Lab 4 Flashcards

1
Q

what is enteral nutrition

A
  • nutrients given via the GI tract
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2
Q

why is enteral nutrition used?

A
  • when the patient cannot ingest food thru their mouth

- but they are still able to digest & absorb nutrients

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3
Q

what is a nasogastric or nasointestinal tube

A
  • feeding tube inserted thru the nose into the stomach or intestine
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4
Q

what is an orogastric or orointestinal tube

A

= feeding tube inserted thru the mouth into the stomach or intestine

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5
Q

what is a gastrostomy

A
  • feeding tube surgically placed thru a stoma into the stomach
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6
Q

what is a jejunostomy

A
  • feed tube placed thru a stoma into the jejunum
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7
Q

what is a stoma

A
  • surgically created opening
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8
Q

list some indications for enteral nutrition

A
  • cancer
  • critical illness or trauma
  • neuro or muscular disorders
  • GI disorders
  • other
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9
Q

what types of cancer indicate enteral feeding

A
  • head & neck

- upper GI tract

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10
Q

list some examples of critical illnesses or trauma that indicates enteral feeding

A
  • 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)
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11
Q

what are some examples of neuro or muscular disorders that indicate enteral feeding(5)

A
  • stroke
  • brain neoplasm
  • cerebrovascular accidents
  • neuromuscular disorders (ex. parkinsons, MS)
  • dementia
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12
Q

what are some examples of GI disorders that indicate enteral feeding (3)

A
  • enterocutaneous fistula
  • inflammatory bowel disease
  • mild pancreatitis
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13
Q

what are some examples of other situations that indicate enteral feeding (5)

A
  • inadequate oral intake
  • continuous feedings
  • anorexia nervosa
  • difficulty chewing or swallowing
  • severe depression
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14
Q

what is a large-bore (diameter) sump tubing nasogastric tube used for>

A

-both decompression and short-term enteral feeding

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15
Q

what is small bore, silastic tubing with an insertion stylet used for

A
  • longer-term feeding
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16
Q

why are small bore nasogastric or nasojejunal tubes preferred over large-bore tubes?

A
  • reduce patient discomfort & gastric erosion

- can be used over long periods

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17
Q

why might a large tube be used first and then switched to a small?

A
  • 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
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18
Q

why might the physician choose to leave both the small bore tube & the large bore sump in at the same time?

A
  • for gastric decompression

- to prevent vomitting & aspiration

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19
Q

what period of time are nasoenteral tubes used for?

A
  • less than 6 weeks
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20
Q

what kind of tubes are preferred for long term feeding (>4 weeks)? why?

A
  • surgical or endoscopically placed tubes

- to reduce the discomfort of a nasal tube and provide more secure, reliable access

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21
Q

what is gastroparesis

A
  • decreased or absent innervation to the stomach, causing decreased gastric emptying
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22
Q

pts with gastroparesis, esophageal refluc, risk of aspiration, and history of aspiration pneumonia, require…

A
  • placement of tubes beyond the stomach into the intestine
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23
Q

who inserts the nasoenteral tube and can administer enteral feedings?

A
  • the nurse can insert

- nurse & others (including family in a home setting) can administer

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24
Q

how can tube placement be verified? when should it be verified?

A
  • via Xray examination

- BEFORE the pt received their first enteral feeding

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25
what is paralytic ileus
- obstruction of the intestine due to cessation of peristalsis - no peristalsis = prevents passage of food = blockage of the intestine
26
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
27
what are the 3 parts of the small intestine
- duodenom (first part - jejunum - ileum
28
what is the pyloric sphincter
- band of smooth muscle around the junction where the pylorus (end of) of the stomach and the duodenom meet
29
enteral feedings can be administered thru a ... (3)
- nasoenteric tube - gastrostomy - jejunostomy
30
tube feedings are typically started...
- at full strength at slow rates
31
when does the hourly rate increase?
- every 12-24 if there are no signs of intolerance
32
what are some signs of intolerance (4) to tube feeding
- nausea - cramping - vomitting - diarrhea
33
what is a serious complication of enteral feeding
- aspiration of enteral feeding into the tracheobronchial tree
34
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
35
what does the high glucose content of formulas promote?
- serves as a bacterial growth medium = promote infection
36
what else is frequently associated w pulmonary aspiration?
- adult respiratory distress syndrome
37
list common conditions that increase the risk of aspiration (5)
- coughing - nasotracheal suctioning - an artificial airway - decreased LOC - lying flat during & after feeding
38
how long is small-bore feeding tube for adults
- 8-12 Fr | - 91-109 cm long
39
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
40
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
41
list GI complications of enteral feeding see table 42-9 for details on cause, intervention, etc. for all complications
- diarrhea - constipation - abdominal cramping - NV
42
list complications r/t the tube
- tube occlusion (blockage) | - tube displacement
43
list complications r/t imbalances
- fluid overload - hyperosmolar dehydration - serum electrolyte imbalance
44
list a gastric complication associated with eneteral feeding
- delayed gastric emptying
45
what are severely malnourished patients at a risk for?
- developing refeeding syndrome
46
what is refeeding syndrome
- metabolic disturbances that occur as a result of reinstituting nutrition
47
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
48
list some things that may indicate need for enteral feeding (3)
- difficulty swallowing - decreased LOC - surgical procedures involving the upper GI tract
49
what should you specifically verify in the physicians order before administering enteral feeding (4)
- formula - rate - route - frequency
50
what needs to be auscultated before feeding? what would indicate need to consult the physician
- bowel sounds | - if they are absent
51
what should you assess before feeing
- gastrostomy or jejunostomy site for breakdown, irritation, drainage
52
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
53
what should you do to prep for intermittent feeding?
- have syringe ready | - ensure formula is at room temp
54
what angle should the HOB be at for enteral feeding
30-45*
55
what need to be done before initiating food tubing
- verify tube placement
56
describe how to verify the tube placement for a gastrostomy tube
- attach syringe & aspirate gastric secretion | - measure?
57
what should you assess after aspirating GI content?
- observe the appearance (color) - measure pH - GRV
58
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
59
why is gastric residual volume important?
- indicates if gastric emptying is delayed
60
what GRV volume indicated delayed gastric emptying?
- >200 mL ( may vary based on age)
61
what do you do if the GRV is less than 200 mL
- return the aspirated contents to the stomach
62
describe how to verify tube placement for a jejunostomy
- aspirate intestinal secretions - observe appearance - check pH
63
what do you flush the tube with and how much?
- 30 mL room temp tap water
64
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
65
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
66
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
67
why is water administered via feeding tube with or between feedings?
- helps maintain fluid & electrolyte balance
68
what doe continuous feeding reduce the risk of
- diarrhea | - abdominal discomfort
69
patients who receieve continuous drip feedings should have their GRV & tube placement checked how often?
- every 4-6 hr
70
why do we hang the container for continuous drip feeding?
- allows for gravity-based flow = prevents accumulation of air in their stomach
71
what should you do when tube feedings are not being administered?
- cap or clamp the proximal end of the tube
72
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
73
how often should the container & tubing be replaced?
- every 24 hrs
74
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
75
how often/long do you monitor bg
- every 6 hr until max admin rate has been reached & maintained for 24 hrs
76
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
77
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
78
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
79
describe the patient's eating status the night before the procedure
- NPO
80
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
81
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
82
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
83
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
84
how much water do you flush with between meds
- 15-30
85
describe the stops post-med administration via gastrostomy or small bore feeding tube
- remove gloves - hand hygeine - document - evaluate response to meds
86
define ileus
- obstruction of the ileum or other part of the intestine
87
define peritoneum
- the serous membrane lining the abdominal cavity
88
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
89
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
90
what is an ileostomy
- a surgical opening into the ilieum (3rd part of the small intestine)
91
what is a colonostomy
- a sugrical opening into the colon
92
what determines the consistency of stool?
- the location of the stoma
93
describe the consistency of an ileostomy; why does this happen?
- bypasses the entire large intestine = liquidy & frequent stools
94
list the parts of the large intestine from beginning to end
- ascending - transverse - descending - sigmoid
95
describe the consistency of stool for a colonostomy of the ascending colon
- liquid & frequent
96
describe the stool of a colostomy of the transvers colon
- more solid & formed stool
97
describe the stool for a colostomy of the descending & sigmoid colon
- near normal stool
98
what determines the location of a colostomy
- the medical problem | - the pt's general condition
99
what are the 3 types of colostomy construction
- loop - end - double-barrell
100
what is a loop colostomy
- temporary large stomas constructed in the transverse colon
101
when is a loop colostomy performed
- in a medical emergency when closure of the colostomy is anticipated
102
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
103
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
104
when might an end colostomy be used
- often a result of surgical treatment for colorectak cancer - pts with diverticulitis who are treated surgically
105
what is a double barrel ostomy
- when the bowel is surgically severed and the 2 ends are brought out onto the abdomen
106
how many stomas does a double barrel colostomy have? what is the purpose of each?
- 2 - proximal functioning stoma - distal nonfunctioning stoma
107
what is a kock continent ileostomy
- created using the patient's small intestine as a pouch
108
when is a kock continent ileostomy used?
- in the treatment of ulcerative colitis
109
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
110
how is the kock continent ileostomy protected
- with a protective dressing or stoma cap
111
when is an ascending colostomy done?
- for right-sided tumours
112
when is the double barrelled colostomy used
- emergencies such as intestinal obstruction or perforation bc it can be created quickly
113
define peristomal
skin around the stoma
114
define effluent
- the stool discharged from the ostomy
115
how is the effluent collected
- pt must wear a pouch or appliance to collect it from the stoma
116
why is skin care so important for pts with ostomies
- to prevent liquid stool from irritating the skin around the stoma
117
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
118
what is used to irrigate a colostomy? why?
- a special cone-tipped irrigator | - prevents bowel penetration & backflow of irrigating solution
119
what should never be used to irrigate a colostomy
- an enema set
120
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
121
what determines how much and the type of solution to irrigate with
- the physical
122
for adults, what is the typical amt of solution used to irrigate
500-700 mL
123
how long should irrigation take
5-10 min
124
if a pt chooses to irrigate their colostomy, how often is it done
- timing is individualized to match the pt's lifestyle
125
describe the characteristics of an effective pouching system
- protects the skin - contains fecal material - remains odour free - comfortable - inconspicuous
126
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
127
define enterostoma; therapist
- a nurse trained to care for wound & ostomy management
128
a pouching system consists of...
- a pouch | - and skin barrier
129
what different ways do pouches come in
- one or two piece systems - disposable or reusable - precut or not
130
list different types of skin barriers for pouching systems
- wafers - pastes - powders - liquid film
131
what are wafer skin barriers
- one piece pouch systems permanently attached to the ostomy pouch
132
describe how a 2-piece pouching system works
- pouch can be detached from the skin barrier for emptying or changing
133
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
134
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
135
a good skin barrier....
- protects the skin - prevent irritation from repeated removal of the pouch - comfortable for the pt to wear
136
see textbook for steps to pouch an ostomy (way too long for flashcards)
...
137
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
138
when is enteral nutrition indicated
- if the pt is unable or unsafe to orally maintain/improve nutritional status
139
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)
140
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
141
what determines route of enteral feeding
- condition of the GI tract | - anticipated duration
142
for what duration can nasoenteral tubes be used for? enterostomy (gastro & jejuno)?
<6 weeks = naso | - enterostomy = >6 week
143
what is PEG
percutaneous endoscopic gastrostomy - uses an endoscope to ensure correct positioning of the gastrostomy - eventually replaced w a balloon tube
144
describe how to initially verify the correct placement of enteral tubes
- xray
145
describe how to verify that the tube is in the correct place with each ongoing verification
- measure external length - observe aspirate - pH
146
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
147
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
148
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
149
what is the usual volume delivery for continuous administration
- 25-150 mL/hr over 12-24 hrs
150
what is the usual volume of admin for intermittent
- 235-500 mL over 30-90 min several times/day
151
what is the usual volume & duration of admin for bolus
- 200-500 ml over <15 min several times/day
152
how is continuous, intermittent, and bolus delivered?
- continous = pump - intermittent = pump or gravity - bolus = syringe
153
what is the only method of admin used for small bowel feeds
- continuous
154
describe the risk of aspiration for continuous, intermittent, and bolus
- continuous = low - intermittent = higher - bolus = highest