
- at full strength at slow rates
when does the hourly rate increase?
- every 12-24 if there are no signs of intolerance
what are some signs of intolerance (4) to tube feeding
- nausea
- cramping
- vomitting
- diarrhea
what is a serious complication of enteral feeding
- aspiration of enteral feeding into the tracheobronchial tree
what does aspiration of enteral feeding into the lungs cause?
- irritates the bronchial mucosa = decreased blood supply to affected pulmonary tissue
- this leads to necrotizing infection, pneumonia, and potential abcess formation
what does the high glucose content of formulas promote?
- serves as a bacterial growth medium = promote infection
what else is frequently associated w pulmonary aspiration?
- adult respiratory distress syndrome
list common conditions that increase the risk of aspiration (5)
- coughing
- nasotracheal suctioning
- an artificial airway
- decreased LOC
- lying flat during & after feeding
how long is small-bore feeding tube for adults
- 8-12 Fr
- 91-109 cm long
what is a stylet? what is it’s purpose?
- used during insertion of a small bore tube
- is removed once the tube is in the right place
what are 2 different ways to verify that a feeding tube is in the right place
- xray = most reliable
- measure the pH of secretions aspirated from the tube
list GI complications of enteral feeding
see table 42-9 for details on cause, intervention, etc. for all complications
- diarrhea
- constipation
- abdominal cramping
- NV
list complications r/t the tube
- tube occlusion (blockage)
- tube displacement
list complications r/t imbalances
- fluid overload
- hyperosmolar dehydration
- serum electrolyte imbalance
list a gastric complication associated with eneteral feeding
- delayed gastric emptying
what are severely malnourished patients at a risk for?
- developing refeeding syndrome
what is refeeding syndrome
- metabolic disturbances that occur as a result of reinstituting nutrition
what should you assess/complete before administering enteral feedings via gastrostomy or jejunostomy
- need for enteral feeding
- baseline weight
- baseline lab values
- verify physicians order
- hand hygeine & gloves
- explain procedure to pt
list some things that may indicate need for enteral feeding (3)
- difficulty swallowing
- decreased LOC
- surgical procedures involving the upper GI tract
what should you specifically verify in the physicians order before administering enteral feeding (4)
- formula
- rate
- route
- frequency
what needs to be auscultated before feeding? what would indicate need to consult the physician
- bowel sounds
- if they are absent
what should you assess before feeing
- gastrostomy or jejunostomy site for breakdown, irritation, drainage
describe how to prepare the feeding container to administer formula (4)
- have tube feeding at room temp
- connect tubing to container as needed or prepare ready-to-hang bag
- shake formula well
- fill contain and tubing with formula
what should you do to prep for intermittent feeding?
- have syringe ready
- ensure formula is at room temp
what angle should the HOB be at for enteral feeding
30-45*
what need to be done before initiating food tubing
- verify tube placement
describe how to verify the tube placement for a gastrostomy tube
- attach syringe & aspirate gastric secretion
- measure?
what should you assess after aspirating GI content?
- observe the appearance (color)
- measure pH
- GRV
what should the pH of GI contents be? what about for intestinal? for someone who has continious tube feeding?
- gastric = 0-5
- intestinal = higher than 6
- continuous = 5 or higher
why is gastric residual volume important?
- indicates if gastric emptying is delayed
what GRV volume indicated delayed gastric emptying?
- > 200 mL ( may vary based on age)
what do you do if the GRV is less than 200 mL
- return the aspirated contents to the stomach
describe how to verify tube placement for a jejunostomy
- aspirate intestinal secretions
- observe appearance
- check pH
what do you flush the tube with and how much?
- 30 mL room temp tap water
describe how to initiate a syringe feeding
- pinch proximal end of gastrostomy or jejunostomy tube
- remove plunger& attach barrel end of syringe to end of tube
- fill syringe with formula
- release tube & elevate syringe
- allow syringe to emoty gradually by gravity
- refill until prescribed amount has been deliveru
describe how to initiate a continuous drip feeding
- verify that volume in container is sufficiency for length of feeding (4-8 hrs)
- hang container on iv pole
- clear tubing of air
- thread tubing into pump according to manufacturs instructions
- connect tubing end to gastrostomy or jejunostomy tube
- begin infusion @ prescribed rate
when should we flush the tube with water and how much?
flush tube with water:
- every 4-6 hours
- and before & after administering meds via feeding tube
why is water administered via feeding tube with or between feedings?
- helps maintain fluid & electrolyte balance
what doe continuous feeding reduce the risk of
- diarrhea
- abdominal discomfort
patients who receieve continuous drip feedings should have their GRV & tube placement checked how often?
- every 4-6 hr
why do we hang the container for continuous drip feeding?
- allows for gravity-based flow = prevents accumulation of air in their stomach
what should you do when tube feedings are not being administered?
- cap or clamp the proximal end of the tube
describe care for the container and tubing after all intermittent feedings; why do we do this?
- must be rinsed w water
- to reduce bacterial growth in the container & tubing
how often should the container & tubing be replaced?
- every 24 hrs
what should be done post initiation of feeding?
- assess skin around tube exit site
- dispose of supplies
- hand hygeine
- evaluate tolerance to tube feeding
- measure amount of aspirate every 8-12 hr
- monitor BG
- monitor intake & output, weights
- observe lab values
- inspect stoma site
how often/long do you monitor bg
- every 6 hr until max admin rate has been reached & maintained for 24 hrs
how long/often should you measure the pt’s I+Os and daily weight
- I&O: every 24 hrs
- weight daily until max admin rate is reached & maintained for 24 hours, then 3 times/week
describe the care of skin around the exit site
- before it has healed, clean with NS –> small precut gauze may be applied to exit site & secured w tape
- clean daily w warm water & mild soap once the site has healed
- assess dressing for drainage, and change daily/as needed
- fully healed tubing exit site is left open to air
if a patient has receievd nasogastric tube feedings before tube insertion & then undergoes a procedure, how long is the tube not to be used after the procedure?
4-6 hr
describe the patient’s eating status the night before the procedure
- NPO
provide a summary of how to administer enteral feedings via gastrostomy or jujenostomy tube
- assess need, baseline weight, lab values
- verify order
- hand hygeine
- explain procedure to pt
- auscultate bowel sounds
- assess site
- hand hygeine & gloves
- prepare feeding containe
- elevate HOB to 30-45*
- verify tube placement
- flush tube with 30 mL water
- initiate feedings
- flush tube w water every 4-6 hr, before, after, and between feedings
- rinse container & tubing
- assess skin
- evaluate response, BG, I&O, weight, lab values, skin
describe steps for med admin via a gastrostomy tube or small-bore feeding tube prior to initiation
- verify order
- investigate and if possible, use alternative route of med admin
- prep med & do your med checks
- determine if med must be given on empty stomach or if it is compatible with enteral feeding
- hand hygeine
- identify patient
- explain procedure & meds to pt
- verify tube placement
- assess gastric residual
what type of meds do you avoid giving via gastrostomy or small bore feeding tube
- avoid med regimens that frequently interrupt enteral feedings
- avoid if have pH less than 4
- do not give whole or undissolved meds
- do not mix meds
describe steps to initiate administration of meds via gastrostomy or small bore feeding tube
- draw med in syringe
- connect syrige to tube ( do not use pigtail vent)
- administer med by push the med thru the tube by pressing the plunger or allow it to flow freely using gravity
- administer each med seperately & flush between each
- after giving all meds, flush again w water
how much water do you flush with between meds
- 15-30
describe the stops post-med administration via gastrostomy or small bore feeding tube
- remove gloves
- hand hygeine
- document
- evaluate response to meds
define ileus
- obstruction of the ileum or other part of the intestine
define peritoneum
- the serous membrane lining the abdominal cavity
what kind of disorders may result in the need for a stoma?
- certain diseases that cause conditions that prevent the normal passage of feces thru the rectum
what is a stoma
- temporary or permanent artificial opening in the abdominal wall
- the ends of the intestine are brought thru the abdominal wall to create the stoma
what is an ileostomy
- a surgical opening into the ilieum (3rd part of the small intestine)
what is a colonostomy
- a sugrical opening into the colon
what determines the consistency of stool?
- the location of the stoma
describe the consistency of an ileostomy; why does this happen?
- bypasses the entire large intestine = liquidy & frequent stools
list the parts of the large intestine from beginning to end
- ascending
- transverse
- descending
- sigmoid
describe the consistency of stool for a colonostomy of the ascending colon
- liquid & frequent
describe the stool of a colostomy of the transvers colon
- more solid & formed stool
describe the stool for a colostomy of the descending & sigmoid colon
- near normal stool
what determines the location of a colostomy
- the medical problem
- the pt’s general condition
what are the 3 types of colostomy construction
- loop
- end
- double-barrell
what is a loop colostomy
- temporary large stomas constructed in the transverse colon
when is a loop colostomy performed
- in a medical emergency when closure of the colostomy is anticipated
describe how a loop colostomy is constructed
- surgery pulls a loop of bowel onto the abdomen
- it has 2 openings thru one stoma: the proximal for stool & distal for mucus
what is a end colostomy
- one stoma formed from one end of the bowel with the distal portion of the GI tract removed or sewn
when might an end colostomy be used
- often a result of surgical treatment for colorectak cancer
- pts with diverticulitis who are treated surgically
what is a double barrel ostomy
- when the bowel is surgically severed and the 2 ends are brought out onto the abdomen
how many stomas does a double barrel colostomy have? what is the purpose of each?
- 2
- proximal functioning stoma
- distal nonfunctioning stoma
what is a kock continent ileostomy
- created using the patient’s small intestine as a pouch
when is a kock continent ileostomy used?
- in the treatment of ulcerative colitis
describe how a kock continent ileostomy works
- has a continent stoma with a nipple-type valve that is drained with an external catheter
- pt places the external catheter intermittently in the stoma & empties the pouch several times a day
how is the kock continent ileostomy protected
- with a protective dressing or stoma cap
when is an ascending colostomy done?
- for right-sided tumours
when is the double barrelled colostomy used
- emergencies such as intestinal obstruction or perforation bc it can be created quickly
define peristomal
skin around the stoma
define effluent
- the stool discharged from the ostomy
how is the effluent collected
- pt must wear a pouch or appliance to collect it from the stoma
why is skin care so important for pts with ostomies
- to prevent liquid stool from irritating the skin around the stoma
how often is irrigating a colostomy done? when in particular is it done?
- not as common as it once was
- pts with a left-sided colostomy may be instructed to irrigate to regulate their colon emptying
what is used to irrigate a colostomy? why?
- a special cone-tipped irrigator
- prevents bowel penetration & backflow of irrigating solution
what should never be used to irrigate a colostomy
- an enema set
describe how irrigation is usually done
- pt sits on the toilet & places an irrigating sleeve over the stoma (other end goes into the toilet bowl)
- the solution is instilled slowly thru the lubricated cone tip
- pt then removes the cone tip
- pt waits 30-45 min for the solution and feces to drain out of the irrigation sleeve
- once it stops, apply stoma cap or pouch
what determines how much and the type of solution to irrigate with
- the physical
for adults, what is the typical amt of solution used to irrigate
500-700 mL
how long should irrigation take
5-10 min
if a pt chooses to irrigate their colostomy, how often is it done
- timing is individualized to match the pt’s lifestyle
describe the characteristics of an effective pouching system
- protects the skin
- contains fecal material
- remains odour free
- comfortable
- inconspicuous
list factors that play a role in the fit of the pouch
- location of the ostomy
- type & size of stoma
- amount & consistency of effluent
- size & contour of the abdomen
- condition of skin around the stoma
- skin sensitivities or allergies
- their physical activity
- cognitive ability for learning
- pt’s preference, age, and dexteruty
- cost of equipment
define enterostoma; therapist
- a nurse trained to care for wound & ostomy management
a pouching system consists of…
- a pouch
- and skin barrier
what different ways do pouches come in
- one or two piece systems
- disposable or reusable
- precut or not
list different types of skin barriers for pouching systems
- wafers
- pastes
- powders
- liquid film
what are wafer skin barriers
- one piece pouch systems permanently attached to the ostomy pouch
describe how a 2-piece pouching system works
- pouch can be detached from the skin barrier for emptying or changing
what does a 2-piece pouching system allow?
- the skin barrier to remain around the stoma for several days
= minimize chance of skin damage from too frequent removal
what is an important thing to consider when using a 2-piece pouching system
- skin barrier & pouch must be the same size & from the same manufacturer
a good skin barrier….
- protects the skin
- prevent irritation from repeated removal of the pouch
- comfortable for the pt to wear
see textbook for steps to pouch an ostomy (way too long for flashcards)
…
describe when enteral vs parental feeding is done
- enteral = if oral intake is inadequate or contraindicated but the GI tract is at least partially functioning
- parental = if gut is nonfunctioning or inaccessible
when is enteral nutrition indicated
- if the pt is unable or unsafe to orally maintain/improve nutritional status
what nutritional statuses indicate enteral eating
- protein calorie malnutrition (PCM)
or risk of PCM with inadequate oral intake (>2-5) - normal nutritional status with prolonged inadequate oral intake (>7-10)
list some contraindications to enteral feeding
- perforation of the GI tract
- GI ischemia
- complete mechanical bowel obstruction
- complete non-mechanical bowel obstruction
- high output enterocutaneous fistula involving proximal small bowel
- inability to access GI tract
what determines route of enteral feeding
- condition of the GI tract
- anticipated duration
for what duration can nasoenteral tubes be used for? enterostomy (gastro & jejuno)?
<6 weeks = naso
- enterostomy = >6 week
what is PEG
percutaneous endoscopic gastrostomy
- uses an endoscope to ensure correct positioning of the gastrostomy
- eventually replaced w a balloon tube
describe how to initially verify the correct placement of enteral tubes
- xray
describe how to verify that the tube is in the correct place with each ongoing verification
- measure external length
- observe aspirate
- pH
ph measurment of aspirated contents is only valid if… ? when is it invalid?
- valid if stomach has been empty for 4-6 h
- invalid if antiacids have been used
what do you do if displacement of the tube is suspected
- hold tube feedings
- consult physician
- in most cases, an abdominal xray must be done
what are the benefits of low profile devices for enteral feeding
- cosmetically appealing to patients
- may be beneficial to children or confused adults who tend to pull at the tube
- may decrease the likelihood of pyloric obstruction from inward migration of the tube
what is the usual volume delivery for continuous administration
- 25-150 mL/hr over 12-24 hrs
what is the usual volume of admin for intermittent
- 235-500 mL over 30-90 min several times/day
what is the usual volume & duration of admin for bolus
- 200-500 ml over <15 min several times/day
how is continuous, intermittent, and bolus delivered?
- continous = pump
- intermittent = pump or gravity
- bolus = syringe
what is the only method of admin used for small bowel feeds
- continuous
describe the risk of aspiration for continuous, intermittent, and bolus
- continuous = low
- intermittent = higher
- bolus = highest
