Nutritional Support in the Critically Ill Flashcards
What is the first thing we need to think about when a malnourished pt is admitted?
Does their GI system work?
Risk factors for malnutrition
Older adults
NPO x5 days
20% weight loss
Chronic disease states, chronic stress
Dementia / altered LOC
Chronic alcohol abuse (choosing alcohol over nutrition)
Disease exacerbation (trauma, burns, sepsis)
Altered albumin/prealbumin
What albumin level shows long term malnutrition
<2.8
What level of prealbumin shows a pt is at high risk for malnutrition?
11-15
What level of prealbumin shows a pt has acute malnutrition?
15-35
What doesn’t giving prealbumin to a pt with low albumin levels help?
It will take 3 months for it to be converted to albumin
Signs of malnutrition
Dry skin
Brittle nails
Frequent infections
Poor wound healing
Bleeding gums
Dry coarse hair
Reduced appetite
Loss of fat, muscle mass, & body tissue
*What would vital signs/lab values be like for a patient with malnutrition?
Increased pulse
Increased RR
Decreased BP
Low SpO2 (b/c inadequate RBCs, so giving O2 won’t help)
Potassium out of range
Decreased skin turgor
Concentrated urine (amber, not cloudy)
Signs of volume depletion
Dry skin / decreased turgor
Altered LOC
Pallor
Tachycardia
Hypotension
Concentrated urine
Dry mucous membranes
3 parts of a nutritional assessment
H&P
Lab data
Anthropometric measurements (height & weight)
*How to weight a patient
- 1st: check pt’s weight from yesterday to compare
- Look at documentation to see how pt was weighed and weight in the same way (ex: chair scale, bed scale)
- Need to take pillow, sheet, pads, and covers (only keep 1 pad & 1 sheet)
- Move everything off bed
- Zero bed
- Get weight
- If variance of 5 lb + need to reweigh
(May be previous nurse’s fault, pass info onto next shift)
Minimum grams of protein for a healthy adult
98 grams
Minimum grams of protein for a critically ill pt
164 grams
Nutritional support is a team effort, who is involved and what are their roles?
- Dietician (type, amt, & orders r/t feeding. In charge of tube feedings)
- Nurse (team leader)
- Pharmacist (in charge of TPN, PPN parenteral feedings, will calculate & make parenteral feedings)
- Physician
Malnutrition goals of nutritional support
Provide minimal kcal/protein support
Evaluate tolerance to nutrition
Stabilize weight (prevent decline)
Prealbumin > 16 mg/dl
How much should prealbumin increase each day?
2 mg/d (about 65% of daily Kcals)
What indicates a poor prognosis for prealbumin levels?
In they increase by < 4 mg/dl in 8 days
Role of the dietician for a pt with enteral tube feedings?
Evaluate nutritional status
Select appropriate enteral feeding formula
Monitor and follow, watch for complications/changes
Role of the nurse for a pt with enteral tube feedings?
Insert tube/check initial placement (RN only)
Give medications (RN/LPN)
Give feedings, bolus and/or flush (RN/LPN)
Monitor for symptoms of intolerance (RN/LPN)
Tube discontinuation (RN/LPN)
Decision tree for determining the appropriate route for a pt’s nutrition
1: does the gut work?
Yes = oral nutrition
No = parenteral nutrition
How to determine if a pt’s gut works
Listening to bowel sounds
*Must be *Normoactive in all 4 quadrants
If no bowel sounds in a quadrant, need to listen for 5 min & document
If unsure about bowel sounds, listen again, if still unsure, get another nurse to listen
Guidelines for when to start a pt on enteral feeding
- For those unable to meet nutritional needs orally for more than 3 days
- *Ideally, begin in first 24 hours or pt arrival
- Prealbumin <11 indicated need for aggressive therapy with enteral or parenteral nutrition
Types of tubes for tube feeding
Nasogastric (large bore)
Orogastric (large bore)
Nasointestinal (small bore)
Gastrostomy or jejunostomy (surgically inserted)
How is placement of ALL feeding tubes checked?
Chest xray
Must have “ok to use”
How should you check placement of feeding tube before giving meds (after initial placement is confirmed)?
Aspirate and test for acidic pH
Inject air into stomach
Important things to remember about placing a nasointestinal tube
Has a small, flexible wire to make it go down
Has black, weighted tip on end
*Once it’s inserted, check placement, get “ok to use”, THEN wire is removed.
*DO NOT remove wire before placement is approved
Called “Dobhoff”
Anchor tube while pulling wire
What should you do if a feeding tube gets clogged?
Flush tube
Can try something carbonated like sprite to help break up solid clots
If still can’t get it unclogged, need to pull tube out and insert new tube
*Components of the tube feeding safety bundle
Prevent aspiration
Rinse tube well
Care of nose
Check residuals per policy
Check BG per protocol
*How do we prevent aspiration while tube feeding?
Keep HOB elevated
*Do not transport pt anywhere while tube feeding. Need to stop it, and leave it behind
*How do you rinse the feeding tube?
*Follow flush orders (Ex: 50 mL sterile water q6hr minimum)
*Can use any kind of water (tap, saliene, free water, etc.)
*Record all rinses on I&O
*How do you care for a pt’s nose while tube feeding?
For NG tube, use alcohol to get goop off nose, use wet 4x4 around tube and nostril
For OG tube, standard oral care, change OG tube if pt needs to be reintubated
*Why should we check a pt’s blood glucose who is being tube fed?
- All tube fed patients will have a high BG because there is a lot of sugar in the milk in the tube feed
- will usually check every 4 hours
(Some pts will need insulin even if they’re not diabetics)
What is a possible side effect for pt’s skin integrity while being tube fed?
Open wounds are more likely to get infected since the tube feed has so much sugar in it
Need to clean them really well
Patients who are at risk for intolerance of tube feeding
Intubated/airway issues
Greater than 70 years old
Decreased LOC
Supine position (cannot tolerate HOB being up)
Reflux
Transport (need to turn it off and leave it behind)
How would you check a patient’s residuals?
Turn tube feeding off
Take syringe and pull back to see how much you get
Color should be greenish/bile with tube feeding in it
What should you do if a patient has 250 mL of residuals?
Put feeding on hold, look at order, follow order, and then call someone
If >30, but not super high, use nursing judgement and see how pt is tolerating
*Symptoms of tube feeding intolerance
Residuals >30 mL
N/V
Hyperactive bowel sounds *that are ongoing
Abdominal distention/cramping
(These all ^ require nursing judgement)
Absent bowel sounds (no judgement needed, must stop tube feed)
Tube feeding complications
Aspiration
Fluid volume excess
Dehydration
Electrolyte imbalances
Glucose imbalances
When would a pt need parenteral nutrition?
If they are unable to tolerate enteral or PO nutrition
(Decision made by physician)
How is parenteral nutrition given?
Via a central line:
- subclavian
- internal jugular (IJ)
- PICC
On the central line, which hole does the TPN go into?
The hole closest to the pt which is most distal
Differences between TPN and PPN
TPN contains large amt of sugar/nutrients (total)
PPN contains half as much sugar
TPN is caustic to peripheral veins (can only be given central line/PICC b/c of all of the sugar)
PPN is temporary and not used long term
Similarities of TPN and PPN
What are the only things that can be added to them?
Both are types of parenteral nutrition
Both require intense blood glucose follow up
IV lipids and albumin infusions may accompany (be added) to either
Parenteral nutrition care of bag, line, and patient
Observe fluid balance (at huge risk of fluid volume overload)
Routine blood sugar levels
Infection control (sepsis is high risk b/c of sugar)
Meticulous IV care
Nothing in IV line except for lipids
