Unit 9 and 10: NG tube, Enteral nutrition, & Ostomy care, medication administration Flashcards
1
Q
What is the distinction between gastric and small-bowel feeding?
A
The pyloric sphincter
2
Q
What is enteral (tube feed) nutrition?
A
Delivery of nutrients through a tube that has been inserted into GI tract.
Direct entrance to the GI tract through the abdominal wall is best for long-term tube feeds
3
Q
What is enteral feeding used for?
A
Patients who cannot ingest, chew, or swallow food.
4
Q
Indications for enteral feeding
A
1) Where normal eating is unsafe due to high risk for aspiration
- Altered mental status, swallowing disorders, impaired gag reflex, mechanical ventilation, esophageal conditions, delayed gastric emptying
2) Conditions that interfere with normal ingestion/absorption, or create a hypermetabolic state
- Surgery of oropharynx, intestinal obstructions, pancreatitis, burns, severe pressure injuries
3) Conditions where diseases or treatments reduce oral intake due to symptoms
- Anorexia, nausea, pain, fatigue, SOB, depression
5
Q
tube feeding timing
A
- Bolus
- Intermittent
- Continuous
- Cyclical
6
Q
Types of tubes for enteral feeding
A
- Percutaneous refers to the fact that the tube is through the skin
- Endoscopic means that the tube is usually inserted endoscopically
- Gastrostomy: gastro means stomach, ostomy means surgical creation of an opening.
7
Q
What can happen if enteral feed is administered straight into small bowel?
A
- Bloating
- Cramping
- Diarrhea
8
Q
Nursing responsibilities for enteral feeds
A
- Inserting NG or OG tube
- Verifying and maintaining proper position of tube
- Keeping tube patent through flushing
- Assessing tissue around tube, providing oral & nasal care
- Administering nutrient formula through tube
- Administering medications through tube
- Keeping patient NPO unless ordered otherwise
- Preventing complications
- Documentation, monitoring I&O
9
Q
Enteral feeding guidelines: Assessment
A
- Allergies (inc. food allergies)
- Abdomen (bowel sounds, edema, distension, stools, cramping)
- Weight
- Fluid volume status (excess or deficit)
- Serum electrolytes
- Blood glucose
- Verify order
- Confirm correct placement
- Keep HOB at 30-45 degrees
- Change tubing q24h or per manufacturer’s standards
- Keep formula at room temperature
- Check gastric residual volume and flush tube with 30mL sterile water before bolus or intermittent feeds, or q4-6h during continuous feeds.
- Clean bag and tubing with water between feeds
10
Q
Transition from enteral to oral intake
A
- Chewing and swallowing assessments must be done
- Formula changed to one with intact protein
- Dietician orders oral diet to progress slowly
- Daytime oral intake with nighttime tube feeds
- Food and fluid intake must be monitored
- Enteral feeds discontinued when patient eats ¾ of oral food and 1L of water daily
- Monitor food intake until 100% of nutrition needs are consistently met
11
Q
Indications for NG intubation
A
- Enteral feeding
- Decompression
- Compression
- Lavage: irrigation of stomach
- Gastric analysis
12
Q
Types of NG tubes:
A
- Small-bore feeding tube
- Levine tube
- Salem sump tube
13
Q
Assessment for NG tube insertion
A
- Verify physician’s order
- Inspect patient’s nares, nasal and oral cavity; pt to breathe through each naris.
- Note history of nasal surgery, allergies, deviated septum, nosebleeds, facial trauma, etc
- Determine whether the patient is on anticoagulation medication(s)
- Auscultate for bowel sounds; palpate abdomen for distension, pain, rigidity
- Assess LOC and ability to follow instructions
- Ask if patient had previous NG tube, and which naris was used
- Assess patency of bilateral nares & for skin breakdown
- Stand on the same side of the bed as the naris you’re inserting into
- Position patient in high- Fowler’s
- Determine how far to insert tube by measuring: tip of nose to earlobe to xiphoid process
- Lubricate tube before insertion
- Do not advance during inspiration or coughing (r/f intubation into respiratory tract)
- Check for positioning with penlight and tongue blade
- Keep HOB at 30-45 degrees
14
Q
NG intubation: Check for correct placement
A
When? - q4-6 hours, before instilling feeds/flushes/medications, prn
How?
- X-ray: this is best practice for determining placement
- Test gastric pH level: ≤5 indicates correct placement in stomach
- Monitor external length of tube and observe appearance and volume of fluid aspirated; most intestinal aspirates are stained yellow by bile, while gastric aspirates are not
15
Q
Possible complications from NG tubes
A
- Discomfort – during insertion, and while tube is in situ
- Intubation into respiratory tract
- Migration of NG tube
- Tissue breakdown & pressure injuries – in the intubated nares and into the GI tract
- Aspiration of gastric contents
16
Q
Pharmacokinetics
A
Study of how medications enter the body, reach the site of action, metabolized and exit the body
17
Q
What factors impact th effectiveness of Meds?
A
- Absorption: the passage of medication molecules into the blood
- Distribution: from the blood to the tissues and organs
- Site of Action: biotransformation (the breakdown of the medication) occurs primarily in liver but also in lungs kidneys, blood and intestine
- Excretion: process by which medications exit the body through the lungs, exocrine glands, bowel, kidneys, and liver
18
Q
Unbound medicine
A
utilized within the body
19
Q
Therapeutic effect
A
- The intended or desired effect/response of a medication
- Knowing its therapeutic response allows the nurse to evaluate and provide patient teaching
20
Q
Adverse effect
A
- Unintended, undesirable, and/or unpredictable effects of medication
- May be apparent right away or after a long period
- Harmful incident, no-harm incidents, or near misses
21
Q
Vanessa’s law
A
- Passed in November 2014 - To ensure all reporting of adverse drug reaction and medical device incidence
22
Q
Side effects
A
- Predictable and often unavoidable
- May be secondary effects of medication
- Need to report side effects as these may be adverse reactions
23
Q
Toxic effects
A
Develop over a prolonged period of medication accumulation. Due to inability to breakdown or excrete medication.
24
Q
Idiosyncratic Reactions
A
Unpredictable overreaction or underreaction to medication, or any reaction different from normal
25
Allergic Reactions
The initial dose causes the patient to be sensitize immunologically causes antibodies to develop
Repeated administration causes patient to develop an allergic response
26
Medication Tolerance
occurs over time and requires the patients to need higher doses to produce the therapeutic effect
27
Medication dependence
Not the same as tolerance; can be physiological (physiological disturbances when drug withheld) or psychological (based on a patient’s desire for effect of the medication)
28
Safe therapeutic range
Between the minimum effective concentration and the toxic concentration
29
Half-life
The time it takes for excretion process to lower the serum medication concentration by half
30
Time intervals of medication action
- Onset of action: time it takes for medication to produce a response
- Peak: time it takes to reach highest effect
- Trough: minimum blood serum level of before next scheduled dose
- Plateau: Blood serum concentrations reached and maintained after repeated fixed doses
31
Nonparenteral routes of medication administration
- Oral, Buccal into side of cheek
- Sublingual
- Topical
- Suppository (vaginal or rectal)
32
Parenteral routes of medication administration
- Intermuscular
- Subcutaneous
- Intradermal
- Epidural
- Intravenous
33
Oral, Buccal, Sublingual Routes: Advantages and disadvantages
- Advantages: Easy to administer, economical, easy to access produce both local and systemic effects
- Disadvantages: gastric secretions destroy medications, NPO patients, cannot administered if altered LOC, irritate GI tract (Ex. NSAIDs), teeth (staining) or taste bad
34
Topical for skin: Advantages and disadvantages
- Advantages: primarily local effect, usually painless, limited side effects
- Disadvantages: extensive application require dressings, not for open skin, may be absorbed by person applying it (person applying should wear gloves)
35
Transdermal for skin: Advantages and disadvantages
- Advantages: Prolonged applications provide systemic effect, route is painless, limited side effects
- Disadvantages: application leaves oily or pasty substance and stains clothing, some patients may be sensitive to adhesive
36
Mucous membranes medication administration: Advantages and disadvantages
Mucous membranes: Eyes, ears, nose, sublingual, vagina, rectum, throat.
- Advantages: provides local application to involved sites; may provide alternative to oral route
- Disadvantages: may be highly sensitive to some medication concentrations, rectal/vaginal may cause embarrassment, any alteration to route such as surgery to rectal area or rupture of eardrop, route is contraindicated
37
Inhalation: Advantages and disadvantages
- Advantages: rapid relief of local respiratory problems
| - Disadvantages: Serious systemic effects, improper administration=medication is ineffective
38
Subcutaneous, Intramuscular, Intravenous, Intradermal, Epidural Routes: Advantages and disadvantages
Advantages: alternative to oral route, rapid absorption’
Disadvantages: higher risk of infection, medication is expensive, bleeding risk, damage to skin after repeated injections, higher absorption = high risk of side effects. Also rapid adverse reactions.
39
What are the 10 rights of medication administration
1. Right Patient
2. Right Dose
3. Right Medication
4. Right Route
5. Right Time
6. Education
7. Right to Refuse
8. Right Assessment
9. Right Evaluation
10. Right Documentation
40
Right patient
Ask patient their name and date of birth.
| Ensure the correct MRN or date of birth
41
Right dose
- Best practice notes that the patient-specific dose should be dispensed to the hospital unit in an oral syringe
- Nurse can use an independent double check with a second nurse to verify the dose.
42
Some consideration for proper medication administration
- Graduated cups
- Splitting meds: Should be done by pharmacy.
- Crushed medication: Make sure meds can be crushed, should not be mixed with food.
43
Right medication
- ALWAYS compare the medication administration record with the physician’s order
- Long-term care comparison between what is being prescribed and physician’s orders is done at the end of every week.
- Acute care comparison between what is being prescribed and physician’s orders is done every day.
44
Now
Within 90 mins of ordered time.
45
Stat
Right away and only once.
46
3 medication checks
1) before removing the container from the supply drawer or shelf
2) As the prescribed medication is removed from the container
3) At the bedside before administration
47
Right route
When preparing a label for a medication syringe ensure you indicate route or location of administration.
48
Right time
- Nurses can alter the timing of medication administration
- Time-sensitive medication: have a 30 minutes before and 30 minutes after scheduled time
- Non-time sensitive medication: have a 1-2 hour before and after schedule time
- Nurses need to note medications that need to be given at certain times of the day or at specific intervals
49
Right education
- Understanding what the medication is/does
- Desired effect
- Side Effects
- Nurse should ask about allergies
50
Right to refuse
- Every patient or legal decision maker has the right to refuse any medication
- It is the nurses role to ensure that the patient or decision maker is aware of the consequences of the refusal.
51
Right assessment
Based on the assessment, if the medication is deemed not safe to administer the nurse will hold the medication until they notify the health care provider
52
Right evaluation
- Assess the effectiveness of the medication
- Is the patient experiencing any Side effects
- Is the patient experiencing any adverse effects
- Is the patient experiencing any allergic reactions
53
Right documentation
Prescriptions and medications forms need to include:
- Patient’s name
- Medication name
- Medications dosage
- Medication route
- Frequency of administration
Regarding medication administration the nurse need to accurately document the time of medication
Documentation is also required for PRN medications, and refusal of medication
54
Medication administration and the older adult
- Pulmonary function is reduced
- Blood pressure gradually increases
- Slowed gastrointestinal tract
- Reduced bladder size and men may have increase in prostate
- Decrease in immune system
- Increase in Polypharmacy
