Pancreatitis, TPN, NG and enteral tube therapy Flashcards
Hard to manage, having no relief, cannot be stopped, even with medication and prolonged
Intractable
Why can we not administer a central TPN solution through a peripheral route?
Due to the high osmolarity of the solution (33% dextorse) is that it will blow the peripheral vein very rapidly - large molecule size
Can diabetics receive TPN?
Yes, we just have to offest the glucose by giving more insulin
What do we start patients on when they receive TPN?
Insulin
a person receiving TPN will become diabetic for the limited time they receive TPN; they will stop taking insulin when they stop TPN
What may occur as a result of long term PTN?
Stomach may atrophy
Does the person ever get hungry when given TPN?
No, but may miss taste of food
How is TPN administered?
Through PICC (peripherally inserted central catheter) line or Hickman
Where does the catheter for the PICC line/central line sit in?
Superior vena cavaq
PICC line insertion/clean is a ______ procedure.
This requires that we wear _____.
sterile
masks
How can we get a patient on TPN to produce saliva? Why is that important?
Pt can have gum, or suck on a mint
May use a mouthcare tray - diluted to swish and spit
They will have bad breath without saliva
Describe the two lumen central line.
Red is for taking blood out
white is for feed
A central line in the chest is called what?
Hickman’s
What is the third lumen for?
Blue - for drugs
Nurses hate it when doctor’s put a central line here. Why?
Why is it used?
Jugular vein - compromising to comfort as patient cannot turn their neck
used in emergency stuations, or if the other sites are compromised
(happens with dialysis patients)
TPN administration:
- Before administration we check the bag. What do we check for?
- Administered via pump to prevent _______
- Monitor blood glucose ____ for 24 hours, then ____ if levels are normal
- Monitor for allergy to ______; often occurs within first ____ minutes - fever, shaking, chills, SOB, chest pain or back pain
- Prevent catheter related infection - strict ______ when accessing ports and changing dressings (_____ worn by patient and nurse!)
- change the solution and tubing for lipid containing solutions ______
- solutions should be ______ until administration
check bag for:
- expiry date, appearances, leaks or tears, correct ingredients
bolusing q6h, OD lipids, 30 minutes asepsis - masks q24hrs refrigerated
Why is the pump essential when giving TPN?
If it ran by gravity and were to open really quick - person may get atrial fibrillation and cardiac arrest
When a large amount of fluid is administered rapidly to a patient (too rapidly)
blousing
Why do we see flank pain in lipid allergy?
Get lysis and clots which clog up the kidneys
In LHSC, at what frequency do we change IV tubing?
Why do we change lipid tubing q24hrs?
q72hours
q24hrs for lipid as it coats the inside of the tubing
Before administering the TPN solution we should warn the patient that it will be ____.
cold
IF extravasation occurs, it is often dramatic from a central line - very red, inflammed. What must we do?
Stop the IV, dress the area and do NOT USE IT FOR ANYTHING
Delivery of nutrition through a feeding tube, placed in the stomach of small intestine. It is used when a client is not able to ingest food but is still able to digest food and absorb nutrients.
Enteral nutrition
For the following conditions, describe whether the person would receive enteral nutrition or TPN.
A -Chronic Diarrhea or vomiting B - Pancreatitis C - Comatose state D - GI obstruction E - Oral, head and neck surgeries F - Severe malabsorption G - Confused clients H - Short bowel syndrome I - Intractable diarrhea J - Impaired swallowing or gag reflex (e.g. stroke) K - Sepsis L - Receiving mechanical ventilation M - GI obstruction
A - TPN B - TPN C - EN D - TPN E - EN F - TPN G - EN H - TPN I - TPN J - EN K - TPN L - EN M - TPN
What are the advantages of enteral feeding over parenteral feeding?
EN nutrients are absorbed in the proximal small bowel, promoting distal bowel rest
Prevents GI mucosal atrophy
Less invasive, fewer complications
Less expensive
What are the different ways that EN may be administered?
Intermittent
Continuous
Bolus (J and G tube only)
Gravity flow
Pump
Open - bag and tubing
Closed - pre-filled container with tubing
EN formulas are made up of both _____ and _________, along with ______, which can make up to 85% of the formula
macro, micronutrients
water
Nutrients that can provide fuel or energy.
What are the different types?
Macronutrients
Carbs, proteins, lipids
Micronutrients required for metabolic processes to occur adequately. They cannot be manufactured by the body and are thus ingested.
Vitamins
What are the two vitamin types. Which vitamins fit in which category?
Fat-soluble - ADEK
Water-soluble - B and C (BC is next to water)
Micronutrients required for cell functioning, including the development and health of bone and RBCs.
minerals
What are the five major minerals?
Calcium, phosphorus, potassium, sodium and magnesium
The body is unable to store _____-soluble vitamins and thus they must be supplied daily by one’s diet.
water (i.e. vitamins B and C)
EN route used for clients who require feeding on a short-term basis (less than __ weeks) and is inserted through the nose and stomach.
NG tube
less than 6 weeks
Longer than an NG tube and is placed in the upper small intestine. it is used for clients at high risk for ______.
Nasointestinal tube
aspiration risk
Placed through the abdominal wall into the stomach. Used for long-term feeding.
Gastrostomy (G) tube
Used for clients who require long-term feeding and is placed through the abdominal well into the jejunum.
Jejunostomy (J) tube
Opened cans of EN formula should be used within what time frame?
24 hours.
Generally, reconstituted milk products should not be kept at room temperature for longer than _______.
Ensure tube-feeding formula is at _____ ______. Explain this last point.
4 hours
room temperature
- cold formula causes gastric cramping and client discomfort
- i.e. take it out 30 minutes before administration; or immerse in warm water for 15 minutes before administration
When administering EN we raise the bed, how high and why?
Raise to high-fowler’s if they can tolerate it, or at least 30-45°.
This is essential to decrease aspiration risk.
What do we listen for before commencing EN feeding?
Auscultate bowel sounds
What are two potential adverse outcomes of EN feeding due to incorrect placement?
NG or NI tube in the lung
pulomonary aspiration of gastric contents
What are the ways in which NG or NI tube placement is verified?
X-ray is the most reliable method - done whenever a tube is first inserted into a client
Measure the length of the tube by noting the mark at the exit of the nares and comparing to previous measures
Aspirate gastric contents to measure pH and observe characteristics of the aspirate
Describe the colour of aspirate when verifying tube placement.
Gastric ontents are usually green, off-white to tan, or clear and colourless
Intestinal fluid is usually dark to golden yellow
Pleural fluid is PALE YELLOW
What pHs do we look for when verifying tube placement?
Gastric pH - 1-4 (a client with continuous tube feeding may have a pH of 5+)
Intestinal pH - 6+
pleural fluid - 7+
How long do we wait to test placement of NG tube after administering meds?
1 hour
When do we check gastric residual volume (GRV)?
Before each feeding for intermittent feeding, and q4-6h initially for continuous feedings
When do we flush the feeding tube?
Following a bolus or intermittent feeding, or q4h throughout continous feeding (usually a 30 mL sterile water flush)
At what frequency are closed EN systems changed?
What about open systems?
q24h for closed
generally q24h for open too
How long should a client stay upright after EN feeding?
30-60 minutes
Skin care EN tube:
- cleanse tube insertion site with ______ _____ and apply a dry gauze if drainage is present
- a well established tube site can be cleansed with _____ and _____, and if there is no drainage it may be left open to the _____.
normal saline
soap and water
air
What is the most important complication to consider for enteral therapy?
Aspiration
