TOPIC 7 - parenteral and enteral feeding Flashcards
enteral feedings are given to patients who
are unable to maintain or achieve adequate nutritional status
enteral feeding is administered through
a tube inserted into the stomach, duodenum, or jejunum in a balanced liquefied food
indications for enteral nutriton
patients who have a condition that impacts swallow ability, anorexia, facial fractures, head/neck cancer, neurologic or psychiatric conditions, chemo, critical illness, stroke
tube features for enteral nutrition
polyurethane or silicone tube
soft, flexible, radiopaque, placed in small intestine, decreased likelihood for regurgitation and aspiration
what is the benefit of placement into the small intestine
intestine decreases the chance of regurgitating gastric contents into the esophagus and subsequent aspiration. However, the patient can still aspirate gastric secretions if the stomach is not emptying properly
when is a stylet used
in a comatose patient because the ability to swallow is not essential during insertion. A complication that can result from using a stylet is increased risk for perforation
complications of nasogastric and nasointestinal tubes
clog easily, can be dislodged by vomiting or coughing, can be knotted or kinked in GI tract
gastrostomy and jejunostomy tubes (PEG( may be used for patients
who require tube feedings for an extended time
patient must have intact, unobstructed GI tract
can be placed surgically, radiologically, or endoscopically
placement of PEG tube
Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then is pulled through a stab wound made in the abdominal wall. a retention disk and bumper then secure the tube
delivery options of enteral nutrition
continuous infusion by pump, cyclic feedings by pump, intermittent by gravity, intermittent by bolus by syringe
when are enteral feedings started
when bowel sounds are present, usually 24 hours after placement
PEG tubes are started 2 hours after insertion
interventions for preventing aspiration risk
ensure proper position of tube, maintain head of bed elevation, check gastric residual volume
client position for enteral feedings
sitting or lying with HOB at 30-45 degrees, remain elevated for 30-60 minutes for intermittent delivery
confirming tube placement
mark exit site of tube (observe for change in length)
check placement before each feeding/drug admin or every 8 hours with continuous feeds
check insertion length regularly
methods to check placement
aspiration of stomach contents
pH <5
xray
when to check GRV
every 4 hours during first 48 hours
increased volume leads to aspiration
site care
assess the skin around the tube daily
monitor bumper tension
apply a dressing until site is healed
after healed, wash with soap and water and protective ointment or skin barrier
why is skin at risk around gastrostomy and jejunostomy tubes
digestive juice irritates skin
protective ointments and skin barriers
zinc oxide, petroleum gauze, karava, stomahesive
checking tube patency
flush with 30ml water before and after each feeding, drug admin, and residual check
preventative measure for continuous feedings
occlusion alarm
misconnection
SAFETY ALERT
inadvertent connection between enteral feeding and nonenteral feeding system
admin of feedings pump vs intermittent
pump: gradually increase over 24-48 hrs
intermittent: usually 200-500 mL per feed
nursing considerations
daily weights, assess bowel sounds, I+O, initial glucose checks, label with data and time started
how often is pump tubing changed
every 24 hours
complications of enteral nutrition
vomiting, dehydration, diarrhea, constipation
potential problems of gastrostomy or jejunostomy feedings
skin irritation
pulling out of tube
parenteral nutrition administers …
directly into the bloodstream
minimum caloric intake
1200-1500 a day
parenteral nutrition indications
chronic severe diarrhea and vomiting, complicated surgery or trauma, GI obstruction, intractable diarrhea, severe anorexic, severe malabsorption, short bowel syndrome, GI tract abnormalities
used when ingestion, digestion, and absorption is impaired
composition of parenteral nutrition
base contains dextrose and protein in the form of amino acids
electrolytes, vitamins, and trace elements
IV fat emulsion is added
trace elements
Zinc, copper, chromium, manganese, selenium, molybdenum, and iodine
fat emulsion side effects
vomiting, shivering, fever, chills
lipids should be cautioned in patients with
disturbance in fat metabolism, in danger of fat embolism, allergy to eggs
methods of parenteral administration
central - used for long term support
peripheral - used for short term therapy
central parenteral nutrition
catheter tip lies in SVC
subclavian or jugular vein
PICCs
peripheral parenteral nutrition indications
protein and caloric deficiency
risk of central catheter is too great
supplement inadequate oral intake
difference in peripheral vs central tonicity
central : large vein can handle high tonicity (20-50%)
peripheral : up to 20%
solutions administered to prevent hypoglycemia
10, 20, or 5% dextrose solution
used when a PN bag empties before the next solution is available
complications of PN
refeeding syndrome : fluid retention and electrolyte imbalance
hypophosphatemia
conditions that predispose patients refeeding syndrome
long standing malnutrition, chronic alcoholism, N/V/D, chemo, major surgery
metabolic problems of PN
Hyperglycemia, hypoglycemia, prerenal azotemia, fatty acid deficiency, electrolyte disturbances, hyperlipidemia, mineral deficiencies
mechanical problems of PN
insertion problems
dislodgment, thrombosis of great vein, phlebitis
nursing management of PN
vitals every 4-8 hours, daily weights, glucose checks every 4-6 hours, monitor for hyper or hypoglycemia
signs and symptoms of hyperglycemia
thirst, polyuria, confusion, elevated BS, blurred vision, dizziness, N/V, and dehydration
signs and symptoms of hypoglycemia
sweating, hunger, weakness, tremors
maintain glucose :
110-150
management of increased glucose
maintain accurate infusion rate, never increase or decrease flow rate by more than 10%, never stop PN abruptly unless it is replaced by another glucose source, infusion pump must be used, need to periodically check volume infused
labs to monitor daily
hyper or hypokalemia, hypophosphatemia, hypomagnesemia, BUN, CBC, liver enzymes
air embolus
difficulty breathing or respiratory failure, chest pain, heart failure, stroke, pneumothorax, hemothorax, hydrothorax, hemorrhage
main symptoms of air embolus
SOB and cyanosis
local vs systemic manifestations of infection and septicemia
local : erythema, tenderness, exudate at catheter insertion site
systemic : fever, chills, nausea, vomiting, malaise
if no other cause of infection can be identified what is suspected
catheter related infection
diagnostics for infection status
blood and catheter cultures
xray : to check pulmonary status
what caloric intake should be met before discontinuation
60% caloric needs
